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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: Top Stroke Rehabil. 2019 Oct 17;27(2):118–126. doi: 10.1080/10749357.2019.1667657

The Six-Minute Walk Test as a Fall Risk Screening Tool in Community Programs for Persons with Stroke: A Cross-Sectional Analysis

Elizabeth Regan a, Addie Middleton b, Jill C Stewart a, Sara Wilcox a, Joseph Lee Pearson a, Stacy Fritz a
PMCID: PMC7108500  NIHMSID: NIHMS1541942  PMID: 31622172

Abstract

Background and Purpose

Persons with stroke have increased risk for recurrent stroke and other health conditions. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk to measure aerobic capacity. However, failure to assess balance or fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke.

Methods

Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0–272.1). The six-minute walk test alone and combined with potential co-variates were evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated.

Results

Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p=0.002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p=0.006). The cutoff for increased fall risk was six-minute walk test < 331.65 meters. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%.

Discussion

The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence.

Conclusion

Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.

Stroke is the leading cause of disability in the United States, affecting more than 7 million people.1,2 Persons with stroke have increased risk of additional stroke and other chronic health conditions.1 Despite rehabilitation and medical care, 81% of persons with stroke remain sedentary regardless of their abilities.3 Persons with stroke are less physically active than peers with and without disability.2 The causes of sedentary behavior and reduced physical activity are multifactorial and include remaining impairments such as gait deficits and reduced cardiovascular endurance, personal factors such as low self-efficacy and lack of balance confidence, and environmental factors such as lack of safe community exercise programs, transportation issues and cost.4–6

Persons with chronic stroke ( ≥ 6 months post-stroke) have an increased risk of falls (36%) as compared to age and gender matched peers (24%).7 Identified risk factors for falls include balance deficits, visual-spatial problems, decreased sensation, cognitive deficits, gait impairments and fear of falling.7–10 Individuals with increased fall risk after stroke may find it exceptionally difficult to participate in exercise programs and may also be at risk of injury due to loss of balance.

Aerobic exercise programs, including medical fitness and community programs, are effective in improving health for persons with stroke.11–14 One example, cardiac rehabilitation, has been successfully tested for persons with stroke outside the United States.15–17 The American Heart Association and cardiac rehabilitation professionals have recommended expansion of cardiac rehabilitation services to manage a wider spectrum of participants and include persons with stroke.2,18,19 Cardiac rehabilitation programs are multidisciplinary and include a primary focus on aerobic exercise with varied secondary services such as education, nutrition counseling, and stress reduction.20 Cardiac rehabilitation health benefits for traditional cardiac participants include improvement in exercise capacity, improvement in psychosocial factors/quality of life, and reduction of biological risk factors.20,21 Cardiac rehabilitation programs use clinical performance measures for functional capacity, most commonly exercise stress testing or the six-minute walk test,22 but typically do not include measures of balance or balance confidence. Supervising staff may be unaware of fall risk which is an important safety factor for persons with stroke. The ability to measure fall risk within cardiac rehabilitation and other community programs directly impacts program feasibility and participant safety for persons with stroke. The ability to use the six-minute walk test distance as screening tool for increased fall risk, in addition to walking capacity, avoids additional testing burden and avoids additional skill training for cardiac rehabilitation or community program staff.

The primary objective of this cross-sectional study was to determine the degree to which the six-minute walk test is associated with fall risk in community-dwelling persons with stroke. The hypothesis was that shorter distances on the six-minute walk test would have a moderate to strong association with increased fall risk. A moderate to strong relationship would indicate that fall risk could be assessed along with aerobic capacity with the six-minute walk test for persons with stroke.

Methods

A cross-sectional study design was used to evaluate the relationship between the six-minute walk test and fall risk. Fall risk was defined as a score of < 81.1 on the Activities Specific Balance Confidence Scale. Beninato et al. found that this cutoff score accurately predicted a history of multiple falls [Sensitivity (SN) = 1.00, Specificity (SP) = 0.72 (0.51–0.93)].23 The Beninato study measured actual falls over a 6-month period for stroke survivors > 11 months post-stroke and other common clinical assessment of balance tools.23 The Activities Specific Balance Scale cutoff of > 81.1 was the best predictor of increased fall risk with a sensitivity of 1.00 capturing 100% of those with multiple falls and outperforming the physical measures (the Berg Balance Scale, the Fugl-Meyer Assessment of Sensorimotor Impairment lower-extremity subscale and the Five-Times Sit-to-Stand Test.23 The Beninato et al. study test results identify an excellent basis for utilizing the Activities-Specific Balance Confidence Scale as a delimiter for increased fall risk in the present study’s cross-sectional design.23 Those with a score of <81.1 were placed in the increased fall risk group, while those with a score of ≥81.1 were placed in the no increased fall risk group.

