Commentary on: “Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties”

In their article, Salbach et al1 collected and evaluated time-limited walk tests used with individuals poststroke, focusing on protocols and measurement properties. The authors found that previous studies have primarily investigated the 6-minute walk test (6MWT) and that this test is a valid, reliable tool for assessing functional walking capacity in the poststroke population.1 The 6MWT will be the focus of this commentary, which aims to further explain some of the findings of the review and expand on the authors' recommendations for clinical utility and future research. The 6MWT has construct validity to evaluate functional walking capacity in the 3 primary phases of rehabilitation poststroke: acute (<1 month), subacute (1-6 months), and chronic (>6 months). This means that the 6MWT accurately reflects the individual's endurance and ability to complete the walking required in many activities of daily life. Individuals' 6MWT performance demonstrates moderate to strong correlation with their balance self-efficacy and aerobic capacity in all 3 phases of rehabilitation and is predictive of their health-related quality of life and physical activity. The 6MWT was found to have strong test-retest reliability in both the subacute and chronic populations and likely is reliable for use in acute populations as well. Therefore, results are highly reproducible, and the test can be used with confidence in the clinical setting across evaluation sessions. Minimal detectable change (MDC) values for the 6MWT have been established at a 90% confidence level. The findings across various studies show that the therapist can be 90% confident there was true change between testing sessions if the stroke survivor improved by 39 to 52 m (subacute) or 28 to 42 m (chronic). The variance in MDC distances is likely due to differences among studies in both sample characteristics and testing protocols. Salbach et al1 found wide variability in the way the 6MWTs were administered, including walkway length, the number of turns required, shape of the walkway, instructions for speed of walking, encouragement, the use of walking aids, and whether physical assistance was provided. All of these factors can influence the ability to compare performance to established MDC or normative values. Walking capacity and endurance are essential aspects of community ambulation that are often lacking in stroke survivors who are deconditioned.2 Community ambulation has speed, distance, and surface negotiation requirements.3 Deficits in the distance component of community ambulation can be identified using the 6MWT. These deficits can then be addressed by incorporating endurance and capacity-building activities into the rehabilitation treatment plan. Performance on the 6MWT can be used to guide treatment and help stroke survivors fully reintegrate into the community. 2 The 6MWT has clear evidence to support its use for evaluating walking capacity across the continuum of care and is recommended by both the Canadian Stroke Network and the Academy of Neurologic Physical Therapy StrokEDGE task force. So, why aren't clinicians using it more? There have been several studies to evaluate clinicians' perceptions of standardized tests, and specifically walking tests, in the poststroke population. In Canada, where standardized physical therapy protocols exist for the evaluation of individuals poststroke, standardized tests such as the Chedoke-McMaster Stroke Assessment (which includes a 2-minute walk test), the Functional Independence Measure, gait speed tests, the Timed Up and Go, and the 6MWT were the most-utilized walking tests. Yet, measures of walking ability were not used regularly by more than 50% of physical therapists in one study4 and 28% in another.5 Identified barriers to the use of these measures included lack of knowledge and comfort with the test, physical barriers such as space and ability to permanently mark distances, and limited belief that the test has value. Physical therapists cited observational gait analysis and their own clinical judgment as more trusted methods, especially for evaluation of patients who were not independent ambulators, and for those with cognitive impairments. There was also a consensus that it is difficult to standardize measures across the continuum of care because goals are different in the different settings and the testing should reflect those differences.5 To improve clinical utility, these barriers must be further investigated and addressed in any future protocol recommendations. However, on the basis of this systematic review's recommendations, clinicians can and should use the 6MWT, as it has clinical value. Utilizing the American Thoracic Society's 6MWT protocol6 is recommended across the continuum of care. Limiting test application to independent or balance-assisted ambulators without severe cognitive impairments is also recommended. Performing the test without a practice trial addresses time limitations. Protocol deviations required by individual needs, space limitations, or site barriers should be clearly documented so that deviations in protocol can be repeated in subsequent tests across the continuum of care. Administration of the 6MWT is fairly straightforward, but if needed, inservices by clinicians or physical therapy students familiar with the test can provide appropriate training for physical therapists unfamiliar with the test.5 The goal is to have standardization for improved interpretation of findings, but without significant rigor that may limit the measure's clinical utility. While normative values for the 6MWT are available for healthy populations and for stroke survivors, these serve only as guidelines. These values may not be generalizable to patients who differ significantly from typical patients or to patients assessed using a different 6MWT protocol. Steffen et al7 reported normative data for a cohort of 96 community-dwelling older adults with protocol parameters similar to the American Thoracic Society protocol. These values can be used for goal setting for patients poststroke.7 In addition, findings from a systematic review8 of stroke survivor's performance on the 6MWT are also provided in Figure 1.Figure 1.: 6MWT normative data.3 , 7 , 9Further research is recommended to clarify 6MWT protocols. It is clinically relevant to establish practicability and reliability across the continuum of care. Determining perceptions and barriers within US settings and insurance requirements is important as they may differ from those found in Canada. In addition, it would be useful to establish normative values for stroke survivors across functional ambulation categories using a standard protocol. Clinicians' discharge planning could be aided by determining ranges that predict likely discharge destinations for subacute populations. The 6MWT is an existing, well-studied, recommended test for evaluating walking capacity, and change in walking capacity over time, among stroke survivors in various stages of recovery. While barriers to implementation and opportunities for further clarifying research exist, 6MWT has immediate application across the continuum of care during stroke recovery. The 6MWT offers clinicians a guideline to judge walking capacity and can inform the treatment plan to promote active community participation.

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