Differences in Sensitivity and Specificity of the Time Up and Go Test and Berg Balance Scale in Assessing the Risk of Falls in Chronic Heart Failure Patients with Systolic Dysfunction
Article Sidebar
Published:
Jun 17, 2025
Keywords:
Time Up and Go, Berg Balance Scale, heart failure, risk of falls
Main Article Content
Abstract
Introduction: Chronic heart failure (HF) patients face increased fall risks due to muscle dysfunction and balance impairment. The Time Up and Go (TUG) and the Berg Balance Scale (BBS) are the tests that have been developed to assess the risk of falls in general population, but research specifically investigating their sensitivity and specificity in chronic HF patients remains scarce.
Methods: This study was a cross-sectional study aimed at assessing the sensitivity and specificity of the TUG and BBS for risk of fall, performed using the Receiver Operating Characteristic (ROC) curve, involving patients from the Cardiology Department of Brawijaya University Hospital aged 21 to 60 years who were diagnosed with chronic HF with systolic dysfunction.
Results: Analysis of 32 participants with average age of 56 years showed TUG’s area under the curve (AUC) was 0.85 (95% CI 0.5 – 1), with cut-off at 11.22 seconds, with 75.00% sensitivity, and 96.43% specificity. Meanwhile, BBS had an AUC of 0.72 (95% CI 0.4 - 1), with 71.43% sensitivity, and 75.00% specificity respectively with cutoff at 56.
Conclusion: TUG demonstrated superior sensitivity and specificity compared to BBS, making it a preferred tool for identifying fall risk in chronic HF with systolic dysfunction.
Methods: This study was a cross-sectional study aimed at assessing the sensitivity and specificity of the TUG and BBS for risk of fall, performed using the Receiver Operating Characteristic (ROC) curve, involving patients from the Cardiology Department of Brawijaya University Hospital aged 21 to 60 years who were diagnosed with chronic HF with systolic dysfunction.
Results: Analysis of 32 participants with average age of 56 years showed TUG’s area under the curve (AUC) was 0.85 (95% CI 0.5 – 1), with cut-off at 11.22 seconds, with 75.00% sensitivity, and 96.43% specificity. Meanwhile, BBS had an AUC of 0.72 (95% CI 0.4 - 1), with 71.43% sensitivity, and 75.00% specificity respectively with cutoff at 56.
Conclusion: TUG demonstrated superior sensitivity and specificity compared to BBS, making it a preferred tool for identifying fall risk in chronic HF with systolic dysfunction.
Article Details
How to Cite
Suariastawa Putra, M., Rahmad, Syavitri Dhamayanti, A., Triangto, I., Ridwan, M., Witjaksono, D., & Waranugraha, Y. (2025). Differences in Sensitivity and Specificity of the Time Up and Go Test and Berg Balance Scale in Assessing the Risk of Falls in Chronic Heart Failure Patients with Systolic Dysfunction. Indonesian Journal of Physical Medicine and Rehabilitation, 14(1), 67 - 79. https://doi.org/10.36803/indojpmr.v14i1.441
Section
Case Report
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
- The authors agree to transfer the transfer copyright of the article to Indonesian Journal of Physical Medicine and Rehabilitation effective if and when the paper is accepted for publication.
- Legal formal aspect of journal publication accessibility refers to Creative Commons Attribution-NonCommercial (CC BY-NC), implies that publication can be used for non-commercial purposes.
- Every publications (printed/electronic) are open access for educational purposes, research, and library. Other that the aims mentioned above, editorial board is not responsible for copyright violation.
