Acta Cardiol Sin 2015;31:193-201

Original Article doi: 10.6515/ACS20140721D

Pediatric Cardiology

Six-Minute Walking Test: Normal Reference

Values for Taiwanese Children and Adolescents
Chun-An Chen,1 Chin-Hao Chang,2,3 Ming-Tai Lin,1 Yu-Chuan Hua,4 Wei-Quan Fang,2,3 Mei-Hwan Wu,1,4
Hung-Chi Lue1,4 and Jou-Kou Wang1,4

Background: The 6-minute walking test (6MWT) is a simple method used to evaluate exercise capacity in adults
and children with cardiac diseases. Normal reference values in pediatric populations have been reported, but
significant variations in the walking distance (6MWD) were noted among different studies. We aimed to provide
and validate normal reference values of the 6MWD for healthy Taiwanese pediatric population between 7 and 17
years of age.
Methods: Healthy children and adolescents were recruited from 13 randomly selected schools in Kaohsiung City.
From that recruitment effort, 762 participants (50.1% male) were included, and the 6MWT was conducted using
standardized protocols. The main outcome measure utilized was the 6MWD, which was used to construct centile
charts and Z score equations. Data from additional 64 healthy volunteers recruited from the National Taiwan
University Children’s Hospital were used to validate these standards.
Results: There was an overall linear trend of increase in the 6MWD between 7 and 17 years of age (p < 0.001).
Males covered significantly more distance than females after the age of 14 years, when the 6MWD essentially
plateaued in female adolescents. Upon multivariate analysis, height was the most significant positive predictor of
the 6MWD, while body mass index negatively correlated with the 6MWD. The height-based normal reference
values of the 6MWD, derived from the 6MWT conducted in the school settings, were validated by a second cohort
who received 6MWT inside the hospital.
Conclusions: Normal reference values of the 6MWD in healthy Taiwanese children and adolescents may serve as
useful references for future clinical and research studies.

Key Words: Adolescents · Children · Six-minute walking test · Taiwan

INTRODUCTION tory diseases, oxygen consumption during the 6MWT

The 6-minute walking test (6MWT) is the distance a
subject can walk at a constant and unhurried pace
within 6 minutes. In adult patients with cardiorespira-
Received: January 28, 2014 Accepted: July 21, 2014
1
National Taiwan University Children’s Hospital; 2National Translational
Medicine and Clinical Trial Resource Center; 3Department of Medical
Research at National Taiwan University Hospital; 4Cardiac Children’s
Foundation, Taipei, Taiwan.
Address correspondence and reprint requests to: Dr. Jou-Kou Wang,
Department of Pediatrics, National Taiwan University Hospital, No.
7, Chung-Shan South Road, Taipei 100, Taiwan. Tel: 886-2-2312-3456
ext. 71523; Fax: 886-2-2341-2601; E-mail: jkww@ntuh.gov.tw
does not differ from the maximal oxygen consumption
obtained in a standard cardiopulmonary exercise test.1
This makes the 6MWT a simple and less expensive me-
thod to evaluate exercise capacity.2 In adults, the walk-
ing distance covered in 6 minutes (6MWD) has been
shown to be an independent predictor of morbidity and
mortality in patients with heart failure,3 chronic respira-
tory diseases,4 and idiopathic pulmonary arterial hyper-
tension.5 It can also be used to measure responses be-
fore and after treatment and to guide therapy.6
The use of 6MWT may be particular appealing for
children and adolescents for whom performing standard
cardiopulmonary exercise tests is sometimes problem-

