International J.

of Healthcare & Biomedical Research, Volume: 1, Issue: 3, April 2013, Pages 217-226

Six minute walk distance: Correlation with spirometric & clinical parameters in chronic
obstructive pulmonary disease
1Dr.
5Dr.

Manoj Kumar Khandelwal , 2Dr. V.D. Maheshwari, 3Dr. Sumeet Garg , 4Dr. Kamlesh Kumar,
Reshu Gupta , 6Dr.Shikha Khandelwal

1P.G.

3rd year Resident (Dept. Of Medicine) , Mahatma Gandhi Medical College & Hospital
Jaipur (Rajasthan), India
2Prof. & Head , Dept. Of Medicine , Mahatma Gandhi Medical College & Hospital
Jaipur (Rajasthan) , India
3P.G. 3rd year Resident (Dept. Of Medicine) , Mahatma Gandhi Medical College & Hospital
Jaipur (Rajasthan),India
4P.G. 3rd year Resident (Dept. Of Medicine) , Mahatma Gandhi Medical College & Hospital
Jaipur (Rajasthan),India
5Assistant Professor (Physiology) , Mahatma Gandhi Medical College & Hospital
Jaipur (Rajasthan),India
6Senior Resident, Jaipur (Rajasthan) , India
Corresponding author: Dr. Manoj Kumar Khandelwal ; E-mail: reshugpt@gmail.com
.....................................................................................................................................................................................................................................................................
ABSTRACT
Background: Six minute walk test (6MWT) is used as an indicator of the functional capacity in patients with cardiopulmonary
diseases. This study was designed to assess the correlation of six minute walk distance (6MWD) with spirometric parameters and
various clinical parameters in COPD patients.

Method: A cross sectional study was carried out in 65 COPD patients reporting to the OPD or admitted in the wards. Their severity
was assessed by dyspnoea (MMRC grade), GOLD criteria and additionally other spirometric indices like peak expiratory flow rate
(PEFR), forced expiratory flow (FEF25-75%) and was correlated with 6MWD.
Results: The 6MWD negatively correlated to breathlessness (MMRC grade) (P<0.05). There was statistically significant association
between 6MWD to all spirometry parameters like forced expiratory volume in one second (FEV1 % predicted) , forced vital capacity
(FVC % predicted) , PEFR % predicted ,FEV1/FVC, FEF(25%-75%) % predicted, FEV1(L) ,FVC(L) , PEFR(L), FEF(25%-75%)(L/s) (p
<0.05). The different GOLD stages were found to have positive correlation to 6MWD (P<0.05). The 6MWD correlated positively to
weight, BMI (P<0.05), but not to the height and age. Despite advance GOLD staging (III, IV) seven patients managed to walk more
than 300 meters.
Conclusion: 6MWT is simple and safe test. In our study overall 6MWD had linear relationship with FEV1, FVC, FEV1/FVC, PEFR,
grading of dyspnea and GOLD stages. In conclusion, in COPD patients 6MWT is a useful test to assess severity of disease.
Key words: Chronic obstructive pulmonary disease, Six Minutes Walk Test, Spirometry
......................................................................................................................................................................................................................

INTRODUCTION:

2.7 lac deaths every year in India, hitherto it is under

Chronic obstructive pulmonary disease (COPD) is a

diagnosed. It is now recognized in 4-10 per cent of adult

growing worldwide public health problem. COPD is a

male population of India and several other Asian

major cause of mortality and morbidity globally.

countries. In Asian countries COPD prevalence is

Millions of people suffer from this disease for years and

estimated 6.3 per cent with a range from 3.5 to 6.7%.

die prematurely by its complications(1). COPD causes

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In a large, multi-centric study from India, the

the study.

population prevalence of COPD was 4.1 per cent, with

The diagnosis and staging were made on the basis of

a male to female ratio of 1.56:1. Almost all forms of

spirometric criteria.

smoking products are significantly associated with

All these cases were subjected to:

COPD. In non-smokers,

especially women,

an

Interrogation regarding symptomatology,

exposure to biomass fuels is an important factor (2).

smoking habits and risk factors of COPD patient

According to GOLD international COPD guidelines

as per pre designed Proforma.

(3), spirometry is the gold standard for accurate and

Physical examination both general and systemic

repeatable measurement of lung function. Spirometry

was done with specific emphasis on respiratory

is however only one way of interpreting COPD disease

system

severity. Other measures, such as the MMRC dyspnoea

All routine investigations CBC, ESR, Chest X

scale for measuring breathlessness, exacerbation

ray, spirometry, sputum examination were done

frequency, body mass index, quality of life assessment,

for diagnosis of COPD or to exclude the

and exercise capacity all help to build a more complete

diagnosis of other diseases.

