Chronic Respiratory Disease 2006; 3: 3-9

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ORIGINAL PAPER
The endurance shuttle walking test: a responsive measure in
pulmonary rehabilitation for COPD patients
T Eaton, P Young, K Nicol and J Kolbe
Green Lane Respiratory Services, Auckland City Hospital, Auckland, New Zealand

Background: The endurance shuttle walk test (ESWT) is a standardized externally controlled
constant paced field test for the assessment of endurance capacity in chronic lung disease. The
ESWT has been advocated as a simple, acceptable, repeatable and responsive outcome measure for
COPD patients undergoing pulmonary rehabilitation, but has not been formally compared with the
more commonly used field walking test, the six-minute walk (6MW). We aimed to determine: 1) the
responsiveness of the ESWT in COPD patients attending a hospital-based pulmonary rehabilitation
programme, and 2) to compare the responsiveness of the ESWT with the 6MW. Methods:
Consecutive COPD patients, referred for a standard 8 week pulmonary rehabilitation programme,
were recruited. Outcome parameters studied at baseline and completion of rehabilitation programme
(8 weeks) included spirometric lung volumes, resting oxygen saturation, breathlessness scored
pre and post exercise (modified Borg dyspnoea score), 6MW, ESWT, health-related quality of
life (Chronic Respiratory Questionnaire) and Hospital Anxiety and Depression (HAD) scale. The
incremental shuttle was employed to predict V02 peak; 85% V02 peak was used to determine the
walk speed for the ESWT. Results: Twenty stable COPD patients (11 male), mean (SD), age 71, (9)
FEV1 0.95 (0.51), resting SP02 95% (2) 6MW distance (m) 351 (104) and ESWT distance (m) 313
(193) were studied. Three patients did not complete their rehabilitation programme. Following
rehabilitation, there were significant improvements in 6MW, ESWT, total CRQ and anxiety domain
(HAD). The 6MW distance increased by 17% (47 m 95%CI 3, 90), while the ESWT increased by
92% (302 m 95%CI 104, 501). Conclusion: The ESWT is a simple, acceptable and highly
responsive outcome measure for COPD patients undergoing a pulmonary rehabilitation programme.
The ESWT has potential advantages in that it may be more responsive than the 6MW. Chronic
Respiratory Disease 2006; 3: 3-9

Key words: COPD; endurance shuttle walking test; pulmonary rehabilitation

Introduction self-paced, time-limited and only partly standardized.

Pulmonary rehabilitation is an integral component of
the comprehensive management of COPD patients'
with. proven benefits including reduction in dyspnoea,
increased endurance capacity and improved health-
related quality of life (HRQL).2 4 A variety of exercise
tests have been employed as outcome measures.
Although laboratory-based exercise testing, using
cycle or treadmill, may be regarded the 'gold standard',
field testing is the more practical choice, with the
six-minute walk (6MW) being most widely used.
However, the 6MW has certain disadvantages; it is
Correspondence: Dr T Eaton Respiratory Physician, Green Lane Respiratory
Services, Auckland City Hospital, Auckland, New Zealand
E-mail teaton@adhb.govt.nz
A significant learning effect has been demonstrated, and
therefore two5practice walks are recommended to ensure
repeatability. By the very nature of its self-imposed
6-minute time limit, the 6MW distance does not
directly reflect endurance capacity. Endurance capacity
is the most clinically relevant outcome measure for
COPD patients and has been demonstrated to be a
highly sensitive outcome measure for pulmonary
rehabilitation. 2,3,6,7
Hence the rationale behind the development of the
endurance shuttle walk test (ESWT) as a field exercise
test is to provide a measure of endurance capacity that is
sensitive to change for patients with chronic respiratory
disease.8 The ESWT was designed to complement the
incremental shuttle walk test (ISWT)9'10 and uses the
same 10 m shuttle course and audio signal to control

