Review

M. Jakobsson, RPT, PhD, Back in Mo-

Level of Evidence for Reliability, tion Research Group, Department of
Orthopaedics, Institute of Clinical Sci-

Validity, and Responsiveness of ences, University of Gothenburg, Möl-

ndal Hospital, Göteborgsvägen 31, 431
80 Mölndal, Gothenburg, 41326 Swe-
Physical Capacity Tasks Designed to den. Address all correspondence to Dr
Jakobsson at: max.jakobsson@gu.se.

Assess Functioning in Patients With A. Gutke, RPT, PhD, Division of Physio-

therapy, Department of Health and Re-

Low Back Pain: A Systematic Review habilitation, Institute of Neuroscience

and Physiology, University of Gothen-
burg.
Using the COSMIN Standards

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L.B. Mokkink, PhD, Department of Epi-
demiology and Biostatistics, Amster-
Max Jakobsson, Annelie Gutke, Lidwine B. Mokkink, Rob Smeets, Mari Lundberg dam Public Health Research Institute,
VU University Medical Center, Amster-
dam, the Netherlands.
Background. Physical capacity tasks (ie, observer-administered outcome measures that R. Smeets, MD, PhD, Department
comprise a standardized activity) are useful for assessing functioning in patients with low of Rehabilitation Medicine, Research
back pain. School of CAPHRI, Maastricht Univer-
sity, Maastricht, the Netherlands; and
Purpose. The purpose of this study was to systematically review the level of evidence CIR Revalidatie, Eindhoven, the Nether-
for the reliability, validity, and responsiveness of physical capacity tasks. lands.
M. Lundberg, RPT, PhD, Division
Data Sources. MEDLINE, CINAHL, PsycINFO, Scopus, the Cochrane Library, and rele- of Physiotherapy, Department of
vant reference lists were used as data sources. Health and Rehabilitation, Institute of
Neuroscience and Physiology, Univer-
Study Selection. Two authors independently selected articles addressing the reliabil- sity of Gothenburg; Department of
Orthopaedics, Sahlgrenska University
ity, validity, and responsiveness of physical capacity tasks, and a third author resolved
Hospital, Gothenburg, Sweden; and
discrepancies.
Division of Physiotherapy, Department
of Neurobiology, Care Sciences and
Data Extraction and Quality Assessment. One author performed data extraction, Society (NVS), Karolinska Institutet,
and a second author independently checked the data extraction for accuracy. Two authors Stockholm, Sweden.
independently assessed the methodological quality with the Consensus-Based Standards [Jakobsson M, Gutke A, Mokkink LB,
for the Selection of Health Measurement Instruments (COSMIN) 4-point checklist, and a Smeets R, Lundberg M. Level of ev-
third author resolved discrepancies. idence for reliability, validity, and re-
sponsiveness of physical capacity tasks
Data Synthesis and Analysis. Data synthesis was performed by all authors to de- designed to assess functioning in pa-
termine the level of evidence per measurement property per physical capacity task. The tients with low back pain: a systematic
5-repetition sit-to-stand, 5-minute walk, 50-ft (∼15.3-m) walk, Progressive Isoinertial Lifting review using the COSMIN standards.
Phys Ther. 2019;99:457–477.]
Evaluation, and Timed “Up & Go” tasks displayed moderate to strong evidence for positive

C The Author(s) 2018. Published by
ratings of both reliability and construct validity. The 1-minute stair-climbing, 5-repetition
sit-to-stand, shuttle walking, and Timed “Up & Go” tasks showed limited evidence for Oxford University Press on behalf of
the American Physical Therapy Asso-
positive ratings of responsiveness.
ciation. This is an Open Access ar-
ticle distributed under the terms of
Limitations. The COSMIN 4-point checklist was originally developed for patient- the Creative Commons Attribution Li-
reported outcome measures and not physical capacity tasks. cense (http://creativecommons.org/li
censes/by/4.0/), which permits unre-
Conclusions. The 5-repetition sit-to-stand, 50-ft walk, 5-minute walk, Progressive Isoin- stricted reuse, distribution, and repro-
ertial Lifting Evaluation, Timed “Up & Go,” and 1-minute stair-climbing tasks are promising duction in any medium, provided the
tests for the measurement of functioning in patients with chronic low back pain. However, original work is properly cited.
more research on the measurement error and responsiveness of these tasks is needed to Published Ahead of Print:
be able to fully recommend them as outcome measures in research and clinical practice. December 18, 2018
Accepted: October 23, 2018
Submitted: July 15, 2018

