Abstracts
This study systematically reviewed the six-minute walk test (6MWT) for assessment of functional capacity of adults with hypertension subjected or not to physical rehabilitation, focusing in walked distance (6MWD) and blood pressure. A literature search was conducted in PubMed, SciELO, LILACS, PEDro, Cochrane, Redalyc, and national journals of physiotherapy using the keywords "hipertensão" (hypertension) and "teste de caminhada de seis minutos" (six-minute walk test) without language or period constraints. Six studies were included: one case-control, one clinical trial, two quasi-experimental and two series of cases. Results from cross-sectional studies suggest preservation of the 6MWD in the mild stage of hypertension, whereas significant lower values in the more severe stage of hypertension or in the presence of comorbidities. Longitudinal studies suggest that the 6MWT is sensitive to the increase in functional capacity due to adaptations from physical rehabilitation programs. Two major limitations compromise the external validity of the included studies: samples with specific phenotypes (same sex; same hypertension stage; narrow age group) and the small sample size (range 8 to 32). The low methodological quality reinforces the need for researches with larger samples and different phenotypes of hypertension.
Hypertension; Rehabilitation; Review Literature as Topic
Eso trabajo revisó sistemáticamente los estudios referentes al test de caminada de seis minutos (TC6) para evaluación de la capacidad funcional de adultos con hipertensión que fueron o no sometidos a la rehabilitación física, con foco en la distancia caminada (DC6) y en la presión arterial. Una búsqueda en la literatura fue conducida en PubMed, SciELO, LILACS, PEDro, Cochrane, Redalyc y en periódicos brasileños de fisioterapia con las palabras clave "hipertensión" (hypertension) y "test de caminada de seis minutos" (six-minute walking test) sin restricciones de lengua y periodo. Fueron inclusos uno estudio caso-control, un ensayo clínico, dos casi-experimentales y dos reportos de casos. Los estudios transversales sugieren preservación de la DC6 en los estadios leves de la hipertensión, pero reducciones significativas en los estadios más severos y/o en la presencia de comorbidades. Los estudios longitudinales sugieren que el TC6 es sensible al aumento de la capacidad funcional porque hay adaptaciones advenidas de programas de rehabilitación física. Dos importantes limitaciones comprometen la validad externa de los estudios: muestras con fenotipos específicos (mismo sexo; mismo estadio de HAS; edad estrecha) y pequeño tamaño de la muestra (entre 8 y 32 participantes). La baja cualidad metodológica de los estudios resalta la necesidad de investigaciones con muestras mayores y espectro más amplio de fenotipos de hipertensión.
Hipertensión; Rehabilitación; Literatura de Revisión como Asunto
Este trabalho revisou sistematicamente os estudos sobre teste de caminhada de seis minutos (TC6) para avaliação da capacidade funcional de adultos com hipertensão submetidos ou não à reabilitação física, com foco na distância caminhada (DC6) e pressão arterial. Uma busca na literatura foi conduzida no PubMed, SciELO, LILACS, PEDro, Cochrane, Redalyc e em periódicos nacionais de fisioterapia com as palavras-chave "hipertensão" (hypertension) e "teste de caminhada de seis minutos" (six-minute walk test) sem restrição de idioma e período. Foram incluídos um estudo caso-controle, um ensaio clínico, dois quase-experimentais e duas séries de casos. Os estudos seccionais sugerem preservação da DC6 nos estágios leves da hipertensão, mas reduções significativas nos estágios mais graves e/ou na presença de comorbidades. Os estudos longitudinais sugerem que o TC6 é sensível ao aumento da capacidade funcional em razão das adaptações oriundas dos programas de reabilitação física. Duas importantes limitações comprometem a validade externa dos estudos incluídos: amostras com fenótipos específicos (mesmo sexo; mesmo estágio de HAS; faixa etária estreita) e pequeno tamanho amostral (entre 8 e 32 participantes). A baixa qualidade metodológica dos estudos reforça a necessidade de pesquisas com amostras maiores e espectro mais amplo de fenótipos de hipertensão.
