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HTS Cardiac Protocol

Tools & Patient Information

HTS Cardiac Care Rehab Protocol

1. Identify patients with a cardiac disorder:

o Coronary Artery Disease A disease process with thickening of the inner walls of blood vessels – Arteriosclerosis.

o Congestive Heart Failure Failure of either the right or left side of the heart to adequately pump blood.

o Chronic Obstructive Pulmonary Disorder (COPD) Airway obstruction and alterations in lung function

2. Complete a screen to determine if there has been a significant change in function.

3. Complete the regular evaluation and at least 2 relevant formal tests. (Some examples)

BORG Scale of Perceived Exertion

Karvonen Method of Target Heart Rate

Six-Minute Walk Test

Vital Signs – blood pressure, heart rate, oxygenation, respiration

Dyspnea Levels

4. Consider the following treatment interventions in your plan of care:

Energy Conservation Techniques

Adaptive Equipment Training

Stress Management/Relaxation Strategies

Breathing Techniques

Activity Tolerance Training at Target Heart Rate – include a warm-up and

cool-down activity prior to aerobic exercise (stretching, active ROM, slow

walking)

Diet Education- emphasis on sodium and fluid intake

Education about heart failure

Sternal Precautions – if applicable

Home Exercise Program – Taking own vital signs, knowing warning signs,

balancing rest and activity

Restorative Exercise Program – Caregivers monitoring vital signs

Cardiac Care Report Tool

HTS Cardiac Report Tool 2011. ©All rights reserved. May be printed for use by current HTS staff & partners only

Name:__________________________ Age:_______________ Date:_____________________

Blood Pressure at rest: ____________, during activity___________, after activity____________ Blood Pressure Category Systolic (upper #) mm Hg

(millimeters of mercury) Diastolic (lower #) mm Hg

Normal Less than 120 Less than 80

Prehypertension 120-139 80-89

High Blood Pressure (Hypertension) Stage 1

140-159 90-99

High Blood Pressure (Hypertension) Stage 2

160 or higher 100 or higher

Hypertensive Crisis (Emergency care)

Higher than 180 Higher than 110

Resting Heart Rate/RHR: (take pulse for 10 seconds X 6) = _____________ (Norm 60-80 bpm)

Maximum Heart Rate/MHR: (220 – age) =_________beats /one minute

Target Heart Rate/THR: (Karvonen method)

MHR________– RHR________ =_________X _____% intensity (50-85%) + RHR=________

Lower limit Intensity % = .50 - .60 / Upper limit Intensity % = .70 - .85

Heart rate during activity: (10 sec. pulse X 6) = _____________________

Heart rate after activity: (10 sec. pulse X 6) = ______________________

Borg Scale of Perceived Exertion: 6 No Exertion at all

7 Extremely light

8

9 Very light

10

11 Light

12

13 Somewhat hard “Training Range”

14

15 Hard

16

17 Very hard

18

19 Extremely hard

20 Maximal exertion

Edema Measurements: Pitting or Non-pitting (Circumferential)

Upper body Lower body

Location: Measurement: Location: Measurement:




Depth and Duration - PITTING Distance Measure – PITTING

+1=Mild edema (0-1/4” indentation), disappears rapidly From medial malleolus, palpate proximally until there is no more pitting.

+2=Moderate Pitting (1/4-1/2”), disappears 10-15 sec. Measure distance from medial malleolus to the spot where pitting stops.

+3=Severe Pitting (1/2-1”), disappears in 1-2 minutes

+4=Severe Pitting (>1”), may be present after 5 minutes

Borg Scale Score______during activity (goal during activity= moderate 12-14 range)

Activity description:

□ light seated exercise □ light exercise in standing

□self care activity □ ambulation ___ft. ____mins □other ________________________________________

Dyspnea – labored or difficult breathing

Dyspnea Intensity – Method 1

1. = mild, noticeable to patient but not to observer

2. = some difficulty, noticeable to observer

3. = moderate difficulty, but can continue

4. = severe, patient cannot continue

Dyspnea Intensity – Method 2

0. = able to count to 15 easily

1. = able to count to 15 but must take one breath

2. = must take 2 additional breaths

3. = must take 3 additional breaths

4. = unable to count

THE BORG SCALE 0 Nothing at all 0.5 Very, very slight (just noticeable) 1 Very slight 2 Slight (light) 3 Moderate 4 Somewhat severe 5 Severe (heavy) 6 7 Very severe 8 9 10 Very, very severe (maximal) At the beginning of the 6-minute exercise, show the scale to the patient and ask the patient this: “Please grade your level of shortness of breath using this scale.” Then ask this: “Please grade your level of fatigue using this scale.” At the end of the exercise, remind the patient of the breathing number that they chose before the exercise and ask the patient to grade their breathing level again. Then ask the patient to grade their level of fatigue, after reminding them of their grade before the exercise.

American Thoracic Society

Am J Respir Crit Care Med Vol 166. pp 111–117, 2002DOI: 10.1164/rccm.166/1/111Internet address: www.atsjournals.org

ATS Statement: Guidelines for the Six-Minute Walk Test

T

HIS

O

FFICIAL

S

TATEMENT

OF

THE

A

MERICAN

T

HORACIC

S

OCIETY

WAS

APPROVED

BY

THE

ATS B

OARD

OF

D

IRECTORS

M

ARCH

2002

CONTENTS

Purpose and ScopeBackgroundIndications and LimitationsContraindicationsSafety IssuesTechnical Aspects of the 6

-

Minute Walk TestRequired EquipmentPatient PreparationMeasurementsQuality AssuranceInterpretationReferences

PURPOSE AND SCOPE

This statement provides practical guidelines for the 6-minutewalk test (6MWT). Specifically, it reviews indications, detailsfactors that influence results, presents a brief step-by-step pro-tocol, outlines safety measures, describes proper patient prep-aration and procedures, and offers guidelines for clinical inter-pretation of results. These recommendations are not intendedto limit the use of alternative protocols for research studies.We do not discuss the general topic of clinical exercise testing.

