Validity: TUG is correlated to gait speed around .70 in ... Web viewPediatric Blood & Cancer, ... 60.Wong, R. and W. Miller, ... Improvement in aerobic fitness during rehabilitation

TIMED UP & GO TEST (TUG)

Type of test: Timed performance measure. The TUG is a test of general mobility.1

Time to administer: 1 practice trial and 2 recorded trials, with each trial usually taking less than 1 minute. Clinical Comments: The multi-part directions can be complex for some persons, thus a practice trial is

always recommended.

Purpose/population for which tool was developed: The TUG was developed as a mobility test for geriatric clients. The test contains the balance and gait maneuvers used in everyday life. The first authors to devise the instrument used a 1 to 5 scale based on observer’s perception of the patient’s risk of falling.2 The second set of authors 1 did the same test but timed it instead of using the 1-5 scale

Dual task use of TUG: Some authors have suggested using the TUG test along with challenging the client with a dual task called the TUGO (obstacle).The obstacle can be a box (width 120cm, depth 20 cm) the height which varies (0,5, 17 cm) placed 5 cm away from chair client steps over it in both directions.3

When appropriate to use: The TUG is most appropriate for use with the frail elderly who have diagnoses such as CVA, Parkinson’s disease, rheumatoid arthritis, osteoarthritis, multiple sclerosis, hip fracture, cerebellar degeneration, and general de-conditioning. The individual must be able to follow directions and must be able to independently rise from a chair, walk at least 6 meters, and turn around, with or without an assistive device.

Scaling: The score for the TUG is in seconds (ratio scale). A lower score represents better (faster) performance.

Equipment needed: Stopwatch, measuring to 100ths Tape markers, 3 meters apart Standard height chair (approx 46 cm / 18 inches), with arms and backrest

Directions: Measure in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46cm / 18 inches), walk a distance of 3 meters, turn, walk back to the chair, and sit down again. The subject should wear regular footwear and use his/her customary walking aid. No physical assistance is given, but guarding for safety is appropriate. The client starts with his back against the chair, toes behind the first tape marker, arms resting on the chair’s arms and the walking aid at hand. The client is instructed that, on the word “go” he/she is to get up and walk at a comfortable and safe pace to a tape line on the floor 3 meters away*, turn, return to the chair, and sit down again with the back touching the backrest. The person has a practice trial then 2 timed trials that are averaged.*Data collected in Table 1: a small plastic cone was placed on the 3-meter mark and subjects were instructed to walk around the coneThe tester may want to document the quality of the transition phases: rising from chair, initiating walking, turning and descent into chair. Footwear and floor conditions (linoleum vs. carpet) make a difference in outcomes.4

Factors affecting performance: Ankle plantar-flexor and subtalar invertor muscle force accounted for 48% of the variance in TUG scores 5 in a group of 39 people reporting no fall history. In a study of people with LE amputation, age at amputation explained only 10% of the variance in the TUG scores and 1-leg balance explained 32% of the variance.6 Self-efficacy explained 45% of the variance in TUG scores of older adults with knee OA (n=54).7

Reliability:

Summary: Intra and interrater reliability are high (.92-.99) for adults with the exception of Botolfsen (2008) study and lower on children (.85-.86)

Reference N = Sample description Reliability statisticIntrarater reliability: same rater within one session (or one day)

Hughes, 19988 20 Community dwelling older adults ICC = .92Katz-Leurer, 20089

Pediatric Physical Therapy Journal

2424

traumatic brain injury children (mean age 9)typical developed children (mean age = 9)

ICC(1,1)=0.86(CI .71-.94) SEM 0.60ICC(1,1)=0.85(CI .74-.92) SEM 0.23

Reference N = Sample description Reliability statisticBotolfsen, 200810 28 older people with impaired mobility ICC(1,1)==0.68Yeung, 200811 24 Patients on an inpatient orthopedic

rehabilitation ward 1 dayICC(2,2)=.80 (CI .56-.91) SEM 10.2 sec, MDC(90) 24sec

Interrater ReliabilityPodsiadlo, 1991 1 60 Community dwelling older adults ICC =.99Shumway-Cook, 1997 12 30 Community dwelling older adults ICC = .98Noren, 200113 19 Dx/o RA or other peripheral arthritis,

median age = 55Agreement = R = .97

Test-retest reliability on the TUG are generally high .85 in people with PD to .99 in community dwelling elderly, & children with CP. MDCs was lowest 3 for people with Alzheimers and highest 15 for adults for people in nursing homes.

Test-retest reliability: same rater over time (e.g., 2 days; 1 week)author n= population time frame correlation coefficient MDCPodsiadlo, 19911

60 Community dwelling older adults

ICC = .99

Rockwood, 200014

1115 Community dwelling older adults, cognitively impaired & unimpaired

ICC=.56

Gan, 200815 26 Children with Cerebral Palsy

7-10 daysInitial mean 25.9(30.4)

ICC=.99 ( CI 0.98-0.99) MDC=8.2

Manor, 2007 20 adults with peripheral neuropathy

7 days 1 trial ICC(1,1) = 0.93 ( CI 0.86-0.96)2 trials ICC(1,1) = 0.00 (0.98-0.99)4 trials ICC(1,1) = 0.99 (0.99-0.99)6 trials ICC(1,1) = 0.97 (0.94-0.99)

Steffen, 200816 37 Patients with Parkinson’s disease

7-10 daysinitial TUG mean 15(10)

ICC (2,1) = .85MDC=11

Nilsagard, 200717

43 people with multiple sclerosis, in Sweden

1 week ICC(2,1) =0.91( CI 0.83-0.95)

Ries,200918 51 people with Alzheimers disease

tests separated by 30-60 minute rest periodInitial Meanmild to moderate AD19.95(9.81)moderately severe to severe AD 28.1(17.49

ICC=.985-.988 MDC(90) =4.09

MDC (95)= 3.3

MDC(95)=6.8

Nordin, 200619 78 older adults with 5-7 days ICC= .92 MDC=15

arthritis in nursing homes

30(17.4) (1,1) and (3,1) seconds

Campbell, 200320

9 males with parkinsons disease

within 7 days ICC=.72 MDC=4.83 seconds

Test-retest reliability: same rater over time (e.g., 2 days; 1 week)author n= population time frame correlation coefficient MDCNoren, 200113 22 adults with arthritis 2-7 days r=.97 unable to

calculatePodsiadlo, 19911

22 older adults with CVA,PD,RA, OA, general deconditioning,, postsurg, hip fx

up to 5 weeks ICC=.99 unable to calculate

Validity: TUG is correlated to gait speed around .70 in most studies. Many other tests are correlated with the TUG but most at correlations .3-.5 There appears to be no gold standard to compare the mobility test TUG with.

