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Saskatoon Falls Consortium Meeting September 28, 2009 2:30 ­ 4:30 p.m. Saskatoon City Hospital Room 1932

Timed Up and Go....and Beyond

Robynne Smith, Physical Therapist, Vestibular Therapist Off Broadway Physiotherapy & Dizziness Clinic

With permission from Jeff Hoder, PT, DPT, NCS, Emory University, as presented at the course: Advances in Vestibular Rehabilitation ­ Competency Renewal Course, August 12 ­ 15, 2009 Duke University, Durham, NC, Course Director ­ Dr. Susan Herdman

GAIT SPEED (preferred and maximal)

Gait speed is considered to be the 4th "Geriatric Vital Sign". Slower speeds are indications for risk for falling in Older Adults (OA). There are age/gender referenced values and test/retest reliability are .90/.91. Test Protocol Measure a standard distance (e.g., 20 feet) and place markers at the start and finish. Start the patient 5 feet in front of the mark and have the patient walk 5 feet past the finish mark. Begin the stopwatch as soon as the person's foot crosses the start line and stop recording when the person's second foot crosses the finish line. Gait speed = distance (ft or m) time (s) Instructions for the Patient: First ask the patient to walk at his normal walking speed. Instruct the patient to continue walking 5 feet beyond the finish line. Then repeat the test by asking the patient to walk a quickly but as safely as possible. Instruct the patient to continue walking 5 feet beyond the finish line. References values for preferred and maximal gait speed: Feet per second:

Age 20's 30's 40's 50's 60's 70's frail Preferred (ft/s) Men Women 3.57 3.47 4.17 3.81 3.72 3.53 3.07 3.59 3.11 2.85 3.08 2.79 1.18 1.38 Maximal (ft/s) Men Women 6.40 6.43 5.99 5.43 5.70 5.16 3.85 4.90 3.95 4.15 4.44 3.89 1.97 1.57

Meters per second: Age Preferred (m/s) Men Women 20's 1.09 1.06 30's 1.27 1.16 40's 1.13 1.08 50's 0.94 1.09 60's 0.95 0.87 70's 0.94 0.85 frail 0.36 0.42

Maximal (m/s) Men Women 1.95 1.96 1.83 1.65 1.74 1.57 1.17 1.49 1.21 1.27 1.35 1.19 0.60 0.48

NOTE: Reference values are based on small sample sizes. Gait speeds shown are Mean - 2SD Adapted from Bohannon RW (1997). Frail data from Lusardi et al. (2002).

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TIMED UP AND GO TEST (TUG)

This is a valid and reliable test and has been validated with the frail, elderly population. Scoring based on time it takes to go from sitting, stand and walk 3 meters and back to sitting. Clients can use assistive devices during the test. TUG correctly classified 13/15 fallers (87% sensitivity) and 13/15 non fallers (87% specificity) and longer than 13.5 seconds correlated with fall risk in OA (ShumwayCook, 2000). In the vestibular population, the sensitivity and specificity is not as great as with the older adults. Sensitivity (80%) and specificity (56%) in vestibular clients using cut off 11.1 seconds (Whitney, 2004) Test Protocol The timed "Up & Go" test (TUG; Podsiadlo, Richardson, 1991) measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (approximately 9.8 feet), turn, walk back to the chair, and sit down again. The subject wears his/her regular footwear and uses his customary walking aid (none, cane, or walker). No physical assistance is given. They start with their back against the chair, their arms resting on the arm rests, and their walking aid at hand. The subject walks through the test once before being timed in order to become familiar with the test. A stop-watch is used to time the performance. Instructions for the Patient: They are instructed that, on the word "go" they are to get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair, and sit down again. Timing starts with the word "go" and ends when the subject sits down. Normative Data for TUG in seconds: Age (years) Male Female S.D. 60-69 8 8 2 70-79 9 --3 --9 2 80-89 10 --1 --11 3

Normal Range (mean +/- 2 SD) 4-12 3-15 5-13 8-12 5-17

Time < 10 seconds is normal 11-20 seconds are considered WNL for frail elderly or individuals with a disability >14 seconds indicates risk for fall > 20 seconds are indicative of impaired functional mobility > 30 seconds indicates dependency in most ADLs & mobility skills Divided Attention, or Dual Task Assessment, or Allocation of Attention Evidence suggests that an impaired ability to allocate attention to balance during dual-task situations may contribute significantly to falls in older adults. One study of assisted living residents revealed that the inability to walk while talking was highly predictive of a future fall: 83% of those who stopped walking while talking (WWT) experienced a subsequent fall (Lundin-Olsson et al., 1997).

