Timed Up and Go (TUG)

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT; Geneva Zaino Bsc PT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Timed Up and Go (TUG) is a screening tool used to test basic mobility skills of frail elderly patients (60-90 years old). The TUG can be used with, but is not limited to, persons with stroke.

In-Depth Review

Purpose of the measure

The TUG is a general physical performance test used to assess mobility, balance and locomotor performance in elderly people with balance disturbances. More specifically, it assesses the ability to perform sequential motor tasks relative to walking and turning (Schoppen, Boonstra, Groothoff, de Vries, Goeken, & Eisma, 1999; Morris, Morris, & Iansek, 2001).

Available versions

The “Get Up and Go” test (the original TUG) was developed by Mathias, Nayak, and Issacs in 1986.

The TUG was published by Podsiadlo and Richardson in 1991 to address the issues of poor inter-rater reliability observed with intermediate scores in the “Get Up and Go”. The TUG incorporates time as the measuring component to assess general balance and function.

Features of the measure

Items:

There are no actual items in the TUG. The individual must stand up from a chair (which should not be leaned up against a wall), walk a distance of 3 meters, turn around, walk back to the chair and sit down – all performed at a comfortable and safe pace (Figure 1). One practice trial is permitted to allow the individual to familiarize him/herself with the task. Timing commences with the verbal instruction “go” and stops when the client returns to seated position. The individual wears their regular footwear and is permitted to use their walking aid (cane/walker) with its use indicated on the data collection form. No physical assistance is given.

Figure 1.

Scoring:

Performance of the TUG is rated on a scale from 1 to 5 where 1 indicates “normal function” and 5 indicates “severely abnormal function” according to the observer’s perception of the individual’s risk of falling (Podsiadlo & Richardson, 1991). The score consists of the time taken to complete the test activity, in seconds.

Steffen, Hacker and Mollinger (2002) reported that on average, healthy individuals between the ages of 60-80 years complete the TUG in 10 seconds or less. Males between the ages of 80-89 years old take on average 10 ± 1 seconds to complete, and women take 11 ± 3 seconds to complete. Formal norms have not yet been established for patients with stroke.

Standardized cut-off scores to predict risk of falling have not yet been established. In one study, a cut-off score of ? 13.5 seconds has been shown to predict falling in community-dwelling frail elders, but this score has not been verified in other studies (Shumway-Cook et al., 2000).

Scoring and interpretation of the TUG
Score Interpretation
< 10s Completely independent

With or without walking aid for ambulation and transfers

< 20s Independent for main transfers

With or without walking aid, independent for basic tub or shower transfers and able to climb most stairs and go outside alone

> 30s Requires assistance

Dependent in most activities

(Adapted from Podsiadlo & Richardson, 1991)

Subscales:

None typically reported.

Equipment:

The TUG does not require any specialized equipment and can therefore be accomplished in community as well as institutional settings.

  • Standard chair with armrests (46cm seat height and 63-65cm armrest height)
  • Tape measure
  • Brightly colored tape or cone to mark off the 3m path 3m path free from obstruction
  • Stopwatch or wrist watch with a second hand to time the performance.

Training:

Minimal training is required to score the test or interpret the results. The assessor should be aware of safety issues during mobility in individuals with stroke.

Time:

The TUG requires 1 to 2 minutes to administer (Finch, Brooks, Stratford, & Mayo, 2002).

Alternative forms of the TUG

  • TUG Cognitive (Shumway-Cook, Brauer, & Woollacott, 2000). In the TUG Cognitive, patients must complete the task while counting backwards from a randomly selected number between 20 and 100.
  • TUG Manual (Lundin-Olsson et al., 1998). In the TUG Manual, patients must complete the task while carrying a full cup of water. Lundin-Olsson et al. (1998) found that frail older adults who had a time difference of greater than 4.5 seconds between the TUG Manual and the TUG were more prone to falls during the following 6 months.

