Six-Minute Walk Test (6MWT)

Purpose

The Six-Minute Walk Test (6MWT) (Butland, Pang, Gross, Woodcock, & Geddes, 1982) is a functional walking test in which the distance that a client can walk within six minutes is evaluated. This test has been used to assess individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Kosak & Smith, 2005), head injury (Rossier & Wade, 2001), and Parkinson’s disease (Garber & Friedman, 2003), as well as pulmonary and cardiac diseases.

Please, refer also to the iWalkAssess app: The latest evidence-informed approach to walking assessment post-stroke (Click for the iWalk Toolkit)

In-Depth Review

Purpose of the measure

The Six-Minute Walk Test (6MWT) (Butland, Pang, Gross, Woodcock, & Geddes, 1982) is a functional walking test in which the distance that a client can walk within six minutes is evaluated. This test has been used to assess individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (Kosak & Smith, 2005), head injury (Rossier & Wade, 2001), and Parkinson’s disease (Garber & Friedman, 2003), as well as pulmonary and cardiac diseases.

Available versions

There are 5 versions of walking tests available in the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population, the 12-, 6-, 5-, 3-, and 2-Minute Walk Tests. The differences between the 12-, 6-, and 2-Minute Walk Tests are summarized in the table below.

Version of walking test in StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	Purpose	Strength	Limitation
12MWT (Kosak & Smith, 2005)	To evaluate the level of physical fitness of healthy individuals. Adapted to assess disability in patients with chronic bronchitis.	Compared to the 2 and 6MWTs, the 12MWT was the most responsive to change during post-stroke rehabilitation (Kosak & Smith, 2005).	Exhausting for patients.
6MWT (Kosak & Smith, 2005)	To evaluate exercise tolerance among individuals with respiratory diseases. Derived from the 12 MWT.	Easy to administer Better tolerated than 12MWT More reflective of performance in ADLs than the other walking tests (Solway, Brooks, Lacasse & Thomas, 2001) Good measure of endurance	Does not assess balance, quality of movement, use of assistive devicesAssistive devices are any piece of equipment that you use to make your daily activities easier to perform. and amount of physical assistance needed (Barak & Duncan, 2006) Described as a test of functional capacity, endurance, fatigability and cardiovascular fitness Stroke-specific impairments (ie muscle weakness, spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. , balance, hemiparesis) may influence distance walked (Barak & Duncan, 2006).
2MWT (Kosak & Smith, 2005)	To assess exercise tolerance in chronic air flow limitation.	Highly correlated with the 6 and 12 MWTs. A valid measure of self-selected walking speed. The most time efficient.	Compared to the 6 and 12 MWTs, the 2MWT was the least responsive to change for strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. over the course of inpatient rehabilitation (Kosak & Smith, 2005).

There are two more adaptations of the 6MWT that have been used in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.: 3MWT (Sakai, Tanaka, & Holland, 2002), and 5MWT (Teixeira da Cunha-Filho et al., 2003)

Features of the measure

Items:
There are no actual items to the 6MWT.

The 6MWT is a simple test that requires a 100-ft, quiet, indoor, flat, straight rectangular hallway. The walking course must be 30m in length. The length of the 30m corridor must be marked by colored tape at every 3m. The turnaround must be marked with a cone. Some studies have used 20 and 50m corridors.

(American Thoracic Society “ATS (http://ajrccm.atsjournals.org/cgi/reprint/166/1/111?ijkey=58e74d53a3942c7bf82e79d2495f8b944bf3f0c2) statement: guidelines for the six-minute walk test,” 2002).

To prepare for the 6MWT, the client should be encouraged to:

• Wear comfortable clothing
• Wear appropriate walking shoes
• Use their usual walking aides during the test (cane, walker, etc.)
• Take their usual medications
• Avoid engaging in vigorous exercise 2 hours prior to testing

To prepare for the 6MWT, clinicians may wish to:

• Have the client stand and rate their baseline dyspnea and overall fatigue using the Borg scale. The Borg scale is a 15 or 12 grade rating scale of perceived exertion – the client’s perception of physical effort or strain.
• Pulse oximetery is optional. If it is conducted, baseline heart rate, and oxygen saturation should be measured and recorded.

(“ATS statement: guidelines for the six-minute walk test,” 2002)

According to the American Thoracic Society (ATS) protocol, patients should be instructed in the following way:
“The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes are a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones. You should pivot briskly around the cones and continue back the other way without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.”

