Exploring the Learning Effect of the 6-minute Walk Test in Patients with Arterial Hypertension

Kaoutar Kabbadj, Faiza Aziouaz, Abdelkader Jalil El Hangouche

Abstract


Background: The 6-minute walk test (6MWT) is widely used for assessing functional capacity in various clinical populations. However, the presence and extent of a learning effect in hypertensive patients remain insufficiently explored, particularly in Moroccan populations. Objective: This study aims to evaluate the learning effect in the 6MWT among hypertensive patients and to identify potential predictors influencing performance variation across repeated tests. Methods: This is a cross-sectional study in which 90 hypertensive patients completed three consecutive 6MWTs on the same day, with a 30-minute rest period between each trial. The distance walked was measured in meters during each test, while heart rate, blood pressure, and perceived exertion (Borg scale) were recorded before and after each test. Effect sizes were calculated to assess the magnitude of performance changes. Regression analyses were performed to explore potential predictors of the learning effect. Results: A significant improvement in walking distance was observed between the first and second trials (5.11% increase; Cohen’s d = -1.57; p < 0.001), with no further significant changes between the second and third trials (Cohen’s d = 0.15; p = 0.152). The Kruskal-Wallis test analysis revealed that baseline walking distance significantly influenced the learning effect (p < 0.001, η² ≈ 0.210). Among all variables examined, baseline walking distance emerged as the only significant predictor, with participants who walked less than 300 meters during the first 6MWT trial exhibiting a markedly smaller improvement between trials compared to those with higher initial performance. No significant associations were found with other clinical or demographic factors (p for gender = 0.501; p for weight = 0.334; p for height = 0.387; p for BMI = 0.524; p for physical activity = 0.966). Conclusion: The results demonstrate a clear learning effect in hypertensive patients performing the 6MWT, stabilizing after the second trial. These findings underscore the importance of conducting at least two 6MWTs to accurately assess this population’s functional capacity. Repeated trials in routine practice may help avoid underestimating patients’ true exercise tolerance, thereby aiding more tailored rehabilitation planning.

Keywords


Walk Test, Hypertension, Exercise Test, Physical Fitness

Full Text:

PDF

References


Adsett, J., Mullins, R., Hwang, R., Hogden, A., Gibson, E., Houlihan, K., Tuppin, M., Korczyk, D., Mallitt, K.-A., & Mudge, A. (2011). Repeat six-minute walk tests in patients with chronic heart failure : Are they clinically necessary? European Journal of Cardiovascular Prevention & Rehabilitation, 18(4), 601‑606. https://doi.org/10.1177/1741826710389403

Arney, B. E., Glover, R., Fusco, A., Cortis, C., Koning, J. J. de, Erp, T. van, Jaime, S., Mikat, R. P., Porcari, J. P., & Foster, C. (2019). Comparison of RPE (Rating of Perceived Exertion) Scales for Session RPE. https://doi.org/10.1123/ijspp.2018-0637

Asmar, R., Khabouth, J., Topouchian, J., El Feghali, R., & Mattar, J. (2010). Validation of three automatic devices for self-measurement of blood pressure according to the International Protocol : The Omron M3 Intellisense (HEM-7051-E), the Omron M2 Compact (HEM 7102-E), and the Omron R3-I Plus (HEM 6022-E). Blood Pressure Monitoring, 15(1), 49. https://doi.org/10.1097/MBP.0b013e3283354b11

ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. (2002). ATS statement : Guidelines for the six-minute walk test. American Journal of Respiratory and Critical Care Medicine, 166(1), 111‑117. https://doi.org/10.1164/ajrccm.166.1.at1102

Balady, G. J., Arena, R., Sietsema, K., Myers, J., Coke, L., Fletcher, G. F., Forman, D., Franklin, B., Guazzi, M., Gulati, M., Keteyian, S. J., Lavie, C. J., Macko, R., Mancini, D., Milani, R. V., Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, & Interdisciplinary Council on Quality of Care and Outcomes Research. (2010). Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults : A Scientific Statement From the American Heart Association. Circulation, 122(2), 191‑225. https://doi.org/10.1161/CIR.0b013e3181e52e69

Belayachi, S., Boukhari, F. Z., Essayagh, F., Terkiba, O., Marc, I., Lambaki, A., Zohoun, A., Essayagh, M., Essayagh, T., & Essayagh, S. (2024). Uncontrolled blood pressure and its risk factors among hypertensive patients, Marrakech, Morocco. Scientific Reports, 14(1), 2953. https://doi.org/10.1038/s41598-024-53115-y

Bellet, R. N., Adams, L., & Morris, N. R. (2012). The 6-minute walk test in outpatient cardiac rehabilitation : Validity, reliability and responsiveness—a systematic review. Physiotherapy, 98(4), 277‑286. https://doi.org/10.1016/j.physio.2011.11.003

Butland, R. J., Pang, J., Gross, E. R., Woodcock, A. A., & Geddes, D. M. (1982). Two-, six-, and 12-minute walking tests in respiratory disease. British Medical Journal (Clinical research ed.), 284(6329), 1607‑1608.

