84 Physiotherapy Research International

Physiother. Res. Int. 13(2): 84–93 (2008)

Published online 30 April 2008 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pri.398

The six-minute walk test in outpatients

with obesity: reproducibility and known
group validity
ULLA EVERS LARSSON Department of Neurobiology, Care Sciences and Society,
Karolinska Institutet, Sweden
SIGNY REYNISDOTTIR Department of Medicine, Karolinska Institutet, Sweden

ABSTRACT Background and Purpose. To assess the reproducibility and validity of the
six-minute walk test (6MWT) in men and women with obesity in order to facilitate evalua-
tion of treatment outcome. Method. A test—retest design was used to test reproducibility
and a comparative design to test known group validity. Forty-three obese outpatients (16
male), mean age 47 (21–62) years, mean body mass index (BMI) 40 (3–62)kg-m–2 per-
formed the 6MWT twice within one week. Intraclass correlation (ICC1.1) and measurement
error (Sw) were calculated from the mean square values derived from a one-way repeated-
measures ANOVA (fixed effect model). The reproducibility was also analysed by means of
coefficient of variation (CV) and the Bland Altman method including 95% limits of agree-
ment. The variance of the distance walked was analysed by means of regressions. The
known group validity of the 6MWT (distance walked and the work of walking) in obese
participants was shown by comparisons with 41 lean participants (18 male), mean age 47
(24–65) years, mean BMI 22.7kg-m–2 (19–25). Results. The obese group walked 534 m
(confidence interval [CI] 508–560 the first and 552 m (CI 523–580) the second walk (p <
0.001). Sw was 25 m, CV 4.7%, ICC1.1 was 0.96. The limits of agreement were –46 m+80 m.
The validity tests showed that they walked 162 m shorter (p < 0.001) and performed much
heavier work (p < 0.001) than the lean group. In the obese group, BMI alone explained
38% of the variance of the distance walked. Conclusions. The 6MWT showed good repro-
ducibility and known group validity and can be recommended for evaluating walking ability
in subjects with obesity. For individual evaluation, however, an improved walking distance
of at least 80 m was required to make the difference clinically significant. Despite shorter
walking distance the obese participants performed heavier work than the lean. Copyright
© 2008 John Wiley & Sons, Ltd.

Key words: clinical application, distance walked, reproducibility, validity, work of

walking

Physiother. Res. Int. 13: 84–93 (2008)