Hipertensão; Reabilitação; Literatura de Revisão como Assunto
INTRODUCTION
The systemic arterial hypertension is a public health issue with a prevalence estimated
at 3.3% in 2010, in Brazil11. Ministério da Saúde. Secretaria executiva. Datasus. Informações de
saúde. Indicadores de fatores de risco e proteção. [Citado 17 maio 2013]. Disponível
em: http://datasus.saude.gov.br/.
http://datasus.saude.gov.br/...
. High blood pressure
increases death risk due to cardiovascular diseases (CDD)22. Mancia G, Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et
al. Management of Arterial Hypertension of the European Society of Hypertension;
European Society of Cardiology. The Task Force for the Management of Arterial
Hypertension of the European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105-87. and is associated with blood functional anatomy adjustments that result in
injuries of target-organs like heart, kidneys, and brain22. Mancia G, Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et
al. Management of Arterial Hypertension of the European Society of Hypertension;
European Society of Cardiology. The Task Force for the Management of Arterial
Hypertension of the European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105-87.. Blood remodeling also happens in the musculoskeletal vessels33. Hernández N, Torres SH, Finol HJ, Vera O. Capillary changes in
skeletal muscle of patients with essential hypertension. Anat Record.
1999;256(4):425-32., which individually compromises its function and
globally results in functional limitation of the hypertensive adult44. Hajjar I, Lackland DT, Cupples LA, Lipsitz LA. Association between
concurrent and remote blood pressure and disability in older adults. Hypertension.
2007;50(6):1026-32.. Functional capacity investigation may contribute for
comprehending hypertension limitations, as well as for determining the effects of
interventions and planning of strategies aimed at preventing disabilities due to
injuries in the target-organs.
Among the methods of functional capacity evaluation in hypertensive subjects55. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of
illness in the aged. The index of ADL: a standardized measure of biological and
psychosocial function. JAMA. 1963;185(12):914-9.
6. Nagi SZ. Congruency in medical and self-assessment of disability. IMS
Ind Med Surg. 1969;38(3):27-36.
7. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, Forman
D, et al. Clinician's Guide to cardiopulmonary exercise test in adults: a scientific
statement from the American Heart Association. Circulation.
2010;122(2):191-225.
8. McGavin CR, Gupta SP, McHardy GJ. Twelve-minute walking test for
assessing disability in chronic bronchitis. Br Med J.
1976;1(6013):822-3.
9. Butland RJ, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six-, and
twelve-minute walking distance tests in respiratory disease. Br Med J.
1982;284(6329):1607-8.
-
1010. Gusmão JL, Mion Jr D, Pierin AMG. Health-related quality of life and
blood pressure control in hypertensive patients with and without complications.
Clinics. 2009;64(7):619-29., the six-minute walking test (6MWD) is applied
due to its simplicity and easy use1111. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor
DW, et al. The 6-minute walk: a new measure of exercise capacity in patients with
chronic heart failure. Can Med Assoc J. 1985;132(8):919-23.
,
1212. Solway S, Brooks D, Lacasse Y, Thoimas S. A qualitative systematic
overview of the measurement properties of functional walk tests used in the
cardiorespiratory domain. Chest. 2001;119(1):256-70.. The 6MWD assesses the tolerance to
self-limited exercise and is similar to daily life activities (DLAs), therefore it
becomes clinically attractive99. Butland RJ, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six-, and
twelve-minute walking distance tests in respiratory disease. Br Med J.
1982;284(6329):1607-8.
,
1111. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor
DW, et al. The 6-minute walk: a new measure of exercise capacity in patients with
chronic heart failure. Can Med Assoc J. 1985;132(8):919-23.
