European Journal of Cardiovascular Prevention

& Rehabilitation
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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

Six-minute walking test after cardiac surgery: instructions

for an appropriate use
Stefania De Feoa, Roberto Tramarinb, Roberto Lorussoc
and Pompilio Faggianod
a

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

Received 7 August 2008 Accepted 5 November 2008

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

rehabilitation has been the symptom-limited exercise

test with bicycle or treadmill. This test, however, might
not be suitable for older adults as they tend to have poor
balance, poor neuromuscular coordination, impaired
vision, abnormal gait patterns, and might experience fear
of exercising. In contrast, the 6MWT test has close
similarities to daily living activities and can be carried out
even by many elderly and severely limited patients who
are not able to perform symptom-limited exercise tests,
as are cardiac patients after recent major surgery.
The test has been also proposed in various categories of
patients (postmyocardial infarction, chronic heart failure,
postcardiac surgery) admitted to cardiac rehabilitation
programs both as a functional status indicator and as an
outcome measure.
The purpose of this study is to evaluate the utility of the
6MWT for the evaluation of patients entering a cardiac

c 2009 The European Society of Cardiology

1741-8267

DOI: 10.1097/HJR.0b013e328321312e

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6-min walk test after cardiac surgery Feo et al. 145

rehabilitation program early after a cardiac/thoracic

surgery procedure.

Reliability and validity of the test

Several studies have shown that the test is feasible and
safe, even in elderly and frail patients, shortly after
admission to an in-hospital rehabilitation program. In
patients entering a cardiac rehabilitation program early
after cardiac surgery, the 6MWT is well tolerated and no
cardiopulmonary complications are reported [811].
Several factors are known to potentially influence the
results of walk tests. A training effect is well documented
in the performance of walk tests [12]. According to the
American Thoracic Society (ATS) review of previously
published 6MWT studies and guidelines, the increase in
walking distance because of the learning effect ranges
from a mean of 0 to 17% [7]. Performance usually reaches
a plateau after two walk tests done within a week. Larson
and colleagues [13] had 48 participants with COPD
performing four 12-min walks at 1-week intervals.
Average walk distances improved significantly through
the third test. Differences of 46 m (151 ft) occurred
between the first and second walks, and 78 m (256 ft)
between the first and third walks. Similar results have been
reported by other investigators [14,15]. The reproducibility
results from one study of 112 patients with stable severe
COPD suggest that an increase of at least 70 m in the
distance walked during the 6MWT after an intervention is
necessary to be 95% confident that the improvement in
functional capacity is a true consequence of the therapeutic
measure and not intertest variability [16].
Most programs surveyed using 6MWT usually provide
verbal encouragement to patients while walking, although

Table 1

not always consistently. The effect of encouragement on

test outcomes was studied by Guyatt and colleagues [17].
Inclusion of standardized encouraging phrases to patients
every 30 s was associated with an average increase of
30.5 m (100 ft) in distance walked, compared with
distances achieved when the supervisor remained silent.
Moreover, other factors such as instructions given prior
walking, monitoring during walks, awareness of distances
accomplished while walking, directions given to patients
while walking, and positioning of the tester (walking with
the patient vs. technician stationary in one area of the
track) can significantly influence walking performance.
The American Association of Cardiovascular and Pulmonary
Rehabilitation stated the value of timed distance walk tests
as outcome measures for pulmonary rehabilitation, and
cautioned of the need to standardize test procedures
[18]. In 2002, an ATS statement was published on
6MWT, including the standard procedure for conducting
the walking test, to provide useful and comparable
information [7] (Table 1). According to this guideline,
the test should be supervised by cardiac rehabilitation
professionals (presence of a physician is not required)
although all testers are trained in advanced cardiac life
support, and resuscitation equipment is immediately
available. The test might be carried out, if indicated by
the physician, using telemetry monitoring. Participants
are asked to walk at their own maximal pace along a flat
and straight hospital corridor of at least 30 m in length.
The instructions are given to participants before the test
and during the walk encouragement is provided at
intervals, to comfort the patient who might find it
awkward to walk in silence for 6 min. Blood pressure and
heart rate are measured before and after testing.
Monitoring of oxygen saturation during testing is not
mandatory, but such monitoring might occasionally add

