ORIGINAL ARTICLE

Six-minute walk test in pulmonary rehabilitation: Do all patients

need a practice test? resp_1841 1192..1196

SUE JENKINS1,2,3 AND NOLA M. CECINS1,2,3

1
Physiotherapy Department, Sir Charles Gairdner Hospital, 2School of Physiotherapy and Curtin Health
Innovation Research Institute, Curtin University, and 3Lung Institute of Western Australia and Centre for
Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Western Australia, Australia

ABSTRACT SUMMARY AT A GLANCE

Background and objective: The six-minute walk test This study shows that the majority of patients
(6MWT) is widely used as an outcome measure in entering a pulmonary rehabilitation program
pulmonary rehabilitation programs (PRP). A learning increase their 6MWD when a repeat test is per-
effect for the test has been reported in COPD; however, formed. The findings support the recommenda-
limited data exist in patients with other respiratory tion of a practice 6MWT at baseline assessment in
diagnoses. The objectives of this study were to: (i) order to provide an accurate measure of the effects
report the magnitude of change in 6MWD with test of rehabilitation on 6MWD.
repetition in patients referred to an outpatient PRP,
and (ii) compare the magnitude of change in 6MWD
with test repetition in patients with COPD, interstitial
lung disease (ILD), bronchiectasis and asthma. ing a pulmonary rehabilitation program (PRP) with
Methods: Retrospective study of 349 patients with the primary outcome reported being the distance
stable COPD (n = 245), ILD (n = 21), bronchiectasis walked.1–3 In patients undergoing rehabilitation, the
(n = 33) or asthma (n = 50) who performed two 6MWT test is also used to prescribe a walking training
at enrolment into a PRP. program with the initial speeds prescribed equivalent
Results: 6MWD increased in all groups on the second to 70–80% of the average speed achieved during the
test (all P < 0.001). At least 80% of patients in each diag- baseline 6MWT.4–7 This prescription complies with
nostic group walked further on their second 6MWT.
international pulmonary rehabilitation guidelines
The magnitude of change (mean, 95% CI) was greater
that recommend high intensity training with the aim
(P < 0.05) in the COPD (37 m, 95% CI: 33–41 m) and
ILD (41 m, 95% CI: 27–55 m) cohorts compared with of achieving a physiologic benefit.2
the bronchiectasis (22 m, 95% CI: 14–31 m) and Strict standardization of the 6MWT protocol is
asthma (19 m, 95% CI: 11–27 m) cohorts. required if reliable data are to be obtained. The factors
Conclusions: Respiratory diagnosis influences the that influence 6MWD include track length and layout,
magnitude of the learning effect for the 6MWT. The and encouragement during the test.8–11 A learning
findings support the recommendation of a practice effect has been documented in patients with COPD
6MWT at baseline assessment in order to provide an with the majority of individuals showing an increase
accurate measure of the effects of rehabilitation on in 6MWD when the test is repeated and little or no
6MWD. further increase when a third test is performed.8,9,12–14
Reports of the effect of test repetition on 6MWD in
Key words: exercise test, learning effect, lung disease, patients with chronic lung diseases (CLD) other than
outcome assessment, rehabilitation. COPD are limited to two studies in patients with inter-
stitial lung disease (ILD).15,16 Repeat 6MWT were sepa-
INTRODUCTION rated by a maximum of 4 weeks and both studies
showed a significant increase in 6MWD with test rep-
The six-minute walk test (6MWT) is widely used to etition.15,16 To our knowledge, the effect of test repeti-
assess changes in functional exercise capacity follow- tion on 6MWD has not been reported for individuals
with bronchiectasis or asthma, patient cohorts that
are referred to PRP and in whom 6MWD has been
Correspondence: Sue Jenkins, School of Physiotherapy, used as an outcome of exercise training.17–20
Curtin University, GPO Box U1987, Bentley, WA 6845, Australia.
Email: s.jenkins@curtin.edu.au
In PRP, it is important to minimize the effect of an
Received 12 April 2010; invited to revise 5 May 2010, 15 June increase in 6MWD resulting from test repetition.
2010; revised 24 May 2010, 19 June 2010; accepted 21 June 2010 Failure to do so will result in an overestimate of the
(Associate Editor: C C Leung). effects of rehabilitation on 6MWD. However, despite
© 2010 The Authors Respirology (2010) 15, 1192–1196
Respirology © 2010 Asian Pacific Society of Respirology doi: 10.1111/j.1440-1843.2010.01841.x
6MWT learning effect in lung disease 1193

