Beyond the 6-minute walk test: integrating balance and functional mobility into contemporary cardiac rehabilitation

Cardiac rehabilitation (CR) has traditionally emphasized aerobic capacity, cardiovascular riskfactor modification, and improvements in exercise tolerance. The 6-Minute Walk Test (6MWT) remains one of the most widely used clinical measures for evaluating functional exercise capacity because it is inexpensive, practical, and responsive to rehabilitation. However, walking distance alone cannot fully describe the complex physical limitations experienced by many individuals with cardiovascular disease. Older adults and patients with heart failure, coronary artery disease, recent cardiac surgery, and multiple comorbidities may also experience impaired balance, reduced lower-limb strength, slow gait, difficulty transferring between positions, postural instability, and an increased risk of falls. These limitations can persist even when walking distance improves. Contemporary cardiac rehabilitation therefore requires a broader assessment strategy that combines aerobic capacity with balance, gait, strength, and functional mobility measures. Tools such as the Short Physical Performance Battery (SPPB), Timed Up and Go (TUG), Berg Balance Scale (BBS), gait speed, five-time sit-to-stand test, and functional reach test can identify deficits that are not adequately represented by the 6MWT. Multidomain rehabilitation programmes incorporating progressive resistance exercise, balance training, gait practice, coordination activities, and task-specific functional exercises may improve physical independence and support safer participation in daily activities. Evidence from the REHAB-HF trial and other studies demonstrates the importance of addressing strength, balance, mobility, and endurance together, particularly in older adults with heart failure and frailty. Recent cardiac rehabilitation guidance also recognizes the importance of assessing frailty and fall risk rather than relying exclusively on aerobic exercise outcomes. This review discusses the limitations of the 6MWT as a stand-alone assessment, the physiological and functional basis of balance impairment in cardiovascular disease, practical assessment tools, evidence for multidomain rehabilitation, exercise prescription, clinical applications, safety considerations, and future directions for integrating balance and functional mobility into contemporary cardiac rehabilitation.