INT J TUBERC LUNG DIS 17(4):698–703
© 2013 The Union
http://dx.doi.org /10.5588/ijtld.12.0474
Reference equation for the 6-minute walk test in healthy
North Indian adult males
H. Vaish,* F. Ahmed,* R. Singla,† D. K. Shukla‡
* Department of Rehabilitation Sciences, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard
(Hamdard University), New Delhi, † Department of Tuberculosis and Respiratory Diseases, Lala Ram Swarup Institute of
Tuberculosis and Respiratory Diseases, New Delhi, ‡ Division of Non Communicable Diseases, Indian Council of Medical
Research, New Delhi, India
SETTING: Lala Ram Swarup Institute of Tuberculosis
and Respiratory Diseases, New Delhi, India.
B A C K G R O U N D : The 6-min walk distance (6MWD)
correlates well with functional capacity. However, previ-
ous reference equations for the 6MWD have failed to
accurately predict the 6MWD due to variations in popu-
lation ethnicity and geography.
O B J E C T I V E : The aims of this study were 1) to measure
6MWD in healthy North Indian adult males, 2) to de-
termine the applicability of Enright and Sherrill’s refer-
ence equation to healthy North Indian adult males, and
3) to develop a regression equation for Indian males.
D E S I G N : After physical examination and investigations,
the 6-minute walk test was conducted in male subjects
aged 40–60 years.
ASSESSMENT of functional exercise capacity is im-
portant in understanding the impact of disease.1
Functional walk tests are typically administered as a
means of evaluating functional status.2 The 6-min
walk test (6MWT) is an example of a functional walk
test that assesses the sub-maximal level of functional
capacity.3 It is easy to administer, better tolerated and
more reflective of activities of daily living than other
walk tests.4
Several studies have been conducted worldwide to
derive normal values for the 6MWT, and several ref-
erence equations have been developed to predict dis-
tance in healthy subjects.1,5–11 One of the most popu-
lar equations for the prediction of 6-minute walk
distance (6MWD) is that of Enright and Sherrill,5
who in 1998 derived reference equations and con-
cluded that they may be used to compute the 6MWD
for adult patients performing the test for the first time
using the standardised protocol. Regression equations
that predict the expected 6MWD for a subject in the
absence of pathology allows the magnitude of an in-
dividual’s functional limitation to be quantified.10 Cer-
Correspondence to: Hina Vaish, 108/54 A, P Road, Kanpur, Uttar Pradesh, India. Tel: (+91) 94501 24758. Fax: (+91) 11
2651 7834. e-mail: hina22vaish@gmail.com
Article submitted 20 June 2012. Final version accepted 25 November 2012.
SUMMARY
R E S U LT S : The mean (±SD) 6MWD was 536.1 ±
46.9 m. Enright and Sherrill’s reference equation did not
correctly predict distance in an Indian population: walk
distance was overestimated by a mean (±SD) of 46.8 ±
32.9 m. The regression equation developed for males
was 6MWD (m) = 3.654 × height (cm) − 4.139 × age
(years) + 127.121, and accounted for 63.9% of total
variance.
C O N C L U S I O N S : Enright and Sherrill’s equation cannot
be used to predict the 6MWD in healthy North Indian
adult males. The new regression equation is expected to
prove useful for various purposes in healthy North
Indian adult males.
K E Y W O R D S : ethnic variations; evaluation; functional
capacity; 6MWD
tain studies have demonstrated that the equation de-
rived from one population did not correctly predict
the 6MWD in another population.9–13 Ethnic and geo-
graphic variations have been reported as some of the
factors responsible for the discrepancies in 6MWD.
Literature on the 6MWT reference equation for
Indian subjects is scarce.14,15 The present study there-
fore aimed to measure 6MWD in healthy North In-
dian adult males, to check the applicability of Enright
and Sherrill’s5 reference equation to this group and, if
required, to develop a prediction equation.
