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Quantitative Evaluation of Gait Disturbance on an Instrumented Timed Up-and-go Test
Shigeki Yamada 1,2,*, Yukihiko Aoyagi 3, Kazuo Yamamoto2, Masatsune Ishikawa1,4
1Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Rakuwakai Healthcare System, Kyoto, Japan.
2Department of Neurosurgery and Stroke Center, Rakuwakai Otowa Hospital, Rakuwakai Healthcare System, Kyoto, Japan.
3Digital Standard Co., Ltd., Osaka, Japan.
4Rakuwa Villa Ilios, Rakuwakai Healthcare System, Kyoto, Japan
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Abstract  

Although the 3-m timed up-and-go test (TUG) is reliable for evaluating mobility, TUG time is insufficient to evaluate mild gait disturbance; we, therefore aimed to investigate other measurements with instrumented TUG (iTUG) using a free smartphone application. Our inclusion criterion in this study is only that participants can walk without any assistance. This study included three heterogeneous groups; patients who underwent a tap test or shunt surgery, 29 inpatients hospitalized for other reasons, and 87 day-care users. After the tap test, 28 were diagnosed with tap-positive idiopathic normal-pressure hydrocephalus (iNPH) and 8 were diagnosed with tap-negative. Additionally, 18 patients were assessed iTUG before and after shunt surgery. During iTUG, time and 3-dimensional (3D) acceleration were automatically recorded every 0.01 s. A volume of the 95% confidence ellipsoid (95%CE) of all plots for 3D acceleration was calculated. Additionally, an iTUG score was defined as (95%CE volume) 0.8 / 1.9 - 1.9 × (time) + 60. The measurement reliability was evaluated using intraclass correlations and Bland-Altman plots. The participants with mild gait disturbance who accomplished within 13.5 s on the iTUG time had the 95%CE volumes for 3D acceleration of ≥70 m3/s6 and iTUG scores of ≥50. The mean iTUG time was shortened and the mean 95%CE volumes and iTUG scores were increased after the tap test among 28 patients with tap-positive iNPH and after shunt surgery among 18 patients with definite iNPH. Conversely, the mean iTUG score among 8 patients with tap-negative was decreased after the tap test. The intraclass correlations for the time, 95%CE volume and iTUG score were 0.97, 0.80 and 0.90, respectively. Not only the iTUG time but also the 95%CE volume was important for evaluating mobility. Therefore, the novel iTUG score consisting both is useful for the quantitative assessment of mobility.

Keywords gait disturbance      gait assessment      diagnostic test assessment      timed up-and-go test      idiopathic normal-pressure hydrocephalus      cerebrospinal fluid tap test     
Corresponding Authors: Yamada Shigeki   
Just Accepted Date: 01 May 2018  
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Shigeki Yamada
Yukihiko Aoyagi
Kazuo Yamamoto
Masatsune Ishikawa
Cite this article:   
Shigeki Yamada,Yukihiko Aoyagi,Kazuo Yamamoto, et al. Quantitative Evaluation of Gait Disturbance on an Instrumented Timed Up-and-go Test[J]. A&D, 10.14336/AD.2018.0426
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http://www.aginganddisease.org/EN/10.14336/AD.2018.0426     OR     http://www.aginganddisease.org/EN/Y0/V/I/0
Figure 1.  Flow chart for patient selection in this study. Yellow parallelograms indicate the patients included in the study.
Figure 2.  Motion analysis in three axial directions during instrumented 3-m timed up-and-go test (iTUG). A 75-year-old woman underwent the tap test to assess the diagnosis of iNPH. The time on iTUG before the tap test (left) was 10.25 s and shortened 7.88 s after the tap test (right). On the basis of the turn angle (degree, purple) and angular speed for bob movement (degree/s, light green) measured every 0.01 s by an inertial gyroscope, movement during the iTUG was automatically segmented into stand up, go straight forward, turn, go back, turn, and sit down (upper panel). During the iTUG, acceleration in three axial directions was also automatically recorded every 0.01 s (lower panel) by an acceleration sensor. Longitudinal acceleration (red) indicates acceleration toward forward (+) and backward (-), vertical acceleration (blue) indicates acceleration toward upward (+) and downward (-), and horizontal acceleration (green) indicates acceleration toward left (+) and right (-).
Figure 3.  Two-dimensional (2D) scatter plots and their 95% confidence ellipse for 2D acceleration. Blue plots indicate the changes of 3D acceleration every 0.01 s in the same case as shown in Figure 2. The red ellipse indicates a 95% confidence ellipse that contains 95% of all plots. Before the tap test, the chronological changes of the plots both in the longitudinal and vertical acceleration (A) and horizontal and vertical acceleration (B) were very small, and the areas of the red ellipses were calculated as 33.0 m2/s4 and 27.1 m2/s4, respectively. After the tap test, not only forward acceleration but also upward and downward vertical acceleration was increased. The area of the red ellipse for the longitudinal and vertical acceleration was calculated as 142.5 m2/s4 (C), and that for the horizontal and vertical acceleration was102.5 m2/s4 (D).