Copyright © 2008 John Wiley & Sons, Ltd DOI: 10.1002/pri

INTRODUCTION
Walking and moving around have been
ranked as key issues concerning disability in
patients with obesity (WHO, 2001; Stucki et
al., 2004). Several studies show that women
with obesity walk slowly, perceive musculo-
skeletal pain, exertion, chafing and swelling
(Donnelly et al., 1992; Mattsson et al., 1997;
Evers Larsson and Mattsson, 2001). Apart
from causing a reduction of the quality of
life of the obese subjects, walking disability
may also limit the ability to participate
in lifestyle intervention programmes. With
increasing prevalence of obesity, there is a
growing demand for simple tests to identify
and assess individual walking disability in
order to tailor suitable advice and interven-
tions as well as evaluate outcomes.
In clinical settings, the six-minute walk
test (6MWT) is used in several diagnoses,
including obesity (Redelmeier et al., 1997;
American Thoracic Society [ATS], 2002;
Hulens et al., 2003). The ATS has published
standardized guidelines for performing the
test and considers factors such as gender,
height, age, length of the walkway and
encouragement to have impact on the
distance walked (6MWD). Thus published
values on 6MWD range considerably, also
for healthy subjects (Troosters et al., 1999;
Gibbons et al., 2001; Enright, 2003). In addi-
tion a significant learning effect has been
described (Wu et al., 2003; Andersson et al.,
2006). To estimate a patient’s functional
capacity, the product of 6MWD and body
weight, can be used, since this product,
named 6MWORK, is considered to reflect
the work of walking during the 6MWT
better than merely the distance (Chuang
et al., 2001; Carter et al., 2003). Three studies
have used the 6MWT in women with obesity
(Hulens et al., 2003; Maniscalco et al., 2006;
Sarsan et al., 2006). Obese women walked a
Copyright © 2008 John Wiley & Sons, Ltd
6MWT in subjects with obesity 85
shorter distance than lean subjects and, after
exercise and weight loss, they increased
6MWD. Since no measurement error (Sw)
was given, outcome and the group validity
are difficult to interpret. Walking disability
in obese men has not been thoroughly
studied, apart from a negative correlation
between walking efficiency and body fatness
(Chen et al., 2004).
Tests used for assessments and outcomes
should be reliable and valid for the group
studied (Finch et al., 2002). Knowledge of
the test reproducibility is necessary to clini-
cians to evaluate the individual effect of
an intervention. A combination of several
methods, including intraclass correlation
coefficient (ICC) and Bland and Altman
tests, are recommended to analyse reproduc-
ibility (Rankin and Stokes, 1998). Once the
Sw is presented, the validity of the test for
the specific study group can be calculated.
Known group validity refers to a validation
process where two distinctive groups are
compared (Finch et al., 2002). Reproduc-
ibility of the 6MWT has been tested in
healthy adults (Gibbons et al., 2001; Wu et
al., 2003) and in a number of diagnoses, but
not yet in obesity. Therefore, the aim of the
present study was to assess the reproduc-
ibility of the 6MWT for a mixed group of
care-seeking men and women with obesity
and to assess the known group validity of
the test in comparison to lean people.
METHOD
Study design
A test—retest design was used to test the
reproducibility of 6MWT in obese partici-
pants. 6MWT was repeated twice (test—
retest) within one week. A comparative
design was used to test the known group
validity. Results from the first 6MWT in the
Physiother. Res. Int. 13: 84–93 (2008)
DOI: 10.1002/pri
86 Evers Larsson and Reynisdottir

obese group were compared with results
from one test in a lean group.
Subjects
For the reproducibility testing, male and
female outpatients registered at The Centre
for Obesity Treatment, Norrtulls Hospital,
Karolinska University Hospital, Stockholm
and Sweden, were during six months con-
secutively recruited and invited to partici-
pate in the study. Patients with known severe
psychiatric diagnoses, difficulty in under-
standing Swedish, walking aids or total hip
replacements were excluded. Forty-three
patients chose to participate. Seven were
medicating with beta-blockers and all medi-
cation was stable during the study period.
Their mean age was 46.8 (21–62) years and
mean body mass index (BMI) 39.6 (30.4–
59.1)kg-m–2. Those 43 patients who declined
participation due to tight working schedule,
vacation or unknown reason did not sig-
nificantly differ from those who chose
participation.
For the validation process of the 6MWT
in the obese group, reference values were
collected from lean volunteers, recruited by
flyers posted at the hospital. Forty-one, mean
BMI 22.7 (19–25)kg-m–2, aged 46.5 (24–65)
years, volunteered to participate.
Anthropometric data on obese and lean
participants are presented in Table 1. Age
and height did not differ significantly, but
weight and BMI did (p < 0.001).
Informed consent was obtained from all
participants and the study was approved by
the local ethics committee.
Methods and procedure
The obese participants performed the 6MWT
twice with a median interval of 5 (range 2–
14) days. They were instructed to wear com-
fortable shoes and clothes. Each participant
was tested at the same time in the morning
and by the same physiotherapist at both
occasions.
The 6MWT was performed according to
ATS’ (2002) guidelines in an indoor corri-
dor. Two cones 40 m apart indicated the
length of the walkway. The instructions
were: ‘You shall now walk as far as possible
for six minutes, but don’t run or jog’. Stan-
dardized encouragement was given every
minute by telling how many minutes were
left. Heart rate (HR) before (at rest) and
directly after the 6MWT was palpated at the
wrist. A stopwatch (Sport Timer, K-Tech R)
was used for timekeeping and HR measures.
Directly after the tests the participants were
asked to rate perceived exertion and/or pain

