ORIGINAL ARTICLE
Six-minute walk test in pulmonary rehabilitation: Do all patients
need a practice test?
SUE JENKINS1,2,3 AND NOLA M. CECINS1,2,3
1
Physiotherapy Department, Sir Charles Gairdner Hospital, 2School of Physiotherapy and Curtin Health
Innovation Research Institute, Curtin University, and 3Lung Institute of Western Australia and Centre for
Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Western Australia, Australia
ABSTRACT
Background and objective: The six-minute walk test
(6MWT) is widely used as an outcome measure in
pulmonary rehabilitation programs (PRP). A learning
effect for the test has been reported in COPD; however,
limited data exist in patients with other respiratory
diagnoses. The objectives of this study were to: (i)
report the magnitude of change in 6MWD with test
repetition in patients referred to an outpatient PRP,
and (ii) compare the magnitude of change in 6MWD
with test repetition in patients with COPD, interstitial
lung disease (ILD), bronchiectasis and asthma.
Methods: Retrospective study of 349 patients with
stable COPD (n = 245), ILD (n = 21), bronchiectasis
(n = 33) or asthma (n = 50) who performed two 6MWT
at enrolment into a PRP.
Results: 6MWD increased in all groups on the second
test (all P < 0.001). At least 80% of patients in each diag-
nostic group walked further on their second 6MWT.
The magnitude of change (mean, 95% CI) was greater
(P < 0.05) in the COPD (37 m, 95% CI: 33–41 m) and
ILD (41 m, 95% CI: 27–55 m) cohorts compared with
the bronchiectasis (22 m, 95% CI: 14–31 m) and
asthma (19 m, 95% CI: 11–27 m) cohorts.
Conclusions: Respiratory diagnosis influences the
magnitude of the learning effect for the 6MWT. The
findings support the recommendation of a practice
6MWT at baseline assessment in order to provide an
accurate measure of the effects of rehabilitation on
6MWD.
Key words: exercise test, learning effect, lung disease,
outcome assessment, rehabilitation.
INTRODUCTION
The six-minute walk test (6MWT) is widely used to
assess changes in functional exercise capacity follow-
Correspondence: Sue Jenkins, School of Physiotherapy,
Curtin University, GPO Box U1987, Bentley, WA 6845, Australia.
Email: s.jenkins@curtin.edu.au
Received 12 April 2010; invited to revise 5 May 2010, 15 June
2010; revised 24 May 2010, 19 June 2010; accepted 21 June 2010
(Associate Editor: C C Leung).
© 2010 The Authors
Respirology © 2010 Asian Pacific Society of Respirology
resp_1841 1192..1196
SUMMARY AT A GLANCE
This study shows that the majority of patients
entering a pulmonary rehabilitation program
increase their 6MWD when a repeat test is per-
formed. The findings support the recommenda-
tion of a practice 6MWT at baseline assessment in
order to provide an accurate measure of the effects
of rehabilitation on 6MWD.
ing a pulmonary rehabilitation program (PRP) with
the primary outcome reported being the distance
walked.1–3 In patients undergoing rehabilitation, the
test is also used to prescribe a walking training
program with the initial speeds prescribed equivalent
to 70–80% of the average speed achieved during the
baseline 6MWT.4–7 This prescription complies with
international pulmonary rehabilitation guidelines
that recommend high intensity training with the aim
of achieving a physiologic benefit.2
Strict standardization of the 6MWT protocol is
required if reliable data are to be obtained. The factors
that influence 6MWD include track length and layout,
and encouragement during the test.8–11 A learning
effect has been documented in patients with COPD
with the majority of individuals showing an increase
in 6MWD when the test is repeated and little or no
further increase when a third test is performed.8,9,12–14
Reports of the effect of test repetition on 6MWD in
patients with chronic lung diseases (CLD) other than
COPD are limited to two studies in patients with inter-
stitial lung disease (ILD).15,16 Repeat 6MWT were sepa-
rated by a maximum of 4 weeks and both studies
showed a significant increase in 6MWD with test rep-
etition.15,16 To our knowledge, the effect of test repeti-
tion on 6MWD has not been reported for individuals
with bronchiectasis or asthma, patient cohorts that
are referred to PRP and in whom 6MWD has been
used as an outcome of exercise training.17–20
In PRP, it is important to minimize the effect of an
increase in 6MWD resulting from test repetition.
Failure to do so will result in an overestimate of the
effects of rehabilitation on 6MWD. However, despite
Respirology (2010) 15, 1192–1196
doi: 10.1111/j.1440-1843.2010.01841.x
6MWT learning effect in lung disease
good justification for a practice 6MWT at the baseline
assessment, over 50% of PRP perform a single
6MWT.21,22 The resources available for PRP, in particu-
lar staff time, are likely to be the most important
factor that determines the number of 6MWT
performed.
The objectives of this study were to: (i) report the
magnitude of change in 6MWD with test repetition at
baseline assessment in patients with CLD referred to a
PRP, and (ii) compare the magnitude of change in
6MWD with test repetition in patients with COPD,