Six-minute walk test protocol [7]

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

European Journal of Cardiovascular Prevention and Rehabilitation 2009, Vol 16 No 2

clinical data in selected patients with concomitant heart

and lung diseases and elevated pulmonary arterial
pressures. Standardization of encouragement may be of
value. The test is symptom-limited, therefore patients are
allowed to stop if signs or symptoms of significant distress
occur (severe dyspnea, dizziness, angina, skeletal muscle
pain), though they are instructed to resume walking as soon
as possible. The distance covered during the test is
recorded in meters. Secondary measures can include
fatigue and dyspnea, measured with a modified Borg or
visual analogue scale, and presence or severity of angina [7].

Determinants of walk performance

Several studies have reported that functional capacity is
affected by demographic variables, such as sex and age:
the distance walked is greater in men than women and
inversely related to age [1927], perhaps reflecting
problems with balance and joints and progressive
reduction of skeletal muscle mass and strength in older
participants. The dependence of distance walked from
sex and age underlines the need for expressing the results
of 6MWT both as an absolute value in meters and as
a percentage of the predicted value, according to the
reference equation published previously [11]. Expressing
the distance walked in these two different ways (absolute
value and percentage of predicted value) might have
clinical relevance. In fact, the same absolute distance
walked, 250 m for example, may be within the normal
range for an 80-year-old man and severely reduced for
a 45-year-old man. Instead, the percentage of predicted
value, taking into account demographic and anthropometric
variables such as sex, age, weight, and height, allows
physicians to express the functional capacity of an individual
participant compared with the healthy population with
similar demographic characteristics. In contrast, the
result expressed as an absolute value can be more
appropriate when evaluating the effects of therapeutic
interventions in the single patient.
In studies including patients enrolled in cardiac
rehabilitation program early after cardiac surgery, the
presence of one or more comorbid conditions (particularly
diabetes mellitus, arthritis, and other musculoskeletal
diseases) and inactive physical state negatively affected
the walking performance, independently of sex and age
[9,28]. Fiorina et al. [9] found that distance walked was
significantly shorter at 6MWT carried out in patients early
after cardiac surgery compared with patients early after
acute myocardial infarction. Several factors, including
postoperative prolonged bed rest, chest pain and
respiratory limitation following sternotomy may be
responsible for this difference.
Contrasting data have been reported on the influence of
postoperative left ventricular function on distance walked
before the rehabilitation program. In one large study, no

relation was found between left ventricular ejection

fraction and the results of 6MWT [9]. In contrast, in
other studies a poor left ventricular systolic function
negatively influenced the distance walked in all patients
[2931] or only in men, but not in women [28], possibly
as a consequence of physical deconditioning in patients
with cardiac dysfunction and higher left ventricular
ejection fraction usually observed in women. Of interest,
an improvement in distance walked at 6MWT carried out
at the end of the cardiac rehabilitation program, compared
with early postoperative test, was observed in most
patients, independently from presence or absence of left
ventricular systolic dysfunction [9,30,32]; moreover, in the
study of Polcaro et al. [30] the relative increase in distance
walked from baseline was significantly larger in patients
with left ventricular ejection fraction less than 40%,
compared with those with left ventricular ejection fraction
greater than 40% (36 vs. 23%). Accordingly, these data
confirm that a left ventricular dysfunction does not
represent a contraindication to a physical program, even
in cardiac surgery patients.
Clinical conditions, such as anemia or atrial fibrillation,
frequently observed early after cardiac surgery, are known
to negatively affect the walking performance [33,34].
The 6MWT, however, can be performed safely, although
relative contraindications to the test include a resting
heart rate of more than 120 bpm [7].
Walk performance also correlates with history of
sedentary lifestyle, patient self-reported physical activity
levels, and physical function as determined by the Short
Form-36 questionnaire [35] and disability [36]. In a study
on old people in community centres and retirement homes
in the Los Angeles area, the 6-min walk distance was
significantly greater for active than for inactive older adults,
moderately correlated with chair stands, standing balance,
and gait speed. It had a low correlation with body mass
index. The study showed a moderate correlation of the
6MWT with self-reported physical functioning and general
health perceptions. Self-report and performance measures
explained 69% of the variance in 6-min walk scores.
In a cardiac rehabilitation population with milder disease
setting (mean age of patients 63 10 years), the 6-min walk
was moderately correlated with scores of quality of life
questionnaires, such as the Activity Status Index (r = 0.502,
P < 0.001) and the Physical Function subscale of the Short
Form 36 Health Survey (r = 0.624, P < 0.001) [37].
In a previous study carried out with elderly patients
admitted to cardiac rehabilitation unit early after cardiac
surgery, the 6MWT performed within the first week of
hospital admission was feasible and safe [38]. The timing
of the test and the walking performance were strongly
influenced by the patients disability and dependence

