Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2014;95:892-9

ORIGINAL ARTICLE

Incremental Shuttle Walking Test: A Reproducible and

Valid Test to Evaluate Exercise Tolerance in Adults
With Noncystic Fibrosis Bronchiectasis
Anderson Alves de Camargo, PT, MSc,a Tatiane S. Amaral, PT,a Samia Z. Rached, MD,b
Rodrigo A. Athanazio, MD,b Fernanda C. Lanza, PT, PhD,a Luciana M. Sampaio, PT, PhD,a
Celso R. de Carvalho, PT, PhD,c Alberto Cukier, MD, PhD,b Rafael Stelmach, MD, PhD,b
Simone Dal Corso, PT, PhDa
From the aPostgraduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo; and the bPulmonary Division, Heart
Institute, and cPhysiotherapy Department, Department of Physical Therapy, University of São Paulo School of Medicine, São Paulo,
Brazil.

Abstract
Objective: To analyze the reliability, validity, and determinants of the incremental shuttle walk test (ISWT) in adults with noncystic fibrosis
bronchiectasis.
Design: Cross-sectional study.
Setting: Outpatient clinic.
Participants: Subjects (NZ75; 26 men) underwent, on different days, cardiopulmonary exercise testing (CPET) and 2 ISWTs, 30 minutes apart.
The number of steps in daily life was recorded. Concurrent validity was tested by the relation between distance walked with peak load and oxygen
consumption (V_ O2).
Interventions: None.
Main Outcome Measures: Distance walked (m) was compared between the first and second ISWTs; greatest distance walked was correlated with
peak load and VO2peak obtained from CPET, steps per day, and dyspnea evaluated by the Medical Research Council (MRC) scale; and
desaturation was compared between CPET and the ISWT.
Results: Distance walked was equivalent between the first ISWT (441
152m) and the second ISWT (445
153m) with an excellent intraclass
correlation coefficient (.995; 95% confidence interval, .99e.997). There were significant correlations between distance walked and peak load
(rZ.82), V_ O2 (rZ.72), steps per day (rZ.61), and the MRC scale (rZ.69). Age, body mass index, sex, forced vital capacity (% predicted),
dyspnea, and steps per day explained 70% of the variation in distance walked (m) and 60% of the variance when expressed as percent
predicted. Higher desaturation was observed during the ISWT (4%
4%) than cycling (2
3%) (P<.001).
Conclusions: The ISWT is reliable, represents functional capacity, and induces greater desaturation than cycling. Age, body composition,
pulmonary function, dyspnea, and physical activity in daily life are determinants of the distance walked on the ISWT.
Archives of Physical Medicine and Rehabilitation 2014;95:892-9
ª 2014 by the American Congress of Rehabilitation Medicine

Non-cystic fibrosis (CF) bronchiectasis is characterized by a
progressive loss of lung function and a decline in lung diffusing
capacity.1-3 It is also associated with recurrent exacerbations
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
leading to dyspnea and fatigue,4,5 contributing to reduced exer-
cise tolerance.
Cardiopulmonary exercise testing (CPET) is the criterion
standard for assessing exercise capacity, but it is not easily available
in clinical practice. In this context, field walking tests have been
used to evaluate functional capacity in patients with chronic

