Timed "Up & Go" test in children and adolescents

Renata D'Agostini Nicolini-Panisson; Márcio Vinícius F Donadio

doi:10.1590/S0103-05822013000300016

. 2013 Sep;31(3):377–383. doi: 10.1590/S0103-05822013000300016

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Timed "Up & Go" test in children and adolescents

Renata D'Agostini Nicolini-Panisson ¹, Márcio Vinícius F Donadio ²

PMCID: PMC4182976 PMID: 24142322

Abstract

OBJECTIVE

To evaluate, by a literature review, the Timed "Up & Go" (TUG) test use and its main methodological aspects in children and adolescents.

DATA SOURCES

The searches were performed in the following databases: PubMed, CINAHL, Web of Science, SciELO and Cochrane Library, from April to July 2012. Studies published from 1990 to 2012 using the terms in Portuguese and English "Timed "Up & Go", "test", "balance", "child", and "adolescent" were selected. The results were divided into categories: general characteristics of the studies, population, test implementation METHODS, interpretation of results and associations with other measurements.

DATA SYNTHESIS

27 studies were analyzed in this review and most of them used the TUG test along with other outcome measures to assess functional mobility or balance. Three studies evaluated the TUG test in significant samples of children and adolescents with typical development, and the most studied specific diagnoses were cerebral palsy and traumatic brain injury. The absence of methodological standardization was noted, but one study proposed adaptations to the pediatric population. In children and adolescents with specific clinical diagnoses, the coefficient of within-session reliability was found to be high in most studies, as well as the intra and inter-examiner reliability, which characterizes the good reproducibility of the test.

CONCLUSIONS

The TUG test was shown to be a good tool to assess functional mobility in the pediatric population, presenting a good reproducibility and correlation with other assessment tools.

Keywords: mobility limitation, postural balance, child, adolescent

Introduction

The Timed "Up & Go" (TUG) test was developed by Podsiadlo and Richardson in 1991⁽ ¹ ⁾, based on the version named Get-up and Go test, proposed by Mathias et al in 1986⁽²⁾. The "Get-up and Go" test originally aimed to clinically evaluate dynamic balance in elderly people during the performance of a task, involving critical situations for falls. Podsiadlo and Richardson proposed using time in seconds to score the test, naming it Timed "Up & Go", because there was a time limitation on the score of the original scale⁽ ¹ ⁾.

The TUG test measures, in seconds, the time required for an individual to stand up from a standard chair with armrest (height of approximately 46cm), walk 3m, turn around, walk back to the chair, and sit down again⁽ ¹ ⁾. The test has been widely used in clinical practice as an outcome measure to evaluate functional mobility, fall risk or dynamic balance in adults, and its normative values have already been established in this population⁽ ³ ^, ⁴ ⁾. Several studies used the test to assess fall risk in the elderly⁽ ⁵ ^- ⁸ ⁾; other studies assessed balance and functional mobility in adults with motor limitations, such as cerebral palsy (CP)⁽ ⁹ ⁾, Parkinson disease⁽ ¹ ^, ¹⁰ ⁾, stroke⁽ ¹ ^, ¹¹ ^- ¹³ ⁾, Down syndrome (DS)⁽ ¹⁴ ⁾, among others.

Because of its practicality, the TUG test began to be used in children and adolescents with some type of motor limitation and/or balance deficit⁽ ¹⁵ ^- ¹⁷ ⁾. In order for ambulatory children or adolescents to have functional independence, balance is required during movements performed in sitting and bipedal postures. The activities that constitute the test assess the functional mobility and the balance required to move from the sitting to the standing position, walk, turn around, and sit down again.

Thus, considering the practicality of the TUG test to assess functional mobility, its increasing use in Pediatrics, and the lack of theoretical studies critically reviewing the use of the test, this study evaluated, through a literature review, the use of the TUG test and its methodological aspects in children and adolescents.

Method

This study consisted of a bibliographical review. References for electronic research were selected in July 2012, in PubMed, CINAHL, Web of Science, SciELO and Cochrane Library databases. Searches used the following terms in Portuguese and English: "timed 'up and go'", "test", "balance", "child" and "adolescent". In order to obtain more specific results on the topic, searches were limited to title/abstract and to papers published from 1990 to 2012. All abstracts identified using these terms were reviewed, and those that addressed the proposed topic were fully examined. The reference list of the selected articles was also examined, in order to obtain other relevant articles. The study included only articles that evaluated or used the TUG test in children and adolescents with an observational or experimental design. Exclusion criteria consisted of abstracts from annals of events and articles using the TUG test in adults and elderly people. No review articles or case reports on the topic were found.

After studies were selected, according to the previously described criteria, they were critically read, in order to systematize test implementation and the main methodological aspects involved. To do so, the following categories were defined: general characteristics of the studies, populations, implementation METHODS, result interpretation, and associations with other measures.

Results and Discussion

Search strategies identified 56 references. According to the established inclusion and exclusion criteria, the reading of titles and abstracts allowed us to exclude 26 articles. Thus, 30 studies were reviewed in full and in more detail, of which three were excluded for not meeting the criteria and 27 were selected for this review.

General characteristics of the studies

Of the 27 studies included in the review, 17 (63%) were cross-sectional⁽ ¹⁵ ^- ³¹ ⁾ and 10 (37%) were clinical trials⁽ ³² ^- ⁴¹ ⁾. Only one article had the primary OBJECTIVE of evaluating the test in children and adolescents⁽ ¹⁷ ⁾. Fifteen studies included the TUG test as one of the outcome measures for their primary OBJECTIVE of assessing functional balance⁽ ¹⁵ ^, ¹⁶ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁸ ^, ³⁰ ⁾, functional mobility^{(19,25-27,29,31)}or activity⁽ ¹⁸ ⁾, according to the International Classification of Functioning, Disability and Health (ICF)⁽ ⁴² ⁾. Of the remaining articles, nine used the TUG test as a secondary outcome measure for the evaluation of some type of intervention⁽ ³² ^- ³⁵ ^, ³⁷ ^- ⁴¹ ⁾ and two used it for the concurrent validation of other tests⁽ ²¹ ^, ²⁹ ⁾.