good justification for a practice 6MWT at the baseline period. If necessary, the rest period was extended
assessment, over 50% of PRP perform a single until heart rate, oxygen saturation (SpO2) and dysp-
6MWT.21,22 The resources available for PRP, in particu- noea had returned to within five beats per minute, 1%
lar staff time, are likely to be the most important and 1 point of baseline values, respectively.26
factor that determines the number of 6MWT Heart rate was measured before and throughout the
performed. 6MWT using telemetry (Polar a1, Polar Electro Oy,
The objectives of this study were to: (i) report the Kempele, Finland). Oxygen saturation (Ohmeda Biox
magnitude of change in 6MWD with test repetition at 3700e, Ohmeda, CO, USA) was continuously moni-
baseline assessment in patients with CLD referred to a tored during the first 6MWT with measures recorded
PRP, and (ii) compare the magnitude of change in pre-test, upon test completion, at the end of each
6MWD with test repetition in patients with COPD, minute and during any rests.23 For the second 6MWT,
ILD, bronchiectasis and asthma. The cohort for this SpO2 was recorded before and at test completion, and
study comprised 349 outpatients with stable CLD. at the start of any rests. Dyspnoea was assessed before
and at the end of the 6MWT, and at the commence-
ment of any rests27 with the highest dyspnoea score
METHODS used in the analyses. Leg fatigue was recorded on test
completion.27 The number of rests and the total rest
Patients time during the test were recorded.

This retrospective study reports data on all individu-

als who completed two 6MWT before commencing an Data management and statistical analyses
outpatient PRP at a tertiary hospital (Sir Charles
Gairdner Hospital, SCGH, Perth, Western Australia), Comparison of age, anthropometric and 6MWT data
over a 9-year period (2000–2008). The diagnoses of between diagnostic groups was performed using one-
these patients were COPD (n = 245), ILD (n = 21), way analysis of variance (anova) with Scheffe’s post-
bronchiectasis (n = 33) and asthma (n = 50). The hoc test, Kruskall–Wallis test (scores for dyspnoea and
baseline assessment for the PRP included two 6MWT leg fatigue) and chi-square test (categorical variables).
unless: (i) the patient had performed a 6MWT in the Within each diagnostic group: (i) the magnitude of
previous 6 weeks; (ii) an adverse event was observed change in 6MWD between tests 1 and 2 was com-
during the first test;23 (iii) walking ability was limited pared using a paired t-test; (ii) the coefficient of
by musculoskeletal or neurological impairment, or repeatability (defined as twice the SD of the difference
claudication pain, and (iv) the patient declined to in 6MWD measured on the two tests) was calculated;
complete a second 6MWT. Data presented in this (iii) the effect of gender and supplementary oxygen
study are restricted to patients who had no prior therapy on the magnitude of change in 6MWD with
experience of performing the 6MWT in accordance test repetition were examined using unpaired t-tests,
with the protocol used in the PRP. Approval to use and (iv) associations were sought between 6MWD on
these data was obtained from the Human Research the first test (expressed in metres and %predicted)28
Ethics Committee of SCGH. and the difference in 6MWD between tests 1 and 2
The diagnosis of lung disease and referral to the using Pearson’s correlation coefficients.
PRP were made by a respiratory physician. The results The distribution of the data was examined and no
of spirometry testing,24 performed at the time of refer- transformations were required. Statistical analyses
ral, were extracted from the patient’s medical records. were performed using spss software (Version 17,
SPSS Inc., Chicago, IL, USA). P-values of ⱕ0.05
were regarded as significant. Data are expressed as
6MWT protocol mean ⫾ SD or 95% CI.