Demonstrate by walking one lap yourself. Walk and pivot around a cone briskly. Then say:
“Are you ready to do that? I will write down each time you turn around at this starting line. Remember that the object is to walk as far as possible for 6 minutes, but don’t run or jog. Start now or whenever you are ready.”

The patient should be positioned at the starting line. The clinician should stand near the starting line during the test. As soon as the patient starts to walk, the timer should be started.

No conversations should take place during the walk. An even tone of voice should be used when providing the standard phrases of encouragement (see below). The patient should be supervised. The clinician should remain focused and not lose count of the laps.

After the first minute, the patient should be told the following (in an even tone):
“You are doing well. You have 5 minutes to go.”

When the timer shows 4 minutes remaining, the patient should be told the following:
“Keep up the good work. You have 4 minutes to go.”

When the timer shows 3 minutes remaining, the patient should be told the following:
“You are doing well. You are halfway done.”

When the timer shows 2 minutes remaining, the patient should be told the following:
“Keep up the good work. You have only 2 minutes left.”

When the timer shows only 1 minute remaining, the patient should be told the following:
“You are doing well. You have only 1 minute to go.”

Other words of encouragement or body language (eg. to speed up) should not be used.

Please note:

• Do not provide a “warm-up” period.For at least 10 minutes before the beginning of the test, the client should sit in a chair located near the starting position. During this time, the clinician should review the contraindications (see Client Suitability section of module), the appropriateness of the client’s clothing and shoes, and complete the first part of the worksheet (see below).(“ATS statement: guidelines for the six-minute walk test,” 2002)
  The following elements should be present on the 6MWT worksheet and report:
  Lap counter: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
  Patient name: ____________________ Patient ID# ___________
  Walk # ______ Tech ID: _________ Date: __________
  Gender: M F Age: ____ Race: ____ Height: ___ft ____in, ____ meters
  Weight: ______ lbs, _____kg Blood pressure: _____ / _____
  Medications taken before the test (dose and time): __________________
  Supplemental oxygen during the test: No Yes, flow ______ L/min, type _____
  Baseline End of Test
  Time ___:___ ___:___
  Heart Rate _____ _____
  Dyspnea ____ ____ (Borg scale)
  Fatigue ____ ____ (Borg scale)
  SpO2 ____ % ____%
  Stopped or paused before 6 minutes? No, Yes, reason: _______________
  Other symptoms at end of exercise: angina, dizziness hip, leg, or calf pain
  Number of laps: ____ (_60 meters) _ final partial lap: _____ meters _
  Total distance walked in 6 minutes: ______ meters
  Predicted distance: _____ meters Percent predicted: _____%
  Tech comments:
  Interpretation (including comparison with a pre-intervention 6MWT).
• A lap counter (or pen and paper) should be used to note the number of laps that the client is able to walk during the 6 minutes.

Upon completion of the test:

• Clients should be asked to rate their post walk dyspnea and overall fatigue levels using the Borg scale.
• The following should be asked: “What, if anything, kept you from walking farther?”
• If using a pulse oximeter, measure SpO2 and pulse rate from the oximeter and then remove the sensor.
• The number of laps should be recorded on the worksheet.
• The total distance walked, rounded to the nearest meter, should be calculated and recorded on the worksheet.
• The client should be congratulated for good effort and should be offered a drink of water (if not on a liquid restricted diet due to dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
  ).

Scoring:

• The lap counter or pen and paper should be used to note the number of laps that the patient is able to walk during the 6MWT.
• Distance walked, and the number and duration of rests during the 6 minutes should be measured.
• Scores range from 0 meters or feet for patients who are non-ambulatory to the maximum biological limits for normal healthy individuals (approximately 900 meters or 2953 feet).

Time:
Six minutes.

Subscales:
None.

Equipment: (“ATS statement: guidelines for the six-minute walk test,” 2002)

1. Stopwatch (countdown timer).
2. Pulse oximeter when indicated (optional).
3. A chair at the end of track in case patients are tired and wish to rest midway through the test.
4. Two small cones to mark the turnaround points.
5. Other safety equipment (source of oxygen, telephone, automated electronic defibrillator).

Training:
There is no need for training of clinicians as long as they comply with the 6MWT protocol.

