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 Table of Contents  
Year : 2019  |  Volume : 13  |  Issue : 1  |  Page : 14-17

Validation of Duke Activity Status Index questionnaire to determine functional capacity in young healthy nonexercising individuals

Physiotherapy Department, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India

Date of Submission30-Oct-2018
Date of Acceptance01-Apr-2019
Date of Web Publication29-Jun-2019

Correspondence Address:
Dr. Razia Nagarwala
11/12, Thube Park, Shivajinagar, Pune - 411 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PJIAP.PJIAP_38_18

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OBJECTIVE: The objective of the study is to correlate maximum oxygen uptake (VO2 max) obtained from subjective measure using Duke Activity Status Index (DASI) scale with objective assessment of aerobic capacity measured by VO2 max during submaximal exercise testing in young healthy individuals.
MATERIALS AND METHODS: Fifty-eight young healthy nonexercising individuals were recruited in the study according to inclusion and exclusion criteria. The participants were made to undergo exercise testing on treadmill using modified Bruce protocol and maximal aerobic capacity was calculated. The participants were made to answer DASI questionnaire, and VO2 max was calculated using the questionnaire.
RESULTS: There was a statistically significant but moderate correlation (r = 0.339 and P= 0.001) found between VO2 max obtained from DASI scale and VO2 max obtained from exercise testing.
CONCLUSION: The subjective functional scales (DASI) used to assess basic physical capacity have moderate ability to predict actual functional capacity as measured by VO2 max achieved by objective assessment of aerobic capacity by exercise testing in young healthy individuals.

Keywords: Cardiopulmonary exercise testing, Duke Activity Status Index, VO2 max

How to cite this article:
Khan S, Nagarwala R, Shyam A, Sancheti P. Validation of Duke Activity Status Index questionnaire to determine functional capacity in young healthy nonexercising individuals. Physiother - J Indian Assoc Physiother 2019;13:14-7

How to cite this URL:
Khan S, Nagarwala R, Shyam A, Sancheti P. Validation of Duke Activity Status Index questionnaire to determine functional capacity in young healthy nonexercising individuals. Physiother - J Indian Assoc Physiother [serial online] 2019 [cited 2023 Mar 21];13:14-7. Available from: https://www.pjiap.org/text.asp?2019/13/1/14/261819

  Introduction Top

Directly measured maximum oxygen uptake (VO2 max) is considered as the most valid measure of functional capacity of the cardiorespiratory system. The VO2 max, or rate of oxygen uptake during maximal exercise, reflects the capacity of the heart, lungs, and blood to deliver oxygen to the working muscles during dynamic exercise involving large muscle mass.[1] VO2 max is widely accepted as the criterion measure of cardiorespiratory fitness. In clinical and research settings, VO2 max is typically measured directly, using expensive equipment and experienced personnel. Although VO2 max can be predicted from maximal exercise intensity, submaximal exercise tests also provide a reasonable estimate of cardiorespiratory fitness level.

Exercise testing is a cardiovascular stress test using treadmill or bicycle exercise and electrocardiographic and blood pressure monitoring. Cardiopulmonary exercise testing is performed clinically to obtain an objective assessment of a patient's functional status, to evaluate symptoms, to assess the efficacy of therapeutic interventions, to estimate prognosis, and to determine disability. Maximal exercise testing cannot be feasible because of financial, physical, or time limitations or maximal exercise testing may expose a given patient to higher-than-normal risk. Several self-administered and interview-based activity questionnaires have been developed to estimate a patient's exercise capacity.[2],[3],[4],[5],[6],[7],[8]

Oxygen uptake (VO2), carbon dioxide production, and cardiopulmonary parameters such as heart rate and minute ventilation are directly measured during cardiopulmonary exercise test (CPET). Although CPET is the noninvasive gold standard for determining dynamic cardiac fitness, it does have its disadvantages. It requires qualified personnel to perform the test, and laboratory equipment, machinery, and well-equipped institute may be difficult to access from rural settings. CPET is generally a safe procedure, but both myocardial infarction and death have been reported and can be expected to occur at a rate of up to 1 per 2500 tests.[9] Hence, good clinical judgment is needed before giving CPET, keeping in mind indications and contraindications of the test.

