873
Comparison Between an Indoor and an Outdoor 6-Minute
Walk Test Among Individuals With Chronic Obstructive
Pulmonary Disease
Dina Brooks, PhD, Sherra Solway, MSc, Krisztina Weinacht, Dip(PT), David Wang, MSc, Scott Thomas, PhD
ABSTRACT. Brooks D, Solway S, Weinacht K, Wang D,
Thomas S. Comparison between an indoor and an outdoor
6-minute walk test among individuals with chronic obstructive
pulmonary disease. Arch Phys Med Rehabil 2003;84:873-6.
Objectives: To investigate the feasibility of an outdoor
6-minute walk test (6MWT) as a measure of functional status
among individuals with chronic obstructive pulmonary disease
(COPD), and to examine the relationship between performance
on an indoor and an outdoor 6MWT.
Design: An experimental, repeated-measures crossover de-
sign. Subjects were studied on 2 separate days in the same
week. Two 6MWTs— one indoors and the other outdoors—
were performed on each study day, with a rest in between. The
test order was randomly selected on the first day and reversed
on the second day. Outdoor tests were performed on days of
moderate weather conditions (mean temperature ⫾ standard
deviation, 21°⫾3°C; mean wind speed, 15⫾7km/h; no precip-
itation) and on a flat surface (sidewalk).
Setting: Outpatient rehabilitation program in Ontario.
Participants: Eighteen subjects with COPD (10 men, 8
women; age, 70⫾8y), 5 using supplemental oxygen at rest
(forced expiratory volume in 1s, 1.0⫾0.3L; 42%⫾8% of pre-
dicted).
Interventions: Not applicable.
Main Outcome Measures: Distance walked in 6 minutes
(in meters), duration of rest (in seconds), and change in rate of
perceived dyspnea.
Results: There was no significant effect of setting (indoors
vs outdoors) on distance walked (394⫾86m vs 398⫾84m,
P⫽0.4), duration of rest (13⫾28s vs 9⫾20s, P⫽0.4), or change
in rate of perceived dyspnea (2.3⫾1.7 vs 2.3⫾2.0, P⫽0.8).
Testing day had no significant effect on walk test performance
(all P⬎0.1).
Conclusions: The results indicate that the 6MWT performed
outdoors within reasonable climatic parameters may be reflec-
tive of 6MWT performance indoors.
Key Words: Exercise test; Exercise tolerance; Pulmonary
disease, chronic obstructive; Rehabilitation; Walking
© 2003 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Physical Therapy (Brooks, Solway, Wang, Thomas),
University of Toronto; Institute for Work & Health and Toronto Rehabilitation
Institute (Solway); and Toronto East General Hospital (Weinacht), Toronto, ON,
Canada.
Supported by the Ontario Respiratory Care Society and Ontario Lung Association.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Dina Brooks, PhD, Dept of Physical Therapy, University of
Toronto, 500 University Ave, Rm 848, Toronto, ON M5G 1V7, Canada, e-mail:
dina.brooks@utoronto.ca.
0003-9993/03/8406-7772$30.00/0
doi:10.1016/S0003-9993(03)00011-X
NDIVIDUALS WITH CHRONIC obstructive pulmonary
Ilevels
disease (COPD) show variable exercise capacity and activity
that do not necessarily correlate with severity of airflow
obstruction.1-4 Measures of functional status are commonly
used in this population and are essential for optimal clinical
management.2,5 In a national survey of pulmonary rehabilita-
tion programs in Canada, 98% of respondents reported inclu-
sion of a measure of functional exercise capacity, usually the
6-minute walk test (6MWT) or the 12-minute walk test.6
The 6MWT is a valid measure of functional status com-
monly used for evaluating individuals with COPD.7 Typically,
this test is administered in an enclosed indoor corridor, free of
distractions, and patients are asked to cover as much distance
as they can in 6 minutes.2 This environment is somewhat
artificial and may not reflect activities that individuals usually
do on a daily basis.
There is no literature on the amount of time that individuals
with advanced pulmonary disease spend indoors versus out-
doors. Nevertheless, activities of daily living (ADLs) likely
require them to ambulate outdoors regularly (eg, walking from
their car to a doctor’s office, shopping mall, or grocery store).
Many of these individuals will have experience with pulmo-
nary rehabilitation programs, in which they are encouraged to
maintain their exercise program by ambulating. From our clin-
ical experience, individuals with COPD value the opportunity
to exercise outdoors. Furthermore, health care professionals in