TABLE 1: Anthropometric data

Obese females Lean females Obese males Lean males

n = 27 n = 23 n = 16 n = 18

Age (years) 43.9 (39.2–48.5) 45.2 (40.1–50.3) 51.8 (47.1–56.4) 47.9 (42.0–54.1)
Body mass (kg) 107.8 (101.7–113.8) 61.9 (58.6–65.2) 126.0 (113.8–138.2) 76.1 (73.1–79.0)
Height (m) 1.66 (1.63–1.69) 1.67 (1.65–1.70) 1.78 (1.75–1.82) 1.80 (1.77–1.82)
BMI 39.4 (37.1–48.5) 22.1 (21.3–22.8) 39.9 (35.8–44.0) 23.6 (22.9–24.2)

Mean (95% confidence interval). Obese (n = 43), and lean participants (n = 41).
BMI = body mass index.

Physiother. Res. Int. 13: 84–93 (2008)

Copyright © 2008 John Wiley & Sons, Ltd DOI: 10.1002/pri
 6MWT in subjects with obesity 87

ICC1.1
on the Borg CR10-scale (Borg, 1982). For

0.96
the validation, one 6MWT in the lean group

Sw = measurement error; CV = coefficient of variation; SDdiff = standard deviation of the differences; ICC1.1 = intraclass correlation coefficient.
was sufficient to make comparisons with the
first walk in the obese group.

SDdiff
Weight was measured to the nearest

31.6
0.1 kg on an electronic scale (Vetek ‘Unis-
cale’, Vetek AB, SE-760 40 Sweden) and

CV

4.7
height was measured to the nearest 0.5 cm
with a wall-mounted stadiometer (Seca-220,

25.3
701/702). Weight and height were then used

Sw
to calculate BMI.

agreement
Statistical analysis

Mean (95% confidence interval) or median (range). P calculated with ANOVA or Sign test (ordinal data).
56
47
%
Since beta-blockers could affect the HR
response and thus the sub maximal work and

<0.001
=0.92
=0.65
distance walked, an analysis of differences

=1.0
between obese participants with and without

p
this medication was performed by means of

Systematic
unpaired t-tests. Descriptive statistics are

difference
TABLE 2: Reproducibility of the distance walked in the obese participants (n = 43)
presented as mean (standard deviation [SD])

17.6
or 95% confidence interval (CI) or median
and range. The methods for assessing the
reproducibility of the 6MWD are presented 125 (118.6–131.4)
551.5 (523–580)

in Table 2 and Figure 1. Intraclass correla- 3 (1–9.5)

tion (ICC1.1; Rankin and Stokes, 1998) and 1 (0–7)
Sw between the two 6MWD were calculated
Test 2

from the mean square values derived from

one-way repeated-measures ANOVA (fixed
effect model). Sw was calculated as the
124.8 (119.6–130.0)

square root of the within-groups (between

534 (508–560)

measures + error) mean square (Weir, 2005).

3.5 (1–9.5)

Further the reproducibility by means of

2 (0–7)

test—retest was analysed with Pearson’s

Test 1

correlation coefficient or Sign test (for ordinal

data). The coefficient of variation (CV; Sw
100/x) was calculated. Agreement between
Final HR (bpm) (n = 36)

the two 6MWD was assessed according to

Bland and Altman (1996), including the
Exertion (CR10)

mean difference between measures and

Distance (m)

the standard deviation of the differences

Pain (CR10)

(SDdiff). The 95% limits of agreement

(1.96·SDdiff) illustrating the bias between
the two measurements are demonstrated by

Physiother. Res. Int. 13: 84–93 (2008)