MATERIALS AND METHODS
A total of 101 healthy North Indian adult male sub-
jects volunteered to participate in the study at the
Lala Ram Swarup (LRS) Institute of Tuberculosis and
Respiratory Diseases, New Delhi. The study was ap-
proved by the research and ethical committees of the
LRS Institute, and by the Board of Studies of the
Department of Rehabilitation Sciences, Hamdard
Institute of Medical Sciences and Research, Jamia

Hamdard, New Delhi. All participants provided writ-
ten informed consent prior to the study.
The sample was selected from among individuals
accompanying patients, those visiting the institute
and from nearby community dwellings. Only perma-
nent residents of the various states of North India
were included. North Indian status was confirmed by
proof of residential address and the language spoken.
The mother tongues accepted for inclusion were
Hindi, Urdu, Punjabi, Pahari, Marwari, Gharwali
and other accepted languages of the Northern states.
Subjects aged 40–60 years were included. The age of
the subjects was confirmed by their identity cards.
Most of the subjects had a sedentary lifestyle;16 all
were non-smokers and none were involved in any
kind of sports activities.
Subjects included were asymptomatic North In-
dian male adults with normal health status, defined
as being asymptomatic with stable vital signs, normal
chest X-ray (CXR), normal electrocardiogram (ECG)
and normal spirometry values (forced vital capacity
[FVC] > lower limit of normal [LLN] of predicted;
forced expiratory volume in 1 second [FEV1] > LLN
of predicted; FEV1/FVC > LLN of predicted),17 body
mass index (BMI) 18.5–29.9 kg /m2 and absence of
any acute disease in the 6 weeks preceding the study.
Exclusion criteria were any health problem or use of
medication that might interfere with the ability to
perform physical exercises (such as impaired cogni-
tion, and metabolic, cardiac, neuromuscular or mus-
culoskeletal disease), use of walking aids, past or
current smokers, sensory deficits, blood pressure
>139/89 mmHg, resting heart rate (HR) ⩾100 beats
per min.
Subjects were enrolled after screening by an as-
sessment and various investigations at the LRS Insti-
tute. Height was recorded using a height scale (Avery
Healthcare, Northampton, UK), body weight was re-
corded using a beam balance scale (Equinox, New
Delhi, India) that was calibrated every month and
BMI was calculated using the formula kg /m2. Spi-
rometry was performed (Transfer Test Model C, P K
Morgan Private Limited, Hertford, UK) to determine
FVC, FEV1 and FEV1/FVC following the American
Thoracic Society (ATS) and European Respiratory
Society guidelines for spirometry.18 The results were
reported as percentage of predicted values.17 We per-
formed ECG and CXR, and recorded the subject’s
systolic and diastolic blood pressure (Digital Sphyg-
momanometer, HEM7111, Omron, Tokyo, Japan).
Use of medication, smoking habits and physical ac-
tivities, history of diabetes mellitus, hypertension,
stroke, cardiac disorder, or any history of heart or
lung surgery were self-reported.
6MWT procedure
The 6MWT was conducted according to a stan-
dardised protocol, as prescribed by ATS guidelines,3
6MWT reference equation 699
in a quiet, undisturbed 30-m indoor level hospital
corridor with marks at 3 m intervals. All tests were
conducted between 9:00 am and 1:00 pm to avoid
intra-day variability. All subjects performed the
6MWT for the first time with no warm-up period.
The subjects sat in a chair located near the starting
position for at least 10 min before the test. During
this time, rate of perceived exertion (Borg Rating of
Perceived Exertion), HR and oxy-haemoglobin satu-
ration (Finger Pulse-oxymeter, MD300C2, Beijing,
China) and systolic and diastolic blood pressures
were recorded. The ATS test instructions were used:3
subjects were asked to walk as far down the length
of the corridor as they could at their own pace for
6 min. Standardised encouragement was provided
every 60 seconds during the test, with the following
phrases: ‘You’re doing well’ and ‘Keep up the good
work’. Subjects were allowed to stop if they devel-
oped symptoms of dyspnoea, dizziness, chest pain or
leg cramps, but were encouraged to continue walking
as soon as they could. At the end of the test, each sub-
ject’s HR, blood pressure, oxygen saturation and
Borg value was measured along with the distance
covered in the allotted 6 min. None of the subjects
stopped during the test.