2019 Volume 99 Number 4 Physical Therapy  457

Systematic Review of Physical Capacity Tasks
R
esearch suggests that low back pain (LBP) causes
more years lived with disability than any other
condition.1 Many patients with acute LBP recover
quickly, but the pain becomes a chronic condition for
some, with significant consequences related to restricted
functioning.2 The measurement of functioning is complex
and covers multidimensional constructs.3 Functioning is
divided into 3 domains according to the International
Classification of Functioning, Disability, and Health (ICF).
The body functions and structures domain refers to
psychological and physiological processes and anatomical
structures; the activity domain refers to people’s ability to
perform activities in their daily life; and the participation
domain describes people’s interactions with their
sociocultural environment (eg, when buying groceries,
participating in sports, or working).3 Researchers have
argued for the use of outcome measures that specifically
measure functioning in the activity domain.4–6
The ICF activity domain is typically measured with
patient-reported outcome measures (PROMs), with which
patients rate their perceived ability to perform various
activities in their usual environment.7–11 PROMs are
relatively time saving, easy to administer, and, importantly,
include the patient’s perspective.12 However, PROMs as
used in LBP research have shown both floor and ceiling
effects as well as low- to very-low-quality evidence for
content validity.13,14 Clinical experience and scientific
evidence also indicate frequent discrepancies between
how patients score PROMs and how they actually move
and perform activities when observed in the clinic.15–17
Several authors5,6,16–18 have therefore recommended the
use of physical capacity tasks that measure the capacity
qualifier of the ICF activity domain,5,6,16–18 defined as “the
ability to execute a task or an action in a standardized
environment.”3 In a physical capacity task, a patient
performs a standardized activity that is administered by an
observer using predefined criteria such as repetition
counts or task timing.18
Physical capacity tasks are designed to assess what
patients actually can do rather than what they think they
can do, and can therefore capture important information
about functioning that PROMs often do not.17,19,20 Physical
capacity tasks also appear to be less influenced by
education level and language skills compared with
PROMs.17,18,21,22
All outcome measures should have sufficient support for
their reliability, validity, and responsiveness in order to be
used in research or in clinical practice. Otherwise, there is
a significant risk of imprecise or biased results that might
lead to incorrect conclusions regarding the patient’s level
of functioning.23–25 However, to our knowledge, no study
has yet summarized the level of evidence of measurement
properties of physical capacity tasks for patients with LBP.
458  Physical Therapy Volume 99 Number 4
The objective of this study was to systematically review
the level of evidence of the measurement properties of
physical capacity tasks that are designed to assess
functioning in patients with LBP.
Methods
The study protocol was registered at the International
Prospective Register of Systematic Reviews (PROSPERO;
http://www.crd.york.ac.uk/PROSPERO; registration
number: CRD42016042011). We followed the working
procedure developed by the Consensus-Based Standards
for the Selection of Health Measurement Instruments
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(COSMIN) for conducting a systematic review of
measurement properties.23 The systematic review was
reported according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA).26
Data Sources and Searches
The electronic data sources were MEDLINE (through the
Ovid interface), CINAHL (EBSCOhost), PsycINFO (Ovid),
Scopus (Elsevier), and the Cochrane Library (Wiley). The
reference lists of the articles from the electronic data
sources that were identified for full-text reading were used
as additional data sources.
A search strategy was developed in collaboration with 2
medical librarians who also performed the search
(eAppendix 1, available at https://academic.oup.com/ptj).
The search strategy included 4 main filters, specifically
tailored for each electronic information source: target
population (ie, LBP), the construct of interest (ie,
capacity), type of outcome measures (ie, physical capacity
tasks), and article type (ie, articles on the reliability,
validity, and responsiveness of outcome measures). The
search strategy was based on a preliminary search strategy
as described in the PROSPERO protocol. Improvements of
the preliminary search strategy included: (1) adaptation of
a validated search filter for measurement properties;27 (2)
addition of the specific names of all physical capacity
tasks identified by the preliminary search strategy; (3) use
of the Ovid interface rather than PubMed for MEDLINE
due to the benefit of positional operators; and (4) the
addition of supplementary search terms for LBP. The first
search with the final search strategy was performed on
May 11, 2017 (no limitations for publication period) and
an updated search was performed on August 29, 2018
(publication period from January 1, 2016). No restrictions
were applied for language. Two authors (M.J. and either
A.G. or M.L.) independently performed a hand search of
the reference lists of all articles that had been identified
for full-text reading.
Study Selection
Two authors (M.J. and either A.G. or M.L.) independently
screened the titles and abstracts of articles from the
electronic and hand searches. A third author (R.S.) was
consulted to resolve the disagreement if consensus could
not be reached on the eligibility of articles for full-text
2019

review. Two authors (M.J. and A.G., R.S., or M.L.) then
independently reviewed the full-text articles for eligibility,
and a third author (A.G., R.S., or M.L.) was consulted if
needed for consensus.
Articles that met 4 criteria (target population, construct,
outcome measure, and article type) were included.
Target population. Patients in the study population
were at least 18 years old and had had LBP for 6 weeks or
more.28 Articles that contained pregnant participants or
participants with fibromyalgia, confirmed rheumatic
diseases, infections, tumors, osteoporosis, fractures,
structural deformities (eg, scoliosis), or cauda equina
syndrome were excluded unless data were presented
specifically for patients who met the eligibility criteria.
Construct. The test was a measure of “capacity” under
the ICF activity domain, defined as the ability to execute a
task or an action in a standardized environment.3
Outcome measure. The test was a physical capacity
task, defined as a standardized test that is used for an
evaluative purpose and that is administered by an
observer, includes an activity (as classified by the ICF) that
is performed in a standardized setting, and requires
readily available, low-cost, and portable equipment.
Articles that exclusively investigated test batteries and did
not present results for individual physical capacity tasks
were excluded. If an article cited an original test manual
that could then not be obtained, the test was excluded.
Article type. The article presented original data
reporting the reliability (including reliability, measurement
error, and internal consistency), validity (including content
validity, construct validity, and criterion validity), or
responsiveness of physical capacity tasks.29
Data Extraction and Quality Assessment
A pilot version of a data extraction form was developed by
the first author (M.J.) and piloted by 3 authors (M.J., R.S.,
and M.L.) on 5 randomly selected, included articles. The
data extraction form was modified in response to the pilot
to include the following 6 data items: (1) patient sample
characteristics; (2) eligibility criteria; (3) setting; (4)
procedure and equipment for performing the physical
capacity tasks; (5) results of the measurement properties,
and (6) minimal important change. Minimal important
change is not considered a measurement property in the
COSMIN taxonomy29 but was included in the data
extraction form because this measure is necessary to
determine the level of evidence for measurement error.30
Data from all included articles were subsequently
extracted by 1 author (M.J.) and then independently
checked for accuracy by a second author (A.G., R.S., or
M.L.).
2019
Systematic Review of Physical Capacity Tasks
Two authors (M.J. and M.L.) independently assessed all of
the included studies for methodological quality using the
COSMIN 4-point checklist,31,32 and a third author (A.G.,
R.S., or L.B.M.) was consulted if needed to reach
consensus. The COSMIN 4-point checklist is specifically
designed to determine methodological quality scores of
studies of measurement properties. The scores (excellent,
good, fair, or poor) are assigned for each measurement
property using the “worst score counts method.”31,32 The
item for sample size in the checklist was excluded from
the “worst score counts method” as recommended when
performing systematic reviews of measurement properties
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of physical capacity tasks.33 The rating authors (M.J. and
M.L.) pretested and then discussed the ratings of the
checklist with a third author (L.B.M.) to achieve
consistency in scoring, as recommended to ensure the
validity of the scoring method.34
Data Synthesis and Analysis
A “best-evidence synthesis” approach was performed by
consensus of all authors to synthesize the level of
evidence of measurement properties per physical capacity
task.35 This procedure is similar to the Grading of
Recommendations Assessment, Development, and
Evaluation (GRADE),36 but different in that the
best-evidence synthesis determines the level of evidence
for the results of measurement properties, rather than the
results of clinical trials.23 First, the results of each
measurement property for each physical capacity task
were rated as “positive,” “negative,” or “indeterminate”
according to result rating criteria accepted with consensus
in an international Delphi study (Tab. 1).30 Then, the level
of evidence for the ratings of measurement properties was
determined on the basis of the consistency of the result
ratings of the measurement properties, the sample size of
the combined eligible articles, and the methodological
quality of the articles. Multiple articles were combined if
they concerned the same physical capacity task and
included samples with comparable characteristics. The
possible levels of evidence were assigned according to 5
criteria (strong, moderate, limited, unknown, and
conflicting) used in previous systematic reviews of the
reliability, validity, and responsiveness of physical capacity
tasks.33,35
Strong. This criterion encompassed consistent result
ratings in at least 2 good-quality articles or at least 1
excellent-quality article, with a total sample size of eligible
articles equal to or greater than 100.
Moderate. This criterion encompassed consistent result
ratings in at least 2 fair-quality articles or 1 good-quality
article, with a total sample size of eligible articles equal to
or greater than 50.
Limited. This criterion encompassed at least 1 fair-,
good-, or excellent-quality article, with a total sample size
of eligible articles of 25 to 49.
Volume 99 Number 4 Physical Therapy  459
Systematic Review of Physical Capacity Tasks

