Revision of 06/15/2018 Form #133 Page 1 of 4 PVDOMICS STUDY Six-Minute Walk Test Form #133
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1 Revision of 06/15/2018 Form #133 Page 1 of 4 PVDOMICS STUDY Six-Minute Walk Test Form #133 Instructions: Review PVDOMICS MOP Chapter prior to completing participant s 6-minute walk test (6MWT). Borg Dyspnea Scale is appended to end of this form for quick reference. 1. Identification Number 2. Alphacode 3. Date of 6-minute walk test (mm/dd/yyyy) 4. a. Is participant capable of completing a 6-minute walk test?... 0=No, wheelchair use only, skip to Q200 1=No, medical condition significantly restricts walking abilities, skip to Q200 2=Yes, no walking restrictions 3=Yes, but will need to use a mobility device such as cane, crutches 4=No, PI feels that performing 6MWT would jeopardize participant s safety and test should not be started, skip to Q200 b. If 4a=3, type of walking aid used?... 1=Cane/arm-assist cane 2=Crutches 3=Walker 4=Rollator (rolling walker) 8=Other, specify: 5. Does this participant have a congenital heart condition? (0=No, 1=Yes) a. Start time of 10-minute rest period (24-hour clock) (hh:mm)... : b. Has participant refrained from doing any rigorous activity in the last 2 hours? (0=No, 1=Yes)... 6-MINUTE WALK TEST - Pre-Test 7. Pre-test blood pressure (systolic/diastolic)(mmhg)... / 8. Pre-test Borg Dyspnea Score (use scale on at end of this form) a. Was the provided Masimo oximeter used? (0=No, 1=Yes)... a.1. If Q9a=no, why was Masimo oximeter not used?... 1=Participant tested in location separate from where equipment stored 2=Equipment malfunctioned (includes new batteries not available.) 3=Different staff member conducted 6MWT and did not realize that the Masimo equipment should have been used b. Was the provided lanyard used? (0=No, 1=Yes)... b.1. If Q9b=no, why was lanyard not used?... 1=Participant refused to wear lanyard 2=Morbidly obese and lanyard could not be adjusted to fit 3=Study staff refused to use the lanyard c. Type of pulse oximetry probe used? (1=Finger, 2=Ear-not recommended, 3=Forehead-preferred) Room air oxygen saturation at rest (%)... (Room air oxygen after 5 minutes of resting. If on 4L of supplemental oxygen at rest, must get permission from supervising provider.)
2 Revision of 06/15/2018 /PID AC Date of 6MWT / / Form # 133 Page 2 of Is supplemental O2 required to obtain a SpO2 at rest > 92%? (0=No-skip to Q12, 1=Yes)... a. Mode of oxygen administration? (1=Nasal cannula, 2=Rebreather, 8=Other)... b. Type of delivery? (1=Continuous, 2=Pulse)... c. What is O2 flow used during 6MWT (L/M)?.... d. How did participant transport oxygen during 6MWT? (1=Pull, 2=Push, 3=Carry, protocol deviation) Pre-test baseline SpO2 (%) (resting/sitting, on O 2)... (Note: If participant requires oxygen, starting SpO2 (on oxygen) will be different than room air O2 saturation at rest. If the test is done on room air, then this value will be the same as Q10. Continuous pulse oximetry must be measured throughout the test. Technician should NOT walk with the participant) 13. Pre-test baseline heart rate (beats/minute) (resting/sitting)... Post-Test 14. a. Total distance walked (meters).... b. Time participant started to walk (24-hour clock) (hh:mm)... : c. Time participant stopped walking (24-hour clock) (hh:mm)... : 15. a. SpO2 at end of walk (%)... b. SpO2 at 1 minute recovery (%)... c. SpO2 at 2 minutes recovery (%)... d. Lowest SpO2 recorded (%)... e. Time of lowest recorded SpO2 (24-hour clock) (hh:mm)... : 16. a. Heart rate at end of walk (beats/minute)... b. Heart rate at 1 minute recovery (beats/minute)... c. Heart rate at 2 minutes recovery (beats/minute) Post-test blood pressure (systolic/diastolic)(mmhg)... / 18. Post-test Borg Dyspnea Score (use scale at the end of this form) Total number of stops Duration of combined stops (minutes:seconds)... : 21. Was walk test terminated before 6 minutes? (0=No, 1=Yes, by study staff, 2=Yes, by participant)... If No, skip to Question If yes, time test was terminated (24-hour clock) (hh:mm)... :
3 Revision of 06/15/2018 PID AC Date of 6MWT / / Form #133 Page 3 of 4 If test terminated, identify reason(s): a. Chest pain (0=No, 1=Yes)... b. Dizziness (0=No, 1=Yes)... c. Dyspnea (0=No, 1=Yes)... d. Near syncope (lightheaded, feeling faint) (0=No, 1=Yes)... e. Ataxic gait (staggering) (0=No, 1=Yes)... f. Lower extremity claudication (cramping) (0=No, 1=Yes)... g. Fatigue, weakness (0=No, 1=Yes)... h. Mental confusion (0=No, 1=Yes)... i. Lower extremity joint/leg pain (0=No, 1=Yes)... j. Diaphoresis, pale or ashen appearance (0=No, 1=Yes)... k. Participant refused to continue (0=No, 1=Yes)... l. Oxygen saturation dropped down to < 80%... m. Participant fell down... n. Other (0=No, 1=Yes) (specify ) Username of PVDOMICs staff member completing this test Date form completed (mm/dd/yyyy)... / / 201. Username of person completing/reviewing completeness of this form... Clinical Center Use Only Date Form Entered (mm/dd/yyyy) / / Username of person entering this form As of 04/16/2018: Q4a: response code of 4 added. Old Q5 Time of 6MWT (24-hour clock) (hh:mm) dropped. Q6b. new question refrained from rigorous activity added. New Q14b (same as old Q5) & Q14c added. New Q15d added. New Q22 added. Q22, items l & m added. Other is now 22n. 06/15/2018: 9a-b added; Q9c-ear probe not recommended, forehead preferred; Q9a1 & b1 reason why oximeter and/or lanyard not used.
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5 Revision of 06/15/2018 PID AC Date of 6MWT / / Form #133 Page 4 of 4 Modified Borg Rating Scale for Perceived Dyspnea 0 Nothing at all 0.5 Very, very slight shortness of breath 1 Very mild shortness of breath 2 Mild shortness of breath 3 Moderate shortness of breath or breathing difficulty 4 Somewhat severe 5 Strong or hard breathing 6-7 Severe shortness of breath or very hard breathing 8-9 Extremely severe 10 Shortness of breath so severe you need to stop Reference for Modified Borg Dyspnea Score: Burdon JGW, Juniper EF, Killian KJ, Hargrave FE, Campbell EJM. The perception of breathlessness in asthma. Am Rev Respir Dis 1982;126:825-8 As of 04/16/2018: Q4a: response code of 4 added. Old Q5 Time of 6MWT (24-hour clock) (hh:mm) dropped. Q6b. new question refrained from rigorous activity added. New Q14b (same as old Q5) & Q14c added. New Q15d added. New Q22 added. Q22, items l & m added. Other is now 22n. 06/15/2018: 9a-b added; Q9c-ear probe not recommended, forehead preferred; Q9a1 & b1 reason why oximeter and/or lanyard not used.
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