timed-up-and-go-test-blog

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Introduction

The Timed Up-and-Go (TUG) test is used as a measure of independent mobility, in specific gait and balance control (Beauchet et al., 2010). The test measures the time it takes for a person to stand from sitting in a chair, walk 3 meters, turn around, walk back to the chair, and sit down (Beauchet et al., 2010). Age and cognitive development both influence motor development and consequently gait and balance control (Beauchet et al., 2010). The TUG test was developed with the purpose of assessing daily physical movements and is a useful test of functional mobility in older adults to predict the probability of falls (Demura & Uchiyama, 2007).

The greatest degree of physical change occurs during the first 2 years of life (Boyd, Johnson & Bee, 2017). Gains in motor developments continue to increase at a steady rate following the first 2 years of life, with the greatest gains in large muscles involved in gross motor skills (Boyd, Johnson & Bee, 2017). Moving forwards into later childhood and adolescence, as gains in cognitive and motor development continue to occur, motor functioning continues to improve and individual’s motor activity levels begin to increase, peaking between ages 7 and 9 (Boyd, Johnson & Bee, 2017). The combination of gains in cognitive and motor development and increased motor activity results a greater ability to control behavior and movements which in turn leads to greater incidences of successful task achievement (Boyd, Johnson & Bee, 2017). Due to the progressive development and improvements in motor functioning and task achievement from birth to adolescence, it is likely that performance on the timed get-up-and-go test will consequently improve. However, by older adulthood it is likely that performance will decline due to consequent cognitive and motor declines (Beauchet et al., 2010). (254)

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Timed Up and Go Test in Early Childhood (2-6 years)

Timed Up and Go Test in Early Childhood (2-6 years)

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Analysis of the Timed Up and Go Test in Early Childhood (2-6 years)

In healthy individuals, motor development occurs rapidly from birth, with the most significant gains occurring during the first 2 years of life (Boyd, Johnson & Bee, 2017). During early childhood, rapid synaptogenesis and myelinization occurs, leading to significant cognitive and motor development (Boyd, Johnson & Bee, 2017). By 12 months of age, independent walking begins to occur and by 36 to 48 months, mature gait patterns are established (Williams, Carroll, Reddihough, Phillips & Galea, 2005). Such gains in early development are dependent on the individual’s growth and maturity characteristics as well as the environment in which they are reared (Malina, 2004). A child growing up in a more intellectually challenging and stimulating environment will retain a more complex network of synapses and will have more opportunities to engage in motor activity, allowing for greater improvements in motor functioning, motor control and task achievement (Malina, 2004).

While the TUG test is typically used to assess independent mobility in an older population, it is still a reliable test of early childhood mobility and if often used to identify and assess any deficiencies in motor development (Williams et al., 2005). In a study put forth by Williams et al (2005), 176 children without physical disabilities, ages 3 to 9, completed the TUG test. The average TUG score was 5.83 seconds (Williams et al., 2005). The sample was then subdivided into 2 different age groups: early childhood (ages 3 to 5) and adolescence (ages 6 to 9) (Williams et al., 2005). The mean score for the early childhood group was 6.7 seconds and the mean score for the adolescence group was 5.1 seconds, indicating the vast gains made in motor development moving forward from early childhood into adolescence (Williams et al., 2005). Furthermore, over a 5-month follow-up period, the mean TUG scores reduced significantly in the early adolescence group, exhibiting how elastic and rapidly developing the early childhood brain is (Williams et al., 2005).

In the following video, the participant, a healthy 5-year-old female, completes the TUG test in 7.18 seconds. The participant is able to complete the task without any motor difficulties, exhibiting her ability to complete the motor tasks included in the motor milestones of individuals her age such as walking in a line and combining various motor tasks into a motor sequence (Boyd, Johnson & Bee, 2017). However, when compared to mean TUG scores observed by Williams et al for the early childhood sample, the participant’s score is slightly higher. A possible explanation for the participant’s slightly elevated score is the behavioral variations in young children, which play a large role in the range and relatability of their performance on such a test (Williams et al., 2005). As shown in the video, the participant is distracted by her environment, in specific by being filmed. The participant looks into and speaks at the camera while completing the task, thus diverting her attention away from completing the task which likely resulted in more time being used to complete the task than if she was not distracted. (453)

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Timed Up and Go Test in Later Childhood (6-12 years)

Timed Up and Go Test in Later Childhood (6-12 years)

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Analysis of the Timed Up and Go Test in Later Childhood (6-12 years)

The ability for infants to begin walking and exploring their surroundings suggests a critical period that is carried on throughout childhood. Considering motor development improves rapidly during childhood, the TUG test provides a measure to assess the normative age progression through motor milestones in late childhood. Furthermore, the test demonstrates the same settings as a child would experience in a classroom, another reason for it being a very reliable test.

