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Abstract

Purpose: The Timed Up and Go (TUG) test is a reliable, cost-effective, safe, and time-efficient way to evaluate overall functional mobility. However, the TUG does not have normative reference values (NRV) for individuals younger than 60 years. The purpose of this study was to establish NRV for the TUG for individuals aged between 20 and 59 years and to examine the relationship between the TUG and demographic, physical, and mental health risk factors. Methods: Two hundred participants, 50 per decade (ages 20-29, 30-39, 40-49, 50-59 years) were selected at their primary care visit, and timed as they performed the TUG by standing up out of a chair, walking 3 m, turning around, walking back to the chair, and sitting down. Information regarding the risk factors socioeconomic status, body mass index, an index of multimorbidities, perceptions of overall physical and mental health was obtained and used as predictors of TUG time independent of age. Results: TUG times were significantly different among the decades (F = 6.579, P = .001) with slower times occurring with the 50-year-old decade compared with the 20s (P = .001), 30s (P = .001), and 40s (P = .020). Slower TUG times were associated with lower SES, higher body mass index, more medical comorbidities, and worse perceived physical and mental health. Regression results indicated that perceived physical and mental health accounted for unique variance in the prediction of TUG time beyond age, gender, and socioeconomic status. Conclusions: This study provided TUG NRV for adults in their 20s, 30s, 40s, and 50s. The TUG may have utility for primary care providers as they assess and monitor physical activity in younger adults, especially those with physical and mental health risk factors.

Keywords

TUG test normative reference values physical activity primary care

Introduction

Physical fitness can lessen the detrimental effects of many chronic illnesses,¹ as a result, primary care providers have been called on to assess or review every patient’s physical activity program.² Reliable measures of physical activity have been developed, but are not used consistently in primary care clinics. Unfortunately, time constraints, insufficient space, or inability to interpret results due to a lack of normative reference values (NRV) have contributed to inadequate assessment and monitoring of physical activity in primary care.³

Walking speed tests can quantify physical mobility and have been shown to predict future health outcomes and quality of life for patients³. The Timed Up and Go (TUG) test is a reliable, cost-effective, safe, and time-efficient way to evaluate overall functional mobility.⁴ The TUG has a high correlation with other proven tests that measure pure gait speed for longer lengths such as a 10-m walk.^4,5 The TUG has NRV for each decade in the 60- to 99-year-old range,⁴ but not for younger age ranges. One purpose of this study was to establish NRV for the TUG for individuals in their 20s, 30s, 40s, and 50s while attending a primary care clinic visit with its usual space and time constraints.

While TUG appears to be related to age, it may also be associated with other demographic, physical, and mental health risk factors. Socioeconomic status (SES) has been found to exert an influence early in life, with effects on overall health extending into adulthood.⁶ Measures of physical status such as body mass index (BMI)⁷ and the presence of multiple comorbidities as well as mental health concerns have also been found to be related to overall health status.⁸ TUG could have utility in the assessment of patients at risk for health decline and as a baseline against which to measure treatment progress toward improved function and quality of life. A second purpose of this study was to examine the relationship between TUG and gender, SES, 3 physical health measures, and a mental health measure known to be related to health status.

Methods

This descriptive, cross-sectional study was performed in a busy primary care clinic. The 200 patients in this study were selected as they presented for a routine clinic visit. Patient recruitment continued until 50 participants per decade (ages 20-29, 30-39, 40-49, 50-59 years) consented and completed the study as approved by the university’s institutional review board. Demographic information for the participants within each age decade is provided in Table 1.

Table 1.

Descriptive Statistics and Normative Reference Values (NRV) by Decade.^a

Decade	Age (Years)		Gender, n		Race % Non-Hispanic White	NRV: TUG Time (Seconds)				95% Confidence Interval for Mean		% of 50 Patients in Each Decade With TUG Greater Than 10
Decade	M	SD	Female	Male	Race % Non-Hispanic White	M	SD	Median	Range	Lower Bound	Upper Bound	% of 50 Patients in Each Decade With TUG Greater Than 10
20s	24.22	2.33	27	23	66	8.57	1.40	8.42	6.10-12.55	8.175	8.968	16
30s	33.88	2.96	32	18	66	8.56	1.23	8.55	5.62-12.03	8.211	8.910	12
40s	45.00	2.76	27	23	62	8.86	1.88	8.55	6.28-16.83	8.329	9.40	16
50s	53.66	2.81	25	25	68	9.90	2.29	9.90	6.17-16.69	9.253	10.553	21

Abbreviation: TUG, Timed Up and Go.