,
1212. Solway S, Brooks D, Lacasse Y, Thoimas S. A qualitative systematic
overview of the measurement properties of functional walk tests used in the
cardiorespiratory domain. Chest. 2001;119(1):256-70.. The American Thoracic Society (ATS)
stablished indications, safety measures and procedures to apply the 6MWD1313. ATS Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J
Respir Crit Care Med. 2002;166(1):111-7.. The distance walked during the 6MWD (DW6) is
used as a closure for the evaluation of adjustments from physical rehabilitation
protocols and for the study of factors associated with functional capacity in absolute
values or percentages cited in equations obtained from the healthy population1313. ATS Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J
Respir Crit Care Med. 2002;166(1):111-7.
,
1414. Papathanasiou JV, Ilieva E, Marinov B. Six-minute waling test: an
effective and necessary tool in modern cardiac rehabilitation. Hellenic J Cardiol.
2013;54(2):126-30.. However, it is not clear if the 6MWD is an
indicator of functional incapacity in hypertension and if it captures adjustments
performed at physical rehabilitation programs. Therefore, this paper systematically
reviewed studies on the 6MWD to assess the functional capacity of adults with high blood
pressure submitted, or not, to physical rehabilitation focused on the 6DW and blood
pressure (BP).
METHODOLOGY
A systematic review15 15. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-9.was conducted in free electronic databases like PubMed, Scielo, LILACS, PEDro, Cochrane and Redalyc using the keywords "hypertension" (hipertensão) and "six-minute walking test" (teste de caminhada de seis minutos) without language and time constraints. Additional research was conducted in sites of Brazilian journals about physical therapy (Revista Brasileira de Fisioterapia; Revista Fisioterapia e Pesquisa; Revista Fisioterapia em Movimento). The last research was done on April 2013 (Figure 1).
Abstracts from the identified articles were examined as to the inclusion criteria: articles (originals), outline (all except review), target population (>18 years old; both genders), diagnosis (systemic arterial hypertension, with or without comorbidities), intervention (none; physical rehabilitation), and observation or intervention outcomes (6DW; systolic and diastolic BP). Double copies between the referred basis and studies about other diseases (e.g. pulmonary arterial hypertension) were excluded.
After completely reading the included studies, the following information were gotten: outline; samples (case and control groups if applicable); clinical characteristics; systolic and diastolic BP values (baseline and post-intervention if applicable); absolute values of 6DW (in meters); and assumed 6DW values (in the percentages and equations used). Incomplete pieces of information were achieved by mailing the authors, whenever it was possible. Data were typed in an electronic spreadsheet with automatic control of data validation with regard to consistence, which is available upon request to the authors.
The methodological quality of studies was assessed by bias criteria1616. Higgins JPT, Green S. Cochrane handbook for systematic reviews of
interventions, version 5.1.0 2009 [updated March 2011]. The Cochrane Collaboration.
[Citado 17 maio 2013]. Disponível em: http://handbook.cochrane.org/
http://handbook.cochrane.org/...
: selection, performance, detection, discord, and report. Quality
was ranked as low/inaccurate/high risk of bias (low risk: "Yes"; high risk: "No"; other
cases: "Inaccurate"). Studies were classified in three levels: low risk of bias (all
items = "low risk"), high risk (at least one item = "high risk") and inaccurate (at
least one item = "inaccurate risk"). All procedures were independently performed by two
examiners, and disagreements were solved by mutual agreement.
RESULTS
Seventy-six articles were found and six of them were included in this study: one
case-control study1717. Ribeiro A, Younes C, Mayer D, Fréz AR, Riedi C. Teste de caminhada
de seis minutos para avaliação de mulheres com fatores de risco cardiovascular.
Fisioter Mov. 2011;24(4):713-9., one clinical essay1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação
cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres
hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6., two quasi-experimental1919. Lima MMO, Britto RR, Baião EA, Alves GS, Abreu CDG, Parreira VF.