As with other American Thoracic Society statements onpulmonary function testing, these guidelines come out of aconsensus conference. Drafts were prepared by two members(P.L.E. and R.J.Z.) and were based on a comprehensive Med-line literature search from 1970 through 2001, augmented bysuggestions from other committee members. Each draft re-sponded to comments from the working committee. The guide-lines follow previously published methods as closely as possi-ble and provide a rationale for each specific recommendation.The final recommendations represent a consensus of the com-mittee. The committee recommends that these guidelines bereviewed in five years and in the meantime encourages furtherresearch in areas of controversy.

BACKGROUND

There are several modalities available for the objective evalu-ation of functional exercise capacity. Some provide a verycomplete assessment of all systems involved in exercise per-formance (high tech), whereas others provide basic informa-tion but are low tech and are simpler to perform. The modalityused should be chosen based on the clinical question to be ad-dressed and on available resources. The most popular clinicalexercise tests in order of increasing complexity are stair climb-ing, a 6MWT, a shuttle-walk test, detection of exercise-inducedasthma, a cardiac stress test (e.g., Bruce protocol), and a cardio-

pulmonary exercise test (1, 2). Other professional organiza-tions have published standards for cardiac stress testing (3, 4).

Assessment of functional capacity has traditionally beendone by merely asking patients the following: “How manyflights of stairs can you climb or how many blocks can youwalk?” However, patients vary in their recollection and mayreport overestimations or underestimations of their true func-tional capacity. Objective measurements are usually betterthan self-reports. In the early 1960s, Balke developed a simpletest to evaluate the functional capacity by measuring the dis-tance walked during a defined period of time (5). A 12-minutefield performance test was then developed to evaluate thelevel of physical fitness of healthy individuals (6). The walkingtest was also adapted to assess disability in patients withchronic bronchitis (7). In an attempt to accommodate patientswith respiratory disease for whom walking 12 minutes was tooexhausting, a 6-minute walk was found to perform as well asthe 12-minute walk (8). A recent review of functional walkingtests concluded that “the 6MWT is easy to administer, bettertolerated, and more reflective of activities of daily living thanthe other walk tests” (9).

The 6MWT is a practical simple test that requires a 100-fthallway but no exercise equipment or advanced training fortechnicians. Walking is an activity performed daily by all butthe most severely impaired patients. This test measures the dis-tance that a patient can quickly walk on a flat, hard surface in aperiod of 6 minutes (the 6MWD). It evaluates the global and in-tegrated responses of all the systems involved during exercise,including the pulmonary and cardiovascular systems, systemiccirculation, peripheral circulation, blood, neuromuscular units,and muscle metabolism. It does not provide specific informa-tion on the function of each of the different organs and systemsinvolved in exercise or the mechanism of exercise limitation, asis possible with maximal cardiopulmonary exercise testing. Theself-paced 6MWT assesses the submaximal level of functionalcapacity. Most patients do not achieve maximal exercise capac-ity during the 6MWT; instead, they choose their own intensityof exercise and are allowed to stop and rest during the test.However, because most activities of daily living are performedat submaximal levels of exertion, the 6MWD may better reflectthe functional exercise level for daily physical activities.

INDICATIONS AND LIMITATIONS

The strongest indication for the 6MWT is for measuring the re-sponse to medical interventions in patients with moderate tosevere heart or lung disease. The 6MWT has also been used asa one-time measure of functional status of patients, as well as apredictor of morbidity and mortality (

see

Table 1 for a list ofthese indications). The fact that investigators have used the6MWT in these settings does not prove that the test is clinicallyuseful (or the best test) for determining functional capacity orchanges in functional capacity due to an intervention in pa-tients with these diseases. Further studies are necessary to de-termine the utility of the 6MWT in various clinical situations.

112

AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 166 2002

Formal cardiopulmonary exercise testing provides a globalassessment of the exercise response, an objective determina-tion of functional capacity and impairment, determination ofthe appropriate intensity needed to perform prolonged exer-cise, quantification of factors limiting exercise, and a defini-tion of the underlying pathophysiologic mechanisms such asthe contribution of different organ systems involved in exer-cise. The 6MWT does not determine peak oxygen uptake, di-agnose the cause of dyspnea on exertion, or evaluate thecauses or mechanisms of exercise limitation (1, 2). The infor-mation provided by a 6MWT should be considered comple-mentary to cardiopulmonary exercise testing, not a replace-ment for it. Despite the difference between these two functionaltests, some good correlations between them have been re-ported. For example, a significant correlation (r

�

0.73) be-tween 6MWD and peak oxygen uptake has been reported forpatients with end-stage lung diseases (36, 37).

In some clinical situations, the 6MWT provides informa-tion that may be a better index of the patient’s ability to per-form daily activities than is peak oxygen uptake; for example,6MWD correlates better with formal measures of quality oflife (38). Changes in 6MWD after therapeutic interventionscorrelate with subjective improvement in dyspnea (39, 40).The reproducibility of the 6MWD (with a coefficient of varia-tion of approximately 8%) appears to be better than the re-producibility of 1-second forced expiratory volume in patientswith chronic obstructive pulmonary disease (COPD) (8, 41–43). Questionnaire indices of functional status have a largershort-term variability (22–33%) than does the 6MWD (37).

The shuttle-walking test is similar to the 6MWT, but it usesan audio signal from a tape cassette to direct the walking paceof the patient back and forth on a 10-m course (44–47). Thewalking speed is increased every minute, and the test ends whenthe patient cannot reach the turnaround point within the re-quired time. The exercise performed is similar to a symptom-limited, maximal, incremental treadmill test. An advantage ofthe shuttle walking test is that it has a better correlation withpeak oxygen uptake than the 6MWD. Disadvantages includeless validation, less widespread use, and more potential forcardiovascular problems.

CONTRAINDICATIONS

Absolute contraindications for the 6MWT include the follow-ing: unstable angina during the previous month and myocar-

dial infarction during the previous month. Relative contraindi-cations include a resting heart rate of more than 120, a systolicblood pressure of more than 180 mm Hg, and a diastolic bloodpressure of more than 100 mm Hg.

Patients with any of these findings should be referred to thephysician ordering or supervising the test for individual clini-cal assessment and a decision about the conduct of the test.The results from a resting electrocardiogram done during theprevious 6 months should also be reviewed before testing. Sta-ble exertional angina is not an absolute contraindication for a6MWT, but patients with these symptoms should perform thetest after using their antiangina medication, and rescue nitratemedication should be readily available.