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6-min walk test after cardiac surgery Feo et al. 147

level, as assessed by nursing needs. Moreover, the walking

capacity affected the patients self-perceived health
status and identified more severely compromised patients
with lower susceptibility to recovery; interestingly, even
in the elderly, functional capacity is still affected by age
and sex, with a decreasing performance in older patients
and in females [8,38].
The correlation between the walk performance and
standard assessment of exercise capacity, such as the
symptom-limited exercise test, has not been widely
investigated in cardiac rehabilitation setting. One study
conducted on a small group of patients admitted to a
cardiac rehabilitation program has compared the results of
the 6MWT and those of a symptom-limited graded
exercise test. The 6MWT was linearly related to peak
oxygen uptake, as expressed by exercise metabolic
equivalents (r = 0.687, P < 0.001), with maximum metabolic equivalents accounting for 47% of the variance in
distance walked, hence supporting the validity of the test
[39]. In a study that enrolled only 10 elderly patients who
underwent cardiac surgery 3 months before, distance
walked at 6MWT was highly and significantly correlated
(r = 0.93) with functional capacity assessed at symptomlimited graded exercise testing [40]. Accordingly, it is
possible to argue that factors associated with a shorter
distance walked at 6MWT are similar to those associated
with a reduced peak oxygen uptake at maximal exercise,
as reported by previous investigators. In this perspective,
the value of the 6MWT as alternative to symptom-limited
exercise test, with or without oxygen uptake, should be
confirmed.

Interpreting the results

Exercise testing is a key component of the initial
assessment performed when a patient is enrolled in
a cardiac rehabilitation program, and the evaluation of
change in functional capacity has become a common
clinical outcome in cardiac rehabilitation programs [18].
Assessment of functional capacity at program entry can be
an effective tool for appropriate exercise prescription in
any single patient. Several studies have shown that the
6MWT is safe and reliable within the first few days of
admission in a rehabilitation program after cardiac surgery.
This finding is relevant as the evaluation of individual
patient functional capacity may provide important
information to guide exercise training prescription. In
fact, for cardiac patients to achieve favorable physical
training responses, and enable the appropriate prescription of physical activities, it is important that functional
physical capacity be established and it is recommended to
provide flexible programs and that exercise intensity be
prescribed relative to fitness level [41].
Distance walked also provides prognostic information
beyond the clinical assessment. Poor performance on
6MWT at the entry can be useful in the identification of

