Outcome Measures

Home ▶ Members ▶ Assemblies and Sections ▶ Assemblies ▶ Pulmonary Rehabilitation ▶ Outcome Measures ▶ Field Walking Tests


Field Walking Tests

The data presented is from a wider systematic review of the minimum important difference of field walk tests further details can be found here:  https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=185565

Authors: E. Daynes 1,2, R.E. Barker 3,4, A. Jones 2, J.A. Walsh 3, C.M. Nolan 3,4, N.J. Greening 1,2, S. Singh 1,2, L. Houchen-Wolloff 1,2, R.A. Evans 1,2

  1. Centre of Exercise and Rehabilitation Sciences, National Institute of Health Research Biomedical Research Centre – Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, UK.

  2. Department of Respiratory Sciences, University of Leicester, Leicester, UK.

  3. Harefield Respiratory Research Group, Royal Brompton and Harefield NHS Foundation Trust, UK

  4. National Heart and Lung Institute, Imperial College London, UK
    Summarised for the ATS PR Assembly website by L. Houchen-Wolloff 1,2, T Harvey-Dunstan 5 and R.A. Evans 1,2

  5. Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, The University of Nottingham, Nottingham, UK.

 

Introduction: Field walking tests are commonly used to assess functional exercise capacity in people with Chronic Respiratory Diseases (CRD). The aims of these tests are to assess the degree of functional limitation, prescribe interventions and measure the outcome of an intervention, such as, pulmonary rehabilitation. In this section, the commonly applied field walking tests in pulmonary rehabilitation are reported.

 The following outcome measures are described:

 1. Six-Minute Walk Test

 2. Incremental Shuttle Walk Test

 3. Endurance Shuttle Walk Test

 We thank the following who collated this material: Dr Ana Machado ([NOVA University of Lisbon, Lisbon, Portugal), Dr Linzy Houchen-Wolloff (University Hospitals of Leicester NHS Trust, Leicester, UK), Dr Suzanne Lareau (University of Colorado, Denver, US) and Professor Clarice Tang (Victoria University, Melbourne, Australia).  

Studies evaluating a minimum important difference in walking distance to Pulmonary Rehabilitation in chronic respiratory disease

We have included 20 studies conducted in a range of chronic respiratory diseases (CRD’s) with three exercise tests ISWT (n=4), 6MWT (n=12) and ESWT (n=4).  The range of CRD’s identified included COPD (n=11; ISWT=2, 6MWT=5, ESWT=4), Non-cystic fibrosis (NCF) Bronchiectasis (n=2; ISWT=1, 6MWT=1), Interstitial Pulmonary Fibrosis (n=5; ISWT=1, 6MWT=4), Lung cancer (n=1 for the 6MWT), Respiratory Failure (n=1 for the 6MWT).  Findings for each MID can be seen below and in Table 1.  All but one study (10) applied a combined methodological approach employing both distribution and anchor based measures.

ISWT

For patients with COPD (n=372 to 613) an MID of 35-47.5m is suggested by two studies (10, 11). For patients with Non-Cystic Fibrosis Bronchiectasis (n=37) a similar MID of 35m was suggested by one single study (12), and 31-46m has been proposed for patients with Interstitial Pulmonary Fibrosis (n=50 and 72) in a single study (13).

6MWT

For patients with COPD/ severe COPD (n=75 to n=2112), an MID of 25-71m is suggested from five studies when including any proposed ranges (14-18).  When excluding any ranges (using absolute values), the suggested MID reduces to 25-54m.

A single study in patients with NCF-Bronchiectasis (n=37), identified an MCID of 25m (no ranges reported: 12).  As similar range has been proposed by four studies in patients with Interstitial Pulmonary Fibrosis (n=48 to 822) of 24-37m (19-22).

Only one study reported the MID as a marker for clinical deterioration for patients with lung cancer (n=56).  A deterioration of between 22-42m was considered clinically important (23).

A further study has reported an MID of 20-30m for patients diagnosed with acute respiratory failure [ARF (n=641)].  Underlying causes of ARF were not detailed in this paper (24).

ESWT

COPD was the only CRD reporting an MID for the ESWT (n=55 to n=531).  Taking the four studies collectively, an MID of 144-279 seconds for time to limitation is proposed (25-28).  This included stated ranges for change.  One study was unable to accurately estimate an MID due to weak correlations between the anchors and the measured change in ESWT performance (27).

 Summary: We have included 20 studies of MID for common exercise tests in CRD.  All but one study (10) applied a combined methodological approach employing both distribution and anchor based measures.