Pre-test date from two different studies contributed to analyses for this paper. Both studies, the Virtual Environment Rehabilitation for Stroke (study 1) 24 and the Intensive Mobility Training for Stroke (study 2), were approved by the University of South Carolina Institutional Review Board.25 All data were collected on the same day prior to the start of the intervention trials for study 1 from 2008–2011 and for study 2 from 2008–2012. Potential bias in data collection included utilizing different raters, however, this bias was minimized by utilization of standard procedures across raters.

Participants

Data from 66 participants (26 from study 1, 38 from study 2) were available with no missing data. Inclusion and exclusion criteria were similar in both studies (see Table 1; study differences are noted).

Table 1:

Inclusion and Exclusion Criteria

Inclusion Criteria
○ History of stroke > 6 months prior
○ Presence of unilateral hemiplegia
○ Stand without assistive device with only minimal assistance for 5 minutes
○ Ability to ambulate 10 feet with or without assistance (study 1 only)
○ Ability to ambulate 20 feet with or without an assistive device with no more than occasional moderate assistance for balance only (study 2 only)
Exclusion Criteria
○ Ability to ambulate less than 150 feet before stroke
○ Currently receiving physical therapy
○ Significant co-morbidities including diabetes, chronic obstructive pulmonary disease, other neurological condition(s), seizure disorder
○ Lower Extremity amputation
○ History of deep venous thrombosis or pulmonary embolism within 6 months
○ Severe resting hypertension (>200 mm Hg systolic, >110mm Hg diastolic)
○ Pain > 5 out of 10 on visual analog scale
○ Vision or hearing impairment
○ Lower Extremity joint contractures (study 2 only)
○ Intracranial hemorrhage (study 2 only)
○ Renal dialysis (study 2 only)
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Demographic Data

Age, gender (Male/Female), affected stroke side (Right/Left) and stroke chronicity (months) were available for all study participants (Table 2).

Table 2:

Group Characteristics and Comparisons

Characteristic All Increased Fall Risk Group No Increased Fall Risk Group P Value
N 66 39 27
Sex, male/female 44/22 27/12 17/10 p=0.595
Side affected, right/left 39/27 22/17 17/10 p=0.594
Age (years), mean (SD) 66.0 (12.0) 64.6 (13.1) 68.0 (10.3) p=0.258
Stroke Chronicity (months), median (range)† 60.9 (6.0 –272.1) 63.6 (6.0–272.1) 55.6 (8.0–129.0) p=0.024
SIS Recovery % (0–100), median (range)† 60 (10–90) 60 (10–90) 70 (15–90) p=0.166
ABC (0–100), median (range)† 78 (33–100) 67.5 (5–81) 92 (82–100) N/A
6MWT(m), mean (SD) 274.1(152.5) 234.4 (130.3) 338.2 (159.7) p=0.004
BBS (0–56), median(range)† 48 (24–56) 47 (24–54) 50 (27–56) p=0.012
SSWS(m/s), mean (SD) 0.56 (0.27) 0.48 (0.23) 0.68 (0.27) p=0.002
FWS(m/s), mean (SD) 0.79 (0.36) 0.67 (0.31) 0.97 (0.35) p=0.001
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Abbreviations: SD=Standard Deviation, SIS=Stroke Impact Scale, ABC=Activity Balance Confidence, 6MWT=6-minute walk test, m=meters, BBS=Berg Balance Scale, SSWS=Self-Selected Walking Speed, m/s=meters/second, FWS=Fast Walking Speed.

†

indicates medians due to skewed data. P-values determined by t-test for age, 6MWT, SSWS, FWS; chi-squared test for gender and side affected; Mann-Whitney U test for Stroke Chronicity, SIS Recovery %, BBS.