Rationale

Patients with the previously mentioned risk factors may be atincreased risk for arrhythmias or cardiovascular collapse duringtesting. However, each patient determines the intensity of theirexercise, and the test (without electrocardiogram monitoring)has been performed in thousands of older persons (31, 48–50)and thousands of patients with heart failure or cardiomyopathy(32, 51, 52) without serious adverse events. The contraindica-tions listed previously here were used by study investigatorsbased on their impressions of the general safety of the 6MWTand their desire to be prudent, but it is unknown whether ad-verse events would occur if such patients performed a 6MWT;they are, therefore, listed as relative contraindications.

SAFETY ISSUES

1. Testing should be performed in a location where a rapid,appropriate response to an emergency is possible. The ap-propriate location of a crash cart should be determined bythe physician supervising the facility.

2. Supplies that must be available include oxygen, sublingualnitroglycerine, aspirin, and albuterol (metered dose inhaleror nebulizer). A telephone or other means should be inplace to enable a call for help.

3. The technician should be certified in cardiopulmonary re-suscitation with a minimum of Basic Life Support by anAmerican Health Association–approved cardiopulmonaryresuscitation course. Advanced cardiac life support certifi-cation is desirable. Training, experience, and certificationin related health care fields (registered nurse, registered re-spiratory therapist, certified pulmonary function techni-cian, etc.) are also desirable. A certified individual shouldbe readily available to respond if needed.

4. Physicians are not required to be present during all tests.The physician ordering the test or a supervising laboratoryphysician may decide whether physician attendance at aspecific test is required.

5. If a patient is on chronic oxygen therapy, oxygen should begiven at their standard rate or as directed by a physician ora protocol.

Reasons for immediately stopping a 6MWT include the follow-ing: (

1

) chest pain, (

2

) intolerable dyspnea, (

3

) leg cramps, (

4

)staggering, (

5

) diaphoresis, and (

6

) pale or ashen appearance.Technicians must be trained to recognize these problems

and the appropriate responses. If a test is stopped for any ofthese reasons, the patient should sit or lie supine as appropri-ate depending on the severity or the event and the technician’sassessment of the severity of the event and the risk of syncope.The following should be obtained based on the judgment ofthe technician: blood pressure, pulse rate, oxygen saturation,and a physician evaluation. Oxygen should be administered asappropriate.

TABLE 1. INDICATIONS FOR THE SIX-MINUTE WALK TEST

Pretreatment and posttreatment comparisonsLung transplantation (9, 10)Lung resection (11)Lung volume reduction surgery (12, 13)Pulmonary rehabilitation (14, 15)COPD (16–18)Pulmonary hypertensionHeart failure (19, 20)

Functional status (single measurement)COPD (21, 22)Cystic fibrosis (23, 24)Heart failure (25–27)Peripheral vascular disease (28, 29)Fibromyalgia (30)Older patients (31)

Predictor of morbidity and mortalityHeart failure (32, 33)COPD (34, 35)Primary pulmonary hypertension (10, 36)

Definition of abbreviation

: COPD

�

chronic obstructive pulmonary disease.

American Thoracic Society 113

TECHNICAL ASPECTS OF THE 6MWT

Location

The 6MWT should be performed indoors, along a long, flat,straight, enclosed corridor with a hard surface that is seldomtraveled. If the weather is comfortable, the test may be per-formed outdoors. The walking course must be 30 m in length.A 100-ft hallway is, therefore, required. The length of the cor-ridor should be marked every 3 m. The turnaround points shouldbe marked with a cone (such as an orange traffic cone). A start-ing line, which marks the beginning and end of each 60-m lap,should be marked on the floor using brightly colored tape.

Rationale.

A shorter corridor requires patients to take moretime to reverse directions more often, reducing the 6MWD.Most studies have used a 30-m corridor, but some have used20- or 50-m corridors (52–55). A recent multicenter studyfound no significant effect of the length of straight coursesranging from 50 to 164 ft, but patients walked farther on con-tinuous (oval) tracks (mean 92 ft farther) (54).

The use of a treadmill to determine the 6MWD might savespace and allow constant monitoring during the exercise, butthe use of a treadmill for 6-minute walk testing is not recom-mended. Patients are unable to pace themselves on a tread-mill. In one study of patients with severe lung disease, themean distance walked on the treadmill during 6 minutes (withthe speed adjusted by the patients) was shorter by a mean of14% when compared with the standard 6MWD using a 100-fthallway (57). The range of differences was wide, with patientswalking between 400–1,300 ft on the treadmill who walked1,200 ft in the hallway. Treadmill test results, therefore, arenot interchangeable with corridor tests.

REQUIRED EQUIPMENT

1. Countdown timer (or stopwatch)2. Mechanical lap counter3. Two small cones to mark the turnaround points4. A chair that can be easily moved along the walking course5. Worksheets on a clipboard6. A source of oxygen7. Sphygmomanometer8. Telephone9. Automated electronic defibrillator

PATIENT PREPARATION

1. Comfortable clothing should be worn.2. Appropriate shoes for walking should be worn.3. Patients should use their usual walking aids during the test

(cane, walker, etc.).4. The patient’s usual medical regimen should be continued.5. A light meal is acceptable before early morning or early af-

ternoon tests.6. Patients should not have exercised vigorously within 2 hours

of beginning the test.

MEASUREMENTS

1. Repeat testing should be performed about the same timeof day to minimize intraday variability.

2. A “warm-up” period before the test should not be performed.3. The patient should sit at rest in a chair, located near the

starting position, for at least 10 minutes before the teststarts. During this time, check for contraindications, mea-sure pulse and blood pressure, and make sure that cloth-ing and shoes are appropriate. Compete the first portionof the worksheet (

see

the A

PPENDIX

).

4. Pulse oximetry is optional. If it is performed, measure andrecord baseline heart rate and oxygen saturation (SpO

2

)and follow manufacturer’s instructions to maximize the sig-nal and to minimize motion artifact (56, 57). Make sure thereadings are stable before recording. Note pulse regularityand whether the oximeter signal quality is acceptable.