N = 50 per decade.

Timed Up and Go Test

A sturdy armchair with a back was placed at the end of a hallway adjacent to where height and weight measures are routinely taken in the process of rooming participants. A piece of tape was placed on the floor 3 m away from the front edge of the chair. Patients were seated in the chair with back against the chair back, arms resting on the armrests, and given general instructions about the task, including walking at a normal rather than a rapid speed. The TUG required patients to stand up out of the chair, walk 3 m, turn around, walk back to the chair, and sit down. Patients were given the following instructions: “stand up on the word ‘go,’ walk to the tape, turn around, walk back to the chair, and sit down.” The timing of the test began at the word “go,” and ended when the participant was seated.^4,9 Patients performed the test one time, if a clear error was made, they were asked to repeat the TUG. In the primary care setting, time constraints would likely not allow for multiple trials, so the procedure and subsequent results of this study attempted to mirror these real life primary care conditions. The interrater reliability between 2 authors’ TUG times for 20 randomly selected patients was .96.

Measurement of Demographic and Health Risk Factors

Patients were also asked to complete the MacArthur Scale of Subjective Social Status, or the SES ladder.¹⁰ This method has been used in research studies as a measure of SES, and has been shown to be more strongly related to poorer health-related outcomes and psychological functioning than single objective SES indicators such as education, income, or occupation.¹¹ There is also evidence for greater agreement to participate and better adherence in answering questions related to subjective rather than objective SES measures.¹¹ The model was modified to have a slightly larger font and ladder, but otherwise the content of the text and appearance of the ladder was the same as the original.¹⁰

Height and weight were obtained to calculate the BMI for each of the 200 patients. BMI has been found to be highly correlated with all-cause mortality.⁷ The Cumulative Index Rating Scale (CIRS) was used to quantify multimorbidities. The CIRS has been shown to be a reliable and valid index of multi-morbidities in the primary care context.¹² Scores were determined through extensive chart review and assigned scores (1-4) per body system. The numerical values given to each organ system were based on the abbreviated guidelines for scoring the CIRS in primary care.¹³ The interrater reliability between 2 authors’ scoring of the CIRS for 25 randomly selected participants was .98.

Participants’ perceived physical and mental health was quantified via the 12-Item Short Form Health Survey (SF-12 (v1) modified), which is composed of the following summary measures: SF-12 Physical Component Summary (PCS) and SF-12 Mental Component Summary (MCS).¹⁴ The PCS and MCS are highly correlated with those of the well-known predecessor, the 36-Item Short Form Health Survey.^15,16 If a survey was left partially incomplete, the participant was called and asked to provide answers. The survey was scored with software provided by QualityMetrics.¹⁷

Results

Normative Reference Values

The NRVs including means, standard deviations, medians, 95% confidence interval for means, and percent of participants with a time greater than 10 seconds for the TUG by age decade are presented in Table 1. A significant overall difference in the TUG test times among the decades was found by analysis of variance (F = 6.579, P = .001). Multiple comparisons then showed significant differences between the 50-year-old decade and the 20s (P = .001), 30s (P = .001), and 40s (P = .020). No significant differences were found between the 20-, 30-, and 40-year-old decades.