 

6-Minute Walk Test

  Description
Name of Test 6-Minute Walk Test
Abbreviation 6MWT
Description A commonly-used self-paced test of walking capacity.
Developer Butland1
E-mail Not applicable
Cost Free
License required No
Administration Standardized instructions and encouragement must be given during the test. (ATS/ ERS Technical Standard 2014)2
Time to complete 6 minutes
Normal values Healthy adults (>30 years) 538.7-643 m3 Reference equations available4,5
Test-retest/ reproducibility ICCs: COPD=0.88-0.99 6
IPF= 0.72-0.836
CF= 0.93-0.946
 Asthma= 0.917
non-CF bronchiectasis= 0.958
Validity V’O2peak on CPET:
COPD r=0.4-0.86
Asthma r=0.617
CF r=0.769
ILD r= -0.3510 with UCSD SOBQ
Responsiveness to PR Responsive to PR in stable COPD (mean difference= 44 m, 95%CI 33-55 m)11
Exacerbation of COPD (mean difference= 62 m, 95%CI 38-86 m)12
ILD (mean difference= 40m, 95%CI 33-47 m)13
non-CF bronchiectasis (mean difference= 32 m, 95%CI 21-45 m)8
MID COPD= 25-33 m6
non-CF bronchiectasis=25 m14
IPF= 21.7-45 m15
Lung cancer= 22-42 m16
References
  1. Butland RJ et al. BMJ 1982; 284:1607-1608.
  2. Holland, AE et al. Eur Respir J 2014;44:1428-46.
  3. Oliveira, MJ et al. Pulmonol 2019;25:83-89.
  4. Troosters, T et al. Eur Respir J 1999;14:270-274.
  5. Marques, A et al. Physiother 2020;109:54-64.
  6. Singh, SJ et al. Eur Respir J 2014;44:1447–1478.
  7. Meys, R et al. Pulmonol 2023;29:486-494.
  8. Lee, AL et al. JCRP 2015;35:439-445.
  9. Gulmans, VA et al. Pediatr Pulmonol 1996: 85-89.
  10. Nthan, SD et al. Respir Med 2015;109:914-922.
  11. McCarthy, B et al. Cochrane 2015;2:CD003793.
  12. Puhan, MA et al. Cochrane 2016;12:CD005305.
  13. Dowman, L et al. Cochrane 2021;2:CD006322.
  14. Lee, AL et al. Respir Med 2014;108:1303-1309.
  15. Kang, M et al. Breathe 2021;17:200345.
  16. Granger, CL et al. Chron Respir Dis 2015;12:146-154.
Date of most recent changes November 2024

 

Incremental Shuttle Walk Test

  Description
Name of Test Incremental Shuttle Walk Test
Abbreviation ISWT
Description A symptom-limited, externally paced exercise test, conducted along a 10-meter course.
Developer Singh SJ, Morgan MDL, Scott S, et al.1
E-mail leslie.shortt@uhl-tr.nhs.uk
Cost £35 for CD or USB.
License required Yes. Copyright © 2002, University Hospitals of Leicester NHS Trust http://www.leicestershospitals.nhs.uk/aboutus/departments-services/pulmonary-rehabilitation/for-health-professionals/incremental-shuttle-walk/
Administration Best of two walks, recorded to the nearest 10 m completed. (ATS/ ERS Technical Standard 2014)2
Time to complete Up to 12 minutes
Normal values Presented as mean / lower limit of normal:3
40-49 years= 824m / 765 m
50-59= 788m / 730 m
60-69= 699m / 649 m
≥70=, 633m / 562 m
Reference equation available4
Test-retest/ reproducibility ICCs: COPD= 0.895
ILD= 0.916
non-CF bronchiectasis= 0.967
Asthma= 0.858
Validity r=0.75-0.88 V’O2peak on CPET (cardiopulmonary exercise test) in COPD9
r=0.79 with V’O2peak on CPET in ILD6
r=0.76 with 6MWT in ILD6
r=0.82 with 6MWT in COPD9 and non-CF bronchiectasis7
r=0.81 with 6MWT in IPF10
Responsiveness to PR Mean differences of ISWT pre-post PR range between -14 m to 96 m 7,9, 10, 11
MID COPD=35-36.1 m12
non-CF Bronchiectasis=35 m13, 45-70 m14
IPF=31-46 m10
ILD=40 m15
References
  1. Singh, SJ et al. Thorax 1992;47:1019-1024.
  2. Holland, AE et al. Eur Respir J 2014;44:1428-46.
  3. Harrison, SL et al. JCRP 2013;33:309-313.
  4. Marques, A et al. Physiotherapy 2020;109:54-64
  5. Eiser, N et al. Respir Med 2003;97:407–414.
  6. Singh, S et al. JCRP 2018;38:425-429.
  7. Lee, AL et al. JCRP 2015; 35:439-445.
  8. Labadessa, IG et al. Respir Care 2019;64:55-62.
  9. Singh, SJ et al. Eur Respir J 2014; 44:1447-1478.
  10. Nolan, CM et al. Thorax 2018;73:680-682.
  11. Puhan, MA et al. Cochrane 2016;12:CD005305.
  12. Evans, RA & Singh, SJ. Thorax 2019;74:994-995.
  13. Lee, AL et al. Respir Med. 2014;108:1303-9.
  14. Walsh, JA et al. Ann Am Thorac Soc. 2020;17:375-378.
  15. Houchen-Wolloff, L et al. Am J Respir Crit Care Med 2023;207:A5954.
Date of most recent changes November 2024