The rationale for measuring oxygen saturation is that al-though the distance is the primary outcome measure, im-provement during serial evaluations may be manifest eitherby an increased distance or by reduced symptoms with thesame distance walked (39). The SpO

2

should not be used forconstant monitoring during the exercise. The technicianmust not walk with the patient to observe the SpO

2

. If wornduring the walk, the pulse oximeter must be lightweight (lessthan 2 pounds), battery powered, and held in place (perhapsby a “fanny pack”) so that the patient does not have to holdor stabilize it and so that stride is not affected. Many pulseoximeters have considerable motion artifact that preventsaccurate readings during the walk. (57)

5. Have the patient stand and rate their baseline dyspneaand overall fatigue using the Borg scale (

see

Table 2 forthe Borg scale and instructions [58]).

6. Set the lap counter to zero and the timer to 6 minutes. As-semble all necessary equipment (lap counter, timer, clip-board, Borg Scale, worksheet) and move to the startingpoint.

7. Instruct the patient as follows:

“The object of this test is to walk as far as possible for 6minutes. You will walk back and forth in this hallway. Sixminutes is a long time to walk, so you will be exerting your-self. You will probably get out of breath or become ex-hausted. You are permitted to slow down, to stop, and torest as necessary. You may lean against the wall while rest-ing, 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 continueback the other way without hesitation. Now I’m going toshow you. Please watch the way I turn without hesitation.”

Demonstrate by walking one lap yourself. Walk andpivot around a cone briskly.

“Are you ready to do that? I am going to use thiscounter to keep track of the number of laps you complete. Iwill click it each time you turn around at this starting line.Remember that the object is to walk AS FAR AS POSSI-BLE for 6 minutes, but don’t run or jog.

Start now, or whenever you are ready.”

TABLE 2. THE BORG SCALE

0 Nothing at all0.5 Very, very slight (just noticeable)1 Very slight2 Slight (light)3 Moderate4 Somewhat severe5 Severe (heavy)67 Very severe8910 Very, very severe (maximal)

This Borg scale should be printed on heavy paper (11 inches high and perhaps lami-nated) in 20-point type size. At the beginning of the 6-minute exercise, show the scaleto the patient and ask the patient this: “Please grade your level of shortness of breathusing this scale.” Then ask this: “Please grade your level of fatigue using this scale.”

At the end of the exercise, remind the patient of the breathing number that theychose before the exercise and ask the patient to grade their breathing level again. Thenask the patient to grade their level of fatigue, after reminding them of their grade be-fore the exercise.

114


8. Position the patient at the starting line. You should alsostand near the starting line during the test. Do not walkwith the patient. As soon as the patient starts to walk,start the timer.

9. Do not talk to anyone during the walk. Use an even toneof voice when using the standard phrases of encourage-ment. Watch the patient. Do not get distracted and losecount of the laps. Each time the participant returns to thestarting line, click the lap counter once (or mark the lapon the worksheet). Let the participant see you do it. Ex-aggerate the click using body language, like using a stop-watch at a race.

After the first minute, tell the patient the following (ineven tones): “You are doing well. You have 5 minutes togo.”

When the timer shows 4 minutes remaining, tell the pa-tient the following: “Keep up the good work. You have 4minutes to go.”

When the timer shows 3 minutes remaining, tell the pa-tient the following: “You are doing well. You are halfwaydone.”

When the timer shows 2 minutes remaining, tell the pa-tient the following: “Keep up the good work. You have only2 minutes left.”

When the timer shows only 1 minute remaining, tell thepatient: “You are doing well. You have only 1 minute togo.”

Do not use other words of encouragement (or body lan-guage to speed up).

If the patient stops walking during the test and needs arest, say this: “You can lean against the wall if you wouldlike; then continue walking whenever you feel able.” Donot stop the timer. If the patient stops before the 6 minutesare up and refuses to continue (or you decide that theyshould not continue), wheel the chair over for the patient tosit on, discontinue the walk, and note on the worksheet thedistance, the time stopped, and the reason for stopping pre-maturely.

When the timer is 15 seconds from completion, say this:“In a moment I’m going to tell you to stop. When I do, juststop right where you are and I will come to you.”

When the timer rings (or buzzes), say this: “Stop!” Walkover to the patient. Consider taking the chair if they lookexhausted. Mark the spot where they stopped by placing abean bag or a piece of tape on the floor.

10. Post-test: Record the postwalk Borg dyspnea and fatiguelevels and ask this: “What, if anything, kept you from walk-ing farther?”

11. If using a pulse oximeter, measure SpO

2

and pulse ratefrom the oximeter and then remove the sensor.

12. Record the number of laps from the counter (or tick markson the worksheet).

13. Record the additional distance covered (the number of metersin the final partial lap) using the markers on the wall as dis-tance guides. Calculate the total distance walked, rounding tothe nearest meter, and record it on the worksheet.

14. Congratulate the patient on good effort and offer a drinkof water.

QUALITY ASSURANCE

Sources of Variability

There are many sources of 6MWD variability (

see

Table 3).The sources of variability caused by the test procedure itselfshould be controlled as much as possible. This is done by fol-

lowing the standards found in this document and by using aquality-assurance program.

Practice Tests

A practice test is not needed in most clinical settings butshould be considered. If a practice test is done, wait for at least1 hour before the second test and report the highest 6MWD asthe patient’s 6MWD baseline.

Rationale.

The 6MWD is only slightly higher for a second6MWT performed a day later. The mean reported increaseranges from 0 to 17% (23, 27, 40, 41, 54, 59). A multicenterstudy of 470 highly motivated patients with severe COPD per-formed two 6MWTs 1 day apart, and on average, the 6MWDwas only 66 ft (5.8%) higher on the second day (54).

Performance (without an intervention) usually reaches aplateau after two tests done within a week (8, 60). The trainingeffect may be due to improved coordination, finding optimalstride length, and overcoming anxiety. The possibility of apractice or training effect from tests repeated after more thana month has not been studied or reported; however, it is likelythat the effect of training wears off (does not persist) after afew weeks.

Technician Training and Experience

Technicians who perform 6MWTs should be trained using thestandard protocol and then supervised for several tests beforeperforming them alone. They should also have completed car-diopulmonary resuscitation training.

Rationale.

One multicenter study of older people foundthat after correction for many other factors, two of the techni-cians had mean 6MWDs that were approximately 7% lowerthan the other two sites (31).

Encouragement

Only the standardized phrases for encouragement (as speci-fied previously here) must be used during the test.

Rationale.