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.11.019
Incremental shuttle walking test and bronchiectasis
respiratory diseases because these tests are more representative of
the demands required during activities in daily life.6 Additionally,
field walking tests are more sensitive in detecting desaturation than
cycling tests.7,8
Although non-CF bronchiectasis is a chronic and debilitating
disease, few studies have assessed functional capacity in these
patients, and the incremental shuttle walk test (ISWT) has been
the field test of choice in most of these studies.9-12 Interestingly,
the reproducibility and/or validity of the ISWT have been tested in
patients with chronic obstructive pulmonary disease (COPD),13
CF,14 pacemakers,15 advanced cancer,16 and fibrotic interstitial
pneumonia17 but not in those with bronchiectasis. With the
growing interest in pulmonary rehabilitation for other chronic lung
diseases, such as non-CF bronchiectasis,18 it is crucial to know the
within-subject reproducibility of the ISWT to correctly interpret
the impact of interventions on functional capacity when using this
test. Moreover, because of the similarity of symptoms and pul-
monary impairment in relation with COPD, the ISWT may
determine a greater desaturation compared with cycling in patients
with non-CF bronchiectasis.
Therefore, this study investigated 3 questions: (1) Is the ISWT
reproducible and a valid test for measuring exercise tolerance in
patients with non-CF bronchiectasis? (2) Is exercise-induced
desaturation higher on the ISWT than for CPET? (3) What are
the determinants of the distance walked in the ISWT?
Methods
Participants
Patients were recruited from a tertiary referral university hospital
in the state of São Paulo. The inclusion criteria were as follows:
diagnosis of bronchiectasis confirmed by high-resolution
computed tomography, 18 years of age, clinical stability (no
change in medication dosage, quantity, color of secretions, and
symptoms of dyspnea in the preceding 4wk), and never partici-
pated in a rehabilitation program. Patients were excluded if they
had other lung diseases, unstable heart diseases, smoking history
10 pack-years, and any inability to perform the tests because of
musculoskeletal limitations. There are 348 patients registered in
this outpatient clinic. During the recruitment period, between
November 2011 and October 2012, 83 patients met the inclusion
criteria, representing 21% of the total number of subjects treated
in this clinic. Eight patients were excluded for the following
reasons: 1 performed regular physical activity, 1 was a smoker, 3
did not complete all the evaluations, 1 had severe kyphoscoliosis,
1 had a previous pneumonectomy, and 1 had severe heart disease.
List of abbreviations:
BMI body mass index
CF cystic fibrosis
CI confidence interval
COPD chronic obstructive pulmonary disease
CPET cardiopulmonary exercise testing
FVC forced vital capacity
ISWT incremental shuttle walk test
MRC Medical Research Council
6MWT 6-minute walk test
SpO2 oxyhemoglobin saturation
V_ O2 oxygen consumption
VO2peak oxygen uptake at the peak of CPET
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Therefore, a total of 75 patients (26 men) were assessed. The
ethical committees (Nove de Julho University: protocol 921/11
and University of São Paulo: protocol 451538) approved the study.
All the procedures and any associated risks were described to the
participants, and informed consent was obtained from all patients.
Study design
This is a cross-sectional study. Patients rated dyspnea according to
the Medical Research Council (MRC) scale19 and underwent
bioelectrical impedance. Afterward, they performed CPET. On
another day (48h apart), 2 ISWTs were performed (30min apart),
and an accelerometer was given to the patients.
Assessments
Body composition
Body height was determined to the nearest 0.1cm with subjects
standing barefoot. Body weight was assessed with the beam scale
to the nearest 0.1kg with subjects standing barefoot and in light
clothing. Body mass index (BMI) was calculated as weight/height
(kg/m2). Fat-free mass was estimated with a body composi-
tion analyzer.a
Cardiopulmonary exercise testing
The maximal incremental cycle ergometer test was carried out on
an electromagnetically braked cycle ergometerb with gas ex-
change and ventilatory variables analyzed breath by breath.c The
test was performed as previously described.20 The main outcome
for this test were pulmonary oxygen consumption (V_ O2)
(mL · kg1 · min1), peak load (W), and oxyhemoglobin saturation
(SpO2) measured with pulse oximetry.d A change 4 in SpO2
between rest and exercising was considered desaturation.21 Sub-
jects were asked to rate dyspnea and leg fatigue at exercise
cessation by using the 0 to 10 Borg category ratio scale.22
Incremental shuttle walking test
The tests were conducted in an unobstructed and quiet 10-m
corridor. Two ISWTs were performed with at least 30 minutes of
rest in between. The walking speed was dictated by an audio
signal, which started at 0.5m/s, and progressively increased .17m/s
every minute according to the triple beep.13 The tests were ended
by the patient because of dyspnea and/or fatigue or by the phys-
iotherapist if the patient was unable to complete the shuttle at the
time of the audio signal for the second time. Heart rate, SpO2
measured by pulse oximetry, perception of effort22 for dyspnea,
and leg fatigue were assessed before and immediately after the test
was interrupted. The distance walked was expressed in meters and
predicted values.23 The test with the longest distance walked was
used for correlation with CPET and the number of steps recorded
by the pedometer.
Assessment of daily physical activity
Daily physical activity was assessed with an accelerometer.e The
patients received the accelerometer and were instructed to use it in
the right pocket on the anterior surface of their pants for 5
consecutive days during the weekdays and then to return to our
laboratory with the device. Patients were instructed not to change
their daily physical activity behavior on the days using the device.
They attached the accelerometer in the morning, used it
throughout the day, and removed it only to shower and sleep. For
894 A.A. de Camargo et al