Contraindications to performing the 6MWT in this

PRP have been published elsewhere.23 RESULTS
Patients were instructed to take their usual medica-
tions on the day of testing. Individuals with asthma Anthropometric and lung function data of the 349
who required prophylactic bronchodilators before patients are shown in Table 1.
exercise took their medication before performing the The 6MWD was lower in the COPD cohort when
6MWT. compared with the ILD, bronchiectasis and asthma
All 6MWT were supervised by a physiotherapist cohorts (all P < 0.05) (Table 2). The proportion of
(NC or SJ) in accordance with published guidelines.25 patients in the COPD cohort who rested during the
A 45-m straight course within a level enclosed corri- test was higher than in any other group (Table 2,
dor was used. Standardized instructions were read to P < 0.001). In the COPD and ILD cohorts, dyspnoea
the patient before each 6MWT. At the end of each scores were higher, and peak heart rate and nadir
minute, patients were notified of the elapsed time and SpO2 were lower compared with the bronchiectasis
given standard encouragement.25 If a patient rested and asthma cohorts (all P < 0.05).
during the 6MWT, encouragement to recommence There was an increase in 6MWD with test repetition
walking was given at 15 s intervals.25 At the end of the in each cohort (all P < 0.001) with at least 80% of
first test, patients were informed they would be per- patients in each cohort walking further on their
forming another 6MWT following a 30-min rest second test (Table 2). The magnitude of increase in
© 2010 The Authors Respirology (2010) 15, 1192–1196
Respirology © 2010 Asian Pacific Society of Respirology
1194 S Jenkins and NM Cecins

Table 1 Anthropometric and lung function data of the 349 patients grouped according to diagnosis

COPD ILD Bronchiectasis Asthma

n = 245 n = 21 n = 33 n = 50

Male (n, %) 162 (66) 13 (62) 8 (24) 22 (44)

Age (years) 67.5 ⫾ 9.2 62.3 ⫾ 13.2 65.1 ⫾ 7.9 67.1 ⫾ 10.1
Height (m) 1.70 ⫾ 0.8 1.68 ⫾ 0.7 1.66 ⫾ 0.9 1.68 ⫾ 10.0
Weight (kg) 70.1 ⫾ 15.8 72.2 ⫾ 17.7 67.1 ⫾ 16.2 77.2 ⫾ 16.9
BMI (kg/m2) 24.5 ⫾ 4.8 25.5 ⫾ 5.6 24.2 ⫾ 5.6 27.4 ⫾ 5.1*
FEV1 (L) 1.06 ⫾ 0.50 1.61 ⫾ 0.60* 1.45 ⫾ 0.49* 1.48 ⫾ 0.66*
FEV1 %pred 41 ⫾ 18 59 ⫾ 18* 58 ⫾ 22* 56 ⫾ 18*
GOLD stage
I (n, %) 6 (2)
II 61 (25)
III 110 (45)
IV 68 (28)
FVC (L) 2.59 ⫾ 0.92 2.14 ⫾ 0.78 2.26 ⫾ 0.83 2.89 ⫾ 1.09
FVC %pred 74 ⫾ 21 59 ⫾ 18 72 ⫾ 21 82 ⫾ 18*†

* P < 0.05 compared with COPD cohort, † P < 0.05 compared with ILD cohort.
Data are presented as means ⫾ SD or number (n) and percentage (%) of patients.
ILD, interstitial lung disease.