Statistical analyses
Statistical analyses were performed using SPSS soft-
ware, version 16 (Statistical Package for the Social
Sciences Inc, Chicago, IL, USA). Correlations were
estimated using Pearson’s coefficient of correlation
for parametric data and Spearman’s Rank coefficient
of correlation for non-parametric data. Bland-Altman
comparison was performed between the measured
and predicted 6MWD, based on Enright and Sherrill’s
reference equation. Limits of agreement, calculated
as mean difference between measured and predicted
6MWD ± 1.96 standard deviation (SD), were used
for comparison. The individual differences (mea-
sured—predicted 6MWD) were plotted against the
corresponding mean values. Comparisons between
measured and predicted 6MWD also included paired
t-test. Stepwise multiple regression analysis was used
to develop the reference equation for 6MWD. P <
0.05 was considered significant.
RESULTS
The baseline characteristics of the study population
and results are summarised in Table 1. There were sig-
nificant correlations between 6MWD and height (Fig-
ure 1), age (Figure 2), weight (Figure 3), FEV1, FVC,
FEV1/FVC, change in HR (post-6MWT HR—pre-
6MWT HR). Multiple regression analysis showed that
age and height were independent predictors for 6MWD.
Based on the results of correlation and regression
analysis, the 6MWD for males can be determined by
6MWD (m) = 3.654 × height (cm) − 4.139 × age
700 The International Journal of Tuberculosis and Lung Disease

Table 1 Baseline characteristics of the subjects and results of

the 6MWT (N = 101)

Mean ± SD R P value*
Characteristic
Age, years 46.02 ± 6.52 –0.619 0.0001
Height, cm 164.07 ± 6.52 0.558 0.0001
Weight, kg 67.65 ± 10.91 0.306 0.002
BMI, kg /m2 25.04 ± 3.19 0.054 NS†
Lung function
FVC, l 3.68 ± 0.52 0.525 0.0001
FVC% predicted 94.55 ± 8.63 — —
FEV1, l 2.94 ± 0.43 0.559 0.0001
FEV1% predicted 92.20 ± 9.20 — —
FEV1 /FVC, % 80.32 ± 3.89 0.238 0.016
Level of physical activity
Physically active 9.9 — — Figure 2 Correlation of 6MWD with age. 6MWD = 6-min
subjects, % walk distance walked by North Indian subjects.
Sedentary subjects, % 90.1 — —
6MWD test results
Resting HR, bpm 76.15 ± 8.05 0.044 NS† was a systematic bias between measured and pre-
Post-test HR, bpm 107.11 ± 8.11 0.170 NS†
Change in HR dicted 6MWD. The correlation between mean 6MWD
(post-pre), bpm 30.96 ± 9.9 0.225 0.0001 difference and mean 6MWD was found to be signifi-
Resting oxygen cant (R = 0.205, P = 0.04), indicating a proportional
saturation, % 98.28 ± 0.51 0.034 NS
Resting systolic BP, mmHg 123.01 ± 8.96 –0.146 NS† error of 6MWD predicted with Enright and Sherrill’s
Resting diastolic BP, reference equation.
mmHg 79.45 ± 5.05 –0.096 NS†
Resting RPE 0 — —
Actual 6MWD, m 536.12 ± 46.96 — — DISCUSSION
Predicted 6MWD, m‡ 582.91 ± 53.07 0.790 0.0001
Actual 6MWD – predicted The study aimed to determine the mean 6MWD of a
6MWD, m – 46.80 ± 32.91 — —
healthy North Indian adult male population and to
* Significant at P < 0.05 (2-tailed). compare this value with those generated by the previ-
† Non-significant at P < 0.05.