Alternative forms of the Six-Minute Walk Test

• 12MWT and 2MWT are also valid and reliable measures in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Kosak & Smith, 2005). The other versions of MWTs that have also been used in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population include the 3MWT and 5MWT.

Client suitability

Can be used with: Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (acute, subacute, and chronic)

Other groups tested with this measure:

• Chronic Obstructive Pulmonary Disease (Steele et al., 2000),
• Heart failure (Guyatt, Sullivan et al., 1985)
• Peripheral arterial disease (Montgomery & Gardner, 1998),
• Fibromyalgia (King et al., 1999; Pankoff, Overend, Lucy, & White, 2000; Pankoff, Overend, Lucy, & White, 2000),
• Cystic fibrosis (Gulmans, van Veldhoven, de Meer, & Helders, 1996),
• Renal failure (Fitts & Guthrie, 1995),
• Elderly individuals ( King, Judge, Whipple, & Wolfson, 2000),
• Healthy adults (Harada, Chiu, & Stewart, 1999),
• Individuals with pacemakers (Langenfeld et al., 1990),
• Transplant candidates with end stage lung disease (Cahalin, Pappagianopoulos, Prevost, Wain, & Ginns, 1995).

Should not be used in: (“ATS statement: guidelines for the six-minute walk test,” 2002; Enright, 2003)

• Absolute contraindications for the 6MWT include: unstable angina and myocardial infarction (MI) in the previous month.
• Relative contraindications: resting heart rate> 120, systolic blood pressure (BP) > 180mm Hg, and diastolic BP > 100 mm Hg.
• Testing should be performed in a location where a rapid appropriate response to emergency is possible.
• Supplies that must be available in rehabilitation and hospital settings include oxygen, sublingual nitroglycerine, aspirin, and albuterol. A telephone should be in place to enable an emergency call.
• The clinician should be certified in cardiopulmonary resuscitation with a minimum of basic life support.
• If a client is on chronic oxygen therapy, oxygen should be given at the standard rate or as directed by a physician or a protocol.
• Reasons for immediately stopping a 6MWT include the following: (1) chest pain, (2) intolerable dyspnea, (3) leg cramps, (4) staggering, (5) diaphoresis, and (6) pale or ashen appearance. If the test is stopped for any of the above reasons, the patients should sit or lie supine as necessary depending on the severity of events. Based on judgment of clinician, blood pressure, pulse rate, oxygen saturation, and physician evaluation should be obtained.

NOTE: Care should be taken to evaluate safety in ambulation prior to testing to ensure that the patient is safe to walk alone without supervision before the test is chosen as an assessment.

In what languages is the measure available?

No information available.

Summary

What does the tool measure?	It is a functional walking test that determines the distance that a client can walk within six minutes.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., head injury, Parkinson’s, pulmonary and cardiac diseases, elderly individuals and healthy adults.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment.
Time to administer	6 minutes
Versions	12MWT, 5MWT, 3MWT, 2MWT
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Test-retest: Four studies examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the 6MWT and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). (ICC = 0.97 – 0.99). Intra-rater: One study examined the intra-rater and inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the 6MWT and found the test to have adequate intra-rater (ICC = 0.74) and excellent inter-rater (ICC = 0.78) reliabilities.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: – Three studies examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the 6MWT and reported excellent correlations with Vo2max gold standardA measurement that is widely accepted as being the best available to measure a construct. ; with five-meter walk velocities for preferred speed and fast speed; and with the Locomotion subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). of the Functional Independence Measure (FIM). – Two studies reported adequate correlations between the 6MWT and Vo2peak and exercise test duration, and between the 6MWT and the Motor subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). of the FIM and the total FIM. Predictive: One study examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the 6MWT in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and found it to be an excellent predictor of mean steps per day. Construct: Convergent: Four studies examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the 6MWT and found excellent correlations with the 2 MWT, the 5 MWT, the 12 MWT, the Berg Balance Scale, and the Reintegration to Normal Living (RNL) Index as well as an adequate relationship with the Quadriceps Eccentric Paretic Strength.
Does the tool detect change in patients?	Six studies have used the 6MWT to demonstrate the effectiveness of various exercise interventions and found an increase in the distance walked ranging from 28.21m to 102.8m post-intervention. One study directly examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the 6MWT and reported that the 6MWT has a large standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores. (SRM), indicating that it is a sensitive measure in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Acceptability	The 6MWT has been used in acute, sub-acute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. populations. Note: Care should be taken to evaluate safety in ambulation prior to testing to ensure that the patient is safe to walk alone without supervision before the test is chosen as an assessment.
Feasibility	The 6MWT requires no specialized training to administer and only simple equipment is required (a stop-watch, Borg Scale, and pulse oximeter when necessary). It is a simple test that required 100-ft, quiet, indoor, flat, straight rectangular hallway. The walking course must be 30m in length and for 30m the length of corridor must be marked every 3m with colored tape.
How to obtain the tool?	Detailed instructions for administration as found in the 6MWT module are sufficient information for administering the 6MWT.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the 6MWT in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Floor/Ceiling Effects

