Timed Up and Go test

Timed Up and Go test

Clinical studies on patients with lumbar degenerative diseases increasingly employ objective measures of function, which offer high potential for improving the quality of outcome measurement in patient-care and research.

The Timed Up and Go test (TUG) is a simple test used to assess a person’s mobility and requires both static and dynamic balance.

It has previously been described as a reliable tool to evaluate objective functional impairment in patients with lumbar degenerative disc disease.

It uses the time that a person takes to rise from a chair, walk three metres, turn around, walk back to the chair, and sit down. During the test, the person is expected to wear their regular footwear and use any mobility aids that they would normally require.

The TUG is used frequently in the elderly population, as it is easy to administer and can generally be completed by most older adults.

Of 2389 identified articles, 82 were included in the final analysis. There was a significant increase of 0.12 per year in the number of publications dealing with objective measures of function since 1989 (95% CI 0.08-0.16, p<0.001). Some publications studied multiple diagnoses and objective measures. The US was the leading nation in terms of scientific output for objective outcome measures (n=21; 25.6%), followed by Switzerland (n=17; 20.7%), Canada, Germany and the United Kingdom (each n=6; 7.3%).

The search revealed 21 different types of objective measures, predominantly applied to patients with lumbar spinal stenosis (n=67 publications; 81.7%), chronic/unspecific low back pain (n=28; 34.2%) and lumbar disc herniation (n=22; 26.8%). The Timed-Up-and-Go (TUG) test was the most frequently applied measure (n=26 publications; 31.7%; cumulative number of reported subjects: 5181), followed by the Motorized Treadmill Test (MTT; n=25 publications; 30.5%, 1499 subjects) and with each n=9 publications (11.0%) the Five Times Sit-to-Stand (5R-STS; 955 subjects), as well as accelerometry analyses (336 subjects). The reliability and validity of many of the less-applied objective measures was uncertain. There was profound heterogeneity in their application and interpretation of results. Risk of bias was not assessed. 1).

Nikaido et al. investigated the differences in postural control disability between idiopathic normal pressure hydrocephalus (iNPH) and Parkinson’s disease (PD).

Twenty-seven iNPH patients, 20 PD patients, and 20 healthy controls (HCs) were examined using the Timed Up and Go test (TUG) and a force platform for recording the center of pressure (COP) trajectory during quiescent standing and voluntary multidirectional leaning (forward, backward, right, and left for 10 s each).

In the leaning task, postural control in PD patients was impaired during forward and backward leaning, whereas postural control in iNPH patients was impaired in all directions. In particular, postural control during right and left leaning was significantly worse in iNPH patients than in PD patients. No significant difference was observed between iNPH and PD patients in TUG and postural sway during quiescent standing.

The results showed that the characteristics of impaired voluntary COP control in iNPH and PD patients might reflect pathophysiological differences in postural instability for each disease. In particular, postural instability during right and left leaning in iNPH patients may be responsible for wider steps and a higher risk of falling 2).

One source suggests that scores of ten seconds or less indicate normal mobility, 11 – 20 seconds are within normal limits for frail elderly and disabled patients, and greater than 20 seconds means the person needs assistance outside and indicates further examination and intervention. A score of 30 seconds or more suggests that the person may be prone to falls.

Alternatively, a recommended practical cut-off value for the TUG to indicate normal versus below normal performance is 12 seconds.

A study by Bischoff et al. showed the 10th to 90th percentiles for TUG performance were 6.0 to 11.2 seconds for community-dwelling women between 65 and 85 years of age, and determined that this population should be able to perform the TUG in 12 seconds or less.

TUG performance has been found to decrease significantly with mobility impairments. Residential status and physical mobility status have been determined to be significant predictors of TUG performance.

The TUG was developed from a more comprehensive test, the Get-Up and Go Test.

Research has shown the Timed up and Go test has excellent interrater (intraclass correlation coefficient [ICC] = .99) and intrarater reliability (ICC = .99).[8] The test score also correlates well with gait speed (r = -.55), scores on the Berg Balance Scale (r = -.72), and the Barthel Index (r = -.51).

Many studies have shown good test-restest reliability in specific populations such as community-dwelling older adults and people with Parkinson’s disease.

The TUG Test (measured in seconds) was correlated with validated patient-reported outcome measures (PROs) of pain intensity (Visual Analog Scale for back and leg pain), functional impairment (Oswestry Disability Index, Roland Morris Disability Index), and health-related quality of life measures (Short Form-12 and EuroQol 5D). Three established methods were used to establish anchor-based MCID values using responders of the following PROs (Visual Analog Scale back and leg pain, Oswestry Disability Index, Roland Morris Disability Index, EuroQol 5D index, and Short Form-12 Physical Component Summary) as anchors: (1) average change, (2) minimum detectable change, and (3) change difference approach.