Figure 4.  Three-dimensional (3D) plots and their 95% confidence ellipsoid (95%CE) for 3D acceleration. Blue plots indicate acceleration every 0.01 s in the same case as shown in Figure 2 and 3. Accelerations were very small in all three axial directions before the tap test (A and B), but they changed larger after the tap test (C and D). The yellow ellipsoids (B and D) indicate a 95% CE that contains 95% of all plots in the 3D graph. The 95%CE volume before the tap test was calculated as 95.19 m3/s6 (B) and increased to 552.10 m3/s6 after the tap test (D).
Tap +Tap -P valueShunt
Total number28818
Male: Female18: 102: 60.1212: 6
History of falls
none: 1 or 2 times: ≥3 times8: 6: 142: 1: 50.797: 4: 7
Co-morbidity
Alzheimer's disease11 (39%)3 (38%)1.004 (22%)
spinal disease6 (21%)4 (50%)0.255 (28%)
cerebral infarction1 (4%)01.002 (11%)
Age, year77.5 ± 5.978.3 ± 9.00.8276.6 ± 5.1
Disease duration, month33.5 ± 24.035.0 ± 10.20.2934.8 ± 21.0
Duration time to shunt, day──75.1 ± 61.3
Before tapBefore tapBefore shunt
modified Rankin scale, point2.6 ± 0.92.6 ± 0.70.902.4 ± 0.6
3-m timed up-and-go test, s24.9 ± 20.316.3 ± 7.00.3914.6 ± 5.8
10-m straight walk test, s16.0 ± 17.312.7 ± 5.10.9711.2 ± 3.8
MMSE, point22.5 ± 6.923.5 ± 3.30.8224.1 ± 4.5
FAB, point10.5 ± 3.310.5 ± 2.30.9212.4 ± 4.4
Table 1  Baseline characteristics before tap test or shunt surgery.
Initial TUG time<13.5 s≥13.5 sP value
Total number1018
Male: Female8: 210: 80.38
History of falls
none: 1 or 2 times: ≥3 times4: 3: 34: 3: 110.29
Co-morbidity
Alzheimer's disease2 (20%)9 (50%)0.25
spinal disease2 (20%)4 (22%)1.00
cerebral infarction01 (6%)1.00
Age, year73.5 ± 5.279.8 ± 5.2<0.01
Disease duration, month32.9 ± 28.933.9 ± 21.80.63
modified Rankin scale, point2 ± 03 ± 0.9<0.01
MMSE, point26.0 ± 2.422.8 ± 5.90.06
FAB, point11.8 ± 3.411.9 ± 5.60.06
10-m straight walk test, second8.5 ± 1.312.9 ± 3.0<0.01
Table 2  Clinical characteristics in the groups with <13.5 and ≥13.5 seconds (s) on iTUG time before the tap test.
Figure 5.  Scatter plots for time and volume of 95% confidence ellipsoid (95%CE) for 3D acceleration. The x-axis shows the time on iTUG, and the y-axis shows the 95%CE volume at the first time (A), the second time (B), and the best performance in the two times of iTUG (C). Red circles indicate patients with tap-positive iNPH before the tap test. Purple open squares indicate patients hospitalized for other reasons and did not undergo the tap test, and green open triangles indicate day-care users. There are inverse relationships between the time and 95%CE volume for the 3D acceleration.
Inpatient for other reasons(29)Day-care user(87)P
Man18400.20
Age, years74.3 ± 7.479.5 ± 7.0<0.01
First time of iTUG
Time, second11.9 ± 4.312.5 ± 4.10.35
95%CE volume, m3/s6210.0 ± 256.8143.2 ± 139.20.31
iTUG score72.5 ± 38.462.8 ± 25.10.41
Second time of iTUG
Time, second11.7 ± 3.510.9 ± 3.00.42
95%CE volume, m3/s6176.1 ± 139.2183.8 ± 150.60.87
iTUG score69.2 ± 25.771.8 ± 25.30.60
Table 3  Characteristics and results on iTUG in the inpatient for other reasons and day-care user.
Figure 6.  Scatter plots for the correlations among time, volume of 95% confidence ellipsoid (95%CE) for 3D acceleration and iTUG score. The left panel (A) indicates the relationships between the time on iTUG (x-axis) and iTUG score (y-axis) at the best performance in the two times on iTUG. The time on iTUG had a negative correlation to the iTUG score in a linear fashion (y = -1.8x + 70) at the iTUG time of >13.5 s and iTUG scores of <50. The right panel (B) indicates the relationships between the 95%CE volume for the 3D acceleration (x-axis) and iTUG score (y-axis). The 95%CE volume had a positive correlation to the iTUG score in a linear fashion (y = 0.18x +40) at the 95%CE volume of ≥70 m3/s6 and the iTUG scores of ≥50. Red circles indicate patients with tap-positive iNPH before the tap test. Purple open squares indicate patients hospitalized for other reasons, and green open triangles indicate day-care users.