those patients who are more deconditioned and might

gain more at the end of their rehabilitation program [9].
A poor 6MWT performance on admission identifies
patients with a longer rehabilitation stay; these patients
also have significant persistent functional impairment at
discharge [9,28].
The distance that the patient can walk may be used
either as a generic one-time measure of functional status
or as an outcome measure for the rehabilitation program.
In fact, the 6MWT is also a valuable instrument to assess
progression of functional capacity in different clinical
intervention studies [4245]. The definition of clinical
outcomes in cardiac rehabilitation programs plays
a pivotal role. Outcome indicators have been included
in the Best Practice Guidelines because it is difficult
to monitor a number of outcomes usually requiring
long-term follow-up. Further testing of the recommended
process and outcome indicators is required to identify
suitable benchmarks.
The average age of individuals undergoing coronary artery
bypass grafting or valve procedure has progressively
increased and nearly 30% of surgical patients are now
above 70 years of age. In this context, the 6MWT might
play a role as a submaximal measure of the functional
impairment that is more accessible and user friendly. The
6MWTusually improves at the end of cardiac rehabilitation
program: the increase in distance walked does not seem to
be affected by age, sex, diabetes, type of surgery (valve or
coronary), and left ventricular function, and is 30% on
average [9]. Of interest, those patients walking longer at
baseline have less room for improvement, with a sort of
ceiling effect, whereas a greater impairment of functional
capacity at the beginning of the cardiac rehabilitation
program is the main determinant of the magnitude of the
walk test performance improvement [9]. It is, however,
important to realize that the relationship between walking
distance and long-term mortality or hospitalization has not
been validated in a cardiac rehabilitation population.
As emphasized before, the results of the 6MWT can be
given as an absolute value (meters or feet) or as a
percentage of the predicted distance using equations
from published studies of healthy people of the same age
group [11,20,25]. Furthermore, for a correct interpretation of the distance walked, Opasich et al. [28] proposed
to compare this value with a specific reference value
derived from a population with the highest affinity to the
patient. The authors tried to develop an easy algorithm
from a large sample of patients performing a 6MWT
at admission to an intensive in-hospital rehabilitation
unit early after cardiac surgery (Fig. 1). Reference tables
were built up taking into account the variables,
which independently affected the distance walked:
demographic variables (sex and age), left ventricular
ejection fraction (only in men), and presence of any

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148

European Journal of Cardiovascular Prevention and Rehabilitation 2009, Vol 16 No 2

comorbid conditions (diabetes mellitus, renal failure,

chronic cerebrovascular diseases, and COPD). Once the
patient has been categorized according to these variables,
the distance walked can be compared with his or her
matched reference value, and the interpretation of the
result becomes more efficient (Tables 2 and 3).

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

capacity. The 6MWT has been shown to be safe and well

accepted, even early after the intervention.
In recent years, the distance walked at the 6MWT has also
gained prominence for use in clinical practice and in a
research setting to assess changes in functional capacity
after cardiac rehabilitation programs, not only in heart
failure and postmyocardial infarction, but even in surgical
patients.
Some features must be taken into account in the
interpretation of the tests results. For example, participants
who are less motivated usually have shorter 6MWT
performance. The learning effect has been often described,
with better values obtained at a second testing, and the
need for multiple walk tests remains controversial. Nevertheless, repeated testing might be less applicable in
clinical settings and in more compromised patients, and
the majority of studies chose to use the results from a
single test administration.

Fig. 1

Male patient
Age?

Female patient

< 61/6170/>71 (years)

Age?

< 61/6170/ >71 (years)

50% /< 50%

LVEF?

Comorbidity?

Yes No

Diabetes
Creatinine >1.5 mg/dl
Cerebrovascular diseases
COPD

Comorbidity?

Yes No

However, use of walk tests to measure changes in

performance necessitates careful standardization of testing
procedures; in this perspective, the new ATS guidelines
provide a standardized approach for performing the 6MWT
to improve its clinical value.

Table 3 Reference values for the distance walked stratified by age

and comorbidity in women

Diabetes
Creatinine > 1.5 mg/dl
Cerebrovascular diseases
COPD

See Table 2

See Table 3

Algorithm suggested by Opasich et al. [28] for a correct interpretation

of the walking test in the individual patient early after cardiac surgery.
See the text for details. Source: modified from Opasich et al. [28].
COPD, chronic obstructive pulmonary diseases; LVEF, left ventricular
ejection fraction.

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

Modified from Opasich et al. [28].

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 6170 years

Age Z 71 years

LVEF Z 50%

LVEF < 50%

LVEF Z 50%

LVEF < 50%

LVEF Z 50%

LVEF < 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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6-min walk test after cardiac surgery Feo et al. 149

Acknowledgements

24

The authors state that (i) the paper is not under

consideration elsewhere, (ii) none of the papers contents
have been previously published, (iii) there was no support for
the work, (iv) they have read and approved the manuscript,
and (v) there is no potential conflict of interest.

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