Timed Up & Go Test Score in Patients With Hip Fracture Is Related to the Type of Walking Aid

Article Outline

• Abstract
• Methods
  • Participants
  • Procedure
  • Timed Up & Go Test
  • Data Analysis
• Results
  • Walker Versus Rollator Timed Up & Go Performance
  • Elbow Crutches Versus Rollator Timed Up & Go Performance
• Discussion
  • Study Limitations
• Conclusions
• References
• Copyright

Abstract 

Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed Up & Go test score in patients with hip fracture is related to the type of walking aid.

Objective

To determine the relationship between Timed Up & Go (TUG) test scores and type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG in patients with hip fracture who were allowed full weight-bearing (FWB).

Design

Prospective methodological study.

Setting

An acute orthopedic hip fracture unit at a university hospital.

Participants

Patients (N=126; 90 women, 36 men) with hip fracture with a mean age ± SD of 74.8±12.7 years performed the TUG the day before discharge from the orthopedic ward.

Interventions

Not applicable.

Main Outcome Measures

The TUG was performed with the walking aid the patient was to be discharged with: a walker (n=88) or elbow crutches (n=38). In addition, all patients also performed the TUG using a rollator.

Results

Patients who performed the TUG with a walker were on average 13.6 (95% confidence interval [CI], 11.2–16.1) seconds faster using a rollator compared with the walker (P<.001). Correspondingly, patients who performed the TUG with crutches were on average 3.5 (95% CI, 1.5–5.4) seconds faster using a rollator compared with elbow crutches (P=.001). In both patient groups, the between walking-aid scores were strongly correlated (r>.833, P<.001).

Conclusions

TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who are allowed FWB when discharged from the hospital, but all patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid when evaluating changes or comparing TUG scores in patients with hip fracture.

Key Words: Self-help devices, Hip fractures, Rehabilitation, Research design, Reproducibility of results

List of Abbreviations: ASA, American Society of Anesthesiologists, BBS, Berg Balance Scale, CI, confidence interval, FWB, full weight-bearing, ICC, intraclass correlation coefficient, log, logarithmic, TUG, Timed Up & Go

CLINICIANS ENGAGED IN research or rehabilitation of patients with hip fracture need valid and reliable tools that objectively measure functional outcomes. The TUG¹ is an objective, valid, and reliable test that measures the time in seconds it takes a subject to rise from a chair with arms, walk 3m to a line drawn on the floor, and return to the chair.

The TUG test is reliable,¹, ², ³ correlated with the gait speed, BBS, Four Square Step Test, FIM, and Tinetti Balance,¹, ², ³, ⁴ and discriminates multiple from nonmultiple fallers³, ⁵ in the elderly. Also, the TUG score is related to sex, age, chair seat height, and use of walking aids in the elderly.², ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ With respect to the use of walking aids during the TUG test, independent community-dwelling elderly perform the test slower using an assistive device compared with those who ambulate with no assistive device, indicating that the type of walking aid influences TUG scores in the healthy elderly.¹²

In patients with hip fracture, the TUG has proven useful in predicting nonfallers,¹³ it has been used to evaluate the outcome of rehabilitation,¹⁴, ¹⁵, ¹⁶, ¹⁷ and it seems to correlate with BBS performance¹⁸ and gait speed.¹⁶ However, the validity of TUG scores using different walking aids in patients with hip fracture is questionable.¹⁹ Patients using a walker seem to require more time to perform the TUG compared with patients using elbow crutches, which may be related to the type of walking aid used.¹⁹ Because these results were obtained using multivariate analyses comparing TUG scores of patient groups using different types of walking aids, it remains to be investigated with the same patient using different walking aids.

The above-mentioned notion seems particularly important, because a number of trials conducted in patients with hip fracture used the TUG as an outcome measure to evaluate the effects of rehabilitation postsurgery. Most of these studies reported significantly reduced TUG times postrehabilitation,¹⁴, ¹⁵, ¹⁷, ²⁰, ²¹ without a detailed¹⁵, ²¹ or any¹⁴, ²⁰ report of the type of walking aid used during the test. Hence, the effect of the rehabilitation postsurgery may be overestimated if the same type of walking aid is not used at the prerehabilitation and postrehabilitation assessment.

Therefore, the objectives of this study were to determine the relationship between TUG scores and the type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG test in patients with hip fracture who were allowed FWB.