Construct / Concurrent Validity: It is difficult to always differentiate between these 2 types of validity. Evaluating this property requires a “gold standard” measure with which to compare the tests results. Such a “gold standard” is often not available.

Population N = Support for validityorthopedic

s/p TKR and THR 78 The TUG is correlated with gait speed (r =.745 at admission, r = .816 at discharge) unless gait speeds were faster than .5m/s or TUG scores faster than 30 s. The authors conclude that, in some elderly populations with orthopedic problems, measuring both TUG and gait speed may not be necessary.21

Hip Fx 20 TUG correlated with FIM (r = -.47 at admission) and with self-paced walking (r = -.68)22

Lower Limb Amputation

84 TUG correlated with Frenchay Activities Index (r =-.486),23

Pre-total knee arthroplasty

59 TUG correlated with: Voorips Questionnaire of physical activity (r = -.31). 24

patients with hip and knee joint replacements

200 TUG scores correlate preoperatively with WOMAC (.29) and SF-36 physical functioning (-.28) SF-36 role-physical (-0.21) at 12 week followup WOMAC(0.43) p<0.0001 and SF-36 physical functioning (r=0-.39,) and SF-36 role-physical (r=0-.33)25

Patients with lower limb amputation

13 TUG correlates with 6 minute walk test (-.76)26

patients with hip osteoarthritis

118 TUG correlates with WOMAC pain (.25), WOMAC function (.28) and SF-36 PF (-.34)It also helps predict the WOMAC function score when used in regression.27

generalOlder Adults in residential care with

17 TUG correlated with full turn test (r = .66), sit-to-stand test (r = .36), forward reach (r = .57), one-legged stand (r= .31).28

Mild Cognitive Imp.Community dwelling elderly

48 TUG correlated with: tandem balance (-.37); sit-to-stand (.37); grip strength (-.40); bimanual dexterity (.46).29

30 TUG correlated with: composite score for Timed Movement Battery: self-selected time (.89); maximum movement time (.79).30

20 TUG correlated with: Functional Stair Test (r = .59)8

60 TUG correlated with: Berg Balance scale (r = -.72), Gait Speed (r = -.55), Barthel Index (r = -.51)1

81 TUG correlated with the four square step test (r = .88) and Functional Reach (r = -.47).31

35 TUG correlated with: 4 of the 6 subscales of the Fast Evaluation of Mobility, Balance and Fear Test (r = -.38 to .60).32

Construct / Concurrent Validity: It is difficult to always differentiate between these 2 types of validity. Evaluating this property requires a “gold standard” measure with which to compare the tests results. Such a “gold standard” is often not available.

Population N = Support for validitygeneral

Frail Elderly 30 The TUG is correlated with all subscales of the SF-36: (r = -.36 to -.66).33

Older adults with balance impairment

167 TUG correlated with: Maximal stepping task (r = -.68); rapid step test (r = .35); tandem stance time (r = -.49); uni-pedal stance time (r = -.56); tandem walk (r = .56); 6MW (r = -.75); POMA (r = -.65); EPESE physical function test (r = .50); ABC (r = -.61).34

40 TUG is correlated with: gait speed (r =-.75), postural sway path (r=.50), step frequency (r=-.59), step length (r=-.74)2

30 TUG scores were significantly higher (p < .0001) for elderly persons who had difficulty in turning than for elderly persons who did not have difficulty turning.35

Patients with Huntington’s disease

30 TUG scores correlate with UHDRSfor measures of gait speed(0.72)for velocity (0.67) for stride length (0.42) for cadence dynamic balance (0.33) for double support, and (.63) for support base in meters, , falls and gait patterning (0.16) for falls, CoV stride length (0.45) step time (0.54), CoV step time (0.66) and measures of functional limitations HD-ADL (0.4) and total functional capacity (-0.68)36

Older adults, fallers and non fallers

21 TUG correlates with accelerometry (.62), with Berg (-.77)37

Patients with Parkinson’s Disease

65 TUG correlated with Dizziness Handicap Index (-.42) and Barthel Index (.39)38

Home dwelling patients with Parkinson’s Disease

122 TUG scores correlate with UPDRS scores (.51-.58), H & Y scale (.45), and gait speed (.21). When TUG was used in regression they were not shown to be independent risk factors for falling.39

Residents of long term care facility

38 Higher levels of depression were associated with slower TUG scores (.30)40

Community dwelling Post-menopausal women in Australia

104 TUG (OR = 1.69, CI=.04-2.73) & speed of sound (SOS) calcaneal quantitative ultrasound measurements helped predict falls risk.41

Older people in the community

344 TUG correlated with Fall Risk for Older People-Community (FROP-Com ) (.63)42

Patients with type 2 diabetes

747 TUG (a measure of impaired mobility) was predicted by typed 2 diabetes, female gender and BMI but not coronary stenoses or age,43

healthy older men 44 The study looked at the effect of graded doses of testosterone on physical function and muscle performance TUG did not correlate with testosterone dose or concentrations or changes in muscle strength or power.44

patients with multiple sclerosis in Sweden

43 TUG correlated with 30 m timed walk test (.85) and with 10 m timed walk test (.83).17

patients with acute stroke (5 days post) in county hospital in Sweden

Group1 30 in 2000 & group 2 30 2004

TUG correlates with falls efficacy scale (FES) (-.70)/(-.55) and BBS (-.68)/ (-.72) in group 1 & 2 respectively,45

postmenopausal women with osteoporosis

53 mean age 55 (43-73)

