How do patients improve their timed up and go test? Responsiveness to rehabilitation of the TUG test in elderly neurological patients

Exploring the effects of anti-gravity treadmill training in musculoskeletal disorders: A systematic review

Musculoskeletal disorders (MSD) comprise a great variety of medical conditions, and the economic and sanitary burdens they cause are a major concern for the sanitary systems worldwide. Conventional rehabilitation is effective; however, with the rise of new technologies, it can be further improved. Anti-gravity treadmills are starting to enter the clinical rehabilitation practice of MSD due to their characteristics, which allow weight support while performing walking and running exercises. Thus, this systematic review aims to explore the effects and use of anti-gravity treadmills in MSD. A systematic search of literature was performed by collecting articles from PubMed, Scopus, and Web of Science on the use of anti-gravity treadmills in MSD management. The PEDro scale tool and the Joanna Briggs Institute checklist were used to assess the methodological quality of the included studies. Relevant data were collected in tables, and the primary outcomes were discussed narratively. Of the 185 articles screened, 11 were included in the qualitative synthesis. The findings of the selected articles encourage the use of anti-gravity treadmills in MSD rehabilitation to improve gait functionality, balance, pain relief rct, range of motion, and fracture healing. The protocols and outcomes evaluated showed high heterogeneity, and quantitative synthesis could not be performed. In conclusion, the anti-gravity treadmill proved feasible, safe, and well tolerated by individuals with different MSD, and greater improvements were seen in participants who performed anti-gravity exercises than in those who performed only conventional rehabilitation.

The effect of neurofeedback and somatosensory exercises on balance and physical performance of older adults: a parallel single-blinded randomized controlled trial

This study examines the effects of a 5-week program of neurofeedback combined with somatosensory exercises on balance and physical performance in older adults, with the goal of addressing age-related declines in sensory processing and motor function. Sixty older adult men with balance disorders were randomly assigned to one of three groups: neurofeedback combined with somatosensory training, somatosensory training alone, or a control group. The interventions were administered over 5 weeks, with participants attending three sessions per week. Assessments were conducted both before and after the intervention period, including measurements of static balance using the Stork test, dynamic balance using the Timed Up and Go (TUG) test, and physical performance using the Continuous Scale Physical Functional Performance-10 (CS-PFP-10) test. The findings revealed significant improvements in balance and physical performance among participants who received either neurofeedback combined with somatosensory training or somatosensory training alone. Specifically, the Stork test (with both open and closed eyes) showed significant increases in duration, while the TUG test indicated reductions in completion times for both intervention groups (p = 0.001), suggesting enhanced balance and mobility. Additionally, the CS-PFP-10 test results demonstrated a significant difference following the interventions (p = 0.001). These findings suggest that incorporating neurofeedback training into somatosensory exercises may provide additional benefits for older adults in improving balance and mobility.

The test-retest reliability and minimal detectable change of the six-minute walk test, timed up and go test, and 30-second chair stand test in people with epilepsy

BACKGROUND

The available evidence suggests that people with epilepsy have reduced cardio-respiratory fitness and muscle strength endurance, and impaired balance and mobility. The 6-minute walk test (6MWT), Timed Up and Go (TUG), and 30-second chair stand test (30CST) are physical performance tests frequently used in clinical practice.

OBJECTIVE

To establish the test-retest reliability and minimal detectable change of the 6MWT, TUG, and 30CST in people with epilepsy.

METHODS

The study was designed as an observational study. Forty-one people with epilepsy (23 females, 18 males; mean age 34.7 ± 10.4 years) participated. The 6MWT, TUG, and 30CST were tested by a trained physiotherapist during two sessions, which were conducted 7-14 days apart. The test-retest reliability of measures was assessed using the intra-class correlation coefficients (ICC) using two-way random effects and absolute agreement methods. The 95% limits of agreement, standard error of measurement (SEM), and minimal detectable change (MDC₉₅) were calculated.

RESULTS

The 6MWT (ICC = 0.92, SEM = 15.8, MDC₉₅ = 43.8), TUG (ICC = 0.95, SEM = 3.2, MDC₉₅ = 0.5) and 30CST (ICC = 0.92, SEM = 1.0, MDC₉₅ = 2.8) performance measurements demonstrated excellent test-retest reliability. The 95% limits of agreement was calculated, as illustrated in a Bland-Altman plot.

