Clin Physiol Funct Imaging (2018) doi: 10.1111/cpf.

12525

Six-minute walk test: a tool for predicting maximal aerobic

power (VO2 max) in healthy adults
€ntta
Ari Ma €ri1 , Jaana Suni1, Harri Sieva
€nen1, Pauliina Husu1, Henri V€aha
€-Ypya
€1, Heli Valkeinen2, Kari Tokola1
1
and Tommi Vasankari
1
The UKK Institute for Health Promotion Research, Tampere, and 2National Institute for Health and Welfare, Finland – THL, Helsinki, Finland

Summary

Correspondence
Ari M€antt€ari, The UKK Institute for Health
Promotion Research, P.O. Box 30, FI-33501
Tampere, Finland
E-mail: ari.manttari@uta.fi
Accepted for publication
Received 3 February 2018;
accepted 2 May 2018
Key words
6MWT; cardiorespiratory fitness; criterion
validity; field test; MET
Background The 6-min walk test (6MWT) is cost-effective and well-documented
field test for assessing functional exercise capacity and response to medical inter-
ventions in diverse patient groups, and predicting cardiorespiratory fitness among
healthy people.
Objective Assessments of cardiorespiratory fitness in terms of maximal aerobic
power (VO2max) have great potential in public health monitoring to predict
future health, early retirement and ability to independent living. This study aimed
to develop a prediction model for VO2max based on 6MWT results among
healthy adults.
Design The study comprised of pilot and validation studies. In validation study, sev-
enty-five 19- to 75-year-old adults (39 men, 36 women) were equipped with porta-
ble gas analyser and heart rate monitor. Participants performed 6MWT on a 15-m
indoor track and maximal graded exercise test (GXT) on a treadmill. We evaluated
performance of the developed prediction model among 1583 Finnish adults.
Results Participant’s mean walking distance was 652 m (SD
74). Their mean
VO2max in GXT and O2 uptake at the end of the 6MWT were 344 ml kg1min1
(SD
76) and 272 ml kg1min1 (SD
65), respectively. For men, the best
predictors for VO2max were walking distance, age, BMI, heart rate at the end of
6MWT and height, and for women, walking distance, age and weight. The predictors
explained 82% and 79% of men’s and women’s measured VO2max with the standard
error of estimate of 36 ml kg1min1 and 35 ml kg1min1, respectively.
Conclusion The 6MWT performed along a 15-m track is a valid field test for pre-
dicting VO2max of healthy adults with accuracy of about 1MET.

Introduction
Cardiorespiratory fitness (CRF) is a strong predictor of future
health and functioning. Prospective cohort studies have
reported a lower risk of cardiovascular diseases (LaMonte &
Blair, 2006; Ekblom-Bak et al., 2010) and type 2 diabetes
among individuals with high levels of CRF (Katzmarzyk et al.,
2007; Lee et al., 2009). Population-level changes in CRF have
indicated that increase in 1MET (metabolic equivalent, i.e.
oxygen consumption of 35 ml min1kg1) substantially
reduces the all-cause mortality risk by 10–25% in different
age groups of men and women (Kodama et al., 2009). From
this point of view, the prediction error of population mea-
surements of CRF should not be more than 1MET.
Walking tests assessing maximal aerobic power have a great
potential in public health monitoring to predict future health,
early retirement, ability to independent living and need for care
(Bull & Bauman, 2008; Hallal et al., 2012). The traditional out-
come measure of the 6-min walk test (6MWT) is the distance
walked (Duncan et al., 2015), which is a good predictor of
functional endurance, treatment success and recovery of patients
from cardiac diseases (Bittner et al., 1993; Rostagno & Gensini,
2008). However, there are only few published studies on
6MWT’s ability to predict maximal aerobic power (VO2max) in
healthy adults. Andersson & Nilsson (2011) concluded that the
distance alone is not a valid predictor of VO2max in young col-
lege students of physical education. Burr et al. (2011) used mul-
tiple regression approach to estimate maximal aerobic power in
healthy working-aged adults. In addition to distance walked,
their prediction model included participant’s body weight, gen-
der, resting heart rate and age. Those predictors accounted for
72% of variance in measured VO2max.
The main purpose of this study was to validate the 6MWT
as a tool for predicting maximal aerobic power (VO2max)