TUG and age (.42)46

adult survivors of childhood acute lymphoblastic leukemia

75 TUG was positively correlated with BMI (0.34)47

Construct / Concurrent Validity: It is difficult to always differentiate between these 2 types of validity. Evaluating this property requires a “gold standard” measure with which to compare the tests results. Such a “gold

standard” is often not available.Population N = Support for validity

generalwomen with breast cancer treated with taxane chemotherapy

40 TUG correlated with COP (center of pressure), eyes open /head back (.55), eyes closed/head straight(.50) and eyes closed/head back (.47)48

older adults in geriatric unit of tertiary care hospital

50 TUG correlated with L test( L test measure walking speed and resembles the TUG except the path has 4 turns and is 20 meters) (.96),49

People with balance defecits secondary to a Vestibular disorder

32 TUG correlated with Four Square Step Test (FSST) (.69).50

community dwelling older adults

67 TUG correlated with Ambulatory Self Confidence Questionaire (ASCQ) (-.46) 51

elderly women 22 TUG correlated with height of subjects r=0.43 not age, body mass or BMI.3

PD 79 TUG correlated to OARS,(.37-.58) UPDRS total (.67), UPDRS ADL (.52), UPDRS motor (.66), and HY stage (.71)52

elderly people in Europe

59 Correlation between the TUG and the GMF subscales(Gross Motor Function Assessment Scale); dependence (0.68), pain (.37) and insecurity (0.55)at baseline and was about the same at 3 weeks and end of rehab.53

D/c ambulatory OP rehabilitation patients

215 No correlation between TUG and phase angle (derived from resistance and reactance measurements obtained from bioelectric impedance analysis)54

childrenChildren with cerebral palsy

26 The TUG and BBS (-0.88), FRT(-0.77)15

children in a rehabilitation hospital, traumatic brain injury, cerebral palsy and typically developed

60N=15CPN= 15 TBIN=30 TD

TUG correlates with step length and time with TBI children using preferred leg step length NS/.88, non preferred leg NS/.62 time preferred leg NS/.67, timed non preferred leg NS/.43Children with typically development (TD) and CP did not have any significant correlation on these variables.55

children in a rehabilitation hospital, traumatic brain injury and typically developed

48 Step length and TUG correlates (.53) among children post TBI only (n=24)It was not correlated to step time or correlated in typically development children9

Predictive Validity Summary: TUG cut off scores of 12-14 seconds are often used to predict falling. Not all studies were able to predict falls using TUG.Population N= ResultsCommunity dwelling older adults

167 TUG scores, adjusted for age & gender, were significant predictors of fall risk (odds ratio = 1.70; p <.05) 34

older people with history of falls

78 TUG scores were predictive of falls for single fallers n=17, 21.02(6,35) vs controls 17,07(2.76) p=0.025 and in multiple fallers n=22, 42.11(23.18) vs controls 17.34(3.6) p<0.00156

patients with Huntington’s

24 TUG scores predictive value for fallers for people with HD if ≥14 seconds. Fallers (> or = 2 falls over 12 mos) TUG scores 15.6(7.7 to 52.6) non-fallers 12.6(7.7 to

disease 16.6)57

Home dwelling Patients with Parkinson’s disease

122 TUG scores were not predictive of falling at least once in the last 3 mos based on logistic regression. Although the mean scores were different fallers (n=43), 15.1(9,0) vs non fallers (n=79) 11.9(5.8)39

Population N= ResultsPatients with suspected normal pressure hydrocephalus

87 Initial TUG scores were not different for responders and nonresponders to cerebral spinal fluid drainage. They were different post-drainage 29.91 (52%) to 57.28 (11%) seconds respectively58

community living elderly adults France

2368 Women and men had an increased risk of failure (>12 sec) on TUG, older participants with higher BMI, lower clock test scores, poorer health score, and women’s use of psychotropic drugs also predicted scoring less than 12 on the TUG using logistic regression.The MMSE did not predict scoring on the TUG using a cutoff of 1259

patients on an inpatient orthopedic rehabilitation ward

142 TUG scores did not predict of length of stay11

medical patients 147 Initial TUG scores predicted length of stay in hospital using regression analysis. TUG score was associated with increased adjusted hazard ratiofor an adverse event in 6 months.60

healthy volunteers 100 There was no significant difference in TUG between fallers n=11and non fallers n=71, 9.4(3.4) and 7.98(2.3) respectively61

patients with ALS 31 TUG correlated with risk of falling 10% in the next 6 mos using a cutoff of 14 sec62

Community dwelling Post-menopausal women in Australia

104 TUG (OR = 1.69, CI=.04-2.73) & speed of sound (SOS) calcaneal quantitative ultrasound measurements helped predict falls risk.41

elderly patients after intravenous sedation with midazolam

18 TUG correlated with dynamic balance test(CDP)(0.70)63

older adults 55 TUG was not correlated with disability components. It was correlated with LLFDI(late life functional and disability Instrument) (-0.52)64

patients with hip fracture

196 Regression showed that poorerTUG scores can be predicted with lower pre-fracture function, increased age, having an intertrochanteric fracture, performing TUG with a walker, and performing TUG in the later postoperative period65

Discriminate Validity:Population N= support for validityPatients with Huntington’s

30 TUG discriminates between Huntington’s disease severity stages:HD stage 1 9.29(2.06), HD stage 2 11.07(2.4), HD stage 3 17.00(9.72)36

diseasepatients with Parkinson’s disease

79 TUG discriminated between H&Y 2 versus 2.5/3(graphs presented not #)52

Sensitivity/specificity: Therapists need to use cutoff scores based on patient population they treat. The sensitivity/specificity on the TUG is variable with little consensus amongst researchers.