Few studies have investigated the Timed Up and Go Test in young, healthy children. In this video, the TUG test was performed by a healthy 9-year-old male. The participant maintained his balance throughout the duration of the test - he did not stumble, fall or require any assistance. The participant shows appropriate step strokes and also appropriate arm movement. It took the participant 7.51 seconds to complete the test. The subject was able to complete the test, demonstrating proper motor coordination. These measures were recorded and compared to norm TUG values in children ages 6-12 to ensure validity.

Itzkowitz et al (2016) collected normative data from middle school children. They examined 1481 children between the ages of 5-13. The average TUG score or children aged 9 were approximately 6.20 seconds (Itzkowitz, et al., 2016). One noted change compared to the early childhood group is the child's ability to complete the TUG test at a faster pace. This relates to normative findings that as age increases, TUG times will decrease until early adulthood, then increasing again into late adulthood (Itzkowitz, et al., 2016). Throughout childhood, increases in motor activity leads to associated improvements in task achievement (Boyd, Johnson & Bee, 2017). During late childhood, as more time is spent in a classroom setting, it is likely that individuals will engage in more motor activities related to getting up from and returning back to a seated position which is similar to the tasks involved in the TUG test. Therefore, performance on the TUG test is likely to improve at this age due to gains made in task achievement associated with movements related to sitting, standing and walking as experienced in both a classroom setting and the TUG test.

Environmental surroundings influence a child’s maturity and growth (Malina, 2004). Environmental settings can either enhance or restrict a child movement as they begin to interact more with the outside world. Malina (2004) briefly considers the social context in relation to movement patterns and physiological growth. This research provides evidence that children are dynamic beings and the changes in locomotion, including walking, standing and sitting are attributed to physical, metabolic and environmental characteristics (Malina, 2004). (413)

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Timed Up and Go Test in Adolescence (12-18 years)

Timed Up and Go Test in Adolescence (12-18 years)

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Analysis of the Timed Up and Go Test in Adolescence (12-18 years)

The Timed Up and Go Test (TUG) is a significant tool in assessing functional mobility, gross motor function, quality of life, muscle strength, range of motion, functional capacity, and physical activity level in the pediatric/adolescent population (Nicolini-Panisson and Donadio, 2013). The following participant is a healthy 18-year-old female. As a young, healthy adolescent, the participant maintained controlled gait and balance, without assistance, while completing the TUG test. The participant followed a standard pace with appropriate foot strides and little arm movement, completing the TUG test in 6.82 seconds. As the joints and muscles develop in the adolescent body, the individual becomes stronger and more coordinated, explaining the decrease in performance time compared to the previous developmental stage of later childhood.

Nicolini-Panisson and Donadio (2013) examined performance on the TUG test among 129 10-13-year-olds and 126 14-18-year-olds. The average TUG test performance for 10-13-year-olds was 5.57 seconds (Nicolini-Panisson & Donadio, 2013). The average for 14-18-year-olds was 4.9 seconds (Nicolini-Panisson & Donadio, 2013. The improvements made in performance on the TUG test between 14-18-year-old group and the 10-13-year-old group are attributable to gait and balance gains that occur with age (Nicolini-Panisson & Donadio, 2013. Gait and balance begin developing in the early stages of infancy. During adolescence, motor improvements and refinement of gait and balance control continue to occur. At this time, the experiences of the adolescent and the environment in which such experiences take place has a significant impact on the adolescent’s progression through motor development and the associated age-specific motor milestones (Nicolini-Panisson & Donadio, 2013). For example, if the participant fails to develop movement skills during the critical years of development, it would be difficult for this participant to achieve high performance in the TUG test as an adolescent. In contrast, if a normal progression of motor-development occurs, it can be expected that performance on the TUG test will improve from infancy into adolescence (Nicolini-Panisson and Donadio, 2013).