CONCLUSION

The 6MWT, TUG, and 30CST are reliable for measuring physical performance. The findings of this study can support researchers and clinicians to decide if a change score of a person with epilepsy is likely to be measurement error or true change.

Minimal detectable change of gait and balance measures in older neurological patients: estimating the standard error of the measurement from before-after rehabilitation data thanks to the linear mixed-effects models

BACKGROUND

Tracking gait and balance impairment in time is paramount in the care of older neurological patients. The Minimal Detectable Change (MDC), built upon the Standard Error of the Measurement (SEM), is the smallest modification of a measure exceeding the measurement error. Here, a novel method based on linear mixed-effects models (LMMs) is applied to estimate the standard error of the measurement from data collected before and after rehabilitation and calculate the MDC of gait and balance measures.

METHODS

One hundred nine older adults with a gait impairment due to neurological disease (66 stroke patients) completed two assessment sessions before and after inpatient rehabilitation. In each session, two trials of the 10-meter walking test and the Timed Up and Go (TUG) test, instrumented with inertial sensors, have been collected. The 95% MDC was calculated for the gait speed, TUG test duration (TTD) and other measures from the TUG test, including the angular velocity peak (ωpeak) in the TUG test's turning phase. Random intercepts and slopes LMMs with sessions as fixed effects were used to estimate SEM. LMMs assumptions (residuals normality and homoscedasticity) were checked, and the predictor variable ln-transformed if needed.

RESULTS

The MDC of gait speed was 0.13 m/s. The TTD MDC, ln-transformed and then expressed as a percentage of the baseline value to meet LMMs' assumptions, was 15%, i.e. TTD should be < 85% of the baseline value to conclude the patient's improvement. ωpeak MDC, also ln-transformed and expressed as the baseline percentage change, was 25%.

CONCLUSIONS

LMMs allowed calculating the MDC of gait and balance measures even if the test-retest steady-state assumption did not hold. The MDC of gait speed, TTD and ωpeak from the TUG test with an inertial sensor have been provided. These indices allow monitoring of the gait and balance impairment, which is central for patients with an increased falling risk, such as neurological old persons.

TRIAL REGISTRATION

NA.

Pay attention: you can fall! The Mini-BESTest scale and the turning duration of the TUG test provide valid balance measures in neurological patients: a prospective study with falls as the balance criterion

Background

Balance, i.e., the ability not to fall, is often poor in neurological patients and this impairment increases their risk of falling. The Mini-Balance Evaluation System Test (Mini-BESTest), a rating scale, the Timed Up and Go (TUG) test, and gait measures are commonly used to quantify balance. This study assesses the criterion validity of these measures as balance measures.

Methods

The probability of being a faller within nine months was used as the balance criterion. The Mini-BESTest, TUG (instrumented with inertial sensors), and walking test were administered before and after inpatient rehabilitation. Multiple and LASSO logistic regressions were used for the analysis. The diagnostic accuracy of the model was assessed with the area under the curve (AUC) of the receiver operating characteristic curve. Mobility measure validity was compared with the Akaike Information Criterion (AIC).

Results

Two hundred and fourteen neurological patients (stroke, peripheral neuropathy, or parkinsonism) were recruited. In total, 82 patients fell at least once in the nine-month follow-up. The Mini-BESTest (AUC = 0.69; 95%CI: 0.62-0.76), the duration of the TUG turning phase (AUC = 0.69; 0.62-0.76), and other TUG measures were significant faller predictors in regression models. However, only the turning duration (AIC = 274.0) and Mini-BESTest (AIC = 276.1) substantially improved the prediction of a baseline model, which only included fall risk factors from the medical history (AIC = 281.7). The LASSO procedure selected gender, disease chronicity, urinary incontinence, the Mini-BESTest, and turning duration as optimal faller predictors.

Conclusion

The TUG turning duration and the Mini-BESTest predict the chance of being a faller. Their criterion validity as balance measures in neurological patients is substantial.