Encouragement significantly increases the dis-tance walked (42). Reproducibility for tests with and withoutencouragement is similar. Some studies have used encourage-ment every 30 seconds, every minute, or every 2 minutes. Wehave chosen every minute and standard phrases. Some studies(53) have instructed patients to walk as fast as possible. Al-though larger mean 6MWDs may be obtained thereby, we rec-ommend that such phrases not be used, as they emphasize ini-tial speed at the expense of earlier fatigue and possibleexcessive cardiac stress in some patients with heart disease.

TABLE 3. 6MWD SOURCES OF VARIABILITY

Factors reducing the 6MWDShorter heightOlder ageHigher body weightFemale sexImpaired cognitionA shorter corridor (more turns)Pulmonary disease (COPD, asthma, cystic fibrosis, interstitial lung disease)Cardiovascular disease (angina, MI, CHF, stroke, TIA, PVD, AAI)Musculoskeletal disorders (arthritis, ankle, knee, or hip injuries, muscle wasting, etc.)

Factors increasing the 6MWDTaller height (longer legs)Male sexHigh motivationA patient who has previously performed the testMedication for a disabling disease taken just before the testOxygen supplementation in patients with exercise-induced hypoxemia

Definition of abbreviations

: COPD

�

chronic obstructive pulmonary disease; 6MWD

�

6-minute walking distance.


Supplemental Oxygen

If oxygen supplementation is needed during the walks and se-rial tests are planned (after an intervention other than oxygentherapy), then during all walks by that patient oxygen shouldbe delivered in the same way with the same flow. If the flowmust be increased during subsequent visits due to worseninggas exchange, this should be noted on the worksheet and con-sidered during interpretation of the change noted in 6MWD.The type of oxygen delivery device should also be noted onthe report: for instance, the patient carried liquid oxygen orpushed or pulled an oxygen tank, the delivery was pulsed orcontinuous, or a technician walked behind the patient with theoxygen source (not recommended). Measurements of pulseand SpO

2

should be made after waiting at least 10 minutes af-ter any change in oxygen delivery.

Rationale.

For patients with COPD or interstitial lung dis-ease, oxygen supplementation increases the 6MWD (17, 59,61, 63). Carrying a portable gas container (but not using it forsupplemental oxygen) reduced the mean 6MWD by 14% inone study of patients with severe respiratory disability, but us-ing the container to deliver supplemental oxygen during theexercise increased the mean 6MWD by 20–35% (59).

Medications

The type of medication, dose, and number of hours taken be-fore the test should be noted.

Rationale.

Significant improvement in the distance walked,or the dyspnea scale, after administration of bronchodilatorshas been demonstrated in patients with COPD (62, 63), as wellas cardiovascular medications in patients with heart failure (19).

INTERPRETATION

Most 6MWTs will be done before and after intervention, andthe primary question to be answered after both tests havebeen completed is whether the patient has experienced a clini-cally significant improvement. With a good quality-assuranceprogram, with patients tested by the same technician, and af-ter one or two practice tests, short-term reproducibility of the6MWD is excellent (37). It is not known whether it is best forclinical purposes to express change in 6MWD as (

1

) an abso-lute value, (

2

) a percentage change, or (

3

) a change in the per-centage of predicted value. Until further research is available,we recommend that change in 6MWD be expressed as an ab-solute value (e.g., the patient walked 50 m farther).

A statistically significant mean increase in 6MWD in agroup of study participants is often much less than a clinicallysignificant increase in an individual patient. In one study of112 patients (half of them women) with stable, severe COPD,the smallest difference in 6MWD that was associated with anoticeable clinical difference in the patients’ perception of ex-ercise performance was a mean of 54 m (95% confidence in-terval, 37–71 m) (64). This study suggests that for individualpatients with COPD, an improvement of more than 70 m inthe 6MWD after an intervention is necessary to be 95% confi-dent that the improvement was significant. In an observationalstudy of 45 older patients with heart failure, the smallest dif-ference in 6MWD that was associated with a noticeable differ-ence in their global rating of worsening was a mean of 43 m(20). The 6MWD was more responsive to deterioration thanto improvement in heart failure symptoms.

Reported Mean Changes in 6MWD After Interventions

Supplemental oxygen (4 L/min) during exercise in patients withCOPD or interstitial lung disease increased mean 6MWD byapproximately 95 m (36%) in one study (59). Patients taking

an inhaled corticosteroid experienced a mean 33 m (8%) in-crease in 6MWD in an international COPD study (16). Pa-tients with COPD in a study of the effects of exercise and dia-phragmatic strength training experienced a mean increase in6MWD of 50 m (20%) (65). Lung volume reduction surgery inpatients with very severe COPD has been reported to increase6MWD by a mean of 55 m (20%) (13).

Cardiac rehabilitation in patients referred with various heartdiseases increased 6MWD by a mean of 170 m (15%) in a recentstudy (66). In 25 older patients with heart failure, an angiotensin-converting enzyme inhibitor medication (50 mg captopril perday) improved 6MWD a mean of 64 m (39%) compared with amean increase of only 8% in those receiving a placebo (19).

Interpreting Single Measurements of Functional Status

Optimal reference equations from healthy population-basedsamples using standardized 6MWT methods are not yet avail-able. In one study, the median 6MWD was approximately 580m for 117 healthy men and 500 m for 173 healthy women (50).A mean 6MWD of 630 m was reported by another study of 51healthy older adults (55). Differences in the population sam-pled, type and frequency of encouragement, corridor length,and number of practice tests may account for reported differ-ences in mean 6MWD in healthy persons. Age, height, weight,and sex independently affect the 6MWD in healthy adults;therefore, these factors should be taken into considerationwhen interpreting the results of single measurements made todetermine functional status. We encourage investigators to pub-lish reference equations for healthy persons using the previ-ously mentioned standardized procedures.

A low 6MWD is nonspecific and nondiagnostic. When the6MWD is reduced, a thorough search for the cause of the im-pairment is warranted. The following tests may then be help-ful: pulmonary function, cardiac function, ankle–arm index,muscle strength, nutritional status, orthopedic function, andcognitive function.

Conclusions

The 6MWT is a useful measure of functional capacity targetedat people with at least moderately severe impairment. The testhas been widely used for preoperative and postoperative eval-uation and for measuring the response to therapeutic inter-ventions for pulmonary and cardiac disease. These guidelinesprovide a standardized approach to performing the 6MWT.The committee hopes that these guidelines will encourage fur-ther research into the 6MWT and allow direct comparisonsamong different studies.