One hundred patients with a mean ± SD age of 56.2 ± 16.1 years, 57 (57%) male, 45 patients undergoing microdiscectomy, 35 undergoing lumbar decompression, and 20 undergoing fusion surgery were studied. The 3 MCID computation methods revealed a range of MCID values according to the PRO used from 0.9 s (Oswestry Disability Index based on the change difference approach) to 6.0 s (EuroQol 5D index based on the minimum detectable change approach), with a mean MCID of 3.4 s for all measured PROs.

The MCID for the TUG Test time is highly variable depending on the computation technique used. The average TUG Test MCID was 3.4 s using all 3 methods and all anchors 3).

The TUG test is preferred over a battery of PROMs by 60-70% of patients with lumbar DDD not only in the preoperative, but also in the postoperative setting. High functional disability does not result in avoidance of the TUG test and repeated assessments lead to higher preference4).



Stienen MN, Ho AL, Staartjes VE, Maldaner N, Veeravagu A, Desai A, Gautschi OP, Bellut D, Regli L, Ratliff JK, Park J. Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature. Spine J. 2019 Mar 1. pii: S1529-9430(19)30076-2. doi: 10.1016/j.spinee.2019.02.014. [Epub ahead of print] Review. PubMed PMID: 30831316.

Nikaido Y, Akisue T, Kajimoto Y, Tucker A, Kawami Y, Urakami H, Iwai Y, Sato H, Nishiguchi T, Hinoshita T, Kuroda K, Ohno H, Saura R. Postural instability differences between idiopathic normal pressure hydrocephalus and Parkinson’s disease. Clin Neurol Neurosurg. 2018 Jan 10;165:103-107. doi: 10.1016/j.clineuro.2018.01.012. [Epub ahead of print] PubMed PMID: 29331870.

Gautschi OP, Stienen MN, Corniola MV, Joswig H, Schaller K, Hildebrandt G, Smoll NR. Assessment of the Minimum Clinically Important Difference in the Timed Up and Go Test After Surgery for Lumbar Degenerative Disc Disease. Neurosurgery. 2016 Jun 24. [Epub ahead of print] PubMed PMID: 27352275.

Chronic subdural hematoma neuroendoscopy

Chronic subdural hematoma neuroendoscopy

Some authors recommend the endoscopic treatment of chronic subdural hematomas, especially the septated ones 1) 2).

Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients.

Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization.

The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy 3).

Treatment of loculated chronic subdural hematoma using neuroendoscopy combined with closed system drainage is a minimally invasive method and a therapeutic alternative to the craniotomy-membranectomy technique 4).

The application of visualization features of soft neuroendoscopy in the treatment of CSDH can significantly improve hematoma clearance, shorten the time of drainage tube, reduce postoperative complications and recurrence rate, and improve surgical outcomes 5).

Case series

Between January 2012 and October 2016, eight patients diagnosed with multi-lobular CSDH using computed tomography(CT)imaging underwent endoscopic evacuation. First, we established a 3×3cm craniotomy at a position where a rigid endoscope and aspiration tube would be able to reach as much of the hematoma cavity as possible in the longitudinal plane. Second, after identifying and removing the outer membrane of the CSDH with the scope, we evacuated the hematoma longitudinally, keeping the inner membrane intact. We also applied monopolar diathermy to any obvious bleeding points and the capillary network on the outer membrane of the CSDH, using the aspiration tube.

The mean duration of surgery was 42 minutes. Follow-up CT scan revealed no recurrence in any of the cases, and neurologic function improved in all patients postoperatively.

A multi-lobular CSDH can be drained quickly and effectively using a rigid endoscope and aspiration tube through a small craniotomy. In a cohort of eight patients, postoperative neurologic recovery was observed in all cases with no evidence of recurrence. This technique could be used in any facility with ready access to CT imaging and a rigid endoscope 6).

