Motor Fitness and Flexibility Tests in Older Adults: Comparison
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Strong evidence indicated that (i) slower gait speed predicts falls and institutionalization/hospitalization in adults over 60 years old, cognitive decline/impairment over 55 years old, mobility disability over 50 years old, disability in instrumental activities of daily living (IADL) over 54 years old, cardiovascular disease risk over 45 years old, and all-cause mortality over 35 years old; (ii) impaired balance predicts falls and disability in IADL/mobility disability in adults over 40 years old and all-cause mortality over 53 years old; (iii) worse timed up&go test (TUG) predicts falls and fear of falling over 40 years old. Evidence supports that slower gait speed, impaired balance, and worse TUG performance are significantly associated with an increased risk of adverse health outcomes in adults. 

  • speed
  • agility
  • prediction
  • health issues
  • adults

1. Introduction

Increases in life expectancy in addition to the high proportion of deaths being attributed to unspecified causes and the multi-morbidity mainly common in older adults (≥65 years old) are associated with increased rates of healthcare use and cost, resulting in challenges for health policies around the world [1].
Among the dominant causes of death in adults and older adults, non-communicable diseases have a high prevalence and in developing countries; it is estimated that, in coming years, seven out of every ten deaths will be attributed to these diseases [2]. Moreover, disabilities related to pain (such as musculoskeletal pain), depressive disorders, dementia, osteoarthritis, and falls are becoming a great burden in older people [1]. Impaired musculoskeletal health (including mobility and function limitations) is characterized by a reduced quality of life (QoL), loss of independence [3], mental illness, and mortality [4]. Depression is the fourth leading cause of disability and the foremost cause of non-fatal disease burden [5]. In adults and older adults, that interconnection between impaired mental health and QoL is associated with an increased risk of morbidity and mortality [5]. Falls occur in over 30% of older populations [6] and include other adverse outcomes such as lower body fractures, fear of falling, loss of mobility, hospitalization [7], reduced QoL, [8] and even premature death [9]. Collectively, these factors may connive to globally increase healthcare costs [4].
In high-income settings, cardiovascular disease (CVD) is the leading cause of global mortality [10][11][12]. In these countries, a regular medical checkup is well-established in order to control adverse health outcomes, such as CVD risk factors (e.g., hypertension or elevated cholesterol in asymptomatic adults) [13]. Nevertheless, no clear benefits, or even a reduction in adverse health outcomes, such as disability, cognitive decline, risk of falls, well-being, or mortality risk, have been found from annual checkups in the general adult population [13]. In contrast, among older adults, some evidence of a reduction in mortality and an increase in independence has been found [13]. Even so, that examination involves elevated time and health resources and may result in false-positive diagnoses or unnecessary treatment.
It is also well established that by adopting a healthy lifestyle, such as adequate levels of physical fitness, the majority of the aforementioned non-communicable diseases and deterioration in health could be potentially reduced [3][14]. Indeed, maintaining an adequate physical fitness level is considered a powerful marker of health, making it a good indicator of possible adverse health events in different populations including adults and older adults [3][15][16]. In fact, numerous systematic reviews conclude that cardiorespiratory fitness and muscular fitness have predictive validity in relation to diverse health outcomes [10][17][18][19][20][21], being inversely associated with morbidity and all-cause mortality.
On the other hand, there are some other components of physical fitness that need to be analyzed to clarify whether they have predictive value for diverse health outcomes in adults and older adults. Physical fitness is composed of skill-related attributes, such as cardiorespiratory fitness, muscular strength and endurance (muscular fitness), body composition, and flexibility. Motor fitness is considered the performance aspect of physical fitness in daily activities which requires speed of reaction, speed of movement (hereafter, gait speed), agility, coordination, and balance [22]. Flexibility is that component of physical fitness which refers to the ability to move a joint through its full range of motion with ease [23]. These components of physical fitness are related to disabilities that can impair movement common in several health complications, which may imply a reduction in QoL [3]. Therefore, assessment of motor fitness and flexibility could help to identify adults and older adults who may be at risk of suffering from these health outcomes. Through its predictive value, motor fitness and flexibility could be postulated as a health marker in these populations.
Little scientific literature has systematically addressed this issue [14][15][24][25][26][27], and there are some limitations and gaps that still need to be investigated thoroughly, since they only were based on older adults, gait speed was the predominant motor fitness test evaluated, and other important health outcomes (such as cause-specific mortality, hip fracture, or mental health and well-being) have not been deeply investigated. Furthermore, no previous systematic review has presented an overview of the different wide range of motor fitness and flexibility tests used in standard health practice (i.e., balance assessment, multidimensional measures, or flexibility assessment, in addition to gait speed assessment).