Table 2 6MWT data in the 349 patients grouped according to diagnosis

COPD ILD Bronchiectasis Asthma

n = 245 n = 21 n = 33 n = 50

6MWD Test 1 (m) 390 ⫾ 116 446 ⫾ 130* 497 ⫾ 113* 503 ⫾ 103*
6MWD Test 1 (%pred) 60 ⫾ 17 67 ⫾ 17 78 ⫾ 14*† 80 ⫾ 14*†
6MWD Test 2 (m) 427 ⫾ 122 487 ⫾ 135* 519 ⫾ 125* 522 ⫾ 105*
DTest 2–Test 1 (m) 37 (33–41) 41 (27–55) 22 (14–31)* 19 (11–27)*
DTest 2–Test 1 (%) 11 (9–12) 10 (6–14) 4 (3–6)* 4 (2–6)*
Walked further on Test 2 (n, %) 213 (87) 18 (86) 28 (84) 40 (80)
6MWT test 1 data
Pre-exercise HR (bpm) 89 ⫾ 14 88 ⫾ 16 89 ⫾ 16 87 ⫾ 13
Peak HR test (bpm) 113 ⫾ 15 120 ⫾ 19 121 ⫾ 14* 124 ⫾ 15*
Peak HR %pred HRmax 68 ⫾ 9 71 ⫾ 11 72 ⫾ 8 75 ⫾ 9
Pre-exercise SpO2 (%) 95 ⫾ 2 95 ⫾ 2 96 ⫾ 2* 96 ⫾ 2*
Lowest SpO2 (%) 89 ⫾ 4 88 ⫾ 6 92 ⫾ 4*† 94 ⫾ 4*†
Pre-exercise dyspnoea 1.1 ⫾ 1.1 0.9 ⫾ 1.0 1.1 ⫾ 1.2 0.7 ⫾ 0.8
Peak dyspnoea 4.6 ⫾ 1.8 3.9 ⫾ 2.2 3.4 ⫾ 1.3* 3.1 ⫾ 1.5*
End-test leg fatigue 1.4 ⫾ 1.4 1.5 ⫾ 1.6 1.3 ⫾ 1.5 1.2 ⫾ 1.3
Rested during test (n, %) 80 (33) 3 (14)* 2 (6)* 1 (2)*

* P < 0.05 compared with COPD cohort; † P < 0.05 compared with ILD cohort.
Data are presented as means ⫾ SD or number (n) and percentage (%) of patients; data for change (D) in 6MWD
between Test 1 and Test 2 are mean and 95% confidence intervals.
%pred 6MWD, percentage of predicted 6MWD; SpO2, oxygen saturation; HR, heart rate; bpm, beats per minute;
%pred HRmax, peak HR as a %predicted HRmax (210 - 0.65 ¥ age).

6MWD with test repetition was significantly greater in There was no relationship between 6MWD and
the COPD and ILD cohorts when compared with the the magnitude of change in 6MWD with test repeti-
bronchiectasis and asthma cohorts (both P < 0.05) tion in any of the diagnostic cohorts (all r < 0.5,
(Table 2). The difference between repeat 6MWT was P > 0.05).
37 ⫾ 37, 41 ⫾ 32, 22 ⫾ 24 and 19 ⫾ 26 m in the COPD, Seventeen (5%) patients performed the 6MWT
ILD, bronchiectasis and asthma cohorts, respectively. breathing supplementary oxygen (COPD, n = 11; ILD
The corresponding coefficients of repeatability were n = 5; bronchiectasis n = 1) and transported their
74, 63, 48 and 53 m. There was no significant differ- oxygen cylinder using a trolley or a rollator. The
ence in the magnitude of increase in 6MWD with test increase in 6MWD was similar in patients receiving
repetition between men and women in any of the supplementary oxygen and those who performed the
diagnostic cohorts (all P > 0.05). test breathing room air (COPD: 36 ⫾ 35 m, n = 11 vs
Respirology (2010) 15, 1192–1196 © 2010 The Authors
Respirology © 2010 Asian Pacific Society of Respirology
6MWT learning effect in lung disease 1195