analysis, the first and last days were discarded, and the daily
number of steps was the mean over 3 consecutive days because it
has been demonstrated that 3 days provides the best reliability in
comparison with other combinations of days in comparison with a
week of measurement.24 The main outcome from this assessment
was steps per day.
Statistical analysis
sex (these variables usually explain the variability of the distance
walked)23,25; and in the second model (block 2), forced vital
capacity (FVC) (percent predicted), MRC scale, and steps per
day were included (they contemplate different clinical aspects of
the patients, eg, lung function, dyspnea, and functional capacity,
respectively). The probability of a type I error was set at 5%
(P<.05). Statistical tests were performed with SPSS
version 14.0.f

The normality of the data was analyzed by the Kolmogorov- Results

Smirnov test. The MRC scale, steps per day, and Borg dyspnea
and fatigue scales are expressed as median (interquartile range),
and other variables are expressed as mean (95% confidence
interval [CI]). To analyze the reliability of the ISWT, 3 steps
were followed. First, a paired Student t test was used to compare
distance walked (m), heart rate (beats/min), percentage heart rate
predicted, SpO2%, and DSpO2% (difference in oxyhemoglobin
saturation between resting and peak of exercise) at the peak of
exercise, whereas a Wilcoxon rank-sum test was used to
compare the Borg dyspnea and fatigue scales. Second, intraclass
correlation coefficients and 95% CIs were calculated to verify
the reproducibility of these variables between the first and sec-
ond ISWTs. Finally, agreement between the 2 tests (first and
second ISWTs) was evaluated by the Bland-Altman analysis.
Comparisons between the farthest distance walked between
sexes were made with the unpaired Student t test. To answer the
second question of the study, the chi-square (Fisher exact) test
was used to evaluate the association between desaturation in the
best ISWT and CPET. For concurrent validity, the Pearson cor-
relation was used (distance walked vs VO2peak [oxygen uptake
at the peak of CPET], peak workload). This correlation was also
used to analyze the strength of association between distance
walked and steps per day. The Spearman correlation was per-
formed to correlate distance walked with the MRC scale scores.
To observe the determinants of distance walked in the ISWT
(third question of the study), a hierarchical multiple regression
analysis was used. In the first model (block 1) of hierarchical
regression, the following factors were included: age, BMI, and
The etiologies of bronchiectasis were idiopathic in 30 (40%)
patients, postinfectious in 18 (24%) patients, primary ciliary
dyskinesia in 9 (12%) patients, chronic aspiration in 5 (6.7%)
patients, bronchiolitis obliterans in 3 (4%) patients, Mounier-
Kuhn syndrome in 3 (4%) patients, common variable immuno-
deficiency in 2 (2.7%) patients, rheumatoid arthritis in 2 (2.7%)
patients, and chemotherapy, alpha-1 antitrypsin deficiency, and
Sjögren syndrome each having 1 (4%) patient. Pulmonary gas
exchange was not performed in 19 patients (5 men) during the
CPET because they needed oxygen supplementation. Then, the
concurrent validity of the distance walked with V_ O2 was con-
ducted with 56 patients but was tested in the total sample (75
patients) with peak load. The characteristics of the subjects are
summarized in table 1.
Most patients (nZ37) performed their best distance walked
during the second ISWT, 27 patients performed their best during
the first ISWT, and 11 patients walked the same distance during
both ISWTs. In both tests, the distance walked ranged from 190 to
940 m. No difference was observed in the variables between the 2
tests either at rest or at the peak of exercise (table 2). On average,
the distance walked increased by 4m (95% CI, 11 to 2m). The
distance walked was higher for men than women [values in
brackets] (532 m [176] vs 411 m [122], PZ.001). Both sexes
showed reduced distance walked in predicted values (47% [13]
and 55% [12], respectively; PZ.008).
In the Bland-Altman plot, the patients who walked the farthest
distance during the second test are represented by a negative mean

