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Timed Up and Go Test (TUG)

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Introduction

The Timed Up and Go (TUG) test is a quick, practical and clinic-friendly screening tool that is widely used to evaluate fall risk, functional mobility and dynamic balance in adults.[1] The Timed Up and Go (TUG) test was developed by Podsiadlo and Richardson in 1991 [2] as a timed modification of the earlier "Get-Up-and-Go" test.[3] The person rises from an armchair, walks 3 metres, turns, walks back and sits down, and the time taken is recorded in seconds. The objective of the test is to determine the risk of fall and measure the progress of balance, sit to stand and walking ability.

Validity and Reliability

The Timed Up and Go (TUG) test demonstrates excellent inter-rater reliability in older adults indicating almost perfect agreement between different assessors and is moderately to strongly negatively correlated with gait speed meaning that faster walking is generally associated with shorter TUG completion times and strongly negatively correlated with functional independence measured using the Barthel Index indicating that shorter TUG times are generally associated with greater independence in daily activities.[2] A subsequent study also found a moderate negative correlation between TUG performance and the Barthel-20 index indicating that better TUG performance tends to be associated with greater functional independence.[4]

Intended Population

Materials Needed

  • One chair with armrest (standard armchair, seat height of 44-47cm[5])
  • Stopwatch
  • Tape or cone to mark 3 meters

Method

  1. Patients wear their regular footwear and can use a walking aid, if needed.
  2. The patient starts in a seated position
  3. On the therapist's command "go", the patient stands up, walks 3 metres at a comfortable and safe pace, turns, walks back to the chair and sits down.
  4. The time stops when the patient is seated.
  5. Be sure to document the assistive device used.

Note: A practice trial should be completed before the timed trial.

Observations

Observe the patient’s postural stability, gait, stride length and sway.

  • Note all that apply: Slow tentative pace; loss of balance; short strides; little or no arm swing; steadying self on walls; shuffling; en bloc turning; not using assistive device properly.
  • These changes may signify neurological or musculoskeletal problems that require further evaluation.[6]

Interpretation

The TUG should be interpreted with caution, because its ability to identify who will go on to fall is limited. In a meta-analysis of studies in community-dwelling older adults, the results at a cut-off of ≥13.5 seconds were pooled using a bivariate random-effects model. This gave a sensitivity of 31% and a specificity of 74%. The test is therefore better at ruling in than ruling out future falls.[7] A larger systematic review and meta-analysis of 53 studies (12,832 participants) reached a similar conclusion. Predictive ability and diagnostic accuracy were at best moderate, and the TUG was of little use for separating fallers from non-fallers in healthy, high-functioning older people. It was more useful in less healthy, lower-functioning people, where the average difference between fallers and non-fallers ranged from 0.63 seconds in high-functioning groups to 3.59 seconds in institutional settings. Cut-off points varied greatly between studies, and the authors concluded that no single cut-point can be recommended.[8]

The TUG should therefore be used alongside a multifactorial falls risk assessment (history of falls, medications, vision, cognition, strength and balance) rather than on its own.

Population Cut-off (seconds)
Community-dwelling older adults ≥13.5 [9]
Older stroke patients ≥14 [10]
Frail older adults ≥32.6 [11]
Lower limb amputees ≥19 [12]
Parkinson's disease ≥11.5 [13]
Hip osteoarthritis ≥10 [14]
Vestibular disorders ≥11.1 [15]


Example score sheet TUG score sheet

[16]

[17]

Clinical Implications

Orthopaedic

  • Hip osteoarthritis: excellent inter-rater reliability (ICC = 0.87).[18]
  • Total knee arthroplasty: excellent test-retest reliability (r = 0.98).[19]
  • Total hip replacement: excellent test-retest reliability (r = 0.96).[20]