Copyright © 2008 John Wiley & Sons, Ltd DOI: 10.1002/pri
88 Evers Larsson and Reynisdottir
100
80
60
40
diff (m)
20
0 (mean)
-20
-40
-60
0 200 400
mean distance walked (m)
FIGURE 1: Agreement between two tests of distance walked in six-minute walk test.
means of a Bland-Altman plot (Bland and
Altman, 1986).
Known group validity (Finch et al., 2002)
of the 6MWT and 6MWORK (kg·km) was
analysed by comparing results from obese
and lean participants with unpaired t-tests or
the Mann-Whitney U-test. For identification
of variables (Table 3) with large impact on
the variance of 6MWD in the patients, first
univariate and then backwards multiple
regressions were used.
All comparisons are based on results
from test 1 if nothing else is stated. All anal-
yses were performed in Microsoft® Office
Excel 2003 and StatSoft, STATISTICA 6.0.
RESULTS
Results from the 6MWT are presented in
Table 2, Figure 1 (reproducibility) and Table
3 (validity). The seven obese and two lean
participants who medicated with beta-block-
ers are included since beta-blockers did not
influence the results. Since the medication
may affect the HR response, the HR values
of these nine participants were excluded
from the analyses.
Copyright © 2008 John Wiley & Sons, Ltd
Limit of
agreement
(mean+2SD)
Bias
Limit of
agreement
(mean-2SD)
600 800
All but one obese participant could com-
plete the 6MWT without stopping for breaks
due to pain and/or dyspnoea. Twenty-eight
others perceived musculoskeletal pain and
all 43 perceived exertion. The distance
walked was 17.6 m longer at the second test
(p < 0.001), but neither final HR, perceived
pain nor exertion differed between the tests.
Analyses of reproducibility of the 6MWD
showed that r was 0.94, Sw was 25.3 m, CV
was 4.7%, SDdiff was 31.6 m and ICC1.1
was 0.96 (Table 2). The agreement between
the two tests is illustrated with a Bland
Altman plot in Figure 1. Considering bias,
the limits of agreement were –45.6 m and
79.5 m.
Twelve lean participants perceived pain
and all 41 perceived exertion. They walked
161.5 m further (p < 0.001), perceived less
pain and exertion (p < 0.001), but their final
HR did not differ (p = 0.24) from that of the
obese participants. 6MWORK was heavier
in obese than in lean participants (p < 0.001;
Table 4).
In the obese group, women walked 531
(76) m and men 539 (89) m (p = 0.77).
6MWD correlated negatively with BMI
Physiother. Res. Int. 13: 84–93 (2008)
DOI: 10.1002/pri
 6MWT in subjects with obesity 89

TABLE 3: Backwards multiple regression between the second distance walked and BMI, fi nal heart rate, heart rate at rest, height and age in the obese

=0.002
(r = –0.63), pain (rs = –0.28) and age (r =

<0.001
–0.16) and positively with height (r = 0.44),

p
final HR (r = 0.35) and exertion (rs = 0.17).
Multiple regressions in steps showed that the

0.54
1.47
variables BMI, HR, height and age could

R2 = adjusted amount of explanation; B = regression coefficient; Std err = standard error of B; HR = heart rate; BMI = body mass index.
explain 71% of the variances in the second
R 2 = 0.52

6MWD, while BMI alone could explain 38%

–8.20
1.81
656.41
Step 4

(Table 3).
B

DISCUSSION
=0.003
<0.001
<0.001

Our purpose was to examine the utility of

p

the 6MWT in a mixed group of patients with

obesity. Utility conveys knowledge of the
Std err

0.57
1.35

0.77

reproducibility of the test in the selected

group as well as knowledge of the known
R 2 = 0.63

group validity; that is considering the Sw,

672.44
–6.86
2.83
–2.51
Step 3

do subjects with obesity walk significantly

shorter distance than lean subjects? The
B

6MWD showed good reproducibility in our

=0.005

obese group. The CV was low and the test—

<0.001
<0.001

=0.01

retest correlation and intraclass correlation

p

were very high (Rankin and Stokes, 1998;

Domholdt, 2000). The Sw was 25.3 m
Std err

1.27
0.52
0.72
95.16

whereas the upper limit of agreement was

79.5 m. Hence in our setting, an improved
walking distance of at least 80 m was
R 2 = 0.69

–6.22
202.88

2.77

250.76
–2.17

required to be 95% certain of a true change

Step 2

in the individual. The 6MWT also proved

B

valid for our sample of obese participants.