2. Predictive Validity of Motor Fitness and Flexibility Tests in Adults and Older Adults

Results revealed that there exists strong evidence indicating that: (1) slower gait speed predicts falls in adults over 60 years old, cognitive decline and impairment (including develop of dementia and Alzheimer’s disease) in adults over 55 years old, mobility disability in adults over 50 years old, disability in instrumental activities of daily living (IADL) in adults over 54 years old, CVD risk in adults over 45 years old, all-cause mortality in adults over 35 years old, and risk of institutionalization or hospitalization in adults over 60 years old; (2) impaired balance predicts falls in adults over 40 years old, disability in IADL or mobility disability in adults over 40 years old, and all-cause mortality in adults over 53 years old; (3) worse TUG performance predicts falls and fear of falling in adults over 40 years old. Herein have also found that there exists moderate evidence indicating that: (1) slower gait speed predicts hip fracture in older women over 75 years, depressive symptoms in adults over 50 and older men over 65 years, and other-cause mortality in adults over 50 years old; (2) worse TUG performance predicts falls in women over 40 years old. Due to a limited number of studies, the results also suggested limited evidence showing that: (1) slower gait speed predicts hip fracture in adults over 55 years old, frailty status in older adults over 65 years, decrease in functional autonomy in older adults over 68 years, and that does not predict stroke risk in adults over 35 years old; (2) impaired balance predicts hip fracture in women over 75 years old, incident of dementia in adults over 90 years old, functional decline in older adults over 68 years, CVD risk in older adults over 65 years, other-cause mortality in older adults over 65 years, and risk of hospitalization in adults over 60 years old; (3) worse TUG performance predicts cognitive decline and dementia in older adults over 65 years, disability in IADL in older adults over 65 years, decline in well-being in older adults over 70 years, and frailty status and loss of functional autonomy in older adults over 65 years; (4) poor flexibility predicts falls in older adults over 70 years, mobility disability in older adults 65 years, and does not predict all-cause mortality in adults over 60 years old; (5) a shorter step length predicts risk of falling in older adults over 70 years, slower speed of movement predicts mobility disability in older adults over 65 years, shorter maximum step length predicts disability in IADL in older adults over 76 years, and worse performance in the stair mounting test predicts disability in IADL in older men over 75 years. At the age of 30, the biological system functioning reflects a critical transition point into decline and ageing [28]. Adults over 60 years old suffer from more diseases related to aging [1], and they are users of more healthcare resources [29]. Ageing is characterized by gait changes, which may be a manifestation of compromised motor executive function [30]; then, these results imply the neurological ability to coordinate motor tasks, reflecting in motor fitness tests, such as gait speed, balance, or the TUG tests. The results suggest a predictive value of motor fitness tests related to diverse adverse health outcomes mainly for adults aged over 60, which is in agreement with this fact. Indeed, previous reviews are in accordance with the findings in this population [14][15][24][25][26][27]. Moreover, predictive value has also been found for motor fitness tests related to health outcomes in younger adults. Thus, an early screening of physical fitness performance could help prevent adults from more harmful aging deterioration. For instance, evidence seems to indicate adverse health outcomes from 35 years old related to slower gait speed (mobility disability, disability in IADL, CVD risk, all-cause mortality), or related to impaired balance or worse TUG performance (i.e., risk of falling, disability). Therefore, knowing the predictive ability of each test to detect health outcomes can facilitate to incorporate an early screening into clinical and practical settings.

2.1. Predictive Validity of Gait Speed Tests

Walking ability is a global measure of mobility that reflects a basic aspect of daily activity [31]. Gait speed seems to begin to decrease in old age [26] and is related to difficult in walking, which may indicate more healthcare needs, higher incident disability, and shorter life expectancy [31]. Our review supports the idea that gait speed assessment might be used for risk stratification and to guide health practitioners and clinicians in the management of altered health outcomes.
Although physical assessment is proposed mainly for older adults [13], and all the selected reviews corroborated it, as they included only older adults [14][15][24][25][26][27], based on the present review, we propose the inclusion of younger populations. Specifically, gait speed assessment is a good tool to identify adults at risk of cognitive decline and impairment, mobility disability/IADL, CVD and all-cause mortality in adults from 35 years old. Moreover, gait speed may also identify depressive symptoms in adults over 50 years old. However, further research is needed, because only two studies have explored this relationship [32][33].
The elderly population shows a wide range of adverse health outcomes, including those mentioned above. In this sense, assessment of gait speed is currently recommended for older adults in the health practice environment [7][34]. Gait speed is a good measure of overall ability to compensate for decline in multiple body systems, including sensorimotor and cognitive function, which are common risk factors for falls [7]. The reduction in gait speed may be due to loss of physical functioning or the deterioration of brain motor control centers [8][26]. Moreover, evidence suggests that inflammatory markers [26][35] play a role in the association between gait speed and mortality events, since they are associated with disability, worse cognitive performance and motor functioning, frailty, and death [26][35].
Different gait speed cut-off points have been reported for risk stratification of adverse health outcomes, but a single threshold was not yet evident. Nevertheless, and independent to the distance of the chosen test, cut-off points of <0.8 m/s and <1.0 m/s in gait speed appear to be sensitive to predict the risk of most of these adverse health outcomes in adults and older adults (Figure S2). In fact, these cut-off points have been previously proposed [15][26].