Puberty reflects a key characteristic of adolescence in which physiological and anatomical changes affect motor performances and results in a change in motor development (Davies & Rose 2000). A popular belief is that puberty poses an awkward phase for adolescent development however results from a study conducted by Davies and Rose (2000) analyzed 80 adolescents within the prepubertal, pubertal and post-pubertal stages of development. Results show that opposed to the common perception of puberty negatively impacting performance, puberty, in fact, did not impair coordination and motor skills but rather contributed to a growth in motor development (Davies & Rose 2000). This research helps contribute to the understanding of TUG scores and the notable declines in TUG test performance times from infancy into early adulthood. (430)

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Timed Up and Go Test in Early Adulthood (19+ years)

Timed Up and Go Test in Early Adulthood (19+ years)

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Analysis of the Timed Up and Go Test in Early Adulthood (19+ years)

It is widely known that post-puberty, the adolescent has matured both physically and cognitively into early adulthood, in which peak physical and cognitive abilities are attained (Boyd, Johnson & Bee, H, 2017). The Timed Up-and-Go (TUG) test is reliable in examining mobility, gait and balance in everyday movements that shift the center of gravity, such as standing up, walking, turning around and sitting down (Kear, Guck & McGaha, 2017). By the time they reach early adulthood, the majority of healthy, young adults are at the peak of their physical abilities and are able to complete such daily physical movements (Boyd, Johnson & Bee, H, 2017).

There has been limited examination of the performance of individuals in early adulthood (aged 20 to 40) on the TUG test. However, the TUG test may be valuable to predict and assess any pre-meditative motor problems that may present in the futures of young adults. The present demonstration was completed by a healthy, 21-year-old female. As a healthy young female with no physical deficits, the participant showed no difficulties in performing the task. Gait and balance were constantly controlled throughout the TUG test. While the TUG test seems fairly simple, it is composed of several physical movements which require the individual to alter their speed, as well as movements that offset the individuals’ center of gravity. From standing up, walking, turning around, walking back and sitting down; gait, balance, and speed were consistently composed. The participant completed the TUG test in 6.58 seconds, the fastest recorded time amongst the five developmental stages studied.

Performance results of the TUG test in early adulthood can be attributed to the fact that healthy young adults reach optimum physical and cognitive function in this stage of development (Boyd, Johnson & Bee, 2017). In adolescence – the stage immediately prior to early adulthood – both the skeletal system and muscular system of healthy males and females grow stronger, enabling adolescents to mature into stronger and increasingly coordinated young adults (Boyd, Johnson & Bee, H, 2017). This may help to explain the very similar but slightly faster results in the early adulthood trial compared to the adolescence trial.

Kear, Guck and McGaha (2017) noticed the gap in literature regarding the TUG test in early adulthood and as a result, compared TUG test performance in different decades of life (i.e., individuals in their 20s, 30s, 40s, and 50s). In this study, Kear, Guck and McGaha (2017) took into account the social determinants of health that may impact performance on the TUG test at various developmental decades. Results showed distinctive changes in TUG test performance between different decades, with the fastest performance being on the younger end of the spectrum in individuals in their 20s, 30s and even 40s compared to individuals in their 50s (Kear, Guck & McGaha, 2017). Their findings align with the participant’s results and demonstrate the peak in physical development attained in early adulthood. While age is an important factor in TUG test performance, the Kear, Guck and McGaha (2017) study as well as the present study demonstrate that social determinants of health and personal factors may play a role in functional mobility. (487)

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Timed Up and Go Test in Later Adulthood (60+ years)

Timed Up and Go Test in Later Adulthood (60+ years)

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Analysis of the TUG Test in Later Adulthood (60+ years)

Distinct physical changes that are associated with aging include reduction in balance, dexterity and stamina (Manini, Hong, & Clark, 2013). The loss of balance, which is extremely important in one’s gait, arises in large part from the loss of muscle strength and dendritic loss at the neurological level (Manini, Hong, & Clark, 2013). With age, atrophy of the motor cortical regions and corpus callosum may also provoke motor decline in one’s balance and subsequently their gait (Kleim & Jones, 2008). Numerous comprehensive studies have been done on the Timed Up and Go Test (TUG) test and its relationship with mobility of the elderly, demonstrating the impairments that old age presents.

