|Year : 2013 | Volume
| Issue : 1 | Page : 30-34
Association timed "up and go" test with respect to gross motor function classification system level in children diagnosed as cerebral palsy
Sanjivani N Dhote, Suvarna S Ganvir
Department of Physiotherapy, Padmashri Dr. Vittalrao Vikhe Patil Foundation's Campus, Maharashtra, India
|Date of Web Publication||17-Apr-2013|
Sanjivani N Dhote
Department of Physiotherapy, Flat No 8, Pooja Apartment, Tanaji Nagar, Chinchwadgaon, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Timed "up and go" (TUG) test is a quick test, used in clinical practice as an outcome measure to assess functional ambulatory mobility or dynamic balance in adults. However, little information is available of TUG test used in cerebral palsy (CP). Hence, the purpose of our study was to find score of TUG with respect to gross motor function classification system (GMFCS) in CP children. Aims: To find the mean score of TUG test with respect to GMFCS level in children diagnosed as CP. Materials and Methods: It was a cross-sectional observational study conducted in neuro rehabilitation unit and included 30 CP children of 4-12 years, those within GMFCS level I, II, III, and IQ ≥50. The sampling technique used was purposive sampling excluding children with cognitive deficit. Subjects performed on TUG on three occasions: Initial assessment (time 1); 30 min after initial assessment (time 2); 1 week after initial assessment (time 3). Three trials were conducted for each of the three occasions. A mean score of three trials was documented as final score. The mean of scores of TUG test of all the subjects within the particular GMFCS levels was calculated. Results: Significant variation was seen in the TUG score for three levels of GMFCS. Conclusions: Significant variation was seen as GMFCS levels get increases time duration of TUG also increases.
Keywords: Cerebral palsy, gross motor function classification system levels, timed "up and go" test
|How to cite this article:|
Dhote SN, Ganvir SS. Association timed "up and go" test with respect to gross motor function classification system level in children diagnosed as cerebral palsy. Int J Health Allied Sci 2013;2:30-4
|How to cite this URL:|
Dhote SN, Ganvir SS. Association timed "up and go" test with respect to gross motor function classification system level in children diagnosed as cerebral palsy. Int J Health Allied Sci [serial online] 2013 [cited 2020 Apr 4];2:30-4. Available from: http://www.ijhas.in/text.asp?2013/2/1/30/110564
| Introduction|| |
Cerebral palsy (CP) is "a group of permanent disorders of development of movement and posture, causing activity limitation which is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain."  Common impairments are abnormal tone, posture and movement which limit ambulation. , Spastic diplegia is commonest form of CP in which more involvement of lower than upper limb. ,
There are different methods to measure balance and mobility in both children and adult. Many sophisticated methods in assessing balance and mobility include computerized motion analysis system, force platforms, and posturography.  These methods are very sensitive to change of gait and postural sway. However, they require high technology, specific equipment, and training. , One of the common methods widely used for evaluating balance and mobility is timed "up and go" test (TUG).
The TUG test is a quick and practical test widely used as an outcome measure, to assess basic or functional ambulatory mobility, or dynamic balance in adults. ,,, The TUG test has been shown to have validity by virtue of its correlation with measures such as the Berg balance scale, , gait speed/time, ,, stair climbing,  and functional indexes  and by its ability to discriminate between patients on the basis of residential status, falls. 
However, this TUG has rarely been used in children. Literature review reveals very few published reports indicating the use of the TUG test as an outcome measure to grade functional performance in children.
Podsiadlo and Richardson had conducted a pilot study in children without disabilities (aged 3-6 year), and an 8-year-old child with CP (spastic diplegia) and have suggested few modifications to the standard TUG test, to be used in children. A concrete task was used, in that children were asked to touch a target on a wall, instead of the more abstract verbal instructions of the standard TUG test. Abstract instructions have been shown to limit performance in children with CP.  Podsiadlo and Richardson and others have reported that the TUG test can be performed reliably. ,,
Gross motor function classification system (GMFCS) features a five-level ordinal scale which reflects, in a decreasing order, the level of independence and functionality of children with CP.  The focus is on determining which level best represents the child's present abilities and limitations in motor function. Emphasis is on the child's usual performance at home, in school, and in community settings. It is therefore important to classify on ordinary performance (not best capacity), and not to include judgments about prognosis.  Hence, the purpose of study was to find score of TUG test with respect to GMFCS level in children diagnosed as CP.