Outcome Measures

Six-minute walk test

The six-minute walk test is a rehabilitation outcome measure of aerobic and walking capacity that is validated and recommended for persons with stroke.26,27 The six-minute walk test has good test-retest reliability (ICC=0.99)27,28 and concurrent validity with walking speed and Berg Balance Scores.29 Both studies used the same standardized procedure for administering the six-minute walk test, reducing risk of biased results. Participants walked unassisted in a hallway for six minutes. Instructions were to “Walk as fast as comfortable for a period of six minutes. You are allowed to rest as much as you need, but I will not stop the time”. Distance was measured after completion.26,27

Activities Specific Balance Confidence Scale

The Activities Specific Balance Confidence Scale evaluates a person’s confidence to perform walking tasks and activities of daily living with varying complexity without losing their balance.30 Ratings for each of the 16 tasks vary from 0–100% and an average is calculated as an overall score. The score ranges from 0% to 100% confidence.30 The Activities Specific Balance Confidence Scale has adequate construct validity with the Berg Balance Scale (r=0.36) and excellent test-retest reliability (ICC=0.85).31 This score was used to create the increased fall risk (Score <81.1) and no increased fall risk groups (Score ≥ 81.1).30

Sample Descriptors and Potential Co-Variates

Stroke Impact Scale Recovery %

Stroke Impact Scale Recovery % is a self-report item of perception of overall stroke recovery from 0% (no recovery) to 100% (full recovery).32 The recovery % question test-retest reliability is excellent (ICC = 0.79) and concurrent validity is moderate with the National Institute of Health Stroke Scale (ICC = −0.48) and the Barthel Index (ICC= 0.49).33

Walking Speed

Both self-selected walking speed34 and fast walking speed34 were calculated using an average of three trials of the 3-meter walk test with additional distance provided for acceleration/deceleration (1 m each) to ensure steady state measurement. Speeds of <0.4m/s indicate status as a household ambulator, speeds of 0.4–0.8 m/s suggest limited community ambulation and speeds of greater than 0.8 m/s suggest unlimited community ambulation ability.35 The three meter walk test is reliable (ICC = 0.85–9.97) for persons with stroke.36

Berg Balance Scale

The Berg Balance Scale37 consists of 14 tasks of varying difficulty to measure balance. The tasks are rated 0–4, with scores aggregated for a maximum score of 56. Lower scores indicate increased fall risk.38,39 The Berg Balance Scale is valid in persons with stroke with correlations to the Barthel Index (r≥0.78)40 and single leg stance time (r=0.65–0.79).41 It has excellent test-retest reliability (ICC= 0.95).41

Data Analysis

Data analysis was completed using SPSS version 24 (Armonk, NY: IBM Corp). Descriptive statistics were generated for the entire sample and for subgroups based on fall risk (increased fall risk; no increased fall risk). Normality Tests (Shapiro-Wilk Test) and data type (numerical or categorical) determined the test used to examine fall risk group differences. Independent sample t-tests were completed for age, six-minute walk test, self-selected walking speed, and fast walking speed; chi-squared tests were completed for gender and stroke side affected; Mann-Whitney U tests were completed for stroke chronicity, Stroke Impact Scale Recovery %, and Berg Balance Scale. Walking speed values and Berg Balance Scale scores were included as sample descriptors but excluded as covariates due to multicollinearity (six-minute walk test and fast walking speed r = 0.93, six-minute walk test and self-selected walking speed r = 0.91, six-minute walk test and Berg Balance Scale r = 0.66; p <0.01). The remaining variables with between fall risk group differences became potential co-variates in logistical models.

Logistic regression was completed for six-minute walk test (independent variable) and fall risk group (dependent variable). Additional logistic regression evaluated the six-minute walk test combined with identified potential co-variates to determine statistical impact and resulting best fit model.

Receiver operating characteristic curves were calculated for the six-minute walk test best fit model. Area under the curve was evaluated to determine the accuracy of identifying fall risk group (increase fall risk, no increased fall risk).42 The cutoff point that maximized both sensitivity and specificity was chosen. 42 Using the selected cutoff score and associated sensitivity (SN) and specificity (SP), positive and negative likelihood ratios (LR) were calculated (+LR=SN/1-SP, -LR=1-SN/SP).

A post-test probability was calculated. The incidence of increased fall risk in the sample was used as the pre-test probability and was converted to an odds ratio for calculation. The converted pre-test odds ratio was multiplied by the LR to calculate post-test odds ratios for +LR and -LR. The post-test odds ratios were converted to post-test probabilities.43

Results

Participants (n=66) were adults aged 65.98 (SD 11.96) years and were 66.7% male. The Stroke Impact Scale Recovery % ranged from 0 to 90 out of 100 demonstrating that self-perception of recovery varied widely among the sample (Table 2).

Of the 66 participants, 59.1% (n=39) were in the increased fall risk group (Activities Specific Balance Confidence Scale < 81.1) while the remaining 40.9% (n=27) were in the no increased fall risk group (Activities Specific Balance Confidence Scale ≥ 81.1). Between group comparisons revealed that those in the increased fall risk group and significantly more impaired scores on the six-minute walk test and Berg Balance Scale, slower self-selected and fast walking speeds, and significantly longer stroke chronicity than those in the no increased fall risk group. No significant differences were found in between group comparisons for gender, affected stroke side, age, and Stroke Impact Scale Recovery %. (Table 2).

