Disability & Rehabilitation, 2012; Early Online: 1–5

© 2012 Informa UK, Ltd.

ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2012.726313

RESEARCH PAPER

Reference values for the 6-Min Walking Test in obese subjects

Paolo Capodaglio1, Shirley A. De Souza2, Cinzia Parisio1, Helmer Precilios1, Luca Vismara1,
Veronica Cimolin1,3 & Amelia Brunani1
1Rehabilitation Unit and Laboratory of Research in Biomechanics and Rehabilitation, S Giuseppe Hospital, Istituto

Auxologico Italiano IRCCS, Verbania-Piancavallo, Italy, 2Department of Physiotherapy, Hospital Universitario de Londrina,
Disabil Rehabil Downloaded from informahealthcare.com by Dip di Bioingegneria - Bib on 10/15/12

Londrina State University, Londrina, Paraná, Brazil, and 3Department of Bioengineering, Politecnico di Milano, Milan, Italy

Purpose: The 6-Min Walking Test (6MWT) is widely used to
measure the performance in various chronic conditions, such as
in obese subjects. Reference equations for predicting distance
walked during 6MWT specifically in adult obese subjects are
not available. The aim of the paper is to establish reference
values for 6MWT in an adult obese population. Methods: 323
obese patients (body mass index: BMI > 30 kg/m2, age range
For personal use only.
Implications for Rehabilitation
r
The 6-Min Walking Test (6MWT) is generally used
to measure functional capacity in various chronic
conditions.
r
Obesity is associated with reduced aerobic capacity
and mobility disability but no reference equations for

20–60 years) admitted to our hospital for multidisciplinary
rehabilitation and weight reduction programs were evaluated
using 6MWT, heart rate, blood pressure, oxygen saturation,
anthropometric measurements and level of dyspnoea were
considered as outcome measure. Results:: Distance walked during
the 6MWT was significantly correlated to age, gender and BMI.
The proposed reference equation is: 6MWTm = 894.2177 −
(2.0700 × ageyrs) − (51.4489 × gendermales = 0; females = 1) − 5.1663
× BMIKg/m2. In the multiple linear regression analysis age, gender
and BMI explained 48% of the total variance in 6MWT. The
average difference between predicted and measured 6MWT
values (11.33 ± 52.98 m) did not reach statistical significance
and the correlation was significant (r = 0.698). Conclusions:
Conclusions
A reference equation specific for the obese population
was provided; it can be used as realistic benchmark in the
rehabilitation setting to assess functional capacity, plan exercise
intensity and monitor changes over time.
Keywords: 6-Min Walking Test, body mass index, exercise,
obesity, performance
Introduction
The ability to walk for a distance is a quick and inexpensive
measure of physical function, and an important component of
quality of life, since it reflects the capacity to undertake day-to-
day activities. Since the introduction of the 12-min walking test
predicting distance walked during 6MWT are present.
r
This study provides reference values specific for the
obese population.
by McGavin et al. [1], timed walk tests have become popular
outcome measures to assess “functional” exercise tolerance in
patients with chronic cardiopulmonary disease [2,3]. Timed
walk tests have enjoyed widespread clinical application
because of their convenience of administration, their closer
similarity to activities of daily living than tests of maximal
exercise capacity, and the lack of need for sophisticated
equipment [2]. The 6-Min Walking Test (6MWT) can
be performed by many elderly, frail, and severely limited
patients who cannot be tested with maximal cycle ergometer
or treadmill exercise tests. The test was originally developed
to evaluate the functional capacity, monitor the effectiveness
of several treatments and establish the prognosis of patients
with chronic diseases [4]. In 2002, the American Thoracic
Society endorsed and published guidelines for performing
the 6MWT in clinical settings, also considering the impact of
factors such as gender, height, age, length of the walkway on
the distance walked [5]. Reference values for prediction of the
distance walked during the 6MWT for healthy populations
of different age range have been published [4,5]. Some of
these reference values were obtained before the publication
of the consensus of the American Thoracic Society, which

Correspondence: Veronica Cimolin, PhD, Department of Bioengineering, Politecnico di Milano, p.zza Leonardo Da Vinci 32, 20133 Milano, Italy.
E-mail: veronica.cimolin@polimi.it
(Accepted August 2012)

