Six Minute Walk Test (6MWT)

GENERAL DESCRIPTION
Purpose The original purpose of the six minute wal was to test exer!ise toleran!e in !hroni! respirator" #isease an# heart failure$ The test has sin!e %een use# as a performan!e&%ase# measure of fun!tional exer!ise !apa!it" in other populations in!lu#ing health" ol#er a#ults' people un#ergoing nee or hip arthroplast"' fi%rom"algia' an# s!lero#erma$ It has also %een use# with !hil#ren$ Content The six&minute wal test ()*+T, measures the #istan!e an in#i-i#ual is a%le to wal o-er a total of six minutes on a har#' flat surfa!e$ The goal is for the in#i-i#ual to wal as far as possi%le in six minutes$ The in#i-i#ual is allowe# to self&pa!e an# rest as nee#e# as the" tra-erse %a! an# forth along a mar e# wal wa"$ Developer/contact information The )*+T was #e-elope# in ./)0 %" 1al e to e-aluate fun!tional !apa!it"1$ Different -ariations of the time# wal ha-e %een teste#' an# the six minute time# wal was re!ommen#e#

gi-en its repro#u!i%ilit" an# ease of a#ministration !ompare# to longer time# tests2$ Later stu#ies showe# that time# wal s un#er 2 minutes were foun# to %e not as sensiti-e to e-aluate the #ifferen!es in wal e# #istan!es ! "$ #um$er of items in scale Not appli!a%le$ Su$scales Not appli!a%le$ Populations The )*+T was #e-elope# in frail el#erl" patients )3&/3 "ears of age referre# to a geriatri! hospital' an# it targets !ommunit" #welling frail el#ers1$ 4owe-er' the test has %een use# in a -ariet" of !hroni! #isease a#ult an# pe#iatri! populations as well as in health" a#ults$ %t&er uses The )*+T has also %een use# to #ete!t !hanges following inter-entions to impro-e exer!ise toleran!e for health" ol#er a#ults'! 6 as well as people with rheumatologi! !on#itions su!h as nee or hip osteoarthritis( an# fi%rom"algia)$ The )*+T has %een use# with a -ariet" of other !on#itions su!h as heart failure*! 1+' !hroni! o%stru!ti-e pulmonar" #isease (COPD,11 an# stro e12! 1 It has also %een use# to pre#i!t hospitali5ation an# mortalit"6!1"$

WHO ICF COMPONENTS

Changing an# maintaining %o#" position (#2.3&#26/, an# wal ing (#273,$

ADMINISTRATION
Met&o, This is i#eall" !on#u!te# in an en!lose#' 8uiet hallwa" %" a single a#ministrator$ 4owe-er' it is important to note that there are -ariations among stu#ies in how the test is !on#u!te# whi!h affe!ts performan!e$ These -ariations in!lu#e the instru!tions pro-i#e# to the parti!ipant' the num%er of turns in the !ourse' the fre8uen!" an# t"pe of en!ouragement gi-en' an# the num%er of trials performe#$ Ea!h of these -ariations will %e outline# %riefl"$ Test instructions- Due to the #iffering fun!tional statuses of parti!ipants' the ) minute wal test ma" !ause some people to perform at higher exertion le-els than others$ 9or patients with mo#erate to se-ere heart or lung #isease' there are #etaile# instru!tions pro-i#e# %" the Ameri!an Thora!i! So!iet" (ATS,1'whi!h highlight how patients ma" %e!ome out of %reath or exhauste# an# instru!t them on ta ing rest %rea s$ In !ontrast' some arti!les instru!t people to wal as 8ui! l" as possi%le1"$ +hile man" stu#ies #o not report the exa!t instru!tions' most #es!ri%e the instru!tion as ha-ing parti!ipants wal at their usual pa!e or a !omforta%le pa!e an# to wal as far as possi%le$

