J Rehabil Med 2013; 45: 105–108

Short Communication

RELATIONSHIP BETWEEN LOWER LIMB MUSCLE STRENGTH AND

6-MINUTE WALK TEST PERFORMANCE IN STROKE PATIENTS

Didier Pradon, PhD, Nicolas Roche, MD, PhD, Lievyn Enette, MS and Raphaël Zory, PhD
From the Groupement de Recherche Clinique et Technologique sur le Handicap, CHU Raymond Poincaré,
Garches, France

Objective: The aim of this study was to determine if lower is routinely used to assess the functional walking ability of
limb muscle strength and/or spasticity are related to perfor- stroke patients for either clinical or research purposes. How-
mance in the 6-min walk test (6MWT) in stroke patients. ever, the relationship between the 6MWT and aerobic fitness
Methods: A total of 24 patients (12 males and 12 females) in the stroke population may be confounded by limitations in
participated in the study. Muscle strength (Medical Research walking capacity related to alterations in neuromotor control.
Council (MRC) scale) and spasticity (modified Ashworth For example, 6 months after stroke, 50% of patients still have
scale) were assessed prior to the 6MWT. Heart rate was re- impaired muscle function (8). Danielsson et al. (9) showed that
corded at rest and during the 6MWT. Subjects were divided the 6MWT distance covered by stroke patients correlates with
into two groups: (i) those with a high MRC sum score, and the Fugl-Meyer score, which is an evaluation of sensorimotor
(ii) those with a low MRC sum score. The relationship be-
impairment. Impairment of function may result from a com-
tween the 6MWT distance and the other parameters was
bination of spasticity and weakness in the same or antagonist
analysed using a Spearman’s rank correlation coefficient.
muscle groups. Ordinal scales are frequently used in clinical
Results: There was a significant and positive relationship
practice to grade spasticity (modified Ashworth scale) (10)
between 6MWT distance and lower limb muscle strength
(p = 0.001), whereas no significant correlations were found and strength (Medical Research Council (MRC) scale). The
between the 6MWT distance and spasticity, resting heart validity and reliability of the MRC for the evaluation of muscle
rate and heart rate during the 6MWT. strength has been established (11). Several previous studies
Conclusion: The 6MWT distance may be a good indicator of have reported significant correlations between gait velocity
lower limb muscle strength, and lower limb strengthening and lower limb muscle strength (12, 13), but no study has
may improve gait capacity in stroke patients. examined the relationship between lower limb muscle strength
and performance in the 6MWT.
Key words: motor impairment; gait; spasticity; heart rate.
Within this context, the aim of this study was to evaluate
J Rehabil Med 2013; 45: 105–108 the relationship between lower limb muscle strength and/or
Correspondence address: Didier Pradon, Laboratoire spasticity and performance in the 6MWT in stroke patients.
d’analyse de la marche – Hôpital Raymond Poincaré, 104 Bd Our hypothesis was that 6MWT performance would correlate
Raymond Poincaré, 92380 Garches, France. E-mail: didier. strongly with lower limb muscle strength.
pradon@rpc.aphp.fr
Submitted February 10, 2012; accepted July 11, 2012
METHODS
Subjects
INTRODUCTION A total of 24 patients (12 males and 12 females, 18 ischaemic and 6
haemorrhagic, stroke duration 16 months (standard deviation (SD) 8))
The 6-min walk test (6MWT) (1) is derived from the Cooper were included in this study (age: 53.3 years (SD 13.7); height: 171.6
12-min run test (2) and is designed to evaluate the exercise cm (SD 9.0), mass: 73.4 kg (SD 12.3); Table I). Inclusion criteria
and cardiorespiratory capacity of patients with cardiac and were: (i) history of a single stroke at least 6 months previously; (ii)
independent gait (with or without assistive devices); (iii) medically
respiratory disease (3, 4). A review of the validity data sup-
stable (i.e. no uncontrolled hypertension, arrhythmia, or unstable
porting functional exercise tests has shown the 6MWT to be cardiovascular status); (iv) no previous myocardial infarction; and (v)
the most extensively researched and established test for use in no significant musculo-skeletal problems relating to conditions other
clinical or research contexts in the cardiorespiratory domain than stroke. The study was approved by the local ethics committee and
(5). The 6MWT is easy to administer, better tolerated, and all subjects provided written informed consent prior to participation
in any study-specific procedures.
more accurately reflects activities of daily living than other
functional gait assessments. Experimental procedure
After stroke, between 52% and 85% of patients re-gain Firstly, a heart rate (HR) monitor (Polar S625X, Polar Elektro Oy,
the capacity to walk; however, their gait usually remains Kempele, Finland) with a storage function was attached to the patient
different from that of healthy subjects (6, 7). The 6MWT using a chest strap, and the resting HR was recorded while the patient