2006 Edward Arnold (Publishers) Ltd 10. 1 191/1479972306cdO77oa

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 Endurance shuttle walking test
T Eaton et al.
4
pace. A measure of endurance capacity, such as the
ESWT, that was simple, acceptable, field-based, with
nominal cost or resource implications, minimal
learning effects, valid and highly responsive would
have considerable merit. Specific advantages of the
ESWT over the 6MW are that it is standardized,
externally controlled and constant paced. Although the
ESWT has been advocated as a simple, acceptable,
repeatable and responsive outcome measure for COPD
patients undergoing pulmonary rehabilitation, pub-
lished clinical experience remains limited. This study
aimed to determine: 1) the responsiveness ofthe ESWT
in COPD patients attending a hospital-based pulmon-
ary rehabilitation programme, and 2) to compare the
responsiveness of the ESWT with the 6MW
Methods
Eligible patients were identified from consecutive
pulmonary rehabilitation referrals at Green Lane
Hospital.
Inclusion criteria
The inclusion criteria were:
1. moderate or severe COPD as defined by BTS
criteria; 1 published guidelines5"15 with standardized verbal
2. exertional dyspnoea interfering with daily activity;
3. clinically stable (defined as no deterioration in
respiratory symptoms requiring intervention with
antibiotics or oral corticosteroids by an attending
physician within the previous four weeks)'2 on
standard optimal therapy;
4. ability to complete HRQL questionnaires.
Patients with important co-morbidities (e.g., limiting
angina or significant musculoskeletal disability) were
excluded.
Pulmonary rehabilitation programme
Patients attended a comprehensive multidisciplinary
hospital-based outpatient programme twice weekly for
8 weeks. This was a continuous revolving programme
consisting of one hour sessions of supervised exercise
training, which included aerobic treadmill walking,
cycling and peripheral muscle strength training for the
upper and lower limbs and thoracic mobility, as
described previously. 13 Group and individual edu-
cational sessions, aimed at self-management, dyspnoea
coping strategies, nutrition and lifestyle issues, were
Chronic Respiratory Disease
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provided by our multidisciplinary team. Patients also
received an individualized home activity program
based on their supervised exercise programme.
Data collection
Forced expiratory volume in one second (FEVy) and
forced vital capacity (FVC) (R-Model Vitalograph
Limited, Buckingham, England) were measured
according to ATS standards and expressed as %
predicted using the European Coal and Steel prediction
equations. 14
Field exercise testing
All field testing was performed in a standardized
manner by experienced respiratory physiotherapists
(PY, KN). Patients performed all exercise testing
breathing room air, apart from one patient on long-term
oxygen therapy who received supplementary oxygen.
Patients rested for at least 30 minutes between tests.
Cutaneous oximetry (Nellcor N-20PA Puritan Bennett
Inc., Pleasanton, CA, USA) was measured by finger
probe.
Six-minute walking test (6MWT)
The 6MWT was performed in accordance with
prompts. Walk distance, resting and 6 minute SP02
and pre and post walk modified Borg dyspnoea scores
were measured.'6 The minimally clinically important
change in 6MW distance is > 54 m. 17
Endurance shuttle walking test (ESWT)
The ESWT was performed in accordance with
published guidelines.8 Briefly, an initial incremental
shuttle walk was performed with one practice walk,
enabling prediction of V02 peak; 85% V02 peak and
the corresponding walking speed for the ESWT were
calculated. During the ESWT, patients received
standardized instructions to walk for as long as
possible, although there was a predetermined 20
minute maximum.8 Walk distance, walk time, resting
and post exercise SP02 and pre and post walk modified
Borg dyspnoea scores were measured.
Health-related quality of life (HRQL)
Chronic respiratory questionnaire (CRQ)
This validated, repeatable and responsive disease-
specific interviewer-administered instrument has four
domains; dyspnoea, fatigue, emotional function, and