Exercício aeróbico no controle da hipertensão arterial na pós-menopausa. Fisioter
Mov. 2011;24(1):23-31.
,
2020. Souza JF, Nogueira IDB, Lira MJL, Silva EC, Ferreira GMH, Nogueira
PAMS. Correlação entre capacidade funcional e qualidade de vida em idosas hipertensas
submetidas a treinamento resistido. ConScientiae Saúde.
2011;10(2):312-8., and two case reports2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64.
,
2222. Pedrosa R, Holanda G. Correlação entre os testes da caminhada,
marcha estacionária e TUG em hipertensas idosas. Rev Bras Fisioter.
2009;13(3):252-6. (Table
1). The sample size varied from eight in the clinical essay1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação
cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres
hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6. to 45 subjects in the case-control study1717. Ribeiro A, Younes C, Mayer D, Fréz AR, Riedi C. Teste de caminhada
de seis minutos para avaliação de mulheres com fatores de risco cardiovascular.
Fisioter Mov. 2011;24(4):713-9.. Studies analyzed patients grouped per gender,
hypertension stage, and/or age range. Most studies followed integrally or partially all
recommendations from the ATS1313. ATS Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J
Respir Crit Care Med. 2002;166(1):111-7. for the 6MWD. Two
studies1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação
cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres
hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6.
,
2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64. calculated the predicted distance with
reference equations for the healthy population2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk
in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7.
24. Troosters T, Gosselink R, Decramer M. Six minute walking distance in
healthy elderly subjects. Eur Respir J. 1999;14(2):270-4.
-
2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98.. All studies included reported the use of drug
therapy for hypertension and good tolerance to the 6MWD, and none of them reported side
effects of the 6MWD.
Characteristics of the Studies
Ribeiro et al.1717. Ribeiro A, Younes C, Mayer D, Fréz AR, Riedi C. Teste de caminhada de seis minutos para avaliação de mulheres com fatores de risco cardiovascular. Fisioter Mov. 2011;24(4):713-9. compared the functional capacity of hypertensive and diabetic (G1), hypertensive (G2) and healthy (G3) women. The 6MWD was applied twice according to the ATS1313. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. recommendations with one-hour interval between the repetitions. Significantly higher values in the second 6MWD (p<0.05) were seen in all groups. It was observed a significant difference between the three groups (G1<G2<G3; p<0.05). Values of systolic (SBP) and diastolic (DBP) BP and of heart frequency (HF) showed significant increases after the 6MWD (p<0.05), which confirms the characteristics of safety and sub-maximum test.
Accyoli e Piotto1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6. analyzed the cardiovascular adaptations induced by a cardiac rehabilitation program in hypertensive sedentary women. Voluntaries were randomly assigned into two groups, and undergone a program conducted in a therapeutic pool (G1) and on the floor (G2) during eight weeks, twice a week, for an hour. 6MWD was performed satisfying ATS requirements1313. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7.. Although the study mentions using a prediction equation2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7., the 6DW numerical results and predicted values were not presented. There was a significant decrease in the SBP (p=0.034) and DBP (p=0.020), therefore there may have been a good result of the physical exercise to control BP.
Lima et al.1919. Lima MMO, Britto RR, Baião EA, Alves GS, Abreu CDG, Parreira VF. Exercício aeróbico no controle da hipertensão arterial na pós-menopausa. Fisioter Mov. 2011;24(1):23-31. investigated the result of a 12-week aerobic training in the functional capacity and in controlling BP of stage I hypertensive, sedentary and going through menopause women. The rehabilitation program consisted of aerobic activity of moderate intensity (warming, stretching, walking, stretching and relaxing) for 50 minutes. 6MWD was performed following ATS protocol1313. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7.. The study showed an increase of the 6DW (p=0.009) after practice period and decrease of BP values (p=0.033), therefore the aerobic training may contribute for hemodynamic and functional improvement.