37 ⫾ 34 m, n = 234, P = 0.97; ILD 37 ⫾ 32, n = 5 vs be due to a ceiling effect as their 6MWD on the first
42 ⫾ 33 m, n = 16, P = 0.77). test was ⱕ80% predicted values.28
During the study period, 223 patients referred to The coefficients of repeatability derived in this
the PRP did not undergo a repeat 6MWT for the study are relevant if one 6MWT is performed and
following reasons: (i) completed a 6MWT within accurate if the variability is constant. It is difficult to
the previous 6 weeks during a hospital admission, or directly compare the magnitude of increase in 6MWD
to assess response to ambulatory oxygen therapy with test repetition in this study with studies reported
(n = 57); adverse event observed during the 6MWT previously due to differences in methodology. Specifi-
(n = 20); walking ability limited by musculoskeletal cally, other studies included patients who had recent
(n = 129) or neurological impairment (n = 6), or clau- experience of the 6MWT,9 or the two 6MWT were per-
dication pain (n = 5), and (iv) patient declined to formed on different days.8,15,16 However, the coefficient
repeat the test (n = 6). Compared with the patients of repeatability in our COPD cohort is similar to that
who completed two 6MWT, these patients were older recently reported when subjects performed two
(69.8 ⫾ 11.4 vs 66.9 ⫾ 9.5 years, P = 0.014) and a 6MWT on a straight track.9
higher proportion had cardiac disease (39% vs 25%, Although we cannot be certain that further
P < 0.002). Data from 38 patients were not included in improvement would not have occurred if a third test
this analysis as these patients showed profound was undertaken, in patients with COPD, our previous
oxygen desaturation on the 6MWT and performed a study,33 consistent with published data,12,14,34 showed
second 6MWT breathing a higher fraction of inspired no significant increase on a third test. The magnitude
oxygen. of learning effect in the bronchiectasis and asthma
cohorts was similar to that observed in healthy sub-
jects who increased their 6MWD on a third test by
only 10 m (1.5%).35 It remains unknown whether
DISCUSSION
patients with ILD increase their 6MWD on a third test.
The main findings of this study are: (i) the majority of
patients with stable CLD increased 6MWD when a
Limitations
repeat 6MWT was performed before commencing a
PRP, and (ii) the magnitude of increase with test rep-
This was a retrospective study and prospective
etition in patients with COPD and ILD was signifi-
studies are required to confirm these findings. Only 17
cantly greater than in patients with bronchiectasis or
patients were aged over 80 years, therefore our find-
asthma.
ings may not extend to an older population.
To the authors’ knowledge this is the first study
A measure of daily physical activity would have
describing the effect of test repetition on 6MWD in a
allowed us to determine whether habitual walking
large cohort of patients with CLD, representative of
speed influenced the magnitude of the learning
patients referred to PRP, who were tested using a stan-
effect, however, this was beyond the scope of this
dardized protocol administered by the same two
study.
testers. In contrast to previous studies,8,13,15,16 repeat
None of the patients in this study had prior experi-
6MWT were performed on the same day thereby
ence of a 6MWT performed in accordance with the
eliminating the potential for daily variation in exer-
standardized protocol used in the outpatient PRP.
cise performance to influence the magnitude of
However, it is possible that some patients had
change with test repetition.9
performed a 6MWT previously although we found
no evidence of this in their medical records.
We did not explore whether a practice test is
Learning effect for 6MWT required at the end of a PRP. Previous research sug-
gests that a repeat 6MWT may not be necessary in
Proposed mechanisms for the increase in 6MWD with COPD patients at the end of an 8-week PRP.13
test repetition include familiarity with the walking
course, improved pacing, increased motivation and
habituation to dyspnoea.8,25,29 One possible explana- Recommendations for clinical practice
tion for the greater learning effect in patients with
COPD and ILD is that both cohorts reported higher We recommend that patients with CLD referred to a
levels of dyspnoea on the first 6MWT compared with PRP perform a practice 6MWT at their baseline
patients with bronchiectasis or asthma and therefore assessment if 6MWD is used as an outcome measure
had more capacity to accommodate to the levels of of rehabilitation.
dyspnoea on the second test. Support for this expla-
nation is provided by evidence of only a small learn-
ing effect in populations in whom dyspnoea does not ACKNOWLEDGEMENTS
play a major role in exercise limitation, for example,
individuals with mild cardiac impairment,30 stroke,31 The authors thank Peter McKinnon, School of Physio-
end-stage renal disease32 and in healthy subjects.28 We therapy, Curtin University, Perth, Western Australia,
consider that the smaller change in our patients with for statistical advice. We also thank Dr Kylie Hill,
bronchiectasis and asthma, compared with that School of Physiotherapy, Curtin University, Perth,
observed in the COPD and ILD cohorts, is unlikely to Western Australia, for reviewing the paper.
© 2010 The Authors Respirology (2010) 15, 1192–1196
Respirology © 2010 Asian Pacific Society of Respirology
1196 S Jenkins and NM Cecins

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Respirology © 2010 Asian Pacific Society of Respirology