R E S E A R C H R E P O R T

Timed Up and Down Stairs Test:

Preliminary Reliability and Validity
of a New Measure of Functional
Mobility
Christopher A. Zaino, PT, PhD, Victoria Gocha Marchese, PT, PhD, and Sarah L. Westcott, PT, PhD
Hong Kong Society of Rehabilitation–WHO Collaborating Centre for Rehabilitation, Hong Kong (C.A.Z.); St. Jude
Children’s Research Hospital, Memphis, Tennessee (V.G.M.); Drexel University (S.L.W.), Philadelphia, Pennsylvania;
University of Puget Sound (S.L.W.), Tacoma, Washington

Purpose: The reliability and validity of a new test, the Timed Up and Down Stairs (TUDS), were examined in children
with and without cerebral palsy (CP). Methods: A convenience sample of 47 children age eight to 14 years partic-
ipated, 20 with CP and 27 with typical development (TD). Using intraclass correlation coefficients (ICC), interrater,
intrarater, and test–retest reliability of the TUDS were examined by two raters simultaneously testing nine children,
by one rater who then rescored at a later time a video of the testing of 24 children, and by one rater testing 25
children twice with a two-hour separation, respectively. Concurrent validity was examined using Spearman rank
correlations between TUDS scores and performance on the Timed Up and Go (TUG), the Functional Reach Test
(FRT), and a Timed One Legged Stance (TOLS), which were completed in a random order on all children. Construct
validity was examined by correlation and Kruskal-Wallis analysis of variance of scores across ages and three
functional level groups. Results: The TUDS demonstrated excellent intrarater, interrater, and test–retest reliability
[ICC (2,1) ⱖ0.94] and moderate to high concurrent validity (Spearman rs ⫽ 0.78, ⫺0.57, and ⫺0.77, with the
TUG, FRT, and TOLS, respectively). Age accounted for 37% and 56% of the variance in the TUDS for the TD group
and for the Gross Motor Function Classification Scale level I CP group, respectively. Significant differences in TUDS
scores were found between all three functional level groups. Conclusion: The TUDS has adequate reliability and
validity in children with and without CP and appears to complement current clinical measures of functional
mobility and balance. Further investigations on across larger age ranges and samples are warranted. (Pediatr Phys
Ther 2004;16:90 –98) Key words: activities of daily living, locomotion, musculoskeletal equilibrium, reproducibility
of results, time factors, child, cerebral palsy, physical therapy/instrumentation

INTRODUCTION United States.1 These children commonly demonstrate an im-

Children with cerebral palsy (CP) represent one of the
largest populations treated by physical therapists in the
0898-5669/04/1602-0090
Pediatric Physical Therapy
Copyright © 2004 Lippincott Williams & Wilkins, Inc.
Address correspondence to: Sarah L. Westcott, 5019 218th Ave. NE, Red-
mond, WA 98053. Email: wests@isomedia.com
Grant support: The work was supported in part by grants made to MCP
Hahnemann University by the US Department of Health and Human
Services grant (H029D0005) and US Department of Health and Human
Services grant (PHS 5-T32-Hdo7467– 04) and grants to Dr Zaino by the
Section on Pediatrics of the American Physical Therapy Association, the
Foundation for Physical Therapy, and the Institute for Neuroscience Re-
search, Allegheny Health, Education and Research Foundation.
DOI: 10.1097/01.PEP.0000127564.08922.6A
pairment in postural control.2 Purposeful interaction with the
surrounding environment is improved through the control of
posture, which is hypothesized to involve many systems in-
cluding, at a minimum, the musculoskeletal, neuromuscular,
and sensory systems.3 Evaluation of these systems is impor-
tant for the development of appropriate interventions. Addi-
tionally, reliable and valid measures of limitations in func-
tional activities that reflect aspects of underlying postural
control are required to document functional outcomes of
intervention.4
The Timed Up and Down Stairs (TUDS) was developed
as a functional mobility outcome measure that would poten-
tially reflect improvements in the musculoskeletal and neuro-
muscular systems that contribute to the control of posture.
The TUDS involves the subject ascending one flight of stairs,