This statement was developed by the ATS Committee on Proficiency Stan-dards for Clinical Pulmonary Function Laboratories.Members of the committee are:

R

OBERT

O. C

RAPO

, M.D.,

Chair

*R

ICHARD

C

ASABURI

, P

H

.D, M.D.A

LLAN

L. C

OATES

, M.D.P

AUL

L. E

NRIGHT

, M.D.*N

EIL

R. M

AC

I

NTYRE

, M.D.R

OY

T. M

C

K

AY

, P

H

.D.D

OUGLAS

J

OHNSON

, M.D.J

ACK

S. W

ANGER

, M.S.R. J

ORGE

Z

EBALLOS

, M.D.*Ad Hoc Committee members are:

V

ERA

B

ITTNER

, M.D.C

ARL

M

OTTRAM

, R.R.T.*Writing Committee Members

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APPENDIX

The following elements should be present on the 6MWT worksheet and report:

Lap counter: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Patient name: ____________________ Patient ID# ___________

Walk # ______ Tech ID: _________ Date: __________

Gender: M F Age: ____ Race: ____ Height: ___ft ____in, ____ meters

Weight: ______ lbs, _____kg Blood pressure: _____ / _____

Medications taken before the test (dose and time): __________________

Supplemental oxygen during the test: No Yes, flow ______ L/min, type _____

Baseline End of Test

Time ___:___ ___:___

Heart Rate _____ _____

Dyspnea ____ ____ (Borg scale)

Fatigue ____ ____ (Borg scale)

SpO2 ____ % ____%

Stopped or paused before 6 minutes? No Yes, reason: _______________

Other symptoms at end of exercise: angina dizziness hip, leg, or calf pain

Number of laps: ____ (�60 meters) � final partial lap: _____ meters �

Total distance walked in 6 minutes: ______ meters

Predicted distance: _____ meters Percent predicted: _____%

Tech comments:

Interpretation (including comparison with a preintervention 6MWD):

Sternal Precautions: Follow for 4-6 weeks

1. Do not raise arms past shoulder height in front and on the side 2. Do not push or pull especially when standing up or sitting down 3. Do not bend hips more than 45 degrees so your organs won’t be pushing up into the chest cavity 4. Do not cross legs especially if your legs have been grafted 5. Do not carry items that weigh more than 10 pounds

Sternal Precautions and Activities of Daily Living: (You should keep frequently used items in bathroom, kitchen, bedroom, within reach at or below shoulder height.) Grooming:

Comb or dry hair by keeping both arms and shoulders close to the body or turn head side to side with elbows rested on table

Tie or pin hair by tucking chin under or have someone else do it

Raise arm to shoulder height to apply roll-on or spray deodorant

Extend handle on hair brush or comb/bend head forward Bathing/Showering:

Dry off back of body by flipping towel overhead and draping over back, keep elbow at side of body and move towel side to side.

Use long-handled sponge for back and legs Toilet Hygiene:

Wipe from front to back or reach to the side Dressing:

Use reacher to obtain or return light weight items from high compartments

Put on shirt by placing arms through sleeves keeping elbows close to body. Gather collar and put head through by tucking chin under. Pull shirt down by reaching across chest and under arm.

Take shirt off by reaching behind bent head for collar and pulling shirt over head

Put on bra by fastening hook in front at waist level and turn hook to back. Put arms through straps. Reverse steps to take off.

My doctor’s adviceAsk your doctor to fill in the blanks with recommendations that will help you recover.

Medicine Notes: ____________________________________________________________________________________

Diet Notes: _________________________________________________________________________________________

Exercise Notes: _____________________________________________________________________________________

Example: No salt allowed

Here are some examples:

1. Angiotensin Converting Enzyme (ACE) Inhibitor — lowers blood pressure and decreases the heart’s workload.

2. Angiotensin Receptor Blocker (ARB) — lowers blood pressure.

3. Diuretic — helps your body get rid of extra water and sodium.

4. Beta-blocker — lowers blood pressure and slows heart rate.

5. Digoxin — helps your heart pump better.

6. Vasodilator — lowers blood pressure by relaxing blood vessels and allowing them to open (dilate).

About 5 million Americans are living with congestive heart failure today. In fact, it’s one of the most common reasons people 65 and older go into the hospital.

Fortunately, heart failure can be treated. Getting good medical care, following doctor’s orders and learning about heart failure will help you lead a comfortable life.

You can help by taking your medicine as your doctor tells you, and by following your eating and exercise plans.

How Can I Live With Heart Failure?

What medicine might I take?

• Visit the doctor and follow his or her advice.

• Read food labels and avoid foods high in salt or sodium.

• Start an aerobic exercise plan as your doctor advises.

• Keep up your interests and be upbeat!

What will help me get better?

Tell your doctor right away if...

• You gain 3 or more pounds in a day or so.

• You see that your feet, ankles or other parts of your body are puffy.

• It’s hard to breathe.

• You can’t do what you could do the day before.

• You have “the flu.”

• You get a fever.

• You have chest pain.

What should I watch out for?

Take a few minutes to write your own questions for the next time you see your healthcare provider. For example:

Do you have questions or comments for your doctor?

How can my family help me?

Should I stay in bed?

How can I learn more?1. Talk to your doctor, nurse or other health-care

professionals. If you have heart disease or have had a stroke, members of your family also may be at higher risk. It’s very important for them to make changes now to lower their risk.

2. Call 1-800-AHA-USA1 (1-800-242-8721) or visit americanheart.org to learn more about heart disease.

3. For information on stroke, call 1-888-4-STROKE (1-888-478-7653) or visit StrokeAssociation.org.

We have many other fact sheets and educational booklets to help you make healthier choices to reduce your risk, manage disease or care for a loved one.

Knowledge is power, so Learn and Live!

Warning Signs of Heart Attack

Some heart attacks are sudden and intense, but most of them start slowly with mild pain or discomfort with one or more of these symptoms:

• Chest discomfort

• Discomfort in other areas of the upper body

• Shortness of breath with or without chest discomfort

• Other signs including breaking out in a cold sweat, nausea or lightheadedness

Warning Signs of Stroke

• Sudden weakness or numbness of the face, arm or leg, especially on one side of the body

• Sudden confusion, trouble speaking or understanding

• Sudden trouble seeing in one or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden, severe headache with no known cause

Learn to recognize a stroke. Time lost is brain lost.