Table 1 Characteristics of the subjects

Variables NZ75 (26 male) Range
Age (y) 45.0 (40.0e47.0) 19.00e81.00
BMI (kg/m2) 25.0 (24.0e27.0) 16.00e35.00
FFMi (kg/m2) 17.0 (16.0e17.0) 13.00e21.00
FVC (L) 2.4 (2.2e2.6) 0.95e4.20
FVC (% predicted) 68.0 (63.0e72.0) 26.00e107.00
FEV1 (L) 1.5 (1.4e1.7) 0.36e2.74
FEV1 (% predicted) 53.0 (49.0e58.0) 16.00e98.00
FEV1/FVC 65.0 (61.0e68.0) 29.00e92.00
MRC* 2.0 (2.0e3.0) 1.00e5.00
No. of steps/d* 8753.0 (5158.0e12,632.0) 1382.00e27,808.00
Peak load (W) 77.0 (68.0e75.0) 7.00e178.00
Peak load (% predicted) 63.0 (58.0e68.0) 13.00e117.00
VO2peak (mL$kg1·min1)y 18.0 (16.0e19.0) 11.00e34.00
VO2peak (% predicted)y 62.0 (59.0e66.0) 23.00e90.00
NOTE. Values are expressed as mean (95% CI) or as otherwise noted.
Abbreviations: FEV1, forced expiratory volume in 1 second; FFMi, fat-free mass index.
* Values are median (interquartile range).
y
56 patients.

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Incremental shuttle walking test and bronchiectasis 895

Table 2 Data at the peak of the 2 ISWTs

Variables ISWT-1 ISWT-2 P ICC (95% CI)* Best ISWT
Distance (m) 441 (406 to 476) 445 (410 to 481) .20 .99 (.99e.995) 453 (415 to 489)
Heart rate (bpm) 136 (132 to 140) 137 (132 to 141) .50 .92 (.88e.950) 138 (134 to 143)
Heart rate (% predicted) 78 (75 to 80) 78 (76 to 80) .49 .90 (.85e.940) 79 (76 to 81)
SpO2 (%) 91 (90 to 93) 91 (90 to 93) .76 .91 (.85e.940) 91 (90 to 93)
DSpO2 (%) 4 (5 to 3) 4 (6 to 3) .63 .87 (.80e.920) 4 (5 to 3)
Borg dyspnea scale (points)y 4 (2 to 5) 3 (2 to 5) .55 .91 (.86e.940) 3 (2 to 5)
Borg fatigue scale (points)y 4 (1 to 5) 3 (2 to 5) .29 .91 (.86e.950) 3 (2 to 5)
NOTE. Values are expressed as mean (95% CI) or as otherwise noted. P values are listed for comparisons between ISWT-1 and ISWT-2.
Abbreviations: bpm, beats per minute; ICC, intraclass correlation; ISWT-1, first ISWT; ISWT-2, second ISWT; DSpO2, difference in Spo2 between resting
and peak of exercise.
* P<.001 for all.
y
Values are median (interquartile range).

