Aging Clinical and Experimental Research
The five-times-sit-to-stand test: validity,
reliability and detectable change in older females*
Allon Goldberg1,2, Martina Chavis1, Johnny Watkins1 and Tyler Wilson1
1Department of Health Care Sciences, Physical Therapy Program, Mobility Research Laboratory,
2Institute of Gerontology, Wayne State University, Detroit, MI, USA
ABSTRACT. Background and aims: The five-times-
sit-to-stand test (FTSST) is a physical performance
test commonly-used in clinical geriatric studies. The re-
lationship between FTSST times and dynamic bal-
ance has not been widely investigated in older adults.
The main objective of this study was to evaluate the
validity of the FTSST as a measure of dynamic bal-
ance in older adults. A second objective was to quan-
tify relative and absolute reliability, as well as mini-
mum detectable change (MDC) of the FTSST in older
adults. Methods: Twenty-nine females (mean age,
73.6 years) performed two trials of the FTSST, timed
up and go (TUG), and functional reach (FR) tests.
Validity of the FTSST as a measure of dynamic bal-
ance was evaluated by quantifying strength of rela-
tionships between the FTSST and two measures of dy-
namic balance, TUG and FR, using Pearson’s corre-
lation coefficient. Measures of relative [intraclass cor-
relation coefficient (ICC)] and absolute [standard error
of measurement (SEM)] reliability, as well as the MDC
at the 95% confidence level (MDC95) were computed
for the FTSST. Results: The Pearson’s correlation co-
efficient between FTSST and TUG (r=0.64, p<0.001)
indicates that FTSST is a valid measure of dynamic
balance and functional mobility in older adults. The
ICC2,1 of 0.95 is indicative of excellent relative relia-
bility of the FTSST. SEM was 0.9 seconds and MDC95
was 2.5 seconds for the FTSST. SEM (6.3% of mean
FTSST) and MDC (17.5% of mean FTSST) percent
values were low. Conclusions: The FTSST is a valid
measure of dynamic balance and functional mobility
in older adults. The high ICC and low SEM and
SEM% suggest excellent relative and absolute relia-
bility and reproducibility of the FTSST in older adults.
Change in FTSST performance should exceed 2.5
*Portions of the data in this manuscript were presented in podium format at the Combined Sections Meeting of the American Physical Ther-
apy Association in February 2012.
Key words: Dynamic balance, minimum detectable change, older adults, relative and absolute reliability, sit to stand.
Correspondence: Allon Goldberg, Department of Health Care Sciences, Physical Therapy Program, Mobility Research Laboratory, Wayne
State University, 259 Mack Ave., Detroit, MI, 48201, USA.
E-mail: agoldberg@wayne.edu
Received May 13, 2011; accepted in revised form November 3, 2011.
339 Aging Clin Exp Res, Vol. 24, No. 4
seconds to be considered real change beyond mea-
surement error.
(Aging Clin Exp Res 2012; 24: 339-344)
©2012, Editrice Kurtis
INTRODUCTION
More than 30% of older adults fall each year (1), in-
dicating an urgent need to uncover reliable and valid
clinical assessment tools to predict falls in older adults. Nu-
merous clinical tests and measures are used to evaluate fall
risk in older adults. The five-times-sit-to-stand test (FTSST)
is a physical performance test commonly used in clinical
geriatric studies. Although sit-to-stand performance is
associated with leg strength in older adults (2, 3), it is be-
coming increasingly apparent that it is associated with
many other factors in addition to strength. These in-
clude a variety of physiological and psychological factors
such as vision, proprioception, peripheral tactile sensitivity,
reaction time, postural sway, anxiety, and pain, all of
which together with leg strength explained 34.9% of
the variance in FTSST time in older adults (2).
Older adults with balance dysfunction have significantly
slower FTSST times (16.4 seconds) than older control
adults (13.4 seconds) and FTSST times correlate with
scores on the Activities-specific Balance Confidence scale
(Spearman rho =–0.58; p<0.001) (4), a self-report balance
confidence assessment tool (5). In older adults, FTSST
times correlate with static balance assessed as postural
sway with eyes open on foam (r=0.26; p<0.01) (2), and
with dynamic balance assessed as 360° turn (r=0.26;
p<0.001) (6). Although strength of the relationship between
FTSST times and balance based on these studies is weak,
these studies suggest that the FTSST exhibits some asso-
ciation with static balance as well as with dynamic balance
capabilities in older adults. The relationship between FTSST