Populations

As for the population assessed in the articles, children from different nationalities were evaluated by the TUG test. Most studies evaluated American children and adolescents⁽ ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁹ ^, ³¹ ^, ³⁵ ^, ³⁸ ^, ⁴⁰ ⁾; two of them evaluated Australians⁽ ¹⁷ ^, ¹⁸ ⁾; two of them, the Chinese⁽ ¹⁵ ^, ³² ⁾; five of them, Israelis⁽ ¹⁶ ^, ²² ^- ²⁴ ^, ³⁶ ⁾; three of them, Spaniards⁽ ³⁴ ^, ³⁹ ^, ⁴¹ ⁾; one of them, the English⁽ ³⁷ ⁾; one of them, Brazilians⁽ ³³ ⁾; and two of them, Pakistanis⁽ ²⁰ ^, ³⁰ ⁾. The main clinical diagnoses identified in the study samples are shown in Table 1, with CP being the most frequent.

Table 1. Main studies that used the Timed "Up & Go" (TUG) test in children and adolescents.

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Up to now, only one group of researchers⁽ ²⁰ ^, ³⁰ ⁾ evaluated the TUG test specifically in children and adolescents with typical development (TD), aiming to describe normal parameters. Another study developed reference values for the Functional Mobility Assessment tool, which includes the TUG test in one of its categories⁽ ³¹ ⁾. However, several studies included a population with these characteristics, in order to compare this population with that of children with specific conditions⁽ ¹⁶ ^- ¹⁹ ^, ²¹ ^- ²⁴ ^, ²⁷ ^, ²⁹ ⁾.

Most studies with CP patients included children and adolescents from three to 19 years old⁽ ¹⁵ ^, ¹⁷ ^, ¹⁸ ^, ²² ^, ²⁹ ^, ³² ^, ³³ ^, ³⁶ ^- ³⁸ ^, ⁴⁰ ⁾. On the other hand, the only studies with children and adolescents with DS evaluated four five-year old boys, seven girls from eight to 14 years⁽ ²⁸ ⁾, and two subjects from six to 21 years⁽ ²¹ ⁾. Typically-developed subjects evaluated by the TUG test were aged from three to 15 years old⁽ ¹⁶ ^- ²⁰ ^, ²² ^- ²⁴ ^, ²⁷ ^, ²⁹ ^, ³⁰ ⁾, and only three studies had significant samples⁽ ¹⁷ ^, ²⁰ ^, ³⁰ ⁾. CP children evaluated by the test showed the following Gross Motor Function Classification System (GMFCS) levels⁽ ⁴³ ⁾: I and II⁽ ¹⁸ ^, ²² ^, ³³ ^, ³⁶ ⁾; I, II and III⁽ ¹⁵ ^, ³⁷ ^, ³⁸ ^, ⁴⁰ ⁾.

Evaluation of the methodology used

As for the equipment used in the TUG test, some studies describe chairs with backrest and without armrest⁽ ¹⁷ ^, ³⁸ ⁾, with backrest and armrest⁽ ²⁰ ^, ²¹ ^, ³⁰ ^, ³² ⁾, without backrest nor armrest⁽ ¹⁵ ⁾; in most studies, this was not described in the methodology section⁽ ¹⁶ ^, ¹⁹ ^, ²² ^- ²⁹ ^, ³¹ ^, ³⁴ ^- ³⁷ ^, ³⁹ ^- ⁴¹ ⁾. The height of the seat was described as adjustable in some studies⁽ ¹⁶ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³³ ^, ³⁶ ⁾, was selected with the individual with feet flat on the floor and hip and knees flexed to 90Â°⁽ ¹⁵ ^- ¹⁷ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³³ ^, ³⁶ ⁾, or was not reported⁽ ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁸ ^, ³¹ ^, ³² ^, ³⁴ ^, ³⁵ ^, ³⁷ ^- ⁴¹ ⁾. A study used a bench and did not describe adjustments for height⁽ ¹⁸ ⁾. The original article by the authors of the TUG test recommended the use of a standard chair with armrest and an approximate height of 46cm⁽ ¹ ⁾. The paper that described in more detail the methodology used to perform the test in the pediatric population was the same that had the primary OBJECTIVE of investigating the TUG test in children and recommended the use of a chair with backrest but without arms and height respecting 90Â° of knee flexion, measured with a goniometer⁽ ¹⁷ ⁾.

Most studies maintained the original route of the test, which was of 3m⁽ ¹⁵ ^- ²⁶ ^, ²⁹ ^, ³⁰ ^, ³² ^- ³⁴ ^, ³⁶ ^, ³⁸ ^, ³⁹ ^, ⁴¹ ⁾, with the chair positioned at this distance from different points: a wall⁽ ¹⁷ ⁾, a line on the floor⁽ ¹ ^, ²¹ ^, ³⁸ ⁾, a mark on the floor⁽ ¹⁶ ^, ²² ^- ²⁴ ^, ³⁶ ⁾, a cone⁽ ²⁷ ⁾, or a strip placed on the floor⁽ ²⁰ ^, ³⁰ ⁾. One study considered a distance of 9m for the route⁽ ²⁸ ⁾, another used 10ft (3.048m) as the unit of measurement⁽ ²⁷ ⁾, an two used another test with a distance of 10m in addition to the 3-m one, describing them as TUG 10m and TUG 3m⁽ ³⁴ ^, ³⁹ ⁾. Four studies did not report the route used, although providing bibliographical references for the test⁽ ³¹ ^, ³⁵ ^, ³⁷ ^, ⁴⁰ ⁾. The article that adapted the test to the pediatric population maintained the distance of 3m⁽ ¹⁷ ⁾.

