RESEARCH ARTICLE
Cardiorespiratory fitness assessment and
prediction of peak oxygen consumption by
Incremental Shuttle Walking Test in healthy
women
Liliana Pereira Lima1,2☯, He´rcules Ribeiro Leite1,2☯, Mariana Aguiar de Matos2‡, Camila
Danielle Cunha Neves2‡, Vanessa Kelly da Silva Lage2‡, Guilherme Pinto da Silva1,2‡,
Gladson Salomão Lopes2‡, Maria Gabriela Abreu Chaves2‡, Joyce Noelly Vitor Santos2‡,
Ana Cristina Resende CamargosID1,2‡, Pedro Henrique Scheidt Figueiredo1,2‡, Ana
Cristina Rodrigues Lacerda1,2☯, Vanessa Amaral Mendonc¸aID1,2☯*
1 Programa de Po´s-Graduac¸ão em Reabilitac¸ão e Desempenho Funcional, Departamento de Fisioterapia,
Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brasil, 2 Laborato´rio
de Inflamac¸ão e Metabolismo – LIM, CIPq Sau´de, Universidade Federal dos Vales do Jequitinhonha e
Mucuri, Diamantina, Minas Gerais, Brasil
☯ These authors contributed equally to this work.
‡ These authors also contributed equally to this work.
* vaafisio@hotmail.com
Abstract
Introduction
Preliminary studies have showed that the Incremental Shuttle Walking Test (ISWT) is a
maximal test, however comparison between ISWT with the cardiopulmonary exercise test
(CEPT) has not yet performed in the healthy woman population. Furthermore, there is no
regression equation available in the current literature to predict oxygen peak consumption
(VO2 peak). Thus, this study aimed to compare the ISWT with CEPT and to develop an
equation to predict peak oxygen uptake (VO2 peak) in healthy women participants.
Methods
First, the VO2 peak, respiratory exchange ratio (R peak), heart rate max (HR max) and per-
centage of predicted HR max (% predicted HR max) were evaluated in the CEPT and ISWT
(n = 40). Then, an equation was developed to predict the VO2 peak (n = 54) and its validation
was performed (n = 20).
Results
There were no significant differences between the ISWT and CEPT of VO2 peak, HR max
and % predicted HR max values (P>0.05), except for R peak measure in the ISWT (1.22 ±
0.13) and CEPT (1.18 ± 0.1) (P = 0.022). Therefore, both tests showed a moderate positive
correlation of VO2 peak (r = 0.51; P = 0.0007), HR max (r = 0.65; P<0.0001) and R peak (r =
0.55; P = 0.0002) and the Bland-Altman analysis showed agreement of VO2 peak (bias =
-0.14). The distance walked on ISWT and age explained 36.3% (R2 Adjusted = 0.363) of the
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OPEN ACCESS
Citation: Lima LP, Leite HR, Matos MAd, Neves
CDC, Lage VKdS, Silva GPd, et al. (2019)
Cardiorespiratory fitness assessment and
prediction of peak oxygen consumption by
Incremental Shuttle Walking Test in healthy
women. PLoS ONE 14(2): e0211327. https://doi.
org/10.1371/journal.pone.0211327
Editor: Gustavo Batista Menezes, UFMG, BRAZIL
Received: May 23, 2018
Accepted: January 3, 2019
Published: February 7, 2019
Copyright: © 2019 Lima et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
variance in VO2 peak. The equation developed was VO2 peak (predicted) = 19.793 + (0.02 x
distance walked)—(0.236 x age). There was no statistically significant difference between
the VO2 peak measured directly and the predicted, and the Bland-Altman analysis showed
agreement (bias = 1.5 ml/kg/min).
Conclusion
ISWT is a maximal test showing similar results compared to the CEPT, and the predicted
equation was valid and applicable for VO2 peak assessing in young adult healthy women.
Introduction
Cardiorespiratory fitness (CRF) is defined as the ability to sustain dynamic exercise by large
muscle groups over time at moderate to high intensity levels [1]. Furthermore, CRF has been
used to measure exercise capacity and provide information about physical limitation, morbid-
ity prognosis, and responsiveness to treatment [2]. The current gold standard for the evalua-
tion of CRF is the direct measurement of maximal oxygen uptake (VO2max) which represents
the maximal achievable level of oxidative metabolism involving large muscle groups [3]. How-
ever, in clinical testing situations, the exercise usually is limited by symptoms before the indi-
vidual achieve the VO2max. Consequently, VO2 peak is often used as an estimate for VO2max
and they are used interchangeably [3].