Table 1.
Criteria for Result Ratings of Measurement Propertiesa

Measurement Property Ratingb Criterion for Result Rating

Reliability + ICC or weighted κ ≥0.70

? ICC or weighted κ not reported

− Criteria for “+” not met

Measurement error + SDC or LoA < MICc

? MIC not defined

− Criteria for “+” not met

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Hypothesis testing for construct validity + 75% of the results in accordance with the hypotheses

? No hypotheses defined

− Criteria for “+” not met

Criterion validity + Correlation with gold standard ≥ 0.70 or AUC ≥ 0.70

? Not all information for “+” reported

− Criteria for “+” not met

Responsiveness + 75% of the results in accordance with the hypotheses or AUC ≥ 0.70

? No hypotheses defined

− Criteria for “+” not met

a
Based on Prinsen et al. AUC = area under the receiver operating characteristic curve; ICC = intraclass correlation coefficient; LoA = limits of
30

agreement; MIC = minimal important change; SDC = smallest detectable change.

b
+ = positive rating; ? = indeterminate rating; − = negative rating.
c
This evidence can come from different studies.

Unknown. This criterion encompassed the following 4 Results

options: indeterminate result ratings, all eligible articles
were of poor methodological quality, the total sample size
of eligible articles was less than 25, or conflicting result
ratings.
Conflicting. This criterion encompassed conflicting
findings.
If an article lacked a priori hypotheses for validity and
responsiveness, we extracted what the authors had
expected in relation to those measurement properties
from the description found in the article. We generated
our own hypotheses for validity and responsiveness based
on these descriptions, which were then added to the data
synthesis (eAppendixes 2 and 3, available at
https://academic.oup.com/ptj).
Role of the Funding Source
This review was supported by AFA Försäkring 120216, the
Eurospine Research Grants 8-2014, the Health and Medical
Care Executive Board of the Västra Götaland Region, and
Vetenskapsrådet 2015-02511. The funders played no role
in the study design, data analysis, interpretation of data, or
writing of the manuscript. The views expressed here are
those of the authors and do not necessarily reflect those of
the funding sources.
Study Selection and Characteristics
The search of electronic data sources and the hand search
of reference lists resulted in 7900 articles after duplicates
had been removed (Figure). Of these, 25 articles fulfilled
the eligibility criteria (Tab. 2). The included articles
comprised 18 physical capacity tasks that involved the
following activities: walking (10 tasks), stair-climbing (1
task), lifting (3 tasks), rising from a chair (2 tasks), a
combination of walking/rising from a chair (1 task), and a
combination of walking and carrying (1 task) (Tab. 3).
One article included patients with a pain duration of at
least 6 weeks (“subacute” LBP28 ),37 whereas the rest
included patients with a pain duration of at least 12 weeks
(“chronic” LBP28 ). Eleven articles included patients with
back-related diagnoses known to affect walking capacity
severely.15,20,38–46 Of these, 1 article included patients with
lumbar spondylolisthesis and postlaminectomy,38 6 articles
included patients with lumbar spinal stenosis,20,39–43 3
articles included patients with lumbar disk herniation and
lumbar spinal stenosis,15,44,45 and 1 article included
patients with lumbar disk herniation, lumbar spinal
stenosis, and spondylolisthesis.46
The included articles investigated 5 measurement
properties: reliability, measurement error, construct

460  Physical Therapy Volume 99 Number 4 2019

 Systematic Review of Physical Capacity Tasks

12,301 Articles Identified Through 2302 Articles Identified Through 1557 Articles Identified Through
the First Database Search the Second Database Search Hand Search of 362 Reference
[Inception – May 11, 2017] [Jan 1, 2016 – Aug 29, 2018] Lists

7900 Articles After Duplicates Removed

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Abstracts of 7900 Articles Screened 7440 Articles Excluded

435 Full-Text Articles Excluded:

460 Full-Text Articles Assessed for Eligibility 1. Original data not included: 201

2. Wrong condition or not fulfilling inclusion criteria for

age: 47

3. Tests not adequately described or original reference

for test procedure not obtained: 14

25 Articles Included in the Data Extraction 4. Wrong construct: 65

(of which, 5 were from hand search)
5. Tests not evaluated by an observer: 15

6. Insufficient standardization/expensive equipment: 18

7. Aim was not to evaluate measurement properties: 69

8. Results only presented for composite score of a test

25 Articles Included in the Methodological battery: 5
Quality Assessment
Full-text articles not found: 1

3 Articles Not Included in the Data Synthesis

22 Articles Included in the Data Synthesis for Any Measurement Property
(poor methodological quality)

Figure.
Flow of information through the different phases of the systematic review.

validity (hypothesis testing), criterion validity, and
responsiveness.
Quality Assessment and Data Synthesis
Reliability. The results for reliability are shown in
Table 4. Regarding methodological quality, 11 articles
investigated reliability.5,17,37,39,40,42,46–50 Three studies of
reliability in 1 article48 were rated as poor for
methodological quality and therefore excluded from the
best-evidence synthesis. The poor scores were due to the
fact that patients received treatment between the first and
second administration of the tasks.
With regard to best-evidence synthesis, a strong level of
evidence for positive ratings for test-retest reliability was
found for 3 tasks (50-ft [∼15.3-m] walk, 5-minute walk,
and 5-repetition sit-to-stand tasks). A moderate level of
evidence for positive ratings for test-retest reliability was
found for 4 tasks (1-minute stair-climbing, Progressive

2019 Volume 99 Number 4 Physical Therapy  461

462

Table 2.