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The same prediction is also applicable to non-demented, community-dwelling older adults (Verghese et aI., 2002). This study revealed a 71% positive predictive value for walking while reciting every other letter of the alphabet (WWT-complex) versus 42% for walking only. Tests which combine gait with cognitive or manual tasks are used to assess more natural function Modified TUG Equipment: Firm, standard, straight back chair (seat height 40cm, arm height 66 cm); table (70 cm); stopwatch; 3 meters measured (measuring tape). Description: Place chair against a wall or stable object if possible. Mark 3 meters in front of the chair. Patient should have back against the chair. If feet do not touch the floor add a pillow to back of chair. Patient can rise in any way comfortable (may use armrests). The test is performed twice (first practice, second actual test). Instructions: "Start sitting in the chair with your back against the chair and your feet flat on the floor. Stand up, walk as quickly and as safely as you can, cross the tape, turn around, walk back to the chair, and sit down." 1. Practice TUG 2. TIMED UP & GO ­ Basic - (***start stopwatch on the 'GO' command and stop when buttocks touch chair seat.) 3. TIMED UP & GO - Cognitive ­ Subjects complete the test while counting backward by threes from a randomly selected number between 20 and 100. 4. TIMED UP & GO - Manual ­ Subjects complete the test while carrying a full cup of water (5 cm from top). Cut-off numbers: TUG - >13.5 s TUG-manual >14.5 s TUG-cognitive >15 s A difference between TUG manual and TUG (TUG manual - TUG) > 4.5 sec indicates fall risk Frail OA with difference in TUG manual and TUG of >4.5 seconds is more prone to falls in a 6 mo follow-up (Lundin-Olsson) Modified TUG no better at identifying fallers in Community dwelling OA (Shumway-Cook, 2000)

WALK WHILE TALK (WWT)

Divided Attention, or Dual Task Assessment, or Allocation of Attention A study by Lundin-Olsson et al, 1997, looked at 58 residents of Assisted Living who were tested with the WWT. They were able to identify 21 fallers in 6 month follow-up. The positive predictive value = 83% (10/12) and negative predictive value = 76% (35/37).

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In 2002 Verghese et al, also studied the WWT test and found 46% sensitivity and 89% specificity for WWT-simple. WWT complex has 38% sensitivity and 96% specificity with a positive predictive value = 71%. Please note that there is a ceiling effect in community dwelling OA. Description: Subjects are timed while they walk at self-selected speed 20 feet, turn around and return (40 feet total). Start timing on 'Go' and stop with second foot crossing starting line. Second trial (WWT -simple) is timed while subject walks the same course and recites letters of the alphabet. Third trial (WWT-complex) is timed while subject walks the same course and recites every other letter of the alphabet (e.g., "a-c-e"). Instructions: "Start walking at your normal pace to the end of the walkway, turn around and walk back." Cut off times: WWT (40 ft): WWT-simple: WWT-complex:

> 18 s at risk for falls > 20 s at risk for falls > 33 s at risk for falls

REFERENCES

Bohannon RW. Comfortable and maximum walking speed of adults aged 20-79 years: Reference values and determinants. Age Ageing 1997; 26:15-19 Lundin-Olsson L, Nyberg L, et al 1997. Stops walking when talking. Lancet 349:617. Lundin-Olsson L, Nyberg L, et al, 1998 Attention, frailty and falls: the effect of a manual task on basic mobility. Journal of the American Geriatrics Society 46:758-761. Lusardi MM, Austin G, Gill T, Comfortable and fast gait speeds for frail community-living older adults. Paper presented at the CSM of the APTA, Boston MA, 2002. Podsiadlo 0, Richardson S. The timed "up & go": A test of basic functional mobility for frail elderly persons. JAm Geriatr Sac 1991 ;39:142-148. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, IL, 2001 ,Human Kinetics. Rose DR, Jones, CJ, Lucchese N. Predicting the probability of falls in community-residing older adults using the 8-foot up-and-go: A new measure of functional mobility. JAPA. 2002; 10:466475. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in communitydwelling older adults using the Timed Up & Go test. Phys Ther 2000;80:896-903 . Verghese J, Buschke H, et al, 2002 Validity of divided attention tasks in predicting falls in older individuals: a preliminary study. Journal of the American Geriatrics Society 50(9):1572-1576.

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