The laboratory assessment of CRF through maximal tests on treadmills or cycle ergometers
(cardiopulmonary exercise testing-CEPT) has a high cost [4] and require specialized profes-
sionals and equipments that is not always available [5]. Thus, field tests were developed and
have been increasingly used in clinical practice, such as the Six-minute walk test and the Incre-
mental Shuttle Walking Test (ISWT). ISWT was created by Singh et al. [6] to assess the CRF of
patients with chronic pulmonary obstructive disease (COPD) and later used in other condi-
tions or healthy subjects [7, 8, 9, 10, 11].
Several studies had already shown strong correlations between the performance on
CEPT and ISWT [5, 12, 13, 14]. Some studies have showed that the ISWT is a maximal test
in the pediatric and elderly population [15, 16, 17, 18], however the intensity of ISWT was
often indirectly assessed by predictive equations [15, 16, 17]. Hence, our study group com-
pared cardiorespiratory responses between ISWT and CEPT in healthy young adult men
[14] and adolescent boys (data not published), where the results showed moderate to high
significant correlation and agreement, concluding that the ISWT is a maximal test in these
subjects. In addition, a VO2 peak prediction equation based on ISWT variables was devel-
oped and it demonstrated feasibility and validity [14]. However, this study did not include
women in the assessments, remaining a gap in the literature about the ISWT in healthy
women.
In this paper, we evaluate the CRF in healthy young women by comparing and correlating
VO2 peak, respiratory quotient peak (R peak), maximum heart rate (HR max) and percentage
of predicted maximum heart rate (% predicted HR max), between ISWT with CEPT through
direct analysis of the exhaled gases, aiming to classify the ISWT intensity and to elaborate a
predictive equation to estimate the VO2 peak in young adult women population.
Incremental Shuttle Walking Test in healthy women
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Materials and methods
Subjects
Women between 18 and 45 years of age were recruited by convenience from Diamantina city,
Minas Gerais state, Brazil. The inclusion criteria were: self-report of no acute or chronic dis-
eases; eutrophic according to the body mass index (BMI between 18.5 and 24.9 kg/m2); no
smoker; sedentary (not performing physical activity for 30 minutes or more at least three
times a week) [19]. The participants were excluded from the study if did not reach the maximal
test values on the treadmill (% predicted HR max higher than 90%) and those who failed to
understand the tests. This study was approved by the Ethics and Research Committee of Uni-
versidade Federal dos Vales do Jequitinhonha e Mucuri, Brazil (protocol 1.184.419/2015) and
conducted in accordance with the Resolution N˚ 466/12 of the National Health Council and
the Declaration of Helsinki. The participants were informed about the procedures and poten-
tial risks associated with the study and all gave written informed consent.
Stages of the study
This was a cross-sectional study divided into three stages: (1) To compare the CEPT and the
ISWT and evaluate the correlation and agreement between the variables VO2 peak, R peak,
HR max and % predicted HR max, as well as determine the ISWT intensity in the female popu-
lation; (2) To elaborate an equation to predict the VO2 peak; and (3) validate this equation.
The sample size was calculated using the statistical program G.Power 3.1 and was based on the
number of variables to be included in the multiple regression analysis and the minimum num-
ber of observations required. Considering an effect size of 0.68 and power of 0.99, 54 volun-
teers were required in order to develop a linear model including up to four variables [14]. To
validate the equation, another 20 volunteers were required [14].
To evaluate the cardiorespiratory fitness, all participants were instructed to avoid physical
activity and intake caffeine and alcohol in the 24 h prior to the test, to get at least 8 hours of
sleep the night before, to eat a light meal and to ingest 500 ml of water two hours before the
tests [19]. During all tests performed, the exhaled gases were collected and assessed by a porta-
ble telemetric gas analysis system (K4b2, Cosmed, Rome, Italy). Among other variables, VO2,
R and HR breath-by-breath were monitored. The data were tabulated and was defined as VO2
peak and R peak the highest value of these measures at peak effort [20]. Predicted HR max was
calculated by the equation HR max = 220 –age [21].