Population N= Cutoff Score and Description ResultsIdentifying independence in basic mobility

60 Scores < 20 sec (n=17 of 60): all subjects were independent in basic transfers (chair & toilet); most were able to go outside alone and climb stairs; and many were independent for tub or shower transfers.1

< 20 sec = more independent with basic mobility

Identifying older persons who fall

30 Cutoff score of ≥13.5 sec. (community dwelling older adults)66 sensitivity = 80%; specificity =100 %

81 Cutoff score of > 13 sec: (community dwelling elderly)31 sensitivity =89%; specificity = 67%

278

Cutoff score of >16 sec (longitudinal study of community dwelling older adults, non-fallers)67

sensitivity = 54%specificity = 74%

180

Cutoff score of ≥ 20 sec (community dwelling elderly)68 sensitivity = 10%;specificity = 95%

Identifying increased dependency in basic mobility

60 Scores > 30 sec (n =26 of 60): subjects tended to show increased dependency in that many needed assistance with transfers; most needed help in/out of tub or shower; and almost all were unable or needed help with climbing stairs. 1

> 30 sec = more dependent with basic mobility

Patients with Parkinsons disease

120

Mak, 200969

TUG time of ≥16 seconds was independently associated with increased risk of falling (1 fall in past 12 mos) OR=3.86, CI: 1.05. 14.2TUG cutoff score of 13.569

TUG cutoff score of 20.1

Sensitivity 87%specificity 36%Sensitivity 59%Specificity 10%

patients with vestibular disorders

32 Whitney, 200970

TUG>11.1 seconds gaze stability test (GST) cutoff value <63 for yaw70

TUG>11.1 seconds GST cutoff value <65 for pitch

Sensitivity 100%specificity 89%LR =9.1

Sensitivity 100%Specificity 82%LR=5.6

Population N= Cutoff Score and Description Resultspost menopausal women in Australia

104

Tan, 200841

The study looks at comparison of physical performance measurements by osteoporotic fracture risk groupnon osteoporotic group n=55osteoporotic group n=49

TUG score 7.8(1.2)secondsTUG score 8.4(1.4) seconds

frail persons living in residential care facilities in Sweden

183

Nordin, 200871 (1 fall in 6 mos)TUG cut-off 12 seconds

TUG cutoff 15 seconds






Sensitivity 98specificity 13

sensitivity 96 specificity 32sensitivity 79specificity 32sensitivity 62specificity 62

sensitivity 49(specificit72

sensitivity36specificity86

sensitivity26specificity89

older community dwelling women with vertebral fractures

104

Morris, 200772

predicting fallers (2+ falls)TUG cutoff score 10 seconds

TUG cutoff score 15 seconds




TUG cutoff score 40seconds

sensitivity 94.9%specificity 10.6%






sensitivity 12.8%

TUG cutoff score 50 seconds specificity 97.9%

Population N= Cutoff Score and Description Resultspatient with unilateral transtibial amputation

40 Dite, 200773

predictive for falls (more than 1 fall in 6 mos)TUG ≥ 19 seconds

sensitivity 85%specificity 74%

older adults 974

Thrane, 200774 1 or more falls in 12 mos

TUG cutoff scores > 12 seconds n= (women/men) 239/114

TUG cutoff score > 13 seconds n=183/84

TUG cutoff score >14 seconds n=142/190



TUG cutoff scores >17 seconds n=66/23

sensitivity.44 /37%specificity58/79%

sensitivity 35/30%specificity69/80%



sensitivity17/11%specificty86/97%sensitivity 14/11%specificity 90/98%

older men and women with hip pain from osteoarthritis

106

Arnold, 200775 (one fall in past 12 mos)

TUG >10 sec n=77

TUG >11 seconds n=56

TUG >12 seconds n=38

sensitivity faller 73%specificity faller35%sensitivity near-faller 081%specificity near-faller 36%

sensitivity faller 67%specificity faller55%sensitivity near faller 68%specificity near –faller 51%

sensitivity faller 44%specificity faller70%sensitivity near-faller 55%specificity near-

faller 70%

Population N= Cutoff Score and Description ResultsTUG >13 seconds n=30 sensitivity faller

33%specificity faller74%sensitivity near-faller 45%specificity near-faller 77%

TUG >14 seconds n=27 sensitivity faller27%specificity faller77%sensitivity near-faller36%specificity near faller 79%

patients with hip fracture surgery

59 Kristensen, 200776

TUG as predictor of falls within 6 months after surgery

cutoff point > or = 20 seconds

cutoff point > or= 24 seconds

cutoff point > or = 30 seconds

cutoff point> or = 34 seconds

sensitivity 95%specificity10%


sensitivity 84%specificity55%


NOTE: Clinicians need to choose a cut-off score based on the specific purpose for which the test is used

Responsiveness / sensitivity to change:Summary: TUG is a responsive instrument to use to measure functional mobility in persons with musculoskeletal disorders, and is frequently used to assess patients in rehabilitation. Higher scores in seconds indicate more difficulty with the task and are often used as predictor for falls, although no particular score is a gold standard for this.

Population descriptor

N Reference, sample size, intervention

ResponsiveYes / No

Data supporting responsiveness

Community dwelling elderly

35 Gras, 2004 77

Rx 1: HEP hip strength/stretch exercisesRx 2: HEP ankle strength/stretch exercisesIntensity: 5 days/wk, 3x/wk, x8 wks

no Mean scores (SD):Rx 1:Initial: 11.0(3.2) secEnd: 10.3 (3.1) sec NSRx 2:Initial: 10.9 (3.4) secEnd: 10.0 (2.0) sec NS

99 Hakim, 2004 78

Rx 1 (n=29): Tai Chi exercise with trained instructorRx 2 (n=29): Structured exercise programControl (n=41): no regular exerciseIntensity: 1-2x/wk for > 1 year

yes Mean scores (SD):Rx 1 (Tai Chi): 8 (1.8)sRx 2: 9.5 (1.9)sControl: 13 (7.7)s

Rx 1 (Tai Chi) >control (p=.001), but Rx 1 = Rx 2 (NS)

45 Nitz, 2004 79

Rx: (n=24): functional balance exercises + fall prevention educationControl (n=21): open & closed chain UE/LE ROM exercise + fall prevention education (see reference for excellent write-up of interventions)Intensity: 1 hr/session, 1x/wk, x10 wks

yes Mean scores (SD):Rx:Initial: 10.7(.6)sEnd: 9.4(.5)s (p=.01)