The 6MWT is a continuous variable without ceiling effects (Kosak & Smith, 2005).

Reliability

Test-retest:
Eng, Dawson, and Chu (2004) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the 6MWT in 12 community-dwelling individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The test-rest reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the 6MWT was found to be excellent for distance covered in meters (ICC = 0.99) and for the submaximal exercise variable Vo2Blood oxygen level.
(ml/kg.min) (ICC = 0.96).

Flansbjer, Holmback, Downham, Patten, and Lexell (2005) studied the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
performance tests in 50 men and women with hemiparesis after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.). They reported the 6MWT had excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC = 0.99) with smallest real differences of 13% (SRD) when compared to the Timed Up & Go, gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed tests, and stair climbing ascend and descend tests.

Fulk, Echternach, Nof, and O’Sullivan (2008) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the 6MWT in 37 clients undergoing inpatient rehabilitation post-stroke. Clients were on average 33.7 days post-stroke and a mean age of 66.3 years. Clients were administered the 6MWT twice, with 1-3 days between trials. The 6MWT was found to have excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC = 0.97).

Liu, Drutz, Kumar, McVicar, Weinberger, Brooks et al. (2008) investigated whether a practice effect as verified by various criteria including test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
occurred across 2 trials of the 6-minute walking test on 91 people with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were administered the 6MWT twice with 30-minutes between trials. Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
calculated using Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficients (ICC) was excellent (ICC = 0.98).

Intra-rater & Inter-rater:
Kosak and Smith (2005) examined the inter- and intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the 6MWT in 18 clients enrolled in an inpatient strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation program (28 ± 34 days post-stroke). The intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
was found to be adequate (ICC = 0.74). The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was also found to be excellent (ICC = 0.78).

Validity

Criterion:
Concurrent:
The 6MWT had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with Vo2Blood oxygen level.
max in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (r = 0.66) (Vo2Blood oxygen level.
max is the maximum volume of the oxygen that the body can consume during intense whole body exercise, while breathing air at sea level) (Eng et al., 2004; Pang, Eng, & Dawson, 2005).

Tang, Sibley, Bayley, McIlroy, and Brooks (2006) administered the 6MWT to 36 individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (sub-acute) and reported excellent correlations between the 6MWT and the Five Meter Walk Velocity for preferred (r = 0.79), and fast speed (r = 0.82). This suggests that the speed selected by the patient during the 6MWT was strongly related to velocities chosen during the Five Meter Walk Distance (Kelly, Kilbreath, Davis, Zeman, & Raymond, 2003; Tang et al., 2006).

Tang et al. (2006) found an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the 6MWT and both a record of patients’ average oxygen uptake during cardiopulmonary exercise test (Vo2peak) (r = 0.56) and exercise test duration (r = 0.60) in 36 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This suggests that even though the 6MWT may challenge the cardiorespiratory system, it appears to be more strongly influenced by walking speed rather than cardiorespiratory capacity (Tang, Sibley, Bayley, McIlroy, & Brooks, 2006).

Fulk et al. (2008) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the 6MWT using Pearson product moment correlations and Spearman Rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients in 37 clients undergoing inpatient rehabilitation post-stroke. Clients were on average 33.7 days post-stroke and a mean age of 66.3 years. The 6MWT was compared to subscales of the Functional Independence Measure (FIM) (Keith, Granger, Hamilton & Sherwin, 1987). The 6MWT had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with discharge locomotion (walk) FIM scores (Spearman r = 0.69), and with discharge locomotion (walk) + stairs FIM scores (Spearman r = 0.69). The 6MWT had adequate correlations with discharge motor FIM scores (Pearson r = 0.52), and discharge total FIM scores (Pearson r = 0.45).