Parti!ipants are instru!te# prior to the test to wear !omforta%le !lothing an# shoes an# to use their t"pi!al wal ing ai# #uring the test$ Walk.a/ len0t& an, num$er of turns in t&e course- The ATS re!ommen#s an in#oor' 03 meter !orri#or or wal wa" with !ones pla!e# at the %eginning an# en# of the 03 meter %oun#ar" to in#i!ate turns$ In the literature' the !orri#or #istan!e a!ross stu#ies -aries whi!h is li el" #ue to the nee# to use what is rea#il" a-aila%le$ A re!ent stu#"22 in stro e patients suggest the 03 meter length (-ersus .3 or 63 meter, resulte# in the longest #istan!e !o-ere#$ Although trea#mills ha-e %een use# to !on#u!t the )*+T' trea#mills ma" un#erestimate# total #istan!e !ompare# to the stan#ar# metho# #one in a hallwa" or exer!ise room$27&2) 1se of 2ncoura0ement- En!ouragement is often gi-en an# is t"pi!all" stan#ar#i5e#' although it -aries in fre8uen!" a!ross stu#ies from pro-i#ing en!ouragement e-er" 03 se!on#s to e-er" 6 minutes$ En!ouragement in!reases the #istan!e wal e#6 an# if use#' the exa!t proto!ol shoul# %e reporte#$ #um$er of Trials Performe,- Num%er of trials has %een nown to in!rease ) minute wal #istan!e1(31*' with largest impro-ements seen o-er the first 0 trials"! 2+$ :ariation on the tests performe# is less than .3; %etween the first two

trials an# ma" refle!t true -ariation in fun!tional !apa!it" 1(! 21 $ Therefore' one to two pra!ti!e trials ma" %e useful"$ In most populations' at least two pra!ti!e wal s shoul# %e a#ministere# (with a#e8uate time for rest an# re!o-er", prior to re!or#ing measurements22$ Safet/ 4ssues an, Contrain,ications- As with an" ph"si!al performan!e test' te!hni!ians shoul# ha-e !ertifi!ation in 1asi! Life Support$ 9or people with mo#erate to se-ere heart #isease' a##itional safet" pre!autions are re!ommen#e# %" the ATS1' in!lu#ing !ertifi!ation in a#-an!e# !ar#ia! life support an# a!!ess to supplies an# e8uipment (su!h as a !rash !art, that woul# allow for a rapi# response to an a#-erse e-ent$ Contrain#i!ations for this test as re!ommen#e# %" the ATS in!lu#e unsta%le angina in the pre-ious month' m"o!ar#ial infar!tion in the pre-ious month' an# high %loo# pressure (resting heart rate of < .63' s"stoli! %loo# pressure of .=3 mm 4g' or #iastoli! %loo# pressure < .33 mm 4g,$ The test shoul# %e stoppe# if a person reports !hest pain' intolera%le shortness of %reath' leg !ramps' staggering' #iaphoresis' or pale>ashen appearan!e1'$ Trainin0- A stan#ar# proto!ol shoul# %e followe# an# ea!h new te!hni!ian shoul# %e traine# in test a#ministration an# o%ser-e# se-eral times$

Time to a,minister/complete .7 minutes or less$ 25uipment nee,e,

A 03 meter' pre&measure# flat wal ing area with inter-al mar ings e-er" three meters$ Cones or %rightl" !olore# tape to mar %oun#aries of the !ourse +at!h or timer to time ) minutes

Chair a-aila%le if patients nee# to rest #uring testing 6vaila$ilit//cost Rea#il" a-aila%le

SCORING
%utcomes measure, The primar" out!ome is the #istan!e !o-ere# in meters or !on-erte# measure (su!h as feet, o-er ) minutes$ To measure fun!tional aero%i! !apa!it" or general fitness' this test ma" %e use# in !on?un!tion with :O6 testing (often using a porta%le meta%oli! s"stem whi!h measures ox"gen upta e #uring exer!ise,$ 4nterpretation of scores A lower s!ore (refle!ting less #istan!e !o-ere# in ) minutes, in#i!ates worse fun!tion$ Met&o, of scorin0

A#ministrator tallies the total #istan!e wal e# using the pre& mar e# inter-als as a gui#e$ Time to score *inimal Trainin0 to score *inimal Trainin0 to interpret None re8uire#$ #orms availa$le The six minute wal #istan!e in health" a#ults has %een reporte# to range from 233m to @33m2 $ Age an# sex&spe!ifi! referen!e stan#ar#s are a-aila%le an# ma" %e helpful for interpreting )*+T s!ores for %oth health" a#ults an# those with !hroni! #iseases$2@ 4owe-er' it is #iffi!ult to use normati-e -alues %e!ause of the #iffering metho#s use# in stu#ies$ An impro-ement of 72m has %een shown to %e a !lini!all" important #ifferen!e2" in a stu#" of people with !hroni! lung #isease whi!h is similar to the re!ommen#e# !riteria of meaningful !lini!al !hange of 73m %ase# on anal"ses from a sample of )/6 !ommunit" li-ing ol#er a#ults an# in#i-i#uals who ha-e sur-i-e# a stro e2'$