What are the warning signs of heart attack and stroke?

Call 9-1-1 … Get to a hospital immediately if you experience signs of a heart attack or stroke!

How Can I Live With Heart Failure? (continued)

Your contribution to the American Heart Association supports research that helps make publications like this possible.

The statistics in this sheet were up to date at publication. For the latest statistics, see the Heart Disease and Stroke Statistics Update at americanheart.org/statistics.©2007, American Heart Association 10/07LS1466

The heart – it is perhaps the organ you are most conscious of, as it is the one you can feel beating every day. As such, you know that its health is

directly related to your own. But are you aware of what can go wrong

with the heart, as well as how to maintain its strength and stability? If not, you should be. Heart disease is the number-one cause of death in the United States today, meaning it is vital that you take the steps necessary to protect yourself and your heart. Below is a brief overview of how to become and re-main heart healthy. For further information, speak with a medical practitioner or check out the American Heart Association’s web-site (www.heart.org).

HEART CONDITIONSWithout proper care and attention, you can develop a number of heart conditions of vary-ing severity, and/or conditions that put you at a higher risk for heart disease. These conditions include:

• Arrhythmia (irregular heartbeat)• Cardiac arrest• High cholesterol• High blood pressure

• Diabetes• Stroke• Peripheral Artery Disease• Heart attack• Heart failureThe best protection against these conditions

is heart-healthy prevention—a multi-faceted process, outlined below:

NUTRITIONThe first step in the process is also the most publicly discussed: nutrition. A healthy weight and a well-nourished body are keys to maintaining heart health. As each person is unique, each person’s diet and nutritional needs will vary. To fi nd out exactly what and how much you should eat, speak with your doctor or nutritionist. Until then, here are a few general guidelines:

• Saturated fats – avoid them. Saturated fats should make up less than seven percent of your daily caloric intake.

• Fruits and vegetables – have at least 4.5 cups of fruits and vegetables per day.

• Meat and fi sh – limit your processed meat intake to no more than 2 servings per week. As a replacement, consider fi sh. It is advised that you have at least two 3.5-ounce serv-ings per week.

• Fiber – include fiber in your daily diet. Have at least 3 one-ounce servings per day, preferably in the form of whole grains.

• Sodium – limit your intake to no more than 1,500 mg per day. And remember, sodium and salt are not synonyms. Read your labels carefully.

• Labels – check them. Know what you’re putting in your body. One of the best ways to know if you have a heart-healthy food in your hands is to look for the American Heart Association’s seal of approval. However, in the absence of that, get used to reading nutrition labels and learn how to tell what’s healthy and what’s not.

• Portions – anything in excess is a bad thing. Eat in moderation and when you’re not hungry, don’t eat.

EXERCISEHand in hand with a proper diet is exercise. Exercise can take many forms, from walking and running to aerobics and weight lifting. What you are able and/or advised to do will differ depending on your current health, fi tness level, ability, age and weight. All that matters is that you move.

STRESSYou know that stress affects your daily function-ing. On the days that you are most stressed, everything seems a little more harried and a little less manageable. But did you know that stress can also affect your heart?

The effects take different forms and, in fact, doctors are still trying to fi gure out exactly what links stress and heart disease. However, it is known that when you are constantly stressed, your body, and thus your heart, are in a con-stant, heightened (and unhealthy in the long-term) state. So here are a few tips on how to keep the stress levels down:

• Stay positive – instead of using “I can’t” and similar negative statements, think about what you can do. Affi rming yourself and your abilities goes a long way.

• Take time for yourself.• Do things that bring you pleasure.• Employ emergency stress busters – count to

ten, or take a few deep breaths or a quick walk. Figure out what takes you from boil-ing to calm and cool (or at least down to a simmer).

• Meditate.• Exercise – for some exercise is one of the

great stress relievers. • Eliminate unhealthy habits.You can eat well, exercise regularly and be

stress-free as often as humanly possible, but you can still be at risk for heart disease, thanks to your unhealthy habits. The number one unhealthy habit is smoking. As hard as it may be to stop, it is also vital to your heart and your health. Excessive drinking and other habits can put you at risk, as well. Check with your doctor to fi nd out what needs to be cut and what needs to be added for your optimal heart health. ■

Information for this patient handout was gath-

ered from the American Heart Association (www.

heart.org).

[ PATIENT HANDOUT ]

DISCLAIMER: Your doctor or therapist has given you this patient handout to further explain or remind you about an issue related

to your health. This handout is a general guide only. If you have specifi c questions, discuss them with your doctor or therapist.

How to Be Heart Healthy

AD

VAN

CE

www.heart.org/nutrition 1

Test Your Sodium Smarts Quiz You may be surprised to learn how much sodium is in many foods. Sodium, including sodium chloride or salt, can come from natural sources or be added to foods. High-sodium diets are linked to increased blood pressure and a higher risk for heart disease and stroke. The American Heart Association recommends that you aim to eat less than 1,500 mg of sodium per day. When you buy prepared and packaged foods, you can read the amount of sodium in the product per serving, in milligrams (mg), by looking at the Nutrition Facts panel. Read the Nutrition Facts panel for the overall nutrition information — including calorie, fat and sodium content — before you make food choices. Select and prepare foods with little or no salt. Test your sodium smarts by answering the questions below about which food products are higher in sodiu m. Most examples use the USDA National Nutrient Database for Standard Reference, which shows the average nutrient values of multiple commercially prepared food products of the same type. Sodium amounts can vary depending on the brand, which is why we are showing averages. We’ve chosen “regular” or “traditional” varieties of foods as examples to illustrate their high sodium content. When you shop, we recommend that you select sodium-free, low-sodium, or reduced-sodium foods whenever they are available to reduce your sodium consumption. Q1. Which food has more sodium? Check the item you believe has more sodium.

A.) Raisin bread (enriched) 1 large slice (32g)

B.) French or Vienna bread (including sourdough) 1 small slice (32g)

Q2. Which food has more sodium? Check the item you believe has more sodium.

