Clinical Investigations
Received: July 19, 2002
Respiration 2003;70:579–584
DOI: 10.1159/000075202
Shuttle Walking Test and 6-Minute Walking
Test Induce a Similar Cardiorespiratory
Performance in Patients Recovering from an
Acute Exacerbation of Chronic Obstructive
Pulmonary Disease
B. Vagaggini M. Taccola S. Severino M. Marcello S. Antonelli S. Brogi
C. De Simone A. Giardina P.L. Paggiaro
Cardio-Thoracic Department, Pneumology Section, University of Pisa, Pisa, Italy
Key Words
Exercise tolerance W Walking test W Pulmonary
rehabilitation W Chronic obstructive pulmonary disease
Abstract
Background: The incremental shuttle walking test (SWT)
has recently been proposed as a more valid and repro-
ducible alternative to the conventional 6-min walking
test (6MWT) in the evaluation of exercise tolerance in
patients with chronic obstructive pulmonary disease
(COPD). Objective: To compare the cardiorespiratory
performance obtained during two sessions of SWT with
that obtained during two sessions of 6MWT. Methods:
We examined 18 patients (forced expiratory volume in
1 s: 48 B 14%) recovering from an acute exacerbation of
COPD that had required hospitalization. In the same
afternoon, each patient performed two SWT and two
6MWT, with an interval of at least 30 min between each
test; the sequence of the tests was randomized. Results:
Mean walking distance was greater in the second SWT
test than in the first SWT. The changes from baseline in
systolic blood pressure, heart rate, respiratory rate, oxy-
gen saturation and dyspnea Borg index at the end of the
© 2003 S. Karger AG, Basel
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E-Mail karger@karger.ch Accessible online at:
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Accepted after revision: May 12, 2003
test were similar between the two 6MWT and the two
SWT. There was a highly significant correlation between
walking distances measured during SWT and during
6MWT (Ú: 0.85, p ! 0.0005). Neither SWT nor 6MWT cor-
related with functional data of COPD. Conclusions: SWT,
though being considered to be closer to a submaximal
exercise test than 6MWT, does not induce a greater car-
diorespiratory performance than 6MWT in patients re-
covering from acute exacerbation of COPD.
Copyright © 2003 S. Karger AG, Basel
Introduction
Exercise limitation is a prominent complaint in pa-
tients with chronic obstructive pulmonary disease
(COPD). However, the correlation between exercise ca-
pacity and disease severity, in terms of lung function and
gas exchange impairment, is generally poor [1]. The
reduction in exercise tolerance is due to different factors:
abnormal lung mechanics (e.g. airflow limitation or dy-
namic hyperinflation), inefficient pulmonary gas ex-
change, peripheral muscle weakness [2], abnormal oxygen
transport and energy production in the exercising muscle
Dr.sa Barbara Vagaggini
Dipartimento Cardiotoracico, Ospedale Cisanello
Via Paradisa, 2
IT–56100 Pisa (Italy)
Tel. +39 050 995366, Fax +39 050 580124, E-Mail ppaggiaro@qubisoft.it
[3]. It is widely known that pulmonary rehabilitation can
improve exercise tolerance and consequently the quality
of life and daily living [4, 5].
The 6-min walking test (6MWT) is frequently used to
evaluate the functional status as well as the effects of phar-
macologic therapy and rehabilitation programs in COPD
patients [4, 6]. 6MWT is a self-paced test, and the degree
of the therapist encouragement can be crucial in setting
walking speed. The test is reliable, safe and inexpensive
[7], but it is not considered a submaximal exercise test.
More recently, an incremental shuttle walking test (SWT)
has been developed [8]. It is an externally paced test, less
influenced by the therapist encouragement, and it has
been proposed as a more reproducible test to evaluate
exercise tolerance. Studies comparing the performance
obtained during SWT with that obtained during 6MWT
had shown a moderate correlation between 6MWT and
SWT, with a higher heart rate observed at the end of SWT
[8]. Another study compared SWT performance with that
obtained by the conventional treadmill test, showing a
highly significant correlation between the VO2max value
obtained during the treadmill test and that obtained dur-
ing SWT [9]. Thus, SWT is considered to be closer to a
submaximal exercise test than 6MWT.
The aim of our study was to compare the cardiorespi-
