18/09/13

Use of the 6-Min Walk Test: A Pro and Con Review | The American College of Chest Physicians
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Home Use of the 6-Min Walk Test: A Pro and Con Review

Use of the 6-Min Walk Test: A Pro and Con Review

PCCSU Article | 06.15.09 By Daniel R. Smith, MD, FCCP Dr. Smith is Assistant Professor, National Jewish Medical and Research C enter, Denver, C O. Dr. Smith has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within this chapter. Objectives

1. Review the history of the development of functional testing. 2. Review indications for exercise testing. 3. Review the appropriate methodology for 6-min walk testing. 4. Understand the use of 6-min walk testing as a prognostic test. 5. Understand the use of 6-min walk testing as a method of determining the effectiveness of therapeutic interventions.
Key words: 6-min walk; exercise; functional assessment Abbreviations: 6MWD = 6-min walk distance; 6MWT = 6-min walk test The 6-min walk test (6MWT) has been widely used and accepted as a simple, cost-effective means of clinically assessing the functional status of patients with cardiopulmonary diseases and other disorders. Essentially, this test relies on the basic parameter of total distance walked during a specified time. This relatively low-technology and easily performed test remains a standardized tool in both clinical and research settings despite the availability of more sophisticated physiologic testing. The 6MWT has proven reliable in providing reproducible data to serve as measures of preand posttreatment comparisons,1 - 6 in the assessment of functional status,7 - 9 and in predicting morbidity and mortality for various disease states.2 ,1 0 - 1 3 Despite the widespread use of 6MWT in various settings, many clinicians are unfamiliar with the specifics regarding proper testing and accepted standards for the use of this measure. This paper will briefly review the history of and guidelines for the 6MWT and provide a pro/con discussion of its use. Distance testing was first advocated by Balke 1 4 in 1963 as a means of assessing physical fitness. Kenneth H. C ooper1 5 later used a 12-min walk/run test in healthy Air Force personnel that demonstrated a strong correlation with maximal oxygen consumption, as obtained on maximal exercise testing on a treadmill, as well as the ability to detect changes in conditioning. McGavin1 6 made additional modifications to the test in 1976, as he used a walk test to assess disability in patients with C OPD. Subsequent work determined the effectiveness and reliability of shorterdistance walk testing and, eventually, the 6-min time became the most widely accepted protocol. The 6MWT is a submaximal, self-paced test that is currently used to assess functional capacity in various settings. In 2002, the American Thoracic Society (ATS) outlined specific guidelines regarding the background and use of the 6MWT and methodology for performing the test.1 7 This invaluable reference reviewed the concept of functional testing as a means of assessing the global and integrated physiologic responses to exercise, rather than specifically measuring the function of individual organ systems. Accepted indications (Table 1) and contraindications for 6MWT were outlined with recommendations to address safety issues related to testing. Technical aspects of testing that were reviewed included performing the test indoors along a straight, flat corridor with a hard surface. A 30-m distance course was specified, and turnaround points were identified with traffic cones and 3-m interval measurements well marked with colored tape on the floor. Recommendations also were specified for required testing equipment, patient preparation, and detailed instructions for performing the testing. Subjective patient dyspnea assessments are to be obtained pre- and posttesting using the Borg scale.1 8 The ATS reference also addressed the need for standardized pretest patient instructions and specified scripted verbal interactions at timed intervals during testing to eliminate the possibility of coaching or encouragement effects. Guidelines were suggested to limit controllable factors for variability, address the potential use of practice tests, and outline standardized testing for patient use of oxygen and/or medications prior to or during testing. Finally, the ATS paper referenced studies regarding the interpretation of 6MWT results before and after interventions and recommended that changes in 6-min walk distance (6MWD) be expressed by absolute value. Values for statistically significant changes in 6MWD for groups and individuals were referenced from the work of Redelmeier and colleagues.1 9 The use of single 6MWT values as a measure of the functional status of individuals was not recommended with the recognition of the lack of adequate standardized normal values.