times and dynamic balance performance, however, has not
been widely investigated in older adults. Further studies are
needed to evaluate and establish the validity of the FTSST
as a measure of dynamic balance capabilities in older
adults in order to facilitate its use as an outcome measure
in dynamic balance intervention studies. Therefore the
main objective of this study was to evaluate the validity of
the FTSST as a measure of dynamic balance by quantifying
strength of relationships between the FTSST and two
measures of balance which incorporate dynamic tasks,
the timed up and go (TUG) (7) and functional reach (FR) (8)
tests. The TUG is a measure of dynamic balance as it in-
corporates control of the center of gravity during sit to stand
and during return to sitting. The TUG also incorporates
turning while taking steps; turning while stepping assesses
dynamic balance as it requires changes to the base of
support to accomplish the turning task (6). The FR is a test
of the margin of stability in which the individual maximal-
ly reaches forward with an outstretched arm while bending
at the waist and with the feet stationary. We hypothe-
sized that the FTSST times would be associated with per-
formance on the TUG and FR tests, but that the relation-
ship with TUG would be stronger than with FR. The second
objective of this study was to quantify relative and absolute
reliability, as well as minimum detectable change (MDC) of
the FTSST in older adults. The MDC is the smallest dif-
ference between repeated trials of a variable of interest that
is not due to chance variation (9), and in clinical studies rep-
resents real change beyond that attributable to measurement
error (10). Knowledge of real change values for the FTSST
will enable clinicians and researchers to evaluate whether
change in FTSST performance constitutes real change or
is due to measurement error.
METHODS
Participants
The study participants were a sample of convenience
and included 29 female older adults who were recruited at
an urban senior center. Participants were recruited by di-
rect person-to-person solicitation at the center and
through flyers posted in the center. All testing took place
at the center during a single testing session. Individuals
were included if they were female community-dwelling
adults aged 60 years and older, able to walk at least 10
meters and stand at least 10 minutes without an assistive
device, and were alert and oriented. Exclusionary criteria
were based on a detailed medical history and included
shortness of breath with minimal exertion, neurological
disease that may affect balance, diabetes with peripheral
neuropathy, vestibular impairments, significant pain in the
lower extremities that might affect participation, active in-
fection or diagnosis of cancer, current injury, history of
fracture within the past year, recent dizziness or fainting
episodes, uncorrected visual deficits, and amputation of an
extremity. Participants also provided a rating of their
Sit to stand in older adults
state of health (excellent; very good; good; fair; poor), and
reported their level of physical activity or exercise on a
weekly basis (more than 30 minutes 3 times per week; 5-
30 minutes 3 times per week; sedentary). They were
fully informed of the procedures employed in the study
and participated voluntarily. An informed consent docu-
ment approved by the Human Investigation Committee of
Wayne State University was signed by each participant pri-
or to testing.
In order to estimate sample size for the study, we
conducted a power analysis based on a prior study show-
ing that FTSST times correlate with TUG in individuals
with vestibular deficits (r=0.53; p<0.01) (11). To achieve
80% power for a Pearson’s correlation coefficient of
r=0.50 and α=0.05, 28 individuals needed to be tested.
Assessments
Three testers were involved in data collection. The
same tester conducted two trials for each of the three vari-
ables for a single participant. This ensured maximum
consistency of data collection for each variable for each
participant. Prior to initiation of data collection, all testers
underwent a training session at which they were in-
structed by the senior author in the testing procedures
conducted in this study.
Five-times-sit-to-stand
Participants rose from a chair and returned to the
seated position as quickly as possible for five repetitions.
Participant’s arms were folded across their chests during
the test. In community-dwelling older adults test-retest re-
liability of the FTSST is excellent [intraclass correlation co-
efficient (ICC)=0.89] (2). Two trials were performed with
approximately one-minute rest in between each trial as
needed. Mean of the two trials was computed for use in
the analysis.
Timed up and go
TUG is a measure of functional mobility (7) and balance
(12-14), incorporating a series of dynamic activities. Par-
ticipants stood up from a chair, walked 3 meters at their
usual safe walking speed, turned around and returned to
the seated position (7). A TUG cutoff score of 13.5 sec-
onds classifies fallers and non-fallers in older adults with
sensitivity of 80% (percent fallers) and specificity of 100%
(percent non-fallers), and with an overall correct faller pre-
diction rate of 90% (12). Interrater reliability of TUG is ex-
cellent in community-dwelling older adults (ICC=0.98)
(12). Two trials were performed with approximately one
minute rest in between each trial as needed. Mean of the
two trials was computed for use in the analysis.
Functional reach
FR is a measure of balance and margin of stability (8).
In standing, participants reached forward with the arm ex-
Aging Clin Exp Res, Vol. 24, No. 4 340
A. Goldberg, M. Chavis, J. Watkins et al.