The first stage of the study was performed on three consecutive days. On the first day, the
anthropometric variables weight, height and BMI, were measured and a familiarization was
performed. On subsequent days, the CEPT or the ISWT was performed by randomization.
The ISWT was performed in a 10-m course identified by two cones placed 0.5 m from each
end point, with an initial speed of 0.5 m/s, increasing 0.17 m/s every minute. The protocol
used was composed of 15 stages of 1 min, to prevent the ceiling effect [10, 22] and the walking
speed was dictated by a sound [6]. The test was interrupted if the volunteer did not reach the
cone once, at the request of the volunteer or for some other reported symptom (dyspnea, dizzi-
ness, vertigo, and angina). The CEPT protocol was based on the progression of the ISWT, with
the same initial speed and the same speed increase every minute, without changing the incline
of the treadmill. The criteria for interrupting the CEPT was systolic blood pressure (SBP)
greater than 210 mm Hg; diastolic blood pressure greater than 120 mm Hg; sustained decrease
in SBP; angina; dyspnea; cyanosis; nausea; dizziness; or by volunteer’s request [19].
In the second and third stage, the participants performed two ISWT with an interval of 30
minutes between then [23] and the results of the test with the longest walking distance were
Incremental Shuttle Walking Test in healthy women
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used for the statistical analysis. To validate the equation, a different group of women was
selected according to the same inclusion criteria of the study. The VO2 peak obtained by the
gas analyzer was compared with the VO2 peak predicted by the elaborated equation.
Statistical analysis
Statistical analysis was performed with the Statistical Package for Social Sciences programs ver-
sion 22.0 (SPSS Inc., Chicago, IL, USA) and GraphPad Prism 5.0 (Inc., USA). Data were pre-
sented as mean (standard deviation). In the first stage the normality of the data was calculated
by Shapiro-Wilk test. As the data presented normal distribution, the comparison between the
means of the physiological variables evaluated (VO2 peak, R peak, HR max and % predicted
HR max) were performed using Paired T-test. The correlation analysis of the variables col-
lected was performed by Pearson‘s correlation. The agreement of the variables collected was
performed by the Bland-Altman analysis. In the second stage, the Kolmogorov-Smirnov test
was used, and the analysis of multiple linear regression was performed with the variables age,
weight, height and distance walked defined a priori to elaborate the VO2 peak prediction equa-
tion. For the validation of the equation, the Shapiro-Wilk test was performed and then the
paired T-test to compare the mean values of the VO2 peak values obtained by the equation
with those obtained by the analyzer of gases. In addition, the comparison between the women
of first and third stages were realized using the Independent test t or Mann-Whitney test,
according of normality of data. The level of statistical significance adopted was P <0.05.
Results
First stage: Comparison between CEPT and ISWT
The general characteristics of the participants of first and second stage and their performance
on ISWT are showed in Table 1.
Forty volunteers performed both ISWT and CEPT and their cardiorespiratory responses
are presented in Table 2. There was no statistically significant difference for any of the vari-
ables, except for the R peak, which was higher in the ISWT. According to the percentage of
predicted HR max (above 90%) and R peak (> 1.1), the ISWT could be considered a test of
maximum intensity [14, 24, 25]. Blood pressure and heart rate were monitored during all tests
and there were no intercurrences.
Significant correlations were found for the variables VO2 peak, HR max and R peak (Fig 1).
The Bland-Altman analysis also demonstrated agreement between the VO2 peak in the ISWT
and in the CEPT (Fig 2).
Table 1. General characteristics of participants study.
Variable
N = 54
Age (years)
26.41± 5.6 (24.89–27.92)
Weight (kg)
56.56 ± 9.1 (54.08–59.05)
Height (m)
1.63 ± 0.1 (1.608–1.641)
BMI (kg/m2)
21.86 ± 1.8 (21.38–22.33)
Distance walked (m)
821.10 ± 118.9 (788.7–853.6)
Walking speed (m/s)
2.06 ± 0.2 (2.013–2.104)
The data is presented as mean ± SD (95% CI). BMI = body mass index.