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Use of the 6-Min Walk Test: A Pro and Con Review | The American College of Chest Physicians

Use of t he 6-Min Walk Test : Pros

Perhaps the best rationale for use of the 6MWT lies in the practicality and simplicity of the test itself. The 6MWT is a cost-effective procedure that may be performed in nearly any clinical location without the need for either direct physician involvement or invasive, and often expensive, monitoring equipment. As a self-paced and submaximal exercise procedure employing the familiar activity of walking, the 6MWT is well tolerated by patients over a wide span of fitness levels and debility. The 6MWT, in comparison to other functional walking tests, is also felt to offer advantages that include established standards for testing, reference values, and correlation with the capacity to perform activities of daily living.6 ,2 0 The safety of 6MWT is ensured by adherence to specific ATS guidelines1 7 regarding contraindications for testing, and it has been confirmed by two large studies.7 ,2 1 The 6MWT is, importantly, a measure of functional exercise performance that reflects the integrated and global responses of multiple factors involved in exercise. The 6MWT may demonstrate pulmonary dysfunction occurring from the combination of dyspnea, airflow limitation, dynamic hyperinflation, and skeletal muscle dysfunction associated with C OPD. This functional assessment approach reveals not only limitations from cardiopulmonary system abnormalities, but also potential contributions, such as changes in peripheral circulation and blood composition, and neuromuscular and muscular metabolic responses. There are recognized and previously discussed advantages in using this comprehensive assessment in defining the severity of disease over simpler physiologic parameters alone.2 2 ,2 3 Importantly, the objective data from 6MWT allow a functional assessment of disease outcome and demonstrate less intrasubject variability than subjective questionnaires.2 4 The 6MWT has been validated using physiologic parameters and quality-of-life measurements. In patients with C OPD, 6MWT results correlate well with maximal oxygen consumption and work rate obtained by bicycle ergometer testing (r=0.51 to 0.81).6 ,2 4 - 2 8 The correlation of 6MWT data and maximum oxygen uptake extends to patients with congestive heart failure, pulmonary hypertension, and pulmonary fibrosis.2 ,1 1 ,2 9 - 3 1 Direct comparisons of 6MWD with dyspnea scores and other quality-of-life measures in C OPD patients demonstrate weaker and more variable correlation.6 ,2 8 ,3 2 Test-retest reliability of the 6MWT also has been definitively demonstrated.1 1 ,3 3 The responsiveness of the 6MWT has contributed to the widespread use of the test as an outcomes measure in assessing the impact of pharmacologic, surgical, and rehabilitative interventions. In patients with C OPD, 6MWT data have demonstrated improvements with interventions such as bronchodilators,3 4 mucous clearing devices,3 5 pulmonary rehabilitation,3 6 and lung volume reduction surgery.3 7 C linical studies for numerous disease processes now routinely use 6MWT data as an endpoint to assess responses to therapy. The 6MWT data also are used as a reliable prognostic tool. C elli and colleagues1 3 used 6MWT data as one of four predictive factors in their multidimensional grading system to predict mortality in patients with C OPD. Additional studies have used the 6MWT to predict mortality in heart failure 1 0 ,1 1 and primary pulmonary hypertension.2 ,3 8 Such data also can be invaluable in determining the risks, appropriateness, and timing for major interventions such as lung volume reduction surgery (LVRS) and transplantation. As an example, the finding of a 6MWD of 200 m or less is associated with a mortality rate of 84% rate in patients undergoing LVRS.3 9

Use of t he 6-Min Walk Test : Cons

Results of the 6MWT are subject to significant variability with minor and potentially easily overlooked variances in testing procedures from those specified in the ATS guidelines.1 7 Minor variations in course layout, patient instructions, or inadvertent coaching may significantly affect 6MWT. Treadmills should not be used for the 6MWT. The use of supplemental oxygen during testing or the use of various medications prior to testing may potentially alter performance and must be standardized and documented for accurate comparisons. The recognition of a training effect and subsequent initial improvements in 6MWT results without interventions over the first few weeks of repeat testing must also be taken into consideration. Finally, the 6MWT is not useful in assessing patients with normal or high exercise capacities with an observed ceiling effect and resultant inability to detect performance improvements. Results of the 6MWT do not always correlate well with other measurements of disease severity. C orrelation of 6MWT results with pulmonary function testing in patients with C OPD is generally weak (r=0.17 to 0.55),2 5 ,2 8 ,3 2 and their 6MWD can be minimally reduced despite severe C OPD.6 ,2 4 ,2 8 A number of factors has been identified as sources of variability in 6MWD and summarized in Table 2.1 7 C onsideration of these factors should be made when assessing individual performances and also when comparing results for different populations.

