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Six-minute walking test after cardiac surgery: instructions for an appropriate use
Stefania De Feo, Roberto Tramarin, Roberto Lorusso and Pompilio Faggiano
European Journal of Cardiovascular Prevention & Rehabilitation 2009 16: 144
DOI: 10.1097/HJR.0b013e328321312e
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Review Paper
Cardiology Department, Casa di Cura Polispecialistica Dr Pederzoli, Peschiera del Garda, Verona,
Cardiac Rehabilitation Unit, Fondazione Europea Ricerca Biomedica Onlus, Cernusco S/N, Milano,
c
Cardiac Surgery Division and dCardiology Division, Spedali Civili, Brescia, Italy
b
The 6-min walking test is a practical, simple, inexpensive test, which does not require any exercise equipment or advanced
training. The test has been proposed both as a functional status indicator and as an outcome measure in various
categories of patients (postmyocardial infarction, heart failure, postcardiac surgery) admitted to rehabilitation programs.
The purpose of this study is to review the literature regarding the usefulness of 6-min walking test for the evaluation of
patients entering a cardiac rehabilitation program early after cardiac/thoracic surgery. The test is feasible and safe, even in
elderly and frail patients, shortly after admission to an in-hospital rehabilitation program. The results of the test is
influenced by many demographic and psychological variables, such as age, sex (with women showing lower functional
capacity), comorbidity (particularly diabetes mellitus, arthritis, and other musculoskeletal diseases), disability, self-reported
physical functioning, and general health perceptions; contrasting data correlate walked distance with left ventricular
ejection fraction. Practical suggestions for test execution and results interpretation in this specific clinical setting are given
c 2009 The European Society of Cardiology
according to current evidence. Eur J Cardiovasc Prev Rehabil 16:144149
European Journal of Cardiovascular Prevention and Rehabilitation 2009, 16:144149
Keywords: cardiac rehabilitation, cardiac and thoracic surgery, functional capacity, 6-min walking test
Introduction
The 6-min walking test (6MWT) is used to measure the
maximum distance that a person can walk in 6 min. The
test is a modification of the 12-Minute Walk-Run Test
originally developed by Cooper [1] as a field test to
predict maximal oxygen uptake.
The 6MWT was first used by pneumologists to evaluate
patients with chronic obstructive pulmonary diseases
(COPD) and respiratory failure and then by cardiologists
to assess the functional status of patients with severe
cardiovascular diseases [2], the effects of therapy and to
predict morbidity and mortality in patients with left
ventricular dysfunction [3] and advanced heart failure
[47]. The widespread acceptance of walk tests relates to
their convenience, low cost, and presumed ease of
completion. The traditional functional test in cardiac
Correspondence to Dr Pompilio Faggiano, Via Trainini 14, Brescia 25133, Italy
Tel: + 39 030 3995573; fax: + 39 030 2007785; e-mail: faggiano@numerica.it
DOI: 10.1097/HJR.0b013e328321312e
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1
Contraindications
Absolute contraindications: unstable angina, recent history of myocardial infarction or cardiac dysrhythmia.
Relative contraindications: resting heart rate of more than 120, uncontrolled hypertension (systolic blood pressure of more than 180 mmHg, and diastolic blood
pressure of more than 100 mmHg). Stable exertional angina is not an absolute contraindication for a 6MWT, but patients with these symptoms should perform the test
after using their antiangina medication, and rescue nitrate medication should be readily available.
Procedure
Resting vital signs are recorded before walk: blood pressure, heart rate, and pulse oximetry (if indicated).
The 6MWT should be performed indoors, along a long, flat, straight, enclosed corridor with a hard surface that is seldom traveled. The walking course must be 30 m in
length.
Instruct the patient as follows: The object of this test is to walk as far as possible for 6 min. 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.
Demonstrate by walking one lap yourself. Walk and pivot around a cone briskly.
Are you ready to do that? I am going to use this counter to keep track of the number of laps you complete. I will click it each time you turn around at this starting line.
Remember that the object is to walk as far as possible for 6 min, but dont run or jog. Start now, or whenever you are ready.
Position the patient at the starting line. Stand near the starting line during the test. Do not walk with the patient.
During the walk, words of encouragement are provided at 1-min time interval, such as You are doing well, Keep up the good work. Do not use other words of
encouragement (or body language to speed up).
Posttest: record the postwalk Borg dyspnea and fatigue levels and ask this: What, if anything, kept you from walking farther?
Distance walked is measured and recorded to the nearest foot. If patient had to stop and rest, the duration of the rest time is recorded.
Record patients blood pressure, heart rate, and pulse oximetry (if indicated).
Staff member who administered the test will sign and date the form.
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146
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
148
Conclusion
The 6MWT is widely used for measuring the functional
status, targeted at people with at least moderate
functional impairment. The evaluation of the functional
physical capacity by means of 6MWT at entry of a cardiac
rehabilitation program early after cardiac surgery is
helpful to adapt the modalities of the training program
to obtain the best results at the most appropriate training
intensity. Specially in elderly patients, showing increased
prevalence of comorbidities, physical exercise programs
should be established according to the individual exercise
Fig. 1
Male patient
Age?
Female patient
Age?
LVEF?
Comorbidity?
Yes No
Diabetes
Creatinine >1.5 mg/dl
Cerebrovascular diseases
COPD
Comorbidity?
Yes No
Diabetes
Creatinine > 1.5 mg/dl
Cerebrovascular diseases
COPD
See Table 2
See Table 3
Absence of comorbidities
Mean SD
Median
Lower quartile
Upper quartile
Presence of comorbidities
Mean SD
Median
Lower quartile
Upper quartile
Age r 60
years
Age 6170
years
Age Z 71
years
n = 75
283 96
295
210
350
n = 83
267 100
275
200
340
n = 101
255 93
249
200
318
n = 151
220 86
220
160
280
n = 115
184 83
178
125
240
n = 149
207 105
200
132
280
Table 2
Reference values for the distance walked stratified by age, LVEF, and comorbidity in men
Age r 60 years
Absence of
comorbidities
Mean SD
Median
Lower quartile
Upper quartile
Presence of
comorbidities
Mean SD
Median
Lower quartile
Upper quartile
Age Z 71 years
LVEF Z 50%
LVEF Z 50%
LVEF Z 50%
n = 205
n = 119
n = 191
n = 108
n = 113
n = 79
369 92
370
310
427
n = 109
360 90
360
310
420
n = 63
330 98
340
260
400
n = 156
302 101
309
241
377
n = 105
310 113
300
220
390
n = 124
369 102
270
180
340
n = 85
346 102
350
292
416
341 89
344
282
400
326 109
334
250
400
282 100
286
220
360
287 122
284
200
371
254 119
2480
175
325
Modified from Opasich et al. [28]. LVEF, left ventricular ejection fraction.
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Acknowledgements
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