ControlInitial: 10.4 (.7)sEnd: 9.4(.5) (p=.018)

No significant diff between groups

22 Robinson, 2004 80

Rx: (N=10 fallers, N=7 non-fallers): falls prevention program addressing strength, balance, flexibility and educationControl (N=5): no interventionIntensity: 50 min, 2x/wk, x 6 wks plus daily by subjects at their home

not sensitive to

intervention

Mean scores(SD):Fallers:Pre: 11.5 sPost: 12.7s, NSNon-fallersPre: 10.57sPost: 10.86s, NSControls:Pre: 8.4sPost: 7.4 s, NS

Fallers and non-fallers needed sign greater time to complete TUG than controls (p<.01)



ResponsiveYes / No


Community dwelling elderly

69 McMurdo, 1995 81

Rx 1 (n=21): stretching + progressive strength exercisesRx 2 (n=20): stretching exercisesControl (n=28): health educationIntensity: HEP with 24 daily exercises, 15 min daily for 6 mos; 30 min visit from PT every 3-4 wks for all groups

no Change in scores (pre to post):Rx 1: median = (-.1), range -2.9 to 21.6, NSRx 2: median = (-1.8), range -6.9 to 17.2, NSControl: median = (.1), range -18.3 to 47.1, NS

No significant diff between groups

Community dwelling older adults with hx of falls

45 Rose, 2000 82

Rx (N=24): dynamic balance trainingControl group (N=21): no alteration in daily activity; no ↑ in exerciseIntensity: 45 min sessions, 2x/wk, x 8 wks

yes Mean (SD):Rx:Initial: 14.5 (8.9)End: 11.8 (6.2) (p<.01)Effect size: small-mod = -.30Control:Initial: 12.4(5.7)End: 12.7 (5.4)Effect size: small = .03Sig. difference between groups (p=.026), effect size: mod = -.54

Seniors living continuing-care retirement facilities

47 Edelberg, 2000 83

Rx: no specific RxProspective study monitoring ability to manage medication, x12 mos

Appears to show change

over time, without Rx

Mean (SD):Initial: 13.1(5.9)sec6 mo: 17.5(10.8) sec12-mo: 18.6 (16.3) secBoth 6 and 12 month times changed sig. from baseline (p<.05)

Residents of geriatric facility with knee OA

24 Ng, 2003 84

Rx 1(N=8): ElectroacupunctureRx 2 (n=8): low-frequencyTENSControl (n=8): OA knee care & educationIntensity: 8 sessions in 2 weeks, 20 min/session

yes Mean (SD):Rx 1: initial: 22.25 (9.72)End: improved 11% (p<.01)2 wk p Rx: NS diff from initialRx 2: initial: 26.25 (15.63)End: improved 7% (p<.05)2wk p Rx: NS diff from initialControl: initial: 32.19 (8.90)End: no significant change

Community dwelling elderly with OA

18 Hinman, 2003 85

With-in subject design with 3 conditions:Condition 1: UntapedCondition 2: wearing therapeutic knee tapeCondition 3: wearing neutral knee tape

no No significant difference on TUG scores between conditions, NS



ResponsiveYes / No


Community dwelling older adults w/ knee OA, awaiting TKR

59 Thomas, 2003 24

No RxAdults w/ OA (n=59) compared to adults w/o OA (n=79)

yes

Sensitive to group diff

Mean (SD):Males w/ OA: 10.0 (.5) secFemales w/ OA: 13.8 (.4) sec

Males w/o OA: 7.4 (.5) sFemales w/o OA: 7.6 (.3) sGroup diff: p<.001

Older Persons 97 Hui, 200986

Intervention group n=5223 sessions of dance over twelve weeks

Control group n=45no intervention

yes

Baseline 7.5(1.43)three months 6.97(0.92)change -0.58(0.95)

baseline 7.58(0.95)three months 7.47(1.12)change -1.12(0.62)p=0.01

Patients with hip and knee joint replacements

200 Gandhi, 200925

preoperative TUG scores n=20012 week follow-up n=200

yes

18.6(7.9) seconds12.8(4.7) secondsp ˂0.0001

Patients following total knee arthroplasty

66 Bruun-Olsen 200987

Intervention group n=30CPM and active exercise

Control Group n=33active exercise alone

yes

preoperative TUG 12(4) seconds3 months postoperative TUG11(5) seconds

preoperative TUG 13±6 seconds3 months postoperative TUG12±6 seconds

elderly inpatients

62 Tal-Akabi,200788

intervention group n=33 received high intensity strength training 3 weeks

control group n=29 received regular intensity strength training

Both groups improved baseline 27.6

final 15.90p<0.0001

baseline 29.6final 17.60



ResponsiveYes / No


Older females who have or are at risk for osteoporosis

31 Murphy, 200889

Intervention was 2x/wk 12 weeks of Tai Chi 1day at home

yespost intervention -1.4, p<<0.0001 n=316 months post intervention-1.4, p<0.0001 n=2912 months post intervention-1.1 p<0.001 n=30

older residents living in residential care facility in Aukland, New Zealand

149 Peri, 200790

Intervention group n=73 individualized activity program based on ADL 1x/week

control group n=76no individualized program

no

baseline 29.2(2.4)3 months 27.8(2.4)6 months 30.2(2.4)

baseline 29.9(2.3)3 months 28.4(2.4)8 months 29.8(2.4)p=NS

patients with mild hip or knee osteoarthritis in the Netherlands

104 Wetzels, 200891

Intervention was self management by patient in one of four areas of exercise, weight loss, use of walking aid or use of pain medications

noboth groups improved in TUG no stats givens

sedentary adults

453 Shumway-Cook,200792

intervention group n=212 received 1 hour, three times per week group exercise, 6 hours of fall prevention education, comprehensive falls risk assessment

control group n=217received written materials on fall prevention

yesbaseline10.5(2.8)final 9.1(3.5)