90 Zaino et al Pediatric Physical Therapy

turning around, and descending to the starting point. One can
hypothesize that performance on the TUDS requires a certain
amount of strength of the lower extremities and trunk, range
of motion (ROM) in the lower extremities, coordination for
fast reciprocal movements, and anticipatory and reactive pos-
tural control. The relationship of these types of components
to functional mobility has been supported by a recent study in
elderly men.5 Competence on the Physical Performance Test
(including seven activities of daily living requiring various
levels of mobility from being able to eat, to picking up a
penny, to turning 360 degrees and walking quickly) was
found to be related to component or impairment measures,
including gait speed, stride length, fall risk (Modified Gait
Abnormality Rating Scale), muscle force production (grip
strength), flexibility (active ankle ROM), and fitness (Modi-
fied Sitting Step Test). A linear regression revealed a strong
relationship between the performance test with gait speed and
muscle force production (accounting for 58% and 68% of the
variability, respectively).5 Many of the components of the
functional activities studied are hypothesized to be similar to
those required for the TUDS (gait speed, strength, active
ROM, turning around).
Additionally, Lepage et al6 have provided support
for the relationship between functional abilities and a
stair-walking task in children. They demonstrated that a
timed up and down stairs task similar to the TUDS was
associated with the ability to perform various life habits
related to school and social situations as measured by
the Life Habits Assessment (version 1.0).6 The Life Hab-
its Assessment tool is based on the World Health Orga-
nization’s model of disablement. Life Habits are defined
as “those habits that ensure the survival and develop-
ment of a person in society throughout his or her life.”6
Lepage et al6 found that there was an association be-
tween disruptions in life habits and types of locomotor
measures. Among the locomotor measures used, the
timed up and down stairs task accounted for the largest
amount of variance in the disruption of four life habits
categories: mobility, community, recreation, and resi-
dence for 66%, 37%, 33%, and 22%, respectively.6 Thus,
a TUDS type of measure is associated with the ability to
be active in the community and home and during recre-
ational activities. It was hypothesized that the TUDS-
type task “demands more balance, coordination,
strength, and muscle control than walking demands.”6
Therefore, the TUDS appears to be an important mea-
sure in the evaluation of functional mobility and
balance.
Although there is supporting evidence for the validity
of the TUDS, the reliability and validity of the TUDS need
to be formally evaluated for the test to be used with chil-
dren.4 Therefore, the purposes of this study are threefold.
The first purpose was to determine the intrarater, interra-
ter, and test–retest reliability in a group of children with CP
and children with typical development (TD). The second
purpose was to determine the concurrent validity of the
TUDS with other accepted measures of functional mobility
and balance. Common tests of functional mobility and bal-
Pediatric Physical Therapy
ance include the Timed Up and Go (TUG),7,8 the Func-
tional Reach Test (FRT),9,10 and the Timed One Legged
Stance (TOLS).11 These measures have been demonstrated
to assist in the identification of disorders of postural con-
trol and resultant limitation in functional abilities.7–12 The
third purpose was to determine whether differences in
functional mobility and balance are reflected in the TUDS
score (construct validity) by examining relationships be-
tween 1) children with CP and children with TD, 2) differ-
ent levels of functional mobility and balance in children
without and with CP as classified using the Gross Motor
Function Classification Scale (GMFCS),13 and 3) different
ages.
METHODS
Subjects
As part of a larger study on the neuromuscular control
of a standing reaching task, a sample of convenience of 48
subjects was recruited from the Delaware Valley area of
Pennsylvania, New Jersey, and Delaware. Subjects were
recruited via flyers posted in local hospitals, doctors’ of-
fices, and schools. In addition, the charts of two physicians
were reviewed for potential candidates. All children were
initially contacted by telephone to determine whether they
were interested in participating in the study and to see
whether they met the inclusion criteria. Inclusion criteria
for participation included ages eight to 14 years old, no
orthopedic surgeries within the past six months, no history
of any genetic or neurological disorder besides CP, and
rated as level I or II on the GMFCS (Table 1).13 This age and
functional ability range was chosen due to requirements
for the larger study. One of the subjects was unable to
complete the testing procedure. Of the remaining 47 sub-
jects, 20 were children with CP (nine female) and 27 were
children with TD (14 female). The ethnicity of the subjects
was 11 Asian, two Hispanic, nine African American, and 25
white. The age, weight, and height, as displayed in Figure
1, were not substantially different between the children
with CP and the children with TD (p ⫽ 0.69, 0.63, 0.38,
respectively). Other characteristics of the children are
listed in Table 2.
This study was approved by MCP-Hahnemann Uni-
versity’s and St. Christopher’s Hospital for Children in
Philadelphia’s Internal Review Boards for use of human
subjects. After the subjects and parents/guardians agreed to
participate and signed the assent and consent forms, prep-
arations for data collection and the testing procedures were
completed.
Measurement Tools
Gross Motor Function Classification Scale. The
GMFCS was used to classify the children with CP into
groups based on functional ability. This scale has been
shown to have excellent interrater reliability (␬ ⫽ 0.75) for
children between two and 12 years of age.13 Level I is the
highest level of functional abilities and level V the lowest
(Table 1). Due to demands of the larger study, recruitment
Timed Up and Down Stairs Test 91
solicited only children in levels I and II. However, there
were three subjects who were classified at the time of data
collection as level III who were able to complete the testing.
Timed Up and Down Stairs. For the TUDS, the sub-
ject was asked to stand 30 cm from the bottom of a 14-step
flight of stairs (19.5-cm step height). Subjects were in-
structed to “Quickly, but safely go up the stairs, turn
around on the top step (landing) and come all the way
down until both feet land on the bottom step (landing).”
The subjects were allowed to choose any method of tra-
versing the stairs. This included using a step-to or foot over
foot pattern, running up the stairs, skipping steps, or any
other variation. However, all subjects faced in the direction
of the movement (faced up and down stairs, not to the side)
as they traversed the steps. There were two handrails avail-
able on the stairs, but due to the width of the stairwell, only
one handrail could be used at a time. The testing was done
wearing shoes but not orthoses. The subjects were given
the cues “ready” and “go.” The TUDS score was the time in
seconds from the “go” cue until the second foot returned to
the bottom landing. Shorter times indicated better func-
tional ability.
Timed Up and Go. Previous investigations into the
TUG with adults and children have demonstrated good
reliability and moderate to good levels of association with
other clinical measures.7,12,14 In adults, the TUG has been
shown to be correlated to gait speed, postural sway, and the
Berg Balance Scale.7 In children, the TUG has been shown
to have excellent interrater reliability in children with dis-
abilities [ICC(3,1) ⫽ 0.99]14 and is related to the index of
sway on the Pediatric Clinical Test of Sensory Interaction
in Balance14 and the mobility functional skills and care-
giver assistance sections of the Pediatric Evaluation of Dis-
ability Inventory (Pearson r ⫽ ⫺0.64 and 0.69, respective-
ly).12 The TUG score also reflects changes in functional
abilities as children age.15 Thus, the TUG is thought to
measure components related to gait speed, postural sway,
functional mobility, and balance. For the TUG measure-
ment, the child sat in an adjustable-height chair. The
height of the seat was adjusted so that the subject’s knees
and hips were flexed to 90 degrees when sitting with feet

