Six-Minute Walk Test (6MWT)

Evidence Reviewed as of before: 07-11-2011
Author(s): Mahnaz Hamidzadeh; Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

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 stroke (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 stroke (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 stroke 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 Stroke 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 devices 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, spasticity, 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 stroke over the course of inpatient rehabilitation (Kosak & Smith, 2005).

There are two more adaptations of the 6MWT that have been used in patients with stroke: 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 dysphagia).

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 stroke (Kosak & Smith, 2005). The other versions of MWTs that have also been used in a stroke population include the 3MWT and 5MWT.

Client suitability

Can be used with: Patients with stroke (acute, sub-acute, 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 stroke, head injury, Parkinson’s, pulmonary and cardiac diseases, elderly individuals and healthy adults.
Is this a screening or assessment tool? Assessment.
Time to administer 6 minutes
Versions 12MWT, 5MWT, 3MWT, 2MWT
Other Languages Not applicable.
Measurement Properties
Reliability
  • Four studies examined the test-retest reliability of the 6MWT and reported excellent test-retest reliability (ICC = 0.97 – 0.99).
  • One study examined the intra-rater and inter-rater reliability of the 6MWT and found the test to have adequate intra-rater (ICC = 0.74) and excellent inter-rater (ICC = 0.78) reliabilities.
Validity

Concurrent:

– 3 studies examined the concurrent validity of the 6MWT and reported excellent correlations with Vo2max gold standard; with five-meter walk velocities for preferred speed and fast speed; and with the Locomotor subscale of the Functional Independence Measure (FIM).
– 2 studies reported adequate correlations between the 6MWT and Vo2peak and exercise test duration, and between the 6MWT and the Motor subscale of the FIM and the total FIM.

Convergent:

– 4 studies examined the convergent validity 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.

Predictive:

– 1 study examined the predictive validity of the 6MWT in patients with stroke and found it to be an excellent predictor of mean steps per day.

Does the tool detect change in patients?
  • 6 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 responsiveness of the 6MWT and reported that the 6MWT has a large standardized response mean (SRM), indicating that it is a sensitive measure in clients with stroke.
Acceptability

The 6MWT has been used in acute, sub-acute and chronic stroke 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 stroke.

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 reliability of the 6MWT in 12 community-dwelling individuals with chronic stroke. The test-rest reliability of the 6MWT was found to be excellent for distance covered in meters (ICC = 0.99) and for the submaximal exercise variable Vo2 (ml/kg.min) (ICC = 0.96).

Flansbjer, Holmback, Downham, Patten, and Lexell (2005) studied the reliability of gait performance tests in 50 men and women with hemiparesis after stroke (chronic stroke). They reported the 6MWT had excellent test-retest reliability (ICC = 0.99) with smallest real differences of 13% (SRD) when compared to the Timed Up & Go, gait speed tests, and stair climbing ascend and descend tests.

Fulk, Echternach, Nof, and O’Sullivan (2008) examined the test-retest reliability 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 reliability (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 reliability occurred across 2 trials of the 6-minute walking test on 91 people with stroke. Participants were administered the 6MWT twice with 30-minutes between trials. Test-retest reliability calculated using Intraclass Correlation Coefficients (ICC) was excellent (ICC = 0.98).

Intra-rater & Inter-rater

Kosak and Smith (2005) examined the inter- and intra-rater reliability of the 6MWT in 18 clients enrolled in an inpatient stroke rehabilitation program (28 ± 34 days post-stroke). The intra-rater reliability was found to be adequate (ICC = 0.74). The inter-rater reliability was also found to be excellent (ICC = 0.78).

Validity

Criterion

Concurrent

The 6MWT had an excellent correlation with Vo2 max in patients with stroke (r = 0.66) (Vo2 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 stroke (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 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 stroke. 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 validity of the 6MWT using Pearson product moment correlations and Spearman Rank 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 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 validity of the 6MWT and other widely used clinical measures (FMA LE, self-selected gait-speed, SIS and BBS) in 19 patients with stroke. The 6MWT was found to be an excellent predictor of mean steps per day (r = 0.68; P = 0.001). Although gait speed and balance were related to walking activity, only the 6MWT was found to be a predictor of community ambulation in patients with stroke.

Construct

Convergent

Kosak and Smith (2005) compared the 2MWT to the 6MWT in 18 clients with stroke. An excellent correlation was found between these two measures (r = 0.997).

Kosak and Smith (2005) compared the 12MWT to the 6MWT in 18 clients with stroke. An excellent 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 stroke. 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 stroke. 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 stroke. An adequate correlation was reported between these two measures (r = 0.35).

Fulk et al. (2008) examined the convergent validity 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 correlation, the 5MWT and the 6MWT were found to have an excellent correlation (r = 0.89).

Known groups and Discriminant:

Not available.

Responsiveness

The table below summarizes studies that have examined the responsiveness of the 6MWT among individuals with stroke.

Authors Name Type of study Result of Study
(Kosak & Smith, 2005) Cross-sectional N=18 clients with stroke An inpatient stroke 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 responsiveness to change for the 6MWT as measured by standardized response mean (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) RCT, pilot study N=20 clients with stroke 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) RCT, pilot study N=12 clients with stroke 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) RCT, N=100 clients with stroke 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) RCT, N=91 stroke patients The efficacy of a task-oriented intervention in comparison to usual care in enhancing competence in walking with stroke 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) RCT, N=100 stroke patients (Subacute phase) The efficacy of therapeutic exercise for individuals with subacute stroke 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) RCT, N=52 post-minor ischemic stroke 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.

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