The difference in 6MWD between lean and
=0.004
<0.001
<0.001

=0.08
=0.01

obese participants exceeded the Sw with

p

136.2 m (161.5 m minus 25.3 m). Also the

work of walking differed significantly
Std err

between the groups. In the obese group,

1.25
0.53

0.77
0.71
95.75

BMI could explain 38% of the variance in

6MWD.
R 2 = 0.71

The obese group increased the 6MWD

219.80

–1.90
301.03
–1.42
2.47
–6.75
Step 1

by 18 m (3%) between the first and the

B

second test. The increase was most evident

in males, in those with BMI <41kg-m–2 and
participants

HR at rest

in participants with weak or no pain (≤2 on

Final HR
Intercept

n = 36.
Height

the Borg CR 10-scale) during walking. It

BMI

Age

may be due to a learning effect and insecurity

Physiother. Res. Int. 13: 84–93 (2008)

Copyright © 2008 John Wiley & Sons, Ltd DOI: 10.1002/pri
90 Evers Larsson and Reynisdottir
TABLE 4: Results from the fi rst six-minute walk test in obese (n = 43) and lean participants (n = 41)
Obese participants
Distance (m) 534 (508–560)
Work (kg·km) 60.5 (57.0–64.1)
Final HR (bpm) 124.8 (119.6–130.0)
(n = 36)
Exertion (CR10) 3.5 (1–9.5)
Pain (CR10) 2 (0–7)
Mean (95% confidence interval) or median (range); p calculated with unpaired t-test and Mann-Whitney U
test.
HR = heart rate.
about reactions to the fi rst test. In a few
cases it became apparent that the partici-
pants did not fully understand the instruc-
tions given the first walk. According to ATS’
guidelines they were instructed to walk as
far as possible, which could have resulted in
slightly restricted speed. Some studies have
avoided this problem by instructions to walk
as fast as possible (Gibbons et al., 2001;
Hulens et al., 2003; Sarsan et al., 2006),
which might pose a risk of over-exertion at
an early stage of the 6MWT. It is well known
that familiarisation with the 6MWT, not just
one but several times, may increase the
6MWD and the total learning effect by as
much as 43 m (Troosters et al., 1999; Gibbons
et al., 2001; Andersson et al., 2006). The
recommendations from the ATS suggest that
the first 6MWD results at baseline may be
used for future outline comparisons. The
rationale given is that the 6MWD is only
slightly higher than the second test. This
seems sensible for clinical settings, since it
would be far too time-consuming and expen-
sive to test patients on more than one occa-
sion to get a reliable baseline value.
A statistically significant mean increase
in 6MWD in a group is often much less than
a clinically significant increase in an indi-
vidual (ATC, 2002). For individuals in our
sample of obese participants an improve-
ment of the 6MWD of at least 80 m or 15%
Copyright © 2008 John Wiley & Sons, Ltd
Lean participants p
695.5 (674–717) <0.001
47.5 (44.6–50.4) <0.001
129.1 (122.2–136.1) =0.24
(n = 39)
3 (0.5–4) <0.001
0 (0–7) <0.001
was required to be of clinical significance.
Such an improvement may seem large, but
our results are comparable with others.
Reported improvements of individual clini-
cal importance amount to 65 m–133 m or
10%–23% (Redelmeier et al., 1997; Enright,
2003; Li et al., 2005; Andersson et al., 2006;
Cunha et al., 2006).
Concerning the known group validity we
found a difference between the groups in
6MWD, 6MWORK, pain and exertion. The
influence of BMI on the variance in 6MWD
was reinforced by the multiple regression
analysis within the obese group, where the
amount of explanation was 38%. Continued
analyses revealed that obese participants
with BMI >41kg-m–2, walked 84 m shorter
distance (p < 0.001) than those with less
obesity. As 6MWD did not differ between
genders, our results confirm the validity of
the 6MWT for both men and women with
obesity.
The obese group in the present study
walked 534 (285–716) m and covered only
77% of the distance of the lean group. Our
results are comparable with the study by
Hulens et al. (2003), where women with
BMI >35kg-m–2 walked on average 539 (68)
m and covered 75% of the distance of lean
women. In the studies by Maniscalco et al.
(2006) and Sarsan et al. (2006) women
with obesity walked from 380 to 580 m,
Physiother. Res. Int. 13: 84–93 (2008)
DOI: 10.1002/pri