TABLE 1
GMFCS Levels for Ages 6 to 12 Years Old (pp 221–222)13

GMFCS Description
Level I Children walk indoors and outdoors, and climb stairs
without limitations
Level II Children walk indoors and outdoors, and climb stairs
holding onto a railing but experience limitations
walking on uneven surfaces and inclines, and walking
in crowds or confined spaces
Level III Children walk indoors or outdoors on a level surface with
an assistive mobility device
Level IV Children may maintain levels of function achieved before
age 6 or rely more on wheeled mobility at home,
school, and in the community
Level V Physical impairments restrict voluntary control of
movement and the ability to maintain antigravity head
and trunk postures
Fig. 1.

92 Zaino et al Pediatric Physical Therapy

 resting on the floor. The testing was done barefoot. The
child was given a cue “ready, go.” On the “go” cue, the

[123.5–153.0]
Female Mean

10.4 (⫾1.1)

[22.7–82.3]
40.4 (⫾11)

140 (⫾5.6)
[8.0–13.7]
subject stood up, walked three meters, turned around,

(⫾SEM)
[Range]

H ⫽ 3, Hy ⫽ 0, D ⫽ 6, Q ⫽ 2
walked back, and sat down. The time in seconds was re-

5
GMFCS Level II/III
corded from the “go” cue to when the child sat down in the
chair. If the subject ran during the trial, that trial was re-
peated. Shorter times indicated better functional ability.
Functional Reach Test. In children with disabilities16

[119.5–166.0]
11.4 (⫾0.8)

38.7 (⫾5.5)
[14.5–51.4]
and without disabilities,17 the FRT has been found to dem-

149 (⫾6.4)
Male Mean

[8.1–13.6]
(⫾SEM)
[Range] onstrate good to excellent reliability. The FRT has been
6 shown to be associated with ground reaction forces during
a functional reach task in children.18 Lowes et al12 also
demonstrated a correlation between the FRT and the mo-
bility functional skills section of the Pediatric Evaluation of
Disabilities Index (Pearson r ⫽ 0.63) in children with and
[131.0–155.0]
Female Mean

139.9 (⫾5.3)
11.3 (⫾1.4)

37.8 (⫾7.9)
[28.2–61.4]
[8.1–14.9]
(⫾SEM)
[Range]