Neurological

  • Alzheimer's Disease: In people with Alzheimer's disease reliability is high (ICC = .985-.988).[21]
  • Stroke: a cut-off of ≥14 seconds has been used to identify potential fallers in a stroke unit.[10]
  • Parkinson's Disease: High test-retest reliability in patients with Parkinson's Disease (ICC= 0.80).[22] Furthermore, a later study found excellent test-retest reliability (r=0.97).[23] TUG can be used to differentiate people with and without Parkinson's disease.[24] A strong correlation between longer times to complete the TUG and falls in patients with Parkinson's Disease. Furthermore, a modified version of the TUG (TUG-Cognitive) appeared to show the most promising results in predicting falls in patients with Parkinson's Disease.[25] In patients with Parkinson's the MDC was 3.5 seconds.[22]
    • TUG Manual and TUG Cognitive: Previous studies have shown that people with Parkinson's can show gait changes like a decrease in walking speed, step length and pattern. These changes are due to a decrease in automaticity and attentional flexibility. People with Parkinson's are at a higher risk for falls because when performing dual tasks they "prioritise concurrent tasks over postural tasks."[25]
      • TUG Manual: Carrying a glass of water in one hand while completing the TUG. Low sensitivity of 29% and moderate specificity 68%.[25]
      • TUG Cognitive: Counting backwards in threes from a random start point while completing the TUG. Sensitivity of 76.5% and specificity of 73.7%. It had a moderate accuracy, so it is not recommended as a sole test for fall. The TUG Cognitive was shown to more discriminative than the TUG or TUG Manual.[25]
      • In a retrospective study of 36 people with Parkinson's disease, optimal cut-offs to discriminate fallers from non-fallers (falls in the previous 6 months) were: TUG 12 seconds, TUG Cognitive 14.7 seconds, TUG Manual 13.2 seconds.[25]

Geriatric

  • Intra- and inter-rater reliability are high in older adults (ICC 0.92–0.99), but reliability in community-dwelling older adults was lower (0.56).[26] TUG scores correlate with gait speed (r = 0.75), postural sway (r = −0.48), step length (r = −0.74), Barthel Index (r = −0.79) and step frequency (r = −0.59).[26]
  • In the original derivation study in community-dwelling older adults, the TUG showed high sensitivity and specificity for identifying people with a history of falls.[9] However, a later meta-analysis of prospective studies found limited ability to predict future falls in community-dwelling older adults.[7]
  • TUG has a reported sensitivity and specificity of 87% in the elderly population.[9]

Safety Considerations

  • Environment: use a clear, non-slip, well-lit walkway with the 3 metre line clearly marked and no obstacles in the turning area.
  • Equipment: use a stable armchair of standard height. Chair type affects TUG time, so keep it consistent between assessments.[5]
  • Footwear and aids: the patient should wear their regular, secure footwear and use their regular walking aid, which should be within reach at the start. Document the device used.
  • Supervision: stay close to the patient throughout and be ready to assist. Use a gait belt where the patient is at high risk of loss of balance. Standard protocol gives no physical assistance during the timed trial.[2]
  • Instruction: ask the patient to walk at a comfortable and safe pace, not as fast as possible. Demonstrate the test and allow a practice trial first.[2]
  • Cognitive impairment: give simple, clear instructions and demonstrate. Watch for impulsivity or difficulty following the sequence.
  • Dual-task versions: these add cognitive or manual load and may increase fall risk, so use extra supervision.[25]
  • Stop the test if the patient reports dizziness, pain, shortness of breath or chest symptoms, or if they become unsafe.
  • Precautions: take note of weight-bearing or movement restrictions (for example after hip or knee surgery), orthostatic hypotension and acute pain before testing.

Conclusion

The TUG is a quick, low-cost and reliable test of functional mobility that needs minimal equipment. It is useful for tracking change over time and for screening mobility and balance across orthopaedic, neurological and older adult populations. Cut-off values differ between populations, and in community-dwelling older adults the TUG has limited ability to predict future falls. It should be interpreted alongside a comprehensive, multifactorial assessment, and administered consistently and safely.