depending on obesity level. As pain condi-
tions might well interfere with walking
capacity (Mattsson et al., 1997; Evers
Larsson and Mattsson, 2001; Hulens et al.,
2003) we had expected pain to limit the
6MWD in our obese participants to a higher
extent. More than 65% of them rated pain,
ranging from just noticeable (0.5) to very
strong (7) on the CR10-scale. Most pain
emanated from knees or tibial periosteum.
In the obese group BMI, HR, height and
age explained 71% of the variance of the
6MWD. BMI was the most important con-
tributor, whereas gender and pain unexpect-
edly did not influence the 6MWD. However
other factors might be of importance. It
seems probable that low cardio respiratory
fitness would result in shorter 6MWD in the
present study. Previous studies on obesity
have shown that low aerobic capacity in
women resulted in high oxygen cost during
walking (Mattsson et al., 1997; Browning
and Kram, 2005) and could explain 11% of
the variance of the 6MWD (Hulens et al.,
2003). Calculations of 6MWORK showed
that our obese participants performed much
heavier work during walking than our lean
participants. To use the 6MWORK as a
parameter for individual fitness in patients
with obesity could be a simple method to
estimate the work of walking and functional
capacity if no better methods are available
(Chuang et al., 2001; Carter et al., 2003).
There may be some limitations in our
study. We believe the results can be general-
ized since all test methods are standardized.
However, Swedes living in big cities are
accustomed to walking, thus the results may
not be generalized to obese subjects in all
countries and cultures. Further, the length of
our walkway was 40 m. ATS recommends
30 m, but at the same time states that as long
as the walkway is straight and limited to
between 15 m and 50 m, the walkway length
Copyright © 2008 John Wiley & Sons, Ltd
6MWT in subjects with obesity 91
will have no significant impact on the
6MWD.
We used several statistical methods, such
as the ICC and Bland and Altman tests,
to analyse the reproducibility. ICC-values
depend on measurement precision and vari-
ance between subjects, whereas Sw depends
on variance within subjects. We also pre-
sented the CV as it is expressed in percent-
age, which enables comparisons with other
studies (Gulmans et al., 1996; ATC, 2002;
Wu et al., 2003). Altogether, these statistical
methods complemented each other and yet
showed similar results. This will strengthen
our conclusion.
Also the bias between the two tests of
6MWD will have to be considered. Others
have avoided bias as they used a second test
as baseline value for outcome evaluations
and they recommend test familiarisation
(Gibbons et al., 2001; Wu et al., 2003;
Andersson et al., 2006). Since prevailing cir-
cumstances in most clinical settings will not
make trial walks possible, we relied on the
statement by ATS and deliberately chose
two tests to obtain clinically relevant mea-
sures and, to put focus on the size of the Sw
between the first two tests. We believe that
our results will thus be applicable in patients
similar to our participants for evaluation of
intervention outcomes in individuals or in
groups.
IMPLICATIONS
Just one 6MWT should be sufficient to eval-
uate walking ability and functional capacity
in the clinic in male and female patients with
obesity. We can expect obese patients to
walk significantly shorter distances and yet
perform heavier work than lean subjects.
However, clinicians must be aware of the
size of the Sw. For individual evaluation over
time or after intervention the improvement
Physiother. Res. Int. 13: 84–93 (2008)
DOI: 10.1002/pri
92 Evers Larsson and Reynisdottir
of the distance walked has to be approxi-
mately 15% of the baseline value or 80 m to
be significant.
ACKNOWLEDGEMENTS
We are much obliged to all patients and lean reference
subjects for their participation, as to Elisabeth Berg,
statistician for valuable advice, and Anne Christensson
and Maren Schuldt, physiotherapists for expert help
with the testing and clinical advice.
The study was supported by the Committee for
the Health and Caring Sciences at the Karolinska
Institute.
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Address correspondence to: Ulla Evers Larsson,
Karolinska Institutet, Dept of Neurobiology, Care
Sciences and Society, Division of Physiotherapy 23
100, S-141 83 Huddinge, Sweden. E-mail: Ulla.Evers.
Larsson@ki.se
(Submitted June 2007; accepted January 2008)
Physiother. Res. Int. 13: 84–93 (2008)
DOI: 10.1002/pri