Case reports

A two-month-old male infant presented with a bulging and tense fontanel, a reduced level of consciousness, bradycardia, and significant macrocephaly. Computed tomography (CT) demonstrated massive bilateral, low attenuation subdural fluid collections, reaching a diameter of 4.5 cm. Emergency burr hole washout and insertion of subdural drains was performed. Despite prolonged drainage over 10 days, the protein level remained at 544 mg/dl and the mean erythrocyte count at 6,493/µl. Continuous drainage was required to avoid clinical deterioration due to raised intracranial pressure; however, the fluid condition was still considered incompatible with permanent subdural-peritoneal shunting. We, therefore, performed an endoscopic subdural lavage with a careful evacuation of residual blood deposits. No complications were encountered. Postoperatively, mean protein level was 292 mg/dl and mean erythrocyte count was 101/µl. Endoscopic lavage could be safely performed in a case of extensive subdural low attenuation fluid collections, where conventional burr hole drainage failed to improve protein and cellular contents as a prerequisite for successful permanent shunting. We conclude that adaptation of this technique can be helpful in selected cases as an alternative procedure 7).

A 78-year-old Japanese man with a history of colon cancer was referred to our department of neurosurgery for the management of asymptomatic left chronic subdural hematoma (CSDH). He was receiving bevacizumab therapy for colon cancer, and the size of the CSDH increased or decreased depending on bevacizumab administration. Simple drainage was performed because of the risk of a critical increase in the size of CSDH during bevacizumab therapy, but since the CSDH was organized and firm, the drainage was insufficient. Therefore, neuroendoscope-assisted craniotomy was performed, and the organized CSDH was almost completely removed. The present case indicates the possible involvement of bevacizumab in the occurrence of CSDH and the efficacy of the neuroendoscopic approach in the surgical treatment of organized CSDH 8).



Rodziewicz GS, Chuang WC. Endoscopic removal of organized chronic subdural hematoma. Surgical Neurology. 1995 Jun;43:569–573.

Smely C, Madlinger A, Scheremet R. Chronic subdural haematoma — a comparison of two different treatment modalities. Acta Neurochirurgica. 1997;139:818–826

Berhouma M, Jacquesson T, Jouanneau E. The minimally invasive endoscopic management of septated chronic subdural hematomas: surgical technique. Acta Neurochir (Wien). 2014 Dec;156(12):2359-62. doi: 10.1007/s00701-014-2219-1. Epub 2014 Sep 16. PubMed PMID: 25223748.

Hellwig D, Heinze S, Riegel T, Benes L. Neuroendoscopic treatment of loculated chronic subdural hematoma. Neurosurg Clin N Am. 2000 Jul;11(3):525-34. PubMed PMID: 10918025.

Guan F, Peng WC, Huang H, Dai B, Zhu GT, Mao BB, Xiao ZY, Lin ZY, Hu ZQ. [Efficacy analysis of soft neuroendoscopic techniques in the treatment of chronic subdural hematoma]. Zhonghua Yi Xue Za Zhi. 2019 Mar 5;99(9):695-699. doi: 10.3760/cma.j.issn.0376-2491.2019.09.012. Chinese. PubMed PMID: 30831620.

Ishikawa T, Endo K, Endo Y, Sato N, Ohta M. [Neuro-Endoscopic Surgery for Multi-Lobular Chronic Subdural Hematoma]. No Shinkei Geka. 2017 Aug;45(8):667-675. doi: 10.11477/mf.1436203572. Japanese. PubMed PMID: 28790212.

Beez T, Schmitz AK, Steiger HJ, Munoz-Bendix C. Endoscopic Lavage of Extensive Chronic Subdural Hematoma in an Infant After Abusive Head Trauma: Adaptation of a Technique From Ventricular Neuroendoscopy. Cureus. 2018 Mar 2;10(3):e2258. doi: 10.7759/cureus.2258. PubMed PMID: 29725561; PubMed Central PMCID: PMC5931418.

Takahashi S, Yazaki T, Nitori N, Kano T, Yoshida K, Kawase T. Neuroendoscope-assisted removal of an organized chronic subdural hematoma in a patient on bevacizumab therapy–case report. Neurol Med Chir (Tokyo). 2011;51(7):515-8. PubMed PMID: 21785247.

Anterior cingulate cortex functions

Anterior cingulate cortex functions

see also dorsal anterior cingulate cortex.

The anterior cingulate cortex, appears to play a role in a wide variety of autonomic functions, such as regulating blood pressure and heart rate.

It is also involved in rational cognitive functions, such as reward anticipation, decision-makingempathyimpulse control and emotion.

From January to December 2016, eighteen participants with opiate drug addiction during physical detoxification who completed a Drug Rehabilitation Center of Anhui Province, and eighteen healthy controls recruited performed a cue-elicited craving task in a MRI scanner while signal data were collected. Two regions of interest were the right anterior cingulate and the left anterior cingulate, then the linear correlation between the whole brain and the anterior cingulates was calculated to find out the abnormal functional connectivity of the anterior cingulates.