References

  1. ↑ Avers A. Chapter 7 - Functional Performance Measures and Assessment for Older Adults. In: Guccione's Geriatric Physical Therapy. 4th ed. Mosby; 2020. p. 137-165. doi: 10.1016/B978-0-323-60912-8.00007-5
  2. ↑ 2.0 2.1 2.2 2.3 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8. doi:10.1111/j.1532-5415.1991.tb01616.x.
  3. ↑ Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):387-9.
  4. ↑ Nielsen LM, Kirkegaard H, Ostergaard LG, Bovbjerg K, Breinholt K, Maribo T. Comparison of self-reported and performance-based measures of functional ability in elderly patients in an emergency department: implications for selection of clinical outcome measures. BMC Geriatr. 2016;16(1):199. doi:10.1186/s12877-016-0376-1.
  5. ↑ 5.0 5.1 Siggeirsdóttir K, Jónsson BY, Jónsson H Jr, Iwarsson S. The timed 'Up & Go' is dependent on chair type. Clin Rehabil. 2002 Sep;16(6):609-16. doi: 10.1191/0269215502cr529oa. PMID: 12392335.
  6. ↑ Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3-4):81-95. doi: 10.1007/s00508-016-1096-4. Epub 2016 Oct 21. PMID: 27770207; PMCID: PMC5318488.
  7. ↑ 7.0 7.1 Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC geriatrics. 2014 Dec;14(1):14.
  8. ↑ Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, et al. Discriminative ability and predictive validity of the Timed Up and Go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013;61(2):202-8. doi:10.1111/jgs.12106.
  9. ↑ 9.0 9.1 9.2 Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Phys Ther. 2000;80(9):896-903.
  10. ↑ 10.0 10.1 Andersson AG, Kamwendo K, Seiger A, Appelros P. How to identify potential fallers in a stroke unit: validity indexes of 4 test methods. J Rehabil Med. 2006;38(3):186-91. doi:10.1080/16501970500478023.
  11. ↑ Thomas JI, Lane JV. A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Arch Phys Med Rehabil. 2005;86(8):1636-40. doi:10.1016/j.apmr.2005.03.004.
  12. ↑ Dite W, Connor HJ, Curtis HC. Clinical identification of multiple fall risk early after unilateral transtibial amputation. Arch Phys Med Rehabil. 2007 Jan;88(1):109-14. doi: 10.1016/j.apmr.2006.10.015. PMID: 17207685.
  13. ↑ Dibble LE, Lange M. Predicting falls in individuals with Parkinson disease: a reconsideration of clinical balance measures. J Neurol Phys Ther. 2006 Jun;30(2):60-7. doi: 10.1097/01.npt.0000282569.70920.dc. PMID: 16796770.
  14. ↑ Arnold CM, Faulkner RA. The history of falls and the association of the timed up and go test to falls and near-falls in older adults with hip osteoarthritis. BMC Geriatr. 2007;7:17. doi:10.1186/1471-2318-7-17.
  15. ↑ Whitney SL, Marchetti GF, Schade A, Wrisley DM. The sensitivity and specificity of the Timed "Up & Go" and the Dynamic Gait Index for self-reported falls in persons with vestibular disorders. J Vestib Res. 2004;14(5):397-409. PMID: 15598995.
  16. ↑ Timed Up and Go Test. Available from: https://www.youtube.com/watch?v=s0nqzvt9JSs (last accessed 18/10/26)
  17. ↑ Timed Up and Go Test. Available from: https://www.youtube.com/watch?v=j77QUMPTnE0 (last accessed 18/10/26)
  18. ↑ Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. J Orthop Sports Phys Ther. 2011;41(5):319-27. doi:10.2519/jospt.2011.3515.
  19. ↑ Yuksel E, Kalkan S, Cekmece S, Unver B, Karatosun V. Assessing minimal detectable changes and test-retest reliability of the Timed Up and Go Test and the 2-Minute Walk Test in patients with total knee arthroplasty. J Arthroplasty. 2017;32(2):426-30.
  20. ↑ Yuksel E, Unver B, Kalkan S, Karatosun V. Reliability and minimal detectable change of the 2-minute walk test and Timed Up and Go test in patients with total hip arthroplasty. Hip Int. 2021;31(1):43-9. doi:10.1177/1120700019888614.
  21. ↑ Ries J, Echternach J, Nof L, Blodgett M. Test-retest reliability and minimal detectable change scores for the timed "up go" test, the six-minute walk test, and gait speed in people with alzheimer disease. Phys Ther. 2009;89(6):569-579.
  22. ↑ 22.0 22.1 Huang S, Hsieh C, Wu R, Tai C, Lin C, Lu W. Minimal detectable change of the timed "up go" test and the dynamic gait index in people with parkinson disease. Phys Ther. 2011;91(1):114-121.
  23. ↑ Haas B, Clarke E, Elver L, Gowman E, Mortimer E, Byrd E. The reliability and validity of the L-test in people with Parkinson’s disease. Physiotherapy. 2017 Dec 5.https://www.physiotherapyjournal.com/article/S0031-9406(17)30338-3/fulltext
  24. ↑ Morris S, Morris ME, Iansek R. Reliability of measurements obtained with the Timed “Up & Go” test in people with Parkinson disease. Physical therapy. 2001 Feb 1;81(2):810-8.
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Vance RC, Healy DG, Galvin R, French HP. Dual Tasking With the Timed “Up & Go” Test Improves Detection of Risk of Falls in People With Parkinson Disease. Physical Therapy [Internet]. 2015 Jan 1;95(1):95–102.
  26. ↑ 26.0 26.1 Steffen T, Hacker T, Mollinger L. 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. Phys Ther. 2002;82(2):128-137.
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