H ⫽ 5, Hy ⫽ 1, D ⫽ 3, Q ⫽ 0
without CP. The FRT score has been shown to reflect
4

changes in functional mobility and balance as children

GMFCS† Level I

age.15 Therefore, it appears that the FRT is related to func-

CP Groups

tional mobility and balance12,15 and is an indirect measure

Subject Characteristics by Subject Groups as Divided by GMFCS Levels

of strength.18 For the FRT, the subject stood with the left
Diagnoses for children cerebral palsy are hemiplegia (H), hypotonia (Hy), diplegia (D), and quadriplegia (Q); NA ⫽ not available.

arm next to a ruled grid (marked in centimeters) located at

[123.5–167.0]
143.5 (⫾7.9)
10.4 (⫾1.1)

38.8 (⫾4.7)
[28.2–52.3]
Male Mean

[8.3–14.4]

shoulder height. A 20-cm wide grid was used instead of the

(⫾SEM)
[Range]

yardstick used by Duncan et al9 because many of the chil-

5

dren had difficulty maintaining their arm level in line with

the yardstick. The use of the custom-made grid improved
the investigators’ ability to obtain accurate FRT measure-
ments. The FRT measurement was initiated by having the
[131.0–155.0]
Female Mean

139.8 (⫾5.3)
10.8 (⫾0.8)

37.8 (⫾7.9)
[28.2–61.4]

subjects elevate their arm to horizontal and make a fist. The

[8.0–14.9]
TABLE 2

(⫾SEM)
[Range]

H ⫽ 8, Hy ⫽ 1, D ⫽ 9, Q ⫽ 2

subjects were instructed to “reach as far as possible without

9

touching the wall or taking a step.” The difference between

the starting position and the final position of the third
All Children

metacarpal was measured from the grid. If the subjects

took a step or touched the wall, that trial was repeated.
Raising up on the toes was allowed as long as the child did
[123.5–167.0]
143.5 (⫾7.9)
10.9 (⫾0.7)

38.8 (⫾4.7)
[28.2–52.3]
Male Mean

[8.1–14.4]
(⫾SEM)
[Range]

not lose his or her balance and did not take a step. How-
11

ever, no child raised his or her heels more than approxi-

mately one centimeter off the floor. Testing of the FRT was
done in bare feet without shoes or orthotics. The FRT was
measured in centimeters, with longer distances indicating
better functional abilities.
[124.5–160.0]
Female Mean

10.4 (⫾0.4)

[22.7–53.2]
142 (⫾2.9)
[8.0–14.0]
37 (⫾2.7)
(⫾SEM)
[Range]

Timed One Legged Stance

N/A
14
TD Group with CP

One-legged stance time is used in some developmen-

tal assessment tools.19 –21 In addition, there is some evi-
dence that reduced one-legged stance time is associated
with limitations in the stability of the ankle and a resultant
[119.5–187.5]

limitation in postural control in children.11 Thus, TOLS

11.9 (⫾0.8)

45.7 (⫾5.4)
[8.1–14.11]

[19.1–82.7]
154 (⫾5.8)

SEM ⫽ standard error of the mean.

Male Mean
(⫾SEM)
[Range]

appears to be an important measure of functional mobility

N/A
13

and balance and is probably related to the control of the

center of gravity within the base of support. The TOLS has
been shown to have excellent interrater and test–retest
reliability.22
(years.months)

For the TOLS, the subject was barefoot and stood with
Variables

hands on hips 61 cm from a visual target (smiling face) lo-

Weight (kg)

Height (cm)
Age (years)

Diagnoses

cated at eye level on a wall. When the subject was ready, he or

Number

she would stand on the foot of choice. The knee of the other
leg was flexed to 90 degrees. During the test, the subject
would continue to focus on the visual target. If the subject’s