difference (4.4m) (fig 1). The limits of agreement ranged from
57 to 48m.
Nineteen patients performed the tests with oxygen supple-
mentation, and the same amount was used during the 2 ISWTs and
CPET. Higher desaturation was observed during the ISWT (4%
[4]) than cycling (2% [3], PZ.001). Twenty-one percent of the
patients presented with desaturation on the ISWT but not during
CPET (PZ.01).
There were significant positive linear correlations (P<.001 for
all) between the distance walked in the ISWT and the workload,
VO2peak, and steps per day; there was a negative association with
the MRC scale (fig 2).
In the hierarchical multiple regression analysis, the results of
block 1 indicated that the variance (R2) accounted for with the first
3 independent variables (age, BMI, sex) equaled .397 (adjusted
R2Z.372), which was significantly different from zero
(FZ15.583, P<.001). In block 2, the other 3 independent vari-
ables were entered into the regression equation (FVC % predicted,
MRC scale, steps/d). The change in variance (DR2) accounted for
Fig 1 Bland-Altman plot of the between-test difference in the
distance walked on the ISWT. The solid horizontal line represents the
mean bias; dashed horizontal lines represent the lower and upper
limits of agreement. Abbreviations: ISWT-1, first ISWT; ISWT-2, sec-
ond ISWT.
was equal to .328, which was significantly different from zero
(FZ27.101, P<.001). The percent of variability in the dependent
variable that can be accounted for by all the predictors together is
70%. When the distance walked was expressed as percent pre-
dicted, the results of block 1 indicated that the variance (R2)
accounted for was .104 (adjusted R2Z.066, FZ2.745, PZ.049).
In block 2, the change in variance (DR2) accounted for was equal
to .496 (FZ28.069, P<.001). All predictors explained 60% of the
variation in distance walked (% predicted).
Discussion
The major findings of this study were as follows: the ISWT
showed to be reproducible when performed on the same day, a
valid test for quantifying exercise capacity, and more sensitive
than CPET for detecting oxygen desaturation. Additionally, the
determinants of the distance walked on the ISWT in patients
with non-CF bronchiectasis are related to age, body composi-
tion, pulmonary function, dyspnea, and physical activity in
daily life.
In our study, patients increased the distance walked by an
average of 4m, which represented a <1% improvement in relation
with the first test. In the Bland-Altman analysis, the mean bias was
close to zero (4.4m). This was much lower than that observed
between the first and second trials of the ISWT (31m) in the study
describing the ISWT for the first time in patients with COPD.13
However, it was higher compared with patients with CF (0m),14
even though the 95% CIs of the differences were similar among
the studies (57 to 48m, 49 to 13m, 40 to 40m, respectively).
Additionally, the test-retest reliability of the distance walked (see
table 2) was similar to that recently reported involving COPD pa-
tients >70 years of age (.93; 95% CI, .89e.96).26 Then, a small
learning effect for the ISWT occurred in our patients. The smaller
variability in the ISWT can be attributed to an externally paced
characteristic that overcomes the motivation limitations present in
the 6-minute walk test (6MWT) whose learning effect varies from
2.6% to 22%.27 Taking into consideration that 51% of our patients
had already performed better than, or the same as, the first ISWT (27
and 11 patients, respectively), we believe that the best performance
can be achieved when 2 tests are undertaken on the same day in
patients with non-CF bronchiectasis.
Although the minimum important difference has not yet been
established for patients with non-CF bronchiectasis, we suggest
using the lower limit of agreement from the Bland-Altman