tended while flexing the trunk, without rotating their Table 1 - Characteristics of 29 older adult females.
shoulders or stepping forward. FR was the maximum
Characteristic Mean (SD) or % Range
distance they were able to reach forward beyond arm
length while maintaining a fixed base of support, and was Anthropometric/demographic
measured with a yardstick affixed to the wall at the level Age (yr) 73.6 (7.4) 60-90
Height (cm) 162.7 (5.9) 149.9-172.7
of the acromion. Reliability of FR is excellent (ICC>0.92) Weight (Kg) 74.0 (14.5) 50.0-107.7
in community-dwelling older adults (13). Two trials were Body mass index (Kg/m2) 27.9 (5.2) 19.0-43.4
performed with approximately one-minute rest in be- Self-report state of health
tween each trial as needed. Mean of the two trials was Fair (%) 3.5 -
computed for use in the analysis. Good (%) 51.7 -
Very good (%) 37.9 -
Excellent (%) 6.9 -
Statistical analysis
Physical activity/exercise
Descriptive statistics including means, standard devia- Sedentary (%) 3.4 -
tions, ranges, and percentages were computed for par- 5-30 min 3 times/week (%) 41.4 -
ticipant characteristics. Means, standard error of the More than 30 min 3 times/week (%) 55.2 -
mean, 95% confidence intervals, and ranges were com- n
puted for FTSST, TUG and FR. The Kolmogorov-
Smirnov test was used to evaluate normality of the
FTSST, TUG and FR tests. The three tests all conformed RESULTS
to a normal distribution, allowing for the use of parametric Characteristics
statistical procedures. Strengths of relationships between The sample’s characteristics are presented in Table 1.
the FTSST and clinical balance measures (TUG and FR) A large proportion (55.2%) reported exercising or being
were computed using the Pearson correlation coeffi- physically active for more than 30 minutes 3 times per
cient. Difference between FTSST trials was assessed us- week. Forty-five percent of the sample reported their
ing a paired t-test. Test-retest reliability of the FTSST was health as very good or excellent.
computed using ICC2,1 (15), a measure of relative relia-
bility. The standard error of measurement (SEM) is a Assessments
measure of absolute reliability expressing measurement er- Means, standard error of means, 95% confidence in-
ror in the same units as the original measurement (16, tervals and ranges are presented for the FTSST, TUG and
17). The SEM of the FTSST was computed using the for- FR in Table 2.
mula SD×㲋(1- ICC2,1), (18), where SD was the standard
deviation of the FTSST trial with the highest standard de- Relationships among variables: validity of the FTSST
viation, and ICC2,1 the test-retest reliability coefficient. A FTSST times correlated significantly with TUG, such
Bland-Altman plot of each participant’s mean FTSST that better sit-to-stand performance is associated with
time plotted against their FTSST difference score (trial 1 better TUG score. The Pearson’s correlation coefficient
minus trial 2) depicts the spread of difference scores (r=0.64, p<0.001) revealed a moderate relationship be-
about the zero difference score. The Bland-Altman plot al- tween FTSST and TUG. There was a weaker relationship
so depicts the 95% limits of agreement (95% LOA) (19), between FTSST and FR (Pearson’s r= -0.36, p=0.06).
which represent an expected range of difference scores
across trials of the FTSST. The 95% LOA containing ze- Reliability and minimum detectable change of FTSST
ro indicates statistically the absence of systematic bias be- Mean FTSST times for each trial as well as reliability
tween repeated trials of a variable (10). The 95% LOA and minimum change values for FTSST times are pre-
was computed as –x ±1.96×SD, (19), where –x was the
mean of the difference scores between the first and sec-
ond trials of FTSST time, and SD the standard deviation
of the difference scores. The MDC at the 95% confidence Table 2 - Means, confidence intervals, and ranges for assessment
level (MDC 95 ) was computed for the FTSST as measures for 29 older adult females.
z×SEM×㲋2 (18). A value of 1.96 was used as the z- Mean±SEM 95% CI Range
score associated with the 95% confidence level and 㲋2 ac-
counted for added uncertainty in measurement associat- Assessments
ed with repeated trials of the FTSST. SEM and MDC95 FTSST (s) 14.3±0.7 12.9-15.8 8.00-21.3
were expressed as percentages (SEM% and MDC95%) of TUG (s) 10.4±0.6 9.2-11.6 6.8-22.1
FR (cm) 23.8±1.2 21.3-26.2 13.0-37.5
mean FTSST to enhance interpretation of the absolute
values of measurement error and minimum change (20). FTSST: five-times-sit-to-stand test; TUG: timed up and go; FR: functional
reach; SEM: standard error of the mean; CI: confidence interval.
Statistical significance was set at p≤0.05.