baseline 10.8(3.3)final 10.1(4.4)p=.005 between group comparison

community dwelling elderly individuals with chronic anemia

62 Agnihotri, 200793

phase 1 intervention weekly for 16 weeks, subcutaneous epoetin alfa n=32placebo=26

phase two crossover to opposite treatmentepoetin alpha n=24placebo n=30

no

27.9(2.8)27.9(3.2) p=NS

23.8(1.7)24.5(1.5 )p=.NS



ResponsiveYes / No


community dwelling older adults

40 Cromwell, 200794

intervention group n=20, Tae Kwon Do exercise class one hour twice per week for 11 weeks

control group n=20 no exercise

yes

pretest 9.5(1.7)posttest 8.6(2.1)p<.05

pretest 11.3(2.7)posttest 10.9(2.9)

community living elderly adults

37 Nakagawa, 200795

control group n=17no exercise instruction

intervention group n=20received instruction in trunk and lower extremity strengthening program. Told to exercise 2-3x/week

yesbefore interventionmale n=11 5.8(0.97)female n=6 6.3(1.47)

after interventionmale 5.5(70) p=NSfemale 6.0(.78) p=NS

before interventionmale n=13 6.9(2.43)female n=7 61.(0.91)

after interventionmale 6.4(1.68) p=NSfemale 5.7(0.90) p=NS

Frail elderly residents of LTC facility

20 Baum, 2003 96

RCT with semicrossover:Rx: group exercise (n=11): group exercise; seated strength and flexibilityControl(N=9): Recreational therapy (after 6 months this group also began exercising)Intensity: 1 hr, 3x/week for 6 monthsFollow-up x 1 year

yes Mean:Rx:Initial:45 secEnd change: 18 sec faster (improved)Control:Initial: 49 secEnd change: 5.5 sec slower (worse)Control crossover:Initial: 49 secEnd change: 24 sec faster (improved)All data: Effect size: .54



ResponsiveYes / No


Women in nursing home

10 Connelly, 1997 97

Rx: low intensity, progressive resistance quad strengtheningIntensity: 3x/wk, x8 wks strengthening (follow-up @ 1 yr post exercise)

yes Mean scores (SD):Post-exercise: 15.9 (7)s1 yr after end-exercise:24.5 (15)sP<.05

Community dwelling older adults with dx/ o Diabetes

31 Brandon, 2003 98

Randomized repeated measures controlled trial:Rx (N=16): LE strength training at 50, 60, 70% of 1 rep maxControl group (N=15): not describedIntensity: 3 sets of 8-12 reps/exercise, 2.6 days/week for 24 months

no Mean (SD):Rx:Initial: 8.2 (2.1) sec6 mos: 8.0 (2.5) sec24 mo: 7.6 (1.8) sec, NSControl:Initial: 8.1 (2.2)s6 mos: 7.4 (1.4) sec24 mo: 8.3 (1.0) sec, NS

Elderly in adult day care, with dx/o mild dementia

13 Thomas, 2003 99

(Ave MMSE=18)Pretest-posttest designRx: Moderate-intensity progressive resistive training of Les using theraband Intensity: 1 set of 15 reps, ave. of 2x/wk for 6 weeks

no Mean (SD):Pre: 25 (13.29) secPost: 21.3 (10.30)sec14% improvement in TUG, NS

Effect size: -3.47 ±14 (small)Frail Elderly LaStayo, 2003 100

Rx: High force LE eccentric cycle ergometerControl: traditional LE resistance exerciseIntensity: 11 weeks, 3x/week, 10-20 minutes

yes Mean (SD):Rx:Pre:16.65 (.81) secPost: 11.96 (.72) sec (p<.05)Control:Pre: 17.20 (.87)Post: 15.55 (1.45) sec (p<.05)Between group diff = NS

s/p Hip fx 56 Crotty, 2003 101

Rx 1 (n=28):early discharge / home-based rehab programRx 2 (n=28): Hospital-based team rehabilitation (usual care)Intensity: no information

yes Median scores:Rx 1:Initial: 37sAfter 1 yr: 19s, p<.003Rx 2:Initial: 41.5sAfter 1 yr: 24.5s, p<.001



ResponsiveYes / No


s/p Hip fx 20 Mendelsohn, 2003 22

Rx: Intensive in-patient rehab programIntensity: approx 80 min/session, 5x/wk, 3-5 wks

yes Mean (SD):Initial: 49(26) sEnd: 28(9)s p<.01

patients with hip fracture in an inpatient rehabilitation unit

20 Mendelshon, 2008102

Both groups received physical and occupational therapy 5 times a week

training group n=10 used an arm crank ergometer 3 times per week for 4 weeks

control group n=10 received no additional training

yes

mean(SD)95%CI

admission 93.3(40.2) (67-120)discharge24.7(8.7) (19-30)

admission91.2(23.6) (76-107)discharge 39.5.4(12.34)(31-48)p<.05 between group comparison

patients with total hip arthroplasty and hemiarthroplasty in treatment of displaced femoral neck fracture

40 Macaulay, 2008103

Intervention: hemiarathroplasty n=23Intervention: total hip arthroplasty n=17

no

16.5 (10.1)

17.2(13.5)

p=NSolder hip fracture patients

53 Mard, 2008104

intervention group n=2312 week supervised intensive progressive strength-power training twice per week

control group n-29 maintained pre study level of activity

nobaseline 7.9(2.2) secondsend 7.9(2.7)seconds

baseline 9.3(3.4)end 8.9(2.5)p=NS

patients with hip fracture

72 Ganz, 2007105

surgical repair

mean(SD)admission 6.95(43.9)discharge 32.8(18.7)p=0.001



ResponsiveYes / No


patients in inpatient rehabilitation unit

165 Gosselin, 2008106

intervention was inpatient rehabilitationcomparison of TUG score ofpatients older than 65 years n=17patients less than 65 years old n=42