1
 2 P. Capodaglio et al.
partly justifies the variability of results within the same age
range. Another possible source of variability is geographical:
Casanova et al. [6], have investigated geographical differences
between seven countries in 6MWT distance predicted values
in subjects aged 40–80 years with an average body mass
index (BMI) of 27 kg/m2. Independent of the standardization
technique, they found large differences in distance predicted,
probably due to different speed of habitual walking or cultural
aspects related to lifestyle. Age-specific reference nomograms
for male and female adult subjects independent of the region
of the world have been proposed by the authors. Several
demographic, anthropometric and physiological factors, as
well as external factors such as effort perceived and motivation
[7], can influence the test both in healthy individuals and in
patients with chronic diseases.
The 6MWT has been used to assess patients with various
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conditions including: obstructive lung disease, heart failure,
arthritis, neuromuscular diseases, fibromyalgia, cerebrovas-
cular accident, amputations, morbid obesity, Down’s syn-
drome, Alzheimer’s disease and cerebral palsy [4,8,9]. The
distance walked is known to be reduced by all these condi-
tions. Enright et al. [10] used the 6MWT in a sample of adults
>68 years old to measure the impact of multiple comorbidi-
ties on performance capacity and found that expected values
should be adjusted for age, gender, height and weight. Still,
geographical and ethnical differences among elderly samples
have been reported [10–12].
For personal use only.
Previous studies [2,7] have shown that 6MWT is repro-
ducible in obese subjects, suggesting that it can be used to
evaluate their “global” function. The use of 6MWT as an
outcome assessment tool has been extended to patients with
chronic obstructive pulmonary disease after pulmonary reha-
bilitation, patients awaiting thoracic organ transplantation
and lung volume reduction procedures, patients with chronic
congestive heart failure and morbidly obese patients after bar-
iatric surgery [13–16]. De Souza et al. [14] and Maniscalco et
al. [15] found an increase in the distance walked after BMI
reduction secondary to bariatric surgery. Rasekaba et al. [16]
have suggested that distance improvement of 70–170 m (+12–
40%) can be considered clinically significant and represent a
noticeable change of functional capacity.
However, the erroneous choice of a reference equation
can result in misinterpretation of level of physical fitness or
improvement of physical performance after interventions.
The 6MWT appears useful for measuring pre- and post-inter-
vention changes in functional status in the clinical setting, but
considerable caution is needed when using currently available
reference equations to determine if a given patient’s test results
are normal or low. In obese subjects, the relative reduction of
skeletal muscle strength [17], the reduced cardio-pulmonary
capacity and tolerance to effort [18,19], the higher metabolic
costs and, therefore, the increased inefficiency of gait [20]
together with the increased prevalence of co-morbid condi-
tions might interfere with walking. Gait might also be limited
by pain from overloaded joints and relatively weak muscles
[21–23]. Obese subjects therefore tend to walk slower, are
more exerted and complain more frequently of dyspnoea
and musculoskeletal pain while walking [13]. Hulens et al.
[13] investigated the magnitude of differences in walking
capacity between obese and non-obese women. They found
that a range of variables influence walking capacity in obese
subjects and 75% of the variance in walking performance was
explained by the combination of the following variables: BMI,
peak aerobic capacity, knee extension torque, age, hours of
TV viewing. According to these authors, BMI was the most
important factor explaining 59% of the variance by itself.
Predictive equations considering age, gender, weight and
height have been proposed for clinical use [11,12,24,25].
Although the inclusion of other parameters correlated with
the results of walking test would results in an increased
prediction capacity of the equation, its clinical applicability
would likely be hindered. According to the predictive equa-
tions from the literature, obese subjects consistently show a
deficit in distance walked and in work exerted for walking
when compared with normal-weight subjects [2]. Reference
values obtained from healthy, normal-weight populations
would therefore predictably underline the reduced perfor-
mance capacity of obese individuals. Instead, reference val-
ues specific for this population would serve as benchmark to
assess baseline functional capacity, prescribe proper and safe
exercise intensity and monitor changes after rehabilitation
interventions.
The aim of this study was therefore to develop a reference
equation for predicting distance walked in 6 min specifically
in adult obese subjects to be used in the clinical practice and
compare it with the equations proposed in the literature.
Methods and procedures
Participants
The study group consisted of 323 patients with BMI over
30 kg/m2 and between 20 and 60 years of age admitted to
the San Giuseppe Hospital, Istituto Auxologico Italiano, in
Piancavallo (Italy) for multidisciplinary rehabilitation and
weight reduction programs. The study was approved by the
Ethics Research Committee of the Institute. Written informed
consent was obtained by all of the patients. Data from each
participant included age, gender, height, weight, smoking his-
tory, medication use, medical history, physical examination.
One of the requirements for participating in the study was a
score over the cut-off value of 24 in the Mini Mental State
Examination (MMSE) Italian version [26]. Scores over the
MMSE cut-off suggest the absence of widespread acquired
cognitive disorders in adult people. Our patients were all able
to understand and complete the testing. Exclusion criteria
included cardiac arrhythmia, unstable angina, myocardial
infarction, major respiratory conditions, orthopaedic and
neurological conditions that could cause gait abnormality and
bias the results of this study.
6-Min Walking Test
The 6MWT was performed for all participants. Subjects
were instructed to walk as fast as they could along an even,
undisturbed 30-m hospital corridor marked every 5 m; the
operator used a lap counter system and the complete distance
walked during 6 min was measured using a tape measure
Disability & Rehabilitation