Some changes were made to the TUG test to evaluate children and adolescents. The study that adapted the test to children proposed to use the concrete task of touching their hands on a target on the wall⁽ ¹⁷ ⁾. Other modifications to the original TUG test were: verbal instructions repeated during the test⁽ ¹⁷ ⁾, demonstration of the test tasks⁽ ¹⁷ ^, ²¹ ^, ³⁸ ⁾, and an unrecorded practice trial⁽ ¹⁶ ^, ²¹ ^, ³³ ⁾. Qualitative speed instructions were provided in some studies⁽ ¹⁵ ^, ²⁰ ^, ³³ ⁾, such as "walk as fast as you can, but keep walking"⁽ ¹⁵ ^, ²⁰ ^, ³⁰ ⁾, or "perform the task as fast as you can"⁽ ³³ ⁾. Other studies provided non-qualitative instructions⁽ ¹⁷ ^, ³² ^, ³⁸ ⁾, e.g., "children instructed to walk at their preferred speed or pace"⁽ ³² ^, ³⁸ ⁾, or "this is not a race, you must walk only"⁽ ¹⁷ ⁾. Most papers did not report this type of instruction⁽ ¹⁶ ^, ¹⁸ ^, ¹⁹ ^, ²¹ ^- ²⁹ ^, ³¹ ^, ³⁴ ^- ³⁷ ^, ³⁹ ^- ⁴¹ ⁾.

Time, measured by a chronometer, began to be recorded as children left and stopped as they returned to the chair⁽ ¹⁷ ⁾ or were recorded from the "go" cue to when the child sat down in the chair⁽ ¹⁵ ^, ¹⁶ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁶ ⁾, or this information was not provided⁽ ¹⁸ ^- ²¹ ^, ²⁵ ^- ²⁸ ^, ³⁰ ^- ³⁵ ^, ³⁷ ^- ⁴¹ ⁾. In the original study of the test in elderly people⁽ ¹ ⁾, timing started at the command "go" and stopped as subjects' back touched the chair again, in order to evaluate participants' cognition. In the adaptation of the test to children⁽ ¹⁷ ⁾, in order to measure movement time only, the chronometer started as children left the chair and stopped as they sat down again. Some studies also reported what children were wearing during the test: comfortable tennis shoes⁽ ¹⁵ ^, ²² ^- ²⁴ ^, ³² ^, ³³ ^, ³⁶ ⁾, orthotics⁽ ¹⁵ ^, ²² ^- ²⁴ ^, ³³ ^, ³⁶ ⁾, or no shoes⁽ ²⁹ ⁾; other studies also reported the possibility of using gait assistive devices⁽ ¹⁵ ^, ³² ^, ³⁸ ⁾, such as crutches⁽ ¹⁷ ^, ²⁵ ⁾ and walkers⁽ ¹⁷ ⁾.

As for the number of trials in the test, studies performed three trials⁽ ¹⁵ ^- ¹⁷ ^, ²¹ ⁾, two trials⁽ ¹⁷ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³² ^, ³⁶ ⁾, a single trial⁽ ³⁸ ⁾, or this information was not provided^{(18,19,25-28,31,33-35,37,39-41)}. The value considered as the test result was: the best value (i.e., the lowest) out of three trials⁽ ¹⁵ ^, ¹⁷ ⁾, the best value out of two trials⁽ ¹⁷ ^, ²⁹ ⁾, the mean of two trials⁽ ²⁰ ^, ²² ^- ²⁴ ^, ³⁰ ^, ³² ^, ³⁶ ⁾, the only trial conducted⁽ ³⁸ ⁾, or this information was not provided⁽ ¹⁶ ^, ¹⁸ ^, ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁸ ^, ³¹ ^, ³³ ^- ³⁵ ^, ³⁷ ^, ³⁹ ^- ⁴¹ ⁾. The original article in adults⁽ ¹ ⁾ mentioned performing a trial for familiarization and another one with time recording; in turn, the article that adapted the test to Pediatrics⁽ ¹⁷ ⁾ recommended to perform three trials, recording the lowest score achieved by children with TD, and two trials, recording the lowest score achieved by children with CP and spina bifida (SB).

Methodological differences in test implementation are common in adult and pediatric populations, which makes it difficult to establish an universal measure. A study in adults evaluated whether changes in test methodology or in the instructions provided could interfere with results and concluded that, in elderly people, both verbal instructions and methodology affect test results. In young adults, instructions affect TUG results, but markers (line on the floor or cone) do not. In addition, it was observed that the variability in the results was smaller when instructions on speed were provided⁽ ⁴⁴ ⁾. There are no studies evaluating the influence of these changes on the pediatric population. Thus, it can be suggested that, in order to evaluate the TUG test in children and adolescents, the proposed adaptations to Pediatrics should be used⁽ ¹⁷ ⁾, combined with instructions on speed, such as "walk as fast as you can".

Result interpretation

Table 1 shows the studies that evaluated children and adolescents and reported mean, standard deviation and/or intraclass correlation coefficients (ICC) for within-session, between-session (test-retest), intra-examiner and inter-examiner reliability. In articles that reported pre- and post-intervention measures, the pre-intervention score was considered. The time it took for children with TD to perform the TUG test had a mean variation of 3.21⁽ ²⁷ ⁾ to 6.7 seconds⁽ ¹⁷ ⁾. Children showed improvement in balance as age increased, with a decrease in mean score⁽ ¹⁷ ^, ²⁰ ^, ³⁰ ⁾. In one study, there was no significant difference in the scores of male and female children and adolescents⁽ ¹⁷ ⁾; in another one, there was significant difference in the scores, with boys showing better performance in the TUG test⁽ ²⁰ ^, ³⁰ ⁾. Of these studies, only one used a multiple linear regression model and evaluated the effect of anthropometric variables on TUG values of individuals from five to 13 years old, with test scores being influenced by age in the general sample (R²=0.18)⁽ ³⁰ ⁾. The remaining studies reported means and standard deviations⁽ ¹⁷ ^, ²⁰ ⁾ or median and ranges⁽ ³¹ ⁾ of TUG values for children and adolescents.