Optimal exercise to improve physical ability and performance in older adults with sarcopenia: a systematic review and network meta-analysis

OBJECTIVE

The study aimed to pool and analyze the effects of different forms of exercise on muscle strength (handgrip strength [HGS]), and physical performance (timed up and go test [TUGT], gait speed [GS] and chair stand test [CS]) in older adults with sarcopenia.

METHODS

The effect sizes of all studies retrieved and included by the four databases were analyzed using the network meta-analysis and expressed as standardized mean differences (SMD) and the corresponding 95% confidence intervals (CI).

RESULTS

Twenty studies were included in this study with 1347 older adults with sarcopenia. Compared with control and other intervention groups, resistance training (RT) improved HGS [SMD=3.8, 95% CI (1.3, 6.0), p<0.05] and TUGT [SMD = -1.99, 95% CI (-2.82, -1.16), p<0.05] significantly. comprehensive training (CT) [SMD = -2.04, 95% CI (-3.05, -1.06), Pp<0.05] and Comprehensive training under self-management (CT_SM) [SMD = -2.01, 95% CI (-3.24, -0.78), p<0.05] improved TUGT significantly.

CONCLUSION

In older adults with sarcopenia, RT could improve HGS and TUGT, CT and CT_SM could improve TUGT. There were no significant changes in CS and GS with any of the exercise training modes.

The Rasch Analysis Shows Poor Construct Validity and Low Reliability of the Quebec User Evaluation of Satisfaction with Assistive Technology 2.0 (QUEST 2.0) Questionnaire

This study aims to test the construct validity and reliability of the Quebec User Evaluation of Satisfaction with assistive Technology 2.0 (QUEST)-device, an eight-item questionnaire for measuring satisfaction with assistive devices. We collected 250 questionnaires from 79 patients and 32 caregivers. One QUEST was completed for each assistive device. Five assistive device types were included. QUEST was tested with the Rasch analysis (Many-Facet Rating Scale Model: persons, items, and device type). Most patients were affected by neurological disabilities, and most questionnaires were about mobility devices. All items fitted the Rasch model (InfitMS range: 0.88-1.1; OutfitMS: 0.84-1.28). However, the ceiling effect of the questionnaire was large (15/111 participants totalled the maximum score), its targeting poor (respondents mean measure: 1.90 logits), and its reliability was 0.71. The device classes had different calibrations (range: -1.18 to 1.26 logits), and item 3 functioned differently in patients and caregivers. QUEST satisfaction measures have low reliability and weak construct validity. Lacking invariance, the QUEST total score is unsuitable for comparing the satisfaction levels of users of different device types. The differential item functioning suggests that the QUEST could also be problematic for comparing satisfaction in patients and caregivers.

Improving old tricks as new: Young adults learn from repeating everyday activities

The notion that young healthy adults can substantially improve in activities that are part of their daily routine is often overlooked because it is assumed that such activities have come to be fully mastered. We followed, in young healthy adults, the effects of repeated executions of the Timed-Up-and-Go (TUG) task, a clinical test that assesses the ability to execute motor activities relevant to daily function-rising from a seated position, walking, turning and returning to a seated position. The participants (N = 15) performed 18 consecutive trials of the TUG in one session, and were retested on the following day and a week later. The participants were video recorded and wore inertial measurement units. Task execution times improved robustly; performance was well fitted by a power function, with large gains at the beginning of the session and nearing plateau in later trials, as one would expect in the learning of a novel task. Moreover, these gains were well retained overnight and a week later, with further gains accruing in the subsequent test-sessions. Significant intra-session and inter-session changes occurred in step kinematics as well; some aspects underwent inter-sessions recalibrations, but other aspects showed delayed inter-session changes, suggesting post-practice memory consolidation processes. Even common everyday tasks can be improved upon by practice; a small number of consecutive task repetitions can trigger lasting gains in young healthy individuals performing highly practiced routine tasks. This new learning in highly familiar tasks proceeded in a time-course characteristic of the acquisition of novel 'how to' (procedural) knowledge.

The Falls Efficacy Scale International is a valid measure to assess the concern about falling and its changes induced by treatments

OBJECTIVE

To test with the Rasch analysis the psychometric properties of the Falls Efficacy Scale International, a questionnaire for measuring concern about falling.