Client suitability

Can be used with:

Patients with stroke

  • The TUG can be administered to geriatric clients ? 65 years old with any diagnosis (e.g. arthritis, stroke, vertigo, Parkinson’s disease, cerebellar disorders and general deconditioning) (Shumway-Cook & Woollacott, 2001; Hayes & Johnson, 2003; Morris et al., 2001).
  • The TUG can also be used with patients ? 18 years old with an acute neurological diagnosis (Shumway-Cook & Woollacott, 2001).
  • Clients must be able to walk approximately 6 meters with or without an assistive device but without the assistance of another person.
  • Clients must have sufficient vision to walk to the 3-meter line.
  • Non-English speakers must receive appropriate translation.

Should not be used in:

  • The TUG is not appropriate for clients with severe cognitive impairments that prevent understanding of the tasks. Rockwood, Awalt, Carver, and MacKnight (2000) found that in cognitively impaired frail elderly individuals, 35.5% were unable to physically perform the test.
  • Severely affected patients such as those who cannot leave a seated position. There may be a floor effect with these patients. Instead, you may wish to consider the Postural Assessment Scale for Stroke Patients (PASS), which was designed as a balance assessment for patients with stroke and is applicable for all patients with stroke, even those with the most severe postural performance (Benaim, Pérennou, Villy, Rousseaux, & Pelissier, 1999).
  • Since the TUG is administered through direct observation of task completion. A proxy respondent cannot complete it.
  • The TUG is a limited measure assessing few aspects of balance. For a more comprehensive measure of balance, the Postural Assessment Scale for Stroke Patients (PASS) (Benaim et al., 1999) or the Berg Balance Scale (Berg, Wood-Dauphinee, Williams, & Maki, 1992) is suggested.

In what languages is the measure available?

Given the simplicity of the instructions, the TUG can be administered in different languages with informal translations (Tremblay, Savard, Casimiro, & Tremblay, 2004).

Summary

What does the tool measure? Basic mobility and balance in frail elderly patients
What types of clients can the tool be used for? Elderly patients (60-90 years old), patients with stroke
Is this a screening or assessment tool? Screening
Time to administer 1-2 minutes
Versions TUG Cognitive, TUG Manual
Other Languages Can be completed in any language
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the TUG.
  • Out of 7 studies examining the test-retest reliability.
  • Out of 5 studies examining the inter-rater reliability inter-rater, and 1 reported no significant difference in scoring between two raters, suggesting high inter-rater reliability.
  • Out of 2 studies examining the intra-rater reliability intra-rater reliability.
Validity

Content:

Not available.

Criterion:

No gold standard exists.

Construct:

Excellent correlations between the TUG and the Older Americans Resources and Services Instrumental Activities of Daily Living Scale (OARS IADL), OARS Activities of Daily Living (OARS ADL), Frailty Scale, Berg Balance Scale, Tinetti Balance Scale, measures of gait speed (one study reported adequate correlation), and 6-Minute Walk Test (6MWT). Adequate correlations with the Barthel Index, Functional Independence Measure, Groningen Activity Restriction Scale, Sickness Impact Profile.

Known groups.

The TUG can distinguish between elderly patients using different ambulatory aids, the presence of cognitive impairment, patients with Parkinson’s disease who were on the medication levodopa and those patients who were not on levodopa, and healthy elderly individuals from patients with stroke.

Predictive.

TUG has been found to predict nursing home placement and risk of falling.

Does the tool detect change in patients?

In one study, 35.5% of frail elderly individuals with cognitive impairment were unable to physically perform the test, which may be indicative of a large floor effect.

Although the TUG has been developed as a screening ability to detect change. Another study reported that out of a number of gait speed measures, the TUG was the most able to detect change.