Relationship of TUG to Demographic, Physical, and Mental Health Variables

The means, standard deviations, 95% confidence intervals, and 25th, 50th, and 75th percentile cutoffs for TUG and the physical and mental health variables for the entire sample of 200 participants are presented in Table 2. Using the sample of 200, correlational and regression analyses were conducted in order to examine the relationships between TUG and each of the following variables: gender, age, SES, BMI, CIRS, PCS, and MCS components of the SF-12. The correlation between TUG and gender was not statistically significant, while TUG was significantly correlated with all of the other variables. As expected, TUG was positively correlated with age (r = .257, P = .001) and negatively correlated with SES (r = −.273, P = .001) indicating that slower TUG times were associated with increased age and lower SES. Positive correlations between the TUG test and both BMI (r = .234, P = .001) and CIRS (r = .425, P = .001) indicated that slower TUG times were associated with higher BMI and more medical comorbidities. The negative correlations between the TUG test times and the PCS (r = −.549, P = .001) and MCS (r = −.327, P = .001) indicated that slower TUG scores were associated with worse perceived physical and mental health.

Table 2.

Statistics for TUG and Predictor Variables for the Entire Sample of 200 Participants.

N = 200	Outcome Variable	Predictor Variables
N = 200	TUG	SES	BMI	CIRS	PCS	MCS
Mean	8.98	5.42	30.38	5.73	47.04	45.60
SD	1.82	2.04	7.33	3.48	11.07	11.50
95% CI for mean	8.72-9.23	5.13-5.70	29.35-31.40	5.24-6.22	45.49-48.58	44.0-47.21
25th percentile	7.93	4.0	25.0	3.0	38.16	35.94
50th percentile	8.66	5.50	29.0	5.0	50.25	49.66
75th Percentile	9.79	7.0	35.0	8.0	56.27	55.54

Abbreviations: TUG, Timed Up and Go; SES, socioeconomic status; BMI, body mass index; CIRS, Cumulative Index Rating Scale; PCS, physical component summary of the Short Form–12; MCS, mental component summary of the Short Form–12.

The hierarchical model of regression analysis was used to determine the unique contribution of demographic, physical health, and mental health variables in predicting TUG. In step 1, age, and SES were entered into the equation as a set that accounted for a significant proportion of the variance in TUG, F(2, 197) = 13.95, P < .001. Despite an inner-city sample, SES demonstrated a normal distribution with skewness at −0.58 well within ±1.96 limits. Older patients and those with perceived lower SES performed more poorly by requiring more time to complete TUG. In step 2, BMI, CIRS, and PCS were entered as a set that accounted for significant unique variance beyond demographics in TUG, F(3, 194) = 18.87, P < .001. Patients who perceived worse physical status as measured by PCS performed the TUG more slowly. PCS was significantly correlated with BMI (r = −.32, P < .001) and CIRS (r = −.59, P < .001) and had the highest correlation of the 3 variables with TUG (r = −.549, P < .001). In step 3, MCS accounted for a significant proportion of variance in TUG beyond demographics and physical health variables, F(1, 193) = 5.34, P < .02, with patients who perceived themselves with poorer mental health performing more slowly on TUG. Regression results are presented in Table 3.

Table 3.

Regression Analysis Predicting TUG.

	β	R ²	R² Change	F Change
Step 1		.12	.12	13.95**
Age	.23
SES	−.24
Step 2		.32	.20	18.87**
BMI	.03
CIRS	.13
PCS	−.44
Step 3		.34	.02	.02*
MCS	−.16	.34	.02	.02*

Age was entered as a continuous variable with N = 200.

P < .05; **P < .001.

Discussion

Results of this study supplement the available NRV for the TUG test beyond the 60 years and older age range⁴ to individuals in their 20s, 30s, 40s, and 50s. The broader range of TUG test reference values comprise a complete adult data set that can be used in a primary care setting. TUG results for participants in their 50s where significantly slower than participants in their 20s, 30s, and 40s. No significant differences in TUG times were found among the 3 younger decades. These results indicate that providers might want to consider routine assessment of physical capacity of patients in their 50s rather than waiting until later decades.

The mean TUG score of our 50- to 59-year-old group was 9.9 seconds, which was slower than the mean TUG score for 60-year-olds (8.1 seconds) and 70-year-olds (9.2 seconds) in a previously published meta-analysis.⁴ Our sample was taken from a convenience sample of patients at an inner city primary care clinic, in contrast, the meta-analysis used only samples identified as healthy elders. A TUG score at or more than 10 seconds indicates reduced physical capacity whether compared with healthy elders or younger adults attending a primary care visit.