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 1
 €ntta
2 6MWT: a prediction tool for VO2 max among healthy adults, A. Ma
among healthy adults. Prediction model for submaximal oxy-
gen consumption at the end of the 6MWT (VO2sub) was also
developed. In addition, we applied the prediction model to
the 6MWT data obtained from the physical activity (PA) and
fitness subsample (n = 1583) of Health 2011 Survey (Koski-
nen et al., 2012).
Methods
We conducted three consecutive studies. Research plans
were approved by the Pirkanmaa Hospital District’s Regional
Ethics Committee, Ethical Codes: R10126 (pilot study),
R11115 (criterion-validity study) and R12246 (criterion-
validity study). Preliminary prediction models for aerobic
power in men and women were developed in a pilot study,
which were then field tested in a physical activity promo-
tion programme of a workplace in Tampere, Finland. After
that, we revised the regression models in the two consecu-
tive criterion-validity studies. Short descriptions of these
three studies, their purposes and participants are described
in Fig. 1.
The participants of the criterion-validity studies were (a)
volunteers from the physical activity (PA) and fitness subsam-
ple of the National Health 2011 Survey, and (b) a conve-
nience sample of nearby workplaces. Inclusion of participants
from diverse age and body weight groups was intended to
enhance the applicability of the prediction models among
general population. In addition, the revised prediction models
Figure 1 Study design and description of the participants of the pilot study and the two consecutive criterion-validity studies
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
€ri et al.
were applied to the data of the 6MWT obtained from the PA
and fitness subsample (n = 1583) of population-based Health
2011 Survey (Koskinen et al., 2012).
The pretesting health screening
An exercise physiologist using the safety model developed for
health-related fitness testing (Suni et al., 1998; Malmberg et al.,
2002) performed health screening. The rationale was to dis-
cover health limitations that might compromise the safety of
testing. After that, the participants’ weight (Seca mechanical
column scale, Germany) and height (Microtoise, Stanley
Mabo, UK) were measured and resting electrocardiogram
(CASE, GE Healthcare, Milwaukee, Wisconsin, USA) was
recorded to exclude participants with abnormal findings.
6MWT
The American thoracic association (ATS Committee on Profi-
ciency Standards for Clinical Pulmonary, 2002) recommends
that the 6MWT is conducted on a 30-m indoor track. In for-
mer studies, also track lengths of 50 and 20 m have been
used (Lipkin et al., 1986; Stevens et al., 1999; Troosters et al.,
1999; Beriault et al., 2009) . In the pilot study, we used 15-m
and 30-m indoor tracks in a random order to evaluate also
the effect of the track length on the distance walked. Partici-
pants’ walking distance on the 30-m course was on average
232 m (95% CI 119–345) longer than on the 15-m course.