Acceptability TUG is a short and simple measure that takes only a few minutes to complete and requires only a few basic movements. The TUG has been found to have less reliability among patients with cognitive impairment.
Feasibility TUG requires no specialized equipment. Although only minimal training is required, the assessor must be aware of safety issues during mobility in individuals with stroke.
How to obtain the tool? The TUG can be obtained by contacting the developer, Diane Podsiadlo, CLSC NDG, 2525 Boulevard Cavendish, Bureau 110, Montreal, QC, H4B 2Y4. Fax: 514-485-6406

Psychometric Properties

Overview

There is a paucity of literature published on the reliability and validity of the TUG in patients with stroke. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the TUG.

Floor and Ceiling Effects

Rockwood et al. (2000) found that in frail elderly individuals with cognitive impairment, 35.5% were unable to physically perform the test. This may be indicative of the presence of a large floor effect with the TUG.

Reliability

Internal consistency:
Not reported

Test-retest reliability:
Podsiadlo and Richardson (1991) reported excellent test-retest reliability of the TUG in frail elderly patients (ICC = 0.99).

Steffen et al. (2002) administered the TUG to 97 community-dwelling older adults. The test-retest reliability of the TUG was found to be excellent in this population (ICC = 0.97).

Thompson and Medley (1995) examined the test-retest reliability of the TUG in elderly individuals without any health problems and found excellent test-retest correlations ranging from 0.81 to 0.99.

Rockwood et al. (2000) examined the test-retest reliability of the TUG as part of the Canadian Study of Health and Aging. Adequate test-retest reliability was reported for all participants (ICC = 0.56), for individuals without cognitive impairment alone (ICC = 0.50), and for those with cognitive impairment alone (ICC = 0.56). The results of this study are substantially lower than the results of previous studies examining the test-retest reliability of the TUG in elderly patients. The authors suggest this may be due to the fact that unlike other similar studies, they did not exclude medically unstable patients in their study, and further, they did not control for certain factors (e.g. the time and setting in which the TUG was readministered).

Morris et al. (2001) examined the test-retest reliability of the TUG in 12 patients with Parkinson’s disease and 12 subjects without Parkinson’s disease. Patients were videotaped and timed by 2 experienced raters. Three experienced clinicians and 3 inexperienced clinicians later rated the videotape. The test-retest reliability of the TUG was found to be excellent (ranging from r = 0.87 to r = 0.99).

Flansbjer, Holmback, Downham, Patten, and Lexell (2005) assessed the test-retest reliability of the TUG in 50 patients with chronic mild to moderate post-stroke hemiparesis. The patients performed the TUG twice, with 7 days between each evaluation. The test-retest reliability of the TUG was found to be excellent (ICC = 0.96).

Ng and Hui-Chan (2005) administered the TUG to 10 healthy elderly subjects and 10 patients with chronic stroke twice, at the same time of day, on different days within one week. The results showed excellent test-retest reliability for both healthy elderly subjects (ICC = 0.97) and patients with stroke (ICC = 0.95). The results of this study and the previous study by Flansbjer et al. (2005) suggest that the TUG is a reliable measure in patients with stroke.

Inter-rater reliability:
Podsiadlo and Richardson (1991) compared the inter-rater reliability of the TUG, the TUG Manual and the TUG Cognitive using same day comparisons of three raters. Excellent inter-rater reliabilities were found for the TUG (ICC = 0.98), the TUG Manual (ICC = 0.99), and the TUG Cognitive (ICC = 0.99).

Siggeirsdottir, Jonsson, Jonsson, and Iwarsson (2002) examined the inter-rater reliability of the TUG in 31 elderly individuals in a retirement home. No significant difference was found between the two raters (mean difference = 0.04s). The results of this study suggest that the TUG has high inter-rater reliability.

Norén, Bogren, Bolin, and Stenstrom (2001) examined the inter-rater reliability of the TUG in patients with peripheral arthritis. The inter-rater reliability among three physiotherapists was found to be excellent (ICC = 0.97).