Physical Therapy
Characteristics of Included Studies in Alphabetical Order of First Authors’ Namesa

Patient-
Sample Age, Eligible
Criteria for Setting Back Pain Back Pain Reported
Study Size Mean (SD) Physical
Patient Inclusion (Country) Durationb Intensityb Disability,
(% Women) [Range] Capacity Task

Volume 99
Mean (SD)
Andersson Nonspecific LBP for >3 198 (47) 41.9 (9.1) Tertiary care Median: 24.0 VAS: 48.9 RMDQ: 13.8 (3.6) 1 min of stair climbing,
et al51 (2010) mo (the Netherlands) mo (IQR: (24.7) 5-min walk, 50-ftc walk,
12.0–73.0 PILE, sit-to-stand
mo)

Number 4
Armstrong LBP for ≥6 mo 10 (80) 40.8 (11.3) Tertiary care 77.1 (35.8) VAS: 46 (23) Shuttle walking test
Systematic Review of Physical Capacity Tasks

et al52 (2005) (United Kingdom) mo

Campbell LBP for >12 mo,
et al38 (2006) considered for surgical
stabilization of the spine
(unspecified LBP,
spondylolisthesis, or
postlaminectomy)
250 (44) 40 (8.7) Hospitals 7.6 (6.7) y ODI for improved: Shuttle walking test
[19–55] (United Kingdom) 42.6 (13.6); ODI
for stable: 46.8
(13.7); ODI for
deteriorated: 51.8
(13.5)

Conway Lumbar spinal stenosis 12 (25) 66.3 (9.8) Tertiary care 4.7 (1.5) y VAS: 39.9 ODI: 48.9 (11.6); Self-paced walking test
et al20 (2011) [53–81] (United States) (27.0) QBPDS: 48.2 (16.8)

Deen et al39 Lumbar spinal stenosis 28 (39.3) 73.8 [57–91] Treadmill examination
(2000) (only the test parameter
“total ambulation”)

Gautschi Lumbar disk herniation, 253 (42.3) 58.4 (16.1) Hospitals VAS: 39.1 RMDQ: 11.8 (5.2); Timed “Up & Go” Test
et al15 (2016) lumbar spinal stenosis, (Switzerland) (28.5); VAS ODI: 48.4 (20.8)
and lumbar degenerative for the leg:
disk disease scheduled for 48.8 (29.0)
lumbar spine surgery

(continued)

2019
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 2019
Table 2.
Continued

Patient-
Sample Age, Eligible
Criteria for Setting Back Pain Back Pain Reported
Study Size Mean (SD) Physical
Patient Inclusion (Country) Durationb Intensityb Disability,
(% Women) [Range] Capacity Task
Mean (SD)
Gautschi Lumbar disk herniation, 136 (44.1) 57.7 (15.8) Hospitals VAS: 45.6 ODI: 45.6 (17.6); Timed “Up & Go” Test
et al45 (2016) lumbar spinal stenosis, (Switzerland) (17.6); VAS RMDQ: 11.3 (5.1)
and lumbar degenerative for the leg:
disk disease scheduled for 5.5 (2.6)
lumbar spine surgery

Gautschi Lumbar disk herniation, 100 (43) 56.2 (16.1) Hospitals VAS: 38.0 RMDQ: 12 (5); Timed “Up & Go” Test
et al44 (2017) lumbar spinal stenosis, (Switzerland) (10); VAS for ODI: 46 (18)
and lumbar degenerative the leg: 55.0
disk disease scheduled for (28)
lumbar spine surgery

Kahraman Nonspecific LBP for >12 38 (37) 35 (10) 7 (3) mo VAS with ODI: 22.6 (14.2) 30-s chair stand test
et al47 (2016) wk rest: 21.3
(15.1); VAS
with activity:
64.5 (20.1)

Lee et al19 LBP with mechanical, 83 (57.8) 45.64 (10.12) Orthopedic spine 108.2 (127.9) VAS: 36.9 RMDQ: 10.4 (6.1) 5-min walk, 50-ft walk,
(2001) structural, or nonspecific [24–65] clinic (United mo (27.0) 5-repetition sit-to-stand
origins States)

Magnussen LBP for >8 wk 32 (66%) 38.1 (9.2) Tertiary care RMDQ: 10.0 (4.0); Lift test
et al37 (2004) (Norway) FFbH-R: 22.5 (4.9)

Ocarino Nonspecific LBP for ≥3 30 43.16 (11.23) University clinic 42.3 (80.6) RMDQ: 9.9 (3.7) 50-ft walk, sit-to-stand
et al53 (2009) mo (Brazil) mo

Volume 99
Odebiyi LBP for ≥3 mo with 23 [25–65] Two hospitals VAS for men: RMDQ for men: 8.4 50-ft walk, 5-min walk,
et al54 (2007) radiating leg pain (Nigeria) 45.2 (19.4); (5.3); RMDQ for 5-repetition sit-to-stand
VAS for women: 9.6 (4.9)
women: 64.1

Number 4
(22.4)

Pratt et al40 Lumbar spinal stenosis 29 (41) 69 [49–82] Orthopedic hospital ODI: 39.8 (16.5) Shuttle walking test
(2002) (United Kingdom)

(continued)