Yes for rehab

No diff between age

groups

differences between admission and discharge

5.4(5.8) p<0.018.7(15.9)p<0.01p=NS between groups

postmenopausal women

53 Gunendi,200846

Group 1 n=26 postmenopausal women with osteoporosis intervention was submaximal aerobic exercise program on treadmill, lasting for 30 minutes, twice a week for 4 weeks

group 2 n=25 postmenopausal women without osteoporosis received no intervention

yesinitial 7.1(0.6)final 6.2(0.8)p<0.001

initial 6.9(1.2)final 6.8(1.2)p=NS

Nursing home residents

31 MacRae, 1996 107

Rx (n=19): Supervised self-paced walking programControl (n=12): social visit, 1x/wkIntensity: 5 days/wk, x12 weeks, times increased 10% weekly

no Mean scores (SD):Rx:Initial: 24 (17) sEnd: 36(27)sControl:Initial: 40(34)sEnd: 34(14)sNS

28 Carmeli, 2000 108

Rx: supervised group exercise (warm-up; aerobics; strengthening; stretching; relaxation) divided into males(A) and

females(B) and younger old (1) and older old

(2):Control (n=29): non-exercisingIntensity: 3x/wk, x12 week

no in “younger

old”

yes in “older old”

Mean scores:Rx:A1: pre: 9.2; post: 8.3sA2: pre: 15.7; post: 11.4s (p<.05)B1: pre: 10.2; post: 9.2sB2: pre: 14.2; post: 10.1s (p<.05)

Control: pre: 9.1 s; post: 9.0 s

Older adults in residential care with mild cognitive impairment

17 Carmeli, 2003 28

Rx (N=17): ball exercises and walking programControl A: in residential care, with cog imp (N=12): no RxControl B: in community, w/o cog imp (N=20): no RxIntensity: 5 days/wk for 27 weeks

no Mean (SD):Rx:Pre: 24.2 (2.4) sPost: 21.5 (3.6)s, NS

Control A:23.9 (2) secControl B:18.1 (3.5)Controls signif diff than post-exercise group: (p<.05)

26 Carmeli, 2002 109

Rx: (N=16) treadmill walking programControl (N=10): non-walking groupIntensity: time initially 10-15 min and increased to 45min; 3x/wk for 25 weeks

yes Mean (SD):Pre: 28.5 (4)sPost: 25.9 25.9 (3) secMean difference: -3.2 (9%)(p<.05)

Outpatients with hemiplegia, s/p stroke

13 Geiger, 2001 110

Rx (N=7): same tx as control group plus Balance Master trainingIntensity: 2-3 sessions/wk on PT interventions (35 min), 15 min on Balance MasterControl group (N=6): PT to improve muscle force, ROM, balance and mobilityIntensity: 50 min, 2-3 x/wk, x4 weeks

yes Mean change pre to post (SD):Rx: -5.69 (5.64) secControl: -8.79 (9.68) secDiff between groups, NS

Combined groups:Pre: 23.08(13.7)Post: 14.62(11.18) (p<.008)



ResponsiveYes / No


patients post stroke , long-term survival

13 Sharp, 1997 111

Rx: LE strengthening & stretching exercisesIntensity: (3 days/wk, 40 min/day, x6 wks)

no Mean scores(SD):Initial: 31 (27) secEnd: 30 (27 sec)Follow-up (4 wks): 31 (31) secNS

patients post stroke

46 Walker, 2000 112

Rx 1(n=16): regular therapy + visual feedback training on Balance MasterRx 2(n=16): regular therapy + 30 min balance trainingControl(n=14): regular PT/OT therapyIntensity: 2 hrs minimum, 5 days/wk, 3-8 wks

yes Mean (SD):Rx 1:Initial: 54.2 (34.4)Discharge: 33.4 (20.3)1 month p d/c: 28.2 (20.2)Rx 2:Initial: 45.8 (26.8)Discharge: 21.3 (12.8)1 month p d/c: 17.8 (9.8)Control:Initial: 52.8 (40.1)Discharge: 29.3 (21.6)1 month p d/c: 28.8 (25.2)All groups improved significantly over time (p<.001)

stroke survivors with low hand function

3 Carter, 2008113

Intervention was structured whole body, increased intensity, activity dependent practice strategy

yes meanTUG scoreinitial 14.9 secondspost 6.8 seconds

chronic stroke survivors

30 Wing, 2008114

intervention was comprehensive stroke rehabilitation

yes pretest 31(7.8 )secondsposttest20.2(3.9) secondsp=.03

In hemiplegic patients,

4 Pavlik, 2008115

TUG scores compared with AFO and without AFO

mean with AFO 27.5(19.87)without AFO 30.92(17.99)p=NS



ResponsiveYes / No


Bilateral vestibular loss

9 Brown, 2001 116

Rx: Customized PT program, with vestibular adaptation, balance and gait training, strengthening and flexibilityIntensity: 2-9 visits

yes Mean scores:Initial: 22sEnd: 18 sp=.007

Dx/o Osteoporosis and vertebral fx

Papaionnou, 2003 117

Rx (N=37): Home-based exercise program following “lifestyle exercise”Control (N=37): no exerciseIntensity: 60 min/day, 3 days/wk for 12 months

no No significant change in TUG scores after 6 or 12 months.

s/p Lumbar surgery

Kumar, 2001 118

Grp 1: (N=28) Lumbar fusion for degenerative disc diseaseGrp 2: (N=28) S/p DDD surgery w/o fusion

no NS difference between 2 grps

Persons attending geriatric day hospital

Malone, 2002 119

Clients received at least 5 visitsyes Significant improvement at

discharge

Persons with residual gait deficits

50 Salbach, 2001 120 (SRM has been used to indicate responsiveness of a measure to change; SRM = mean change score / SD of change score )

yes SRM (standardized response mean) = .73

patients who use cane for ambulation assist

47 Marston, 2007 121

Comparison of patients using moulded vs conventional cane.

yes mean change intug score for moulded stick -5.3(6.5) and for conventional cane 1.8(3.9)

Older adults 1165 Dam, 2008122

In women, not men, lower 25(OH) Vitamin D levels were associated with impaired performance on TUG

yesMen baseline 10.8(2.8) absolute change baseline to follow-up .22(2.4) percent change 3.3(20.1)