1. Inclusion criteria:

picture.
Quantitative assessment of symptoms like
dyspnoea, measurement of PEFR and exercise test like
6-minute walk test (6-MWT), which are cheaper modes

a. Diagnosis of COPD (GOLD criteria)

b. Age 40.
2. Exclusion criteria:

of diagnosis, can be considered to substitute the

a. Asthma and respiratory failure

spirometry at places where it is not available. Recently,

b. Domiciliary oxygen therapy and non invasive

ventilation.

guidelines developed under the WHO-Govt. of India

c. Diseases (eg, lung cancer, pulmonary

committee group also suggest that if spirometry is not

available then both staging of the disease and follow up

tuberculosis, unstable angina, CHF, any other

of patient can be done on the basis of severity of

disease limiting patients movement.)

symptoms, PEFR and 6 MWT (4).Therefore this study

d. Acute exacerbation of COPD.

aims to find out correlation of Six Minutes Walk Test

e. Patients with active neurological,

rheumatological or peripheral vascular diseases.

with Spirometric and Clinical parameters in COPD

f.

patients.

Patients with elevated systolic blood pressure

more than 180 mm Hg.

MATERIAL AND METHODS

A cross sectional study was carried out in COPD

Six minute walk test

patients at Mahatma Gandhi Medical College &

At the time of test, the patients heart rate, blood pressure

Hospital Sitapura, Jaipur. A total of 65 patients were

and oxygen saturation were measured. The 6MWT was

included in the study, reporting to the OPD or admitted

performed according to the ATS guidelines (5). Subjects

in the wards. . The purpose of the study was explained

were asked to walk at their own pace, along a 30 m long

to the patients and written consent was obtained

and straight hospital hallway marked at intervals of one

thereof. Institutional ethical clearance was obtained for

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International J. of Healthcare & Biomedical Research, Volume: 1, Issue: 3, April 2013, Pages 217-226
meter each.. Each patient was instructed to walk as
much

distance

as

possible

in

minutes.

Pulmonary Function Test

No

Patients

with

definite

respiratory

diagnosis

encouragement was offered, but the patient was told

underwent a pulmonary function test, using standard

standardized phrase to indicate the time remaining. The

protocol. Spirometric indices including FEV 1, FVC,

patient was allowed to stop if symptoms of significant

FEV1/FVC and peak expiratory flow rate, FEF25-75% were

distress occurred, like severe dyspnea, chest pain,

tested using computerized spirometer (ndd Medizintechnik

dizziness, diaphoresis, or leg cramps. However, the

AG). Reproducibility was ensured by doing at least three

patient was asked to resume walking as soon as

measurements for each lung function.

possible, if he or she could. At the end of six minutes,

Statistical Analysis

the patient was asked to stop and a repeated

Statistical analysis was performed using SPSS

measurement of blood pressure, heart rate, oxygen

software. The data were reported as mean standard

saturation by pulse oximeter , were measured and the

deviation (SD). The absolute (6MWD) in meters was

distance walked for 6 minutes was recorded. The

used. The correlation between 6MWD and the patients

patients were asked to be observed for a 10-15 minutes

demographic features and pulmonary function test

period

possible

measurements, were evaluated using Pearson's coefficient.

complications. Patients who started to walk but did not

One way analysis of variance was used to study the

complete the test, were included in the study.

relationship between the 6MWD results and the severity

after

the

test,

to

assess

any

of COPD stages based on the measured FEV1. The criteria

for statistical significance was set to be P <0.05.
RESULTS
Table No. 1: Distribution of number and percentage of patients according to age & gender

Age group

Male (%)

Female (%)

Total (%)

40-49

10 (15.38)

4(6.15)

14(21.53)

50-59

10(15.38)

7(10.76)

17(26.15)

60-69

21(32.30)

3(4.61)

24(36.92)

70-79

4(6.15)

2(3.07)

6(9.23)

80

3(4.61)

1(1.53)

4(6.15)

Total

48(73.84)

17(26.15)

65(100)

(In yrs)

Perusal of table 1 shows that out of 65 COPD patients, 48 (73.84%) were males and 17 (26.15%) were
females.