Physical Therapy 
463
Systematic Review of Physical Capacity Tasks

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464

Table 2.
Continued

Physical Therapy
Patient-
Sample Age, Eligible
Criteria for Setting Back Pain Back Pain Reported
Study Size Mean (SD) Physical
Patient Inclusion (Country) Durationb Intensityb Disability,
(% Women) [Range] Capacity Task
Mean (SD)
Rainville et al41 Lumbar spinal stenosis 50 (42) 68 (7.9) Spine center of a VAS: 61; VAS ODI: 35 Motorized treadmill test,

Volume 99
(2012) [48–86] hospital for the leg: self-paced walking test
(United States) 54

Simmonds Nonspecific, mechanical 44 (63.6) 42.6 Orthopedic clinic 12.4 (20.8) VAS: 27.3 RMDQ: 8.3 (6.0) 1 min of stair climbing,
et al17 (1998) LBP (United States) [1–72] mo (23.9) 5-min walk, 50-ft walk,

Number 4
[0.0–7.2] 50-ft walk (preferred
speed), 5-repetition
Systematic Review of Physical Capacity Tasks

sit-to-stand

Smeets Nonspecific LBP for >3 53 (52.8) 43.19 (9.27) Tertiary care 53.4 (67.7) VAS: 44.5 RMDQ: 13.2 (4.2) 1-min of stair climbing,
et al5 (2006) mo (the Netherlands) mo (23.5) 5-min walk, 50-ft walk,
PILE, 5-repetition
sit-to-stand

Soer et al55 LBP for >3 mo 53 (39.6) 38.5 (9.8) 250 (375) wk RMDQ: 9.2 (5.5) PILE
(2006)

Staartjes and Lumbar disk herniation, 157 (49) 49.9 (14.1) Outpatient spine VAS: 5.8 ODI: 43.0 (17.6); 5-repetition sit-to-stand
Schroder46 lumbar spinal stenosis, surgery clinic (the (2.8); VAS for RMDQ: 11.7 (5.3)
(2018) spondylolisthesis, Netherlands) the leg: 7.4
degenerative disk disease (2.0)

Strand LBP for >3 mo 114 (60) 43.9 (10.6) Tertiary care 10 (9.0) y VAS: 52.6 Disability Rating Lift test
et al56 (2002) (Norway) (20.5) Index: 56.2 (13.3)

Strand LBP for >3 mo 98 (49.0) 37.4 (10.4) Tertiary care RMDQ: 11.8 (4.4); 15-m walk test, lift test
et al48 (2011) [18–60] (Norway) FFbH-R: 7.9 (5.3) (modified), PILE

Taylor Mechanical LBP with or 44 (59.2) 48.2 (9.1) Tertiary care (Great ODI: 28.5
et al49 (2001) without sciatica for ≥6 Britain)
mo

(continued)

2019
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 2019
Table 2.
Continued

Patient-
Sample Age, Eligible
Criteria for Setting Back Pain Back Pain Reported
Study Size Mean (SD) Physical
Patient Inclusion (Country) Durationb Intensityb Disability,
(% Women) [Range] Capacity Task
Mean (SD)
Teixeira da LBP for >3 mo 30 (63.3) 33.0 (10.6) Tertiary care (Brazil) VAS: 44 (26) RMDQ: 9.8 (5.8) 50-ft walk, 5-min walk,
Cunha-Filho 5-repetition sit-to-stand,
et al50 (2010) Timed “Up & Go” Test

Tomkins Lumbar spinal stenosis 45 (57.8) 66.9 (9.6) 10 (11) y; leg Self-paced walking test,
et al42 (2009) pain: 7 (9) y treadmill protocol

Whitehurst Lumbar spinal stenosis 57 (56.1) Men: 69 (5); Treadmill walking test,
et al43 (2001) women: 70 (3) weight-carrying test
a
FFbH-R = Hannover Functional Ability Questionnaire; IQR = interquartile range; LBP = low back pain; ODI = Oswestry Disability Index; PILE = Progressive Isoinertial Lifting Evaluation;
QBPDS = Quebec Back Pain Disability Scale; RMDQ = Roland-Morris Disability Questionnaire; SD = standard deviation; VAS = 100-mm visual analog scale.
b
Reported as mean (SD) [range] unless otherwise indicated.
c
50 ft ≈ 15.3 m.

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Systematic Review of Physical Capacity Tasks
Table 3.
Brief Descriptions of Included Physical Capacity Tasks
Physical Capacity Task
1-min stair climbing
30-s chair stand test
5-repetition sit-to-stand
50-fta walk
50-ft walk, preferred speed
5-min walk
Lift test
Lift test, modified
Motorized treadmill test
Progressive isoinertial lifting
evaluation
Self-paced walking test
Shuttle walking test
Timed “Up & Go” Test
Treadmill examination, 1.2
mphb
Treadmill examination,
preferred speed
Treadmill protocol
Treadmill walking test
Weight-carrying test
a
50 ft ≈ 15.3 m.
b
1.2 miles ≈ 1.9 km.
466  Physical Therapy
Activity Quantification Measure Equipment Needed
Stair climbing No. of stairs climbed in 1 min A flight of stairs with handrails,
stopwatch
Rising from a chair No. of repetitions (sitting to standing) performed in Chair, stopwatch
30 s
Rising from a chair Seconds to complete 5 repetitions of sitting to Chair, stopwatch
standing
Walking Seconds to complete a 50-ft course at maximum Measuring tape, stopwatch, markers
speed for indicating track end points
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Walking Seconds to complete a 50-ft course at preferred Measuring tape, stopwatch, markers
speed for indicating track endpoints
Walking Meters walked in 5 min Measuring tape, stopwatch, markers
for indicating track end points
Lifting Ordinal scale of no. of repetitions of lifting a box with Table, 1.35-kg box with 5-kg sandbag
a sandbag from floor to table and back
Lifting No. of repetitions of lifting a box from floor to table Table, 1.35-kg box with 5-kg sandbag
and back in 1 min (4 kg for women)
Walking Total walking time and distance walked at preferred Treadmill, stopwatch
speed (nonmodifiable during the test) at the moment
when walking-related symptoms make the
participant stop
Lifting Weight (in kg) of the box during the last completed Standardized box, an assortment of
cycle48 /no. of completed lifting cycles5,51 weights
Walking Total walking time, speed, and distance walked at the Distance instrument, stopwatch
moment when walking-related symptoms make the
participant stop
Walking Meters walked until the participant fails to complete a Standardized audiotape, measuring
predefined “shuttle” in the time allocated tape, markers for indicating track end
points
Rising from a chair Seconds to complete rising from a chair, walking 3 m, Chair, stopwatch
and walking turning around, walking back to the chair, and sitting
down
Walking Total time walked at 1.2 mph on a treadmill at the Treadmill, stopwatch
moment when walking-related symptoms make the
participant stop (time limit: 15 min)
Walking Total time walked at preferred speed on a treadmill at Treadmill, stopwatch
the moment when walking-related symptoms make
the participant stop (time limit: 15 min)
Walking Total distance, time, and average speed walked on a Treadmill, stopwatch
treadmill at preferred speed (modifiable during the
test) at the moment when symptoms of lumbar
spinal stenosis or other reasons make the participant
stop (time limit: 30 min)
Walking Distance walked at 53.6 m/min on a treadmill at the Treadmill, stopwatch, heart rate
moment when pain or fatigue makes the participant monitor
stop or when 70% of the predicted maximum heart
rate (70[220 – age]/100) is reached
Walking and Time needed to walk 20 m as quickly as possible Stopwatch, an assortment of
carrying while carrying dumbbells equaling 10% of the dumbbells
person’s weight
Volume 99 Number 4 2019
 2019
Table 4.
COSMIN Methodological Quality Ratings, Result Ratings, and Level of Evidence for Reliability and Measurement Error as Well as Minimal Important Change
Per Physical Capacity Taska