Celli, B., Tetzlaff, K., Criner, G., Polkey, M. I., Sciurba, F., Casaburi, R., Tal-Singer, R., Kawata, A., Merrill, D., & Rennard, S. (2016). The 6-Minute-Walk Distance Test as a Chronic Obstructive Pulmonary Disease Stratification Tool. Insights from the COPD Biomarker Qualification Consortium. American Journal of Respiratory and Critical Care Medicine, 194(12), 1483‑1493. https://doi.org/10.1164/rccm.201508-1653OC

Cleland, B. T., Ingraham, B. A., Pitluck, M. C., Woo, D., & Ng, A. V. (2016). Reliability and Validity of Ratings of Perceived Exertion in Persons With Multiple Sclerosis. Archives of Physical Medicine and Rehabilitation, 97(6), 974‑982. https://doi.org/10.1016/j.apmr.2016.01.013

Delbressine, J. M., Vaes, A. W., Stoop, W. A. M., Van Ranst, D., Spruit, M. A., & Van ’T Hul, A. (2025). Reproducibility of three 6-min walk tests in patients with COPD referred for pulmonary rehabilitation. Respiratory Medicine, 236, 107884. https://doi.org/10.1016/j.rmed.2024.107884

Eiser, N., Willsher, D., & Doré, C. J. (2003). Reliability, repeatability and sensitivity to change of externally and self-paced walking tests in COPD patients. Respiratory Medicine, 97(4), 407‑414. https://doi.org/10.1053/rmed.2002.1462

Gibbons, W. J., Fruchter, N., Sloan, S., & Levy, R. D. (2001). Reference Values for a Multiple Repetition 6-Minute Walk Test in Healthy Adults Older Than 20 Years. Journal of Cardiopulmonary Rehabilitation and Prevention, 21(2), 87.

Guazzi, M., Adams, V., Conraads, V., Halle, M., Mezzani, A., Vanhees, L., Arena, R., Fletcher, G. F., Forman, D. E., Kitzman, D. W., Lavie, C. J., & Myers, J. (2012). Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations. Circulation, 126(18), 2261‑2274. https://doi.org/10.1161/CIR.0b013e31826fb946

Guyatt, G. H., Sullivan, M. J., Thompson, P. J., & Fallen, E. L. (1985). The 6-minute walk : A new measure of exercise capacity in patients with chronic heart failure. CAN MED ASSOC J, 132.

Hajjar, I., Lackland, D. T., Cupples, L. A., & Lipsitz, L. A. (2007). Association Between Concurrent and Remote Blood Pressure and Disability in Older Adults. Hypertension, 50(6), 1026‑1032. https://doi.org/10.1161/HYPERTENSIONAHA.107.097667

Hamilton, D. M., & Haennel, R. G. (2000). Validity and Reliability of the 6-Minute Walk Test in a Cardiac Rehabilitation Population. Journal of Cardiopulmonary Rehabilitation and Prevention, 20(3), 156.

Hanson, L. C., McBurney, H., & Taylor, N. F. (2012). The retest reliability of the six-minute walk test in patients referred to a cardiac rehabilitation programme. Physiotherapy Research International, 17(1), 55‑61. https://doi.org/10.1002/pri.513

Hernández, N., Torres, S. H., Finol, H. J., & Vera, O. (1999). Capillary changes in skeletal muscle of patients with essential hypertension. The Anatomical Record, 256(4), 425‑432. https://doi.org/10.1002/(SICI)1097-0185(19991201)256:4<425::AID-AR9>3.0.CO;2-X

Iellamo, F., Manzi, V., Caminiti, G., Vitale, C., Massaro, M., Cerrito, A., Rosano, G., & Volterrani, M. (2014). Validation of rate of perceived exertion-based exercise training in patients with heart failure : Insights from autonomic nervous system adaptations. International Journal of Cardiology, 176(2), 394‑398. https://doi.org/10.1016/j.ijcard.2014.07.076

Kervio, G., Carre, F., & Ville, N. S. (2003). Reliability and Intensity of the Six-Minute Walk Test in Healthy Elderly Subjects: Medicine & Science in Sports & Exercise, 35(1), 169‑174. https://doi.org/10.1097/00005768-200301000-00025

Laboratories, A. C. on P. S. for C. P. F. (2002). ATS statement : Guidelines for the six-minute walk test. Am J Respir Crit Care Med, 166, 111‑117.