mastery. 18 Each answer is scored from 1 to 7
(7 optimal). The minimally clinically important
= minutes with a post Borg dyspnoea score of 4.7 (1.9).
difference is a change in total CRQ score of > 10.19
Hospital anxiety and depression scale (HAD)
This is a reliable self-assessment scale used for
evaluating anxiety and depression in the physically
ill, scores ranging from 0 to 21 (0 = optimal). 0
The above measures were recorded at baseline and at
completion (eight weeks) of the formal pulmonary
rehabilitation programme.
Data analyses
Results are reported as mean + standard deviation
unless otherwise stated. Changes over the 8-week
period are reported as the mean change and
standardized mean difference (effect size), defined as
the mean difference divided by the pooled standard
deviation of the difference. An effect size of 0.2 is
considered small, 0.5 moderate and 0.8 large.2' All
analysis was performed on SAS statistical software and
a P-value less than 0.05 was considered statistically
significant.
Results
Baseline characteristics
Twenty-two patients satisfied recruitment criteria: two
patients completed the predetermined 20 minute
maximum on the baseline ESWT and were excluded.
A further three patients did not complete the pulmonary
rehabilitation programme and were not available for
final analyses. All patients had significant COPD with a
mean FEV, of 0.93 litres. All but one (FEV, 0.95) had
a smoking history (mean 33 (17) pack years); two were
current smokers. Mean age was 71 (9) 11 255%) were
male and their mean BMI was 25 kg/mi2. They had
significant exertional dyspnoea with a mean post 6MW
Borg dyspnoea score of 4.6 (2.5). Resting oxygen
saturations were generally well preserved with a mean
SPO2 of 95 (2)%. Following the 6MW, mean minimum
desaturation was 87 (6)%. Only one patient was on
long-term oxygen. This patient completed all field
exercise tests on 2 L/min and performed her hospital
and home-based activity programme on supplementary
oxygen. Aside from patients on long-term oxygen,
supplemental oxygen is not routinely provided for
pulmonary rehabilitation programmes in New Zealand.
The mean ISWT distance was 251 (115) m with a post
Borg dyspnoea score of 4.7 (1.9). The mean ESWT
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Endurance shuttle walking test
T Eaton et al.
5
distance walked was 313 (193) m, duration 5.1 (2.8)
Following pulmonary rehabilitation
FEV,, SpO2, field exercise test measures, HRQL and
HAD scores at baseline and following pulmonary
rehabilitation are detailed in Table 1. There was no
significant change in lung function or resting oxygen
saturations over this period.
Changes in ESWT
Following rehabilitation, there was a highly significant
improvement of 92% (302m, 95%C1 104, 501) in
ESWT distance. The standardized mean change was
0.54. The individual ESWT distances, pre and post
rehabilitation, are shown in Figure 1. Following
rehabilitation, four patients reached the predetermined
20 minutes ESWT limit. Two patients did not
demonstrate an improvement in the ESWT; these
patients both died within 6 months of completing
pulmonary rehabilitation.
Changes in 6MW
6MW distance increased by 17% (47 m, 95%Cl 3, 90).
Only five patients attained 54 m or greater, which is
accepted as the minimally clinically important change.
The individual 6MW distances, pre and post rehabilita-
tion, are shown in Figure 2. The standardized mean
change was 0.32
Changes in dyspnoea
Post ESWT and 6MW Borg dyspnoea scores decreased
comparably, 0.9 (2.5) and 0.9 (2.3) respectively, but
these changes were not statistically significant. The
standardized mean changes were - 0.28 and - 0.32,
respectively.
Changes in HRQL
Improvements were noted in all CRQ domains, with a
mean change in total CRQ score of 10 (minimum
clinically significant improvement > 10) (P = 0.005).
The standardized mean change was 0.31.
Discussion
An appropriate measure of functional capacity is
essential as a measure of COPD severity or response to
clinical intervention such as pharmacotherapy or
rehabilitation.3 22,23 There is an array of exercise tests
available, with the choice of test dependent on a number
of factors, such as clinical relevance, repeatability,
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 Endurance shuttle walking test
T Eaton et al.
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Table 1 Changes in six-minute walk, endurance shuttle walk and HRQL following 8 weeks pulmonary rehabilitation
Statndardized mnean
Baseline n = 20 8 weeks n = 17 Mean (SD) P-value change (SD)
Lung function
FEVI, L 0.95 (0.51) 0.85 (0.30) -0.13 (0.48) 0.3
Resting SP02, % 95 (2) 95 (3) 0.29 (1.99) 0.6
Field exercise tests
ESWT
Distancc, m 313 (193) 633 (526) 302 (387) 0.005 0.54 (0.69)
Time, min 5.1 (2.8) 9.6 (7.0) 4.5 (5.4) 0.004 0.59 (0.71)
Post Borg 4.7 (1.9) 3.9 (2.0) -0.9 (2.5) 0.168 -0.32 (0.91)
6MWT
Distance, m 351 (104) 420 (102) 47 (79) 0.038 0.32 (0.54)
Post Borg 4.8 (2.6) 3.9 (2.2) -0.9 (2.3) 0.145 -0.28 (0.70)
HRQL
CRQ
Dyspnoca 17.7 (5.8) 19.6 (5.7) 2.1 (4.0) 0.056 0.26 (0.49)
Fatigue 13.5 (4.2) 15.3 (4.4) 1.8 (3.6) 0.065 0.30 (0.60)
Emotional function 30.0 (8.7) 34.4 (8.4) 4.2 (4.6) 0.002 0.43 (0.47)
Mastery 17.1 (4.4) 18.3 (4.7) 1.3 (3.6) 0.185 0.19 (0.56)
Total 78.3 (18.7) 88.2 (19.1) 9.9 (12.2) 0.005 0.31 (0.45)
HAD
Anxiety 6.9 (3.5) 5.6 (3.8) -1.2 (2.1) 0.024 -0.24 (0.39)
Depression 4.9 (3.2) 3.9 (3.0) - 1.1 (2.8) 0.138 -0.24 (0.64)

