Are you looking for a way to measure your cardio-respiratory endurance and physical fitness level? The six minute walk test is one of the most widely used tests to do just that. With easy administration and evidence-based results, this valuable tool can help you determine if you are meeting your rehabilitation goals or need more time in active recovery. Read on to learn why the six minute walk test is helpful and how to properly utilize its form.
| Question | Answer |
|---|---|
| Form Name | Six Minute Walk Test Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | six minute walk test form, 6 minute walk test template, six minute walk test instructions, minute walk test pdf |
INSTRUCTIONS FOR SIX MINUTE WALK TEST FORM
SMW, VERSION 1.0 (QxQ)
I. GENERAL INSTRUCTIONS
The Six Minute Walk Test Form is filled out by the study clinician conducting the test. Using a paper copy of the form to record the data while the test is in progress is recommended.
The Six Minute Walk, an assessment of lung function is the Flexible Block A procedure. Usually the walk should follow shortly after spirometry since it is performed after bronchodilation (for participants with COPD and/or asthma).
The testing area must be a 30m (100 ft.) segment of straight, unimpeded hallway.
Prepare the area by applying markers for the endpoints and 3m intervals to the baseboard on one side of the hall, with special attention to avoid doorways, etc.
Use the provided 30m metric tape measure. If a
If available, place the traffic cones at the center of the proximal and distal turn points. Place the turn signs at the proximal and distal turn points of the course.
Have ready the following materials: stopwatch/timer, worksheet for counting laps, oximeter, Borg breathlessness and exertion scales, a chair that can be easily moved along the walking course, emergency equipment (according to local policy): telephone, sphygmomanometer, oxygen source.
A
Participants should use their usual walking aids during the test (cane, walker, etc.) and be dressed in comfortable clothing and walking shoes.
In general, it is preferable to use room air. If the participant is on
The University of Utah will use 1.5L/min by continuous nasal canula for all subjects to simulate sea level inspired pO2 unless the participant is receiving a high flow rate of
See the SPIROMICS MOP 2, Section 2.14 for further details on oxygen use.
Prior to the test, the participant should sit in a chair, located near the starting position for at least 10 minutes before assessing pulse and SpO2 (and Blood Pressure if not taken and recorded within 4 hours prior to test).
If systolic BP is > 200mmHg or < 60mmHg, or diastolic blood pressure > 110mmHg discontinue the test.
If resting heart rate is > 120 or < 50 beats per minute discontinue the test.
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If resting SpO2 is < 88% the participant is not eligible to continue the test (exception noted above for participants on
Reasons for immediately stopping the test include:
•if SpO2 falls below 80%
•the participant asks to stop the test
•if the participant experiences chest pain
•intolerable dyspnea
•leg cramps
•staggering
•diaphoresis
•pale or ashen appearance
II. DETAILED INSTRUCTIONS FOR CHALLENGE
Explain the use of the modified Borg scale
Explain the use of the Borg rating of perceived exertion scale
Read the following instructions to the participant:
“The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones. You should pivot briskly around the cones and continue back the other way without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.”
Demonstrate by walking one lap yourself. Walk and pivot around a cone briskly.
Record completed and partial laps on the lap count worksheet.
Say to the participant:
“Are you ready to do that? I am going to use this counter to keep track of the number of laps you complete. I will click it each time you turn around at this starting line. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run or jog. Start now, or whenever you are ready.”
Standardized Encouragement read in a steady voice:
After the 1st minute: “You are doing well. You have 5 minutes to go.”
When the timer shows 4 minutes remaining: “Keep up the good work. You have 4 minutes to go.”
When the timer shows 3 minutes remaining: “You are doing well. You are halfway done.
When the timer shows 2 minutes remaining: “Keep up the good work. You have only 2 minutes left.
When the timer shows 1 minute remaining: “You are doing well. You only have 1 minute to go.
With 15 seconds to go: “In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you.”
At 6 minutes: “Stop”
If the participant stops at any time prior, you can say: “You can lean against the wall if you would like; then continue walking whenever you feel able.”
Do not use other words of encouragement (or body language) to influence the patient’s walking speed. Accompany the participant along the walking course, but keep just behind them. Do not lead them.
If available record the distance at which the oxygen saturation drops < 88%.
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III GENERAL INSTRUCTIONS FOR THE FORM
Header Information: The header information consists of key fields which uniquely identify each recorded instance of a form.
FORM DATE: Record date this is being completed. Select the date from the pop up calendar or type in the date in the space provided. Dates should be entered in the mm/dd/yyyy format.
INITIALS: Record the staff code of the person entering the data on this form. This code is assigned to each person at each site by the GIC. If you do not have a staff code and are collecting SPIROMICS data please contact the GIC in order to receive your own individual staff code.
III. DETAILED INSTRUCTIONS FOR EACH ITEM
Item 1. Medications taken since
Item 2. Blood pressure more than 4 hours prior to 6MW: Record ‘Y’ for Yes or ‘N’ for No. If No, go to Item 3. If Yes, complete
Item2a. Record systolic pressure
Item2b. Record diastolic pressure
Item 3. Supplemental Oxygen during test : Record ‘Y’ for Yes or ‘N’ for No. If No, go to Item 4. If Yes, complete Item
Item3a. Oxygen Flow rate: Record in Liters per minute.
Item3b. Oxygen type: Record 1 for continuous flow nasal canula or 2 for Pulsed delivery system (conserver).
Item4a. SpO2 at rest prior to 6MW: Record as percentage.
Item4b. Pulse: Record beats per minute.
Item 5. Continuous oximetry recorded: Record ‘Y’ for Yes, or ‘N’ for No.
Item 6. Start of
Item 7. Immediately following 6MW: Record the following:
Item7a. SpO2: Record as percentage.
Item7b. Pulse: Record beats per minute.
Item7c. Breathlessness: Record participant’s response from
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severe breathlessness and very severe breathlessness, 7=very severe breathlessness, 8=between very severe breathlessness and very,very severe breathlessness, 9=very, very severe breathlessness, 10=maximum breathlessness.)
Item7d. Exertion: Record participant’s response from
Item 8a. Type of course used: Select the type of course used. Record 1 for 30 meters x 2 lengths, 2 for 100 feet x 2 lengths, or 3 for other. If Other, specify in the space provided.
Item 8b. Record the number of completed laps
Item 8c. Record the distance walked the final partial lap in meters if 8a is in meters or in feet if 8b is in feet.
Item 9. Stopped before 6 minutes: Record Y for Yes or N for No. If No skip out of form. If Yes answer 9a and 10.
Item9a. Duration: Record in minutes and seconds.
Item 10. Reason for stopping: Record one response
Item105. If response to Item 10=5, select all that apply. (a=angina, b=lightheadedness, c=intolerable dyspnea, d=leg cramps, e=staggering, f=diaphoresis, g=pale or ashen appearance, h=mental confusion or headache, i=other). If other is selected, please explain.
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