6MWT: a prediction tool for VO2 max among healthy adults, A. Ma
We considered the 15-m track more feasible in terms of space
constraints and chose that for the criterion-validity studies.
Plastic cones were placed in both ends to mark the turnaround
points of the track. The track had markings at every 3 m to
record the exact distance of the last lap.
After health screening, participants were equipped with
portable heart rate monitor (Polar T31, Kempele, Finland) and
breath-by-breath portable metabolic analyser (Oxycon Mobile,
Carefusion, Yorba Linda, CA, USA) (Rosdahl et al., 2010). We
calibrated flow meter, O2 and CO2 sensors of the telemetric
gas analyser before each exercise session against known vol-
ume and O2 and CO2 gases. Participants warmed up and
familiarized themselves with the equipment by walking
200 m on an oval-shaped indoor track, and then two laps on
the 15-m test track to accustom themselves to steep turns and
to minimize the possible learning effect. The test instructions
were as follows: ‘Walk back and forth around the cones as fast
as possible for 6 min. You may not jog or run, and you
should pivot briskly around the cones as I showed you. Are
you ready? Start!’ Each time the participant passed by the
starting line, the tester marked one line on the worksheet
(corresponding to 30 m). The tester informed the passing of
walking time at every minute. Rating of perceived exertion
(RPE) 6–20 (Borg, 1982), heart rate and distance walked in
last lap were recorded the end of the test. All metabolic data
from Oxycon Mobile during 6MWT were telemetrically moni-
tored, transferred and saved on measurement laptop for fur-
ther analyses.
Maximal graded exercise test (GXT)
After the submaximal 6MWT, the participants rested for
10 min while seated on a chair without the facemask of the
gas analyser. They were advised to drink water as they
desired. After that, the participant conducted the GXT on a
treadmill by walking until exhaustion. The exercise physiolo-
gist adjusted the measurement protocol individually according
to the participant’s results in former test of 6MWT.
Figure 2 An example of GXT protocol for
individual participant with predicted
26 ml kg1min1 oxygen consumption
demand at the end of the 6MWT
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
€ntta
€ri et al. 3
The average walking speed of 6MWT was used to predict
the average VO2 (ml kg1min1) demand (Van der Walt &
Wyndham, 1973) during the last minute of the 6MWT in the
pilot study. The predicted O2 uptake was then individually
converted to the treadmill slopes with constant walking speeds
(Balke & Ware, 1959) according to the below presented maxi-
mal GXT measurement protocol (Fig. 2).
Slopes (°) for each stages were individually adjusted
according to Balke & Ware (1959) to correspond desired
aerobic power of walking. The GXT begun with 4 min of
warm-up stage at the intensity of 70% of the predicted aer-
obic demand of the 6MWT. The next stage lasted for 2 min
followed by 1 min’ stages until exhaustion. The walking
intensity increased by 1MET (35 ml kg1min1) at each
stage. Criterion for VO2max was as follows: respiratory
exchange ratio (RER) > 115, RPE ≥ 17 and/or VO2 level-
ling off or decline in oxygen consumption. Participants
were monitored with the 12-lead ECG (CASE; GE Health-
care) throughout the test, and they wore the same measure-
ment equipment as during 6MWT. Maximal heart rate (HR)
and RPE at the end of the GXT were recorded, and all
metabolic data from Oxycon Mobile were telemetrically
monitored, transferred and saved on measurement laptop
for further analyses.
Statistical analyses
We conducted all analyses separately for men and women.
Descriptive statistics were used to characterize participants’
6MWT results and measured metabolic data. Stepwise linear
regression analyses were used to find the best predictors for
VO2max. Potential predictor variables were weight, height,
body mass index (BMI), walking distance (6MWD), heart
rate (HR) and RPE at the end of 6MWT. Age was forced
into the model. Coefficient of determination (R2) and stan-
dard error of estimate (SEE) were used to evaluate the
goodness and accuracy of the prediction equations. R-
squared indicates how well data fit the prediction model
 €ntta
4 6MWT: a prediction tool for VO2 max among healthy adults, A. Ma €ri et al.