ILD, bronchiectasis and asthma. The cohort for this
study comprised 349 outpatients with stable CLD.
METHODS
Patients
This retrospective study reports data on all individu-
als who completed two 6MWT before commencing an
outpatient PRP at a tertiary hospital (Sir Charles
Gairdner Hospital, SCGH, Perth, Western Australia),
over a 9-year period (2000–2008). The diagnoses of
these patients were COPD (n = 245), ILD (n = 21),
bronchiectasis (n = 33) and asthma (n = 50). The
baseline assessment for the PRP included two 6MWT
unless: (i) the patient had performed a 6MWT in the
previous 6 weeks; (ii) an adverse event was observed
during the first test;23 (iii) walking ability was limited
by musculoskeletal or neurological impairment, or
claudication pain, and (iv) the patient declined to
complete a second 6MWT. Data presented in this
study are restricted to patients who had no prior
experience of performing the 6MWT in accordance
with the protocol used in the PRP. Approval to use
these data was obtained from the Human Research
Ethics Committee of SCGH.
The diagnosis of lung disease and referral to the
PRP were made by a respiratory physician. The results
of spirometry testing,24 performed at the time of refer-
ral, were extracted from the patient’s medical records.
6MWT protocol
Contraindications to performing the 6MWT in this
PRP have been published elsewhere.23
Patients were instructed to take their usual medica-
tions on the day of testing. Individuals with asthma
who required prophylactic bronchodilators before
exercise took their medication before performing the
6MWT.
All 6MWT were supervised by a physiotherapist
(NC or SJ) in accordance with published guidelines.25
A 45-m straight course within a level enclosed corri-
dor was used. Standardized instructions were read to
the patient before each 6MWT. At the end of each
minute, patients were notified of the elapsed time and
given standard encouragement.25 If a patient rested
during the 6MWT, encouragement to recommence
walking was given at 15 s intervals.25 At the end of the
first test, patients were informed they would be per-
forming another 6MWT following a 30-min rest
© 2010 The Authors
Respirology © 2010 Asian Pacific Society of Respirology
1193
period. If necessary, the rest period was extended
until heart rate, oxygen saturation (SpO2) and dysp-
noea had returned to within five beats per minute, 1%
and 1 point of baseline values, respectively.26
Heart rate was measured before and throughout the
6MWT using telemetry (Polar a1, Polar Electro Oy,
Kempele, Finland). Oxygen saturation (Ohmeda Biox
3700e, Ohmeda, CO, USA) was continuously moni-
tored during the first 6MWT with measures recorded
pre-test, upon test completion, at the end of each
minute and during any rests.23 For the second 6MWT,
SpO2 was recorded before and at test completion, and
at the start of any rests. Dyspnoea was assessed before
and at the end of the 6MWT, and at the commence-
ment of any rests27 with the highest dyspnoea score
used in the analyses. Leg fatigue was recorded on test
completion.27 The number of rests and the total rest
time during the test were recorded.
Data management and statistical analyses
Comparison of age, anthropometric and 6MWT data
between diagnostic groups was performed using one-
way analysis of variance (anova) with Scheffe’s post-
hoc test, Kruskall–Wallis test (scores for dyspnoea and
leg fatigue) and chi-square test (categorical variables).
Within each diagnostic group: (i) the magnitude of
change in 6MWD between tests 1 and 2 was com-
pared using a paired t-test; (ii) the coefficient of
repeatability (defined as twice the SD of the difference
in 6MWD measured on the two tests) was calculated;
(iii) the effect of gender and supplementary oxygen
therapy on the magnitude of change in 6MWD with
test repetition were examined using unpaired t-tests,
and (iv) associations were sought between 6MWD on
the first test (expressed in metres and %predicted)28
and the difference in 6MWD between tests 1 and 2
using Pearson’s correlation coefficients.
The distribution of the data was examined and no
transformations were required. Statistical analyses
were performed using spss software (Version 17,
SPSS Inc., Chicago, IL, USA). P-values of ⱕ0.05
were regarded as significant. Data are expressed as
mean ⫾ SD or 95% CI.
RESULTS
Anthropometric and lung function data of the 349
patients are shown in Table 1.
The 6MWD was lower in the COPD cohort when
compared with the ILD, bronchiectasis and asthma
cohorts (all P < 0.05) (Table 2). The proportion of
patients in the COPD cohort who rested during the
test was higher than in any other group (Table 2,
P < 0.001). In the COPD and ILD cohorts, dyspnoea
scores were higher, and peak heart rate and nadir
SpO2 were lower compared with the bronchiectasis
and asthma cohorts (all P < 0.05).
There was an increase in 6MWD with test repetition
in each cohort (all P < 0.001) with at least 80% of
patients in each cohort walking further on their
second test (Table 2). The magnitude of increase in
Respirology (2010) 15, 1192–1196
1194 S Jenkins and NM Cecins