| Materials and Methods|| |
It was observational to find score of TUG test with respect to GMFCS level in children diagnosed as CP within age group of 3-12 year, with preserved comprehensions and those within GMFCS level I, II, and III. The study was carried out at a 950-bedded tertiary care teaching hospital with well-equipped medical and surgical intensive care unit and a neuro rehabilitation unit. The subjects included in this study were those who were diagnosed as having CP and within the age group of 3-12 year, with preserved comprehensions, those within GMFCS level I, II, and III. Subjects having IQ ≥ 50 and with cognitive deficit were excluded from study. Based on inclusion and exclusion criteria 40 subjects were selected. Out of these four subjects were not willing for the study and six subjects did not turn up for follow up assessment (third assessment). Only 30 subjects could finally be studied.
| Main Outcome Measure|| |
Modified TUG test
Methodology of TUG test
The TUG test measure, in second, the timer taken by individual to stand up from a standard arm chair, walk a distance of 3 m, turn, walk back to the chair, and sit down.
The subject wears regular footwear. If participant's usually use assistive devices such as cane or walker, they should use them during the test, but this should be indicated on the data collection form. No physical assistance is given.
Setting up the test area:
- Determine a path free from obstruction
- Place a chair with arms at one end of the path
- Mark off a 3 m distance using tape.
Start the test:
- Speak clearly and slowly
- Inform the participant of sequence and outcome
- "When I say go, you will get up from the chair, walk to the mark on floor, turn around, walk back to chair and sit down" "I will be timing you using the stopwatch" ask participants to repeat the instructions to make sure they understand.
Procedure for modified tug test for children was as follows:
Testing was conducted in rehabilitation set up with the child's parent present.
The test began with subjects sitting on a stable stool, selected according to the height of subjects. The stool was positioned such that it would not move when the subject moved from the sitting to the standing position. Subject was seated with feet flat on the floor, so that the hip and the knee remains in 90° of flexion. A marking tape was used to stick star mark on the wall at distance of 3 m from chair.
A fixed task was given, where-in the subject was asked to touch the target (the star) on the wall, instead of the more abstract verbal instructions of the standard TUG test. Abstract instructions have been shown to limit performances in children with CP. 
The following instructions were delivered to the subject slowly and clearly: "This test is to see how you can stand up, walk, and touch the star, then come back to sit down. The stopwatch (of cell phone) is to time you." Subjects wore their regular footwear or orthosis, and were allowed to use walking aids, but were not allowed to be assisted by another person during the performance of test. There was no time limit for the performance of the test, they could stop and rest (but not sit down) if they needed to do so. Instructions given were "After I say "go," stand up, walk up to and touch the star, and then come back and sit down. Remember to wait until I say "go." This is not a race; you must walk and not run, and I will time you. Do not forget to touch the star, come back and sit down." Timing was started as the child leaves the seat, rather than on the instruction "go" and stopped as the subject's bottom touches the seat, in order to measure "movement time" only. A practice trial was given to the subject. There after test was conducted thrice and time was recorded for each test. The time was measured in seconds. The mean of 3 times was documented and used for analysis. The investigator sat on a chair, in clear view of the subject. Subjects were tested in small groups. Every completed TUG test was scored and noted. The same investigator conducted all testing procedures for the study.
Gross motor function classification system
Gross motor function classification system (GMFCS) was developed by Robert Palisano, Peter Rosenbaum, Stephen Walter, Dianne Russell, Ellen Wood, Barbara Galuppi in the year 1997 at the Can Child Centre for Childhood Disability Research. GMFCS for CP is based on self-initiated movement with particular emphasis on sitting (trunk control) and walking. GMFCS features a five-level ordinal scale which reflects, in a decreasing order, the level of independence and functionality of children with CP. The focus is on determining which level best represents the child's present abilities and limitations in motor function. Emphasis is on the child's usual performance at home, school, and community settings. It is therefore important to classify on ordinary performance (not best capacity), and not to include judgments about prognosis. Remember the purpose is to classify a child's present gross motor function, not to judge quality of movement or potential for improvements. 
General headings for each level
- Level I: Walks without limitations
- Level II: Walks with limitations
- Level III: Walks using a hand-held mobility device
- Level IV: Self-mobility with limitations; may use powered mobility
- Level V: Transported in a manual wheelchair.