pulmonary rehabilitation programs use the results of the indoor
6MWT to advise individuals with COPD about activities out-
doors. Such recommendations are based on the health care
professional’s clinical experience and not on any scientific
evidence. Finally, clinicians making home visits or those in
community clinics may not have access to the indoor space
required for the 6MWT, making an outdoor 6MWT a desirable
alternative for evaluating functional status in these environ-
ments.
Thus, the purpose of this study was to investigate the feasi-
bility of an outdoor 6MWT as a measure of functional status
among individuals with COPD and to determine the relation-
ship between performance on an indoor and an outdoor
6MWT.
METHODS
Participants
Subjects were recruited from the outpatient pulmonary re-
habilitation program at Toronto East General Hospital, in To-
ronto, ON, Canada. Subjects were considered eligible for the
study if they were clinically stable with a diagnosis of COPD,8
were between 55 and 85 years of age, had a forced expiratory
volume in 1 second (FEV1) of less than 60% of predicted, and
reported dyspnea or fatigue with ADLs. Exclusion criteria
included the presence of associated medical conditions that
limited exercise tolerance (eg, symptomatic cardiovascular or
musculoskeletal conditions, recent surgery), inability to com-
municate in English, or the use of a mobility aid. The rationale
Arch Phys Med Rehabil Vol 84, June 2003
874 AN OUTDOOR 6-MINUTE WALK TEST, Brooks
for the last criteria was that the use of a mobility aid could alter
performance outdoors because of changes in the terrain and
that these alterations may be difficult to differentiate from
differences unrelated to aids in a small sample.
Protocol
The Research Ethics Boards at the University of Toronto and
Toronto East General Hospital approved the study. All subjects
gave informed written consent. A randomized crossover design
was used. Each subject was studied at the same time of the day
on 2 separate days in the same week. Subjects were asked to
abstain from caffeine for 4 hours before each session and to
administer their inhaled bronchodilator 30 minutes before each
session. Subjects wore the same footwear on both study days.
On each study day, two 6MWTs were performed with a
minimum of a 30-minute rest between tests (or when perceived
dyspnea, heart rate, and oxygen saturation returned to baseline
levels). One walk test was performed indoors and the other
outdoors. The test order was randomized for the first day and
reversed on the second day. The indoor 6MWT was adminis-
tered in a corridor, 30m in length. Pylons were placed at either
end of the course. The tests were performed under quiet con-
ditions, with a minimum of distractions and corridor traffic.
The outdoor 6MWT was performed by using the same length
of flat sidewalk, in a quiet neighborhood. Outdoor tests were
performed on days in which the weather was “reasonable,”
which was defined as an “apparent” temperature (a composite
of ambient temperature and humidity) of 10° to 25°C, no
precipitation, wind speed of less than 20km/h, and an air
quality index of less than 32. The air quality index ranges from
0 to more than 100, with 0 to 15 representing very good air
quality; 16 to 31, good; 32 to 49, moderate; 50 to 99, poor; and
100 or more, very poor.9 A value below 32 has no known
health effects for the majority of the population.9 Weather
variables were not directly measured; this information was
taken from a weather report website corresponding to the
location and time each outdoor walk test was administered.
All subjects performed at least 2 practice walks before data
collection, to control for learning and practice effects.7 Stan-
dardized instructions were provided to subjects and no encour-
agement was offered during the tests.10 Subjects were re-
quested to cover as much ground as possible during the test
period, stopping only if they felt too tired or too breathless to
continue, and to resume walking as soon as they were able to
do so. The tester accompanied the subjects for each walk test
and walked behind the subject to avoid pacing. A folding chair
was used for sitting if the subject required a rest. Subjects using
supplemental oxygen carried or pulled their tank during each
6MWT.
Measures
For each 6MWT, we recorded distance walked and the
number and duration of rests, and we monitored oxyhemoglo-