Indonesian Journal of Physical Medicine and Rehabilitation is licensed under a https://creativecommons.org/licenses/by-nc/4.0/
References
1. Bloom MW, Greenberg B, Jaarsma T, et al. Heart failure with reduced ejection fraction. Nat Rev Dis Prim [Internet]. 2017;3:1–20. Available from: http://dx.doi.org/10.1038/nrdp.2017.58
2. Lee K, Davis MA, Marcotte JE, et al. Falls in community-dwelling older adults with heart failure: A retrospective cohort study. Hear Lung [Internet]. 2020;49:238–50. Available from: https://linkinghub.elsevier.com/retrieve/pii/S014795631930559X
3. Groenewegen A, Rutten FH, Mosterd A, et al. Epidemiology of heart failure. Eur J Heart Fail [Internet]. 2020;22:1342–56. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1858
4. McCoy J, Bates M, Eggett C, et al. Pathophysiology of exercise intolerance in chronic diseases: the role of diminished cardiac performance in mitochondrial and heart failure patients. Open Hear [Internet]. 2017;4:e000632. Available from: https://openheart.bmj.com/lookup/doi/10.1136/openhrt-2017-000632
5. Lee K, Pressler SJ, Titler M. Falls in Patients With Heart Failure. J Cardiovasc Nurs [Internet]. 2016;31:555–61. Available from: https://journals.lww.com/00005082-201611000-00012
6. Benavent-Caballer V. The Effectiveness of Exercise Interventions and The Factors Associated with The Physical Performance in Older Adult. University CEU Cardenal Herrera; 2016.
7. Muir-Hunter SW, Graham L, Montero Odasso M. Reliability of the Berg Balance Scale as a Clinical Measure of Balance in Community-Dwelling Older Adults with Mild to Moderate Alzheimer Disease: A Pilot Study. Physiother Canada [Internet]. 2015;67:255–62. Available from: https://utpjournals.press/doi/10.3138/ptc.2014-32
8. Bennie S, Bruner K, Dizon A, et al. Measurements of Balance: Comparison of the Timed “Up and Go” Test and Functional Reach Test with the Berg Balance Scale. J Phys Ther Sci [Internet]. 2003;15:93–7. Available from: http://www.jstage.jst.go.jp/article/jpts/15/2/15_2_93/_article
9. Chan PP, Si Tou JI, Tse MM, et al. Reliability and Validity of the Timed Up and Go Test With a Motor Task in People With Chronic Stroke. Arch Phys Med Rehabil [Internet]. 2017;98:2213–20. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0003999317302216
10. Hohtari-Kivimäki U, Salminen M, Vahlberg T, et al. Short Berg Balance Scale, BBS-9, as a predictor of fall risk among the aged: a prospective 12-month follow-up study. Aging Clin Exp Res [Internet]. 2013;25:645–50. Available from: http://link.springer.com/10.1007/s40520-013-0159-x
11. Lam CSP. Heart failure in Southeast Asia: facts and numbers. ESC Hear Fail [Internet]. 2015;2:46–9. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ehf2.12036
12. Cediel G, Codina P, Spitaleri G, et al. Gender-Related Differences in Heart Failure Biomarkers. Front Cardiovasc Med [Internet]. 2021;7. Available from: https://www.frontiersin.org/articles/10.3389/fcvm.2020.617705/full
13. Carbone S, Lavie CJ, Elagizi A, et al. The Impact of Obesity in Heart Failure. Heart Fail Clin [Internet]. 2020;16:71–80. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1551713619300923
14. Bornstein AB, Rao SS, Marwaha K. Left Ventricular Hypertrophy. StatPearls [Internet] [Internet]. 2023; Available from: https://www.ncbi.nlm.nih.gov/books/NBK557534/
15. Gopinathannair R, Chen LY, Chung MK, et al. Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association. Circ Arrhythmia Electrophysiol [Internet]. 2021;14. Available from: https://www.ahajournals.org/doi/10.1161/HAE.0000000000000078
16. Hajouli S, Ludhwani D. Heart Failure And Ejection Fraction. StatPearls [Internet]. 2021 [cited 2022 Feb 11]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK553115/
17. van Poelgeest EP, Handoko ML, Muller M, et al. Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review. Eur Geriatr Med [Internet]. 2023;14:659–74. Available from: https://link.springer.com/10.1007/s41999-023-00752-7
18. Agyemang AA. Social (Pragmatic) Communication Disorder. In: Encyclopedia of Clinical Neuropsychology [Internet]. Cham: Springer International Publishing; 2018. p. 3204–6. Available from: http://link.springer.com/10.1007/978-3-319-57111-9_9172
19. Denfeld QE, Winters-Stone K, Mudd JO, et al. The prevalence of frailty in heart failure: A systematic review and meta-analysis. Int J Cardiol [Internet]. 2017;236:283–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0167527316329771
20. Pandey A, Kitzman D, Reeves G. Frailty Is Intertwined With Heart Failure. JACC Hear Fail [Internet]. 2019;7:1001–11. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2213177919307966
21. Zhang Y, Zhang J, Ni W, et al. Sarcopenia in heart failure: a systematic review and meta‐analysis. ESC Hear Fail [Internet]. 2021;8:1007–17. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ehf2.13255
22. Landi F, Liperoti R, Russo A, et al. Sarcopenia as a risk factor for falls in elderly individuals: Results from the ilSIRENTE study. Clin Nutr [Internet]. 2012;31:652–8. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0261561412000362
23. Umehara T, Kaneguchi A, Yamasaki T, et al. Reduced upper and lower limb muscle strengths without reduced skeletal muscle in elderly patients with heart failure. J Rural Med [Internet]. 2023;18:2022–9. Available from: https://www.jstage.jst.go.jp/article/jrm/18/1/18_2022-029/_article