193 Acta Cardiol Sin 2015;31:193-201

 Chun-An Chen et al.
atic, requiring adequate body height, as well as a high
degree of cooperation and motivation. Previous studies
have demonstrated the usefulness of 6MWT in children
and adolescents with congenital heart disease7 and obe-
sity.8,9 Although reference values have been reported
from several different countries,10-12 significant varia-
tions in these published values suggested that interpre-
tation of the data obtained from individual local popula-
tions with reference to published norms must be viewed
with caution. For example, racial difference may be one
reason that could explain such variations.13,14 In Taiwan,
normal reference values of the 6MWD have yet to be es-
tablished for children and adolescents. Lack of these
reference values might hinder the clinical usefulness of
this test in our young cohort. Therefore, the purpose of
this study was to establish and validate normal refer-
ence values of the 6MWD in Taiwanese healthy children
and adolescents.
MATERIALS AND METHODS
Participants
Between April 2012 and June 2012, we prospec-
tively studied healthy children and adolescents in Kao-
hsiung City between 7 and 17 years of age. They were
recruited from randomly selected local elementary, ju-
nior high and senior high schools. All tests were con-
ducted in the individual schools. Before recruitment, a
questionnaire as well as informed consent was given to
all eligible subjects as well as their parents. The ques-
tionnaire was used to identify children and adolescents
with known cardiopulmonary illness, neuromuscular
disease, long-term medication which might interfere
with the test, or concurrent acute infection. Children
and adolescents with negative disease and medication
history, and written parental informed consent, consti-
tuted the target study population of our present study.
All participants also willingly agreed to perform the
6MWT.
To validate the established normal reference values
of the 6MWD which were obtained in a school setting,
we recruited additional 64 healthy volunteers between
7 and 17 years of age from outpatient clinics of National
Taiwan University Children’s Hospital for 6MWT. All of
these subjects were referred for innocent heart murmur
Acta Cardiol Sin 2015;31:193-201
or nonspecific chest pain, and all had normal echo-
cardiographic findings. The 6MWT was conducted inside
the National Taiwan University Children’s Hospital after
obtaining informed consent from both parents and par-
ticipants.
6MWT
Before the start of the 6MWT, participants’ age, sex,
height, weight, and body mass index were documented.
According to the guidelines published by the American
Thoracic Society,15 all 6MWTs were conducted using a
marked hallway 30 m in length both at the participating
schools and in the hospital. In a period of 6 minutes, the
participants were asked to walk back and forth along
this hallway as far as possible, at their own best pace
but not to run or race. The tests were undertaken by
each participant separately to prevent competition, and
each participant had a personal instructor throughout
the test. Standardized phases of encourage or announ-
cement of time remaining, such as “You are doing well,”
and “You have 3 minutes to go” were often given to the
participants, although the frequency of such encourage-
ment varied across studies from providing encourage-
ment every 30 seconds to every 2 minutes. No com-
ments were made with the intention of speeding up or
slowing down the participant. The participants could ad-
just their speeds any time if they wanted. The partici-
pants were not aware of how long they had walked
throughout the test. We used a wireless pulse oximeter
(Nonin 4000, Nonin Medical, Plymouth, Minnesota,
USA) attached to the participant’s wrist and a finger to
monitor the oxygen saturation and heart rate continu-
ously during the test. Data on heart rates and oxygen
saturations before the start of the walk and after every
minute during the test were recorded. At the end of
test, the total distance walked within 6 minutes was
measured.
Statistical analysis
Data are expressed as percentage, mean ± standard
deviation, or median (25th-75th percentile), as appropri-
ate. Comparisons between groups were made using un-
paired Student’s t test or ANOVA. Potential predictors of
the 6MWD were investigated by univariate analysis, fol-
lowed by stepwise multivariate linear regression analy-
sis. Multicollinearity between covariates was examined
194
 Six-Minute Walking Test in Taiwanese Children
by calculating individual covariate variance inflation fac-
tor. Centile charts were constructed using the maximum
penalized likelihood LMS method.10,16 The LMS method
estimates the measurement centiles in terms of three
height- and sex-specific cubic spline curves: the L curve
(Box-Cox power to transform the data follow a normal
distribution), M curve (median), and S curve (coefficient
of variation). In brief, let Y(t) denote an independent
positive datum (i.e., the 6MWD) at t height in centime-
ters, so that the distribution of Y(t) can be summarized
by a normally distributed SD score (Z) as follows:
{[Y(t)/M(t)] - 1}/[L(t) × S(t)]
Once the L(t), M(t), and S(t) have been estimated
for each height t, the 100a centile at t height in cm can
be derived from
C100a(t) = M(t)[1 + L(t)S(t)Za]1/L(t)
where Za is the a percentile of the normal distribution
(e.g., for the 95th centile, a = 0.95 and Z = 1.65). The
1st, 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, 97th,
and 99th centiles of the 6MWD at 5-cm height intervals
were computed for boys and girls separately.
To obtain a 6MWD Z score for a given height, we
used an exponential regression model as follows:
regression mean = ln(expected 6MWD) = b1 + b2
´ ln(height)
where height was expressed in centimeters, and b1 and
b2 were sex-specific. This model has been shown to of-
fer good fit and yield Z scores evenly distributed around
zero.17-19 Then Z score could be calculated from
ln(6MWD) - regression mean
Z score =
MSE
where 6MWD is the exact walking distance, and mean
standard error (MSE) was sex-specific. All statistical
analyses were performed using the Statistical Package
for the Social Sciences (SPSS, version 15.0; SPSS Inc.,
Chicago, IL, USA) and R statistical software, version
2.11.1 (R Foundation for Statistical Computing, Vienna,
Austria). 20 A p value < 0.05 defined statistical signifi-
cance.
195
RESULTS
Participants from schools
There were 782 participants recruited from 6 ele-
mentary schools, 4 junior high schools, and 3 senior high
schools, and all were of Asian ethnicity. Their heights
were all within the normal age-appropriate ranges of Tai-
wanese children and adolescents (between 3rd and 97th
percentile). However, we found that the case numbers of
participants who are in the highest and lowest body
height groups were limited, which might result in a devia-
tion of the statistical assumption from the reality in these
particular groups. Therefore, before the establishment of
normal reference values for the 6MWD, we excluded sub-
jects whose heights were £ 120 cm or > 180 cm for male
participants (n = 9 and 3, respectively), and £ 110 cm or
> 170 cm for female participants (n = 1 and 7, respec-
tively). A total of 762 participants (50.1% male) were
thereafter included in the following analysis.
Demographic and 6MWT data
Demographic and 6MWT data are shown in Table 1.
All tests were completed uneventfully. The overall 6MWD
was 513 ± 64 m for all participants. The mean oxygen sat-
uration was 98% at baseline, and the lowest saturation
was 94-95% during the test. During the test, the heart
rate increased from a baseline of 103 ± 17 beats per min-
utes (bpm) reaching a peak rate of 142 ± 15 bpm. Pooling
the data from both sexes together, there was no signifi-
cant increase in 6MWD from one year to the next, but an
overall trend of increase was noted between 7 and 17
years of age (p < 0.001). The mean 6MWD increased from
463 ± 62 m at 7 years to 527 ± 71 m at 12 years. The in-
crement in 6MWD subsequently slowed, with the mean
6MWD of 542 ± 54 m at 15 years, and 545 ± 57 m at 17
years of age. Figure 1 shows the 6MWD in male and fe-
male participants in each age group. Between 7 and 14
years of age, the distance walked was similar when com-
paring male and female participants of the same age
group. Between 14 and 17 years of age, however, male
adolescents walked significantly longer than their female
counterparts, while the 6MWD had essentially plateaued
in female adolescents (Figure 1).
Predictors of 6MWD
Results of univariate and multivariate linear regres-
Acta Cardiol Sin 2015;31:193-201
 Chun-An Chen et al.