© 2013 The Authors. doi: 10.2340/16501977-1059 J Rehabil Med 45

Journal Compilation © 2013 Foundation of Rehabilitation Information. ISSN 1650-1977
106 D. Pradon et al.

sat in silence for 10 min. The mean of the HR measured for the last 5 Table I. Age, anthropometric characteristics (height, weight), total score
min was used as the baseline value (resting HR). on the Medical Research Council (MRC) scale, spasticity (Modified
Next, muscle strength of the major muscles of the paretic lower Ashworth Scale (MAS)), 6-min walk test distance (6MWT distance), heart
limb was evaluated using the MRC scale. The MRC scale was initially rate (HR) at rest and during the 6MWT, Physiological Cost Index (PCI)
devised for use in patients with peripheral nerve injuries, but has been
and rating of the perceived exertion (RPE) on the Borg scale for the total
validated in stroke patients and is frequently used in clinical practice
population, the LMRC group and the HMRC group
on this population (11–14). The MRC is an ordinal scale that quanti-
fies muscle weakness (range: 0: absence of movement to 5: muscle Total LMRC HRMC
contracts normally against full resistance) in isolated muscles or muscle (n = 24) (n = 12) (n = 12)
groups (11). Five muscle groups were tested: (i) hip flexors, (ii) knee Mean (SD) Mean (SD) Mean (SD)
extensors, (iii) knee flexors, (iv) ankle plantar flexors, and (v) ankle
Age, years 53.38 (13.71) 51.50 (10.54) 55.25 (16.55)
dorsi flexors. Each measurement was carried out 3 times by the same
Height, cm 171.63 (9.01) 173.83 (6.22) 169.42 (10.97)
therapist. MRC scores were averaged in order to obtain a mean score
Weight, kg 73.42 (12.39) 73.50 (14.98) 73.33 (9.83)
for each muscle group and then summed in order to obtain a total MRC
MRC sum 13.52 (6.87) 8.00 (2.17) 20.00 (3.97)**
score (MRC sum) for the limb (13). Spasticity was assessed using the
MAS sum 3.35 (2.47) 4.17 (2.37) 2.25 (2.26)
Modified Ashworth Scale (MAS) (10) in 3 muscle groups: quadriceps,
6MWT distance, m 273.8 (173.4) 163.3 (101.6) 384.4 (160.8)*
hamstrings and triceps surae. MAS scores were added together to give
Resting HR, bpm 72.29 (11.11) 70.33 (11.44) 74.25 (10.90)
a total MAS score (MAS sum) (15). This method of summing of the
6MWT HR, bpm 106.21 (21.41) 103.50 (16.53) 108.92 (25.86)
MRC and MAS scores has been validated previously and is widely
PCI, bpm 1.11 (1.09) 1.74 (1.26) 0.55 (0.31)*
used in stroke patients (15–17).
RPE 11.38 (1.88) 11.50 (1.31) 11.25 (2.38)
Finally, each subject was instructed to walk as far as possible in 6
min (6MWT distance), at their own speed (4). Subjects walked lengths *p < 0.01 **p < 0.001.
of a 30-m walking track marked by a cone at each end, which they LMRC: 12 subjects with an MRC sum lower than the median (MRC sum
were instructed to walk around. HR was recorded simultaneously. The median = 14.5); HMRC: 12 subjects with an MRC sum higher than the
Physiological Cost Index (PCI, in beats/min (bpm)) was estimated by median. SD: standard deviation.
dividing the difference between walking (6MWT HR) and resting HR
(rest HR) by the walking velocity in m/min (9). To ensure a steady
state, the mean of the last 3 min of the 6MWT was used as the walking the LMRC group (p = 0.008). There were no significant dif-
HR value. Finally, each subject was asked to rate perceived exertion ferences between the two groups for MAS sum, resting HR,
(RPE) on the Borg scale (18) at the end of the test, and the distance
6MWT HR and RPE.
covered was estimated to the nearest metre.
The variable selected in the first stage of the stepwise mul-
Statistical analysis tiple regression was the MRC sum. This variable explained
Subjects were divided into two groups: (i) 12 subjects with an MRC 64% of the variance of the 6MWT distance. The equation for
sum lower than the median (MRC sum median = 14.5) (LMRC); and predictive factors of 6MWT distance was as follows:
(ii) 12 subjects with an MRC sum higher than the median (HMRC). 6MWT distance = –11.4 + 20.37 MRC sum
All statistical calculations were performed with Statistica 7 software. Spearman’s rank correlation coefficients showed a strong,
Means, SDs, range and standard errors were calculated for each para­
meter for the total population and for each group. Medians and modes significant and positive relationship between the 6MWT dis-
were also calculated for the ordinal scales (MRC sum and MAS sum). tance and the MRC sum (r = 0.79, p = 0.001), and a significant,
A multiple linear regression analysis was carried out to identify the moderately strong negative relationship between the 6MWT
variables that were most highly correlated with the 6MWT distance. A distance and the PCI (r = –0.54, p = 0.006, Table II). No sig-
stepwise method with variables entered in the model at a significance
nificant correlation was found between the 6MWT distance
level of p < 0.01 was used. Because the data did not appear to follow
a normal distribution, a Spearman’s rank correlation coefficient (Rs) and spasticity (MAS sum), resting HR, 6MWT HR and RPE.
was used to evaluate the relationship between the 6MWT distance Finally, a moderately strong, significant, negative correlation
and the other parameters evaluated. The Rs values were interpreted was found between the MRC sum and the PCI (r = –0.62,
according to Domholdt’s recommendations (19). Differences between p = 0.001).
LMRC and HMRC groups were determined using a Mann-Whitney
test. p < 0.05 was regarded as statistically significant.
Table II. Spearman’s rank correlation coefficients between the 6-min walk
test (6MWT) distance and the other parameters: age, anthropometric
RESULTS characteristics (height, weight), total score on the Medical Research
Council (MRC) scale, spasticity Modified Ashworth Scale (MAS), 6MWT
Anthropometric characteristics (height, weight) and age were distance, heart rate (HR) at rest and during the 6MWT (6MWT HR),
not significantly different between the two groups (LMRC and physiological cost index (PCI), and rating of the perceived exertion (RPE)
HRMC). Mean 6MWT distance of the total sample was 273.8 Spearman’s r p
m (SD 173.4 m). Median MRC sum of the total sample was Age –0.12 0.566
14.5 (mode: 7) and median MAS sum was 3 (mode: 0). Both Height –0.19 0.383
the distance walked during the 6MWT and the MRC sum were Weight 0.02 0.942
MRC sum 0.79 0.001
significantly lower in the LMRC group than in the HMRC MAS sum –0.39 0.058
group (respectively, p = 0.003 and p = 0.0001, Table I). Mean Rest HR 0.02 0.929
resting HR of the total sample was 72.29 bpm (SD 11.11 bpm) 6MWT HR 0.27 0.200
and mean 6MWT HR was 106.21 bpm (SD 21.41 bpm). The PCI –0.54 0.006
PCI of the HMRC group was significantly lower than that of RPE 0.28 0.185