Reliability Measurement Error

Physical Study Sample Best-Evidence Best-Evidence

Study Result Result MICc
Capacity Task Designb Size COSMIN Synthesis: COSMIN Synthesis:
Ratings Ratings
Score32 Level of Score32 Level of
(+/?/−)30 (+/?/−)30
Evidence Evidence
1-min stair Andersson et al51 Test-retest 134 Test-retest: Poord SDC: 28.6 Test-retest: 14.5
climbing (2010) moderate (+) stepse (−) moderate (−) steps

Smeets et al5 Test-retest 53 Good ICC(1,1): Good LoA: ±14.7

(2006) 0.96 (+) steps (−)
(95% CI:
0.93–0.98)

30-s chair stand Kahraman et al47 Intrarater 38 Goodf ICC(2,1): Intrarater: limited No information
test (2016) 0.94 (+) (+)
(95% CI:
0.89–0.97)

5-repetition Andersson et al51 Test-retest 134 Test-retest: strong Poord SDC: 11.6 se Test-retest: strong −4.1 s
sit-to-stand (2010) (+); interrater: (−) (−); interrater:
unknown unknown

Simmonds et al17 Test-retest 44 Goodf ICC(1,k): Goodf SDC: 6.38 se

(1998) (participants 0.89 (+) (−)
tested on
different days)

Simmonds et al17 Test-retest 44 Fair ICC(1,1): Fair SDC: 18.46 se

(1998) (participants 0.45 (−) (−)

Volume 99
tested on the
same day)

Simmonds et al17 Interrater 22 Fair ICC(1,1): SDC: 1.14 se

(1998) 0.99 (+) (+)

Number 4
Smeets et al5 Test-retest 53 Good ICC(1,1): Good LoA: ±/7.6 s
(2006) 0.91(+) (−)
(95% CI:
0.84–0.94)

(continued)

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468

Table 4.
Continued

Reliability Measurement Error

Physical Therapy
Physical Study Sample Best-Evidence Best-Evidence
Study Result Result MICc
Capacity Task Designb Size COSMIN Synthesis: COSMIN Synthesis:
Ratings Ratings
Score32 Level of Score32 Level of
(+/?/−)30 (+/?/−)30
Evidence Evidence
Staartjes and Test-retest 66 Fair 0.97 (95% SDC: 4.1 se

Volume 99
Schroder46 (2018) CI:
0.94–0.98)

Teixeira da Test-retest 30 Fair ICC(2,1): Fair

Cunha-Filho et al50 0.99 (+)

Number 4
(2010)
Systematic Review of Physical Capacity Tasks

50-ftb,g walk Andersson et al51 Test-retest 133 Test-retest: strong Poord SDC: 3.0 se Test-retest: strong −0.7 s
(2010) (+); interrater: (−) (−); interrater:
unknown unknown

Simmonds et al17 Test-retest 44 Goodf ICC(1,1): Goodf SDC: 4.82 se

(1998) (participants 0.80 (+) (−)
tested on
different days)

Simmonds et al17 Test-retest 44 Fair ICC(1,1): Fair SDC: 1.19 se

(1998) (participants 0.99 (+) (−)
tested on the
same day)

Simmonds et al17 Interrater 22 Fairf ICC(1,1): Fairf SDC: 0.61 s

(1998) 0.99 (+) (+)

Smeets et al5 (2006) Test-retest 52 Good ICC(1,1): Good LoA: ±3.9 s

0.76 (+) (−)
(95% CI:
0.61–0.85)

Strand et al48 (2011) Test-retest 9 Poord ICC(2,1): Poord SDC: 0.6 s (+)
0.77 (+)
(95% CI:
0.24–0.94)

(continued)

2019
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 2019
Table 4.
Continued

Reliability Measurement Error

Physical Study Sample Best-Evidence Best-Evidence

Study Result Result MICc
Capacity Task Designb Size COSMIN Synthesis: COSMIN Synthesis:
Ratings Ratings
Score32 Level of Score32 Level of
(+/?/−)30 (+/?/−)30
Evidence Evidence
Teixeira da Test-retest 30 Fair ICC(2,1):
Cunha-Filho et al50 0.96 (+)
(2010)

50-ft walkg , Simmonds et al17 Test-retest 44 Good ICC(1,1): Test-retest: Goodf SDC: 7.10 se Unknown
preferred walking (1998) (participants 0.64 (−) conflicting; (?)
speed tested on interrater:
different days) unknown

Simmonds et al17 Test-retest 44 Fair ICC(1,1): Fair SDC: 2.74 se

(1998) (participants 0.95 (+) (?)
tested on the
same day)

Simmonds et al17 Interrater 22 Fairf ICC(1,1): Fair SDC: 1.52 se

(1998) 0.98 (+) (?)