Between December 2009 and September 2010 a cross-sectional observational study was carried out in subjects with CP who fitted in the selection criteria. The synopsis of the study was submitted to the Institutional Ethical Committee (IEC) for approval. After obtaining ethical committee approval subjects were selected on the basis of selection criteria. The purpose of the study was explained to the subjects and they were informed about their right to opt out of the study anytime, during the course of the study, without giving reason for doing so. A written informed consent (vernacular language) was obtained from the child's parents/guardian who voluntarily agreed for inclusion of their child in the proposed study.
Performance of subjects on TUG test was observed and documented. During occasions three test trails were conducted, and mean score of three trials was recorded for analysis.
1 st occasions - Initial assessment (time 1).
Data from all the subjects based on the performance of TUG test were entered into a computer database and analyzed with SPSS statistical package (version 14.0). To find the mean score of TUG test with respect to GMFCS level; the mean of scores of TUG test of all the subjects within the particular GMFCS levels was calculated.
| Results|| |
[Table 1] shows out of 30 subjects, 17 were male and 13 were female, of these in age group of 2-4 year, 1 was male and 3 were female. Among the age group of 4-6 years, 5 were male and 1 was female. And in age group of 6-12 years, 11 were male and 9 were female. Mean age of patients was 8.16 years ± 2.76 (age range 2-12 years)
[Table 2] shows out of 30 subjects, 8 (26.67%) subjects were at GMFCS level I, 14 (46.67) subjects were at GMFCS level II, and 8 (26.67%) subjects were at GMFCS level III.
|Table 2: Distribution of subjects according to gross motor function classification system levels|
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[Table 3] shows mean TUG score for children within GMFCS level I was found to be 9.59 s ± 1.60 s (range 7.32-10.81 and median 8.88) for GMFCS level II it was found to be 12.37 s ± 1.69 s (range 9.24-12.56 and median 10.69) and for GMFCS level III it was found to be 46.02 s ± 6.05 s (range 7.90-39.23 and median 33.50).
|Table 3: Timed "up and go" test score with respect to gross motor function classification system levels|
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Significant variation was seen in the TUG score for the three levels of GMFCS.
| Discussion|| |
The present study was carried out with the aim of to find the mean score of TUG test with respect to GMFCS level in children diagnosed as CP.
The result of present study indicates that with respect to GMFCS level shows significant variation in the TUG score for the three levels of GMFCS; where in the mean TUG test score for children within GMFCS level I was found to be 9.59 s ± 1.60 s (range 7.32-10.81 and median 8.88) for GMFCS level II it was found to be 12.37 s ± 1.69 s (range 9.24-12.56 and median 10.69) and for GMFCS level III it was found to be 46.02 s ± 6.05 s (range 27.90-39.23 and median 33.50). Significant variation was seen in the TUG test score for the three levels of GMFCS.
The excellent reliability of TUG test observed in our study can be attributed to the modification of TUG test by using a concrete task where in the subject was asked to touch the target (star) on the wall, instead of the more abstract verbal instructions of the standard TUG test. Abstract instructions have been shown to limit performances in children with CP. 
The limitation of our study was that the number of participants was small and the participants were a convenience sample and therefore, may not be representative of a wider population. Our sample consisted of heterogeneous group of CP children, spread over a wide range of age and some of the children were very young which may have influenced the results.
Studies should be conducted in a larger group representative of wider population and in different age groups of CP children's. Further studies in this population are recommended, for establishing Responsiveness of TUG test.
The TUG test is found to be meaningful, reliable, quick, and practical objective outcome measure which can be used in clinical setting for assessing functional mobility in CP children.
Further, on establishing the responsiveness of TUG test, it can also be used to assess the efficacy of various therapeutic interventions.
| Conclusion|| |
We conclude that the modified TUG test is an excellent tool in children diagnosed with CP within the range of 3-12 years of age, provided that the child can understand instructions. The TUG test integrates transitions and walking skills, and provides a measure of capability that is meaningful to most people; and thus it can be used as a reliable outcome measure for assessing functional mobility in CP children. TUG test score with respect to GMFCS level, we observed significant variation in the TUG test score for the different levels of GMFCS. So it shows that as GMCS levels get increases TUG score also get increases.
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[Table 1], [Table 2], [Table 3]