Schoppen et al. (1999) examined the inter-rater reliability of the TUG in elderly patients with a lower-extremity amputation. The test was performed for two different observers at different times of the same day. An excellent Spearman correlation was found between the scores of the two observers (r = 0.96), demonstrating the excellent inter-rater reliability of the TUG.

Note: Caution should be taken in interpreting these findings as the Spearman correlation is not the preferred method of assessing inter-rater reliability and may have produced higher reliability coefficients than a more appropriate analysis.

Morris et al. (2001) examined the inter-rater reliability of the TUG using three experienced raters and three inexperienced raters. Each rater viewed the sequence of performances for 12 patients with Parkinson’s disease and 12 comparison patients from videotape. Raters viewed the videotapes independently at least one week after testing. ICCs were excellent for both experienced and inexperienced raters, ranging from r = 0.87 to r = 0.99. The results of this study demonstrate the excellent inter-rater reliability of the TUG in patients with Parkinson’s disease.

Intra-rater:
Podsiadlo and Richardson (1991) found that the TUG demonstrated excellent intra-rater reliability in frail elderly individuals (ICC= 0.99).

Schoppen et al. (1999) examined the intra-rater reliability of the TUG in elderly patients with a lower-extremity amputation. Patients performed the TUG for one observer at two different occasions with an interval of two weeks. An excellent Spearman correlation was observed between scores obtained by the same rater on two consecutive visits (r = 0.93).

Note: Caution should be taken in interpreting these findings as the Spearman correlation is not the preferred method of assessing intra-rater reliability and may have produced higher reliability coefficients than a more appropriate analysis

Validity

Content:

Not available.

Criterion:

No gold standard exists.

Construct:

Convergent/Discriminant:
Rockwood et al. (2000) examined the convergent and discriminant validity of the TUG using Phase 2 data from the Canadian Study of Health and Ageing. Both discriminant validity was assessed by comparing the TUG to other functional assessments including: the Older Americans Resources and Services Instrumental Activities of Daily Living Scale (OARS IADL) and OARS Activities of Daily Living (OARS ADL) (Fillenbaum & Smyer, 1981), the Cumulative Illness Rating Scale (CIRS) (Linn, Linn, & Gurel, 1968), and the Frailty Scale (developed for the Canadian Study of Health and Aging-2) using Spearman correlations. The TUG demonstrated excellent correlations with the OARS ADL for all participants, and with participants with cognitive impairment alone (r = -0.69 and r = -0.72 respectively). The OARS IADL also had excellent correlations with the TUG for all participants and with participants with cognitive impairment alone (r = -0.70 and r = -0.70, respectively). The TUG also had an excellent correlation with the Frailty Scale for all participants (r = 0.60). Some correlations are negative because a high score on the TUG indicates abnormal functioning, whereas a high score on some other measures indicates better performance. The TUG correlated poorly with the CIRS (ranging from r = 0.22 to 0.26).

Berg, Maki, Williams, Holliday, and Wood-Dauphinee (1992) compared scores from clinical measures and laboratory tests of balance and mobility in 31 elderly subjects. An adequate correlation between the TUG and the Barthel Index was reported (r = -0.48). Excellent correlations between the TUG and the Berg Balance Scale (r = -0.76) and between the TUG and the Tinetti Balance Scale (Tinetti, 1986) (r = 0.74) were also observed (some correlations are negative because a high score on the TUG abnormal functioning, whereas a high score on other measures indicates better health).

Podsiadlo and Richardson (1989) examined the convergent validity of the TUG in frail elderly individuals and reported an excellent correlation between the TUG and the Berg Balance Scale (r = -0.72), and an adequate correlation between the TUG and gait speed (r = -0.55) and between the TUG and the Barthel Index (r = -0.51).