responsiveness, practicality, availability, cost and
patient acceptance.
Laboratory-based exercise testing has traditionally
been regarded as the 'gold standard'. Laboratory-based
testing has certain disadvantages; 'sophisticated'
laboratory-based equipment is not always readily
available and has associated cost, staff and training
constraints. Furthermore, such testing is not generally
perceived as a clinically relevant activity for many of
our patients. They are often unfamiliar with cycling and
the alternative modality, the treadmill may also present
some concerns to potentially frail elderly patients
attending a rehabilitation programme.
2000
Endurance capacity is a more clinically relevant
outcome measure than an incremental symptom limited
maximal test for the COPD population. Tests of
endurance capacity have been demonstrated to be very
responsive to pulmonary rehabilitation.3 6 7 Niederman
et al. reported a 148% increase in cycle endurance time
following 9 weeks pulmonary rehabilitation but no
significant change in V02max as measured by
incremental cycle ergometry.6
A 'simple', less resource-intensive field-based
walking test that was well accepted by patients,
clinically relevant and highly responsive would be a
very desirable outcome measure for COPD patients
700

600
1500
E 500
0 E
0 0 400
I-
1000 0

a,
3 0
a
300

ul
200
500 to

100

Baseline Post
Baseline Post
Rehabilitation Rehabilitation

Figure 1 Individual endurance walking test distances (m) pre and Figure 2 Individual six-minute walking test distances (m) pre and
post rehabilitation (A patients who did not complete rehabilitation). post rehabilitation (A patients who did not complete rehabilitation).