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International J. of Healthcare & Biomedical Research, Volume: 1, Issue: 3, April 2013, Pages 217-226

Table No. 2: Distribution of number and percentage of patients according to GOLD stages &
subgroups of 6 MWD (meters)
6MWD

II

III

IV

Total

(Meters)

(%)

(%)

(%)

(%)

(%)

101-200

1(5.55)

1(3.57)

1(6.66)

3(4.61)

201-300

4(22.22)

10(35.71)

7(46.66)

21(32.30)

301-400

1(25)

6(33.33)

13(46.42)

6(40)

26(40)

401

3(75)

7(38.88)

4(14.28)

1(6.66)

15(23.07)

Total (%)

4(100)

18(100)

28(100)

15(100)

65(100)

In stage I and II, 5 patients could walk less than 300 meters while in stage III and IV, 7 patients walked
more than 300 meters. It signifies that we cant apply 6MWD universally for the grading , therefore
interpretation should be individualized. Moreover 7 patients in stage III, IV with good walking capacity
(>300 meters) were likely to have better quality of life and prognosis.

Table No 3 : Correlation between 6MWD and Patients parameters

Range

MeanSD

R(correlation

coefficient)
Age(Years)

40-86

58.8310.83

0.21

>0.5

Weight (Kg)

35-81

54.3112.97

0.32

<0.5

Height (Meters)

1.39-1.75

1.60.07

-0.06

>0.5

BMI (Kg/M )

12.55-32.89

21.205.15

0.33

<0.5

Breathlessness

1-4

3.050.84

-0.42

<0.5

(MMRC grade)

The mean 6MWD was 334.46 69.69 meters (range 180-470 m) and correlated positively to
weight, BMI and negatively correlated to breathlessness (MMRC grade) (P<0.05). (Table no 3).

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Table no 4 : Correlation between 6MWD and Spirometry parameters

Range

MeanSD

R(correlation

coefficient)
FEV1

12 98

44.94 19.31

0.56

<0.05

18 108

60.35 21.94

0.42

<0.05

10 66

35.72 13.87

0.74

<0.05

FEV1/FVC

0.31 - 0.69

0.55 0.9

0.46

<0.05

FEF(25%-75%)

5 64

24.80 12.61

0.46

<0.05

FEV1(L)

0.13 - 2.3

1.12 0.44

0.43

<0.05

FVC(L)

0.28 - 3.5

2.03 0.71

0.33

<0.05

PEF(L/s)

0.43 - 5.29

2.67 1.05

0.52

<0.05

FEF(25%-75%) (L/s)

0.07 - 1.53

0.64 0.33

0.31

<0.05

(% predicted)
FVC
(% predicted)
PEFR
(% predicted)

(% predicted)

The mean 6MWD was 334.46 69.69 meters (range 180-470 m) and correlated positively to all
spirometry parameters FEV1 % predicted, FVC % predicted, PEFR % predicted, FEV1/FVC, FEF(25%-75%)
% predicted, FEV1(L), FVC(L), PEFR(L), FEF(25%-75%)(L/s) (p <0.05). (Table No 4)
Table no 5 : Comparison between six minute walk distance (6MWD) and the severity of COPD

GOLD Stages

Number

(MeanSD)6MWD

>80

427.543.49 meters

II (MODERATE)

50-80

18

366.1173.01 meters

III (SEVERE)

30-50

28

319.6461.19 meters

<30

15

299.3350.77 meters

I (MILD)

IV (VERY SEVERE)

FEV1 (%predicted)

F-Ratio=6.734 P<0.05

The different GOLD stages has positive correlation to 6MWD (P<0.05).(Table no 5)

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DISCUSSION

dyspnoea as a sense of increased effort to breathe,

Chronic Obstructive Pulmonary Disease (COPD)

heaviness, air hunger or gasping. However, the terms used

: The chronic airflow limitations characteristic of

to describe dyspnea vary both by individual and by culture.

COPD is caused by a mixture of small airway

In clinical practice, the MMRC grade remains the

disease (obstructive bronchiolitis) and parenchymal

commonest scale used because of its simplicity, ease of

destruction (emphysema).

causes

administration and established validation as a useful marker

extrapulmonary

in COPD. It predicts the likelihood of 3survival of patients

numerous

COPD also

significant

manifestations. These include reduced physical

with COPD (28).

activity, cardiovascular diseases,

loss,

Correlation of Spirometry indices and 6MWD :The

depression and anemia, and they have an enormous

standard spirometry manoeuvre is a maximal forced

impact on the severity, morbidity and mortality of

exhalation (greatest effort possible) after a maximum deep

COPD (6-9).

inspiration (completely full lungs). Several indices can be

6 Minute Walk Test (6MWT):

derived from this blow.

weight

6MWT evaluates the integrated responses of all

Forced Vital Capacity (FVC) and forced

including the respiratory system, cardiovascular

Expiratory Volume in One Second (FEV1 )

systems, blood, neuromusculoskeletal system, and

Present study demonstrate positive correlation

muscle metabolism.