Macchiavelli, A., Giffone, A., Ferrarello, F., & Paci, M. (2021). Reliability of the six-minute walk test in individuals with stroke : Systematic review and meta-analysis. Neurological Sciences, 42(1), 81‑87. https://doi.org/10.1007/s10072-020-04829-0

Mancia, G., De Backer, G., Dominiczak, A., Cifkova, R., Fagard, R., Germano, G., Grassi, G., Heagerty, A. M., Kjeldsen, S. E., Laurent, S., Narkiewicz, K., Ruilope, L., Rynkiewicz, A., Schmieder, R. E., Boudier, H. A. J. S., Zanchetti, A., Vahanian, A., Camm, J., De Caterina, R., … European Society of Cardiology. (2007). 2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Journal of Hypertension, 25(6), 1105‑1187. https://doi.org/10.1097/HJH.0b013e3281fc975a

Mathis, A. (2023). Accurate Pulse Assessment by Radial Artery Palpation : A Pilot Study. Honors Projects. https://digitalcommons.iwu.edu/nursing_honproj/56

Mungall, I. P., & Hainsworth, R. (1979). Assessment of respiratory function in patients with chronic obstructive airways disease. Thorax, 34(2), 254‑258.

Noonan, V., & Dean, E. (2000). Submaximal Exercise Testing : Clinical Application and Interpretation. Physical Therapy, 80(8), 782‑807. https://doi.org/10.1093/ptj/80.8.782

Pankoff, B. A., Overend, T. J., Lucy, S. D., & White, K. P. (2000). Reliability of the six-minute walk test in people with fibromyalgia. Arthritis Care & Research, 13(5), 291‑295. https://doi.org/10.1002/1529-0131(200010)13:5<291::AID-ANR8>3.0.CO;2-X

PENKO, A. L., BARKLEY, J. E., KOOP, M. M., & ALBERTS, J. L. (2017). Borg scale is valid for ratings of perceived exertion for individuals with Parkinson’s disease. International Journal of Exercise Science, 10(1), 76‑86.

Pepera, G., Ingle, L., & Sandercock, G. R. (2015). Predictors of the 6-minute walk test in patients with chronic heart failure. British Journal of Cardiac Nursing, 10(9), 454‑549. https://doi.org/10.12968/bjca.2015.10.9.454

Purwowiyoto, S. L., & Surya, S. P. (2021). The Six Minute Walk Test as a Marker of Functional Capacity in Hypertensive Patients. Jurnal Epidemiologi Kesehatan Komunitas, 6(2), 254‑260. https://doi.org/10.14710/jekk.v6i2.9742

Ramos, R. A., Guimarães, F. S., Cordovil, I., & De Sa Ferreira, A. (2014). The six-minute walk distance is a marker of hemodynamic-related functional capacity in hypertension : A case–control study. Hypertension Research, 37(8), 746‑752. https://doi.org/10.1038/hr.2014.59

Ramos, R. de A., & Ferreira, A. de S. (2014). Functional capacity in adults with hypertension as assessed by the six-minute walk distance test : Systematic review.

Ribeiro, A., Younes, C., Mayer, D., Fréz, A. R., & Riedi, C. (2011). Teste de caminhada de seis minutos para avaliação de mulheres com fatores de risco cardiovascular. Fisioterapia em Movimento, 24(4), 713‑719. https://doi.org/10.1590/S0103-51502011000400016

Rikli, R. E., & Jones, C. J. (1998). The Reliability and Validity of a 6-Minute Walk Test as a Measure of Physical Endurance in Older Adults. Journal of Aging and Physical Activity, 6(4), 363‑375. https://doi.org/10.1123/japa.6.4.363

Rodrigues, S. L., Mendes, H. F. E., & Viegas, C. A. D. A. (2004). Teste de caminhada de seis minutos : Estudo do efeito do aprendizado em portadores de doença pulmonar obstrutiva crônica. Jornal Brasileiro de Pneumologia, 30(2), 121‑125. https://doi.org/10.1590/S1806-37132004000200008

Rostagno, C., Olivo, G., Comeglio, M., Boddi, V., Banchelli, M., Galanti, G., & Gensini, G. F. (2003). Prognostic value of 6-minute walk corridor test in patients with mild to moderate heart failure : Comparison with other methods of functional evaluation. European Journal of Heart Failure, 5(3), 247‑252. https://doi.org/10.1016/S1388-9842(02)00244-1

Schmidt, K., Vogt, L., Thiel, C., Jäger, E., & Banzer, W. (2013). Validity of the Six-Minute Walk Test in Cancer Patients. International Journal of Sports Medicine, 34(07), 631‑636. https://doi.org/10.1055/s-0032-1323746

Sciurba, F., Criner, G. J., Lee, S. M., Mohsenifar, Z., Shade, D., Slivka, W., & Wise, R. A. (2003). Six-Minute Walk Distance in Chronic Obstructive Pulmonary Disease : Reproducibility and Effect of Walking Course Layout and Length. American Journal of Respiratory and Critical Care Medicine, 167(11), 1522‑1527. https://doi.org/10.1164/rccm.200203-166OC