DESIGN

Longitudinal observational study, before-after rehabilitation.

SETTING

Inpatient rehabilitation.

SUBJECTS

A total of 251 neurological patients with balance impairment.

INTERVENTIONS

Physiotherapy and occupational therapy aimed at reducing the risk of falling.

MAIN MEASURES

Participants (median age, first-third quartile: 74.0, 65.5-80.5 years; stroke and polyneuropathy: 43% and 21% of the sample, respectively) received a balance assessment (Falls Efficacy Scale International included) pre- and post-rehabilitation. Rasch analysis was used to evaluate the Falls Efficacy Scale International. Differential item functioning, which assesses the measures' stability in different conditions (e.g. before vs. after treatment) and in different groups of individuals, was tested for several variables.

RESULTS

Patients suffered a moderate balance impairment (Mini-BESTest median score; first-third quartile: 15; 11-19), mild-moderate concern about falling (Falls Efficacy Scale International: 28; 21-37) and motor disability (Functional Independence Measure, motor domain: 70.0; 57.0-76.5). Falls Efficacy Scale International items fitted the Rasch model (range of infit and outfit mean square statistics: 0.8-1.32 and 0.71-1.45, respectively) and the questionnaire's reliability was satisfactory (0.87). No differential item functioning was found for treatment, gender, age and balance impairment. Differential item functioning was found for diagnosis and disability severity, but it is shown that it is not such as to bias measures.

CONCLUSIONS

Falls Efficacy Scale International ordinal scores can be turned into interval measures, i.e. measures of the type of temperature. Being differential item functioning-free for treatment, these measures can be safely used to compare concern about falling before and after rehabilitation, such as when interested in assessing the rehabilitation effectiveness.

Which functional tasks present the largest deficits for patients with total hip arthroplasty before and six months after surgery? A study of the timed up-and-go test phases

Six to eight months after total hip arthroplasty, patients only attain 80% of the functional level of control groups. Understanding which functional tasks are most affected could help reduce this deficit by guiding rehabilitation towards them. The timed up-and-go test bundles multiple tasks together in one test and is a good indicator of a patient's overall level of function. Previously, biomechanical analysis of its phases was used to identify specific functional deficits in pathological populations. To the best of our knowledge, this analysis has never been performed in patients who have undergone total hip arthroplasty. Seventy-one total hip arthroplasty patients performed an instrumented timed up-and-go test in a gait laboratory before and six months after surgery; fifty-two controls performed it only once. Biomechanical features were selected to analyse the test's four phases (sit-to-stand, walking, turning, turn-to-sit) and mean differences between groups were evaluated for each phase. On average, six months after surgery, patients' overall test time rose to 80% of the mean of the control group. The walking phase was revealed as the main deficiency before and after surgery (-41 ± 47% and -22 ± 32% slower, respectively). High standard deviations indicated that variability between patients was high. On average, patients showed improved results in every phase of the timed up-and-go test six months after surgery, but residual deficits in function differed between those phases. This simple test could be appropriate for quantifying patient-specific deficits in function and hence guiding and monitoring post-operative rehabilitation in clinical settings.

Detecting subtle mobility changes among older adults: the Quantitative Timed Up and Go test

BACKGROUND

The Quantitative Timed Up and Go (QTUG) test uses wearable sensors, containing a triaxial accelerometer and an add-on triaxial gyroscope, to quantify performance during the TUG test with potential to capture more minor changes in mobility.

AIMS

To examine the responsiveness, minimum detectable change (MDC) and observed effect size of QTUG in a cohort of socially active adults aged 50 years and over participating in a structured community exercise program.

METHODS

54 participants (91% females, mean age 63.6 ± 6.5 years) completed repeated QTUG testing under single- and dual-task conditions. Responsiveness of the QTUG was assessed by correlation of change in standard TUG with QTUG change (Pearson's correlation coefficient). MDC and effect sizes (standardized mean difference and Cohen's d) were also calculated for QTUG.