Souza et al.2020. Souza JF, Nogueira IDB, Lira MJL, Silva EC, Ferreira GMH, Nogueira PAMS. Correlação entre capacidade funcional e qualidade de vida em idosas hipertensas submetidas a treinamento resistido. ConScientiae Saúde. 2011;10(2):312-8. analyzed the correlation between functional capacity and quality of life of women who have undergone an enduring and self-stretching training program for ten weeks. The women performed the 6MWD according to ATS recommendations1313. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7., and quality of life was assessed by the SF36 questionnaire. It was seen a decrease of BP values after the training period (p<0.05), but there was no significant increase in the 6DW (p=0.081) nor in the functional capacity domain of the SF36 (p=0.72). Authors suggest a moderate positive correlation between 6DW and SF36 domains that express the functional capacity.
Costa et al.2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64. tested the
association between BP, perceived effort index (PEI) and 6DW in men at hypertension
stage I. The 6MWD was performed according to ATS (2002) and the predicted 6DW was
calculated by three equations2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk
in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7.
24. Troosters T, Gosselink R, Decramer M. Six minute walking distance in
healthy elderly subjects. Eur Respir J. 1999;14(2):270-4.
-
2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98.. Results showed 6DW predicted by Enright
et al.2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98. equation
significantly overestimated (p=0.022), but there were no significant differences
according to other equations2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk
in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7.
,
2424. Troosters T, Gosselink R, Decramer M. Six minute walking distance in
healthy elderly subjects. Eur Respir J. 1999;14(2):270-4..
Pedrosa and Holanda2222. Pedrosa R, Holanda G. Correlação entre os testes da caminhada, marcha estacionária e TUG em hipertensas idosas. Rev Bras Fisioter. 2009;13(3):252-6. tested the correlation between two-minute stationery gait test (2SGT), timed up and go test (TUG) and 6MWD. Aged hypertensive women were assessed without hormonal replacement for menopause. The study did not report if the ATS recommendations were followed1313. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7.. Participants performed three tests with a ten-minute break. All chosen women performed the tests without intercurrences. Significant correlations between 6DW and TUG (r=-0.59; p<0.001) and between 6DW and 2SGT (r=-0.66; p<0.001) suggested a relation between cardiovascular resistance and functional mobility.
Bias risk analysis can be seen in Figure 2. It was seen a high bias risk of selection in the longitudinal studies due to the insufficient or absent randomization description. Other studies present high risk for outcome bias because they do not present all outcome data. The majority of studies presented inaccurate bias risk due to lack of description of methods.
DISCUSSION
This paper systematically reviewed studies about 6MWD to evaluate the functional
capacity of adults with high blood pressure who had been or had not been submitted to
physical rehabilitation. The sectional studies suggest that in light hypertension
stages, there is no significant alteration in the functional capacity as evaluated by
the 6MWD2222. Pedrosa R, Holanda G. Correlação entre os testes da caminhada,
marcha estacionária e TUG em hipertensas idosas. Rev Bras Fisioter.
2009;13(3):252-6., but significant decreases can be seen
in more severe stages and/or in the presence of comorbidities1717. Ribeiro A, Younes C, Mayer D, Fréz AR, Riedi C. Teste de caminhada
de seis minutos para avaliação de mulheres com fatores de risco cardiovascular.
Fisioter Mov. 2011;24(4):713-9.
,
2222. Pedrosa R, Holanda G. Correlação entre os testes da caminhada,
marcha estacionária e TUG em hipertensas idosas. Rev Bras Fisioter.
2009;13(3):252-6.. On the other hand, longitudinal studies
suggest that 6MWD is sensitive to the increase of functional capacity due to the
adjustments from physical rehabilitation programs1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação
cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres
hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6.
19. Lima MMO, Britto RR, Baião EA, Alves GS, Abreu CDG, Parreira VF.
Exercício aeróbico no controle da hipertensão arterial na pós-menopausa. Fisioter
Mov. 2011;24(1):23-31.