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Methods 

Participants 

A total of 126 consecutive patients with hip fracture, 90 women and 36 men with a mean age ± SD of 74.8±12.7 years, were included between October 2006 and June 2008 on discharge from an acute orthopedic hip fracture unit. The inclusion criteria were patients with surgical repair of a hip fracture who were allowed FWB and who were able to perform the TUG at discharge with their walking aid—either a walker (n=88) or elbow crutches (n=38). The study is part of Hvidovre University Hospitals hip fracture project, which has been approved by the local ethics committee and the Danish Data Protection Agency. The study was conducted according to the Helsinki Declaration. All participants gave informed consent.

Procedure 

During their hospital stay in the orthopedic ward, all patients followed a well-defined care plan with multimodal fast-track rehabilitation.²² Age, sex, fracture type, and the ASA classification²³ were recorded. Type of surgery was not recorded, but our overall standard procedure is as follows: surgery with 2 nails or screws for undisplaced and displaced (only patients <70y) femoral neck fractures, bipolar hemiarthroplasty for displaced femoral neck fractures, dynamic hip screw with plate or short intramedullary hip screw for intertrochanteric fractures, and long intramedullary hip screw for subtrochanteric fractures. Mental status was evaluated by a validated 9-point Danish version of the Abbreviated Mental Test,²⁴ while the prefracture functional level was evaluated by the New Mobility Score.²⁵ The New Mobility Score is a composite score of a person's ability to perform indoor walking, outdoor walking, and shopping, providing a score between 0 and 3 (0=not at all, 1=with help from another person, 2=with an aid, 3=no difficulty) for each function and resulting in a total score from 0 (no walking ability at all) to 9 (fully independent). Patients were asked about their walking ability in the weeks before hip fracture and, if necessary, relatives or caregivers were consulted for verification. High intertester reliability (ICC_1.1=.98)²⁶ and predictive validity²⁵, ²⁷, ²⁸ of the New Mobility Score have been reported in patients with hip fracture. Thus, a cutoff point of 5 predicted long-term mortality²⁵ and functional level,²⁷ while a cutoff point of 7 predicted short-term outcome of basic mobility.²⁸

Timed Up & Go Test 

The TUG test was performed the day before discharge from the acute orthopedic ward using both the walking aid the patient was to be discharged with (walker or elbow crutches) and a rollator. The rollator was a 4-wheeled rollator (wheel diameter, 7.5in) with 2 handles and handbrakes. The walker was a 4-point lightweight aluminum walker without any wheels, and the elbow crutches were 1-point lightweight aluminum elbow crutches. The patient was given 1 practice trial followed by 1 timed trial for each walking aid. By randomization, half the patients in each of the 2 groups performed the TUG using their discharge walking aid, followed by a new test session using a rollator. The other half began using the rollator. The TUG was measured as the time (in seconds) that it took each patient (as quickly and safely as possible) to rise from a chair with arms (chair seat height, 45cm [the same type of chair was used in all performances]), walk 3m to a line drawn on the floor, and return to the chair and sit down. The time was measured from a seated position (back against the backrest) with a stopwatch started on the command “ready—go” and stopped again when the seated position was regained. No individual physical assistance was allowed, but verbal cuing during the test was allowed. The intratester and intertester reliability of the TUG test was assessed in 23 patients with hip fracture in a pilot study, which demonstrated ICCs_2.1 of .98 and .93, respectively. All TUG tests were supervised by 1 of 5 trained orthopedic physical therapists after instruction in the TUG manual. TUG performance is part of the normal discharge routines in the unit before discharge.