PSYCHOMETRIC INFORMATION
7elia$ilit/

Test/retest. Test&retest relia%ilit" has %een reporte# as high' with an ICC of 3$/3 at %aseline' 3$== at .= wee s' an# 3$/. at 20 wee s in a !ohort of patients with heart failure (49,26$ An ICC of 3$=3 (/7; CIA3$)/&3$=@, was reporte# after one "ear in a group of patients with C49 an# asso!iate# !omor%i#ities in!lu#ing #ia%etes an# h"pertension2($ An ICC of 3$@0 to 3$/= has %een reporte# in in#i-i#uals with fi%rom"algia following a timeframe of .3 #a"s or four wee s in two in#epen#ent stu#ies2)! 2*$ 8ali,it/ Content. The )*+T has %een foun# to ha-e !ontent -ali#it" for patients with se-ere heart failure an# pa!ema ers +! 1$ Dou%ts ha-e %een raise# a%out the -ali#it" of using the six&minute wal test with in#i-i#uals with s"stemi! s!lerosis in parti!ular with using the test as a measure of !hange in inter-ention stu#ies$ 2$ Criterion. *o#erate to high relationships ha-e %een reporte# (rA3$7) to rA3$==, %etween the )*+T #istan!e an# pea :O6 o%taine# %" maximal exer!ise testing in persons with heart failure ! "$ A!!ura!" was =3; an# sensiti-it" an# spe!ifi!it" </3; !ompare# to maximal ox"gen upta e in 7. heart #isease patients$2= In !lients with !hroni! heart failure' Rile" et al$ ' foun# that the pea :O6 in the )*+T was similar to or higher than pea :O6$ In !ertain su%populations' the )*+T su%&maximal test #emonstrates mo#eratel" high asso!iations with those of maximal exer!ise tests$

Concurrent validity. A negati-e !orrelation was foun# %etween the )*+T #istan!e an# the New Bor 4eart Asso!iation (NB4A, fun!tional !lass !lassifi!ation (rA&3$)3' nA/2, in#i!ating as the #istan!e wal e# #e!rease#' the NB4A !lassifi!ation in!rease# (i$e$' a re#u!e# a%ilit" to perform ph"si!al a!ti-it", 6$ A positi-e !orrelation existe# (rA3$)62' nA/2, %etween the )*+T #istan!e an# the S9&0) ph"si!al fun!tion s!ale in#i!ating as wal #istan!e in!rease#' ph"si!al fun!tion in!rease# 6$ There was a wea negati-e !orrelation (rA& 3$6)' nA@)=, %etween the %aseline )*+T #istan!e an# the *innesota Li-ing with 4eart 9ailure Cuestionnaire that loo s at health&relate# 8ualit" of life26$ Minimall/ clinical important ,ifference Re#elmeier et al$2" reporte# a !lini!all" signifi!ant mean !hange of 72 meters (/7; CI' 0@&@. m, in patientsD per!eption of exer!ise toleran!e in ..6 patients with sta%le' se-ere COPD$ ODEeeffe et al$1+ reporte# a !lini!all" signifi!ant mean !hange of 20 m in 27 el#erl" patients with heart failure$ The" note# more responsi-eness to !hange in #eterioration than impro-ement in people with heart failure$ Perera et al$2'#es!ri%e# a meaningful !lini!al !hange of 73m %ase# on anal"ses from a sample of )/6 !ommunit" li-ing ol#er a#ults an# in#i-i#uals who ha-e sur-i-e# a stro e$ 4owe-er' the minimal !lini!all" important #ifferen!e is slower' 67 meters' for !oronar" #isease patients after a!ute !oronar" s"n#rome$2/

7esponsiveness/sensitivit/ to c&an0e9 Olsson et al$ ( performe# a s"stemati! re-iew to assess the )*+TDs a%ilit" to measure !hange o-er time following the use of pharma!ologi!al an# non&pharma!ologi!al inter-entions$ A total of 2) pla!e%o&!ontrolle# trials were re-iewe#$ Thirt"&nine of the trials in-ol-e# pharma!ologi!al inter-entions an# se-en trials in!lu#e# non&pharma!ologi!al treatments$ Results in#i!ate signifi!ant !hanges in )*+T #istan!e in four out of se-en of the non&pharma!ologi!al trials an# onl" nine out of 0/ pharma!ologi!al trials$ ODEeeffe et al$1+ assesse# the repro#u!i%ilit" an# responsi-eness in patients with heart failure %etween a 8ualit" of life assessment an# the six&minute wal test$ In this !ase' the #egree of !orrelation %etween the )*+T #istan!e an# the glo%al rating of !hange in !ar#ia! status was goo# (rA3$@=,$ Olper et al2)' reports the stan#ar# hallwa" metho# has slightl" %etter responsi-eness to !hange (effe!t si5e 3$/, than the trea#mill )*+T (effe!t si5e 3$),$