RESULTS

There was a strong positive correlation between change in the standard TUG and change in QTUG (single task r = 0.91, p < 0.001). MDC in QTUG was calculated as 0.77 (Sd, 1.39; ICC 0.96) seconds (single task) and 2.33 (Sd 2.18; ICC 0.85) seconds (dual task). Several QTUG parameters showed improvements in mean values with small effect sizes (sit -to-stand transition time d = 0.418; walk time d = 0.398; cadence d = 0.306, swing time d = 0.314; step time d = 0.479; gait velocity d = 0.365; time to reach turn d = 0.322) under single-task conditions and with a moderate effect size (d = 0.549) in time taken to turn under the dual-task condition.

CONCLUSION

Initial evidence of QTUG's responsiveness to change in mobility in active middle to older age adults has been demonstrated with small to moderate effect sizes observed in specific QTUG parameters.

Strategies for maintaining dynamic balance in persons with neurological disorders during overground walking

Maintaining a stable gait requires a dynamic balance control, that can be altered in persons with Multiple Sclerosis (MS), Stroke (ST), and Parkinson's disease (PD). The understanding of the strategy for Center of Mass (CoM) positioning adopted by patients during walking is important to be able to program treatments aimed at improving gait control and preventing falls. Forty-four persons with a mild-to-moderate neurological disorder (20 with MS, 14 with ST, 10 with PD) underwent clinical examination and gait analysis. Ten Healthy Subjects (HS) walking at matched speed provided the normative data. Dynamic balance was assessed using the margin of stability (MoS). It was calculated as the distance between the extrapolated Center of Pressure and the extrapolated CoM at mid-stance. The MoS values for lower limbs were calculated in patients and compared with speed-matched values of HS. Persons with neurological disorder showed increased MoS in the medio-lateral direction with respect to HS. Within-group comparison analysis showed a symmetry between lower limbs in HS (Mean (95%CI) [mm], dominant vs non-dominant limb, 43.3 (31.9-54.6) vs 42.9 (28.8-56.9)) and PD (less affected vs more affected limb, 71.1 (59.8-82.5) vs 72.5 (58.5-86.6)), while a significant asymmetry was found in MS (54.4 (46.4-62.4) vs 81.1 (71.2-91.1)) and ST (52.1 (42.6-61.7) vs 74.7 (62.8-86.6)) participants. The history of falls was comparable among PD, MS, and ST groups, and the MoS in the frontal plane showed a strong correlation with these records. Objective assessment of MoS revealed pathology-specific strategies showing different impacts in MS, ST, and PD on the ability to control CoM information to manage the balance between limbs during gait. MoS evaluation will provide useful information to address a tailored rehabilitation program and to monitor disease progression.

Turning and sit-to-walk measures from the instrumented Timed Up and Go test return valid and responsive measures of dynamic balance in Parkinson's disease

BACKGROUND

Balance impairment is a hallmark of Parkinson's disease with dramatic effects for patients (e.g. falls). Its assessment is thus of paramount importance. The aim of this work is to assess which measures from the instrumented Timed Up and Go test (recorded with inertial sensors) are valid balance measures in Parkinson's disease and evaluate their responsiveness to rehabilitation.

METHODS

The Mini-BESTest (a criterion-standard balance measure) and the instrumented Timed Up and Go test (with inertial sensors secured to the trunk) were administered to 20 Parkinson's disease patients before and after inpatient rehabilitation (median [IQR]; 76.5 [8.25] years; 5 females; Hoehn and Yahr stage: 2.5 [0.5]). 81 parameters from the instrumented Timed Up and Go test were evaluated. Multiple factor analysis (a variant of principal component analysis for repeated measurements) and effect sizes were used to assess validity and responsiveness, respectively.

FINDINGS

Only the first component of the multiple factor analysis correlated with the Mini-BESTest, and 21 measures from the instrumented Timed Up and Go test had large loadings on this component. However, only three of these 21 measures also directly correlated with the Mini-BESTest (trunk angular velocities from sit-to-walk and turning; r = 0.46 to 0.50, P = 0.021 to 0.038). Sit-to-walk angular velocity showed greater responsiveness than the Mini-BESTest, while turning showed slightly less.

INTERPRETATION

Angular velocities from the turning and sit-to-walk phases of the Timed Up and Go test are valid balance measures in Parkinson's disease and are also responsive to rehabilitation.