24. Moore DS. The Activities-specific Balance Confidence ( ABC ) Scale. Res Q Exerc Sport. 2011;50:545–54.
25. Barry E, Galvin R, Keogh C, et al. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta- analysis. BMC Geriatr [Internet]. 2014;14:14. Available from: https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-14
26. Hafsteinsdóttir TB, Rensink M, Schuurmans M. Clinimetric Properties of the Timed Up and Go Test for Patients With Stroke: A Systematic Review. Top Stroke Rehabil [Internet]. 2014;21:197–210. Available from: http://www.tandfonline.com/doi/full/10.1310/tsr2103-197
27. Liwsrisakun C, Pothirat C, Chaiwong W, et al. Diagnostic ability of the Timed Up & Go test for balance impairment prediction in chronic obstructive pulmonary disease. J Thorac Dis [Internet]. 2020;12:2406–14. Available from: http://jtd.amegroups.com/article/view/38169/html
28. Choung R, Talley N. Epidemiology and Clinical Presentation of Stress-Related Peptic Damage and Chronic Peptic Ulcer. Curr Mol Med. 2008;8:253–7.
29. Hwang R, Morris NR, Mandrusiak A, et al. Timed Up and Go Test: A Reliable and Valid Test in Patients With Chronic Heart Failure. J Card Fail [Internet]. 2016;22:646–50. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1071916415011240
30. Herman T, Giladi N, Hausdorff JM. Properties of the ‘Timed Up and Go’ Test: More than Meets the Eye. Gerontology [Internet]. 2011;57:203–10. Available from: https://www.karger.com/Article/FullText/314963
31. Lima CA, Ricci NA, Nogueira EC, et al. The Berg Balance Scale as a clinical screening tool to predict fall risk in older adults: a systematic review. Physiotherapy [Internet]. 2018;104:383–94. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0031940618300324
32. Park S-H, Lee Y-S. The Diagnostic Accuracy of the Berg Balance Scale in Predicting Falls. West J Nurs Res [Internet]. 2017;39:1502–25. Available from: http://journals.sagepub.com/doi/10.1177/0193945916670894
33. Lajoie Y, Gallagher S. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr [Internet]. 2004;38:11–26. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0167494303000827
34. Chen H, Smith SS. Item Distribution in the Berg Balance Scale: A Problem for Use With Community-Living Older Adults. J Geriatr Phys Ther [Internet]. 2019;42:275–80. Available from: https://journals.lww.com/10.1519/JPT.0000000000000208
35. Wang, YC, Sindhu B, Lehman L, Li X, Yen SC, Kapellusch J [Internet]. 2018. Rasch Analysis of the Activities-Specific Balance Confidence Scale in Older Adults Seeking Outpatient Rehabilitation Services. Journal of Orthopaedic & Sports Physical Therapy, 48(7), 574-583. Doi:10.2519/jospt.2018.8023.
36. Mak MK, Pang MY. Balance confidence and functional mobility are independently associated with falls in people with Parkinson's disease. J Neurol. 2009 May;256(5):742-9. doi: 10.1007/s00415-009-5007-8. Epub 2009 Feb 25. PMID: 19240961.