between 6MWD and FVC as well as FEV1 (Table

COPD is associated with loss of muscle mass and

No.4).This results were similar to other studies

muscle weakness and finally results in the

Hatem FS Al Ameri

degression of the exercise tolerance (10). Exercise

A et al (31).

tolerance is determinant of patients quality of life

(29)

,Naghshin R et al(30),Mehta

FEV1 /FVC Present study demonstrate positive

and predicts the prognosis. The 6MWT is easy to

correlation between 6MWD and FEV1/FVC (Table

administer, economic, better tolerated, and more

No.4), also demonstrated same result by Chulmsky

reflective of activities of daily life. It may be widely

et al (32).

used to evaluate the exercise tolerance in patients

with heart or lung disease (11).

Forced expiratory flow at 25% to 75% vital

capacity (FEF25-75): FEF25-75% has a wide range of

6MWT is best used to determine the

normality, is less reproducible than FEV1, and is

response the treatment in heart or lung disease (12-

difficult to interpret if the VC (or FVC) is reduced

23). The 6MWT has also been used as a one-time

or increased." Although present study demonstrate

measure of functional status of patients, as well as a

positive correlation between 6MWD and FEF25-

predictor of morbidity and mortality of patients of

75%(Table

COPD and heart failure (24-27).

No.4).

Peaked Expiratory Flow Rate (PEFR): Present

Correlation of Dyspnea (MMRC grade) and

study demonstrate positive correlation between

6MWD : Present study demonstrate that higher the

6MWD and PEFR(Table No.4). similar to data

grade of dyspnoea (MMRC grade), lower

published by Knox et al(33), Naghshin R et

the

distance.(P<0.05) (Table No.3).

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International J. of Healthcare & Biomedical Research, Volume: 1, Issue: 3, April 2013, Pages 217-226
al(30),Mehta A et al (31).

PFT is the gold standard for the diagnosis of COPD at

Our study showed correlation between severity of

present (3). However, PFT is difficult to perform for some

COPD and 6MWD test (P<0.05 ) were similar to those

patients, especially for those patients with seriously

of Naghshin R et al(30) (Table No.5) .

impaired pulmonary function and severe dyspnoea. It is

In stage I and II, 5 patients could walk less than 300

also a costly method with restricted availability. Long-

meters while in stage III and IV, 7 patients walked more

term monitoring of pulmonary function by PFT is also

than 300 meters. It signifies that we cant apply 6MWD

difficult. There is a good correlation between the 6MWT

universally for the grading, therefore interpretation

and spirometric parameters in COPD patients. The 6MWT

should be individualized. Moreover 7 patients in stage

is also a simple, convenient, and effective exercise test

III, IV with good walking capacity (>300 meters) were

which could be widely applied (35-37).

likely to have better quality of life and prognosis (Table

needed to implement the 6MWT, such as finger pulse

no -2).

oximeter, sphygmomanometer, stopwatch, etc are all

Correlation of Age, Height, Weight, Body Mass

simple medical instruments. After a simple training, even

Index (BMI) and 6MWD : Present study demonstrates

non-medical people such as a family member could carry

statistically significant positive correlation between

out the 6MWT, although caution is always needed.

6MWD and the patients weight and BMI. In healthy

Therefore, the 6MWT may be used to assess the response

individual walking distance directly correlated to age

of treatment and progress in COPD patients.

Equipment

and height (34), however this correlation is not proved

There were some limitations in our study.

in our study (Table no. 3) due to different rate of

Females far outnumbered male patients. Possible reason

progression of disease in different individuals due to

for this may be less prevalence and lack of seeking

varied reasons.

medical care due to socioeconomic reasons by females.

The correlation of 6MWT and pulmonary function test,

The test was not repeated to assess test reproducibility.

in patients with respiratory diseases, makes this test easy

CONCLUSION

and a simple tool for assessing the disease status. We

6MWT is simple and safe test. In our study overall

feel that this test is underutilized by clinicians. Test may

6MWD had linear relationship with FEV1, FVC,

be easily carried out in hospital settings with adequate

FEV1/FVC, PEFR, grading of dyspnoea and GOLD

space but may be difficult to be carried out in office

stages. In conclusion, in COPD patients 6MWT is useful

practise due to time and space constrains.

test to assess severity of disease.

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Date of submission: 18 March 2013
Date of provisional acceptance: 24 March 2013
Date of Final acceptance: 05 April 2013
Date of Publication: 15 April 2013
Source of support: Nil; Conflict of Interest: Nil

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