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Second stage: Reference equation for VO2 peak
The univariate analysis was performed with the variables age, weight, height and distance
walked (N = 54). A model of stepwise linear multiple regressions showed distance walked on
ISWT and age explained 36.3% (Adjusted R Square = 0.363) of the variance in VO2 peak and
this was significant (p = 0.014). The reference equation for the VO2 peak in the ISWT was:
VO2 peakðpredictedÞ¼ 19:793þð0:02 x distance walkedÞwith COPD, cystic fibrosis and chronic heart failure, showing strong and significant correla-
tions for VO2 peak of CEPT and ISWT [7, 9, 12].
In a study recently published by our research group, male healthy adults showed HR max,
VO2 peak and R peak values with strong and significant correlations and agreement between
the ISWT and the CEPT, with ISWT being a maximal test for this population [14]. Consider-
ing that the maximum VO2 values for women are about 70% of the average values for men
[27] and that is not known whether ISTW is a maximum test for healthy young women, we
initially investigated the intensity of ISTW.
Since the values of HR max above 90% of predicted and R peak > 1.1 [14, 24, 25], we estab-
lish that this is a maximum test for this population, and similar VO2 peak results were found
between CEPT and ISWT. Further tests carried out with patients with cardiopulmonary dis-
eases concurred with our findings [6, 12, 28, 29]. However, data on the validity of the ISWT to
evaluate VO2 peak in healthy individuals are scarce in the literature [18]. Gonc¸alves et. al [30],
studying subjects of both sexs, different age ( 18 years old), who presented comorbidities
such as arterial hypertension, peripheral vascular disease, arthritis and cardiopathies, also con-
cluded that ISWT above 12 levels requires maximum effort in these individuals.
As the direct analysis of the exhaled gases has a high cost, the use of prediction equations
becomes more applicable due to the feasibility and low cost. Considering our results that
Fig 1. Correlation between (A) VO2 peak, (B) HR max and (C) R peak in the ISWT and the CEPT. ISWT = Incremental Shuttle Walking Test;
CEPT = cardiopulmonary exercise test; VO2 = oxygen uptake; HR max = maximum heart rate; R = respiratory exchange ratio.
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ISTW is a maximum test to healthy women, its usefulness is reinforced as a simple way of mea-
suring CRF. In this context, an equation was then elaborated for the prediction of VO2 peak in
ISTW.
In our study, age and distance walked accounted for more than 30% of VO2 peak variance.
In the literature it is reported that beyond gender, other factors that influence VO2 peak as
genetic factors, age, weight, and training [31]. Findings similar to our study were found in
obese women, where there was a significant correlation between the VO2 peak in the cardio-
pulmonary exercise test with the ISWT VO2 peak and the ISWT distance [5]. In this same
study, the variables age and distance walked by the ISWT explained the predictive model for
the VO2 peak.
Only two other studies have published a reference equation for VO2 peak using ISWT,
highlighting the variables distance and body mass in the prediction [11, 32]. In the study of
Fig 2. Bland-Altman agreement of VO2 peak in the ISWT and the CEPT. ISWT = Incremental Shuttle Walking Test; CEPT = cardiopulmonary exercise test;
VO2 = oxygen uptake.
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Table 3. General characteristics of the study participants.
Variable
N = 20
Age (years)
25.85 ± 5.6 (23,24–28,46)
Weight (kg)
55.84 ± 5.7 (53.16–58.51)
Height (m)
1.62 ± 0.04 (1.594–1.638)
BMI (kg/m2)
21.34 ± 1.5 (20.61–22.07)
Distance walked (m)
865 ± 100.2 (818.1–911.9)
Walking speed (m/s)
2.11 ± 0.14 (2.049–2.181)
The data is presented as mean ± SD (95% CI). BMI = body mass index.
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Dourado et. al [11] the distance in the ISWT was selected, the maximum walking velocity, and
distance in the ISWT × body mass as the only determinants of the peak VO2. This is consistent
with the variables selected in our study. However, they did not compare to another cardiopul-
monary exercise test, nor did they validate the equation.