2. Lee K, Davis MA, Marcotte JE, et al. Falls in community-dwelling older adults with heart failure: A retrospective cohort study. Hear Lung [Internet]. 2020;49:238–50. Available from: https://linkinghub.elsevier.com/retrieve/pii/S014795631930559X
3. Groenewegen A, Rutten FH, Mosterd A, et al. Epidemiology of heart failure. Eur J Heart Fail [Internet]. 2020;22:1342–56. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1858
4. McCoy J, Bates M, Eggett C, et al. Pathophysiology of exercise intolerance in chronic diseases: the role of diminished cardiac performance in mitochondrial and heart failure patients. Open Hear [Internet]. 2017;4:e000632. Available from: https://openheart.bmj.com/lookup/doi/10.1136/openhrt-2017-000632
5. Lee K, Pressler SJ, Titler M. Falls in Patients With Heart Failure. J Cardiovasc Nurs [Internet]. 2016;31:555–61. Available from: https://journals.lww.com/00005082-201611000-00012
6. Benavent-Caballer V. The Effectiveness of Exercise Interventions and The Factors Associated with The Physical Performance in Older Adult. University CEU Cardenal Herrera; 2016.
7. Muir-Hunter SW, Graham L, Montero Odasso M. Reliability of the Berg Balance Scale as a Clinical Measure of Balance in Community-Dwelling Older Adults with Mild to Moderate Alzheimer Disease: A Pilot Study. Physiother Canada [Internet]. 2015;67:255–62. Available from: https://utpjournals.press/doi/10.3138/ptc.2014-32
8. Bennie S, Bruner K, Dizon A, et al. Measurements of Balance: Comparison of the Timed “Up and Go” Test and Functional Reach Test with the Berg Balance Scale. J Phys Ther Sci [Internet]. 2003;15:93–7. Available from: http://www.jstage.jst.go.jp/article/jpts/15/2/15_2_93/_article
9. Chan PP, Si Tou JI, Tse MM, et al. Reliability and Validity of the Timed Up and Go Test With a Motor Task in People With Chronic Stroke. Arch Phys Med Rehabil [Internet]. 2017;98:2213–20. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0003999317302216
10. Hohtari-Kivimäki U, Salminen M, Vahlberg T, et al. Short Berg Balance Scale, BBS-9, as a predictor of fall risk among the aged: a prospective 12-month follow-up study. Aging Clin Exp Res [Internet]. 2013;25:645–50. Available from: http://link.springer.com/10.1007/s40520-013-0159-x
11. Lam CSP. Heart failure in Southeast Asia: facts and numbers. ESC Hear Fail [Internet]. 2015;2:46–9. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ehf2.12036
12. Cediel G, Codina P, Spitaleri G, et al. Gender-Related Differences in Heart Failure Biomarkers. Front Cardiovasc Med [Internet]. 2021;7. Available from: https://www.frontiersin.org/articles/10.3389/fcvm.2020.617705/full
13. Carbone S, Lavie CJ, Elagizi A, et al. The Impact of Obesity in Heart Failure. Heart Fail Clin [Internet]. 2020;16:71–80. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1551713619300923
14. Bornstein AB, Rao SS, Marwaha K. Left Ventricular Hypertrophy. StatPearls [Internet] [Internet]. 2023; Available from: https://www.ncbi.nlm.nih.gov/books/NBK557534/
15. Gopinathannair R, Chen LY, Chung MK, et al. Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association. Circ Arrhythmia Electrophysiol [Internet]. 2021;14. Available from: https://www.ahajournals.org/doi/10.1161/HAE.0000000000000078
16. Hajouli S, Ludhwani D. Heart Failure And Ejection Fraction. StatPearls [Internet]. 2021 [cited 2022 Feb 11]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK553115/
17. van Poelgeest EP, Handoko ML, Muller M, et al. Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review. Eur Geriatr Med [Internet]. 2023;14:659–74. Available from: https://link.springer.com/10.1007/s41999-023-00752-7
18. Agyemang AA. Social (Pragmatic) Communication Disorder. In: Encyclopedia of Clinical Neuropsychology [Internet]. Cham: Springer International Publishing; 2018. p. 3204–6. Available from: http://link.springer.com/10.1007/978-3-319-57111-9_9172
19. Denfeld QE, Winters-Stone K, Mudd JO, et al. The prevalence of frailty in heart failure: A systematic review and meta-analysis. Int J Cardiol [Internet]. 2017;236:283–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0167527316329771
20. Pandey A, Kitzman D, Reeves G. Frailty Is Intertwined With Heart Failure. JACC Hear Fail [Internet]. 2019;7:1001–11. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2213177919307966
21. Zhang Y, Zhang J, Ni W, et al. Sarcopenia in heart failure: a systematic review and meta‐analysis. ESC Hear Fail [Internet]. 2021;8:1007–17. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ehf2.13255
22. Landi F, Liperoti R, Russo A, et al. Sarcopenia as a risk factor for falls in elderly individuals: Results from the ilSIRENTE study. Clin Nutr [Internet]. 2012;31:652–8. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0261561412000362
23. Umehara T, Kaneguchi A, Yamasaki T, et al. Reduced upper and lower limb muscle strengths without reduced skeletal muscle in elderly patients with heart failure. J Rural Med [Internet]. 2023;18:2022–9. Available from: https://www.jstage.jst.go.jp/article/jrm/18/1/18_2022-029/_article