ratory performance during 6MWT and SWT in a group of
COPD patients examined before hospital discharge after
acute exacerbation of COPD. Our hypothesis was that
SWT, being an incremental submaximal test, might in-
duce a greater stress on the cardiorespiratory system than
6MWT. In order to verify this hypothesis, 18 COPD
patients underwent two 6MWT and two SWT, and some
cardiorespiratory parameters were measured before and
after each test.
Patients and Methods
We examined 18 inpatients (15 males and 3 females, mean age 67
B 8.2 years), with moderate-to-severe COPD (forced expiratory vol-
ume in 1 s, FEV1: 48 B 14%). Table 1 shows the demographic and
functional findings of the patients. All of them were in the recovery
phase of an exacerbation of COPD that had required hospitalization.
At the time of the study, they were treated with bronchodilators and/
or inhaled corticosteroids, and were examined at least 14 days after
the beginning of the exacerbation. Pulmonary function tests and
blood gas analysis were performed the day before the study proto-
col.
Patients had never before performed an 6MWT or SWT. After a
training test, patients performed two 6MWT and two SWT during a
1-day session, in a randomized order (6MWT1-SWT1-6MWT2-
SWT2: 9 patients; SWT1-6MWT1-SWT2-6MWT2: 9 patients). The
tests were performed at intervals of 30 min to enable complete recov-
580 Respiration 2003;70:579–584
Table 1. Demographic and functional char-
acteristics of 18 COPD patients
Patients 18
Age, years 67B8.2
Males/females 15/3
FEV1, % predicted 48B14
FVC, % predicted 74.4B16.2
TLC, % predicted 112.4B26.3
FRC, % predicted 128.0B35.1
PaO2, mm Hg 74.8B13.0
PaCO2, mm Hg 41.2B5.5
SatO2, % 93.7B2.6
FVC = Forced vital capacity; TLC = total
lung capacity; FRC = functional residual ca-
pacity.
ery of dyspnea (Borg index: value of the previous test B1). Oxygen
saturation and heart rate were monitored throughout the test by a
pulse oxymeter applied to a fingertip. Before and within 60 s after the
end of both 6MWT and SWT, heart rate, blood pressure, respiratory
rate, oxygen saturation and dyspnea Borg index were measured by
the same therapist.
Six-Min Walking Test. The 6MWT was performed according to
the recommended method [10]. The therapist sat half way in a 38-
meter hospital corridor in a visible position, issuing standardized
instructions and encouragement every 30 s during the test. Patients
were instructed to walk at maximum speed for 6 min; the start and
the end points of the course were delineated to demonstrate the
patients where to turn around and where to walk back; the patients
were allowed to stop anytime and anywhere until they had rested
enough to start walking again. Patients stopped the test either when
they experienced severe dyspnea or at the end of the 6-min interval.
Shuttle Walking Test. The SWT was performed according to a
previously reported method [8]. In summary, the patient had to walk
up and down a 10-m course delineated by two cones set 0.5 m from
either end. The speed at which the patient walked was dictated by an
audiosignal played on a tape cassette. Every minute the speed of
walking was increased by a small increment. The only verbal contact
with the therapist was the advice given each minute to increase the
walking speed slightly. The test was terminated either: (a) by the
patient, when he or she was too breathless to maintain the required
speed; (b) the therapist, if the patient failed to complete a shuttle in
the time allowed (i.e. when he was farther than 0.5 m from the cone at
the time when the beep sounded), or (c) attainment of 85% of the
predicted maximal heart rate derived from the formula [210 – (0.65
! age)].
Statistical Analysis. All indices are expressed as means B SD.
Data comparison among different tests was performed by means of
ANOVA, while data comparison between baseline and the end of
exercise was performed by means of the paired t test. Changes from
baseline were computed for each test and compared by means of
ANOVA. The relationship between meters of 6MWT2 and SWT2
was calculated by the Spearman rank correlation coefficient. A p val-
ue ! 0.05 was considered significant.
Vagaggini/Taccola/Severino/Marcello/
Antonelli/Brogi/De Simone/Giardina/
Paggiaro
Table 2. Cardiorespiratory parameters
before and after 6MWT and SWT 6MWT1 6MWT2 SWT1 SWT2