Pediatric Physical Therapy Timed Up and Down Stairs Test 93

nonstance foot started to drop causing less than 80 degrees of TABLE 3
knee flexion, a verbal cue to lift his or her foot was provided. Mean and Range of Values for the Clinical Measures of Mobility and
The knees were allowed to touch during the testing, but the Balance by Children as Divided by the GMFCS Levels
nonstance foot was not allowed to rest against the stance leg. Mean
The timing was started when the nonstance foot lifted off the Measure Median (⫾ SEM) Minimum Maximum
floor, and the timing was stopped if the subject lifted his or her TD group (N ⫽ 27)
hands off his or her hips, looked down at his or her feet, or TUDS (sec) 8.1 8.1 (⫾0.27) 6.3 12.6
touched the floor with the opposite foot. This method of tim- TUG (sec) 5.0 5.2 (⫾0.13) 4.4 6.7
ing of the TOLS has been shown to be reliable (rs ⫽ 0.91 to FRT (cm) 35.0 35.1 (⫾1.35) 22.0 50.0
TOLS (sec) 45.0 44.8 (⫾0.25) 38.2 45.0
0.99).22 The TOLS was timed for a maximum of 45 seconds. It
was hypothesized based on previous testing22 that any time GMFCS level I (N ⫽ 9)
TUDS (sec) 13.0 15.5 (⫾2.40) 8.0 27.4
greater than 45 seconds would not discriminate between sub-
TUG (sec) 6.1 6.2 (⫾0.37) 5.0 8.4
jects’ functional abilities. The TOLS was measured in seconds FRT (cm) 29 29 (⫾1.60) 19.0 35.0
with longer times reflecting better balance ability. TOLS (sec) 17.3 19.9 (⫾5.80) 1.0 45.0
GMFCS levels II/III (N ⫽ 11)
Procedures
TUDS (sec) 21.6 24.5 (⫾3.83) 15.9 56.1
The clinical measures of functional mobility and bal- TUG (sec) 8.0 8.24 (⫾0.38) 6.1 10.7
ance were measured in a random order determined FRT (cm) 25.0 22.8 (⫾2.6) 6.0 35
TOLS (sec) 1.3 6.92 (⫾12.4) 0.0 37.3
through use of a random numbers table. Two pediatric
physical therapists (C.A.Z., V.G.M.) did all the testing. SEM ⫽ Standard error of the mean.
They had 16 and eight years of experience in physical ther-
apy and 10 and eight years in pediatrics, respectively. simultaneously by the two investigators to determine in-
These investigators had also been trained in the use of the terrater reliability. The two investigators stood where they
tests. The principal investigator (C.A.Z.) had two years of could see the child perform the test but could not see the
training with the tests used and had evaluated more than other investigator’s recordings. Test–retest reliability was
50 children with the tests. The other investigator (V.G.M.) examined by having 24 subjects return for a second testing
was trained in the measurements used for this study prior by the principal investigator two hours later, after complet-
to data collection. Raters also determined the GMFCS level ing the other portion of the study. During the interrater and
and recorded the child’s age. For all the measures of func- test–retest reliability measures, the primary investigator
tional mobility and balance, the better of two trials was did not have the original records available and the time
used in the analyses. Rest breaks were given to the children between the testing was long enough that the investigator
as needed during the testing. was not able to remember the initial scores. The interrater
Reliability of all measures was examined by using sub- reliability of the GMFCS was determined on a subgroup of
groups of the subjects who participated in the study. Twen- nine subjects. Each investigator separately rated the child
ty-five of these children were filmed performing all the after he or she had been at the study site for approximately
tests of functional mobility and balance. These 25 children 20 minutes.
were scored in real time and then rescored later from the
video by the same rater (C.A.Z.) to determine intrarater Data Analysis
reliability. Nine of the children were scored in real time The interrater, intrarater, and test–retest reliabilities
of the TUDS and other tests were analyzed using intraclass
correlation coefficients, ICC(2,1). The percentage of agree-
ment was used to determine the interrater reliability of the
GMFCS scores. The concurrent validity of the TUDS was
evaluated using Spearman correlations between the TUDS
and the TUG, FRT, and TOLS for the children with TD and
CP separately. The Spearman correlation analysis was used
due to skewed data. To determine whether the TUDS mea-
sured differences in functional mobility and balance across
age (construct validity), Spearman correlations between
age and TUDS scores were performed separately for the TD
and CP subject groups. Also, Kruskal-Wallis analysis of
variance (K-W ANOVA), followed by pair-wise testing us-
ing the Mann-Whitney U test, was run on the TD and CP
group data separately, between the three age groups (eight
to 10, 11 to 12, 13 to 14 years old). Last, to establish
construct validity across all the children based on func-
tional mobility and balance, a K-W ANOVA with Mann-
Fig. 2. Whitney U tests were used again. For this analysis, the

94 Zaino et al Pediatric Physical Therapy

 TABLE 4
TUDS Measure in Seconds by Age Group

TD Group CP Group
Age (y) N Mean (⫾ SEM) Median Range N Mean (⫾ SEM) Median Range
8–10 14 8.8 (⫾0.4) 8.3 7.4–12.6 10 23.6 (⫾4.0) 22.2 9.1–56.1
11–12 6 7.6 (⫾0.6) 7.1 6.3–10.3 6 23.1 (⫾5.3) 19.9 8.2–40.1
13–14 7 7.3 (⫾0.3) 7.5 6.3–8.3 4 14.2 (⫾2.5) 14.5 8.0–19.9
SEM ⫽ Standard error of the mean.