bin saturation and heart rate continuously by using a pulse
oximeter.a The oximeter provided a printout of values reflect-
ing maximum and minimum recorded and the mean of the
complete duration (value used in analysis). At the start and at
the end of each test, subjects rated their perceived rate of
dyspnea (“difficulty of breathing”) by using a modified Borg
Scale.11 By using the same scale, subjects were also asked to
rate their perceived leg effort. Furthermore, a self-report of
how the climate affected performance and preference between
the indoor and the outdoor 6MWT was recorded by means of
a simple standardized questionnaire. This brief questionnaire
was piloted for suitability and clarity. Subjects were asked to
identify factors that influenced their ability to walk outdoors
Arch Phys Med Rehabil Vol 84, June 2003
from a list of possible factors (temperature, wind, pollution,
humidity, other).
Functional status was also evaluated by using the modified
version of the Pulmonary Functional Status and Dyspnea Ques-
tionnaire (PSFDQ-M) on the first study day before the start of
testing. The PSFDQ is a 40-item, self-administered functional
status and symptoms (dyspnea and fatigue) questionnaire that
requires less than 10 minutes to complete.12,13 Psychometric
properties of this questionnaire (eg, internal consistency, test-
retest reliability, construct validity) have been established in
adult patients with pulmonary disease.12-14
The questionnaire includes 3 domains: dyspnea, fatigue, and
activity level. For the activity domain, a list of 10 ADLs (eg,
brushing/combing hair, walking) are included, and subjects
were asked to indicate “involvement with the activity now as
compared to before you developed lung problems.” A scale of
0 (as active as I have ever been) to 10 (have omitted entirely)
was used. The same activities were listed again, and the sub-
jects were asked to rate each according to the degree of short-
ness of breath (dyspnea domain) and tiredness (fatigue domain)
experienced. A scale of 0 (none) to 10 (very severe) was used.
Within each domain, the values assigned for each activity were
summed and divided by the number of activities that applied.
Thus, for each domain, the score could range from 0 (minimal
limitation) to 100 (maximal limitation).11
Statistical Analysis
A sample size estimation using a 2-tailed paired t test with a
type I error of .05 and power of 90% determined that a
clinically significant difference in 6MWT distance5 (ie, 54m)
would be detected with a minimum of 16 subjects (standard
deviation [SD], 86m).
Means and SDs were calculated for all outcomes. Descrip-
tive statistics (including frequencies) were also used for subject
characteristics (eg, age, FEV1) and subject preference. A total
of four 6MWTs were performed; two 6MWTs were performed
on each day, one indoors and the other outdoors. To determine
the effect of environment, analyses were performed by using
2-way repeated-measures analysis of variance. The 2 factors
were day (1, 2) and environment (indoors, outdoors). Linear
regression was calculated to examine the relationship between
the distance walked indoors and outdoors. Intraclass correla-
tion coefficients (ICCs) were calculated to represent test-retest
reliability for day and setting. To determine if there was an
association between self-report level of functional status and
outdoor walk test performance, univariate regression was used
to explore the relationship between distance walked outdoors
and PFSDQ-M scores. To determine whether more function-
ally disabled individuals had a greater deterioration in the
outdoor walk test as compared with the indoor walk test, we
also explored the relationship between the change in the dis-
tance walked indoors minus outdoors and PFSDQ-M scores.
SigmaStat, version 2.03,b and SigmaPlot, version 5.0,b statis-
tical softwares were used for all analyses; a P value of .05 or
less was considered significant.
RESULTS
Eighteen individuals with a medical diagnosis of COPD
participated in the study. The characteristics of these subjects
are presented in table 1.
The outdoor 6MWTs were performed on comparable days
with respect to climatic variables—that is, temperature, humi-
dex, and wind speed (all P⬎0.2). The combined data for all
days are presented in table 2.
 AN OUTDOOR 6-MINUTE WALK TEST, Brooks 875