341 Aging Clin Exp Res, Vol. 24, No. 4

 Sit to stand in older adults

Table 3 - Reliability and minimum detectable change for five-times-sit-to-stand test for 29 older adult females.

Mean trial 1 (SD) Mean trial 2 (SD) ICC2,1 95% LOA SEM SEM% MDC95 MDC95%
[range] [range] [95% CI]

FTSST 14.3 (3.8) 14.3 (4.1) 0.95 –2.6 to +2.6 0.9 6.3 2.5 17.5
[7.5-20.7] [8.5-21.8] [0.89-0.97]
FTSST: five-times-sit-to-stand test; SD: standard deviation; ICC: intraclass correlation coefficient; CI: confidence interval; 95% LOA: 95% limits of agreement;
SEM: standard error of measurement; MDC95: minimum detectable change at the 95% confidence interval. FTSST means, 95% LOA, SEM, and MDC95 are
in seconds.

sented (Table 3). Mean FTSST times for each trial were
similar (p=0.94). The ICC2,1 of 0.95 is indicative of ex-
cellent test-retest reliability of the FTSST times. SEM
was computed as 0.9 seconds, while the SEM% was
6.3%, a low measurement error percent value. Visual in-
spection of the Bland-Altman plot indicates that the
FTSST difference scores are distributed above and below
the zero difference score with no evidence of bias across
trials 1 and 2 of the FTSST. The expected range of dif-
ference scores across the two trials of FTSST time was ex-
amined by computing the 95% LOA, which ranged from
–2.6 seconds to +2.6 seconds (Table 3; Figure 1). As the
95% LOA contained zero, there was no statistical evi-
dence of systematic bias across trials 1 and 2 of the
FTSST. The MDC95 for FTSST time was 2.5 seconds,
and the MDC95% was 17.5%, a low minimum change
percent value.
DISCUSSION
The relationship between sit-to-stand performance
assessed as the FTSST, and dynamic balance perfor-
mance has not been widely investigated in older adults.
Previous studies show a weak relationship between
FTSST and dynamic balance assessed as 360° turn in old-
er adults (r=0.26; p<0.001) (6), but a stronger relationship
(r=0.53; p<0.01) between FTSST times and a measure
of dynamic balance, TUG, in individuals with vestibular
deficits (11). In this study we showed that the FTSST cor-
related moderately with TUG, indicating the FTSST is a
ance during performance of the task. The complex nature
of the FTSST task, particularly incorporating control of the
center of mass bi-directionally over the base of support to
avoid losses of balance, renders it a useful measure of bal-
ance impairment and fall risk in older adults.
The ICC2,1, a measure of relative reliability, was ex-
cellent, exceeding the value of 0.89 reported by others in
community-dwelling older adults (2). It has been sug-
gested that for clinical measures, reliability coefficients
should exceed 0.90 (18). Evaluation of absolute reliabili-
ty of the FTSST was conducted by computing the 95%
LOA (19) as well as the SEM (16, 17). The 95% LOA
was narrow and included zero, indicating excellent abso-
lute reliability of the FTSST with no statistical evidence of
systematic bias across repeated trials. Measurement error
computed as the SEM was low in absolute terms as well
as when expressed as a percentage of mean FTSST.
The low SEM and low measurement error percent values
(SEM%) suggest excellent absolute reliability of the FTSST
in older adults. Our comprehensive analyses of the rela-
tive and absolute reliability of the FTSST indicating a
high ICC and low SEM and SEM% values, suggests ex-
5
4
3
2
Difference (s)

valid measure of dynamic balance and functional mobili- 1

ty in older adults. These data add to the body of evidence 0
indicating that sit-to-stand performance is associated with -1
balance capabilities in older adults. As expected, the re- -2
lationship between FTSST and FR was weaker. -3
Sit to stand is a dynamic and complex mobility task un- -4
dertaken multiple times on a daily basis by older adults. -5
Deficits in sit-to-stand performance in older adults (21) and 0 5 10 15 20 25
after stroke (22) are associated with risk for falling. Al- Mean five-times-sit-to-stand (s)
ternately raising and lowering the trunk and body center
Fig. 1 - Bland-Altman plot for the five-times-sit-to-stand test.
of mass during the FTSST requires coordinated func- Means on the x-axis are the average of two trials for the five-times-
tioning from multiple lower extremity muscle groups in- sit-to-stand test; differences on the y-axis are five-times-sit-to-
cluding trunk musculature to effect the requisite move- stand test difference scores (trial 1 minus trial 2). The 95% lim-
its of agreement (LOA) are depicted (dashed lines). The 95%
ments. Coordinated trunk and lower extremity muscle LOA include zero, indicating no systematic bias in performance
functioning are also likely required to prevent losses of bal- between the two trials of the five-times-sit-to-stand test.