5-min walk Andersson et al51 Test-retest 132 Test-retest: strong Poord SDC: 105.1 Test-retest: 21.4 m
(2010) (+) me (−) moderate (−)

Simmonds et al17 Test-retest 44 Goodf ICC(1,1): Goodf SDC: 100.3

(1998) (participants 0.99 (+) me (−)
tested on
different days)

Smeets et al5 (2006) Test-retest 53 Good ICC(1,1): Good LoA: ±82.7 m

0.89 (+) (?)

Volume 99
(95% CI:
0.81–0.93)

Teixeira da Test-retest 30 Fair ICC(2,1):

Cunha-Filho et al50 0.99 (+)
(2010)

Number 4
Lift test Magnussen37 (2004) Interrater 32 Goodf κ: 1.00 (+) Interrater, subacute No information
(95% CI: LBP: limited (+);
1.00–1.00) test-retest,
subacute LBP:
limited (−)

(continued)

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470
Table 4.


Continued

Reliability Measurement Error

Physical Study Sample Best-Evidence Best-Evidence

Study Result Result MICc
Capacity Task Designb Size COSMIN Synthesis: COSMIN Synthesis:
Ratings Ratings
Score32 Level of Score32 Level of
(+/?/−)30 (+/?/−)30
Evidence Evidence

Physical Therapy
Magnussen37 (2004) Test-retest 28 Goodf κ: 0.55 (−)
(95% CI:
0.51–0.59)

Lift test, modified Strand et al48 (2011) Test-retest 9 Poord ICC(2,1): Test-retest: Poord SDC: 6.5 Unknown 2.5

Volume 99
0.87 (+) unknown lifts/min (−) lifts/min
(95% CI:
0.50–0.97)

Progressive Andersson et al51 Test-retest 126 Test-retest: Poord SDC: 4.2 Test-retest: 1.5
isoinertial lifting (2010) moderate (+) stagese (−) moderate (−) stages

Number 4
evaluation
Systematic Review of Physical Capacity Tasks

Smeets et al5 (2006) Test-retest 50 Good ICC(1,1): Good LoA: ±2

0.92 (+) stages (?)
(95% CI:
0.87–0.96)

Strand et al48 (2011) Test-retest 9 Poord ICC(2,1): Poord SDC: 8.4 kg

0.91 (+) (?)
(95% CI:
0.65–0.98)

Self-paced walking Tomkins et al42 Test-retest 33 Fair ICC(3,1): Test-retest, LSS: No information
test (2009) 0.98 (+) limited (+)

Shuttle walking Armstrong et al52 Test-retest Test-retest: limited Goodf LoA: ±22 m Unknown
test (2005) (+); test-retest, (?)
LSS: limited (+)

Pratt et al40 (2002) Test-retest 29 Fairf ICC(?,?):

0.92 (+)

Taylor et al49 (2001) Test-retest 44 Fairf ICC(1,1): Fair LoA: ±49.5 m

0.99 (+) (?)

Timed “Up & Go” Gautschi et al44 Test-retest 18–62 Test-retest: Poord Average SDC: Test-retest:
Test (2017) moderate (+); 4.9 s (?) unknown; LDH/LSS/
interrater: test-retest, DDD:
unknown; LDH/LSS/DDD: 3.4 s
test-retest, unknown
LDH/LSS/DDD:
unknown

(continued)

2019
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 2019
Table 4.
Continued

Reliability Measurement Error

Physical Study Sample Best-Evidence Best-Evidence

Study Result Result MICc
Capacity Task Designb Size COSMIN Synthesis: COSMIN Synthesis:
Ratings Ratings
Score32 Level of Score32 Level of
(+/?/−)30 (+/?/−)30
Evidence Evidence
Simmonds et al17 Test-retest 44 Goodf ICC(1,k): Goodf SDC: 2.74 se
(1998) (participants 0.98 (+) (?)
tested on
different days)

Simmonds et al17 Test-retest 44 Fair ICC(1,1): Fair SDC: 1.16 se

(1998) (participants 0.98 (+) (?)
tested on the
same day)

Simmonds et al17 Interrater 22 Fairf ICC(1,1): Fairf SDC: 0.80 se

(1998) 0.99 (+)

Teixeira da Test-retest 30 Fair ICC(2,1):

Cunha-Filho et al50 0.92 (+)
(2010)

Treadmill Deen et al39 (2000) Test-retest 28 Fairf CCC: 0.90 Test-retest, LSS: No information
examination, 1.2 (+) limited (+)
mi/hh

Treadmill Deen et al39 (2000) Test-retest 28 Fairf CCC: 0.96 Test-retest, LSS: No information
examination, (+) limited (+)
preferred speed
a
CCC = concordance correlation coefficient (comparable to ICC67 ); COSMIN = Consensus-Based Standards for the Selection of Health Measurement Instruments; DDD = lumbar degenerative disk

Volume 99
disease; ICC = intraclass correlation coefficient; LBP = low back pain; LDH = lumbar disk herniation; LoA = limits of agreement; LSS = lumbar spinal stenosis; MIC = minimal important change;
SDC = smallest detectable change. + = positive rating: ICC or weighted κ ≥ 0.70 (reliability), or SDC or LoA < MIC (measurement error); ? = indeterminate rating: ICC or weighted κ not reported
(reliability) or MIC not defined (measurement error); − = negative rating: criteria for “+” not met.
b
Intrarater reliability = when presenting repeatedly the same observations to 1 observer; interrater reliability = when presenting the same observations to 2 or more observers; test-retest reliabil-
ity = when presenting the same task to the same subjects 2 or more times.68
c
The MIC (defined as “the smallest change in score that is perceived as important by patients”23 ) was added for reference because this value is needed to determine the result ratings for measurement

Number 4
error.66
d
Not included in the data synthesis because of the poor methodological score.23
e
The SDC (defined as “the smallest change that can be detected by the measurement instrument,
√ beyond measurement error”23 ) was calculated23 by the authors of the present systematic review by
multiplying the standard error of measurement presented in the original article by 1.96 × 2.
f
The rating changed after removal of the sample size item from the “worst score counts” summary in the COSMIN 4-point checklist.
g
50 ft ≈ 15.3 m.
h
1.2 miles ≈ 1.9 km.