On the other hand, in children and adolescents with specific clinical diagnosis, the time required to perform the TUG test had a mean variation from 3.6⁽ ⁴¹ ⁾ to 50.3⁽¹⁵⁾seconds. Of the two studies that evaluated children and adolescents with DS, one was not included in Table 1 because it used a route of 9m⁽ ²⁸ ⁾. In addition, its results did not report TUG mean; only ICC was below 0.5 in the female group (n=7; eight to 14 years old) and in the male group (n=4; five years old)⁽ ²⁸ ⁾. The other study with subjects with DS that appears in Table 1 reported the mean score and the whole sample of individuals were developmentally-disabled⁽ ²¹ ⁾.

Associations of the test with other measures

Several studies correlated the TUG test with other assessment tools, including motor function, functional mobility, range of motion (ROM), muscle strength, and quality of life. Generally speaking, these correlations are specific for certain clinical diagnoses and vary according to the tool studied. The main results for the associations between the TUG test and other measures are shown in Table 2.

Table 2. Main correlations of the Timed "Up & Go" test with other assessment tools in children and adolescents.

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On the other hand, only one study with sarcoma survivors used multiple and simple regression analyses to explain the result of the TUG test by other variables⁽ ²⁶ ⁾. The variance in the test may be explained 5% by hip extension active ROM, 5% by knee extension passive ROM, and 16% by knee flexion active ROM. In addition, the mental and physical components summarized in the quality of life questionnaire - The Short Form 36 Health Survey, version two (SF36v2) - were significant predictors of TUG time in this population, explaining 26 (p=0.01) and 14% (p=0.01) of test variance, respectively⁽ ²⁶ ⁾.

Final comments

The results of this review demonstrate that there are neither reference equations yet for the TUG test in children and adolescents with TD nor information about the influence of possible predictive variables for the test in the age group from 13 to 18 years old. In children and adolescents with specific clinical diagnoses, the within-session reliability coefficient was found to be high in most studies, as well as intra- and inter-examiner reliability, characterizing the good reproducibility of the test.

Thus, the TUG test was shown to be a good tool to assess functional mobility in the pediatric population and correlated with other tests of balance, functional mobility, gross motor function, quality of life, muscle strength, ROM, functional capacity, and physical activity level. This review may help therapists in the evaluation of functional mobility in children and adolescents by the TUG test. Future studies aiming to determine normative values for healthy children and adolescents are required to improve the evaluation of individuals with specific clinical diagnoses.

Footnotes

Instituição: Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brasil

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Rev Paul Pediatr. 2013 Sep;31(3):377–383. [Article in Portuguese]

Teste Timed "Up & Go" em crianças e adolescentes

Abstract

OBJETIVO:

Avaliar, mediante uma revisão da literatura, a utilização do teste Timed "Up & Go" (TUG) e seus principais aspectos metodológicos em crianças e adolescentes.

FONTES DE DADOS

Foram realizadas buscas nas seguintes bases de dados: PubMed, CINAHL, Web of Science, SciELO e Cochrane Library, entre abril e julho de 2012. Selecionaram-se os estudos publicados de 1990 a 2012, utilizando-se os termos "timed up and go", "teste" ("test"), "equilíbrio" ("balance"), "criança" ("child") e "adolescente" ("adolescent"). Dividiram-se os resultados em categorias: características gerais dos estudos, populações avaliadas, metodologia de aplicação do teste, interpretação dos resultados e associações do teste com outras medidas.

SÍNTESE DOS DADOS

Incluíram-se 27 estudos e a maioria utilizou o TUG juntamente com outras medidas de desfecho para avaliar mobilidade ou equilíbrio funcional. Três trabalhos avaliaram o TUG em amostras expressivas de crianças e adolescentes com desenvolvimento típico e os diagnósticos específicos mais avaliados foram paralisia cerebral e traumatismo cranioencefálico. Não existe uma padronização quanto à metodologia utilizada, porém um estudo propôs adaptações para a população pediátrica. Em crianças e adolescentes com diagnósticos clínicos específicos, o coeficiente de confiabilidade intra-sessão mostrou-se alto na maioria dos estudos, assim como a confiabilidade intra e inter-examinador, caracterizando a boa reprodutibilidade do teste.

CONCLUSÕES

O TUG mostrou-se uma boa ferramenta para avaliar a mobilidade funcional em Pediatria, correlacionando-se com outros instrumentos de avaliação e apresentando boa reprodutibilidade.

Keywords: limitação da mobilidade, equilíbrio postural, criança, adolescente

Introdução

O teste Timed "Up & Go" (TUG) foi desenvolvido por Podsiadlo e Richardson em 1991⁽ ¹ ⁾, a partir da versão denominada Get-up and Go, proposta por Mathias et al em 1986⁽ ² ⁾. O teste "Get-up and Go" apresentava, originalmente, o objetivo de avaliar de forma clínica as alterações do equilíbrio dinâmico em idosos durante o desempenho de uma tarefa, com situações críticas para a queda. Podsiadlo e Richardson propuseram o uso do tempo em segundos para pontuar o teste, denominando-o Timed "Up & Go", pois existia limitação na pontuação da escala original⁽ ¹ ⁾.