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896
Fig 2 Correlations between the distance walked on the ISWT: peak load (A), steps per day (B), V_ O2 (C), and MRC scale score (D). Abbreviation:
DW, distance walked. *P<.001 for all.
analysis (57m) because the variability of the ISWT and a differ-
ence more than this could be considered as the minimal detectable
change after interventions.
We tested the criterion validity of the ISWT as a measure of
exercise capacity by contrasting the distance walked with the main
outcomes from CPET (peak load and VO2peak). The literature is
replete with studies assessing correlations among the 6MWT,
ISWT, and CPET; generally, these studies are performed in pa-
tients with COPD. The present study is the first, to our knowledge,
to verify the strength of association between mean outcomes from
the ISWT and CPET in patients with non-CF bronchiectasis. The
higher values for the distance walked represents a better perfor-
mance on functional capacity, which in turn is related to a better
performance on CPET (rZ.82) (see fig 2). The strength of asso-
ciation between the distance walked and VO2peak in the present
study (rZ.72) was similar to that found in patients with COPD
when the distance walked was correlated with VO2peak obtained
from a treadmill test (rZ.88) and with the V_ O2 measured at the
peak of the ISWT (rZ.81).28 This result was expected because
the higher the distance walked on an incremental walking test, the
greater the aerobic capacity. In adults with CF, the relation be-
tween the distance walked and the directly measured VO2peak
during a treadmill test was stronger (rZ.95).29 However, those
A.A. de Camargo et al
patients were younger (25
7y), most of them (14 out of 20 pa-
tients) walked more than 800m on the ISWT, and they had a high
VO2peak (32.9
10.4mL$kg1 ·min1, 74% of predicted). Also,
the treadmill protocol chosen by Bradley et al29 for comparison
with the ISWT was very intense (12% inclination at a speed of 4.8
to 6.4km/h), providing a close correlation between the distance
walked and V_ O2.
The objective quantification of physical activity has been
increasingly incorporated into assessing patients with cardiopul-
monary diseases. However, daily physical activity has never been
assessed in patients with non-CF bronchiectasis and contrasted
with a field-based test. In clinical practice, steps per day are one of
the most commonly measured outcomes used for determining a
patient’s level of physical activity in daily life. For this purpose,
we used a recently validated accelerometer in patients with
COPD.30 The strength of association found between the steps per
day and distance walked on the ISWT is consistent with that
observed between the 6MWT and the walking time measured with
a triaxial accelerometer in patients with COPD.31 Similarly, in
patients with non-CF bronchiectasis, higher levels of daily phys-
ical activity are associated with better functional capacity, as
represented by the greater distance walked during the ISWT. On
the other hand, patients with non-CF bronchiectasis may
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Incremental shuttle walking test and bronchiectasis
experience disabling dyspnea that could compromise their ability
to perform daily activities. This assumption is supported by the
negative correlation found between the MRC scale and ISWT.
This is the first study to analyze the determinants of the ISWT in
patients with non-CF bronchiectasis. The finding that age, BMI, and
sex (block 1 of the hierarchical regression analysis) were de-
terminants of the ISWT is not surprising because they are commonly
part of the prediction equations for the distance walked on this
test.23,32 However, although these variables were statistically sig-
nificant as predictors of distance walked, they did not explain the
entire variation in distance walked (R2Z.372, P<.001). Adding
markers of pulmonary function (FVC), dyspnea (MRC), and func-
tional capacity (steps/d), the percentage of variability accounted for
went up from 37.2% to 70%. It means that these latter variables have
an effect beyond the effects of demographics and anthropometric
data. For distance walked expressed as percent predicted, the first
block, although statistically significant, contributed in a quite low
proportion (R2Z.104, PZ.049) to explain the distance walked,
probably because the distance walked in the percent of predicted
values is already corrected for age, BMI, and sex.23 The second
block predicted the distance walked (% predicted) above and
beyond the effects of the first block, that is, FVC, dyspnea, and steps
per day are important predictors of the distance walked, even when it
is expressed in predicted values.
In a previous study, the FVC (% predicted) was positively
correlated with the distance in the 6MWT, but this value did not
remain in the multiple regression model, possibly because the pa-
tients presented the pulmonary function relatively preserved.33 In
fact, the FVC (% predicted: 89
20) and forced expiratory volume in
1 second (% predicted: 74
23) were higher than those attained by
our patients (see table 2). In patients with CF, a disease very similar
to bronchiectasis, FVC has been one of the independent variables
that explained the distance walked in the 6MWT.34 The breath-
lessness during daily activities evaluated by the MRC scale was also
a predictor of the ISWT. Dyspnea is one of the most prevalent
symptoms in patients with non-CF bronchiectasis,1,4,5 and it has
been related to reduced exercise capacity.35 Therefore, we can infer
that dyspnea during daily activities may lead to a sedentary lifestyle
and a progressive deterioration in the functional capacity in these
patients. This assumption is based on the reduced functional
capacity presented by our patients because they have walked, on
average, 50% of the predicted distance and on the correlation