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Use of the 6-Min Walk Test: A Pro and Con Review | The American College of Chest Physicians

The use of the 6MWT as a single measurement of the functional status of an individual is inherently problematic. The most widely accepted reference values for normal 6MWD, 576 m for healthy males and 494 m for healthy females, was based on a study 4 0 with 117 men and 173 women ranging in age from 40 to 80 years. To my knowledge, definitive normal values standardized to more specific patient demographics and using stringent ATS recommendations do not exist. Reference values and equations commonly used for patients with C OPD are based on a study by Redelmeier and colleagues1 9 with 112 patients. A low 6MWD finding in a patient is nonspecific and reveals little regarding the various potential factors contributing to the decreased functional status. The use of the 6MWT as a measure of improvement in functional capacity is widespread in current clinical studies. The determination of what constitutes a significant clinical change as a result of an intervention has been debated with generally well-accepted parameters for patients with C OPD. The minimal important clinical difference in patients with C OPD is reported to be approximately 55 m for cohorts1 9 ,4 1 and 86 m for individuals.4 2 Extrapolation of the use of these parameters of minimal important clinical difference to other patient groups may not be appropriate. In addition, the relative small differences in 6MWD accepted as significant are well within the range of improvement seen with minor variations from ATS guidelines, such as patient encouragement, and underscore the importance of standardized testing protocols. The use of the 6MWT has expanded to include applications in predicting morbidity and mortality for various disease states. As described above, prognostic data have been generated that use 6MWD to determine the appropriateness for and timing of surgical interventions, such as LVRS in patients with C OPD 3 9 and patients who undergo lung transplantation for a variety of pulmonary diseases.2 The use of 6MWD in the multidimensional body mass index, airflow obstruction, dyspnea, and exercise capacity index (BODE) grading system to predict mortality in patients with C OPD 1 3 has been somewhat questioned by subsequent studies4 3 of patients with more precisely defined diagnoses of emphysema and severe airflow obstruction. C learly, more definitive studies are needed to clarify the use of a reliably performed 6MWT for application in clinical settings. Perhaps, prior recommendations concerning the use of APAC HE II (Acute Physiologic and C hronic Health Evaluation) score data for patients in the IC U best summarizes the approach for the use of 6MWT data; paraphrasing Scottish writer Andrew Lang, the data should be used as the drunk uses a light postfor support, rather than illumination.

Conclusions
The 6MWT is a widely used and useful measure of functional status. As with any test, there are advantages and disadvantages in the application of 6MWT data. C linicians should be familiar with 6MWT procedures and limitations given the ubiquitous use of this parameter for current clinical studies.

Poststudy Questions

References 1. Holden DA, Rice TW, Stelmach K, et al. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest 1992; 102:1774-1779 2. Kadikar A, Maurer J, Kesten S. The six-minute walk test: a guide to assessment for lung transplantation. J Heart Lung Transplant 1997; 16:313-319 3. Paggiaro PL, Dahle R, Bakran I, et al. Multicentre randomised placebo-controlled trial of inhaled fluticasone propionate in patients with chronic obstructive pulmonary disease. Lancet 1998; 351:773-780 4. Sciurba FC, Rogers RM, Keenan RJ, et al. Improvement in pulmonary function and elastic recoil after lung-reduction surgery for diffuse emphysema. N Engl J Med 1996; 334:1095-1099 5. Sinclair DJ, Ingram CG. Controlled trial of supervised exercise training in chronic bronchitis. Br Med J 1980; 280:519521 6. Solway S, Brooks D, Lacasse Y, et al. A qualitative systematic overview of the measurement properties of functional walk tests used in the cardiorespiratory domain. Chest 2001; 119:256-270 7. Enright PL, McBurnie MA, Bittner V, et al. The 6-min walk test: a quick measure of functional status in elderly adults. Chest 2003; 123:387-398 8. Hajiro T, Nishimura K, Tsukino M, et al. Comparison of discriminative properties among disease-specific questionnaires for measuring health-related quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 157:785-790 9. Zugck C, Kruger C, Durr S, et al. Is the 6-minute walk test a reliable substitute for peak oxygen uptake in patients with