Table 1. Demographic data and 6-minute walking test results in different age groups (n = 762)
Age 2 Resting SpO2 Lowest SpO2 Resting HR Peak HR 6MWD
n M/F Height (cm) Weight (kg) BMI (kg/m )
(year) (%) (%) (bpm) (bpm) (m)
7 067 32/35 124.6 ± 5.5 26.4 ± 5.8 16.9 ± 2.9 98 ± 1 95 ± 2 105 ± 11 148 ± 14 473 ± 62
8 077 38/39 131.6 ± 5.6 31.9 ± 6.9 18.3 ± 3.1 98 ± 1 95 ± 2 101 ± 17 147 ± 14 477 ± 68
9 076 40/36 135.8 ± 6.3 33.8 ± 9.1 18.1 ± 3.6 98 ± 1 95 ± 3 104 ± 15 150 ± 14 498 ± 57
10 080 41/39 141.7 ± 7.5 36.7 ± 8.8 18.1 ± 3.5 98 ± 1 95 ± 4 102 ± 15 147 ± 16 503 ± 57
11 088 41/47 147.2 ± 6.7 43.1 ± 9.7 19.8 ± 3.9 98 ± 1 95 ± 3 104 ± 17 143 ± 13 509 ± 65
12 085 45/40 153.7 ± 7.9 048.0 ± 10.3 20.2 ± 3.4 98 ± 1 95 ± 2 103 ± 16 139 ± 14 527 ± 71
13 058 26/32 156.6 ± 7.3 50.6 ± 9.4 20.6 ± 3.3 98 ± 1 95 ± 2 100 ± 18 136 ± 15 527 ± 52
14 065 31/34 161.2 ± 8.4 054.8 ± 13.5 21.0 ± 4.1 98 ± 2 94 ± 3 104 ± 19 138 ± 16 530 ± 48
15 062 36/26 165.1 ± 7.2 057.4 ± 12.2 21.0 ± 3.8 98 ± 2 95 ± 3 107 ± 18 138 ± 15 542 ± 54
16 052 27/25 165.6 ± 8.0 059.7 ± 12.1 21.6 ± 3.4 98 ± 1 94 ± 3 102 ± 21 135 ± 14 543 ± 61
17 052 25/27 164.9 ± 8.6 056.7 ± 12.8 20.7 ± 3.4 98 ± 2 94 ± 3 101 ± 16 135 ± 15 545 ± 57
All 762 382/380 0148.5 ± 15.3 044.2 ± 14.7 19.5 ± 3.8 98 ± 1 95 ± 3 103 ± 17 142 ± 15 513 ± 64
BMI, body mass index; bpm, beats per minute; F, female; HR, heart rate; M, male; SpO2, oxygen saturation measured by pulse
oximeter; 6MWD, 6-minute walking distance.