The present example of the TUG test was performed by a 65-year-old, healthy male. The subject does not have any disabilities or impairments that would impact one’s motor ability to perform the TUG test. Whilst performing the TUG test, the participant was relatively slow to rise, made slower step strokes and arm movements, was slow to sit back into a seated position and demonstrated relative difficulties when compared to the younger subjects. Consequently, the overall gait of the participant was much slower than the younger participants. The test was performed 3 times, after each trial the time needed to complete the test decreased. The reason that the time taken to complete the test had decreased is most likely due to the subject gaining familiarity of the test. The slowest time was 13.2 seconds, the second 13.1 seconds, and the fastest 12.5 seconds. The average (mean) time to complete the TUG test was 12.93 seconds. For an older adult a healthy time to complete the TUG test is less than 20 seconds. If a patient were to go over this time, it is said they have an increased risk of falling (Barry, Galvin, Keogh, Horgan, & Fahey, 2014). The subject was well within the healthy time to complete the test meaning there is not a high risk of falling.

Some reasons that may explain the subject’s performance are age and physical fitness. The subject is aged 65 years, and while motor skills have declined since early adulthood, the level of reduction is not as substantial as adults in an older age range. Physical fitness also plays a large role in time to complete the TUG test. When older adults are physically active, it is widely known that they will become more physically fit. This leads to increase muscle strength and as a result increased balance (Manini, Hong, & Clark, 2013). These factors play a large role in the one’s performance in the TUG test, the more improved these factors become the better one will perform on the TUG test and therefore decrease the risk of injury due to falls. Older adults who are physically active will mitigate the atrophy of motor cortical regions allowing them to maintain a fair amount motor skill even as they age (Manini, Hong, & Clark 2013). (460)

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Conclusion

The purpose of this cross-sectional observation was to interpret and analyze the motor development that occurs across a lifespan. This study has analyzed 5 different participants in 5 different developmental stages of life; early childhood (2-6 years old), later childhood (6-12 years old), adolescence (12-18 years old), early adulthood (19-60 years old), and later adulthood (60+ years old). The results of the observations have shown that the time to complete the TUG test is fastest in early adulthood while the slowest in later adulthood.                                        

The volume of white matter in children is low, thus the conduction of nerve impulses in neurons is inefficient (Kleim & Jones, 2008). The results of observations of the TUG test have shown an increase in performance from early childhood to early adulthood and a subsequent drop off during late adulthood. The result of this may be the connections of neurons forming neural groups via the connections of other neurons (Kleim & Jones, 2008). When these connections form, skilled performance on motor tasks is increased. In addition, grey matter and muscular strength decline with age. As a result, older adults tend to perform worse in various motor skills (Kleim & Jones, 2008). One reason for the reduction of grey matter is the brain’s efficiency. Only neurons that are often active survive. During childhood there is a large number of neurons which means that there is room for plasticity and learning (Kleim & Jones, 2008). In early childhood, the child is learning a plethora of gross and fine motor skills, which are accompanied with structural changes in the brain. With new knowledge and new neural connections, the less efficient neurons that are not being activated are pruned (Kleim & Jones, 2008). A way to increase neural survival is through the activation of other neural groups, as the connections between them will help delay synaptic pruning. This may have large implications for aging adults, as older adults will show less behavioural plasticity when compared to younger individuals (Kleim & Jones, 2008). Older adults who remain active will maintain more neural connections and thus will show a slower loss of grey matter while aging (Kleim & Jones, 2008).  

While the TUG test is a good measure of functional mobility, this cross-sectional observation of motor development using the TUG test presents limitations that need to be considered. First, causes of variability in TUG test performance may be due to social or personal differences between subjects. For example, the way “normal” walking speed is interpreted by each individual is entirely subjective, explaining some variability or disconnect between results and other literature. Furthermore, the TUG test does not account for demographic differences or social determinants of health that may affect the performance of seemingly healthy individuals. (426)

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References