Brooks, Davis, and Naglie (2006) examined the construct validity of the TUG, and two other measures of physical performance in 52 frail older individuals. Correlations between the TUG and the Functional Independence Measure (Keith, Granger, Hamilton, & Sherwin, 1987) were adequate at both admission (r = -0.59) and at discharge (r = -0.42). Correlations are negative because a high score on the TUG indicates abnormal functioning whereas a high score on the Functional Independence Measure indicates functional independence.

Schoppen et al. (1999) examined the validity of the TUG by comparing it to the Sickness Impact Profile-68 item scale (de Bruin, Diederiks, de Witte, Stevens, & Philipsen, 1994), and the Groningen Activity Restriction Scale (GARS) (Kempen, Doeglas, & Suurmeijer, 1993) in 32 patients over the age of 60 with unilateral transtibial or transfemoral amputation because of peripheral vascular disease. An adequate Spearman correlation was reported between the TUG and the Groningen Activity Restriction Scale (r = 0.39). The TUG also correlated adequately with the total score of the Sickness Impact Profile (r = 0.40) and mobility control and mobility range (r = 0.46 and 0.36). A poor correlation between the TUG and the subscales of the “psychic autonomy and communication” (r = 0.31), “social behavior” (r = 0.19), and “emotional stability” (r = -0.04) of the Sickness Impact Profile was found. The findings confirm that the TUG is not a reflection of mental functioning.

Noren et al. (2001) administered various assessments of balance to 65 patients with peripheral arthritis and found that the Berg Balance Scale (Berg, Wood-Dauphinee, Williams, & Maki, 1989) and the TUG had an excellent correlation (Spearman’s rho = -0.83). The correlation is negative because a high score on the Berg Balance Scale indicates normal balance, whereas a high score on the TUG indicates abnormal functioning.

Ng and Hui-Chan (2005) administered the TUG to 10 healthy elderly participants and 11 patients with chronic stroke. Spearman correlation analyses were conducted to examine the convergent and discriminant validity of the TUG with various measures. No significant associations between the TUG and spasticity of ankle plantarflexors of both affected and unaffected legs were observed. An excellent correlation between the TUG and the peak plantarflexion torque generated by maximum isometric voluntary contraction (MIVC) of the affected plantarflexors was reported (r = -0.86), however the TUG did not correlate with the other MIVC parameters measured. Excellent negative correlations were found between the TUG and gait velocity in both healthy participants and patients with stroke (r = 0.98 and r = 0.99, respectively). For the other gait parameters, the step lengths of both the affected and unaffected legs had excellent correlations with the TUG (ranged from r = -0.67 to r = -0.80). An excellent correlation was found between the distance covered during the 6-Minute Walk Test (6MWT) (Guyatt et al., 1985) and the TUG (r = -0.96). Some correlations are negative because a high score on the TUG indicates abnormal functioning whereas a high score on other measures indicate a high level of performance.

Flansbjer et al. (2005) examined 6 gait performance tests in patients with mild to moderate post-stroke hemiparesis (Comfortable Gait Speed; Fast Gait Speed, Stair Climbing Ascend; Stair Climbing Descend; 6-Minute Walk Test). They found excellent correlations between the TUG and the other gait performance measures examined twice, 7 days apart, ranging from r = -0.84 to r = -0.92 (these correlations are negative because a high score on the TUG indicates abnormal functioning, whereas a high score on other gait measures indicate normal performance). Taken together with the results from the study by Ng and Hui-Chan (2005), the TUG appears to be a valid measure for use in patients with stroke.

Known groups:
Brooks et al. (2006) examined the construct validity of the TUG in 52 frail older individuals. They found that the TUG could distinguish patients using different ambulatory aids. Berg et al. (1992) found that the TUG was able to distinguish between elderly individuals who walked with an aid (cane or walker) versus those who did not use any walking aid (effect size = 1.02).

Rockwood et al. (2000) examined the validity of the TUG using Phase 2 data from the Canadian Study of Health and Ageing. They reported that cognitively unimpaired clients could perform the TUG faster than cognitively impaired clients (12 seconds versus 15 seconds, on average).