‡ Using Enright and Sherrill’s equation. ously reported regression equation of Enright and
6MWT = 6-min walk test; SD = standard deviation; R = correlation coeffi- Sherrill.5
cient with respect to 6MWD; BMI = body mass index; FVC = forced vital
capacity; FEV1 = forced expiratory volume in 1 second; HR = heart rate; To our knowledge, this is the first study to predict
BP = blood pressure; RPE = rate of perceived exertion; 6MWD = 6-min walk 6MWD, particularly among those living in North In-
distance.
dia. The 6MWD reference value determined in the
study was found to be substantially lower than previ-
(years) + 127.121 (Table 2), and accounted for ously reported values of Enright and Sherrill’s refer-
63.9% of total variance. 6MWD was overestimated ence equation,5 which overestimated walking dis-
by the reference equation of Enright and Sherrill5 by tance in Indians by a mean of 46.8 ± 32.9 m.
a mean (±SD) distance of 46.8 ± 32.9 m (Figure 4). Consistent with the study of Enright and Sherrill,5
Figure 5 shows the Bland-Altman comparison be- who described the 6MWD reference equation for
tween the measured and predicted 6MWD. There 290 healthy male and female subjects aged 40–80 years

Figure 1 Correlation of 6MWD with height. 6MWD = 6-min Figure 3 Correlation of 6MWD with weight. 6MWD = 6-min
walk distance walked by North Indian subjects. walk distance walked by North Indian subjects.

Table 2 Predicting model for 6-min walk distance
Independent
variable Coefficients SE 95%CI
Males (N = 101)
r2 = 0.639*
Constant 127.121 76.520 –24.731 to 278.972
Age, years – 4.139 0.439 –5.011 to 3.267
Height, cm 3.654 0.439 2.783 to 4.524
* Variance.
SE = standard error; CI = confidence interval.
using a single test protocol, we took 101 male sub-
jects aged 40–60 years. Like Enright and Sherrill,5 we
performed a single 6MWT, and we provided stan-
dardised instructions and encouragement as per ATS
guidelines.3 We also instructed subjects to cover as
much ground as possible in 6 min and to walk
at their own pace. The level and frequency of encour-
agement were also identical. With regard to pulmo-
nary function, all the subjects of the present study
exhibited normal spirometric parameters using Euro-
pean predicted values, as North Indian values were
not available.
The discrepancies in the distance covered may
have been due to geographic19 and ethnic variations.
There is evidence to suggest that ethnicity influences
physical fitness test performance.20,21 Subjects en-
rolled in Enright and Sherrill’s study5 were randomly
selected by stratified clustered sampling, whereas we
enrolled subjects by convenience sampling. Anthro-
pometric characteristics of subjects may also differ, as
Asians have lower BMI but a higher percentage of
body fat than Caucasians.22
The possibility of differences in 6MWD due to the
level of sub-maximal effort exerted by the subjects is
low, as the male subjects in the present study reached
an average of 61.44 ± 7.70% of their age-predicted
maximal HRs (HRmax% predicted), calculated by us-
ing the formula: 220 – age (years), while subjects in
the Enright’s cohort reached an average of 61–65%
Figure 4 Comparison of 6MWD walked by North Indian sub-
jects and 6MWD predicted using Enright and Sherrill’s equa-
tion. 6MWD = 6-min walk distance.
6MWT reference equation 701
Figure 5 The Bland-Altman representation of measured and
predicted 6MWD using Enright and Sherrill’s equation. ......... =
regression line. 6MWD = 6-min walk distance; SD = standard
deviation.
of their HRmax% predicted. Other contributing fac-
tors may be habitual walking habits, walking effi-
ciency, mood of the subject, cognitive status, psycho-
logical factors and level of motivation.
Consistent with previous studies, we found height
to be strongly correlated with 6MWD and that it was
the predominant variable in the regression equation.