As age is a determining factor for VO2 peak, it is important to highlight that several studies
have used the ISWT in the older population [10, 11, 22, 23, 26] or in children and adolescents
[15–17], and some evaluated stratifying age groups [2, 30]. Due to the influence of cardiorespi-
ratory fitness on functional independence, there is great interest in describing age-related
changes in maximum oxygen consumption. Evidences support a 10% per decade decline in
VO2 max in men and women regardless of activity level [33]. For all the facts reported, it
makes sense for age to be a predictor of VO2 peak in the elaborated equation.
Our study presents differentials when proposing a prediction equation for VO2 peak, the
main variable for evaluation of cardiorespiratory fitness [19, 34], since most of the studies with
ISWT focus on the prediction of walking distance [2, 10, 15, 17, 22, 23]. In addition, those who
did the VO2 peak prediction equation for women did not validate it [5, 11]. The equation devel-
oped in this study was validated in other volunteers and the VO2 peak values obtained by the
equation and the values of VO2 peak obtained by the gas analyzer were similar, indicating that
the application of the equation is feasible to estimate the VO2 peak of the chosen population.
The limitation of the study was the level of physical activity having been self-reported, but
this strategy is adopted in scientific studies [35, 36].
Conclusion
The Incremental Shuttle Walking Test was concordant with the CEPT, requiring maximum
effort in young health women. The elaborated equation is valid and applicable, being a simple
and inexpensive tool to evaluate the cardiorespiratory fitness in the study population.
Fig 3. Bland-Altman agreement of VO2 peak in the validation of the reference equation. ISWT = Incremental Shuttle Walking Test; CEPT = cardiopulmonary
exercise test; VO2 = oxygen uptake.
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Acknowledgments
The authors are grateful to Centro Integrado de Po´s-Graduac¸ão e Pesquisa em Sau´de, Univer-
sidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil, for
providing equipment and technical support for the experiments.
Author Contributions
Conceptualization: Vanessa Amaral Mendonc¸a.
Data curation: Liliana Pereira Lima.
Formal analysis: Liliana Pereira Lima, Ana Cristina Resende Camargos, Pedro Henrique
Scheidt Figueiredo.
Investigation: Liliana Pereira Lima.
Methodology: Liliana Pereira Lima, Camila Danielle Cunha Neves, Vanessa Kelly da Silva
Lage, Guilherme Pinto da Silva, Gladson Salomão Lopes, Maria Gabriela Abreu Chaves,
Joyce Noelly Vitor Santos, Ana Cristina Rodrigues Lacerda.
Project administration: Vanessa Amaral Mendonc¸a.
Supervision: He´rcules Ribeiro Leite, Vanessa Amaral Mendonc¸a.
Writing – original draft: Liliana Pereira Lima, He´rcules Ribeiro Leite, Mariana Aguiar de
Matos, Camila Danielle Cunha Neves, Vanessa Kelly da Silva Lage, Ana Cristina Resende
Camargos, Pedro Henrique Scheidt Figueiredo, Ana Cristina Rodrigues Lacerda, Vanessa
Amaral Mendonc¸a.
Writing – review & editing: Liliana Pereira Lima, He´rcules Ribeiro Leite, Mariana Aguiar de
Matos, Camila Danielle Cunha Neves, Vanessa Kelly da Silva Lage, Guilherme Pinto da
Silva, Gladson Salomão Lopes, Maria Gabriela Abreu Chaves, Joyce Noelly Vitor Santos,
Ana Cristina Resende Camargos, Pedro Henrique Scheidt Figueiredo, Ana Cristina Rodri-
gues Lacerda, Vanessa Amaral Mendonc¸a.
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Cardiorespiratory fitness assessment and prediction of peak oxygen consumption by Incremental Shuttle Walking Test in healthy women.
Lima, Liliana Pereira,Leite, Hércules Ribeiro,Matos, Mariana Aguiar de,Neves, Camila Danielle Cunha,Lage, Vanessa Kelly da Silva,Silva, Guilherme Pinto da,Lopes, Gladson Salomão,Chaves, Maria Gabriela Abreu,Santos, Joyce Noelly Vitor,Camargos, Ana Cristina Resende,Figueiredo, Pedro Henrique Scheidt,Lacerda, Ana Cristina Rodrigues,Mendonça, Vanessa Amaral