While age is an important factor when considering use of TUG, primary care providers may want to use TUG with younger patients who have other demographic, physical, and mental health risk factors. Slower TUG times were significantly related to lower SES. SES differences originating in childhood can influence susceptibility to cardiovascular disease, diabetes, asthma, and obesity in later life,^18,19 and has been consistently associated with greater risk of disease, more rapid progression, and decreased survival.²⁰ Slower TUG times were related to higher BMI and a greater number of comorbidities. These findings suggest that the TUG may be an especially important objective measure for primary care providers as they track the physical progress of patients of any age who have multiple chronic health conditions. Additionally, slower TUG times were associated with the perception of worse physical or mental health. The TUG may be a helpful measure as primary care moves toward a patient-centered medical home model of care with integration of physical and behavioral health.²¹ The TUG can help health care teams assess progress regarding behavioral activation,²² the most commonly delivered intervention in integrated behavioral health settings, directed toward functional improvement.²³

The TUG provides a reliable measure that can be used in primary care that overcomes some of the reasons for not assessing patient physical activity levels. The TUG is inexpensive, requires little investment of time, space, or clinic staff training, and now has reference values across the adult age spectrum. Primary care physicians and their patients can use the objective data provided by the TUG to generate hypotheses about factors that may be contributing to diminished physical capacity. The TUG can serve as a baseline against which progress can be measured as patients engage in exercise, physical therapy, or other rehabilitation programs. Additionally, an objective measure of physical mobility allows physicians to monitor patients’ progress toward treatment goals and alert them to possible issues with adherence or motivation if results are not as expected.

One limitation of the TUG test is the inherently subjective connotation of the phrase “normal walking speed.” Some participants would interpret this as an effortful brisk walk, while others would interpret “normal” as a leisurely pace. It is likely that any discrepancy in interpreting “normal walking speed” was overcome by our sample size. Another limitation of the study was that the NRVs were collected at a primary care clinic, so it could be argued that our sample was more impaired than samples of healthy adults. We would argue that the NRV from our clinic sample is likely more representative of a patient population typically seen in a primary care setting. Primary care providers might consider a TUG test with patients 50 years or older or who have physical or mental health risk factors regardless of age. Time issues may limit busy clinicians willingness to use measures other than age and BMI, which are routinely available. A regression equation, F(2, 197) = 11.23, P < .001, found that using only age (β = .222) and BMI (β = .194) accounted for a significant portion of the variance in TUG time.

Conclusion

This study provides TUG NRVs for adults in their 20s, 30s, 40s, and 50s. The TUG was highly related to age and SES as well as important health factors such as BMI and multiple comorbidities. Perceived physical and mental health functioning appear to be especially critical health factors related to TUG. The TUG may help primary care providers answer the call to assess and monitor every patient’s physical activity program especially those at greatest risk.

Footnotes

Authors’ Note

Parts of this study were presented as a poster, “The Timed Up and Go Test (TUG): The Sixth Vital Sign Assessed in Primary Care,” at the Society of Behavioral Medicine 36th Annual Scientific Meeting, April 22-25, 2015, San Antonio, Texas.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Supported in part by: Community Outreach Primary Care (COPC) grant, National Institutes of Health Grant No. 1S21MD001102-01 (Principal Investigator, Sade Kosoko-Lasaki, MD, Health Sciences’ Multicultural and Community Affairs [HS-MACA], Creighton University).

Author Biographies

Breelan M. Kear is currently a fourth year medical student at Creighton University School of Medicine. She received her BA in Exercise Science from Point Loma Nazarene University in 2013.

Thomas P. Guck, PhD, is a professor and psychologist in the Department of Family Medicine at Creighton University School of Medicine. He sees patients in an integrated primary care clinic and teaches in the Medical School and Family Medicine Residency Program.

Amy L. McGaha, MD, is a professor and director of the Family Medicine Residency Training Program at Creighton University School of Medicine. She practices in a patient centered medical home and teaches in the Medical School and Family Medicine Residency Program.

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Timed Up and Go (TUG) Test