between distance walked and the MRC scale (see fig 2D). Previous
studies also show that the higher the MRC scale score, the lower the
scores for the activity domain in the St George’s Respiratory
Questionnaire10 and the lower the maximum work rate achieved in
incremental CPET.35 In this line of reasoning, it was not surprising
that steps per day were one of the predictors of the distance walked
because the 6MWT is considered representative of patient’s daily
life physical activities.31
The ISWT was more sensitive than cycling in detecting oxygen
desaturation. This phenomenon has already been described in
patients with COPD during walking compared with
cycling.7,8,36,37 The magnitude of the difference in desaturation
between walking and cycling in COPD patients is greater
(z7%)7,8 than that observed in our study (2%), possibly because
the lung diffusing capacity for carbon monoxide in patients with
bronchiectasis has been reported as normative, except in the more
severe disease state.3 However, the percentage of our patients who
demonstrated desaturation only during the ISWT is equivalent to
that shown by patients with COPD (21% and 28%, respectively).7
Although we have not measured the pulmonary gas exchange
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897
parameters during the ISWT, 2 main mechanisms should be
emphasized to explain the differences in desaturation compared
with cycling: amount of muscle mass and ventilatory demand,
both superior during walking, determined a lower mixed venous
oxygen saturation in the ISWT.
Implications of the study
Although the ISWT has been used in patients with non-CF bron-
chiectasis, the reproducibility of the test has never been analyzed in
this population. Based on our data, there is a learning effect, but the
magnitude is small when compared with that described for the
6MWT in patients with COPD. Hence, in clinical practice, as rec-
ommended for other chronic respiratory diseases, 2 tests performed
on the same day appear to be sufficient to elicit the best performance
in patients with non-CF bronchiectasis. However, we suggest that a
third test be performed when the difference between the first 2 tests
exceeds 57m. Additionally, future studies comparing the perfor-
mance in >2 tests should be performed to verify the veracity of this
suggestion. Two tests performed on the same day are also sufficient
to ensure the best performance on the ISWT. However, we suggest
that a third test be performed when the difference between the first 2
tests exceeds 57m. Further studies should be done to define a min-
imum clinically important improvement for the ISWT in patients
with non-CF bronchiectasis undergoing pulmonary rehabilitation.
The strong linear association between the distance walked with
variables from the CPET and daily physical activity confirm that the
ISWT is representative of exercise capacity and functional status in
patients with non-CF bronchiectasis. Because a subgroup of patients
presented with desaturation only during the ISWT, the ISWT should
be used as a complement to CPET to obtain a complete evaluation of
the limiting factors of exercise.
Study limitations
Our patients were recruited from a convenience sample, which
could compromise the external validity of our results. Although
21% of all patients of our clinic have been evaluated, in com-
parison with other studies,1-5,9-11,13 our patients presented MRC
scale scores for dyspnea (2 [2e3]) similar to King2,3 (1.9
1.1
and 2.3
0.9), O’Leary9 (2.1
1), and colleagues and similar
equivalent distance walked on the ISWT (453
153m) with
O’Leary9 (473
153m). In terms of pulmonary function and
functional capacity, the range of forced expiratory volume in 1
second and distance walked is quite huge (see table 1), which
leads us to assume that our studied group is representative of
those patients who are frequently encountered in the outpatient
clinics because they are composed of a wide range of respira-
tory and functional impairment. We did not measure the pul-
monary gas exchange during the ISWT. Future studies
correlating the distance walked with VO2peak measured on the
ISWT should substantiate this test as an objective measure of
the cardiopulmonary capacity in non-CF bronchiectasis pa-
tients. In a recent validation study of the Power Walker accel-
erometer, patients wore it attached to the waist, in the
hemiclavicular line30; because this validation study was pub-
lished after our study had already begun, we followed the
recommendations of the manufacturer. Therefore, we cannot
affirm that the accelerometer presents the same performance
when it is worn in a pocket. We used only steps per day as an
outcome of physical activity in daily life, and future studies are
898
needed to evaluate the duration, intensity, and amount of daily
physical activity in these patients.
Conclusions
The ISWT is reproducible, represents functional capacity, and
induces greater desaturation in patients with non-CF bronchiec-
tasis in comparison with CPET. Age, body composition, pulmo-
nary function, dyspnea, and physical activity in daily life are
determinants of the distance walked on the ISWT.
Suppliers
a. Tanita BC-554; Tanita Corporation of America, 2625 S
Clearbrook Dr, Arlington Hts, IL 60005.
b. Corival; Lode, Zernikepark 16, 9747 AN Groningen, The
Netherlands.
c. CPX Ultima, Medical Graphics Corp, 350 Oak Grove Pkwy, St
Paul, MN 55127.
d. Biox 3740; Ohmeda, 2425 55th St, Ste 111, Boulder, CO
80301.
e. Yamax Power Walker, model PW-610; Yamax Corp, 1-5-7,
Chuo-cho, Meguro-ku, Tokyo 152-8691 Japan.
f. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
Keywords
Bronchiectasis; Exercise test; Exercise tolerance; Rehabilitation
Corresponding author
Simone Dal Corso, PT, PhD, Rua Vergueiro, 235/249 e 2o sub-
solo, 01504-001, Sao Paulo, Brazil. E-mail address: simonedc@
uninove.br.
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