Morris et al. (2001) found that the TUG could distinguish between patients with Parkinson’s disease who were on the medication levodopa and those patients who were not on levodopa when compared to individuals without Parkinson’s disease.

Ng and Hui-Chan (2005) found that the TUG was able to distinguish healthy elderly individuals from patients with stroke (mean time to complete the TUG was 9.1 seconds for healthy individuals and 22.6 seconds for patients with stroke).

Predictive:
Nikolaus, Bach, Oster, and Schlierf (1996) examined predictors of death, nursing home placement and hospital admission in 135 patients admitted to a geriatric hospital and discharged home. In a logistic regression analysis, baseline TUG scores were found to be an independent predictor for nursing home placement.

Schwartz et al. (1999) found that in a sample of elderly Mexican-American women, those with the best and worst performance on the TUG were more likely to fall than those with moderate performance.

Whitney, Marchetti, Schade, and Wrisley (2004) found that patients with vestibular disorders and a history of falls who scored > 11.1 seconds on the TUG were five times more likely to have reported a fall in the previous 6 months.

Sensitivity and Specificity

Shumway-Cook, Brauer, and Woollacott (2000) compared the specificity of the TUG in predicting falls in community dwelling older adults. The TUG correctly classified 13/15 fallers (87% sensitivity) and 13/15 nonfallers (87% specificity). These results suggest that the TUG is a sensitive and specific measure for identifying elderly individuals who are prone to falls.

Whitney, Marchetti, Schade, and Wrisley (2004) examined the sensitivity and specificity of the TUG in 103 patient charts of those with vestibular disorders and a history of falls. Sensitivity (80%) and specificity (56%) were calculated for TUG scores of > 11.1 seconds.

Responsiveness

Brooks, Davis, and Naglie (2006) examined the responsiveness of the TUG in 52 frail older individuals. The TUG demonstrated a large responsiveness to an intervention that occurred between admission and discharge with a standardized response mean (SRM) of 1.1.

Flansbjer et al. (2005) examined the responsiveness of the TUG in 50 individuals with stroke. The smallest real difference (SRD), representing the smallest change that indicates a real (clinical) improvement, was small (SRD = 23%). In other words, the TUG can be used to detect clinically relevant small changes.

Salbach and colleagues (2001) examined the most responsive measure of gait speed from a variety of measures in 50 post-stroke patients with gait deficits. The TUG demonstrated significant change from 8 – 38 days post-stroke (SRM = 0.73). However, there were significant difficulties in obtaining scores since not all patients could complete the test at both times. The SRM reported reflects scores for only those subjects who were able to perform the test. The responsiveness of the TUG also varied depending on the group of patients tested. In the moderate group, the TUG was rated the third most responsive tool after the 5-minute Walk Test (5mWT) (maximum pace), and the 5mWT (comfortable pace). In the fast group, the TUG was rated the second most responsive tool after the 5mWT.

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  • Tremblay, L. E., Savard, J., Casimiro, L., Tremblay, M. (2004). Repertoire des Outils d’Evaluation en Francais pour la Readaptation, Regroupement des intervenantes et intervenants francophones en sante et enservices sociaux de l’Ontario, Ottawa.
  • Whitney, S. L., Marchetti, G. F., Schade, A., Wrisley, D. M. (2004). The sensitivity and specificity of the Timed “Up & Go” and the dynamic gait index for self-reported falls in persons with vestibular disorders. Journal of Vestibular Research, 14(5), 397-409.

See The Measure

How to obtain the TUG

The TUG can be obtained by contacting the developer, Diane Podsiadlo, CLSCNDG, 2525 Boulevard Cavendish, Bureau 110, Montreal, QC, H4B 2Y4. Fax: 514-485-6406.

By clicking here, you can access a video showing how to administer the assessment.

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