TABLE 5 Concurrent Validity

Spearman Rank Correlation of the TUDS with the Other Clinical Correlations between all the tests of functional mobil-
Measures of Functional Mobility and Balance
ity and balance are presented in Table 5. For all subjects,
TUDS the relationship between the TUDS and the other tests of
All TD CP functional mobility and balance (TUG, FRT, and TOLS)
Subjects Group Group demonstrated moderate to good relationships23 (rs ⫽ 0.78,
Clinical Measure (N ⫽ 47) (N ⫽ 27) (N ⫽ 20) ⫺0.57, ⫺0.77; p ⬍ 0.001, respectively). In the TD group,
TUG 0.78* 0.33 0.68* none of the relationships were significant. However, the
FRT ⫺0.57* ⫺0.32 ⫺0.27 TUDS with TUG and FRT did approach significance (rs ⫽
TOLS ⫺0.77* ⫺0.28 ⫺0.41 0.33, p ⫽ 0.046 and rs ⫽ ⫺0.32, p ⫽ 0.053, respectively).
* p ⬍ 0.02. The relationships within the CP group were stronger. The
correlation between the TUDS and the TUG was moderate
(rs ⫽ 0.68, p ⫽ 0.001). The correlation between the TUDS
children were divided into three groups, children with TD, and the TOLS approached significance (rs ⫽ ⫺0.41, p ⫽
children with CP rated level I on the GMFCS, and children 0.038).
with CP rated at levels II and III on the GMFCS. In both
instances, nonparametric tests were used due to unequal Construct Validity
sample sizes and lack of homogeneity of variance across the
The correlation between the TUDS and age was mod-
age and functional groups. For all analyses, an ␣ level of
erate and significant for both the TD and CP groups (rs ⫽
0.10 was used. This was chosen due to the preliminary
⫺0.61, and ⫺0.41, p ⬍ 0.001 and 0.018, respectively). The
nature of this study, the relatively small sample size, and
relationship was not as strong in the CP group; however,
the minimal risk of harm from a type I error. To guard
the relationship with the higher functioning children with
against inflation of type I error, a Bonferroni correction was
CP (GFMCS level I) was stronger (rs ⫽ ⫺0.75, p ⫽ 0.010).
used for each subject group when multiple comparisons or
The K-W ANOVA results showed a statistically significant
correlations were completed. This resulted in an ␣ level of
difference between age groups for the TD group but not for
0.02. All data analyses were done using SPSS version 10
the CP group [␹2(2) ⫽ 9.80, p ⫽ 0.007 and ␹2(2) ⫽ 3.15, p
statistical software (SPSS Inc., Chicago, IL).
⫽ 0.208, respectively]. Pair-wise analyses of the TD group
with the Mann-Whitney U test demonstrated a significant
RESULTS difference between the eight- to 10- and the 11- to 12-
Descriptive Data year-old groups (p ⫽ 0.020), the eight- to 10- and the 13- to
14-year-old group (p ⫽ 0.001) but not between the 11- to
The mean and 95% confidence interval for the TUDS
12- and 13- to 14-year-old groups (p ⫽ 0.423). A K-W
for the three functional groups divided by GMFCS are pre-
ANOVA demonstrated differences between the TUDS
sented in Figure 2. The mean and standard error of the
scores and three groups of children using the TD group and
mean are presented for all the tests of functional mobility
two CP groups based on GMFCS levels [␹2(2) ⫽ 28.5, p ⬍
and balance in Table 3. Table 4 includes descriptive data on
0.001]. Based on Mann-Whitney pair-wise testing, there
the TUDS across three age levels: eight to 10, 11 to 12, and
were statistically significant differences found between all
13 to 14 years.
groups (p ⬍ 0.02).

Reliability
Intrarater reliability and interrater reliability were ex-
cellent. For all tests, except FRT, the ICC(2,1) equaled
0.99. For the FRT, the intrarater reliability and interrater
reliability were ICC(2,1) ⫽ 0.97 and 0.98, respectively.
The test–retest reliability of the TUDS was also excellent
[ICC(2,1) ⫽ 0.94]. The percentage of agreement for inter-
rater reliability of the GMFCS was 100%.
DISCUSSION
Reliability
The study data demonstrate that excellent intrarater,
interrater, and test–retest reliability can be achieved for the
TUDS, comparing one experienced physical therapy rater
to a physical therapy rater who was trained briefly in the
test procedures. The findings of the current study also are