Table 1 Anthropometric and lung function data of the 349 patients grouped according to diagnosis

COPD ILD Bronchiectasis Asthma

n = 245 n = 21 n = 33 n = 50

Male (n, %) 162 (66) 13 (62) 8 (24) 22 (44)

Age (years) 67.5 ⫾ 9.2 62.3 ⫾ 13.2 65.1 ⫾ 7.9 67.1 ⫾ 10.1
Height (m) 1.70 ⫾ 0.8 1.68 ⫾ 0.7 1.66 ⫾ 0.9 1.68 ⫾ 10.0
Weight (kg) 70.1 ⫾ 15.8 72.2 ⫾ 17.7 67.1 ⫾ 16.2 77.2 ⫾ 16.9
BMI (kg/m2) 24.5 ⫾ 4.8 25.5 ⫾ 5.6 24.2 ⫾ 5.6 27.4 ⫾ 5.1*
FEV1 (L) 1.06 ⫾ 0.50 1.61 ⫾ 0.60* 1.45 ⫾ 0.49* 1.48 ⫾ 0.66*
FEV1 %pred 41 ⫾ 18 59 ⫾ 18* 58 ⫾ 22* 56 ⫾ 18*
GOLD stage
I (n, %) 6 (2)
II 61 (25)
III 110 (45)
IV 68 (28)
FVC (L) 2.59 ⫾ 0.92 2.14 ⫾ 0.78 2.26 ⫾ 0.83 2.89 ⫾ 1.09
FVC %pred 74 ⫾ 21 59 ⫾ 18 72 ⫾ 21 82 ⫾ 18*†

* P < 0.05 compared with COPD cohort, † P < 0.05 compared with ILD cohort.
Data are presented as means ⫾ SD or number (n) and percentage (%) of patients.
ILD, interstitial lung disease.