 

 Endurance Shuttle Walk Test

  Description
Name of Test Endurance Shuttle Walk Test
Abbreviation ESWT
Description A symptom-limited externally-paced exercise test, conducted along a 10-meter course. Walking speed is kept constant and ceases when the participant can no longer continue.
Developer Revill SM, Morgan MDL, Singh SJ, Williams J, Hardman AE.1
E-mail pulmonaryrehab@uhl-tr.nhs.uk
Cost £69 for CD or USB.
License required Yes. Copyright © 2002, University Hospitals of Leicester NHS Trust https://www.leicestershospitals.nhs.uk/aboutus/departments-services/pulmonary-rehabilitation/for-health-professionals/swt-mp3format/
Administration ISWT is conducted prior to ESWT to determine walking speed. (ATS/ ERS Technical Standard 2014)2
Time to complete Up to 20 minutes
Test-retest/ reproducibility ICCs=0.96 for endurance time, 0.95 for endurance distance in COPD3
Validity Not available
Responsiveness to PR Improvement in time following PR (mean difference= 303 sec, 95%CI 176-431 sec)4
MID COPD=154-164 m;5 174-279 sec6,7
ILD=170 sec8
References
  1. Revill, SM et al. Thorax 1999;54:213-222.
  2. Holland, AE et al. Eur Respir J 2014;44:1428-46.
  3. Borel, B et al. Eur Respir J 2014;44:1166-1176.
  4. Amber, S et al. Oman Med J 2023;38:e455.
  5. Altenburg, WA et al. Respir Res 2015;16:27.
  6. Zatloukal, J et al. Chron Respir Dis 2019;16.
  7. Hill, K et al. Respir Med 2019;18-22.
  8. Houchen-Wolloff, L et al. Am J Respir Crit Care Med 2023;207:A5954.
Date of most recent changes November 2024

 