Women baseline 10.9(3.1) absolute change 1.19(3.1) percent change 11.2(26.6)

Persons with Multiple Sclerosis

16 Widener, 2009123

The study looked at whether weight placed on the trunk in response to directional balance loss would enhance function and stability in people with MS using BBTW( balance based torso weighting )

yesbaseline15.2(14.1)no weight 14.3(13.9)BBTW 13.6(12.1)

p=0.03



ResponsiveYes / No


Community dwelling older people in Japan

71 Arai, 2007124

Intervention was 3 months of exercise sessions

yes pre 8.3(3.2) secondspost 7.6 (3.6)follow up 7.9±4.2p=0.01

post menopausal women in Australia

104 Tan, 200841

The study looks at comparison of physical performance measurements by osteoporotic fracture risk groupnon osteoporotic group n=55

osteoporotic group n=49

no

TUG score 7.8(1.2) seconds

TUG score 8.4(1.4 )secondsp=NS

patients following transtibial amputation

27 Johannesson, 2008125

removable vacuum formed rigid dressing n-13

conventional rigid plaster of paris dressing n=10

no

41(24) seconds

29(14) seconds

mean difference 14(-2-30)p=NSat the 3-month follow-up

patients with rheumatoid arthritis in warm or cold climates

124 Staalesen Strumse, 2009126

intervention was 4 week rehabilitationMediterranean climate n=72

Norwegian climate n=52

both made progress, climate did not matter

baseline 13.9(2.4)week 4 - baseline-1.5(1.4)okweek 16 - baseline -0.7(1.6)p=0.001

baseline 14.4(3.2)week 4 -1.6(2.5)p=0.001week 16 -1.2(2.4)p=0.002No difference between groups

patients with COPD from an institutional pulmonary rehabilitation program

19 Chang,2008127

The study assessed the affect of an exercise task(6 minute walk test) on TUG performance

no pre exercise score 8.77(1.95)post exercise score 9.01(2.27)p=NS



ResponsiveYes / No


community dwelling elderly

19 Batson, 2008128

intervention was 2 weeks of balance instruction using Alexander technique

yes pretest average 11.22 secondsposttest average 9.53 secondsp=0.006

residents of care homes

249 Sackley, 2007129

intervention group n=128PT and OT targeted to mobility

control group n=121 received standard care

no baseline 60(42)three months 68(50)six months 59(37)

baseline 57(54)three months 59(56)six months 55(37)

Effects of drug therapy

TUG has been used to assess the effects of drug therapy 130, 131 especially the “on” and “off” phase of the levodapa cycle in patients with PD.

Ceiling & floor effect: This issue has not been discussed in the literature. The TUG test is limited to those who can independently stand up and walk 3 meters with or without an assistive device.Reference data:

Subjects TUG(N=10) (ages 70-84, mean 75 years)Healthy men and women1

Mean =8.5 sec (range, 7-10 sec)

(N=20) (ages 65-86 years)Independent community dwelling elderly persons8

Mean(SD) =13.05 sec (2.6)(range 8.7-17.3)

(N=251) (mean age 74, range 60-95)132

Community dwelling older adults; study included 31 persons using an ambulatory device and the test protocol varied from the original in use of a 10-foot distance from the chair to the turn around point and a 41-cm chair height.

Mean (SD) = 15 sec (6.5)(range 5.4-40.8 sec)

(N=92) People who return to the community after a hip fracture vs. healthy, matched cohort (N=92)133

Follow-up was at 6-12 months after surgery.

Mean= 19s (s/p hip fx) = 10.5 s (matched cohort)*differences despite age and gender match. This means many do not return to prefracture lifestyle.

(N=1805) (mean age=66)Large study of clients awaiting THA or TKA, males and females134

Males Mean score= 14.3 + 7.5 secFemales Mean score= 16.4 + 7.3 sec

(N=19) Subjects with total hip arthroplasty for osteoarthritis vs. control (N=5) 135 Women awaiting arthroplasty took 2.2 times longer and men took 1.9 times longer to complete the TUG compared with their healthy controls.

Pre-op Patients= 14.3sControl= 9.5 s

Aslan, 2007 (n=240) Ambulatory middle aged and elderly subjects in Turkey

TUG scores were significantly different for age groups in males and females. TUG scores decrease with age. There was no significant difference in the scores for fallers and non fallers in the TUG

van Iersel, 2008 n=85, people admitted to acute geriatric or old age psychiatry ward in the Netherlands in 2004-5

median 19.3(5-134)seconds

Gunn, 2008 n=215 ambulatory rehabilitation patients ,men 31.7(29.2), women 33.7(21.8)Several studies give test scores for patient populations.6, 32, 136-139

There is no consensus in the literature regarding the effect of aging on TUG scores.136, 138, 140

Vereek, 2007 n=78 TUG time and age (0.82)Women score significantly less than men in asymptomatic adults in Belgium

Table 1 shows reference data by gender for 60-89 year olds.141 Lusardi, et al (2003) reported TUG scores by decades and gender for community dwelling elderly; sample sizes in the 80-89 year and 90-101 age groups are useful.142 These 2 data sets demonstrate an increased (slower) score on TUG as one ages.

Table 1. Timed-Up and Go Scores: Means (X), Standard Deviations (SD), and 95% Confidence Intervals (CI), by Age and Gender (seconds)

Timed-Up and Go

Age (yrs) Gender N X SD CI

60-69 Male 15 8 2 7-8Female 22 8 2 7-9

70-79 Male 14 9 3 7-11Female 22 9 2 8-10

80-89 Male 8 10 1 9-11Female 15 11 3 9-12

Steffen TM, Hacker T, Mollinger L (2002). Age-and gender-related test performance in community-dwelling elderly people: Six Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and Gait Speeds. Physical Therapy 82 (2): 128-127.

Interpreting results: Two studies of community dwelling older adults showed that TUG scores >13 seconds correctly categorized fallers (sensitivity 80- 89%).12, 31 Usually, however, we compare patient/client test results to the 95% confidence intervals in our reference data, categorized by age and gender (see Table 3-1).

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