Systolic blood pressure, mm Hg

Baseline 140B15 133B17 136B16 134B19
End 148B16a 152B20a 149B22a 149B18a
Change from baseline 8B14 20B15 13B12 16B12
Diastolic blood pressure, mm Hg
Baseline 78B7 79B5 79B6 78B7
End 81B9 80B9 79B7 79B7
Change from baseline 3B10 1B8 0B6 1B7
Heart rate, beats/min
Baseline 85B13 86B16 86B16 81B22
End 104B17a 106B20a 103B21a 106B19a
Change from baseline 20B11 20B10 17B12 18B8
Respiratory rate, breaths/min
Baseline 21B4 19B4 20B4 19B4
End 24B5a 24B4a 24B6a 25B6a
Change from baseline 3B3 5B3 5B3 6B4

a p ! 0.05 vs. baseline values.

Results

After the training test, all patients found it easy to pace

themselves and no difficulties were encountered in ad-
ministering both tests.
Significantly more meters were covered with the
6MWT than with the SWT in both the first test (432.6 B
86.4 vs. 272.8 B 101.9 m, respectively, p = 0.0002) and in
the second test (447.2 B 80.8 vs. 312.6 B 119.2 m,
respectively, p = 0.0003; fig. 1). Distances covered during
6MWT2 and SWT2 were longer than distances covered
during 6MWT1 and SWT1, respectively, but the differ-
ence was statistically significant only for SWT2 (fig. 1).
Table 2 shows the mean values of systolic and diastolic
blood pressure, heart rate and respiratory rate at the
beginning and at the end of each exercise test. There was
no difference in baseline values among different tests, sug-
gesting that resting time between tests was adequate. At
the end of each test, systolic blood pressure, heart rate and
respiratory rate significantly increased; the increase was Fig. 1. Mean walking distance (m) during the two 6MWT (X =
not significantly different among the various tests. In par- 6MWT1; i = 6MWT2) and during the two SWT (X = SWT1; i =
SWT2).
ticular, no difference was observed between values at
baseline and after 6MWT2 and SWT2.
SatO2 was similar at the beginning of each test, and
significantly decreased at the end of each test, without any
significant difference among the various tests (table 3).
The dyspnea Borg index showed a similar increase at the

Shuttle Walking Test and 6-Minute Respiration 2003;70:579–584 581

Walking Test
Table 3. Oxygen saturation and dyspnea
Borg index before and after 6MWT and 6MWT1 6MWT2 SWT1 SWT2
SWT
Oxygen saturation, %
Baseline 95.2B2.8 95.6B1.5 95.7B1.8 95.1B1.9
End 93.2B4.3a 92.0B5.8a 92.4B6a 91.8B6.0a
Change from baseline 2.1B3.8 3.7B5.2 3.3B4.8 3.5B5.1
Dyspnea Borg index
Baseline 0.9B1.1 1.2B1.3 1.1B0.9 1.2B1.2
End 4.3B2.2a 5.2B2.2a, b 4.6B2.1a 5.1B2.2a, c
Change from baseline 3.3B1.8 3.9B1.9 3.4B1.6 3.8B2.0

a p ! 0.05 vs. baseline values, b p ! 0.02, c p ! 0.1 vs. the first test.

Discussion

We demonstrated that the cardiorespiratory response

Fig. 2. Correlation between the distances walked in the 6MWT and
SWT.
end of the exercise test in both 6MWT and SWT. The
value of the dyspnea Borg index obtained at the end of
the second test was significantly higher than that mea-
sured at the end of the first test in 6MWT (p = 0.02), but
not in SWT (p = 0.09). There was a significant relation-
ship between the distances walked in 6MWT2 and in
SWT2 (Ú = 0.85, p ! 0.0005; fig. 2).
No correlation was observed between 6MWT and
SWT performance and clinical and functional findings of
COPD patients, such as the duration of the disease, FEV1,
forced vital capacity, total lung capacity and resting
arterial blood gases.
after SWT was similar to that obtained after the standard
6MWT regarding increases in heart rate, respiratory rate,
systolic blood pressure, dyspnea Borg index and decrease
in oxygen saturation. This fact suggests that the subjects
developed a similar cardiorespiratory performance in
both tests. Therefore, our data are not in agreement with
the assumption that SWT induces a greater increase in
cardiopulmonary parameters, because it is an incremental
test and not a self-paced exercise test as 6MWT. The lim-
ited number of subjects studied may however attenuate
the implication of these results.
A previous study reported that maximum heart rate
and the dyspnea Borg index were higher at the end of
SWT than at the end of 6MWT in a group of 15 patients
with severe COPD [8]. Furthermore, maximum heart rate
achieved at the end of both 6MWT and SWT seems
slightly lower in our patients in comparison with the data
reported by Singh et al. [8, 9]. There is no relevant differ-
ence in the level of severity of COPD between our study
and other studies, at least regarding FEV1. However,
FEV1 is a poor predictor of symptoms and disability in
COPD patients [11], and similar FEV1 values may not
reflect similar levels of dyspnea or quality of life. Another
possible explanation for the discrepancy between our
results and the previous ones might be the different phase
of the disease: our patients were observed in the recovery
phase of an acute exacerbation of COPD, and not in the
stable phase as the patients examined by Singh et al. [8, 9].
After an acute exacerbation of COPD, dyspnea and lower
limb muscular weakness may add to the cardiorespiratory
limitation, thus affecting the results of performance.