both in univariate and multivariate analysis, and is a

routinely measured parameter in clinical settings, we
chose height to construct normal centile charts and Z
score equations of the 6MWD for Taiwanese children
and adolescents.

Centile charts and Z score equations of the 6MWD

Figure 2A and B show the height-specific smoothed
centile curves for the 6MWD for males (height > 120 cm
and £ 180 cm) and females (height > 110 cm and £ 170
cm), respectively. The centile curves demonstrated that
males generally could cover a greater 6MWD than their
female counterparts for a given height. The 50th centile
Figure 1. Six-minute walking distance in male and female participants
in each age group. Data are shown as box-and-whiskers plots illustrat- curve for females corresponded approximately to the
ing the median, 25th and 75th centile (box) and 5th and 95th centile (er- 25th centile curves for males.
ror bar). p values refer to the difference between male and female par- Table 3 shows the estimated parameters in the re-
ticipants in each age group. p values not shown indicate no statistical
gression model for calculating Z score for a given mea-
difference.
surement of 6MWD. The Z score can be calculated from
sion between the 6MWD and relevant variables are the following equation:
shown in Table 2. Positive univariate correlates of 6MWD
ln(6MWD) - b1 - b2 ´ ln(height)
included male sex, age, height, weight, body mass index, Z score =
and resting oxygen saturation. On stepwise multivariate MSE
analysis, male sex, height, peak heart rate, the differ- For example, to find the Z score corresponding to a
ence between peak and resting heart rate, and resting 6MWD of 500 m for a boy with a height of 130 cm, first
oxygen saturation were positively related to 6MWD, find the value of b 1 , b 2 , and MSE in Table 3 (3.5247,
while body mass index correlated negatively with 6MWD. 0.5443, and 0.0132, respectively), and then put these
None of the individual covariate variance inflation fac- values into the above equation:
tors were greater than 2 (Table 2), indicating that multi-
ln(500) - 35247
. - 05443
. ´ ln(130)
collinearity is not likely to be a problem in this analysis. Z score = = 0352
.
Because height correlated with the 6MWD most closely 00132
.