Figure 7.  Changes of the best performance at tap test and shunt surgery. The time and volume of 95% confidence ellipsoid (95%CE) for 3D acceleration on iTUG before the tap test (number 1, green marks) move to the number 2 (purple marks) 1 day after the tap test, and move to the number 3 (brown marks) 4 days after the tap test among 28 patients with tap-positive iNPH (A) and 8 patients with tap-negative (B). In the same way, those before the shunt surgery (number 1, green marks) move to the number 2 (brown marks) after the shunt surgery among 18 patients with iNPH (C).
28 patients with tap-positive iNPH
Before tap1 day after tap4 days after tap
Time, s23.8 ± 15.818.3 ± 10.215.1 ± 7.7
∆Time, s-5.1 ± 10.1-7.7 ± 9.8
95%CE volume, m3/s677.9 ± 65.2101.8 ± 87.4138.2 ± 114.2
∆95%CE volume, m3/s622.4 ± 49.852.7 ± 108.9
iTUG score31.1 ± 35.445.4 ± 29.757.0 ± 28.4
∆ iTUG score13.1 ± 19.322.0 ± 17.1
8 patients with tap-negative
Before tap1 day after tap4 days after tap
Time, s16.4 ± 6.818.0 ± 10.016.4 ± 7.6
∆Time, s1.6 ± 4.80.8 ± 2.8
95%CE volume, m3/s6137.7 ± 149.0120.9 ± 93.2120.4 ± 81.8
∆95%CE volume, m3/s6-16.8 ± 68.9-31.5 ± 115.1
iTUG score54.0 ± 32.149.1 ± 31.650.7 ± 26.0
∆ iTUG score-4.9 ± 13.6-7.0 ± 18.0
18 patients with iNPH who underwent V-P shunt surgery
Before shuntAfter shunt
Time, s17.4 ± 5.011.8 ± 3.1
∆Time, s-5.7 ± 4.1
95%CE volume, m3/s687.1 ± 53.3163.7 ± 137.6
∆95%CE volume, m3/s680.9 ± 110.2
iTUG score45.0 ± 15.567.1 ± 24.0
∆ iTUG score21.6 ± 16.2
Table 4  Change of iTUG measurements at the best performance.
Initial TUG time<13.5 s≥13.5 sP value
Total number1018
Before tap test
iTUG time, second11.7 ± 1.830.5 ± 16.2<0.01
95%CE volume on iTUG, m3/s6126.4 ± 74.850.9 ± 40.6<0.01
iTUG score62.4 ± 14.213.7 ± 31.4<0.01
1 day after tap test
iTUG time, s10.3 ± 1.622.7 ± 10.3<0.01
∆iTUG time, s-1.4 ± 1.3-7.2 ± 12.10.023
95%CE volume on iTUG, m3/s6178.7 ± 97.959.2 ± 40.6<0.01
∆95%CE volume on iTUG, m3/s660.9 ± 56.71.1 ± 29.8<0.01
iTUG score72.8 ± 16.830.2 ± 23.7<0.01
∆ iTUG score11.6 ± 10.014.0 ± 23.20.83
4 days after tap test
iTUG time, s9.5 ± 2.018.5 ± 7.9<0.01
∆iTUG time, s-2.2 ± 1.7-10.9 ± 11.2<0.01
95%CE volume on iTUG, m3/s6227.5 ± 139.685.6 ± 48.2<0.01
∆95%CE volume on iTUG, m3/s6109.8 ± 148.219.2 ± 60.80.15
iTUG score81.4 ± 22.042.7 ± 21.2<0.01
∆ iTUG score20.2 ± 22.423.1 ± 13.80.41
Table 5  Change of iTUG measurements in the groups with <13.5 and ≥13.5 seconds (s) on iTUG time.
Figure 8.  Distributions of iTUG time, ellipsoid volume for 3D acceleration and iTUG score. The y-axes show the numbers of patients with tap-positive iNPH before the tap test (red), patients hospitalized for other reasons (purple), and day-care users (green). Distributions of iTUG time (A) and ellipsoid volume for 3D acceleration (B) were biased distribution, but a distribution of iTUG score (C) approximately had a normal distribution.
Figure 9.  Bland-Altman plots of iTUG time, ellipsoid volume for 3D acceleration and iTUG score. The x-axes show the means of the first and the second measurements and the y-axes represent the differences between the two measurements on iTUG time (A), ellipsoid volume for 3D acceleration (B), and iTUG score (C). Red circles indicate patients with tap-positive iNPH before the tap test. Purple open squares indicate patients hospitalized for other reasons and did not undergo the tap test, and green open triangles indicate day-care users.
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