Table 2 6MWT data in the 349 patients grouped according to diagnosis

COPD ILD Bronchiectasis Asthma

n = 245 n = 21 n = 33 n = 50

6MWD Test 1 (m) 390 ⫾ 116 446 ⫾ 130* 497 ⫾ 113* 503 ⫾ 103*
6MWD Test 1 (%pred) 60 ⫾ 17 67 ⫾ 17 78 ⫾ 14*† 80 ⫾ 14*†
6MWD Test 2 (m) 427 ⫾ 122 487 ⫾ 135* 519 ⫾ 125* 522 ⫾ 105*
DTest 2–Test 1 (m) 37 (33–41) 41 (27–55) 22 (14–31)* 19 (11–27)*
DTest 2–Test 1 (%) 11 (9–12) 10 (6–14) 4 (3–6)* 4 (2–6)*
Walked further on Test 2 (n, %) 213 (87) 18 (86) 28 (84) 40 (80)
6MWT test 1 data
Pre-exercise HR (bpm) 89 ⫾ 14 88 ⫾ 16 89 ⫾ 16 87 ⫾ 13
Peak HR test (bpm) 113 ⫾ 15 120 ⫾ 19 121 ⫾ 14* 124 ⫾ 15*
Peak HR %pred HRmax 68 ⫾ 9 71 ⫾ 11 72 ⫾ 8 75 ⫾ 9
Pre-exercise SpO2 (%) 95 ⫾ 2 95 ⫾ 2 96 ⫾ 2* 96 ⫾ 2*
Lowest SpO2 (%) 89 ⫾ 4 88 ⫾ 6 92 ⫾ 4*† 94 ⫾ 4*†
Pre-exercise dyspnoea 1.1 ⫾ 1.1 0.9 ⫾ 1.0 1.1 ⫾ 1.2 0.7 ⫾ 0.8
Peak dyspnoea 4.6 ⫾ 1.8 3.9 ⫾ 2.2 3.4 ⫾ 1.3* 3.1 ⫾ 1.5*
End-test leg fatigue 1.4 ⫾ 1.4 1.5 ⫾ 1.6 1.3 ⫾ 1.5 1.2 ⫾ 1.3
Rested during test (n, %) 80 (33) 3 (14)* 2 (6)* 1 (2)*

* P < 0.05 compared with COPD cohort; † P < 0.05 compared with ILD cohort.
Data are presented as means ⫾ SD or number (n) and percentage (%) of patients; data for change (D) in 6MWD
between Test 1 and Test 2 are mean and 95% confidence intervals.
%pred 6MWD, percentage of predicted 6MWD; SpO2, oxygen saturation; HR, heart rate; bpm, beats per minute;
%pred HRmax, peak HR as a %predicted HRmax (210 - 0.65 ¥ age).