Data Analysis 

Descriptive statistics were used for baseline characteristics. We used Student t tests for normally distributed data and Mann-Whitney U tests for nonnormally distributed data, while chi-square or Fisher exact tests were used for categorical data to evaluate differences between patients performing the TUG with crutches or with a walker. Dichotomous variables used in the analyses were (1) prefracture functional level (New Mobility Score 0–9): 2 through 7 (low) versus 8 through 9 (high); (2) mental status (0–9): 0 through 6 (low), 7 through 9 (high); (3) ASA classification (0–4): 1 through 2 versus 3 through 4; and (4) fracture type: femoral neck versus intertrochanteric.²⁹ Only 4 patients had subtrochanteric fractures, and no differences were found compared with patients with intertrochanteric fractures (P>.50). Accordingly, these fracture types were pooled for the subsequent analyses. We used paired t tests to examine systematic between walking-aid differences in TUG scores (crutches vs rollator and walker vs rollator), while Pearson product-moment or Spearman rho was used for correlation analyses of normally and nonnormally distributed data, respectively. A correlation coefficient of r greater than .75 is considered high correlation.³⁰ We used Bland-Altman plots³¹ with scatters of the between walking-aid TUG score differences plotted against the performance means to indicate whether differences were related to the means (heteroscedasticity). Data were considered heteroscedastic if the numerical between walking-aid differences in TUG scores were significantly (Pearson) correlated with the walking aid means. Under such circumstances, log transformation of both measurements data also should be analyzed, as it allows the results to be interpreted in relation to the original data.³² Data are presented as mean ± SD when normally distributed, otherwise as median (25%–75% quartiles). All data analyses were conducted using SPSS 12.0.^a The level of significance was set at P less than .05.

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Results 

Demographic characteristics are shown in table 1. Patients performing the TUG with crutches were younger, demonstrated a significantly higher prefracture level, performed the TUG faster at an earlier day postsurgery, and had a higher proportion of participants with a femoral neck fracture (P≤.004). All patients performed the TUG using a rollator at a mean of 30.6±15.9 seconds, and the rollator performance correlated with age (r=.252, P=.004), New Mobility Score (r=–.315, P<.001), cognitive status (r=–.291, P=.001), ASA score (r=.234, P=.008), and postsurgery day of performing the TUG (r=.426, P<.001).

Table 1. Baseline Characteristics of Participants (N=126)

Variable	All Patients (N=126)	Walker Group (n=88)	Crutches Group (n=38)	P
Age (y)⁎	74.8±12.7	77.2±12.3(44–100)	69.4±12.4(43–87)	.001
Postsurgery day of TUG performance⁎	10.1±7.8	11.7±8.7(4–71)	6.5±2.5(1–12)	<.001
Women†	90(71)	67(76)	23(60)	.075
Men†	36(29)	21(24)	15(40)
Low prefracture level (NMS 0–7)‡	39(31)	36(41)	3(8)	<.001
High prefracture level (NMS 8–9)‡	87(69)	52(59)	35(92)
Low mental status‡	12(9)	10(11)	2(5)	.236
High mental status‡	114(91)	78(89)	36(95)
Femoral neck fractures†	75(60)	45(51)	30(79)	.004
Intertrochanteric fractures†	51(40)	43(49)	8(21)
ASA 0–2‡	110(87)	75(85)	35(92)	.224
ASA 3–4‡	16(13)	13(15)	3(8)

NOTE. Values are mean ± SD (range) or n (%). P values refer to analyses between walker and crutches groups.

Abbreviation: NMS, New Mobility Score.

Walker Versus Rollator Timed Up & Go Performance 

The TUG score was on average 13.6±11.6 seconds faster using a rollator compared with a walker (P<.001) (fig 1A, table 2), but the rollator and walker performances were strongly correlated (r=.834, P<.001) (fig 1B). The between walking-aid differences in TUG scores correlated significantly with the mean TUG score (heteroscedasticity) as shown in figure 1C. That is, the patients who performed most poorly on the TUG test (required the most seconds) demonstrated the largest between walking-aid differences in TUG scores. Analyses of log-transformed data showed no heteroscedasticity (r=.024, P=.827), but differences between aids were still significant (see table 2) and strongly correlated (r=.858, P<.001). The numerical TUG score differences ranged from 0.8 to 66.8 seconds, and only 2 patients performed the TUG faster with a walker, at a mean of 4.4 seconds. Men displayed faster mean TUG scores than women using a walker (41.5s vs 50.7s, respectively; P=.079) and rollator (28.9s vs 36.7s, respectively; P=.056), but no significant sex differences in the between walking-aid differences in TUG scores (12.6s vs 14.2s, respectively; P=.559) were found.

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• Fig 1. 

  TUG performance differences in seconds: walker versus rollator (A), crutches versus rollator (D), relationship between TUG performances (B and E), and TUG performance differences against means (C and F).

Table 2. Paired t Test of the TUG Performances: Walker Versus Rollator (n=88) and Crutches Versus Rollator (n=38) for Original and Log-Transformed Data

NOTE. Values are mean ± SD or as otherwise indicated.