The six-minute walk test distance was associated with fall risk in unadjusted logistic regression (χ2 = 8.54, p=0.003) with an odds ratio of 0.995 (0.991, 0.999, p=0.007). The model correctly classified 66.7% of the participants as having an increased fall risk. As the six-minute walk test distance increases by 1 meter, the likelihood of having increased fall risk decreases by 0.5%. Stroke chronicity was the only co-variate with a significant difference between fall risk groups (p=0.024) and it also correlated with Activities Specific Balance Confidence Scale score (r= −0.254, p=0.040). Stroke chronicity was tested as a co-variate with six-minute walk test in logistical regression but was not a significant predictor of falls in the model (p=0.055). As a result, the univariate six-minute walk test became the best fit model to support the study objective. The area under the curve for the six-minute walk test receiver operating characteristic curve model is 0.701 (0.570–0.832), p=0.006; 70.1% of randomly selected cases with increased fall risk would have a lower six-minute walk test score than a randomly selected case with no increased fall risk. The cutoff point for predicting fall risk group was 331.65m (SN 0.744, SP 0.630, +LR 2.01, -LR 0.406) (Figure 1 and Figure 2).

Figure 1: Receiver operating characteristic curve for the six-minute walk test:

Figure 1:

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Receiver operating characteristic curve for the six-minute walk test with increased fall risk or no fall risk as the outcome. Black diagonal line is a reference for 0.50 area under the curve. Area under the curve = 0.701 (0.570–0.832) p=0.006. Cutoff point is 331.65 meters, SN=0.74, SP=0.63.

Figure 2: Contingency Table for six-minute walk test:

Figure 2:

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Table presents accuracy of six -minute walk test as a screening tool for fall risk. Abbreviations: ABC = Activities Specific Balance Scale, 6MWT=Six-Minute Walk Test, m=meters

The +LR of 2.01 indicates that a person with stroke who walks less than 331.65m on the six-minute walk test is two times more likely to have increased fall risk than a person with stroke who walks more than 331.65m on the six-minute walk test. The -LR of 0.406 can be interpreted as a person with stroke who walks more than 331.65m on the six-minute walk test is less than half (41%) as likely to have an increased fall risk as a person with stroke who walks less than 331.65m on the six-minute walk test.43

The pretest probability of increased fall risk was 59.1%, based on the number of participants having an Activities Specific Balance Confidence score of <81.1. The post-test probability for the +LR of 2.01 is 74.3% indicating if the six-minute walk test distance is less than the cutoff of 331.65m, one can be 74.3% confident that the participant has an increased fall risk (the 59.1% pre-test probability can be revised to 74.3%). Conversely, the post-test probability for the -LR of 0.406 is 36.9% indicating that if the six-minute walk test distance is equal to or greater than the cutoff score of 331.65 m, there is a 36.9% chance of an increased fall risk (the pre-test probability of 59.1% can be revised down to 36.9%).

Discussion

Study results (0.70 area under the curve) demonstrate a moderate association between the six-minute walk test distance and fall risk category (moderate association = 0.70–0.90).44 The six-minute walk test’s ability to identify increased fall risk among individuals with chronic stroke is comparable to previous research in community dwelling older adults connecting walking speed and fall risk (self-selected walking speed area under the curve=0.69, fast walking speed area under the curve=0.71).45 In a study evaluating falls in persons with stroke 6–36 months post-rehabilitation, six-minute walk test distance was significantly lower for those that fell (median=296 m) than those who did not fall (median=463 m) which is consistent with the current study cutoff of < 331.65 m for increased fall risk.46 Other studies have found that among older adults and persons with stroke, lower balance confidence may result in reduced activity participation or increased falls.47–50 Additionally, Vahlberg et al. noted associations between lower falls self-efficacy and lower mobility as well as lower falls self-efficacy and lower physical activity levels.49 These compatible findings support the current study’s association of six-minute walk test distance and fall risk category.

Six-Minute Walk Association with Community Mobility and Participation

Previous research has demonstrated an association between six-minute walk test distance and status as a community ambulator and an increased capability for activity participation in persons with stroke.51,52 Lee et al. found the six-minute walk test cutoff for community ambulation to be > 332 m, based on community ambulation defined by gait speed >= 0.80 m/s, which is similar to the current study’s six-minute walk test cutoff for no increased fall risk (>331.65 m).52 Another study, by Fulk et al., found a six-minute walk test of > 288 m identified unlimited community ambulators, defined as steps per day >=7500. The current study results combined with prior findings suggest that in addition to capacity and motor function components, the six-minute walk test may include a fall risk/balance confidence component.