O TUG mede, em segundos, o tempo necessário para um indivíduo levantar de uma cadeira de braços padrão (altura de aproximadamente 46cm), caminhar uma distância de 3m, virar, caminhar de volta para a cadeira e sentar-se novamente⁽ ¹ ⁾. O teste tem sido amplamente utilizado na prática clínica como medida de desfecho para avaliar a mobilidade funcional, o risco de quedas ou o equilíbrio dinâmico em adultos e seus valores normativos já estão estabelecidos nessa população⁽ ³ ^, ⁴ ⁾. Vários estudos utilizaram o teste para avaliar o risco de quedas em idosos⁽ ⁵ ^- ⁸ ⁾; outros avaliaram o equilíbrio e a mobilidade funcional em adultos com limitações motoras, como paralisia cerebral (PC)⁽ ⁹ ⁾, doença de Parkinson⁽ ¹ ^, ¹⁰ ⁾, acidente vascular encefálico⁽ ¹ ^, ¹¹ ^- ¹³ ⁾, síndrome de Down (SD)⁽ ¹⁴ ⁾, entre outras.

Em função de sua praticidade, o TUG começou a ser utilizado com crianças e adolescentes que apresentam algum tipo de limitação motora e/ou déficit de equilíbrio⁽ ¹⁵ ^- ¹⁷ ⁾. Para uma criança ou adolescente deambulador contar com independência funcional, é necessário equilíbrio durante movimentos realizados na postura sentada e bípede. As atividades que constituem o teste avaliam a mobilidade funcional e o equilíbrio para passar de sentado para em pé, caminhar, fazer a volta e sentar-se novamente.

Assim, considerando-se a praticidade do TUG para avaliar a mobilidade funcional, sua utilização crescente em Pediatria e a ausência de trabalhos teóricos revisando criticamente o uso do teste, este estudo avaliou, por meio de revisão da literatura, a utilização do TUG e seus principais aspectos metodológicos em crianças e adolescentes.

Fontes de Dados

O trabalho consistiu em uma revisão bibliográfica. Realizou-se a seleção das referências por pesquisa eletrônica em julho de 2012, nas bases de dados PubMed, CINAHL, Web of Science, SciELO e Cochrane Library. Os termos em português e inglês "timed 'up and go'", "teste" ("test"), "equilíbrio" ("balance"), "criança" ("child") e "adolescente" ("adolescent") foram usados nas buscas. Para se obterem resultados mais específicos sobre o tema, utlilizaram-se os limites de busca em título/resumo, de 1990 a 2012. Todos os resumos identificados usando esses termos foram revisados e os que abordavam o tema proposto foram examinados integralmente. A lista de referências dos artigos selecionados também foi examinada, a fim de buscar outros artigos relevantes. Incluíram-se no estudo apenas os artigos que avaliaram ou utilizaram o TUG em crianças e adolescentes com delineamento observacional ou experimental. Os critérios de exclusão adotados foram os resumos de anais de eventos e os artigos com uso do TUG em adultos e idosos. Não se encontraram artigos de revisão ou relatos de caso sobre o tema.

Após a seleção dos estudos, conforme os critérios previamente descritos, efetuou-se uma leitura crítica, para sistematizar a aplicação do teste e os principais aspectos metodológicos envolvidos. Para tanto, definiram-se as seguintes categorias: características gerais dos estudos, populações avaliadas, metodologia para realização, interpretação dos resultados e associações do teste com outras medidas.

Síntese dos Dados

As estratégias de busca localizaram 56 referências. De acordo com os critérios de inclusão e exclusão estabelecidos, a leitura dos títulos e dos resumos permitiu excluir 26 artigos. Dessa forma, 30 trabalhos foram revisados na íntegra e mais detalhadamente, excluindo-se três, por não se enquadrarem nos critérios. Selecionaram-se 27 artigos para esta revisão.

Características gerais dos estudos

Dos 27 estudos incluídos, 17 (63,0%) eram de corte transversal⁽ ¹⁵ ^- ³¹ ⁾ e 10 (37%) eram ensaios clínicos⁽ ³² ^- ⁴¹ ⁾. Apenas um artigo tinha como objetivo primário a avaliação do teste em crianças e adolescentes⁽ ¹⁷ ⁾. Quinze estudos incluíram o TUG como uma das medidas de desfecho para seu objetivo primário de avaliação do equilíbrio funcional⁽ ¹⁵ ^, ¹⁶ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁸ ^, ³⁰ ⁾, da mobilidade funcional^{(19,25-27,29,31)}ou da categoria atividade⁽ ¹⁸ ⁾, segundo a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF)⁽ ⁴² ⁾. Do restante, nove usaram o TUG como medida de desfecho secundária na avaliação de algum tipo de intervenção⁽ ³² ^- ³⁵ ^, ³⁷ ^- ⁴¹ ⁾ e dois utilizaram-no para validação concorrente de outros testes⁽ ²¹ ^, ²⁹ ⁾.

Populações avaliadas

Quanto à população estudada, foram analisadas crianças de diversas nacionalidades com o TUG. A maioria dos estudos avaliou crianças e adolescentes americanos⁽ ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁹ ^, ³¹ ^, ³⁵ ^, ³⁸ ^, ⁴⁰ ⁾, dois avaliaram australianos⁽ ¹⁷ ^, ¹⁸ ⁾, dois chineses⁽ ¹⁵ ^, ³² ⁾, cinco israelenses⁽ ¹⁶ ^, ²² ^- ²⁴ ^, ³⁶ ⁾, três espanhóis⁽ ³⁴ ^, ³⁹ ^, ⁴¹ ⁾, um ingleses⁽ ³⁷ ⁾, um brasileiros⁽ ³³ ⁾ e dois paquistaneses⁽ ²⁰ ^, ³⁰ ⁾. Os principais diagnósticos clínicos das amostras estudadas são apresentados na Tabela 1, sendo PC o mais frequente.

Tabela 1. Principais estudos que utilizaram o teste Timed "Up & Go" (TUG) em crianças e adolescentes.