from the nearest marker with coloured tape on the floor
[3,5]. Encouragement was given every minute during the test
until subject exhaustion using only standardized phrases as
specified in the “ATS Statement: Guidelines for the Six-minute
Walk Test” [5]. Chest pain, severe dyspnoea, physical exhaus-
tion, muscle cramps, sudden gait instability or other signs of
severe distress were additional criteria for stopping the test
[5]. The subject’s pulse, respiratory rate, blood pressure and
perceived fatigue as assessed on the Borg’s scale [27] were
measured before the test and at test completion. The distance
covered in 6 min by each subject was used as variable for the
analysis.
Data analysis
Data are reported as group mean ± standard deviation. Mann-
Whitney U tests was used to compare 6MWT across age and
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6-Min Walking Test in obesity 3
The second sub-group was used to compare the 6MWT
values predicted by the equation in the present study with the
6MWT values actually measured and so to evaluate the reli-
ability of our 6MWT reference equation. Wilcoxon’s signed-
rank test was used to test the difference between the predicted
and measured 6MWT values and Spearman’s correlation (r)
was calculated. Agreement between the predicted values with
the proposed equation and values predicted with the Bland
and Altman method [28] including the correlation between
differences (values predicted with the proposed equation and
values predicted with the equations proposed in the literature)
and average (average of values predicted with the proposed
equation and values predicted with the equations proposed in
the literature) was computed.
Statistical significance was set at p < 0.05. Data were anal-
ysed using the SPSS for Windows 10.0 (SPSS Inc., 1989–1999)

BMI in men and women. The sample group was randomly
divided in two sub-groups: a validation sub-group which
entailed 70% (227 individuals) of sample and a cross validation
sub-group, which included 30% (96 individuals) of the sample.
The groups were matched for general characteristics (age,
BMI, height) and walked distance during the 6MWT. With the
proposed sample sizes the study will have a power of 93%.
Firstly, the Mann-Whitney U-test was used for comparing
the characteristics of the two sub-groups of obese participants.
The first sub-group was used to develop the model for pre-
dicting 6MWT values. The predicting model was constructed
For personal use only.
statistical software package.
Results
The clinical characteristics of the two sub-groups are reported
in Table I, distinguishing between the two sub-groups. Firstly,
the general characteristics (age, BMI, weight) and the distance
walked during the 6MWT were compared and no statistical
differences were found.
As for the first sub-groups, the mean walking distance
measured was 563.60 m (SD = 62.32 m). Distance was sig-