J Rehabil Med 45
 Six-minute walk test in stroke patients 107

DISCUSSION efficiency. Because of the role of muscle strength in the per-

formance of the 6MWT demonstrated by our results, we sug-
The aim of this study was to determine, in stroke patients,
gest that resistance training and/or combined training (aerobic
whether or not lower limb muscle strength and/or spasticity
and resistance) may be appropriate rehabilitation techniques
was related to 6MWT performance. The results of this study
in order to improve 6MWT distance. The 6MWT can also be
confirmed our hypothesis, since 6MWT performance was
used to assess the functional repercussions of specific training
significantly correlated with the MRC sum-score and because
procedures, which opens up many prospects for future work.
the 6MWT HR and the RPE were not significantly different
In summary, the 6MWT is not a good predictor of physical
between the two groups (LMRC and HRMC).
fitness in stroke patients because of the large degree of lower
The mean distance covered during the 6MWT (range
limb motor impairment in this population. However, our results
264–301 m) (20–23), the resting HR, the 6MWT HR and the
clearly show that the 6MWT distance may be a good indicator
RPE were all consistent with data reported in previous studies
of lower limb muscle strength and physical gait capacity in
of hemiplegic patients (24, 25). Both the 6MWT HR and the
stroke patients. The results of the present study have implica-
RPE clearly show that the 6MWT was not very strenuous for
tions regarding the selection and interpretation of tests for the
the included sample, despite instruction and encouragement.
evaluation of walking capacity in stroke patients.
In spite of the fact that the 6MWT was designed to evaluate
physical fitness in patients, there was a lack of correlation
between 6MWT HR and the 6MWT distance. This confirms ACKNOWLEDGEMENT
the results of a previous study, which showed that the relation-
ship between VO2peak and the 6MWT distance was moderately The authors would like to thank all of the subjects who participated in
this study.
strong, suggesting that aerobic fitness is a moderate contribu-
tor of distance walked during the 6MWT in stroke patients
(21). Hence, the use of 6MWT distance alone as an indicator
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