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  • 6 min Walking Test:

    , ..

  • Definition

    The 6 minute walking test (6MWT) is a

    sub-maximal exercise test used to evaluate

    the functional capacity in patients with

    cardiovascular and pulmonary diseases.

  • Background

    The 6MWT was first described by Balke in 1963, mostly to evaluatethe exercise capacity in healthy populations.

    For years it was used to evaluate patients with chronic respiratorydiseases.

    Guyatt in 1985 and Lipkin in 1986 reported that the 6MWT canidentify the most compromised patients suffering from heartfailure.

    Bittner in 1993 reported that the distance walked during the6MWT is a strong and independent predictor of mortality andmorbidity in patients with left ventricular dysfunction.

  • Indications Evaluation of functional capacity Chronic obstructive pulmonary disease Heart failure Cystic fibrosis Peripheral vascular disease Older subjects

    Evaluation of effects of therapeutic interventions Chronic obstructive pulmonary disease Heart failure Lung resection Lung volume reduction surgery Pulmonary rehabilitation Pulmonary hypertension

    Prognostic stratification Heart failure Chronic obstructive pulmonary disease Primary pulmonary hypertension

  • Contraindications for walking tests (1) Absolute Acute myocardial myocardial infarction (3-5 days)

    Unstable Angina

    Exercise induced uncontrolled arrythmias

    Active endocarditis, Acute myocarditis or pericarditis

    Uncontrolled heart failure and pulmonary oedema

    Acute pulmonary embolus

    Thrombosis of lower extremeties

    Suspected dissecting aneurysm

    Acute respiratory failure

    Acute non cardiopulmonary disorder that may affect exercise performance or be aggravated by exercise (i.e. infection, renal failure, thyrotoxicosis)

    Mental impairment leading to inability to cooparate

  • Contraindications for walking tests (2)

    Relative Resting heart rate > 120 bpm

    Systolic blood pressure > 180 mmHg

    Diastolic blood pressure > 100 mmHg

    Left main coronary stenosis or its equivalent

    Severe aortic stenosis

    Tachyarrhythmias or Bradyarrhythmias

    Advanced pregnancy

    Severe orthopaedic impairment that prevents walking

    ERS/ATS (2014)

  • Indentifying a space for the 6MWT A 30 meters long corridor, straight, with no obstacles with a level


    The space should be quiet enough for the participant to clearlyhear your instructions.

    Any clock or timers should not be visible to the participant.

    A chair should be available for the participant to test during orafter the test.

    There should be easy access to a telephone and appropriateequipment in case of emergency. The person administrating thetest is not necessarily a physician, but he should be trained inbasic life support.

  • Required Equipment

    Two cones to mark the turning points at the either end

    Stopwatch or countdown timer

    Measuring tape

    Pen and paper

  • Before the test

    The participant should wear comfortable clothing and appropriate footwear.

    He should continue with his normal medical treatment.

    If he usually walks with an aid, he should use it during the test.

    If he usually uses a GTN spray, chronic oxygen or any other inhaler, he should have them with him and use them during the test if necessary.

  • Instructions The text approved by the ATS is the following:

    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 is 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 Im going to

    show you. Please watch the way I turn without hesitation. Remember

    that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but dont

    run or jog. Start now, or whenever you are ready.ATS 2002

  • Performing the 6MWT

    Set the timer to 6 minutes.

    Demonstrate by walking one lap yourself.

    Start the timer as soon as the participant starts walking

    Record the number of laps.

    Record the additional distance walked from the final

    partial lap.

    Calculate the total distance.

  • Reasons for immediate stopping

    Chest pain

    Intolerable dyspnea

    Leg cramps



    Pale or ashen appearance

    ATS 2002

  • Encouragement

    Encouragement significantly increases the distance


    Participants are told when 2, 4, and 6 minutes have


    Words like keep up the good work or youre doing

    fine are provided with even voice at 1 minute


  • Can Med Assoc J. 1985 ; 132(8): 919923.