Predictive:
Fulk, Reynolds, Mondal & Deutsch (2010) examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the 6MWT and other widely used clinical measures (FMA LE, self-selected gait-speed, SIS and BBS) in 19 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The 6MWT was found to be an excellent predictor of mean steps per day (r = 0.68; P = 0.001). Although gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed and balance were related to walking activity, only the 6MWT was found to be a predictor of community ambulation in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:
Convergent:
Kosak and Smith (2005) compared the 2MWT to the 6MWT in 18 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between these two measures (r = 0.997).

Kosak and Smith (2005) compared the 12MWT to the 6MWT in 18 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between these two measures (r = 0.99).

Patterson et al. (2007) administered both the Berg Balance Scale (BBS) (Patterson, Forrester, Rodgers, Ryan, Ivey, Sorkin, et al., 2007) and the 6MWT to 74 clients (43 men, 31 women) with chronic hemiparetic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An excellent relationship was reported between the BBS and the 6MWT (r = 0.69).

Patterson et al. (2007) compared quadriceps eccentric paretic strength to the 6MWT in 74 individuals (43 men, 31 women) with chronic hemiparetic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An adequate relationship was reported between the 6MWTand quadriceps strength (r = 0.57).

Pang, Eng, and Miller (2007) administered the Reintegration to Normal Living Index (RNL) and the 6MWT to 63 clients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was reported between these two measures (r = 0.35).

Fulk et al. (2008) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the 6MWT by comparing it to the 5MWT in 37 clients undergoing inpatient rehabilitation post-stroke. Clients were on average 33.7 days post-stroke and a mean age of 66.3 years. Using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
, the 5MWT and the 6MWT were found to have an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = 0.89).

Known groups:
Not available.

Responsiveness

The table below summarizes studies that have examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the 6MWT among individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Authors Name	Type of study	Result of Study
(Kosak & Smith, 2005)	Cross-sectional N=18 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	An inpatient strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation program (standard protocol as set out by the American Association of Cardiovascular and Pulmonary Rehabilitation) lasting 3.9 + 2 weeks of observation indicated that the responsivenessThe ability of an instrument to detect clinically important change over time. to change for the 6MWT as measured by standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores. (SRM) score was 1.52. This translates into a 2.4 fold increase in the distance walked by clients enrolled in this rehabilitation program.
(Duncan et al., 1998)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., pilot study N=20 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	The results of an 8-week home-based exercise program indicated a change of 59.4 meters on the 6MWT (mean changes = 195 ft) compared with 34.7 meters (mean changes = 114 ft) following usual care.
(Dean, Richards, & Malouin, 2000)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., pilot study N=12 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	A 4-week exercise class was offered to improve locomotor tasks (Dean et al., 2000). Participants achieved a change of 42.1 meters (SD = 119.0) in the 6MWT compared with only a 4.7 meter change following equal intensity of in upper-extremity (UE) intervention.
(Visintin, Barbeau, Korner-Bitensky, & Mayo, 1998)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., N=100 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	After 6 weeks of treadmill training with body weight support, the mean change in the distance walked in 6 minutes following the intervention was 102.8 meters (SD = 67.4) compared with 58.8 meters (SD = 72.2) in the control group.
(Salbach et al., 2004)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., N=91 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients	The efficacy of a task-oriented intervention in comparison to usual care in enhancing competence in walking with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. was evaluated. Clients with a mild, moderate or severe walking deficit at baseline improved an average of 36 (SD = 96), 55 (SD = 56) and 18 m (SD = 23), respectively, in 6MWT performance at post-intervention.
(Duncan et al., 2003)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., N=100 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients (Subacute phase)	The efficacy of therapeutic exercise for individuals with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. was compared to usual care. The intervention group improved in 6MWT performance by an average of 28.2 meters (12.52%) more than the usual care group.
(Tanne, Tsabari, Chechik, Toledano, Orion, Schwammenthal, et al., 2008)	RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., N=52 post-minor ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.	Three-month outpatient exercise program. Improvement in exercise capacity in the intervention group in comparison to the control group was demonstrated using the 6MWT (from 444 ± 90 at baseline to 557 ± 99 meters post-intervention in the exercise group; from 438 ± 101 at baseline to 418 ± 126 in the control group).

References

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See the measure

How to obtain the 6MWT:

Detailed instructions for administration as found in this module are sufficient information for administering the 6MWT.

By clicking here, you can access a video showing how to administer the assessment.