Chronic Respiratory Disease

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attending pulmonary rehabilitation. This was the
rationale behind the development of the endurance
shuttle walk test (ESWT) as a measure of endurance
capacity for patients with chronic respiratory disease.
The ESWT is an externally paced and hence
standardized field measure endurance walking capacity,
which Revill et al.8 have reported as a simple,
acceptable, repeatable and responsive outcome
measure for COPD patients undergoing pulmonary
rehabilitation.
Our pulmonary rehabilitation programme has
demonstrated previous clinical effectiveness'3 and this
was reaffirmed in the present study. Improvements in
the 6MW distance, although modest, approached the
minimally clinically important difference and were
more than in other published series.2'24 Furthermore,
there were clinically significant improvements in the
CRQ, which is a widely accepted and validated disease-
specific measure of HRQL. The baseline characteristics
of study populations were very similar, apart from a
lower ISWT distance, 251 m, compared with 313 m.
The post Borg dyspnoea scores were very comparable,
mean of 4.7 compared with 4.98. Patient numbers were
similar to those employed by Revill et al. 8 and the
changes in ESWT following rehabilitation were of a
similar magnitude, namely 302 m in the present study
compared with 334 m. We believe our study to be
clinically relevant in that it was performed in the
context of the practical delivery of a standard hospital-
based pulmonary rehabilitation service (rather than a
sanitized research study) and it was in this context that
the ESWT was shown to be a more responsive
outcome measure. Consecutive patient referrals meet-
ing standard criteria were recruited. The results are
therefore more likely to be able to be directly
extrapolated to usual clinical practice.
We confirmed the results of Revill et al. 8 that the
ESWT is a highly responsive outcome measure for
COPD patients undergoing pulmonary rehabilitation.
However, we extended these findings to allow direct
comparison of the responsiveness of the 6MW with
that of the ESWT. We examined effect sizes to
facilitate comparison of the magnitude of responsive-
ness between the ESWT and 6MW; the effect size for
the ESWT was 0.54 and therefore would be judged
moderate as opposed to 0.32 for the 6MW, which
would be considered small.2' However, it must be
noted that using the standardized mean difference to
compare responsiveness does not necessarily imply
that the ESWT is a superior outcome measure for use
in a clinical trial. We demonstrated a highly significant
92% increase in ESWT distance (302 m). This
magnitude of improvement in endurance capacity is
very comparable with improvements reported in
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Endurance shuttle walking test
T Eaton et al.
7
laboratory-based measures of endurance.3'7 Conver-
sely, we demonstrated only a 17% improvement in the
6MW (47 m). The 6MW is self-paced and time-
limited, which may underestimate the response to
rehabilitation. Oga et al. reported that both incremental
cycle ergometry and the 6MW were less responsive
than cycle endurance following pharmacotherapeutic
intervention.25
The predetermined 20 minute maximum for the
ESWT is a practical solution but does invoke a ceiling
effect, potentially reducing its utility as an outcome
measure. Certainly, following an intervention such as
pulmonary rehabilitation, which is expected to improve
endurance capacity, a proportion of patients will reach
the 20 minute limit, hence underestimating the
magnitude of improvement. In our study four patients
achieved the 20 minute maximum following
rehabilitation.
Despite the theoretical and practical advantages of
the ESWT, the absence of subsequent published studies
from other authors is perhaps surprising. The 6MW
remains the most frequently used measure offunctional
capacity. The 6MW is widely understood and
interpretable by both patients and staff, with numerous
publications attesting to its role in providing clinically
meaningful results and prognostic information.26
There is as yet no information on the prognostic utility
of the ESWT. However, in our study the only two
patients who did not demonstrate improvement in the
ESWT with rehabilitation died within 6 months.
Similarly, the one patient that deteriorated in the
study by Revill et al. died within 3 weeks.8 The 6MW
is widely used as the standard assessment for
ambulatory oxygen,28'29 although Revill et al. reported
the ESWT to be a responsive outcome measure in the
acute assessment of ambulatory oxygen.30 While the
minimal clinically significant increase in the 6 minute
walk is well established at 54 M,17 that for the ESWT
is not known, but warrants further study.
The lack of uptake of the ESWT in routine clinical
practice may be due to the requirement for an initial
ISWT performed in duplicate. The ISWT provides
valuable information in its own right; however, this
initial ISWT performed in duplicate in addition to the
ESWT appears to present a real burden to both patients
and staff. Perceived or otherwise, the greater barrier
may be the length of time taken for the testing. Revill
et al. 8 imposed a 20 minute time limit, but nonetheless
the ESWT may take considerably longer to perform
than the 6MW. It is salutary that the 12MW test31 is
now rarely used. Revill et al. 8 recognize that some
patients complete 20 minutes of the ESWT. In our
study, two patients completed 20 minutes at baseline
and were not entered in the study. One might argue that
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 Endurance shuttle walking test
T Eaton et al.
8
they underperformed on ISWT; however, they both
achieved 85% maximum heart rate and discontinued
the test due to dyspnoea. Revill et al. make the
comment that 'in the case of patients achieving the 20
minute limit, a simple reassessment at the next
endurance walking speed on the ESWT tape may form
a practical solution' 8 This is eminently reasonable,
although this has not been further addressed.
Another practical consideration is the burden of a
number of practice walks. Time, staffing supervision,
resources and patient and staff aversion are important
considerations in the clinical setting. Nevertheless,
repeatability is integral to any outcome measure
and rigorous standardization is extremely important in
reducing test-retest variability. Although the 6MW is
stated to be a simple, reproducible and acceptable
measure of functional capacity in COPD, it does require
due care and attention in that the work rate cannot
be controlled. There is an accepted learning effect,
which has led to the recommendation for two practice
walks.5 In practice this does not appear to be routinely
adhered to and recent ATS guidelines state that 'only
one practice walk is required'.'5 The ISWT has proven
repeatability9 after one practice walk, as does the
ESWT.8 It might be argued that given the requirement
for an initial ISWT (one practice walk) and hence
patient familiarity with the circuit and external pacing
format, that the practice walk for the ESWT test might
be practically dispensed with. Indeed Revill et al.
appear to advise this in their ESWT instructions,
although in their original publication they recommend
a practice walk.8 This point needs to be resolved as it
remains a potential barrier to the uptake of a valuable
exercise test.
Conclusion
This study demonstrates that the endurance shuttle walk
is a highly responsive outcome measure for COPD
patients attending hospital-based pulmonary rehabilita-
tion. The ESWT has potential advantages in that it may
be more responsive than the 6MW These results justify
further investigation of the ESWT as the preferred
measure of endurance capacity following interventions
in COPD.
Acknowledgements
The authors would like to gratefully acknowledge
Ms Teena West, Biostatistician for her help with data
analyses.
Chronic Respiratory Disease
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