COMMENTS AND CRITIQUE

The six&minute wal test ()*+T, was first use# in the !lini!al setting to test exer!ise toleran!e in in#i-i#uals with !hroni! respirator" #isease an# respirator" failure$ Current literature reports its use as a su%maximal exer!ise test to measure fun!tional exer!ise !apa!it" (i$e$' the a%ilit" to engage in

ph"si!all" #eman#ing a!ti-ities of #ail" li-ing,22 in in#i-i#uals with a wi#e -ariet" of !hara!teristi!s in!lu#ing health" ol#er a#ults an# those with !hroni! heart an# lung #isease' heart failure' fi%rom"algia' peripheral arterial #isease an# neurologi!al !on#itions ) as well as with ol#er a#ults$ +ith respe!t to the potential limitations in s!lero#erma' the per-a#ing theme is that the )*+TDs la! of #is!riminati-e a%ilit" an# asso!iation with !lini!al worsening' limit its use as an out!ome measure for !lini!al trials 2! *$ +hile it is a pra!ti!al an# simple test that !an %e repeate# to #etermine !hanges asso!iate# with the implementation of an inter-ention #esigne# to impro-e fun!tional !apa!it"' the multi&s"stem nature of s!lero#erma an# other rheumatologi!al !on#itions' as well as the !ommon !o& mor%i#ities present in an aging population' hin#ers the a%ilit" to )*+T to #o!ument organ or s"stem&spe!ifi! !hanges 2 asso!iate# with inter-entions$ *o#erate to strong !orrelations exist (rA3$7) to rA3$==, %etween the )*+T #istan!e an# pea :O6 o%taine# %" maximal exer!ise testing ! "$ :ariations in testing metho#s that allow for a learning effe!t or moti-ation through -er%al !uing ma" lea# to #isparate results$ The Ameri!an Thora!i! So!iet" release# gui#elines for the )*+T an# suggests a#heren!e to stan#ar#i5e# metho#s to minimi5e -arian!es$

E-i#en!e suggests that -ariations in ps"!hometri! properties exist %ase# on t"pe of #iagnosis$ The minimall" !lini!al important #ifferen!e reporte#l" -aries %ase# on #iagnosis$ It is suggeste# that the )*+T ma" %e useful as a self& a#ministere# out!ome tool"$ Although not thoroughl" in-estigate#' the authors in#i!ate that promoting self&awareness an# management of ph"si!al a!ti-it"' su!h as wal ing' !an inform the in#i-i#ual of !hanges in their health status' whi!h ma" prompt a !hange in inter-entions$ 9urther resear!h is nee#e# in this area$

6MWT FOR CHILDREN

This re-iew has primaril" fo!use# on the use of the ) minute wal test in a#ults$ There ha-e %een some stu#ies of the ) minute wal as a test of exer!ise or aero%i! !apa!it" in !hil#ren (either who were !onsi#ere# health" or those with -ar"ing !hroni! !on#itions,"+3" $ Similar to the stu#ies in a#ults' #ifferen!es in a#ministration of the ) minute wal ma es results of these stu#ies #iffi!ult to s"nthesi5e$ Age' height' an# weight are often fa!tors that affe!t ) minute wal times"+3" $ Relia%ilit" estimates (ICC, in !hil#ren range from 3$/) F 3$/= an# minimal !lini!all" important #ifferen!es are highl" -aria%le an# li el" #epen# hea-il" on the t"pe of !hroni! !on#ition'+$ Pearson !orrelations %etween )*+T an# :O6max are also highl" -aria%le ranging

from &3$67 to 3$2)'+$ Among !hil#ren with ?u-enile i#iopathi! arthritis (GIA,' the ) minute wal was asso!iate# with su%maximal le-els of exer!ise intensit" suggesting it is a goo# measure of fun!tional !apa!it"" $ In another stu#" in whi!h !hil#ren with GIA were a su%group' ) minute wal #istan!e multiplie# %" %o#" weight was a stronger measure than ) minute wal #istan!e alone$ Re!entl" the )*+T has %een use# as an out!ome measure in weight loss stu#ies an# ma" %e a pra!ti!al an# promising assessment tool for exer!ise performan!e in the o%ese pe#iatri! population '1! '2$ 9urther wor is nee#e# to test the ) minute wal in !hil#ren with rheumatologi!al !on#itions using stan#ar#i5e# proto!ols$