Pediatric Physical Therapy Timed Up and Down Stairs Test 95

in agreement with those of previous studies on the in-
trarater, interrater, and test–retest reliability of the TUG,8
TOLS,22 and FRT.17 Given these results, it is appropriate to
proceed with further evaluation of the validity of the
TUDS.
Descriptive Data
The TUDS scores for the TD group averaged to 0.58
sec/step for ascending/descending. This average is almost
half of the 1.11 sec/step for children with CP, GMFCS level
I and one third of the 1.75 sec/step for children with CP,
GMFCS level II/III. It would appear that use of this mea-
sure could be an easy method of monitoring change across
time or with therapy. However, the responsiveness of the
TUDS is yet to be determined.
The TUG scores in the TD group are similar to those
found in children from Pakistan at similar ages15 and also
are similar to children as young as six years (mean TUG
times, 5.45).14 Children with CP at GMFCS level I scored
an average of one second higher and children with CP at
GMFCS level II scored an average of three seconds higher
than the children with TD. This small spread in the scores
perhaps reflects the easier nature of the TUG task and sug-
gests that use of the TUG to document differences between
children or across time may be better for children with
more severe mobility problems.
The TD group FRT scores in this study were greater
(approximately 3 cm in the eight- to 10-year-old group and
approximately 6 to 7 cm in the 11- to 12- and 13- to 14-
year-old groups) than previously recorded for children
with TD, but many of the children with CP demonstrated
values that placed them in a “delayed reaching skills” cat-
egory as designated by Donahoe et al.17 Children with CP
and GMFCS level I reached an average of six centimeters
less than the TD group, and those children in the GMFCS
levels II/III reached 12 cm less than the TD group. This
spread of the data across the functional groups suggests
that the FRT also may be a useful test for monitoring
change across time or with intervention.
The TOLS scores demonstrated that most children in
the TD group could stand the maximum of 45 seconds.
Times in the GMFCS level I group dropped dramatically to
an average of 24.9 seconds less than the TD group. There
was an additional drop in the times for the GMFCS level
II/III group. This group decreased an average of 37.9 sec-
onds compared with the TD group. In contrast to the min-
imal spread of the TUG scores, the TOLS test may be too
difficult for many of the children with CP. It may be useful
in the monitoring of children with CP who are functioning
at a very high level.
Concurrent Validity
The initial evaluation of the concurrent validity com-
paring TUDS scores to the TUG, FRT, and TOLS yielded
mixed results. When all subjects were analyzed together,
all the tests were moderately and significantly related, sug-
gesting that static control of balance (TOLS), anticipatory
control of balance (FRT) and strength, and balance for
96 Zaino et al
dynamic movement from sit-to-stand, walking, and turn-
ing on a level surface (TUG) were all related components of
the TUDS task. As previously stated, the TUG has been
shown to be related to measures of functional mobility and
balance along with postural sway measures. These compo-
nents likely include sensory processing to control of the
center of gravity as indicated by the TUG’s relationship to
postural sway and scores on the Pediatric Clinical Test of
Sensory Interaction of Balance.14 The 61% variation in the
TUDS scores accounted for by the TUG scores supports
that the TUDS likely measures the constructs of postural
sway control. The control of the center of gravity within the
base of support is also supported by the higher relationship
between the TUDS and the TOLS (59% of the variance).
When the TD and CP subject groups were analyzed
separately, however, none of the clinical tests of functional
mobility and balance were significantly related to the
TUDS in the TD group. The TUDS was moderately corre-
lated with the TUG in the CP group. The difference in the
correlations between all subjects and when separated into
the TD and CP group separately appears to be due, in part,
to a more normal distribution in these data across the test
range when all subjects were combined. This resulted
mathematically in higher correlations. The children with
TD tended to cluster at the more functional end of the plots
(lower ends for TUG and higher ends for FRT and TOLS).
This was particularly true for the TOLS, where almost all
the children with TD topped out at the 45-second maxi-
mum. For the children with CP, the data were spread out
more but did tend to group at the less functional ends of the
plots.
As Lepage et al24 determined, differences in a timed
stair task better represented different abilities to perform
various types of activities of daily living than did gait speed
on level surfaces. Thus, it was expected that the TUDS
might represent functional mobility and balance better
than the TUG. Even though these two tests show a moder-
ate to high relationship in the subjects used in this study,
the stair-climbing component may better measure differ-
ences in strength, balance, and neuromuscular coordina-
tion than does the TUG in this type of child. This is dem-
onstrated to some extent in the larger difference in scores
across the functional mobility groups noted above for the
TUDS compared with the TUG. The variance in the TUDS
accounted for by the TUG was also only 11% and 46% for
the children with TD and CP, respectively, demonstrating
some similarities but also differences between the two
measures.
The FRT showed only a moderate relationship with