Aging Clin Exp Res, Vol. 24, No. 4 342

A. Goldberg, M. Chavis, J. Watkins et al.
cellent levels of reliability and reproducibility of this test in
older adults.
The MDC95 as computed in this study indicates that for
a change (increase or decrease) in FTSST times to be con-
sidered real change beyond that of measurement error, it
should exceed 2.5 seconds. The MDC95 interpretation is
that the majority of individuals who have truly remained
stable in FTSST performance will display variation of
not more than 2.5 seconds on repeated assessments of
the FTSST. If a change score exceeds 2.5 seconds, one
can be 95% confident that it is a real change; change less
than this value is considered to be attributable to mea-
surement error. This value can guide clinicians in their in-
terpretation of FTSST change scores to evaluate the ef-
fectiveness of therapeutic interventions. Researchers can
use this minimum change score as a benchmark to eval-
uate the success of interventions conducted during clini-
cal trials.
While knowledge of the absolute value of the MDC95
is useful in clinical practice, expressing the MDC95 as a
percent of the mean FTSST enhances interpretability
of the absolute MDC value (20). Expressing MDC inde-
pendent of the units of measurement as a percentage of
the mean provides information as to the sensitivity of a
measure to detect change, with lower MDC95% values
suggesting greater sensitivity to detecting real change in
performance. The MDC95% of 17.5% computed in this
study may be considered a low minimum change percent
value, suggesting that the FTSST may be sensitive to de-
tecting real change in sit-to-stand performance in older
adults. Low measurement error and minimum change per-
cent values support the use of the FTSST as an out-
comes measure of physical performance in geriatric re-
search trials and in clinical practice.
This study has a number of limitations. Some test-
retest studies include observations of performance from
testing sessions one week apart (23), while others involve
a number of observations from a single testing session
(10). In the present study testing was conducted at a sin-
gle session, and therefore testers had knowledge of the
FTSST “test” value when measuring the “retest” trial, a
potential source of bias. To reduce bias, the testers ad-
hered strictly to the testing procedures with which they
were familiarized prior to initiation of data collection. A
second limitation is that evaluation of intra-rater reliability
was not performed as part of this study. A third limitation
is that we recruited a sample of convenience consisting
of older community-dwelling female participants who,
based on self-report, were in most cases fairly active and
in good to excellent health. The SEM and MDC values
computed here may therefore differ in samples of older
adults who are frailer such as individuals in nursing
homes and in assisted living facilities. Therefore caution
should be exercised in generalizing these results to all old-
er adults. A fourth limitation is that we did not address a
343 Aging Clin Exp Res, Vol. 24, No. 4
more individual-centered approach to change in per-
formance, the minimal clinically important difference, de-
fined as the smallest clinical change that would be con-
sidered meaningful, worthwhile and beneficial by an in-
dividual (24, 25).
Future studies of measurement error and minimum
change in FTSST should blind testers as to the purpose of
the study, in order to reduce tester bias. Future studies
should include males, as well as individuals who are more
sedentary and who have a greater disease burden than the
present cohort. Future studies should also include evalu-
ation of FTSST rater reliability as well as minimal clinically
important difference, which represents change that is
important to the individual.
CONCLUSION
These data highlight a moderate relationship between
the FTSST and TUG, indicating that the FTSST is a
valid measure of dynamic balance and functional mobili-
ty in older adults. The high ICC and low SEM and SEM%
values suggest excellent relative and absolute reliability and
reproducibility of the FTSST in older adults. Change in
FTSST performance should exceed 2.5 seconds to be
considered real change beyond measurement error. The
threshold for real change in FTSST performance re-
ported here can be used in geriatric research trials and in
clinical practice to evaluate the effectiveness of therapeutic
interventions.
ACKNOWLEDGEMENTS
Dr. Goldberg was supported by a Fellowship for Advanced Study in
Aging and Lifespan from the Institute of Gerontology and Office of the
Vice President for Research at Wayne State University. The financial
sponsors played no role in the design, execution, analysis, and inter-
pretation of data, or in the decision to publish this manuscript.
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