and SEE is a measure of accuracy of the model. SEE was
calculated as follows:
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
P
ðy  y0 Þ2
SEE ¼
n
where y = measured aerobic power, y0 = predicted aerobic
power and n = number of participants. Bland–Altman differ-
ence plots were used to assess the 95% limits of agreements
for the developed models (Giavarina, 2015). All statistical
analyses were conducted using IBM SPSS statistics software
version 22 (Chicago, IL, USA).
Results
Pilot study
Two participants of the pilot study were dropped out from
the analyses due to pathological changes in ECG and severe
musculoskeletal pain during the maximal GXT. Descriptive
demographic data, results of 6MWT and metabolic data
recorded during the 6MWT and maximal GXT are presented
in Table 1.
The best predictor variables for VO2max in multiple regres-
sion analyses were the distance walked in 6MWT (6MWD),
age, body weight and length of walking track (15 m or
30 m) for both men and women. Predictors for VO2max
explained 85% (R2 = 085) of variation of measured aerobic
power with SEE of 39 ml kg1min1/for men and 90%
(R2 = 090) with SEE of 31 for women, respectively. The best
predictor variables for VO2sub were as follows: 6MWD, body
weight, heart rate at the end of the test and length of walking
course. Predictors for VO2sub explained 98% of variation of
measured VO2sub (R2 = 098) with SEE of 18 ml kg1min1
for men and 94% (R2 = 094) with SEE of 19 for women,
respectively (M€antt€ari et al., 2011) (Fig. 3).
Criterion-validity study
Participants of the criterion-validity study were those of the
pilot study who performed first the 6MWT on 15-m track
(n = 16) and new recruits (n = 67) described in Fig. 1. We
excluded eight participants from the VO2max analyses due to
musculoskeletal pain leading to inadequate effort in maximal
GXT. Results of altogether 75 participants (39 men, 36
women) were accepted and entered into statistical analyses
(Table 2).
The best predictors for VO2max in multiple regression anal-
yses were as follows: 6MWD, age, BMI, body height and heart
rate at the end of the test for men, and body weight, 6MWD
and age for women. These predictors explained 82%
(SEE = 36 ml kg1min1) of variation in the measured
VO2max in men and 79% (SEE = 35 ml kg1min1) in
women. Figure 4 shows both the correlation and Bland–Alt-
man difference plot between the predicted and measured
VO2max.
Corresponding values for VO2sub were 82% (SEE = 30 ml
kg1min1) and 81% (SEE = 28 ml kg1min1) with 95%
limits of agreement of
54 ml kg1min1 (Fig. 5).

Table 1 Gender-specific demographics, 6MWT results and directly measured cardiorespiratory data from 6MWT and GXT in the pilot study (data
are presented as mean
SD).

Weight
Age (years) Height (cm) (kg) BMI (kg/m2) 6MDa (m) 6MHRb (bpm) 6MRPEc (6-20)

Demographics and 6MWT results

Men (n = 12) 57
12 180
5 824
76 256
20 693
123 136
21 14
1
Women (n = 19) 49
14 165
6 642
83 236
30 702
85 152
18 14
1
All (n = 31) 52
13 171
9 75
120 244
28 698
100 146
21 14
1

GXTVO2maxd 6MVO2sube %VO2maxf GXTHRh %HRmaxi GXTRPEmaxj

(ml kg1min1) (ml kg1min1) (%) GXTRER g
(bpm) (%) (6-20)

Metabolic data from 6MWT and GXT (graded exercise test)

Men (n = 12) 376
80 278
90 73
13 127
006 169
13 80
9 19
1
Women (n = 19) 378
90 292
65 78
9 125
007 178
15 85
7 19
1
All (n = 31) 377
85 286
75 76
11 126
007 174
15 83
8 19
1

a
Distance walked in 6 min.
b
Measured 10 s average heart rate at the end of the 6MWT.
c
Rated perceived exertion at the end of the 6MWT.
d
Measured 30 s average maximal aerobic power at the end of the graded exercise test.
e
The average oxygen consumption during the last test minute of test.
f
6MVOsub/GXTVO2max*100.
g
Measured respiratory exchange ratio at the level of the VO2max.
h
Measured 10 s average max heart rate at the end of the GXT.
i
6MHR/GXTHR*100.
j
Rated perceived exertion at the end of the GXT.

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
 €ntta
6MWT: a prediction tool for VO2 max among healthy adults, A. Ma €ri et al. 5

Figure 3 Measured and predicted submaxi-

mal (a) aerobic power (VO2sub) and maximal
(b) aerobic power (VO2max), coefficient of
determination (r2) and standard error of esti-
mate (SEE) in men and women in the pilot
study

Table 2 Gender-specific demographics, 6MWT results and directly measured cardiorespiratory data from 6MWT and GXT in the criterion-valid-
ity study (data are presented as mean
SD).