the TUDS in all subjects combined, which may reflect a
component for better anticipatory postural control to ne-
gotiate stairs more quickly. There may well be a cutoff
point in functional reach distance representing adequate
anticipatory postural control for fast stair climbing and
descending. However, the lower correlation when the CP
and TD groups were analyzed separately is curious and
suggests that the two tests are measuring different aspects
of more static and dynamic balance.
Pediatric Physical Therapy
 The TOLS correlated highly with the TUDS when the
whole group was analyzed but showed low and nonsignif-
icant relationships when the TD and CP groups were sep-
arately analyzed. The data for the TOLS as noted above by
functional groups were variable. The TUDS requires fast
dynamic movement, which does not require long bouts of
one foot standing balance; rather, the person must move
quickly through the one foot balance phase for fast stair
climbing and descending. As with the FRT, there may be a
cutoff point in one foot balance ability that is necessary for
fast stair-climbing negotiation, which was present in the
TD group and variable in the CP group.
Construct Validity
Functional mobility and balance are known to change
as children age.25 In children with TD, changes in age were
related to changes in the TUDS (37% of variance), and
there was a statistically significant difference between the
youngest age group and the two older age groups. Age
accounted for a smaller portion of the variance in the TUDS
scores in all the children with CP (22% of variance). How-
ever, if just the age and TUDS scores for the higher func-
tioning children with CP (GMFCS level I) were examined,
a greater portion of the variance was accounted for by the
child’s age (56% of variance). This high relationship was
not true for the children with CP in the lowest functional
mobility group, and comparison between age groups in the
children with CP also did not show any statistically signif-
icant differences. However, with a larger sample, a signifi-
cant difference between the 8- to 10- and the 13- to 14-
year-old children may have been revealed, as the median
scores were 7.7 seconds different between these groups.
Further testing with larger groups would be necessary to
confirm this.
Considering these data, the correlations within each
separate group (CP and TD) may have been higher if the
age range of subjects was increased. Palisano et al24 have
developed some preliminary growth curves in children
with CP across different levels of functional abilities. These
growth curves were linear initially at the younger ages and
then became curvilinear at the older ages when develop-
ment plateaus. Typical development also follows a similar
pattern.24 This type of developmental pattern may also be
present in the relationship between TUDS scores and age.
Nonlinear approaches to correlations may need to be con-
sidered as the age of the subjects increases.
Age is only one of many factors related to changes in
functional mobility and balance. This is supported by the
relatively small amount of variance in the TUDS score ac-
counted for by age, especially in the subjects with CP.
Children with CP have other impairments affecting the
development of movement related to their original central
nervous system insult and subsequent changes in the mus-
culoskeletal system due to altered movement patterns. It
was our hypothesis that the TUDS would reflect changes in
children’s functional mobility and balance and when func-
tional abilities were measured more directly using the GM-
FCS to assign subjects to groups. Our analysis did reveal
Pediatric Physical Therapy
differences in the TUDS scores across all three functional
groups of children.
CONCLUSION
The Guide to Physical Therapist Practice4 emphasizes
the need to evaluate the reliability and validity of tests and
measurements and weigh the time to administer, cost of
administering, and subject’s tolerance of a test or measure
when determining the suitability of a measure for a partic-
ular subject population. The TUDS has been demonstrated
to be an quick, low-cost, reliable test for children with and
without CP aged eight to 14 years. The TUDS also appears
to have preliminary concurrent validity and construct va-
lidity. Concurrent validity was highest with the TUG test;
however, the TUDS shows a greater range of scores across
functional mobility levels and therefore may be a better
measure of change across time or with intervention. The
TUDS appears to account for variation in developmental
and functional abilities as tested by differences across age
and functional mobility categories based on GMFCS rat-
ings. We suggest that the TUDS is a simple measure of
functional mobility that can be easily done in a variety of
settings and should be considered for testing and poten-
tially documenting improvement of children with sus-
pected limitations in functional mobility and balance.
However, there is a need for further study with subjects
who have a greater range in age and functional mobility
and balance. Responsivity of the measure should also be
evaluated to determine the usefulness of the test to mea-
sure clinically meaningful change across time or with
intervention.
ACKNOWLEDGMENTS
We gratefully acknowledge the generous donations of
prizes for the children provided by Young’s Medical Equip-
ment, Landsdown, PA; Aetna/US HealthCare, Blue Bell,
PA; Theradyne, Jordon, MN; and Sundance Rehabilitation
Corporation, Atlanta, GA. We also are grateful to Dr Peter
Pizzutillo of St. Christopher’s Hospital of Philadelphia for
his assistance in subject recruitment.
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