Contrasted experimental group with the healthy controls, the functional connectivity of bilateral fusiform gyruscaudate nucleus, and the anterior cingulates was increased in the opiate drug addicts during physical detoxification group (P<0.05),and the functional connectivity between anterior cingulates and polus temporalis, hippocampi, Middle frontal gyrus of orbit, Supplementary motor area, dorsolateral superior frontal gyrus was decreased (P<0.05).

The anterior cingulates dysfunction of functional connectivity in a cue-elicited craving task may play a important role in the relapse of opiate drug addicts during physical detoxification 1).

Pica is most often reported in the presence of iron deficiency or gastrointestinal disturbance. The mechanism that underlies the behavior is poorly understood. Lesions to the anterior cingulate gyrus (ACG) can present in many ways, with signs and symptoms including motor and sensory changes, autonomic dysfunction, seizures, and behavioral alterations.

To date, no reports of pica, or eating disturbances, have been tied to anterior cingulate cortex lesions. In a article, Rangwala et al., describe the case of an 8-year-old boy presenting with pica consumption of paper who was shown to have a mass in the left ACG. After surgical resection of the lesion, all of the patient’s symptoms resolved and he returned to his normal life 2).

The somatosensory cortex encodes incoming sensory information from receptors all over the body. Affective touch is a type of sensory information that elicits an emotional reaction and is usually social in nature, such as a physical human touch. This type of information actually coded differently than other sensory information. Intensity of affective touch is still encoded in the primary somatosensory cortex, but the feeling of pleasantness associated with affective touch activates the anterior cingulate cortex more than the primary somatosensory cortex. Functional magnetic resonance imaging (fMRI) data shows that increased blood oxygen level contrast (BOLD) signal in the anterior cingulate cortex as well as the prefrontal cortex is highly correlated with pleasantness scores of an affective touch. Inhibitory transcranial magnetic stimulation (TMS) of the primary somatosensory cortex inhibits the perception of affective touch intensity, but not affective touch pleasantness. Therefore, the S1 is not directly involved in processing socially affective touch pleasantness, but still plays a role in discriminating touch location and intensity.

Qiao et al. reported a case of refractory epilepsy characterized by aura of extreme fear and hypermotor seizures, in which the left (dominant hemisphere) anterior cingulate gyrus (ACG) was determined to be the epileptogenic zone (EZ) through multiple modalities of presurgical evaluation including analysis of high frequency oscillation on intracranial EEG. Tailored resection of EZ was thus performed and pathological examination revealed focal cortical dysplasia (FCD) type IIb. The patient has been seizure free during an 18-month follow-up. The report has provided novel anatomical, electrophysiological and surgical evidences suggesting the critical role of ACG in ictal fear and possibility of surgical management of fear-manifesting refractory epilepsy 3).

Impaired wakefulness (IW) in normal pressure hydrocephalus (NPH) is associated with reduced relative regional cerebral blood flow (rrCBF) in the anterior cingulate cortex. Improved wakefulness following surgery corresponds to rrCBF increments in the frontal association cortex 4).



Han Y, Sun T, Zheng XL, Jiang ZQ, Lou FY, Zhang SJ. [Task-related functional connectivity of anterior cingulate in opiate drug addicts during physical detoxification: a task fMRI study]. Zhonghua Yi Xue Za Zhi. 2019 Mar 5;99(9):700-703. doi: 10.3760/cma.j.issn.0376-2491.2019.09.013. Chinese. PubMed PMID: 30831621.

Rangwala SD, Tobin MK, Birk DM, Butts JT, Nikas DC, Hahn YS. Pica in a Child with Anterior Cingulate Gyrus Oligodendroglioma: Case Report. Pediatr Neurosurg. 2017;52(4):279-283. doi: 10.1159/000477816. Epub 2017 Jul 14. PubMed PMID: 28704833.

Qiao L, Yu T, Ni D, Wang X, Xu C, Liu C, Zhang G, Li Y. Correlation between extreme fear and focal cortical dysplasia in anterior cingulate gyrus: Evidence from a surgical case of refractory epilepsy. Clin Neurol Neurosurg. 2017 Oct 31;163:121-123. doi: 10.1016/j.clineuro.2017.10.025. [Epub ahead of print] PubMed PMID: 29101860.

Tullberg M, Hellström P, Piechnik SK, Starmark JE, Wikkelsö C. Impaired wakefulness is associated with reduced anterior cingulate CBF in patients with normal pressure hydrocephalus. Acta Neurol Scand. 2004 Nov;110(5):322-30. PubMed PMID: 15476461.
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