using a multiple linear regression model and predictor fac- nificantly correlated to age (r = −0.36, p < 0.001), gender
tors that were significantly and independently associated with (r = −0.34, p < 0.001) and BMI (r = −0.49, p < 0.001).
6MWT, using Spearman’s correlation, were included. There was no significant difference between males and
females in terms of age and BMI. Distance walked during the
6MWT was significantly greater in males (591.42 m; SD =
Table I. General characteristics of the two sub-groups. 62.07 m) than in females (546.83 m; SD = 56.37 m) (p < 0.05).
Whole sample number (%) In the multiple linear regression analysis age, gender and
First sub-group Second sub-group BMI were selected as predictors of 6MWT. These three vari-
Variable (n = 227) (n = 96) ables explained 48% of the total variance in 6MWT (Table II).
Gender Therefore, the proposed reference equation is:
Female 141 (62%) 53 (55%) 6MWTm = 894.2177 − (2.0700 × ageyrs) − (51.4489 ×
Male 86 (38%) 43 (45%) gendermales = 0; females = 1) − 5.1663 × BMIKg/m2 ; r2 = 0.48
Age (years)
(SEM = 45.186 m).
Mean (SD) 35.93 (11.11) 39.14 (11.39)
From the second sub-group of obese subjects (96 subjects),
Range 20–60 20.69–59
we calculated the predicted values for the 6MWT using the
BMI (kg/m2)
regression equation proposed in the present study. The aver-
Mean (SD) 43.39 (5.33) 43.87 (5.23) age difference between predicted and measured 6MWT values
Range 30.34–58.43 33.58–58.06 (11.33 m; SD = 52.98 m) did not reach statistical significance
Weight (kg) (p = 0.65) (Figure 1) and the correlation was significant
Mean (SD) 121.13 (20.42) 122.29 (19.18) (r = 0.698; p < 0.05).
Range 70.1–194.0 88.7–171.9 Considering the whole group of obese subjects (n = 323)
BMI, Body mass index.
we compared the distance predicted by the equation proposed

Table II. Predictive model for the total distance walked in the 6MWT.
95% confidence interval
Variable Coefficient SEM p −95% +95%
Constant 894.2177 26.38269 <0.001 842.2252 946.2103
Age (years) −2.0700 0.27365 <0.001 −2.6093 −1.5307
Gender −51.4489 6.23507 <0.001 −63.7364 −39.1614
BMI (kg/m2) −5.1663 0.56828 <0.001 −6.2862 −4.0463
Gender factor: males = 0; females = 1.6MWT, 6-Min Walking Test; BMI, body mass index; SEM, standard error of the estimate.

©  Informa UK, Ltd.