Furthermore, it is difficult to use in large population studies, especially if follow-up measurements are needed to judge the effects of therapy. Hence, functional capacity is also assessed indirectly by inquiring about the patient's ability to perform various activities. One such measure is a well-recognized functional capacity tool, the Duke Activity Status Index (DASI), which is a self-administered questionnaire that measures the ability to perform a set of 12 common activities of daily living. It has been validated as the “gold standard” of functional capacity measurement, i.e., peak oxygen intake during exercise.[2] The nonweighted DASI is scored as 1 point for each activity, whereas the weighted score is calculated by adding together the “MET units” for each activity. Metabolic equivalents (METs) units are a measure of the metabolic cost of the activity and were derived in the original study by Hlatky et al. [Table 1].[2]
Table 1: Duke Activity Status Index Hlatky et al.[2]

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DASI has been used to monitor progress in patients with coronary artery disease (CAD), has demonstrated prognostic value in patients with chronic heart failure, and can be used to identify those with reduced long-term survival following cardiac surgery.[10],[11],[12] It can also be used as a predictor of abnormal myocardial perfusion scintigraphy, for the diagnosis and management of CAD.[13]

The activities in the scale [Table 1] are chosen to represent major aspects of physical function, i.e., personal care, ambulation, household tasks, sexual function, and recreational activities. As such, these responses can also be used to assess physical limitations relevant to the patient's quality of life. The scale is widely used in cardiac disease patients and is used to calculate their functional capacity. By this study, we aim to find if DASI scale can be validated in young healthy individuals to calculate their functional capacity. Hence, by this study, we aim to identify correlations between subjective reporting of physical capabilities and symptoms and objective determinates of functional capacity measured by CPET in young healthy nonexercising individuals.

  Materials and Methods Top


Fifty-eight sedentary (≤150 min of aerobic exercise a week) young individuals between 18 and 28 years of age were recruited to participate in this study. Before starting the program, all participants had to accept their voluntary participation by signing an informed consent form.

The inclusion criteria included males and females in 18–28 years age group who were healthy, nonexercising, recreationally active adults without any comorbid illness.

The exclusion criteria were participants with BMI >40 kg/m 2, any neuromusculoskeletal problems, cardiovascular and respiratory problems, smokers, and any other systemic illness.

Fifty-eight participants were made to answer self-administered questionnaire and DASI and VO2 max were calculated according to the formula:

VO2 peak = (0.43 × DASI score) +9.6 from the questionnaire.[2]

The participants were also made to undergo modified Bruce protocol on treadmill.

The equation for calculation of VO2 max using modified Bruce protocol is – VO2 max = 3.5+ (0.1 × speed) + (1.8 × speed × grade)[14]

DASI = sum of “yes” replies ___________

VO2 peak = (0.43 × DASI) +9.6

VO2 peak = ___________ ml/kg/min ÷ 3.5 ml/kg/min = __________ METS

Statistical analysis

Statistical analysis was done using SPSS-16 (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). The association of DASI scale was measured with VO2 max using Spearman correlation coefficient.

  Results Top

According to [Table 2], the P value was found to be < 0.05, P = 0.009, and hence, it was statistically significant. Bruce VO2 max and DASI VO2 max have a statistically linear relationship. The magnitude and strength of relation are moderate correlation (0.3< / r / <0.5, r = 0.339).
Table 2: Association of DASI scale with Bruce Vo2 max

Click here to view

  Discussion Top

This study shows that a brief, self-administered questionnaire can provide a standardized assessment of functional status that correlates well with an objective measure of maximal exercise capacity. DASI scale uses the patient's ability to perform a set of common activities of daily living to calculate functional capacity. The activities in the scale [Table 1] represent major aspects of physical function – personal care, ambulation, household tasks, sexual function, and recreational activities. These responses can also be used to assess physical limitations relevant to the patient's quality of life.

DASI had a statistically significant (P < 0.01) Spearman correlation with VO2 max by modified Bruce protocol. DASI showed moderate correlation, r = 0.339, when DASI was used as a self-administered questionnaire. A study conducted by Coutinho-Myrrha et al. found a moderate correlation between self-administered DASI scale and exercise testing by Bruce protocol in patients with cardiovascular diseases (r = 0.58 and P < 0.001).[15] This is because the DASI assesses the functional capacity perceived by the individual, which is a subjective measure, while exercise test gives the objective measure of the maximum capacity (VO2 max). A study conducted by Rankin et al. found good correlation between specific activity questionnaire and VO2 peak by exercise test in cardiac patients, r = 0.6216.[7] Arena et al. found a moderate correlation between DASI score and VO2 peak during symptom-limited exercise testing in a group of outpatients with heart failure, r = 0.6417[16] and P < 0.001.

DASI is a useful tool in clinical practice, and in research, it is used to find out different disease severity, assess effects of medical treatment,[17] assess cardiac rehabilitation, and provide relevant information to clinical decisions.[18],[19] Despite the great clinical and scientific utility, the DASI may not be suitable to differentiate individuals with high functional capacity, due to a ceiling effect found in this and other studies.[20] This effect exists when more than 15% of the sample reaches the total score. In our study, 65% of the total sample (n = 58) obtained the total score. This can be because patients with normal functional capacity may underestimate their ability to attend school/work, walk, run, and climb stairs and overestimate their degree of fatigue, palpitations, and chest pain on the questionnaire.

DASI has a good clinical correlation as it provides information about activities limited by the disease and its impact on patient's life. It tells us in which aspect of functional activity patients life is hampered because of the disease. In this study, DASI presented appropriated characteristics to be considered a good tool in considering exercise capacity in healthy young individuals apart from being used in only diseased patients and as a rehabilitation tool.