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Até o presente momento, apenas um grupo de pesquisadores⁽ ²⁰ ^, ³⁰ ⁾ avaliou o TUG especificamente em crianças e adolescentes com desenvolvimento típico (DT), objetivando a descrição de parâmetros de normalidade. Outro trabalho desenvolveu valores referenciais para o instrumento Functional Mobility Assessment, que inclui o TUG em uma de suas categorias⁽ ³¹ ⁾. Contudo, diversos estudos incluíram uma população com essas características, a fim de comparar crianças com patologias específicas⁽ ¹⁶ ^- ¹⁹ ^, ²¹ ^- ²⁴ ^, ²⁷ ^, ²⁹ ⁾.

A maioria dos estudos com portadores de PC incluía crianças e adolescentes de três a 19 anos⁽ ¹⁵ ^, ¹⁷ ^, ¹⁸ ^, ²² ^, ²⁹ ^, ³² ^, ³³ ^, ³⁶ ^- ³⁸ ^, ⁴⁰ ⁾. Por outro lado, os únicos estudos com crianças e adolescentes com Síndrome de Down avaliaram quatro meninos de cinco anos, sete meninas de oito a 14 anos⁽ ²⁸ ⁾ e dois indivíduos de seis a 21 anos⁽ ²¹ ⁾. Indivíduos com desenvolvimento típico e avaliados pelo TUG possuíam de três a 15 anos^{(16-20,22-24,27,29,30)}e apenas três estudos apresentavam amostras expressivas⁽ ¹⁷ ^, ²⁰ ^, ³⁰ ⁾. As crianças com PC avaliadas pelo teste apresentavam os seguintes níveis do Gross Motor Function Classification System (GMFCS)⁽ ⁴³ ⁾: I e II⁽ ¹⁸ ^, ²² ^, ³³ ^, ³⁶ ⁾; I, II e III⁽ ¹⁵ ^, ³⁷ ^, ³⁸ ^, ⁴⁰ ⁾.

Avaliação da metodologia utilizada

Quanto aos equipamentos utilizados, a cadeira descrita para uso com o TUG tinha encosto e não possuía braço de descanso⁽ ¹⁷ ^, ³⁸ ⁾, tinha encosto e possuía braço de descanso⁽ ²⁰ ^, ²¹ ^, ³⁰ ^, ³² ⁾, não tinha encosto e não possuía braço de descanso⁽ ¹⁵ ⁾ ou não foi descrita na metodologia na maioria dos estudos⁽ ¹⁶ ^, ¹⁹ ^, ²² ^- ²⁹ ^, ³¹ ^, ³⁴ ^- ³⁷ ^, ³⁹ ^- ⁴¹ ⁾. A altura da cadeira foi descrita como ajustável em alguns estudos⁽ ¹⁶ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³³ ^, ³⁶ ⁾, foi selecionada com o indivíduo com os pés apoiados no chão e respeitando a angulação de 90Â° de flexão de quadril e de joelho⁽ ¹⁵ ^- ¹⁷ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³³ ^, ³⁶ ⁾ ou não foi descrita⁽ ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁸ ^, ³¹ ^, ³² ^, ³⁴ ^, ³⁵ ^, ³⁷ ^- ⁴¹ ⁾. Um estudo utilizou um banco, não descrevendo ajustes para altura⁽ ¹⁸ ⁾. O artigo original dos autores do teste TUG preconizou o uso de uma cadeira de braço padrão, com altura aproximada de 46cm⁽ ¹ ⁾. O trabalho que descreveu mais detalhadamente a metodologia usada para a aplicação do teste na população infantil foi o mesmo que tinha como objetivo primário investigar o TUG em crianças e preconizou o uso de uma cadeira com encosto, mas sem braço, e altura respeitando 90Â° de flexão de joelho, mensurado com goniômetro⁽ ¹⁷ ⁾.

A maioria dos estudos manteve o percurso original do teste, de 3m⁽ ¹⁵ ^- ²⁶ ^, ²⁹ ^, ³⁰ ^, ³² ^- ³⁴ ^, ³⁶ ^, ³⁸ ^, ³⁹ ^, ⁴¹ ⁾, sendo a cadeira posicionada a essa distância em relação a diferentes pontos: uma parede⁽ ¹⁷ ⁾, uma linha no chão⁽ ¹ ^, ²¹ ^, ³⁸ ⁾, uma marca no chão⁽ ¹⁶ ^, ²² ^- ²⁴ ^, ³⁶ ⁾, um cone⁽ ²⁷ ⁾ ou uma fita colocada no chão⁽ ²⁰ ^, ³⁰ ⁾. Um estudo considerou a distância de 9m para o percurso⁽ ²⁸ ⁾, outro utilizou como unidade de medida 10ft (3,048m)⁽ ²⁷ ⁾ e dois utilizaram, além do teste com 3m, outro com 10m, descrevendo-os como TUG 3m e TUG 10m⁽ ³⁴ ^, ³⁹ ⁾. Quatro estudos não descreveram o percurso utilizado, embora apresentassem referências bibliográficas para o teste⁽ ³¹ ^, ³⁵ ^, ³⁷ ^, ⁴⁰ ⁾. O artigo que adaptou o teste para a Pediatria manteve a distância de 3m⁽ ¹⁷ ⁾.