24. Moore DS. The Activities-specific Balance Confidence ( ABC ) Scale. Res Q Exerc Sport. 2011;50:545–54.
25. Barry E, Galvin R, Keogh C, et al. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta- analysis. BMC Geriatr [Internet]. 2014;14:14. Available from: https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-14
26. Hafsteinsdóttir TB, Rensink M, Schuurmans M. Clinimetric Properties of the Timed Up and Go Test for Patients With Stroke: A Systematic Review. Top Stroke Rehabil [Internet]. 2014;21:197–210. Available from: http://www.tandfonline.com/doi/full/10.1310/tsr2103-197
27. Liwsrisakun C, Pothirat C, Chaiwong W, et al. Diagnostic ability of the Timed Up & Go test for balance impairment prediction in chronic obstructive pulmonary disease. J Thorac Dis [Internet]. 2020;12:2406–14. Available from: http://jtd.amegroups.com/article/view/38169/html
28. Choung R, Talley N. Epidemiology and Clinical Presentation of Stress-Related Peptic Damage and Chronic Peptic Ulcer. Curr Mol Med. 2008;8:253–7.
29. Hwang R, Morris NR, Mandrusiak A, et al. Timed Up and Go Test: A Reliable and Valid Test in Patients With Chronic Heart Failure. J Card Fail [Internet]. 2016;22:646–50. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1071916415011240
30. Herman T, Giladi N, Hausdorff JM. Properties of the ‘Timed Up and Go’ Test: More than Meets the Eye. Gerontology [Internet]. 2011;57:203–10. Available from: https://www.karger.com/Article/FullText/314963
31. Lima CA, Ricci NA, Nogueira EC, et al. The Berg Balance Scale as a clinical screening tool to predict fall risk in older adults: a systematic review. Physiotherapy [Internet]. 2018;104:383–94. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0031940618300324
32. Park S-H, Lee Y-S. The Diagnostic Accuracy of the Berg Balance Scale in Predicting Falls. West J Nurs Res [Internet]. 2017;39:1502–25. Available from: http://journals.sagepub.com/doi/10.1177/0193945916670894
33. Lajoie Y, Gallagher S. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr [Internet]. 2004;38:11–26. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0167494303000827
34. Chen H, Smith SS. Item Distribution in the Berg Balance Scale: A Problem for Use With Community-Living Older Adults. J Geriatr Phys Ther [Internet]. 2019;42:275–80. Available from: https://journals.lww.com/10.1519/JPT.0000000000000208
35. Wang, YC, Sindhu B, Lehman L, Li X, Yen SC, Kapellusch J [Internet]. 2018. Rasch Analysis of the Activities-Specific Balance Confidence Scale in Older Adults Seeking Outpatient Rehabilitation Services. Journal of Orthopaedic & Sports Physical Therapy, 48(7), 574-583. Doi:10.2519/jospt.2018.8023.
36. Mak MK, Pang MY. Balance confidence and functional mobility are independently associated with falls in people with Parkinson's disease. J Neurol. 2009 May;256(5):742-9. doi: 10.1007/s00415-009-5007-8. Epub 2009 Feb 25. PMID: 19240961.