2.2. Predictive Validity of Balance Tests

Maintaining balance is a complex task that demands good functioning of multiple organ systems with an accurate coordination between them [36]. The impaired balance may be due to lack of strength or age-related deterioration of sensory and neuromuscular control mechanisms [37][34].
Although gait speed assessment is well-established, strong evidence indicates that impaired balance is a good tool to identify adults over 40 years old at risk of falling, disability in IADL or mobility disability, and all-cause mortality in adults over 53 years old.
Limited evidence was found for balance and other health outcomes in older adults, such as hip fracture, incident of dementia, functional decline, CVD risk, and other-cause mortality risk. This limited evidence may be primarily due to a lack of consensus on which balance test is most accurate in measuring different health outcomes or populations. A recent meta-analysis has suggested that the one-leg balance test is a good predictor of disability in IADL in older adults [27], although only three studies pooled the analysis. In fact, establishing cut-off points for balance measurement is also challenging, due to the wide range of existing protocols, although some studies have identified that inability to stand on one leg for less than 5 s may be sensitive to changes in risk of falls [38][39][40]. Therefore, more studies are still needed to clarify which protocol is the most accurate in order to identify the most sensitive cut-off in balance performance related to different health outcomes.

2.3. Predictive Validity of Multidimensional Measurement Tests

The TUG test was a reliable and valid test developed by Podsiadlo and Richardson [41] in 1991 to assess “basic mobility skills” in older adults (70–84 years). This test was intended to be a simple and useful compendium between the measures of gait speed, balance, and functional capacity [41]. Although various factors are associated with falls, mobility problems and impaired balance have been consistently identified as the main risk factors [42][38][43][44].
The TUG test has been identified as a good tool to identify adults over 40 years old at risk of falling and fear of falling [45][46][47][39][48][49].
Moreover, worse TUG performance may also predict falls in women over 40 years old [42][38][44].
Therefore, the TUG test could be proposed as a predictive test for risk of falling in community dwelling adults from 40 years old [45][46][47][42][38][39][44][48][49]. Since the risk of falling is associated with loss of independence, injuries, disability, long-term health care and premature mortality [45][42][38][44], an available predictive tool for risk of falling is advisable. The adverse health outcomes related to health have been especially identified for women [42][44], due to the loss of estrogens derived from perimenopause (around the age of 40) that can affect bone quality, being more prone to bone deterioration and fractures (such as hip fracture) [50].
Hence, falls and their consequences could be prevented with early screening by evaluating the TUG test among the aging adult population.
Nevertheless, this motor fitness test presents a series of drawbacks, resulting in limited and inconclusive predictive value in relation to other health outcomes.
Since the TUG test combines gait speed plus balance skills, it is not surprising that in those studies where some of these skills have been evaluated simultaneously (TUG performance plus gait speed or balance performance), all of them proved predictive capacity. In fact, the TUG test, gait speed and balance test were related to falls [51] and to decline in functional autonomy [52] in older adults; the TUG and a gait speed tests were related to falls in older adults [46]; or the TUG and balance tests were related to falls in adult women over 40 years old [38][44].

2.4. Predictive Validity of Flexibility Tests

Although several cross-sectional studies have found associations between flexibility and diverse health outcomes, such as cardiometabolic risk, well-being, etc., its predictive value (through a longitudinal design) is still scarce [51][53][54]. These three studies were carried out in older adults with different flexibility protocols. Furthermore, only Ward et al. [53] found that flexibility was predictive of mobility disability [53], while the other two studies did not confirm its predictive capacity for falls [51] or all-cause mortality [54].

3. Conclusions

Herein emphasized important major points regarding the predictive validity of motor fitness tests in adults and older adults. Slower gait speed predicts falls, cognitive decline and impairment (including develop of dementia and Alzheimer’s disease), mobility disability, disability in IADL, CVD risk, all-cause mortality, and risk of institutionalization or hospitalization. Its use is suggested especially in adults over 35 years old. Impaired balance predicts falls, disability in IADL or mobility disability, and all-cause mortality. Its use is suggested especially in adults over 40 years old. Worse TUG performance predicts falls and fear of falling in adults over 40 years old, especially in women. Therefore, these results provide further justification to integrate the measurement of motor fitness, mainly gait speed and balance, in the prognostic assessment tools as indicators of health outcomes (such as falls risk, cognitive impairment, disability, CVD risk, all-cause mortality, and hospitalization) in both adults and older adults. Identifying these risk factors will allow for early intervention based on adequate levels of physical fitness and potentially decrease morbidity and mortality over lifetime, at the same time increasing their QoL. Finally, in spite of the limited evidence regarding flexibility, our results suggest that flexibility testing may help detect older adults at risk of falling, suffering from disability, or expecting all-cause mortality. Therefore, future studies focusing on the predictive value of flexibility tests in this population are warrantied. Furthermore, it is still necessary to elucidate the relationship between those motor fitness tests that present limited evidence in relation to the predictive value for various health outcomes.

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