BMI 6MHRb 6MRPEc

Age (years) Height (cm) Weight (kg) (kg/m2) 6MDa(m) (bpm) (6-20)

Demographics and 6MWT results

Men (n = 39) 51
12 178
6 902
18 283
53 660
84 143
20 14
2
Women (n = 36) 49
14 165
6 692
14 253
47 624
62 150
18 14
1
All (n = 75) 50
13 172
9 812
19 269
52 652
74 146
19 14
2

GXTVO2maxd 6MVO2sube %VO2maxf GXTHRh %HRmaxi GXTRPEmaxj

(ml kg1min1) (ml kg1min1) (%) GXTRERg
(bpm) (%) (6-20)

Metabolic data from 6MWT and graded exercise test

Men (n = 39) 352
78 270
68 77
13 126
009 176
14 81
9 18
1
Women (n = 36) 336
73 273
63 82
9 123
009 174
17 86
6 18
1
All (n = 75) 344
76 272
65 80
11 124
009 175
15 83
8 18
1

a
Distance walked in 6 min.
b
Measured 10 s average heart rate at the end of the 6MWT;
c
Rated perceived exertion at the end of the 6MWT.
d
Measured 30 s average maximal aerobic power at the end of the graded exercise test.
e
Last minute average aerobic power at the end of the 6MWT.
f
6M VOsub/GXT VOmax*100.
g
Measured respiratory exchange ratio at the level of the VO2max.
h
Measured 10 s average max heart rate at the end of the GXT.
i
6M HR/GXT GXT HRmax*100.
j
Rated perceived exertion at the end of the GXT.

Multiple regression analyses yielded the following VO2max Table 4 provides gender-specific statistical coefficients for
(ml kg1min1) prediction equations for men and women: VO2sub. We applied the developed prediction equations to the
Men data of the 6MWT collected in the PA and fitness subsample of
National Health 2011 Survey (n = 1583) (Husu et al., 2016).
VO2 max ¼ 110546 þ 0063  ð6MWDÞ  0250  ðageÞ
The accuracy of the VO2max prediction model was good
 0486  ðBMIÞ  0420  ðheightÞ
enough to divide 6MWT results into age and gender-specific fit-
 0109  ðHRÞ ness thirds; that is, the SEE was smaller than the range between
Women the lower and upper limits of the middle third (Table 5).

VO2 max ¼ 22506  0271  ðweightÞ þ 0051  ð6MWDÞ

 0065  ðageÞ
where weight is body weight (kg), 6MWD is distance walked
in 6 min (m), age (years), BMI is calculated body mass index
(kg/m2), height is body height (cm) and HR is heart rate at
the end of the walking test (bpm; Table 3).
Discussion
Our findings indicate that 6MWT performed on a 15-m track
is a sufficiently accurate method to predict VO2max, health
and functioning in adults. The prediction accuracy of 1MET
may also provide a sufficient basis to predict risks of

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
 €ntta
6 6MWT: a prediction tool for VO2 max among healthy adults, A. Ma €ri et al.

Figure 4 Coefficient of determination (r2),

standard error of estimate (SEE) (a) and
Bland–Altman difference plot of measured and
predicted maximal aerobic power (VO2max)
with 95% limits of agreement (
2SD) in the
criterion-validity study (b)

Figure 5 Coefficient of determination (r2),

standard error of estimate (SEE) (a) and
Bland–Altman difference plot of measured and
predicted submaximal aerobic power
(VO2sub) with 95% limits of agreement
(
2SD) in the criterion-validity study (b)

Table 3 Coefficients (unstandardized and standardized) for gender- Table 4 Coefficients (unstandardized and standardized) for gender-
specific VO2max regression model. specific VO2sub regression model.

Unstandardized Standardized Significance Unstandardized Standardized Significance

Model coefficients coefficients (P-value) Model coefficients coefficients (P-value)

Women Women
Constant 22506 0083 Constant 47366 0001
Body weight 0271 0515 0001 6MWD 0787 0780 0001
6MWD 0051 0437 0001 Heart rate 0114 0324 0002
Age 0065 0122 0186 Age 0144 0311 0001
Men Men
Constant 110546 0001 Constant 14821 0006
6MWD 0063 0679 0001 6MWD 0055 0709 0001
Age 0250 0530 0001 Heart rate 0076 0223 0015
BMI 0486 0328 0001 Body weight 0061 0157 0041
Body height 0420 0295 0001
Heart rate 0109 0273 0016