  Conclusion Top

There was found to be moderate correlation between aerobic capacity (Vo2 max) calculated by exercise testing and aerobic capacity calculated using functional outcome measure of DASI among young healthy individuals. Thus, one can use DASI for measuring functional capacity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Heywards V. Advanced Fitness Assessment Exercise Prescription. 7th ed. USA: Burgess Publishing Company; 2014. p. 79.  Back to cited text no. 1
Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651-4.  Back to cited text no. 2
Myers J, Do D, Herbert W, Ribisl P, Froelicher VF. A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol 1994;73:591-6.  Back to cited text no. 3
Bader DS, McInnis KJ, Maguire TE, Pierce GL, Balady GJ. Accuracy of a pretest questionnaire in exercise test protocol selection. Am J Cardiol 2000;85:767-70, A8-9.  Back to cited text no. 4
Lee TH, Shammash JB, Ribeiro JP, Hartley LH, Sherwood J, Goldman L, et al. Estimation of maximum oxygen uptake from clinical data: Performance of the Specific Activity Scale. Am Heart J 1988;115:203-4.  Back to cited text no. 5
Roy BA, Grove MA, Christie LG. A model for estimating oxygen uptake in patients who have undergone coronary bypass grafts. J Cardiopulm Rehabil 1992;12:111-6.  Back to cited text no. 6
Rankin SL, Briffa TG, Morton AR, Hung J. A specific activity questionnaire to measure the functional capacity of cardiac patients. Am J Cardiol 1996;77:1220-3.  Back to cited text no. 7
Chang RR, Gurvitz M, Rodriguez S, Hong E, Klitzner TS. Current practice of exercise stress testing among pediatric cardiology and pulmonology centers in the United States. Pediatr Cardiol 2006;27:110-6.  Back to cited text no. 8
Stuart RJ Jr., Ellestad MH. National survey of exercise stress testing facilities. Chest 1980;77:94-7.  Back to cited text no. 9
Alonso J, Permanyer-Miralda G, Cascant P, Brotons C, Prieto L, Soler-Soler J. Measuring functional status of chronic coronary patients. Reliability, validity and responsiveness to clinical change of the reduced version of the Duke Activity Status Index (DASI). Eur Heart J 1997;18:414-9.  Back to cited text no. 10
Parissis JT, Nikolaou M, Birmpa D, Farmakis D, Paraskevaidis I, Bistola V, et al. Clinical and prognostic value of Duke's Activity Status Index along with plasma B-type natriuretic peptide levels in chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 2009;103:73-5.  Back to cited text no. 11
Koch CG, Li L, Lauer M, Sabik J, Starr NJ, Blackstone EH. Effect of functional health-related quality of life on long-term survival after cardiac surgery. Circulation 2007;115:692-9.  Back to cited text no. 12
George MJ, Kasbekar SA, Bhagawati D, Hall M, Buscombe JR. The value of the duke activity status index (DASI) in predicting ischaemia in myocardial perfusion scintigraphy – A prospective study. Nucl Med Rev Cent East Eur 2010;13:59-63.  Back to cited text no. 13
Linda S. Pescatello, Ross Arena, Deborah Riebe, Paul D. ACSM Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia, PA: Thompson; 2014.  Back to cited text no. 14
Coutinho-Myrrha MA, Dias RC, Fernandes AA, Araújo CG, Hlatky MA, Pereira DG, et al. Duke activity status index for cardiovascular diseases: Validation of the Portuguese translation. Arq Bras Cardiol 2014;102:383-90.  Back to cited text no. 15
Arena R, Humphrey R, Peberdy MA. Using the Duke Activity Status Index in heart failure. J Cardiopulm Rehabil 2002;22:93-5.  Back to cited text no. 16
Instituto Brasileiro de Geografia e Estatística. (IBGE) Brazilian institute of geography and statistics. Censo; 2010. Available from: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/. [Last accessed on 2012 Nov 11].  Back to cited text no. 17
Scotto CJ, Waechter DJ, Rosneck J. Adherence to prescribed exercise and diet regimens two months post-cardiac rehabilitation. Can J Cardiovasc Nurs 2011;21:11-7.  Back to cited text no. 18
Hlatky MA, Rogers WJ, Johnstone I, Boothroyd D, Brooks MM, Pitt B, et al. Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. Bypass angioplasty revascularization investigation (BARI) investigators. N Engl J Med 1997;336:92-9.  Back to cited text no. 19
Alonso J, Permanyer-Miralda G, Cascant P, Brotons C, Prieto L, Soler-Soler J, et al. Measuring functional status of chronic coronary patients. Reliability, validity and responsiveness to clinical change of the reduced version of the Duke Activity Status Index (DASI). Eur Heart J 1997;18:414-9.  Back to cited text no. 20


  [Table 1], [Table 2]

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[Pubmed] | [DOI]


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