Elbow Crutches Versus Rollator Timed Up & Go Performance 

Patients who performed the TUG with crutches were on average 3.5±6.0 seconds faster using a rollator compared with crutches (P=.001) (see fig 1D, table 2), but the performances with the rollator and crutches were strongly correlated (r=.925, P<.001) (fig 1E). The between walking-aid differences in TUG scores correlated to the mean TUG score (fig 1F). That is, patients who performed most poorly on the TUG test (required the most seconds) demonstrated the largest between walking-aid differences in TUG score, but analyses of log-transformed data showed no heteroscedasticity (r=.274, P=.095), and differences between aids were still significant (see table 2) and strongly correlated (r=.897, P<.001). The numerical TUG score differences ranged from 0.3 to 22.3 seconds, and 9 patients performed the TUG faster with crutches, at a mean of 3.3 seconds, compared with a rollator. Men had faster mean TUG scores than women with crutches (19.3s vs 27.5s, respectively; P=.063) and a rollator (16.6s vs 23.5s, respectively; P=.021), but no significant sex differences in the between walking-aid differences in TUG scores (2.7s vs 4.0s, respectively; P=.523) were found.

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Discussion 

This study demonstrated that in patients with a hip fracture who are allowed FWB, TUG scores are related to the type of walking aid used during the test when testing is performed on the day before discharge from an acute orthopedic ward. Patients required fewer seconds to perform the TUG using a rollator compared with their planned discharge walking aid (walker or crutches). Finally, all patients in the present study, who were all allowed FWB, were able to perform the TUG using the rollator as a standardized walking aid.

The patients performed the TUG an average of 13.6 and 3.5 seconds faster using the rollator compared with the walker and crutches, respectively. The between walking-aid differences in TUG performance were larger in patients who required the most seconds to perform the TUG as indicated in the Bland-Altman plots (see figs 1C and 1F), but analyses of log-transformed data showed no heteroscedasticity, with similar differences and correlations, as in analyses of the original data. Similar results, with larger differences among subjects with slower TUG scores, were reported in a reliability study³³ of TUG scores in older subjects living in residential care facilities. Correspondingly, we found larger differences among patients with slower TUG scores in both patient groups, but the between walking-aid differences in seconds were largest in the group of patients where the walker and rollator were compared. This difference in TUG scores was expected based on a previous study that indicated slower performances using a walker. Also, this difference in TUG scores is inherent to using a walker, described as delayed 5-point walking, where “point” refers to the number of floor contacts on a line perpendicular to the direction of walking that simultaneously occurs during any part of the stance phase of the lead foot. The term “delayed” refers to the lead foot being slower than the assistive device in making floor contact,³⁴ the lead foot being the foot of the fractured leg in patients with hip fracture.

We expected patients who performed the TUG with crutches and thus had a higher functional level would perform better with the crutches versus the rollator. Interestingly, at a group level, this was not the case, which is in contrast to the findings of previous studies.¹², ¹⁹ One explanation may be that the present study examined differences in TUG performances using different walking aids in the same individual, whereas the above-mentioned studies¹², ¹⁹ compared TUG scores of different subjects using different walking aids. Although the ability to walk independently with crutches as early as day 6 after surgery indicates a very high functional level, the rollator may offer these patients more support during gait, which seems to increase their functional mobility even more. This may also occur because most patients with hip fracture who are using crutches at this time point after fracture use a delayed 3-point technique, which results in a slower walking speed compared with using a 2-point contralateral technique.³⁴ Men displayed faster TUG scores than women in both patient groups, which is likely related to better knee extension strength in men compared with women at the same time point postsurgery.²⁹ However, the between walking-aid differences in TUG scores were not different between the sexes (P>.520).

Overall, patients walking faster with the rollator is probably due to the continuous 4-point rolling support that allows walking similar to a 2-point contralateral walking technique with 2 crutches, without having to lift the device.