6MWD with test repetition was significantly greater in
the COPD and ILD cohorts when compared with the
bronchiectasis and asthma cohorts (both P < 0.05)
(Table 2). The difference between repeat 6MWT was
37 ⫾ 37, 41 ⫾ 32, 22 ⫾ 24 and 19 ⫾ 26 m in the COPD,
ILD, bronchiectasis and asthma cohorts, respectively.
The corresponding coefficients of repeatability were
74, 63, 48 and 53 m. There was no significant differ-
ence in the magnitude of increase in 6MWD with test
repetition between men and women in any of the
diagnostic cohorts (all P > 0.05).
Respirology (2010) 15, 1192–1196
There was no relationship between 6MWD and
the magnitude of change in 6MWD with test repeti-
tion in any of the diagnostic cohorts (all r < 0.5,
P > 0.05).
Seventeen (5%) patients performed the 6MWT
breathing supplementary oxygen (COPD, n = 11; ILD
n = 5; bronchiectasis n = 1) and transported their
oxygen cylinder using a trolley or a rollator. The
increase in 6MWD was similar in patients receiving
supplementary oxygen and those who performed the
test breathing room air (COPD: 36 ⫾ 35 m, n = 11 vs
© 2010 The Authors
Respirology © 2010 Asian Pacific Society of Respirology
6MWT learning effect in lung disease
37 ⫾ 34 m, n = 234, P = 0.97; ILD 37 ⫾ 32, n = 5 vs
42 ⫾ 33 m, n = 16, P = 0.77).
During the study period, 223 patients referred to
the PRP did not undergo a repeat 6MWT for the
following reasons: (i) completed a 6MWT within
the previous 6 weeks during a hospital admission, or
to assess response to ambulatory oxygen therapy
(n = 57); adverse event observed during the 6MWT
(n = 20); walking ability limited by musculoskeletal
(n = 129) or neurological impairment (n = 6), or clau-
dication pain (n = 5), and (iv) patient declined to
repeat the test (n = 6). Compared with the patients
who completed two 6MWT, these patients were older
(69.8 ⫾ 11.4 vs 66.9 ⫾ 9.5 years, P = 0.014) and a
higher proportion had cardiac disease (39% vs 25%,
P < 0.002). Data from 38 patients were not included in
this analysis as these patients showed profound
oxygen desaturation on the 6MWT and performed a
second 6MWT breathing a higher fraction of inspired
oxygen.
DISCUSSION
The main findings of this study are: (i) the majority of
patients with stable CLD increased 6MWD when a
repeat 6MWT was performed before commencing a
PRP, and (ii) the magnitude of increase with test rep-
etition in patients with COPD and ILD was signifi-
cantly greater than in patients with bronchiectasis or
asthma.
To the authors’ knowledge this is the first study
describing the effect of test repetition on 6MWD in a
large cohort of patients with CLD, representative of
patients referred to PRP, who were tested using a stan-
dardized protocol administered by the same two
testers. In contrast to previous studies,8,13,15,16 repeat
6MWT were performed on the same day thereby
eliminating the potential for daily variation in exer-
cise performance to influence the magnitude of
change with test repetition.9
Learning effect for 6MWT
Proposed mechanisms for the increase in 6MWD with
test repetition include familiarity with the walking
course, improved pacing, increased motivation and
habituation to dyspnoea.8,25,29 One possible explana-
tion for the greater learning effect in patients with
COPD and ILD is that both cohorts reported higher
levels of dyspnoea on the first 6MWT compared with
patients with bronchiectasis or asthma and therefore
had more capacity to accommodate to the levels of
dyspnoea on the second test. Support for this expla-
nation is provided by evidence of only a small learn-
ing effect in populations in whom dyspnoea does not
play a major role in exercise limitation, for example,
individuals with mild cardiac impairment,30 stroke,31
end-stage renal disease32 and in healthy subjects.28 We
consider that the smaller change in our patients with
bronchiectasis and asthma, compared with that
observed in the COPD and ILD cohorts, is unlikely to
© 2010 The Authors
Respirology © 2010 Asian Pacific Society of Respirology
1195
be due to a ceiling effect as their 6MWD on the first
test was ⱕ80% predicted values.28
The coefficients of repeatability derived in this
study are relevant if one 6MWT is performed and
accurate if the variability is constant. It is difficult to
directly compare the magnitude of increase in 6MWD
with test repetition in this study with studies reported
previously due to differences in methodology. Specifi-
cally, other studies included patients who had recent
experience of the 6MWT,9 or the two 6MWT were per-
formed on different days.8,15,16 However, the coefficient
of repeatability in our COPD cohort is similar to that
recently reported when subjects performed two
6MWT on a straight track.9
Although we cannot be certain that further
improvement would not have occurred if a third test
was undertaken, in patients with COPD, our previous
study,33 consistent with published data,12,14,34 showed
no significant increase on a third test. The magnitude
of learning effect in the bronchiectasis and asthma
cohorts was similar to that observed in healthy sub-
jects who increased their 6MWD on a third test by
only 10 m (1.5%).35 It remains unknown whether
patients with ILD increase their 6MWD on a third test.
Limitations
This was a retrospective study and prospective
studies are required to confirm these findings. Only 17
patients were aged over 80 years, therefore our find-
ings may not extend to an older population.
A measure of daily physical activity would have
allowed us to determine whether habitual walking
speed influenced the magnitude of the learning
effect, however, this was beyond the scope of this
study.
None of the patients in this study had prior experi-
ence of a 6MWT performed in accordance with the
standardized protocol used in the outpatient PRP.
However, it is possible that some patients had
performed a 6MWT previously although we found
no evidence of this in their medical records.
We did not explore whether a practice test is
required at the end of a PRP. Previous research sug-
gests that a repeat 6MWT may not be necessary in
COPD patients at the end of an 8-week PRP.13
Recommendations for clinical practice
We recommend that patients with CLD referred to a
PRP perform a practice 6MWT at their baseline
assessment if 6MWD is used as an outcome measure
of rehabilitation.
ACKNOWLEDGEMENTS
The authors thank Peter McKinnon, School of Physio-
therapy, Curtin University, Perth, Western Australia,
for statistical advice. We also thank Dr Kylie Hill,
School of Physiotherapy, Curtin University, Perth,
Western Australia, for reviewing the paper.
Respirology (2010) 15, 1192–1196
1196
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Respirology © 2010 Asian Pacific Society of Respirology