-
2020. Souza JF, Nogueira IDB, Lira MJL, Silva EC, Ferreira GMH, Nogueira
PAMS. Correlação entre capacidade funcional e qualidade de vida em idosas hipertensas
submetidas a treinamento resistido. ConScientiae Saúde.
2011;10(2):312-8.. Two studies1818. Accyoli MF, Piotto RF. Efeito de um programa de reabilitação
cardíaca - fase III realizado em piscina terapêutica e no solo, em mulheres
hipertensas. Rev Inst Ciênc Saúde. 2007;25(2):141-6.
,
20 20. Souza JF, Nogueira IDB, Lira MJL, Silva EC, Ferreira GMH, Nogueira
PAMS. Correlação entre capacidade funcional e qualidade de vida em idosas hipertensas
submetidas a treinamento resistido. ConScientiae Saúde.
2011;10(2):312-8.calculated the predicted 6DW, but only
one2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64. reported the predicted values using
international equations2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk
in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7.
24. Troosters T, Gosselink R, Decramer M. Six minute walking distance in
healthy elderly subjects. Eur Respir J. 1999;14(2):270-4.
-
2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98.. This review also identified the high or
inaccurate bias risk in most analyzed criteria.
The high or inaccurate bias risk in the included studies is not uncommon in systematic reviews, but it compromises authors' inferences on the results of the studies alone or collectively2626. Garg AX, Hackam D, Tonelli M. Systematic review and meta-analysis: When one study is just not enough. Clin J Am Soc Nephrol. 2008;3(1):253-60.. Two important methodological limitations were common in the reviewed studies and contributed for the bias risk: approach of specific phenotypes (same gender, same hypertension stage, narrow age range) and small sample size. The study of population subgroups is justified due to the group's higher homogenization because of the varied phenotype of hypertension, but it also characterizes an spectrum bias2727. Willis BH. Spectrum bias - why clinicians need to be cautions when applying diagnostic test studies. Fam Pract. 2008;25(5):390-6. that, when combined to the small sample size, limits even more the external validity of these studies. Another interesting point is the identification of only Brazilian studies. Although both the quantity of longitudinal studies and also sectional ones in adults with CDD have been increasing all around the world, most international studies include patients with heart failure (associated or not with hypertension) or pulmonary arterial hypertension1212. Solway S, Brooks D, Lacasse Y, Thoimas S. A qualitative systematic overview of the measurement properties of functional walk tests used in the cardiorespiratory domain. Chest. 2001;119(1):256-70. , 1414. Papathanasiou JV, Ilieva E, Marinov B. Six-minute waling test: an effective and necessary tool in modern cardiac rehabilitation. Hellenic J Cardiol. 2013;54(2):126-30., which explains the reduced amount of studies included in the qualitative analysis.
The predicted 6DW was highly overestimated by one2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98. among three2323. Enright PL, Sherrill DL. Reference equations for the six-minute walk
in healthy adults. Am J Respir Crit Care Med. 1998;158(5):1384-7.
24. Troosters T, Gosselink R, Decramer M. Six minute walking distance in
healthy elderly subjects. Eur Respir J. 1999;14(2):270-4.
-
2525. Enright PL, McBurnie MA, Bittner V, Tracy RP, McNamara R, Arnold A,
et al. The 6-minute walk test - a quick measure of functional status in elderly
adults. Chest. 2003;123(2):387-98. international equations used in one included
study2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64.. Brazilian equations of 6DW prediction
in a healthy adult population2828. Iwama AM, Andrade GN, Shima P, Tanni SE, Godoy I, Dourado VZ. The
six- minute walk test and body weight-walk distance product in healthy Brazilian
subjects. Braz J Med Biol Res. 2009;42(11):1080-5.
29. Dourado VZ, Vidotto MC, Guerra RLF. Equações de referência para os
testes de caminhada de campo em adultos saudáveis. J Bras Pneumol.