Previous cross-sectional studies in community-dwelling elderly,¹² in inpatient geriatric rehabilitation,⁴ and in patients with hip fracture¹⁹ reported different TUG times in groups of individuals using different walking aids, with recommendations of using the same walking aid if one is to compare TUG performance in individuals over time. However, this study is the first to show that in patients with hip fracture who were allowed FWB, TUG performance is related to the type of walking aid used during the test, and particularly in patients who use a walker. The evaluation of TUG scores using different walking aids at each assessment, or comparing TUG scores on a group basis if different walking aids are used in the different groups, cannot be recommended. Individuals recovering from a hip fracture often change walking aids from a more supportive aid (walker) to a less supportive aid (rollator or crutches) to possibly no aid at all during rehabilitation.¹⁷ We support the process of subjects changing walking aids when moving to a higher functional level, but to measure the progress, a standardized walking aid such as the rollator should be used, because improvements (decreases) in TUG scores of up to 16.1 seconds (95% CI, 11.2–16.1s [walker vs rollator]) may be related to a change in the walking aid used at retest. In this context, previous reports of significant group improvements in TUG scores (up to a mean of 68.6 seconds in 1mo) in intervention studies after hip fracture,¹⁴, ²⁰, ²¹ but without detailed information of the walking aid used at baseline and at retest, need to be interpreted with caution. Also, our findings might be of relevance to previous reports of subjects with hip fracture that categorized participants as showing improvement in gait speed if the TUG time decreased by 2.5 seconds or more.³⁵ Furthermore, physical therapists who use the TUG to determine the expected rate of recovery should be aware of the potential influence of the walking aid used when writing short- or long-term goals. Findings in the present study may also be of relevance for interpreting test results of other timed measures, such as the 10-m and 2-minute walk tests, when used in subjects with hip fracture¹⁶, ²¹ or in inpatient geriatric rehabilitation.⁴ Correlations between the 10-m fast speed walk test, the TUG (.74), and knee extension strength (.77) reported in patients with hip fracture who used a standardized walking aid (rollator)²⁹ support the above-mentioned suggestion. In addition, previous reports of significant correlations between the TUG, the BBS and the Medical Outcomes Study 36-Item Short-Form Health Survey,¹⁸ and the FIM¹⁵ possibly need reinterpretation in relation to the walking aid used.

The TUG was recorded at different days postsurgery, at median day 10 (7–13) and median day 6 (5–8) for subjects in the walker group and crutches group, respectively. Recording the TUG at the same day might have provided other valid data, but we chose to record the TUG the day the patients fulfilled the discharge criteria. In addition, the comparison of TUG scores was made within and not between subjects. Furthermore, the way of recording TUG scores in the present study is similar to other studies recording the TUG at the time of discharge from an orthopedic ward.¹⁹, ²⁹

All patients in our study were allowed FWB by the orthopedic surgeon, which is the standard procedure in our unit and the overall recommendation in Denmark. Only 5% of patients who had surgery for a hip fracture in our unit (50 of 1000 consecutive patients between September 2002 and January 2006) were not allowed any weight-bearing, due to unstable reposition of the fracture. Still, being allowed FWB, as is our standard procedure, does not mean that all patients actually practice this when walking or performing the TUG at the time of discharge from our unit, and therefore some degree of partial weight-bearing when walking may occur (weight-bearing as tolerated). Still, all patients in the present study were able to perform the TUG with the rollator, although it is not as stable as a walker.

Also of interest is the number of practice trials before the timed trial, because many different procedures (eg, different number of practice trials before the timed trial) have been used.³⁶ The purpose of using measures of functional mobility during rehabilitation is to quantify the individual's mobility level at different intervals and to quantify improvements. When using the TUG, clinicians need to ensure that the time recorded for an individual represents the best obtainable time (in seconds). All patients in the present study performed the TUG twice as originally described, with 1 practice trial followed by 1 timed trial.¹ This procedure was used for the session with the normal walking aid (walker or crutches) and the one performed with the rollator, with no indication of fatigue. Aiming to achieve the “true” TUG score of individuals at the time of discharge or later, it might be that more than 1 practice trial followed by a timed trial is needed. This ought to be examined in the future.

Study Limitations 

We are aware that our findings relate to a specific time point after surgery (time of discharge from an acute orthopedic ward on day 10.1±7.8 postsurgery). Thus, we do not know the extent to which TUG scores are related to the type of walking aid used when the test is performed at a later date postsurgery. It seems likely, however, that the TUG score differences will diminish as performance improves. Still, our findings with up to 68 seconds difference for an individual at the time of discharge (related to the walking aid used) indicate that some difference may still exist at a later date postsurgery.

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Conclusions 

We conclude that TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who were allowed FWB when discharged from the hospital. All patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid in addition to the individual walking aid (the discharge walking aid), when evaluating changes in functional mobility over time in individuals or comparing the TUG scores in groups of patients with hip fracture.

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