Solway, S., Brooks, D., Lacasse, Y., & Thomas, S. (2001). A Qualitative Systematic Overview of the Measurement Properties of Functional Walk Tests Used in the Cardiorespiratory Domain. Chest, 119(1), 256‑270. https://doi.org/10.1378/chest.119.1.256

Sousa, N., Furtado, H., Simão, R., Pereira, F., & Vilaça-Alves, J. (2015). Physical exercise and functional fitness in independently living vs institutionalized elderly women : A comparison of 60- to 79-year-old city dwellers. Clinical Interventions in Aging, 795. https://doi.org/10.2147/CIA.S80895

Spencer, L., Zafiropoulos, B., Denniss, W., Fowler, D., Alison, J., & Celermajer, D. (2018). Is there a learning effect when the 6-minute walk test is repeated in people with suspected pulmonary hypertension? Chronic Respiratory Disease, 15(4), 339‑346. https://doi.org/10.1177/1479972317752762

Spruit, M. A., Polkey, M. I., Celli, B., Edwards, L. D., Watkins, M. L., Pinto-Plata, V., Vestbo, J., Calverley, P. M. A., Tal-Singer, R., Agusti, A., Coxson, H. O., Lomas, D. A., MacNee, W., Rennard, S., Silverman, E. K., Crim, C. C., Yates, J., & Wouters, E. F. M. (2012). Predicting Outcomes from 6-Minute Walk Distance in Chronic Obstructive Pulmonary Disease. Journal of the American Medical Directors Association, 13(3), 291‑297. https://doi.org/10.1016/j.jamda.2011.06.009

Topouchian, J., Agnoletti ,Davide, Blacher ,Jacques, Youssef ,Ahmed, Ibanez ,Isabel, Khabouth ,Jose, Khawaja ,Salwa, Beaino ,Layale, & and Asmar, R. (2011). Validation of four automatic devices for self-measurement of blood pressure according to the international protocol of the European Society of Hypertension. Vascular Health and Risk Management, 7(null), 709‑717. https://doi.org/10.2147/VHRM.S27193

Travensolo, C. D. F., Arcuri, J. F., & Polito, M. D. (2020). Validity and reliability of the 6‐min step test in individuals with coronary artery disease. Physiotherapy Research International, 25(1), e1810. https://doi.org/10.1002/pri.1810

Troosters, T., Gosselink, R., & Decramer, M. (1999). Six minute walking distance in healthy elderly subjects. European Respiratory Journal, 14(2), 270‑274. https://doi.org/10.1034/j.1399-3003.1999.14b06.x

Uszko-Lencer, N. H. M. K., Mesquita, R., Janssen, E., Werter, C., Brunner-La Rocca, H.-P., Pitta, F., Wouters, E. F. M., & Spruit, M. A. (2017). Reliability, construct validity and determinants of 6-minute walk test performance in patients with chronic heart failure. International Journal of Cardiology, 240, 285‑290. https://doi.org/10.1016/j.ijcard.2017.02.109

Włoch, T., Mrozińska, A., Piliński, R., Śliwka, A., & Nowobilski, R. (2015). Learning effect of the six-minute walk test in healthy young persons.

World Health Organization [WHO]. (2023). Hypertension. https://www.who.int/news-room/fact-sheets/detail/hypertension

Wu, G., Sanderson, B., & Bittner, V. (2003). The 6-minute walk test : How important is the learning effect? American Heart Journal, 146(1), 129‑133. https://doi.org/10.1016/S0002-8703(03)00119-4

Zielińska, D., Bellwon, J., Rynkiewicz, A., & Elkady, M. A. (2013). Prognostic Value of the Six-Minute Walk Test in Heart Failure Patients Undergoing Cardiac Surgery : A Literature Review. Rehabilitation Research and Practice, 2013, 1‑5. https://doi.org/10.1155/2013/965494

Zugck, C. (2000). Is the 6-minute walk test a reliable substitute for peak oxygen uptake in patients with dilated cardiomyopathy? European Heart Journal, 21(7), 540‑549. https://doi.org/10.1053/euhj.1999.1861




DOI: https://doi.org/10.7575/aiac.ijkss.v.13n.2p.30

Refbacks

  • There are currently no refbacks.




License URL: https://creativecommons.org/licenses/by/4.0/

2013-2025 (CC-BY) Australian International Academic Centre PTY.LTD.

International Journal of Kinesiology and Sports Science

You may require to add the 'aiac.org.au' domain to your e-mail 'safe list’ If you do not receive e-mail in your 'inbox'. Otherwise, you may check your 'Spam mail' or 'junk mail' folders.