582 Respiration 2003;70:579–584 Vagaggini/Taccola/Severino/Marcello/

Antonelli/Brogi/De Simone/Giardina/
Paggiaro
 In two other studies 6MWT and SWT were compared to that of SWT. Indeed, in a recent study in a high per-
in different patient cohorts, e.g. patients with cystic fibro- centage of rehabilitation centers, the standardization of
sis [12] and heart failure [13]; in the latter, both tests were 6MWT is quite poor [18].
also compared with a maximal treadmill peak oxygen At the end of the second test, the dyspnea Borg index
consumption. Both papers showed a correlation between was higher than at the end of the first test, after both
the results obtained in the two tests, although SWT corre- 6MWT and SWT, possibly due to fatigue which devel-
lated better with peak oxygen consumption than 6MWT oped during the first test. However, there was no signifi-
[13]. Peak heart rate obtained after both tests was higher cant difference among the dyspnea Borg index obtained
than peak heart rate obtained in our study [12]. This fact before each test, since the time interval between the tests
might be due to the different patient groups, with patients was sufficient to enable recovery.
with cystic fibrosis being younger and with less airflow No correlation was observed between the performance
limitation. obtained in 6MWT or SWT and main functional parame-
In several studies, maximum oxygen uptake measured ters of the patients, in particular FEV1 or arterial blood
after 6MWT or after SWT correlated with maximal oxy- gas levels, confirming previously reported data [1, 19].
gen uptake during a cardiopulmonary exercise test using Thus, exercise tests must be performed in these patients
cycloergometer or treadmill [9, 13–15], suggesting that in order to assess their disability, because this information
both tests express the ability to perform an exercise in cannot be derived from traditional functional findings.
patients with chronic flow limitation. In COPD patients, In conclusion, in patients recovering from an acute
it is believed that the extent of an impairment can be exacerbation of COPD, SWT and 6MWT induce a simi-
detected more clearly by SWT than by traditional 6MWT, lar cardiorespiratory performance. Both tests are repro-
emphasizing the possible beneficial effects of any treat- ducible and feasible even in hospitalized patients. Further
ment. This hypothesis is based on theoretical consider- studies are required to compare these two tests in patients
ations and on the results of few studies comparing the two at different phases of COPD and in the evaluation of
tests in patients with different diseases [8, 12, 13]. By con- treatment effects on COPD patients.
trast, our data show that the two tests are equivalent when
used in a group of patients with COPD of moderate-to-
severe degree recovering from an acute exacerbation. Fur-
thermore, these differences might be explained by the dif-
ferent stages of the disease in patients at the time of obser-
vation (exacerbation vs. stable phase of COPD).
The correlation between 6MWT and SWT is consider-
ably higher than that reported by other authors [8], con-
firming the similarities between these two tests in our
experience.
According to previous studies [8, 9, 13, 16, 17], our
study confirms the feasibility and the good repeatability
of SWT even for patients with no previous experience
with this test, which can then be used as a routine method
to assess exercise tolerance in COPD patients.
In the second test, maximum distance was significantly
longer than in the first SWT but not in the 6MWT. It may
be argued that the SWT is more difficult, and the ‘learning
effect’ is thus more pronounced than in the 6MWT. How-
ever, this ‘learning effect’ for both tests has been reported
previously [10, 13, 16], but it is considered to be marginal
for SWT because of the lack of encouragement by the
therapist, which could influence patient response. When
6MWT is performed in a standardized manner, as in the
present study, with similar encouragement by the thera-
pist, the reproducibility is quite high and probably similar

Shuttle Walking Test and 6-Minute Respiration 2003;70:579–584 583

Walking Test
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