Acta Cardiol Sin 2015;31:193-201 196

 Six-Minute Walking Test in Taiwanese Children

Table 2. Factors associated with six-minute walking distance

Univariate analysis Multivariate analysis
Predictors
b (95% CI) p b (95% CI) p VIF
Male sex 16.43 (7.33-25.54) < 0.001 < 8.32 (0.15-16.5) 0.050 1.03
Age (years) 7.74 (6.31-9.17) < 0.001 < -- --
Height (cm) 1.70 (1.42-1.97) < 0.001 < 2.16 (1.85-2.47) < 0.001 < 1.41
Weight (kg) 1.34 (1.04-1.63) < 0.001 < -- --
2
BMI (kg/m ) 1.89 (0.67-3.11) 0.002 --1.46 (-2.66--0.27) 0.020 1.23
Resting HR (bpm) -0.19 (-0.47-0.08) 0.170 -- --
Peak HR (bpm) -0.09 (-0.21-0.39) 0.560 0.52 (0.18-0.86) 0.002 1.65
Difference in HR (bpm) -0.18 (-0.04-0.41) 0.110 0.40 (0.15-0.65) 0.002 1.57
Resting SpO2 (%) 5.93 (2.55-9.31) 0.001 07.98 (4.95-11.00) < 0.001 < 1.02
Lowest SpO2 (%) -0.86 (-0.77-2.50) 0.300 -- --
Difference in SpO2 (%) -0.61 (-1.19-2.40) 0.510 -- --
Significant p values are given in bold.
BMI, body mass index; bpm, beats per minute; CI, confidence interval; HR, heart rate; SpO2, oxygen saturation measured by pulse
oximeter; VIF, variance inflation factor.

A B
Figure 2. Normal reference centile charts for 6-minute walking distance in boys (A) and girls (B).

Table 3. Estimated parameters in regression models for Z score within the range between the 1st and 99th percentile
of 6-minute walking distance in boys and girls curves. When converting these data into the scores using
b1 b2 MSE our constructed equations, the corresponding Z scores
ranged between -1.22 and 1.89 for males (n = 25), and
Boys (n = 382) 3.5247 0.5443 0.0132
Girls (n = 380) 4.3204 0.3813 0.0138 -0.98 and 2.50 for females (n = 39). These results vali-
dated the use of our centile charts and Z score equations
MSE, mean standard error.
for the tests conducted in the hospital setting.

Validation using 6MWT performed in the hospital

Data of the 64 participants whose 6MWT were per- DISCUSSION
formed inside the hospital were plotted on the normal
centile charts of the 6MWD (Figure 3A and B). All mea- This study presented normal reference values of the
surements except one from a female participant were 6MWD from a large cohort of Taiwanese children and