Previous reports have attributed the relationship be-
tween height and walked distance to increased leg
length, which generates a longer stride and a more ef-
ficient gait.6,8–10,12 In contrast, weight had a positive
correlation with the 6MWD, and was not represented
in the final regression equation. BMI was not signifi-
cantly correlated with 6MWD. The probable reason
for the positive correlation between weight and
6MWD may be that all of the subjects were healthy
and none were underweight or obese.
Obesity increases the workload for a given amount
of exercise, thus affecting the distance walked.5 Previ-
ous reports of the relationship between weight and
6MWD have been inconsistent.11,12 Our results there-
fore do not necessarily contradict previous studies.
Correlation between age and 6MWD in the pres-
ent study was negative, which is consistent with pre-
vious studies.1,5,6,10 The correlation between age and
6MWD was significant in most previous studies, ex-
cept in the study by Camarri et al.23 The shorter dis-
tance walked as age increased can be explained by
decreases in muscle mass, muscle strength and maxi-
mum oxygen consumption due to aging.24–26 We also
found that the better the chronotropic response, the
greater the 6MWD, also in agreement with previous
findings.13,19
Significant positive correlations were also found
between 6MWD and FEV1, FVC and FEV1/FVC, but
were not represented in the final regression equa-
tion. This correlation is likely as all our subjects
were healthy non-smokers, and were free of any in-
fection or chronic illnesses. Only a few studies have
702 The International Journal of Tuberculosis and Lung Disease
reported a significant correlation between FEV1 and
6MWD.23
Most of our subjects had a sedentary lifestyle.16
Studies related to exercise physiology have revealed a
direct relationship between muscle strength and
physical exercise.27 Decreased physical activity usu-
ally leads to alteration in muscle metabolism, de-
creases in muscle mass and lower physical capacity.27
This could be a reason for the shorter distance walked
by our subjects.
Approximately 64% of the variability in 6MWD
in the current study was explained by age and height.
The high variability of our equation is consistent with
findings from previous studies.1,9,11 However, this is
not in agreement with Enright and Sherrill’s5 equa-
tion for male subjects, which gave a variability of
around 42% in the 6MWD.
Several studies mention a practice test before the
6MWT was performed for the first time.9,10,12 A sin-
gle 6MWT was performed in the present study. ATS
guidelines do not necessarily recommend a practice
test in most clinical settings.3 Repetition may be
important for cardiopulmonary rehabilitation pro-
grammes, where it is important to familiarise patients
with the test, but the single-test method is more ap-
propriate for clinical settings.13 Performance may im-
prove when a second test is performed, and this may
also explain the lower values observed in the present
study.
The findings of two earlier studies conducted in
India14,15 are not in perfect agreement with the results
of the present study. It may be because both were con-
ducted in the southern region of India, whereas our
study was conducted in North India. Lung function
correlates with functional capacity, and studies on
lung function in India have demonstrated differences
in lung function on the basis of regional variations.28
This study was limited by several factors. This was
not a population-based study, and we did not recruit
individuals aged <40 years or >60 years. We did not
want to dilute the sample by combining young adults
and older adults due to physiological differences as
age advances. The 6MWT has clinical utility in sev-
eral diseases such as chronic obstructive pulmonary
disease, which occurs in the older age group, and nor-
mal values for the Indian population are not available
for this age group. Female subjects were not recruited
in the present study as it is difficult to enrol normal
females to volunteer for research purposes in India.
Finally, we did not assess other potential variables that
may have limited physical function, such as periph-
eral muscle strength, cognitive status, lean body mass,
leg length, dietary habits and psychological factors.
CONCLUSIONS
This study highlights the differences in 6MWD be-
tween Indian and Caucasian subjects. Enright and
Sherrill’s reference equation overestimated 6MWD
among healthy North Indian adult males by a mean
(±SD) distance of 46.8 ± 32.9 m. Age and height
were independent predictors for 6MWD. Our regres-
sion equation is expected to prove useful for future
assessments of functional status and the prescription
of exercises for healthy North Indian adult males.