  • Reproducibility The degree of reproducibility of a diagnostic or prognostic

    indicator is one of the factors that can determine its use in clinical practice.

    CLINICS 2008;63(2):201-6

  • The Borg Scale

    The Borg Scale is a frequently used quantitative measure of

    perceived exertion during physical activity.

    The participant is asked to grade his level of shortness of

    breath and of fatigue.

    Borg G. Borgs Perceived Exertion and Pan Scales. Champaign, IL: Human Kinetics, 1998.

  • Advantages of the method

    Easy to administer

    Easy to repeat

    Does not require expensive equipment

    Does not require advanced training for technicians

    Has a good correlation with objective measures of effort

    tolerance, such as oxygen uptake at the peak of exercise

    Well tolerated because it is similar to the activities of

    daily living

  • Limitations of the method

    Does not determine peak oxygen uptake

    Does not provide specific information on the function of

    each of the different organs and systems involved in


    Does not diagnose the cause of dyspnea on exertion

    Does not evaluate the causes or mechanisms of exercise


    Results can be affected by a number of factors ATS 2002

  • 6MWT sources of Variability (1)

    Factors reducing the 6MWT :

    Shorter height

    Older age

    Higher body weight

    Female sex

    Impaired cognition

    A shorter corridor

    Pulmonary disease

    Cardiovascular disease

    Musculoskeletal disorders

  • 6MWT sources of Variability (2)

    Factors increasing the 6MWT :

    Taller height

    Male sex


    A patient who has previously performed the test

    Medication for a disabling disease taken just before the test

    Oxygen supplementation in patients with exercise-induced hypoxemia

  • Normal values

    AM J RESPIR CRIT CARE MED 1998;158:13841387

  • 6MWT

    Evaluation of functional capacity

    Evaluation of effects of therapeutic interventions

    Prognostic stratification

  • Correlation of 6MWT and NYHA Functional class in PPH

    Am J Respir Crit Care Med. 2000;161(2,pt 1):487-492

  • Am Heart J 1997;133:447 53.

    Variation in distancewalked during the 6MWTat baseline, after threeweeks of physical trainingand after three weeks ofactivity restriction in agroup of patients withstable heart failure.

  • Change in 6MWT distance with common treatments

    in COPD from randomized controlled trials

    ICS, inhaled corticosteroids; LABA, long-acting beta agonist; LVRS, lung volume reduction surgery; PRehab, Pulmonary Rehabilitation; SABA, short-acting beta agonist.

    *P < 0.05 versus control.

    Internal Medicine Journal 2009;39: 495501

  • Change in 6MWT distance with common treatments

    in heart failure from randomized controlled trials

    BB, beta-adrenergic blockers; CPAP, continuous positive airway pressure; CRT, cardiac resynchronisationtherapy *P < 0.05 versus control

    Internal Medicine Journal 2009;39: 495501

  • Effects of therapeutic interventions on 6MWT

    o The dashed line shows thevariations of distance walkedduring 6MWT observed inpatients with stable heart failurein whom drug dosages wereunchanged in short-term.

    o The continuous line shows thebehavior of distance walked inheart failure patients in whomdosages of diuretics andvasodilators have been graduallyincreased as tolerated.

    Am J Cardiol 1998;81:1370 2.

  • The PAVE trial prospectively compared chronic biventricular pacing to rightventricular pacing in patients undergoing ablation of the AV node for managementof atrial fibrillation with rapid ventricular rates.

    The results are most positive in those with low EFs. There is very little differencein those with preserved LV function.

    J Cardiovasc Electrophysiol. 2005 ;16:1160-5

  • Galie N, Ghofrani HA, Torbicki A, et al. N Engl J Med 2005; 353:2148-57.

    REVATIO: SUPER- 16-Minute Walk Distance

  • Gali N et al. Circulation 2009;119:2894-2903

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