 Reference List

  1. Butland RJ, Pang J, Gross ER, et al. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed) 1982; 284(6329): 1607–1608.
  2. Singh SJ, Morgan MD, Scott S, et al. Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax 1992; 47(12): 1019–1024.
  3. Revill SM, Morgan MD, Singh SJ, Williams J, Hardman AE. The endurance shuttle walk: a new field test for the assessment of endurance capacity in chronic obstructive pulmonary disease. Thorax 1999 Mar;54(3):213-22.
  4. Schunemann HJ and Guyatt GH. Commentary – goodbye M(C)ID! Hello MID, where do you come from? Health Serv Res 2005; 40(2): 593–597.
  5. Copay AG, Subach BR, Glassman SD, Polly DW, Jr., Schuler TC. Understanding the minimum clinically important difference: a review of concepts and methods. Spine J 2007 Sep;7(5):541-6.
  6. Brozek JL, Guyatt GH, Schunemann HJ. How a well-grounded minimal important difference can enhance transparency of labelling claims and improve interpretation of a patient reported outcome measure. Health Qual Life Outcomes 2006 Sep 27;4:69.
  7. Houchen-Wolloff L and Evans RA. Unravelling the mystery of the ‘Minimum Important Difference’ using practical outcome measures in chronic respiratory disease. Chronic Respiratory Disease. January 2019. 16:1479973118816491. doi: 10.1177/1479973118816491.
  8. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097.
  9. Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures. Qual Life Res 2018 May;27(5):1171-9.
  10. Singh SJ, Jones PW, Evans R, Morgan MD. Minimum clinically important improvement for the incremental shuttle walking test. Thorax 2008 Sep;63(9):775-7.
  11. Evans RA, Singh SJ. Minimum important difference of the incremental shuttle walk test distance in patients with COPD. Thorax. 2019 Oct;74(10):994-995.
  12. Lee AL, Hill CJ, Cecins N, Jenkins S, McDonald CF, Burge AT, et al. Minimal important difference in field walking tests in non-cystic fibrosis bronchiectasis following exercise training. Respir Med 2014 Sep;108(9):1303-9.
  13. Nolan CM, Delogu V, Maddocks M, Patel S, Barker RE, Jones SE, Kon SSC, Maher TM, Cullinan P, Man WD. Validity, responsiveness and minimum clinically important difference of the incremental shuttle walk in idiopathic pulmonary fibrosis: a prospective study. Thorax. 2017 Sep 7:thoraxjnl-2017-210589. doi: 10.1136/thoraxjnl-2017-210589.
  14. Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010 Feb;91(2):221-5.
  15. Polkey MI, Spruit MA, Edwards LD, Watkins ML, Pinto-Plata V, Vestbo J, et al. Six-minute-walk test in chronic obstructive pulmonary disease: minimal clinically important difference for death or hospitalization. Am J Respir Crit Care Med 2013 Feb 15;187(4):382-6.
  16. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997 Apr;155(4):1278-82.
  17. Puhan MA, Mador MJ, Held U, Goldstein R, Guyatt GH, Schünemann HJ. Interpretation of treatment changes in 6-minute walk distance in patients with COPD. Eur Respir J. 2008 Sep;32(3):637-43.
  18. Puhan MA, Chandra D, Mosenifar Z, Ries A, Make B, Hansel NN, et al. The minimal important difference of exercise tests in severe COPD. Eur Respir J 2011 Apr;37(4):784-90.
  19. Swigris JJ, Wamboldt FS, Behr J, du Bois RM, King TE, Raghu G, et al. The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference. Thorax 2010 Feb;65(2):173-7.
  20. Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Small changes in six-minute walk distance are important in diffuse parenchymal lung disease. Respir Med 2009 Oct;103(10):1430-5.
  21. du Bois RM, Weycker D, Albera C, Bradford WZ, Costabel U, Kartashov A, et al. Six-minute-walk test in idiopathic pulmonary fibrosis: test validation and minimal clinically important difference. Am J Respir Crit Care Med 2011 May 1;183(9):1231-7.
  22. Nathan SD, du Bois RM, Albera C, Bradford WZ, Costabel U, Kartashov A, Noble PW, Sahn SA, Valeyre D, Weycker D, King TE Jr. Validation of test performance characteristics and minimal clinically important difference of the 6-minute walk test in patients with idiopathic pulmonary fibrosis. Respir Med. 2015 Jul;109(7):914-22.
  23. Granger CL, Holland AE, Gordon IR, Denehy L. Minimal important difference of the 6-minute walk distance in lung cancer. Chron Respir Dis. 2015 May;12(2):146-54.
  24. Chan KS, Pfoh ER, Denehy L, Elliott D, Holland AE, Dinglas VD, Needham DM. Construct validity and minimal important difference of 6-minute walk distance in survivors of acute respiratory failure. Chest. 2015 May;147(5):1316-1326.
  25. Altenburg WA, Duiverman ML, Ten Hacken NH, Kerstjens HA, de Greef MH, Wijkstra PJ, et al. Changes in the endurance shuttle walk test in COPD patients with chronic respiratory failure after pulmonary rehabilitation: the minimal important difference obtained with anchor- and distribution-based method. Respir Res 2015 Feb 19;16:27.
  26. Hill K, Ng C, Wootton SL, McKeough ZJ, Eastwood PR, Hillman DR, Jenkins C, Spencer L, Jenkins SC, Cecins NM, Alison JA. The minimal detectable difference for endurance shuttle walk test performance in people with COPD on completion of a program of high-intensity ground-based walking. Respir Med. 2019 Jan;146:18-22. doi: 10.1016/j.rmed.2018.11.013.
  27. Pepin V, Laviolette L, Brouillard C, Sewell L, Singh SJ, Revill SM, et al. Significance of changes in endurance shuttle walking performance. Thorax 2011 Feb;66(2):115-20.
  28. Zatloukal J, Ward S, Houchen-Wolloff L, Harvey-Dunstan T, Singh S. The minimal important difference for the endurance shuttle walk test in individuals with chronic obstructive pulmonary disease following a course of pulmonary rehabilitation. Chronic Respiratory Disease. January 2019. doi:10.1177/1479973119853828