Sample size and representativeness of the study

cardiovascular and other non-communicable diseases at the pop-
ulation level. Further studies need to confirm this hypothesis.
The major strength of our study was the use of the portable
gas analyser not only in maximal GXT but also during 6MWT,
which provided us a unique measured data to develop both
maximal and submaximal aerobic prediction models. We also
applied the prediction models into the population-based
Health 2011 Survey data on Finnish adults and created age
and sex-standardized fitness thirds that took into account the
prediction errors (SEE) of the equations. The SEE of predicted
VO2max was similar or somewhat lower than previously
reported accuracy of submaximal field tests based on walking
(Kline et al., 1987; Oja et al., 1991;)
participants
In the criterion-validity study, altogether 75 participants were
included into the statistical analyses of the revised prediction
model of VO2max. Whereas the study sample was small, the
participant characteristics (mean and range) were quite similar
compared to the population sample participating in the PA
and fitness subsample of the national Health 2011 Survey: age
504 years (19–74) versus 505 years (18–74), BMI
269 kg 9 m2 (189–415) versus 265 kg 9 m2 (17–47).
Only the mean 6MWD was about 7% higher in the present
study compared to the PA and fitness subsample: 652 m
versus 609 m.

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd

6MWT: a prediction tool for VO2 max among healthy adults, A. Ma
Table 5 Age and gender-adjusted cardiorespiratory (VO2max, ml kg1min1) fitness percentiles (thirds) predicted from 6-min walk test data in
Health 2011 survey for men (n = 765) and women (n = 887) and differences between standard errors of the estimate (SEE, ml kg1min1).
Gender Age group (years) 333th (ml kg1min1)
Men 18–29 414
30–39 370
40–49 346
50–59 322
60–69 289
Women 18–29 346
30–39 330
40–49 294
50–59 275
60–69 248
SEE for men = 360 ml kg1min1, SEE for women = 351 ml kg1min1.
Walking intensity
The mean walking intensity at end of the 6MWT was 80%
(SD 11%) of the measured VO2max and 83% (8%) of mea-
sured maximal heart rate. The mean walking intensity in the
present study was equal to 80% (5%) of measured VO2max
reported by Kervio et al. (2003) in healthy 60 -to70-year-old
participants and somewhat higher than 73% (12%) reported
by Burr et al. (2011) in healthy 25- to 59-year-old adults. In
the present study, the 6MWT performance was submaximal in
nature and in accordance with the health-related physical
activity recommendation for aerobic exercise corresponding to
the range from 64% to 94% of maximal heart rate (American
College of Sports Medicine, 2006).
Prediction accuracy compared to the previous studies on
field tests of walking
The UKK 2-kilometre and Rockport 1-mile walking tests are
thoroughly validated and widely used field tests. In the devel-
opment study of UKK 2 km, the SEE for VO2max ranged from
9% to 15% and for the Rockport 1-mile test from 12% to
14% (Kline et al., 1987; Oja et al., 1991). In our study, the
SEE ranged from 10% to 11%, showing that 6MWT per-
formed on a 15-m indoor track is at least as accurate as those
established field tests lasting much longer, and in winter time
or in bad weather conditions requiring much longer indoor
facilities. The prediction models accounted for 79% to 81% of
the variance of measured VO2max. Burr et al. (2011) used in
their 6MWT validation study a 20-m track. Their prediction
model explained 72% of the variance of measured VO2max,
but no information on prediction accuracy was provided.
Besides VO2max estimation, we also developed a linear
model for submaximal performance (VO2sub), based on the
last minute average (steady state) oxygen consumption of the
6MWT. Directly assessed VO2 values, both during 6MWT and
in maximal GXT, offered two valid measures of aerobic meta-
bolism. VO2sub reflects the participant’s ability to walk as fast
as possible for 6 min, and VO2max provides a measure of
how much aerobic reserve there is left above that submaximal
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
€ntta
€ri et al. 7
666th (ml kg1min1) (666th–333th) – SEE (ml kg1min1)
446 04
424 +18
399 +18
367 +09
336 +12
384 +03
372 +04
352 +23
323 +13
296 +13
walking performance. Both predictions can be expressed in
metabolic units: in ml kg1min1 or in METs. Kodama et al.
(2009) concluded in their analyses that maximal aerobic
capacity of more than 79 METs was associated with lower
risk of all-cause mortality and cardiovascular events compared
to those with lower maximal aerobic capacity.
Applicability of the 6MWT in population level
Population methods should be feasible to field conditions,
inexpensive and accurate enough to attain valid conclusions
about cardiorespiratory fitness. The 6MWT fulfils most of
those requirements. In countries like Finland, the weather
conditions are often such that outside testing is not possible
all-year-round; thus, indoor facilities are the only possibility.
In terms of feasibility, tracks of 30 m are less feasible than
15 m, especially in healthcare settings, which was an impor-
tant reason to validate the test for the latter.
In our measurement protocol, the only predictor that needs
special equipment and some extra time to complete the test is
heart rate measurement. Contrast to the men’s VO2max pre-
diction model, the heart rate was not a statistically significant
predictor in the women’s equation. Excluding heart rate from
men’s model would reduce the predictive power from 82% to
75% and increase the SEE from 36 to 39 ml kg1min1.
Thus, it seems that to increase feasibility of the test protocol
one might even consider omitting the heart rate measure-
ments in large population studies.
We also applied the prediction model (VO2max) to the popula-
tion data of 6MWT obtained from the PA subsample of Health
2011 Survey. The accuracy of the prediction model was adequate
for population fitness thirds but not for fitness quarters; that is the
prediction errors were bigger than range of one fitness quarter in
ml kg1min1 in many age and gender-specific CRF groups.
Conclusion
In future, the proposed prediction models based on the
6MWT should be cross-validated with new independent sam-
ples of adult. Controlled interventions are needed to reveal the