The McNemar Change Index worked better than the Minimal Detectable Change in demonstrating the change at a single subject level

BACKGROUND AND OBJECTIVE

To assess the agreement between the Rasch Change Index (RCI), minimal detectable change (MDC), and McNemar Change Index (McCI), three statistics for demonstrating the patient's improvement/deterioration.

METHODS

The Mini-Balance Evaluation Systems Test (Mini-BESTest (MB)) (a balance scale developed with the Rasch analysis) was administered before and after rehabilitation to 315 neurological patients. The MB RCI was chosen as the criterion standard for detecting the patient's improvement. Positive likelihood ratios and negative likelihood ratios (PLRs and NLRs, respectively) were used to evaluate the MDC and McCI accuracy in identifying the patient's improvement. Three different MB MDCs were assessed.

RESULTS

One-hundred patients improved their MB in accordance with the RCI. All three MDCs and the McCI were solid in ruling out the patient's improvement (NLR <0.2). The McCI and the largest MDC were also good in detecting the patient's improvement (PLR>5), whereas the smaller MDCs were not. Of the four indices, McCI was the most robust in case of missing items.

CONCLUSION

A patient stable in accordance with the MDCs or McCI is actually stable as per the criterion standard. To be reasonably sure that the patient is actually improved, larger MDC values or the McCI should be preferred, and the McCI is preferable if there are missing items.

Gait analysis of patients with distal radius fracture by using a novel laser Timed Up-and-Go system

BACKGROUND

Postmenopausal women are at risk of fall and fracture with the physical decline. Distal radius fracture (DRF) is considered as the primary fragility fracture, and women with this fracture showed poor results in the usual Timed Up-and-Go (TUG) test, indicating a decline in balance and physical ability. The detailed physical characteristics of female DRF patients have not been extensively examined.

RESEARCH QUESTION

Is the novel laser TUG system able to detect and analyze the detailed gait characteristics in patients with DRF whose physical ability has tended to decline?

METHODS

In this cross-sectional case control study, the gait characteristics of 32 female patients　with DRF who had undergone surgery were evaluated at 2 weeks postoperatively with a　laser TUG system to analyze the detailed leg motion during normal TUG test.　Forty-three age- and sex-matched non-fractured women were evaluated by the laser TUG system as controls. Lifestyle and present illness were corrected at the time of TUG measurement. Detailed data during laser TUG in both groups were compared statistically, and odds ratio and thread shod of the fracture was elucidated through a　logistic regression analysis.

RESULTS

DRF patients showed slower speed and had to do more steps to complete the TUG test. Furthermore, asymmetric trajectory and significantly further distance from the marker were observed. Thirteen steps to complete the TUG test was the thread shod of DRF.

SIGNIFICANCE

Detailed gait characteristics of patients with DRF were detected by the laser TUG system. The gait decline and abnormality could be one of the reasons of consecutive fragility fracture. To prevent secondary fragility fractures, this system can be useful for screening.

The Effects of Ventriculoperitoneal Shunt on Gait Performance

Most studies on patients with normal pressure hydrocephalus (NPH) regard pre-post Tap test and long-term follow-up after shunt surgery. Quantitative and qualitative assessment tools specific to rehabilitation medicine can provide an objective measurement of the benefit of the neurosurgical intervention at 1-month follow-up. The aim of this retrospective study was to assess the early benefit of the ventriculoperitoneal shunt with low or medium pressure valve on the gait capacity of persons with NPH, one month after surgery. This is a retrospective study reviewing 19 inpatients with NPH who underwent neurosurgery for ventriculoperitoneal shunt with low or medium pressure valve, one month after a positive result on a tap test, in a 5-year period. The assessments regarding the gait abilities were performed 24 hours before the surgical intervention and one month after surgery. Assessment tools used were: the 3 meters Timed Up and Go Test (TUG), the 10 Meters Walking Test (10MWT) and the Berg Balance Scale. A positive response to the tap test predicted improvements of gait and balance in patients with NPH after shunt surgery. Best results in regards to gait and balance are achieved when early diagnosis and intervention are performed. Complex comorbidities generate and enhance significant and persistent gait impairment.