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dilated cardiomyopathy? Eur Heart J 2000; 21:540-549 10. Bittner V, Weiner DH, Yusuf S, et al. Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. JAMA 1993; 270:1702-1707 11. Cahalin LP, Mathier MA, Semigran MJ, et al. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest 1996; 110:325-332 12. Casanova C, Cote C, Marin JM, et al. Distance and oxygen desaturation during the 6-min walk test as predictors of long-term mortality in patients with COPD. Chest 2008; 134:746-752 13. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004; 350:1005-1012 14. Balke B. A simple field test for the assessment of physical fitness: rep 63-6. Rep Civ Aeromed Res Inst US 1963; 53:1-8 15. Cooper KH. A means of assessing maximal oxygen intake: correlation between field and treadmill testing. JAMA 1968; 203:201-204 16. McGavin CR, Gupta SP, McHardy GJ. Twelve-minute walking test for assessing disability in chronic bronchitis. Br Med J 1976; 1:822-823 17. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166:111-117 18. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14:377-381 19. Redelmeier DA, Bayoumi AM, Goldstein RS, et al. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155:1278-1282 20. Brown CD, Wise RA. Field tests of exercise in COPD: the six-minute walk test and the shuttle walk test. COPD 2007; 4:217-223 21. Roomi J, Johnson MM, Waters K, et al. Respiratory rehabilitation, exercise capacity and quality of life in chronic airways disease in old age. Age Ageing 1996; 25:12-16 22. Morgan AD. Simple exercise testing. Respir Med 1989; 83:383-387 23. Petty TL. Pulmonary rehabilitation of early COPD: COPD as a systemic disease. Chest 1994; 105:1636-1637 24. Guyatt GH, Thompson PJ, Berman LB, et al. How should we measure function in patients with chronic heart and lung disease? J Chronic Dis 1985; 38:517-524 25. Berry MJ, Adair NE, Rejeski WJ. Use of peak oxygen consumption in predicting physical function and quality of life in COPD patients. Chest 2006; 129:1516-1522 26. Onorati P, Antonucci R, Valli G, et al. Non-invasive evaluation of gas exchange during a shuttle walking test vs a 6-min walking test to assess exercise tolerance in COPD patients. Eur J Appl Physiol 2003; 89:331-336 27. Troosters T, Vilaro J, Rabinovich R, et al. Physiological responses to the 6-min walk test in patients with chronic obstructive pulmonary disease. Eur Respir J 2002; 20:564-569 28. Wijkstra PJ, TenVergert EM, van der Mark TW, et al. Relation of lung function, maximal inspiratory pressure, dyspnoea, and quality of life with exercise capacity in patients with chronic obstructive pulmonary disease. Thorax 1994; 49:468-472 29. Eaton T, Young P, Milne D, et al. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med 2005; 171:1150-1157 30. Guyatt GH, Sullivan MJ, Thompson PJ, et al. The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985; 132:919-923 31. Miyamoto S, Nagaya N, Satoh T, et al. Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension: comparison with cardiopulmonary exercise testing. Am J Respir Crit Care Med 2000; 161:487-492 32. Mak VH, Bugler JR, Roberts CM, et al. Effect of arterial oxygen desaturation on six minute walk distance, perceived effort, and perceived breathlessness in patients with airflow limitation. Thorax 1993; 48:33-38 33. Rejeski WJ, Foley KO, Woodard CM, et al. Evaluating and understanding performance testing in COPD patients. J Cardiopulm Rehabil 2000; 20:79-88 34. Guyatt GH, Townsend M, Keller J, et al. Measuring functional status in chronic lung disease: conclusions from a randomized control trial. Respir Med 1989; 83:293-297 35. Wolkove N, Kamel H, Rotaple M, et al. Use of a mucus clearance device enhances the bronchodilator response in patients with stable COPD. Chest 2002; 121:702-707 36. Goldstein RS, Gort EH, Stubbing D, et al. Randomised controlled trial of respiratory rehabilitation. Lancet 1994; 344:1394-1397 37. Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lungvolume- reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003; 348:2059-2073 38. Cahalin L, Pappagianopoulos P, Prevost S, et al. The relationship of the 6-min walk test to maximal oxygen consumption in transplant candidates with end-stage lung disease. Chest 1995; 108:452-459 39. Szekely LA, Oelberg DA, Wright C, et al. Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery. Chest 1997; 111:550-558 40. Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158:1384-1387 41. Lacasse Y, Wong E, Guyatt GH, et al. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996; 348:1115-1119 42. Wise RA, Brown CD. Minimal clinically important differences in the six-minute walk test and the incremental shuttle walking test. COPD 2005; 2:125-129

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43. Martinez FJ, Foster G, Curtis JL, et al. Predictors of mortality in patients with emphysema and severe airflow obstruction. Am J Respir Crit Care Med 2006; 173:1326-1334 Related Terms: Pulmonary Function Testing, Bronchoprovocation, and Exercise Testing Physiology CME PCCSU Volume 23 PCCSU Pulmonary

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