197 Acta Cardiol Sin 2015;31:193-201

 Chun-An Chen et al.
A B
Figure 3. Walking distances for boys (A) and girls (B) recruited in the hospital plotted on the normal reference centile charts.
adolescents between 7 and 17 years of age. We further
validated the use of these normal reference values,
which were obtained in the community setting, for tests
that were conducted in the hospital setting. Both centile
charts and Z score equations of the 6MWD from our
present study could serve as useful references for future
clinical practice and research application.
Including our present study, there are four reports
from different countries that have published their own
reference values pertaining to the 6MWD in healthy
children and adolescents. Geiger and colleagues re-
ported normal 6 MWD values in 528 Caucasian children
from Austria, aged between 3 and 18 years of age. 11
Based on their data, the median 6MWD was around 580
m in children aged between 6 to 8 years. The distance
increased substantially to 728 m and 661 m in males and
females aged over 16 years, respectively. Comparing our
present study in an Asian cohort, their 6MWDs were
considerably longer than ours (473 ± 62 m and 543 ± 61
m in 7 year old and 16 year old participants). Another
report by Lammers et al. reported 6MWD normal values
from 328 UK children of 4 to 11 years of age.12 Although
83% of their study subjects were Caucasians, interest-
ingly, their data were quite similar to ours. They re-
ported the value of 6MWD of 488 ± 35 m and 512 ± 41
m in 7 year old and 11 year old children, respectively,
comparing to 473 ± 62 m and 509 ± 65 m in children
with the same ages in our study cohort. Besides, refer-
ence values for the Asian pediatric population have
been reported previously by a study from Hong Kong in
Chinese children between 7 to 16 years of age.10 Li et al.
reported an overall mean 6MWD of 664 m, which was
Acta Cardiol Sin 2015;31:193-201
significantly greater than our data. Based on these three
previous reports 10-12 and our present study, it seems
that the results of 6MWT conducted in children varied
significantly among different studies, whether the study
populations were of similar ethnic background or not.
Therefore, some other complicating factors might influ-
ence the 6MWT.
The variations in methodological details during the
performance of 6MWT may be one crucial factor that af-
fects the results of 6MWT. Although the American Tho-
racic Society has published a guideline to standardize
6MWT,15 several differences were still noted among var-
ious studies. First, the level of encouragement during
the test varied. In Geiger’s study,11 they counted down
the time left every minute, while investigators of the
other 3 studies did not regularly inform the participants
about any diminishing time element. Besides, a measur-
ing wheel was used only in Geiger’s study. To avoid com-
petition, the 6MWT should be performed separately or
one by one. This methodological detail was not de-
scribed in Li’s study.10 In addition, the track length var-
ied from 20 to 50 m among these four studies.10-12 All
these methodological variations may result in differ-
ences in the 6MWD of children and adolescents from
different studies. A more strict standardization for the
performance of 6MWT may reduce this difference.
A number of factors correlated with the 6MWD.
Similar to most studies in healthy adults13,21-25 and the
other three studies in children,10-12 our data in this pedi-
atric cohort also showed that height was closely corre-
lated with the 6MWD. Although we did not measure in-
dividual leg length, the correlation between height and
198
 Six-Minute Walking Test in Taiwanese Children
the 6MWD might be attributed to the longer length of
steps in taller individuals.11,22 Body weight, although a
positive univariate predictor of the 6MWD, was not pre-
dictive of the 6MWD in multivariate analysis. This find-
ing has also been noted previously. 10,11 Since body
weight and height were highly correlated with each
other, the independent role of weight in predicting
6MWD may therefore become insignificant once the
height was taken into the consideration. A similar situa-
tion was noted in terms of the effect of age on the
6MWD. Sex is another factor affecting the 6MWD. Male
participants started to walk significantly longer than fe-
males after the age of 14 years, a difference that may
persist through adulthood.22-25 Although the effect of
sex on the 6MWD may be attributed to the difference in
height, sex remains an independent predictor in the
multivariate model after height was adjusted for. Such
result may be explained by the higher muscle mass and
greater strength in men after adolescence. Body mass
index was initially a positive predictor of 6MWD in
univariate analysis. However, it became an independent
negative predictor after other relevant factors were ad-
justed for. As body mass index correlated with height
(data not shown), the direct effect of increased body
mass index on walking distance was likely through the
influence of height. When body height was adjusted for
in the multivariate model, the negative effect of body
