Timed Up and Go Test (TUG)
Original Editor - David Csepe
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Objective[edit | edit source]
- Simple screening test that is a sensitive and specific measure of probability for falls among older adults.
- A recent study published in 2022 found that the TUG test is a strong mortality predictor, displacing other established risk factors such as chronic diseases in geriatric populations of low and middle income countries.
Intended Population[edit | edit source]
- This test was initially designed for elderly persons, but is used for in other populations eg Parkinson's - This tool is validated for a population with Parkinson’s Disease; Multiple Sclerosis; Hip fracture; Alzheimers; CVA; TKR or THR; Huntington Disease
- It is one of the 4 tests used in the The Balance Outcome Measure for Elder Rehabilitation (BOOMER)
Materials Needed[edit | edit source]
- One chair with armrest
- Tape (to mark 3 meters)
Method[edit | edit source]
- Patients wear their regular footwear and can use a walking aid, if needed.
- The patient starts in a seated position
- The patient stands up upon therapist’s command: walks 3 meters, turns around, walks back to the chair and sits down.
- The time stops when the patient is seated.
- Be sure to document the assistive device used.
Note: A practice trial should be completed before the timed trial
Observations[edit | edit source]
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 problems that require further evaluation.
Cut-off time for high risk of falls[edit | edit source]
An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.
Cut of scores indicating risk of falls by Population (in seconds)
- Community dwelling adults - 13.5
- Older stroke patients - 14
- Frail elderly - 32.6
- LE amputees - 19
- PD - 11.5
- Hip OA - 10 -
- Vestibular disorders - 11.1
Cut-off times to classify subjects as high risk for falling vary based on the study and participants.
Example score sheet TUG score sheet
Evidence[edit | edit source]
- Intratester and intertester reliability (ICC) have been reported as high, in elderly populations, from .92-.99.
- Reliability in community-dwelling populations has been found to be moderate (.56).
- In people with Alzheimers disease reliability is high (ICC = .985-.988).
- An ICC of 0.80 for subjects with Parkinson's was found and excellent (0.95) ICC and excellent reliability in another study. Test retest and the interrator reliability are both high, the TUG can be used to assess differences in the Parkinson's and non Parkinson's populations. 
- Construct validity has been shown by correlating TUG scores with gait speed (Pearson r = .75), postural sway (Pearson r = -.48), step length (Pearson r = -.74), Barthel Index (Pearson r = -.79), and step frequency (Pearson r = -.59).
Sensitivity and Specificity
- The sensitivity and specificity have been reported to be 87%.
- Moderate sensitivity in predicting falls in PD, so in isolation it might not be enough to predict falls in this population 
Minimally Detectable Change (MDC)
- MDC is "the smallest amount of difference in individual scores that represents true change (beyond random measurement error)". 
- The MDC was 4.09 seconds in patients with Alzheimers.
- In patients with Parkinson's the MDC was 3.5 seconds
Benefits[edit | edit source]
- Quick to conduct
- Minimal equipment required
- Highly reliable and valid
- Provides useful outcomes related to reduced falls risk
Negatives[edit | edit source]
- Unable to predict falls in the community
- Test re-test user error can be high
- Turning is only assessed in the patient's preferred direction 
TUG Manual and TUG Cognitive[edit | edit source]
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 "prioritize concurrent tasks over postural tasks". 
- TUG Manual: Carrying a class of water in one hand while completing the TUG. Low sensitivity of 29% and moderate specificity 68%.
- TUG Cognitive: Counting backwards in threes from a random start point while completing the TUG. Sensitivity of 76.5% and specificity (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. 
In a retrospective study of 36 participants with PD, participant who reported falls in the last 6 months were compared to participants who reported no falls. In this study the optimal cut off times to discriminate between fallers and non-fallers with Parkinson's were as follows:
- TUG: 12 seconds
- TUG Cognitive: 14.7 seconds
- TUG Manual: 13.2 seconds
A cross-sectional quantitative study investigating the effects of age-related visual dependence on motor performances (turning cadence; gait speed) under increased attention demands by adding a motor task and visual stimulus to the Timed Up and Go (TUG) test sub-components demonstrated significant performance differences in the TUG test tasks due to age and visual dependence.
References[edit | edit source]
- Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical therapy. 2000 Sep 1;80(9):896-903.Available from:https://academic.oup.com/ptj/article/80/9/896/2842520 (last accessed 16.10.2020)
- Ascencio EJ, Cieza-Gómez GD, Carrillo-Larco RM, Ortiz PJ. Timed up and go test predicts mortality in older adults in Peru: a population-based cohort study. BMC geriatrics. 2022 Dec;22(1):1-3.
- CDC govt. TUG Available from:https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf (last accessed 16.10.2020)
- SR ability lab TUG Available from:https://www.sralab.org/rehabilitation-measures/timed-and-go (last accessed 16.10.2020)
- 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.
- 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.
- 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.
- 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
- Huang SL, Hsieh CL, Wu RM, Tai CH, Lin CH, Lu WS. Minimal detectable change of the timed “up & go” test and the dynamic gait index in people with Parkinson disease. Physical Therapy. 2011 Jan 1;91(1):114-21. https://www.ncbi.nlm.nih.gov/pubmed/20947672
- 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.
- 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.
- 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. 2015 Jan 1;95(1):95-102. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.883.6123&rep=rep1&type=pdf
- 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.
- Almajid R, Tucker C, Wright WG, Vasudevan E, Keshner E. Visual dependence affects the motor behavior of older adults during the Timed Up and Go (TUG) test. Archives of gerontology and geriatrics. 2020 Mar 1;87:104004.