Algumas modificações foram realizadas no TUG para avaliar crianças e adolescentes. O estudo que adaptou o teste para crianças propôs utilizar uma tarefa concreta de encostar a mão em um alvo na parede⁽ ¹⁷ ⁾. Outras modificações do TUG original foram: instruções verbais repetidas durante o teste⁽ ¹⁷ ⁾, demonstração das tarefas do teste^(17,21,38)e um ensaio não registrado para praticá-lo⁽ ¹⁶ ^, ²¹ ^, ³³ ⁾. Instruções qualitativas de velocidade foram dadas em alguns estudos⁽ ¹⁵ ^, ²⁰ ^, ³³ ⁾, como, por exemplo, "ande o mais rápido possível, mas permaneça caminhando"⁽ ¹⁵ ^, ²⁰ ^, ³⁰ ⁾, ou "realize a tarefa o mais rápido possível"⁽ ³³ ⁾. Outros realizaram instruções não qualitativas⁽ ¹⁷ ^, ³² ^, ³⁸ ⁾, por exemplo, "criança instruída a caminhar na sua velocidade ou ritmo preferido"⁽ ³² ^, ³⁸ ⁾, ou "isto não é uma corrida, você deve caminhar apenas"⁽ ¹⁷ ⁾. A maioria dos trabalhos não descreveu esse tipo de instrução⁽ ¹⁶ ^, ¹⁸ ^, ¹⁹ ^, ²¹ ^- ²⁹ ^, ³¹ ^, ³⁴ ^- ³⁷ ^, ³⁹ ^- ⁴¹ ⁾.

A marcação do tempo com o cronômetro foi realizada quando a criança saiu e chegou à cadeira⁽ ¹⁷ ⁾ ou a partir do "vai" até a criança se sentar⁽ ¹⁵ ^, ¹⁶ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁶ ⁾, ou não foi descrita⁽ ¹⁸ ^- ²¹ ^, ²⁵ ^- ²⁸ ^, ³⁰ ^- ³⁵ ^, ³⁷ ^- ⁴¹ ⁾. No estudo original do teste em idosos⁽ ¹ ⁾, a marcação iniciou do comando "vai" até o indivíduo encostar as costas novamente na cadeira, com o intuito de avaliar a cognição nos participantes. Na adaptação do teste para crianças⁽ ¹⁷ ⁾, com o intuito de medir apenas o tempo do movimento, iniciou-se o cronômetro quando a criança saiu da cadeira e parou quando sentou-se novamente. Alguns estudos também relataram a forma como as crianças estavam para realizar o teste: com tênis confortável⁽ ¹⁵ ^, ²² ^- ²⁴ ^, ³² ^, ³³ ^, ³⁶ ⁾, com órteses⁽ ¹⁵ ^, ²² ^- ²⁴ ^, ³³ ^, ³⁶ ⁾, ou com pés descalços⁽ ²⁹ ⁾; outros também relataram a possibilidade do uso de dispositivos auxiliares para a marcha⁽ ¹⁵ ^, ³² ^, ³⁸ ⁾, como muletas⁽ ¹⁷ ^, ²⁵ ⁾ e andadores⁽ ¹⁷ ⁾.

Quanto ao número de ensaios no teste, realizaram-se três⁽ ¹⁵ ^- ¹⁷ ^, ²¹ ⁾, dois⁽ ¹⁷ ^, ²⁰ ^, ²² ^- ²⁴ ^, ²⁹ ^, ³⁰ ^, ³² ^, ³⁶ ⁾, um único ensaio⁽ ³⁸ ⁾, ou não houve descrição⁽ ¹⁸ ^, ¹⁹ ^, ²⁵ ^- ²⁸ ^, ³¹ ^, ³³ ^- ³⁵ ^, ³⁷ ^, ³⁹ ^- ⁴¹ ⁾. O valor considerado como resultado do teste foi: o melhor valor (ou seja, o menor) de três ensaios⁽ ¹⁵ ^, ¹⁷ ⁾, o melhor valor de dois ensaios⁽ ¹⁷ ^, ²⁹ ⁾, a média de dois ensaios⁽ ²⁰ ^, ²² ^- ²⁴ ^, ³⁰ ^, ³² ^, ³⁶ ⁾, o único ensaio realizado⁽ ³⁸ ⁾, ou não houve descrição⁽ ¹⁶ ^, ¹⁸ ^, ¹⁹ ^, ²¹ ^, ²⁵ ^- ²⁸ ^, ³¹ ^, ³³ ^- ³⁵ ^, ³⁷ ^, ³⁹ ^- ⁴¹ ⁾. O artigo original em adultos⁽ ¹ ⁾ referiu a utilização de um ensaio para familiarização e a realização de outro com o tempo cronometrado; já o artigo adaptado à Pediatra⁽ ¹⁷ ⁾ preconizou a realização de três ensaios, marcando o menor escore atingido para crianças com desenvolvimento típico, e dois ensaios marcando o menor escore atingido para PC e espinha bífida (EB).

Diferenças metodológicas na realização do teste são comuns na população adulta e infantil, o que dificulta a tentativa de se estabelecer uma medida universal. Um estudo em adultos avaliou se mudanças na metodologia do teste ou nas instruções dadas poderiam interferir nos resultados e concluiu que, nos idosos, tanto as instruções verbais como a metodologia afetam o resultado do teste. Em adultos jovens, as instruções, mas não os marcadores (linha no chão ou cone), afetam os resultados do TUG. Além disso, observou-se que a variabilidade dos resultados foi menor quando instruções sobre a velocidade foram dadas⁽ ⁴⁴ ⁾. Não há estudos que avaliaram a influência dessas alterações na população pediátrica. Sendo assim, pode-se sugerir que, para avaliar o TUG em crianças e adolescentes, utilizem-se as adaptações propostas para a Pediatria⁽ ¹⁷ ⁾, combinadas com instruções sobre a velocidade, como, por exemplo, "ande o mais rápido possível".