 4 P. Capodaglio et al.
in the present study with those obtained by the equations in
the literature [11,12,24,25] (Table III). Significant differences
were evident in the comparison between distance predicted
by our equation and the existing equations in the literature,
except Enright’s equation. This result was confirmed also by
the Bland and Altman analysis which showed a strong cor-
relation (r = −0.82; p < 0.05) between the values predicted
with equation proposed in this study and those predicted with
Enright’s equation.
Discussion
The assessment of an individual’s response to submaximal
exercise is an important clinical tool, as it provides a global
assessment of the respiratory, cardiac and metabolic systems
undergoing everyday exercise intensities. The 6MWT is a
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practical, simple and inexpensive test and for such reasons
often considered the first choice among several modalities for
objective evaluation of tolerance to exercise. However, refer-
ence values from normal-weight healthy populations are of
limited value in the obese population. In those subjects physi-
ological factors (reduced muscle strength, reduced tolerance
to effort, higher metabolic costs of gait) together with the
increased prevalence of co-morbid conditions are responsible
for consistently shorter distance walked. This study aimed
at developing a reference equation for predicting distance
walked during the 6MWT specifically in obese adults that
For personal use only.
would serve as realistic benchmark for assessing their func-
tional capacity.
Several studies have already highlighted the correlations
between distance walked in 6 min and factors as age, gender,
Figure 1. Measured and predicted 6MWT distance (m) in the second
sub-group of participants (n = 96). Data are reported as mean +standard
deviation.
Table III. Comparison between predicted 6MWT distance using different equations in the whole group of participants (n = 323).
Equation Predicted 6MWT (m)
Proposed 561.98 ± 44.99
Gibbons et al. [25] 713.88 ± 48.98
Enrigth et al. [11] 561.12 ± 82.79a
Troosters et al. [12] 663.92 ± 75.40
Chetta et al. [24] 600.01 ± 44.23
Data are reported as mean ± standard deviation.aAverage value between the Enright’s two gender-specific equations.6MWT, 6-Min Walking Test.
height and BMI [11,12,24,25]. In our study, age, BMI and
gender significantly affected test results. In line with previous
findings [11,12,24,25], the distance walked was significantly
greater in males than females. Multiple linear regression
analysis of our data served to develop a new predictive model
including the three variables affecting test results. The equa-
tion proposed in this study explained 44.6% of the variation
in 6MWT results. The predicted values were not statistically
different from the actual 6MWT values measured in another
group of obese subjects (n = 89). Similar comparisons using
different equations proposed in the literature showed sta-
tistically significant differences with the distance measured
in our whole study sample, except for Enright’s equation.
Gibbons’s formula [25] had been calculated from a popula-
tion of healthy subjects aged 20–80 years and did not include
body weight among the variables. Since body weight and BMI
are major determinants of performance in obese subjects, the
exclusion of this variable could account for the differences
reported. Enright et al. [11] found that age, body weight/BMI,
and height (for men) were independently associated with the
distance walked during 6MWT. Enright’s equation had been
calculated from a sample of healthy subjects aged 40–80 years.
About 60% of the variance in 6MWT distance remains unex-
plained by his gender-specific models. Enright’s equations
were originally validated for BMI <35 kg/m2 and therefore,
although they have been used in clinical practice on subjects
with different BMI, the conversion factors in the formula are
not reliable. Troosters et al. [12] observed that age, height,
weight and gender explained 66% of the variance in 6MWT
distance in a small Belgian population.
From a mathematical point of view, the correlation with
the distance covered in 6 min would certainly benefit from the
inclusion of several other factors in the predictive formula, as
already suggested by Hulens et al. [13]. Among the predictors
of the distance walked, other physiological (heart rate, oxy-
gen saturation, blood pressure, muscle strength) and life style
(physical activity levels) factors may well play a role, but their
inclusion in an equation appears unpractical for clinical use.
Such considerations might also in part explain why no refer-
ence values for the obese population are available.
Our choice of including BMI in a simple 3-variable equa-
tion, instead of taking into consideration a wider range of
parameters, is based on the idea that weight/BMI represents
the core measurement in the assessment of performance in
obese subjects.
Pre- and post-assessments after combined weight man-
agement-reconditioning-resistance training interventions in
those subjects revolve around the main expected outcome of
Difference (predicted – measured) (m) p value (vs equation proposed)
3.38 ± 47.64 –
155.27 ± 56.86 p < 0.0001
2.51 ± 64.35 p < 0.912
105.32 ± 61.67 p < 0.0001
41.40 ± 54.62 p < 0.0001
Disability & Rehabilitation

weight loss. The expected functional correlate is an increase
in the distance walked secondary to weight loss. However, if
co-morbid disabling conditions are present, distance might
not necessarily increase after intervention, as expected on the
basis of weight loss solely. Or else, if weight loss is accompa-
nied by improved tolerance to effort after aerobic condition-
ing, the formula may underestimate the real performance.
In our opinion, the advantages of the predictive equation
proposed in this paper are: (i) to have been developed from
a reference population of subjects with BMI >35 kg/m2; (ii)
to be simple and applicable in daily clinical practice; (iii)
to quantify changes in performance related to BMI. As for
the latter, such reference values might help discriminating
whether reduced functional capacity is secondary to co-
morbid conditions. This would help optimizing rehabilitation
planning within safe individual capacity limits. In fact, physi-
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cal exercise programs should be prescribed according to the
individual’s exercise capacity and the co-morbid conditions
interfering with walking.
From a clinical perspective, walking is a key task for weight
reduction programs. The latter play a crucial role in all reha-
bilitation programs for obesity and related disabling condi-
tions, since BMI remains the main independent predictor of
functional capacity in those patients [13]. The obesity-related
disability appears mainly related to mobility impairment [29].
Performance tests, such as 6MWT, can unveil the limitations
in cardio-respiratory and motor functions underlying the
For personal use only.
obesity-related disability. Whereas the existing 6MWT refer-
ence values indicate the reduced functional reserve in obese
subjects, specific reference values will have the advantage of
providing a benchmark for functional capacity assessment
and changes monitoring after rehabilitation or bariatric
surgery. Besides that, our predictive formula can define the
contribution of BMI to the obesity-related disability and its
functional recovery.
Declaration of Interest: The authors report no conflicts of
interest.
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