2011;37(5):607-14.
-
3030. Soares MR, Pereira CAC. Teste de caminhada de seis minutos: valores
de referência para adultos saudáveis no Brasil. J Bras Pneumol.
2011;37(5):576-83. were not available at the time of Costa
et al.2121. Costa HS, Martins AMB, Quirino FC, Severino G, Novais LD, Lima MMO.
Capacidade funcional em homens hipertensos ela distância caminhada e correlação com
valores preditos. Fisioter Mov. 2009;22(4):557-64. study, and they
should be firstly analyzed in future studies due to the regional differences in 6DW3131. Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, et
al. The 6-min walk distance in healthy subjects: reference standards from seven
countries. Eur Respir J. 2010;37(1):150-6..
It should be emphasized that the development of a systematic review does not overcome
the outline problems of the included studies, which is one of their main
limitations3232. Higgins JPT, Altman DG, Gotzsche PC, Jüni P, Moher D, Oxman AD, et
al. The Cochrane Collaboration's tool for assessing risk of bias in randomised
trials. BMJ. 2011;343:d5928.. However, following
international recommendations15 15. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group (2009).
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA
statement. Ann Intern Med. 2009;151(4):264-9.for its
accomplishment minimize the subjectivity of results and its impact on the
interpretations of the included studies3232. Higgins JPT, Altman DG, Gotzsche PC, Jüni P, Moher D, Oxman AD, et
al. The Cochrane Collaboration's tool for assessing risk of bias in randomised
trials. BMJ. 2011;343:d5928.. Given
the high prevalence of hypertension in the adult Brazilian population11. Ministério da Saúde. Secretaria executiva. Datasus. Informações de
saúde. Indicadores de fatores de risco e proteção. [Citado 17 maio 2013]. Disponível
em: http://datasus.saude.gov.br/.
http://datasus.saude.gov.br/...
and its association with functional
disability44. Hajjar I, Lackland DT, Cupples LA, Lipsitz LA. Association between
concurrent and remote blood pressure and disability in older adults. Hypertension.
2007;50(6):1026-32., new studies with more
representative samples (wide spectrum of phenotypes) should be carried out in order to
determine the reference values of 6MWD in hypertensive adults to use in the physical
rehabilitation and to find factors associated with 6DW in such population.
CONCLUSIONS
The functional capacity may be decreased in more severe stages of hypertension and/or in the presence of comorbidities. 6MWD seems sensitive to the increase of functional capacity resulting from physical rehabilitation programs in hypertensive patients. Low methodological quality of studies reinforces the need of researches with bigger samples and a wider spectrum of hypertension phenotypes.
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28Iwama AM, Andrade GN, Shima P, Tanni SE, Godoy I, Dourado VZ. The six- minute walk test and body weight-walk distance product in healthy Brazilian subjects. Braz J Med Biol Res. 2009;42(11):1080-5.
-
29Dourado VZ, Vidotto MC, Guerra RLF. Equações de referência para os testes de caminhada de campo em adultos saudáveis. J Bras Pneumol. 2011;37(5):607-14.
-
30Soares MR, Pereira CAC. Teste de caminhada de seis minutos: valores de referência para adultos saudáveis no Brasil. J Bras Pneumol. 2011;37(5):576-83.
-
31Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, et al. The 6-min walk distance in healthy subjects: reference standards from seven countries. Eur Respir J. 2010;37(1):150-6.
-
32Higgins JPT, Altman DG, Gotzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
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Financing source: Fundação Carlos Chagas Filho de Amparo à Pesquisa no Estado do Rio de Janeiro (FAPERJ) by program APQ1 (E-26/110.450/2012)
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Study conducted at the Centro Universitário Augusto Motta (UNISUAM) - Rio de Janeiro (RJ), Brazil.
Publication Dates
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Publication in this collection
Jul-Sep 2014
History
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Received
June 2013 -
Accepted
Aug 2014