A.) American cheese (pasteurized process, low-fat) 1 slice (21g)

B.) Swiss cheese (low-fat) 1 slice (28g)


A.) Potato salad 1/3 cup (95g)

B.) Mashed potatoes (fast-foods) 1/3 cup (80g)


A.) Raisin bran flake cereal 1 cup (59g)

B.) Raisin-cinnamon English muffin 1 (57g)


Test Your Sodium Smarts Quiz


A.) Potato chips (plain, salted) 1 ounce (28g)

B.) Pretzels (hard, plain, salted) 1 ounce (28g)


A.) Reduced-fat Italian dressing 2 tbsp (30g)

B.) Reduced-fat ranch dressing 2 tbsp (30g)


A.) Ham (sliced, regular) 2 slices (56g)

B.) Turkey breast (oven roasted) 2 sliced (56g)


A.) Pasta sauce (spaghetti/marinara) ½ cup (128g)

B.) Pasta sauce (Alfredo) ½ cup (124g)


A.) Tomato soup (ready-to-serve) 1 cup (245g)

B.) Chicken noodle soup (ready-to-serve) 1 cup (245g)


A.) Soy sauce 1 tbsp (18g)

B.) Teriyaki sauce 1 tbsp (18g)


Test Your Sodium Smarts Quiz (Answer Key)

Q1. The correct answer is: B.) 1 small slice of French bread has more sodium. No matter how you slice it, bread is one of the most common sources of sodium. Sodium is added to bread to help with the texture and rising action of the dough. The amount of sodium differs by bread type and can add up quickly when you eat more than one slice.

A.) Raisin bread (enriched) 1 large slice (32g); Sodium – 125 mg

B.) French or Vienna bread (including sourdough) 1 small slice (32g); Sodium – 208 mg

Q2. The correct answer is: A.) 1 slice of American cheese has more sodium. American cheese is a highly processed “cheese-like” product. Highly processed foods tend to be high in sodium because food manufacturers use salt or other sodium-containing compounds to preserve food and to improve their taste and texture.

A.) American cheese (pasteurized process, low-fat) 1 slice (21g); Sodium – 300mg

B.) Swiss cheese (low-fat) 1 slice (28g); Sodium – 73mg

Q3. The correct answer is: A.) 1/3 cup of potato salad has more sodium. Salt is often added to commercially prepared (e.g., store-bought) potato salad for taste. You can make potato salad with a low-sodium recipe that uses herbs and spices.

A.) Potato salad 1/3 cup (95g); Sodium – 312mg

B.) Mashed potatoes (fast-foods) 1/3 cup (80g); Sodium – 182mg

Q4. The correct answer is: A.) 1 cup of raisin bran cereal has more sodium. Since raisin bran tastes “sweet,” it may come as a surprise as to how much sodium can be in commercial breakfast cereals. Salt is added to sweet foods in processing to enhance their flavor, so even sweet-tasting cereals like raisin bran can have lots of sodium.

A.) Raisin bran flake cereal 1 cup (59g); Sodium – 342mg

B.) Raisin-cinnamon English muffin 1 (57g); Sodium – 189mg

Q5. The correct answer is: B.) 1 ounce (28g) of hard pretzels has more sodium. Don’t get the facts twisted — Hard pretzels can have more sodium for the same total weight than potato chips, because salt is added to hard pretzels for texture, not just for taste. For potato chips, salt is added at the end of food processing and applied on the surface to enhance the flavor. To limit your sodium consumption, buy unsalted potato chips and pretzels. But remember that unsalted potato chips have virtually no sodium, while unsalted pretzels can pack 82 mg per ounce.

A.) Potato chips (plain, salted0 1 ounce (28g); Sodium – 149mg

B.) Pretzels (hard, plain, salted) 1 ounce (28g); Sodium – 385mg

Q6. The correct answer is: A.) 2 tablespoons of Italian salad dressing has more sodium. Prepared salad dressings can be high in sodium, depending on the dressing type, other ingredients and taste preference. Be sure to select low-sodium salad dressings or use a low-sodium recipe to whip up a salad dressing at home.

A.) Reduced-fat Italian salad dressing 2tsp (30g); Sodium – 410mg

B.) Reduced-fat ranch salad dressing 2 tbsp (30g); Sodium – 273mg

Q7. The correct answer is: A.) 2 slices of regular ham has more sodium. Sodium in processed meats like ham, bacon and hot dogs can come from salt added for taste and sodium-containing ingredients used as preservatives to enhance the color or retain moisture. The American Heart Association recommends that you limit the consumption of processed meats to no more than two servings a week.

A.) Ham (sliced, regular) 2 slices (56g); Sodium – 730mg

B.) Turkey breast (oven roasted) 2 slices (56g); Sodium – 540mg

Q8. The correct answer is: B.) ½ cup of Alfredo pasta sauce has more sodium. Alfredo sauce has more sodium, calories and fats than spaghetti/marinara sauce. Prepared pasta sauces are traditionally very high in sodium, although the sodium content can vary greatly depending on the brand and flavor. Several food manufacturers have offered products with less sodium.

A.) Pasta sauce (spaghetti/marinara) ½ cup (128g); Sodium – 525mg

B.) Pasta sauce (Alfredo) ½ cup (124g); Sodium – 760mg

Q9. The correct answer is: B.) 1 cup of chicken noodle soup has more sodium. Salt may be more necessary to provide taste for traditional canned chicken noodle soup than tomato soup, but here is the scoop on soup: All canned varieties can have high amounts of sodium. In recent years, tasty soups with less sodium have become available — pick these whenever you can.

A.) Tomato soup (ready-to-serve) 1 cup (245g); Sodium – 789mg

B.) Chicken noodle soup (ready-to-serve) 1 cup (245g); Sodium – 840mg

Q10. The correct answer is: A.) 1 tbsp of soy sauce has more sodium. Not surprised? The big surprise may be how high in sodium both soy sauce and teriyaki sauce can be. The 1,006 mg of sodium per 1 tablespoon (tbsp) of soy sauce is almost equivalent to that contained in ½ teaspoon (tsp) of salt (1,150 mg). Choose low-sodium or light soy sauce at grocery stores and restaurants.

A.) Soy sauce 1 tbsp (18g); Sodium – 1006mg

B.) Teriyaki sauce 1 tbsp (18g);Sodium – 690mg

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