Six-Minute Walk in Community Exercise Programs for Persons with Stroke

Exercise can enhance activity and participation, reduce additional stroke risk, reduce health complications, and promote quality of life for persons with stroke.2 The American Heart Association suggests filling the gap between exercise recommendations and available programs with evidence-based tertiary prevention programs such as cardiac rehabilitation or similar community exercise programs.53 Exercising with supervision in standardized programs could increase mobility, balance, exercise knowledge and exercise self-efficacy. As a result, more persons with stroke could transition from highly supervised and individualized rehabilitation to self-sustained, supported exercise. Cardiac rehabilitation and other community programs are commonly delivered by exercise physiologists or trainers, who may lack training in identifying fall risk, which could impact safety for persons with stroke. The six-minute walk test is already a commonly used outcome measure in cardiac rehabilitation programs and does not require specialized knowledge to administer. Using the six-minute walk test cutoff of less than 331.65 m to identify potential fall risk could aid cardiac rehabilitation staff in increasing safety for persons with stroke without major change to normal procedures. Additionally, it would be easy to implement in other community programs without substantial training. Knowledge of increased fall risk for a subset of participants with stroke could enable alterations in program delivery. For example, cardiac rehabilitation or other program staff could walk beside participants with stroke with increased fall risk and select alternative safe exercise equipment such as cycling or recumbent stepping when staff are not available to provide stand-by assistance in walking. Standing exercises could be aided by placing participants near a wall or a stable chair. Finally, identification of potential increased falls risk by the six-minute walk test cutoff could also lead to recommendations for balance interventions in physical therapy or other specialized care. These alterations to increase safety would not require additional training in cardiac rehabilitation and would require minimal training in other community programs. Importantly, it would not increase staffing needs. The ability for one test to screen for fall risk, assess walking endurance, and evaluate community activity participation potential--all important factors in health and quality of life for persons with stroke--highlights the benefits using of the six-minute walk test in community exercise programs.

Study Limitations

The cross-sectional design and lack of fall count data are study limitations. Fall count data would have provided greater insight and allowed authors to confirm Beninato et al.’s Activities Specific Balance Confidence score cutoffs. A prospective study design and larger sample size will be needed to validate the six-minute walk test cutoff for falls among persons with stroke. A larger sample may also determine longer stroke chronicity as a significant factor within the model. Additionally, the six-minute walk test LR results fell in the weak diagnostic category. However, the clinical implications are that the six-minute walk test may be a useful safety screening tool. The lower LR values remain clinically useful when a measure is being used for screening rather than diagnostic purposes.43 The logistic regression odds ratio for the six-minute walk test was small; the odds ratio of 0.995 indicates a 0.5% reduction in fall risk for every additional meter walked. Yet, achieving the minimal clinically important difference of 34.4 m in the six-minute walk test for survivors of stroke, would result in a 17% reduction in risk.54 Finally, the current results are applicable only to community dwelling persons with stroke who match the characteristics of the sample: in the chronic stage of stroke, largely geriatric, and ambulatory.

Conclusions

The six-minute walk test is associated with fall risk in community dwelling persons with stroke. Utilizing this commonly administered measure to screen participants in cardiac rehabilitation and other community exercise programs may enhance safety and outcomes including reducing falls and increasing community activity participation potential. Exercise program staff can gain awareness of fall risk without additional staffing and with limited training. Further research is recommended to confirm these findings and establish applicability in community exercise program settings.

Acknowledgments

Funding:

(1) University of South Carolina (USC) Behavioral-Biomedical Interface Program (NIGMS/NIH-T32 2T326M081740-11A1)

(2) 2019 American Heart Association Pre-Doctoral Fellowship

(3) American Heart Association (Scientist Development Grant, 0835160N)

(4) National Institutes of Health (U54GM104941)

(5) Foundation for Physical Therapy’s Center of Excellence in Physical Therapy Health Services and Health Policy Research and Training Grant

(6) Robert Wood Johnson Foundation (Health Games Research, grant 64450)

Abbreviations

ICC

Interclass Correlation Coefficient

LR

Likelihood Ratio

r

Pearson Correlation

SN

Sensitivity

SP

Specificity

m

Meters

m/s

Meters/Second

Footnotes

All participants in the original studies (Study 1-Virtual Environment Rehabilitation for Stroke and Study 2-the Intensive Mobility Training for Stroke) provided informed consent for their participation.

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