8 6MWT: a prediction tool for VO2 max among healthy adults, A. Ma
sensitivity of the prediction models in detecting changes in
cardiorespiratory fitness in adult populations.
Acknowledgments
This study was financially supported by the Ministry of Educa-
tion and Culture of Finland. We would like to thank Niina
Mutanen from the Tampere Research Center of Sports
References
American College of Sports Medicine. ACSM’s
Guidelines for Exercise Testing and Prescription 7th
Edition. (2006), pp. 141. Lipincott Williams
& Wilkins, Philadelphia, PA.
Andersson EA, Nilsson J. Can a six-minute
shuttle walk test predict maximal oxygen
uptake? Gazz Med Ital (2011); 3: 163–170.
ATS Committee on Proficiency Standards for
Clinical Pulmonary. Function Laboratories.
ATS statement: guidelines for the six-min-
ute walk test. Am J Respir Crit Care Med
(2002); 1: 111–117.
Balke B, Ware R. An experimental study of
physical fitness of Air Force personnel. US
Armed Forces Med J (1959); 10: 675–688.
Beriault K, Carpentier AC, Gagnon C, et al.
Reproducibility of the 6-minute walk test in
obese adults. Int J Sports Med (2009); 30:
725–727.
Bittner V, Weiner DH, Yusuf S, et al. Predic-
tion of mortality and morbidity with a
6-minute walk test in patients with left ven-
tricular dysfunction. JAMA (1993); 14:
1702–1707.
Borg GA. Psychophysical bases of perceived
exertion. Med Sci Sports Exerc (1982); 5: 377–
381.
Bull FC, Bauman AE. Consistent risk factor
monitoring systems underpins good public
health practice. Prev Med (2008); 2: 154–
155.
Burr JF, Bredin SS, Faktor MD, et al. The 6-
minute walk test as a predictor of objec-
tively measured aerobic fitness in healthy
working-aged adults. Phys Sportsmed (2011);
39: 133–139.
Duncan MJ, Mota J, Carvalho J, et al. An eval-
uation of prediction equations for the
6 minute walk test in healthy European
adults aged 50-85 years. PLoS ONE (2015);
10: e0139629.
Ekblom-Bak E, Hellenius ML, Ekblom O, et al.
Independent associations of physical activity
and cardiovascular fitness with
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
€ntta
€ri et al.
Medicine for her contribution in data collection and The Fin-
nish Defence Forces Sports School for providing the metabolic
analyser for the stress tests.
Conflict of interests
The authors have no conflict of interests.
cardiovascular risk in adults. Eur J Cardiovasc
Prev Rehabil (2010); 2: 175–180.
Giavarina D. Understanding bland altman
analysis. Biochem Med (2015); 25: 141–151.
Epub 2015/06/26. pmid:26110027
Hallal PC, Andersen LB, Bull FC, et al., Global
physical activity levels: surveillance pro-
gress, pitfalls, and prospects. Lancet (2012);
21: 247–257.
Husu P, Suni J, V€ah€a-Ypy€a H, et al. Objec-
tively measured sedentary behavior and
physical activity in a sample of Finnish
adults: a cross-sectional study. BMC Public
Health (2016); 16: 920.
Katzmarzyk PT, Craig CL, Gauvin L. Adipos-