Acknowledgements
The authors thank the staff of the Pulmonary Function Testing
Laboratory of the Lala Ram Swarup Institute of Tuberculosis and
Respiratory Diseases, New Delhi, India, for their assistance with
subject recruitment and investigations.
Conflict of interest: none declared.
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S I T U AT I O N : Institut Lala Ram Swarup de la Tubercu-
lose et des Maladies Respiratoires, New Delhi, Inde.
C O N T E X T E : La distance parcourue en 6 minutes de
marche (6MWD) est en bonne corrélation avec la
capacité fonctionnelle. Des équations antérieures de
référence pour la 6MWD n’ont pas permis à une pré-
diction précise de la capacité fonctionnelle en raison des
variations ethniques et géographiques de population.
O B J E C T I F : 1) Mesurer la 6MWD chez les hommes
adultes sains du Nord de l’Inde ; 2) déterminer l’applica-
bilité de l’équation de référence de Enright et Sherill
chez les hommes adultes sains du Nord de l’Inde ; et
3) élaborer une équation de régression pour les hommes
indiens.
S C H É M A : On a mené une 6MWD chez les sujets mâles
âgés de 40 à 60 ans après un examen physique et des
investigations.
MARCO DE REFERENCIA: El Instituto de TB y Enfer-
medades Respiratorias Lala Ram Swarup de Nueva
Delhi, en India.
A N T E C E D E N T E S : La prueba de distancia de marcha de
6 min (6MWD) ofrece una buena correlación con la
capacidad funcional. Las previas ecuaciones de referencia
de la prueba 6MWD no permitieron una predicción
exacta de la distancia debido a las variaciones étnicas y
geográficas de las poblaciones.
O B J E T I V O : 1) Realizar la prueba 6MWD en hombres
adultos en el norte de la India; 2) determinar la aplicabi-
lidad de la ecuación de referencia de Enright y Sherrill
en este grupo de personas; y 3) formular una ecuación
de regresión que corresponda a los hombres de la India.
M É T O D O : Después de realizar el examen físico y las
pruebas de laboratorio se llevó a cabo la prueba 6MWD
en hombres entre los 40 y los 60 años de edad.
6MWT reference equation i
RÉSUMÉ
R É S U LTAT S : La 6MWD moyenne (± SD) a été de
536,1 ± 46,9 m. L’équation de référence d’Enright et
Sherill n’a pas pu prédire de façon correcte la distance
parcourue par la population indienne. La distance de
marche est surestimée en moyenne de 46,8 ± 32,9 m.
L’équation de régression élaborée pour les hommes
est la suivante : 6MWD (m) = 3,654 × taille (cm) −
4,139 × âge (années) + 127,121 et a rendu compte de
63,9% de la variance totale.
C O N C L U S I O N S : L’équation d’Enright et Sherill n’est
pas applicable à la prédiction de la 6MWD chez les
hommes adultes sains du Nord de l’Inde. On s’attend à
ce que la nouvelle équation de régression s’avère utile
pour différents objectifs chez les hommes adultes sains
du Nord de l’Inde.
RESUMEN
R E S U LTA D O S : El resultado promedio de la prueba
6MWD fue 536,1 m (desviación estándar [SD] ± 46,9 m).
La ecuación de referencia de Enright y Sherrill no predijo
correctamente la distancia en la población de la India.
Esta distancia se sobrestimó en promedio 46,8 m (SD ±
32,9 m). La nueva ecuación de regresión que se formuló
para los hombres fue: 6MWD (m) = 3,654 × estatura
(cm) − 4,139 × edad (años) + 127,121; esta ecuación
explicó el 63,9% de la varianza total.
C O N C L U S I Ó N : La ecuación de Enright y Sherrill no se
puede aplicar a fin de predecir el resultado de la prueba
6MWD en los hombres adultos normales del norte de la
India. Se espera que la nueva ecuación de regresión sea
útil en las futuras evaluaciones de esta población.