Table 1: Characteristics of the Subjects (Nⴝ18)

Mean ⫾ SD (Range)

Age (y) 70⫾8 (52–81)

FEV1 (L) 1.0⫾0.3 (0.5–1.5)
FEV1 (% predicted) 42⫾8 (28–42)
Sex 10 men, 8 women
Oxygen use (L) (n⫽5) 2.9⫾0.7 (2–4)

Figure 1 shows distance walked indoors and outdoors for

each subject. There was no effect of setting on distance walked
(indoors: 394⫾86m vs outdoors: 398⫾84m, P⫽0.4). Duration
of rest was 13⫾28 seconds for the indoor tests and 9⫾20
seconds for the outdoor tests (P⫽0.4). Furthermore, setting had
no effect on the change in rate of perceived dyspnea (indoors:
2.3⫾1.7 vs outdoors: 2.3⫾2.0, P⫽0.8) or perceived leg effort
(indoors: 1.1⫾1.0 vs outdoors: 0.9⫾0.8, P⫽0.6) (fig 2). Actual
values for rate of perceived exertion are presented in table 3.
Similarly, setting did not influence mean heart rate or oxygen
saturation (SpO2) during the test (P⬍0.3) (fig 3). Day of testing Fig 1. Total distance walked indoors and outdoors. Open circles
represent individual data points. Solid squares represent mean ⴞ SD.
had no significant effect on any of the variables examined (all
P⬎0.1), which indicates that the test was reliable on 2 separate
days (ICC⫽.94). Linear regression between distance walked
indoors from the 2 trials and the distance walked outdoors rial disease, surgical patients, and pediatric patients.7 A recent
revealed a significant correlation (r⫽.97, P⬍.001, slope⫽.99, systematic review of functional walk tests by our group con-
intercept⫽⫺.64), and an ICC of .95. cluded that the psychometric properties of the 6MWT have
Forty-two percent of the subjects had no preference for the been well researched and established, and we have recom-
environment of testing, whereas 36% preferred the indoor mended the 6MWT as the test of choice for clinical and
setting and 22% preferred the outdoor. When asked which research use.7
climatic variable influenced their performance, 30% of respon- An outdoor 6MWT test is more reflective of real life and is
dents identified temperature, 14% wind, 19% pollution, and not as artificial as the conventional 6MWT, in which an indoor
11% humidity. corridor, free of distractions, is used. One of the objectives of
The PFSDQ-M reflected minimal impairment for dyspnea this study was to compare performance on the indoor and on
(1.9⫾1.6; range, 0.1–5.0), fatigue (1.7⫾1.5; range, 0.1–5.6), the outdoor walk tests. The data indicate that the 6MWT
and activity (2.1⫾1.6; range, 0.1–5.0). There was no significant indoors is strongly correlated to the test performed outdoors.
correlation between distance walked outdoors and each of the This finding will enable health care professionals to use the
3 dimensions (r⬍0.2, P⬎0.6) or between the distance walked results of indoor performance to predict outdoor performance
indoors and the 3 dimensions (r⬍0.1, P⬎0.7). Similarly, there and vice versa. Additionally, the results of this study will allow
were no significant correlation between the difference in dis- health care professionals to use the 6MWT in the community
tance walked indoors and outdoors and the PFSDQ-M sub- (ie, during a home visit), to measure functional status and to
scales scores (r⬍0.2, P⬎0.5). monitor treatment effectiveness, when an indoor corridor is not
available.
DISCUSSION The perception of individuals with COPD of the effect of the
The findings indicate that when performed within reasonable environment on functional capacity has not been investigated.
climatic conditions, the outdoor 6MWT is a feasible measure Despite no difference between performance indoors and out-
of functional status among individuals with COPD. Further- doors, slightly more subjects preferred the indoor setting (36%)
more, the outdoor 6MWT test was reproducible on 2 separate
days, and subjects’ performance did not differ significantly
from that indoors.
We were unable to locate any studies that included an
outdoor 6MWT. However, considerable attention has been
given to the indoor 6MWT, especially in recent years. The use
of the 6MWT has been studied in different populations, includ-
ing individuals with COPD, individuals with heart failure,
individuals with pacemakers, individuals with peripheral arte-