ity, physical fitness and incident diabetes:
the physical activity longitudinal study. Dia-
betologia (2007); 3: 538–544.
Kervio G, Carre F, Ville NS. Reliability and
intensity of the six-minute walk test in
healthy elderly subjects. Med Sci Sports Exerc
(2003); 1: 169–174.
Kline GM, Porcari JP, Hintermeister R, et al.
Estimation of VO2max from a one-mile
track walk, gender, age, and body weight.
Med Sci Sports Exerc (1987); 3: 253–
259.
Kodama S, Saito K, Tanaka S, et al. Cardiores-
piratory fitness as a quantitative predictor of
all-cause mortality and cardiovascular events
in healthy men and women: a meta-analy-
sis. JAMA (2009); 19: 2024–2035.
Koskinen S, Lundqvist A, Ristiluoma N. (eds).
Health, functional capacity and welfare in
Finland in 2011. National Institute for
Health and Welfare (THL), Report 68/
2012. 290 pages. Helsinki (2012). Helsinki
2012 ISBN 978-952-245-769-1 (online
publication) http://urn.fi/ URN:ISBN:978-
952-245-769-1.
LaMonte MJ, Blair SN. Physical activity, car-
diorespiratory fitness, and adiposity: contri-
butions to disease risk. Curr Opin Clin Nutr
Metab Care (2006); 5: 540–546.
Lee CD, Jae SY, Iribarren C, et al. Physical fit-
ness and carotid atherosclerosis in men. Int J
Sports Med (2009); 9: 672–676.
Lipkin DP, Scrivin AJ, Crake T, et al. Six min-
ute walking test for assessing exercise
capacity in chronic heart failure. BMJ
(1986); 292: 653–655.
Malmberg JJ, Miilunpalo SI, Vuori IM, et al. A
health-related fitness and functional perfor-
mance test battery for middle-aged and
older adults: feasibility and health-related
content validity. Arch Phys Med Rehabil
(2002); 83: 666–677.
M€antt€ari A, Suni J, Husu P, et al. Prediction of
peak oxygen uptake from 6MWT. 21. Puijo
Symposium (2011), Kuopio, Finland.
Oja P, Laukkanen R, Pasanen M, et al. A 2-km
walking test for assessing the cardiorespira-
tory fitness of healthy adults. Int J Sports Med
(1991); 4: 356–362.
Rosdahl H, Gullstrand L, Salier-Eriksson J, et al.
Evaluation of the oxycon mobile metabolic
system against the Douglas bag method. Eur J
Appl Physiol (2010); 2: 159–171.
Rostagno C, Gensini GF. Six minute walk test:
a simple and useful test to evaluate func-
tional capacity in patients with heart failure.
Intern Emerg Med (2008); 3: 205–212. Epub
2008 Feb 26.
Stevens D, Elpern E, Sharma K, et al. Compar-
ison of hallway and treadmill six-minute
walk tests. Am J Respir Crit Care Med (1999);
160: 1540–1543.
Suni JH, Miilunpalo SI, Asikainen T-M, et al.
Safety and feasibility of a health-related fit-
ness test battery for adults. Phys Ther (1998);
78: 134–148.
Troosters T, Gosselink R, Decramer M. Six
minute walking distance in healthy elderly
subjects. Eur Respir J (1999); 14: 270–274.
Van der Walt WH, Wyndham CH. An equa-
tion for prediction of energy expenditure of
walking and running. J Appl Physiol (1973);
5: 559–563.