Interpretação dos resultados

A Tabela 1 mostra os estudos que avaliaram crianças e adolescentes e apresentaram média, desvio-padrão e/ou coeficientes de correlação intraclasse (ICC) para confiabilidades intra-sessão, inter-sessão (teste-reteste), intraexaminador e interexaminador. Nos artigos que apresentavam mensuração pré e pós-intervenção, considerou-se o escore pré-intervenção. O tempo de realização do TUG por crianças com desenvolvimento típico apresentou variação média de 3,21⁽ ²⁷ ⁾ a 6,7 segundos⁽ ¹⁷ ⁾. Crianças demonstraram melhora no equilíbrio com o aumento da idade, diminuindo a média do escore⁽ ¹⁷ ^, ²⁰ ^, ³⁰ ⁾. Em um estudo, não houve diferença significativa entre os escores apresentados em crianças e adolescentes do sexo feminino e masculino⁽ ¹⁷ ⁾; em outro, houve diferença significativa entre os escores, sendo que meninos tiveram melhor desempenho no TUG⁽ ²⁰ ^, ³⁰ ⁾. Desses estudos, apenas um apresentou modelo de regressão linear múltipla e avaliou o efeito das variáveis antropométricas nos valores do TUG de indivíduos de cinco a 13 anos, sendo que os escores do teste foram influenciados pela idade (R²=0,18)⁽ ³⁰ ⁾. Os demais apresentaram médias e desvios-padrão⁽ ¹⁷ ^, ²⁰ ⁾ ou mediana e intervalos⁽ ³¹ ⁾ dos valores do TUG para crianças e adolescentes.

Já em crianças e adolescentes com diagnóstico clínico específico, o tempo de realização do TUG apresentou variação média de 3,6⁽ ⁴¹ ⁾ a 50,3⁽¹⁵⁾segundos. Dos dois estudos que avaliaram crianças e adolescentes com Síndrome de Down, um não foi incluído na Tabela 1, pois utilizou percurso de 9m⁽ ²⁸ ⁾. Além disso, a média do TUG não foi apresentada nos seus resultados; apenas o ICC foi abaixo de 0,5 no grupo de meninas (n=7; oito a 14 anos) e de meninos (n=4; cinco anos)⁽ ²⁸ ⁾. O outro estudo de Síndrome de Down, que consta na Tabela 1, apresentou toda a amostra de indivíduos com deficiência no desenvolvimento⁽ ²¹ ⁾.

Associações do teste com outras medidas

Vários estudos correlacionaram o teste TUG com outros instrumentos de avaliação, incluindo a função motora, a mobilidade funcional, a amplitude de movimento, a força muscular e a qualidade de vida. De maneira geral, essas correlações são específicas para determinados diagnósticos clínicos e variam de acordo com o instrumento estudado. Os principais resultados de associações do TUG com outras medidas são apresentados na Tabela 2.

Tabela 2. Principais correlações do teste Timed "Up & Go" com outros instrumentos de avaliação em crianças e adolescentes.

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Por outro lado, apenas um estudo com sobreviventes de sarcoma utilizou análises de regressão múltipla e simples para explicar o resultado do TUG por outras variáveis⁽ ²⁶ ⁾. A variabilidade do teste pode ser explicada 5% pela amplitude de movimento (ADM) ativa de extensão de quadril, 5% por ADM passiva de extensão de joelho e 16% por ADM ativa de flexão de joelho. Além disso, os componentes mental e físico resumidos do questionário de qualidade de vida - The Short Form 36 Health Survey, version two (SF36v2) - foram preditores significativos para o tempo do TUG nessa população, explicando 26 (p=0,01) e 14% (p=0,01) do teste, respectivamente⁽ ²⁶ ⁾.

Considerações finais

Os resultados desta revisão demonstraram que ainda não existem equações de referência para o TUG em crianças e adolescentes com desenvolvimento típico, assim como dados da influência de possíveis variáveis preditoras para o teste na faixa etária de 13 a 18 anos. Em crianças e adolescentes com diagnósticos clínicos específicos, o coeficiente de confiabilidade intrassessão mostrou-se alto na maioria dos estudos, assim como a confiabilidade intra e interexaminador, caracterizando a boa reprodutibilidade do teste.

Assim, o TUG mostrou-se uma boa ferramenta para avaliar a mobilidade funcional nessa população e correlacionou-se com outros testes de equilíbrio, mobilidade funcional, função motora grossa, qualidade de vida, força muscular, ADM, capacidade funcional e nível de atividade física. Esta revisão pode auxiliar os terapeutas na avaliação da mobilidade funcional de crianças e adolescentes por meio do teste TUG. Futuros estudos para determinar valores normativos de crianças e adolescentes saudáveis são necessários para aprimorar a avaliação de indivíduos com diagnósticos clínicos específicos.

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PERMALINK

Timed "Up & Go" test in children and adolescents

Prueba Timed "Up & Go" en niños y adolescentes

Renata D'Agostini Nicolini-Panisson

Márcio Vinícius F Donadio

Abstract

OBJECTIVE

DATA SOURCES

DATA SYNTHESIS

CONCLUSIONS

Abstract

OBJETIVO

FUENTES DE DATOS

SÍNTESIS DE LOS DATOS

CONCLUSIONES

Introduction

Method

Results and Discussion

General characteristics of the studies

Populations

Table 1. Main studies that used the Timed "Up & Go" (TUG) test in children and adolescents.

Evaluation of the methodology used

Result interpretation

Associations of the test with other measures

Table 2. Main correlations of the Timed "Up & Go" test with other assessment tools in children and adolescents.

Final comments

Footnotes

References

Teste Timed "Up & Go" em crianças e adolescentes

Abstract

OBJETIVO:

FONTES DE DADOS

SÍNTESE DOS DADOS

CONCLUSÕES

Introdução

Fontes de Dados

Síntese dos Dados

Características gerais dos estudos

Populações avaliadas

Tabela 1. Principais estudos que utilizaram o teste Timed "Up & Go" (TUG) em crianças e adolescentes.

Avaliação da metodologia utilizada

Interpretação dos resultados

Associações do teste com outras medidas

Tabela 2. Principais correlações do teste Timed "Up & Go" com outros instrumentos de avaliação em crianças e adolescentes.

Considerações finais

ACTIONS

PERMALINK

RESOURCES

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