Table 2: Summary of Climatic Variables for the Outdoor Tests

Climatic Variables Mean ⫾ SD (Range)

Fig 2. Comparison of change in perceived dyspnea and leg effort
Temperature (°C) 21⫾3 (16–25.5)
ratings when walking indoors and outdoors. Open circles represent
“Apparent” temperature (°C) 25⫾4 (17–32) individual data points. Solid squares represent mean ⴞ SD. There
Wind speed (km/h) 15⫾7 (5–33) are several individual points at 0 that are reflected by 1 data point
only.

Arch Phys Med Rehabil Vol 84, June 2003

876 AN OUTDOOR 6-MINUTE WALK TEST, Brooks
Table 3: Actual Values for Modified Borg Ratings of Perceived Dyspnea and Leg Effort Before and After 6MWT Indoors and Outdoors
Day 1 (mean ⫾ SD)
Indoors Outdoors
Perceived
Rating Before After Before
Dyspnea 0.5⫾0.8 2.7⫾1.9 0.8⫾0.8
Leg effort 0.5⫾0.9 1.6⫾1.3 0.3⫾0.4
to the outdoor setting (22%). Temperature was the main factor
perceived as influencing ability to walk outside.
The finding that the distance walked outdoors did not cor-
relate with PFSDQ-M scores was not surprising. The 2 mea-
sures provide different information on functional capacity: the
PFSDQ-M examines various ADLs (1 component of which is
walking), and the 6MWT assesses the ability to walk. How-
ever, our sample included individuals at a high level of func-
tion, as shown by the low scores on the PFSDQ-M and indoor
6MWT distances greater than 300m. Studies have indicated
that 300m on the 6MWT is a threshold for level of disability
among individuals with respiratory disease, including those
with COPD.15-17 Thus, it is possible that individuals with
greater disability (eg, 6MWT distances ⬍300m) may be influ-
enced by the outdoor environment.
Two studies18,19 have reported distances walked in 6 minutes
by healthy subjects. In the healthy elderly (aged 60 – 65y), the
distances walked in 6 minutes ranged from 494 to 631m. These
values are higher than those observed in our sample, in which
the distances walked in 6 minutes were between 390 and 400m.
Therefore, although our sample was high functioning com-
pared with others with COPD, they had more disability than a
healthy population.
Limited ranges of climatic parameters were used in this
study. Future studies will need to investigate the effect of a
broader range of environmental factors (eg, more extreme
conditions, ie, colder temperature, higher winds, pollution hu-
midity levels, and different terrains) and walking aids on out-
door performance, to expand our understanding of the feasi-
bility and validity of using the 6MWT as a measure of
functional status in an outdoor setting.
CONCLUSION
The data indicate that the 6MWT performed outdoors within
reasonable climatic parameters may be reflective of 6MWT
performance indoors. Therefore, an outdoor 6MWT may be an
alternative option to the traditional 6MWT for use in the
community when an indoor corridor is not available. Future
Fig 3. Mean oxygen saturation and heart rate during the 6MWT
when walking indoors and outdoors. Open circles represent indi-
vidual data points. Solid squares represent mean ⴞ SD. Note that
the y axis does not start at zero.
Arch Phys Med Rehabil Vol 84, June 2003
Day 2 (mean ⫾ SD)
Indoors Outdoors
After Before After Before After
3.0⫾2.3 0.5⫾0.5 2.9⫾1.8 0.5⫾0.7 3.0⫾2.2
1.4⫾1.3 0.4⫾0.5 1.4⫾1.3 0.4⫾0.6 1.1⫾0.9
studies are needed to increase the generalizability of these
findings.
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