mass index on 6WMD indicated that subjects who are
more overweight tended to walk shorter distances than
those with the same height but lower body mass index.
This relationship was not reported previously in the pe-
diatric population. One possible explanation may be the
difference of body mass index in the study population.
In our present study cohort, the mean body mass index
of all participants was 19.5 kg/m2 , which was highest
among all studies in healthy children and adolescents.10-12
A higher prevalence of obesity or overweight in the
study population may unmask the influence of body
mass index on the 6MWD. This finding not only high-
lights the potential threat of overweight or obesity on
exercise capacity in contemporary Taiwanese pediatric
cohort, but also emphasizes the need for reference val-
ues of the 6MWD that are specific for each population.
The sex-specific, height-based centile charts and Z
score equations of the 6MWD not only serve as user-
friendly tools in the clinical setting, but also provide
199
standard references for future research. Among all an-
thropometric variables correlated with the 6MWD,
height was the single most significant predictor in multi-
variate analysis. Furthermore, body height was easily
measured, and would be routinely recorded before each
pediatric clinic or laboratory evaluation. These features
justify the use of height-based 6MWD reference values.
The use of centile charts could provide an easy method
to evaluate the level of exercise performance, and
quickly identify an abnormal measurement. On the
other hand, calculating a Z score could precisely quan-
tify the exact functional capacity. This approach has
been increasingly used in pediatric cardiology.18,19,26,27
Compared to other adjusting methods, there is no need
to assume a constant variance across the range of body
sizes when using Z scores. This advantage is particularly
important within the pediatric population which covers
a wide range of body sizes. Furthermore, a Z score,
rather than a range of percentile derived from the cen-
tile charts, would be much more convenient for con-
ducting statistical analysis. Of course, Z scores can also
be converted to percentiles. However, the magnitude of
an abnormality is much easier to appreciate with Z
scores than with percentiles. This is another advantage
of using Z scores for clinical and research purposes.
Although many studies have reported their own
normal reference values of the 6MWD, only a few stu-
dies in adults have evaluated the validity of the refer-
ence equations which they proposed.21,23,28 As the refer-
ence values of the 6MWD provided by our present study
were based on tests conducted in the schools, we pro-
spectively evaluated additional individuals with the
same ranges of age and height used in the development
of our reference values, while their tests were per-
formed inside the hospital. We demonstrated the reli-
ability of centile curves and Z score equations of the
6MWD in this independent cohort. This result not only
validated our reference values of the 6MWD, but also
supported the use of these reference values in 6MWT
conducted in the hospital settings, where most clinical
and research studies were performed.
Our study had several limitations. We enrolled only
subjects aged between 7 and 17 years, and body height
between 120-180 cm for male and 110-170 cm for fe-
male. Therefore, caution should be taken when applying
our centile curves and Z score equations to individuals
Acta Cardiol Sin 2015;31:193-201
 Chun-An Chen et al.
whose age or height fall outside the ranges of our study
cohort. Although we validated our normal reference val-
ues in another independent Taiwanese cohort, it remains
unknown whether these values could be applied to popu-
lations from other countries or different ethnic back-
grounds. Most of the data points from the female valida-
tion population appear to scatter above the median curve
of normal centile charts. Although the explanation for this
phenomenon is not clear, it is possible that the observed
deviation from the median curve may be the result of ran-
dom sampling since there are only 39 cases, and such a
situation was not observed in the male counterpart. Be-
sides, we performed only one test per participant. There-
fore, the intra-observer and inter-observer variability could
not be tested. Furthermore, as there might be a training
effect on a repeated test,24,29 our reference values might
systematically underestimate the 6MWD when the test
was performed on a follow-up basis.
CONCLUSIONS
The 6MWT is a simple and practical means to assess
exercise capacity in the pediatric population. This study
provided data on normal reference values of the 6MWD
in healthy Taiwanese children and adolescents. These
standards may serve as useful references for future clini-
cal and research studies.
CONFLICT OF INTEREST
The authors have no conflicts to declare.
ACKNOWLEDGMENTS
This work was supported by a grant (CCFT1105)
from the Cardiac Children’s Foundation, Taiwan. The au-
thors would like to thank Ms. Chiu-Yi Hsu and Ms. Yi-An
Shr for their efforts in the administration of 6MWT.
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