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Systematic Review of Physical Capacity Tasks
Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks).
Four tasks were specifically evaluated for patients with
back-related diagnoses known to severely affect walking
capacity (self-paced walking test, shuttle walking test, and
treadmill examination at 1.2 mph [∼1.9 km/h] and at
preferred speed), and all of these had limited evidence for
positive ratings for test-retest reliability. Intrarater
reliability was assessed for 1 task (30-second chair stand
test), which had limited evidence for a positive rating.
Most of the tasks investigated for interrater reliability
displayed unknown evidence due to small sample sizes.
Measurement error. The results for measurement error
are shown in Table 4.
Regarding methodological quality, 8 articles investigated
measurement error.5,17,44,46,48,49,51,52 Nine studies of
measurement error in 3 articles44,48,51 were rated as poor
and therefore excluded from the best-evidence synthesis.
The poor scores were due to the fact that patients in the
articles received treatment between the first and second
administration of the tasks.
With regard to best-evidence synthesis, a moderate level of
evidence for negative ratings for measurement error was
displayed by the 1-minute stair-climbing, 5-minute walk,
and Progressive Isoinertial Lifting Evaluation tasks. A
strong level of evidence for negative ratings was displayed
by 50-ft walk and 5-repetition sit-to-stand tasks. The
negative ratings were a consequence of failure to meet the
criterion stating that the smallest detectable change must
be smaller than the minimal important change.30 The level
of evidence was unknown for 4 tasks (50-ft walk
[preferred speed] task, modified lift test, shuttle walking
test, and Timed “Up & Go” task), because the minimal
important change was not investigated.
Construct validity (hypothesis testing). The results for
construct validity (hypothesis testing) are shown in
eTable 1 (available at https://academic.oup.com/ptj).
With regard to methodological quality, 12 articles
investigated construct validity.17,19,20,41,43,44,47,48,50,53–55 Five
studies of construct validity in 2 articles53,54 were rated as
poor and therefore excluded from the best-evidence
synthesis. The poor scores were due to an absence of a
priori validity hypotheses (such as the hypothesized
correlation between 2 outcome measures required for
adequate validity).
With regard to best-evidence synthesis, a moderate level of
evidence for positive ratings of construct validity was
found for 6 tasks (50-ft walk task, 5-minute walk task,
modified lift test, Progressive Isoinertial Lifting Evaluation,
5-repetition sit-to-stand task, and Timed “Up & Go” task).
Limited evidence for positive ratings for construct validity
was found for 4 walking tasks investigated specifically for
patients with back-related diagnoses known to severely
472  Physical Therapy Volume 99 Number 4
affect walking capacity (Timed “Up & Go” task, motorized
treadmill test, treadmill walking test, and weight-carrying
test).
Criterion validity. The results for criterion validity are
shown in eTable 1.
With regard to methodological quality, 1 article
investigated criterion validity42 and was rated as good for
methodological quality and was therefore included in the
best-evidence synthesis.
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As regards best-evidence synthesis, the treadmill protocol
displayed limited evidence for a positive rating for
criterion validity for patients with lumbar spinal stenosis.
Responsiveness. The results for responsiveness are
shown in eTable 2.
Regarding methodological quality, 7 articles investigated
responsiveness.38,41,48,49,51,56,57 All studies of
responsiveness in the articles received either fair or good
scores and were therefore included in the best-evidence
synthesis.
With regard to best-evidence synthesis, a limited level of
evidence for positive ratings for responsiveness was found
for 3 tasks (1-minute stair-climbing task, shuttle walking
test, and 5-repetition sit-to-stand task). A moderate level of
evidence for negative ratings was found for 3 tasks (50-ft
walk task, modified lift test, and Progressive Isoinertial
Lifting Evaluation). A limited level of evidence for negative
ratings was found for 4 tasks (5-minute walk task, lift test,
motorized treadmill test, and self-paced walking test). A
limited level of evidence for a positive rating for
responsiveness was found for 1 task (Timed “Up & Go”
task) that was specifically for patients with back-related
diagnoses known to severely affect walking capacity.
Summary of the level of evidence. A summary of the
level of evidence is shown in Table 5.
The 5-repetition sit-to-stand task was the only physical
capacity task that displayed positive ratings for more than
2 measurement properties: test-retest reliability (strong
evidence), construct validity (moderate evidence), and
responsiveness (limited evidence). The 50-ft walk,
5-minute walk, Progressive Isoinertial Lifting Evaluation,
and Timed “Up & Go” tasks displayed moderate to strong
evidence for positive ratings for both test-retest reliability
and construct validity. The above-mentioned tasks,
however, also displayed moderate to strong evidence for
negative ratings for measurement error. The 1-minute
stair-climbing task and shuttle walking test displayed
positive ratings for responsiveness (limited evidence) as
well as for test-retest reliability (moderate evidence for
1-minute stair-climbing task and limited evidence for
shuttle walking test).
2019
 Systematic Review of Physical Capacity Tasks

Table 5.
Overview of the Level of Evidence Per Measurement Property Per Physical Capacity Taska

Physical Test-Retest Interrater Intrarater Measurement Hypothesis Criterion

Responsiveness
Capacity Task Reliability Reliability Reliability Error Testing Validity

1-min stair climbing Moderate (+) 0 0 Moderate (−) 0 0 Limited (+)

30-s chair stand 0 0 Limited (+) 0 Limited (+) 0 0

5-repetition Strong (+) Unknown 0 Strong (−) Moderate (+) 0 Limited (+)
sit-to-stand

50-ftb walk Strong (+) Unknown 0 Strong (−) Moderate (+) 0 Moderate (−)

50-ft walk, preferred Conflicting Unknown 0 Unknown Conflicting 0 0

speed

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5-min walk Strong (+) 0 0 Moderate (−) Moderate (+) 0 Limited (−)

Lift test Limited (−) Limited (+) 0 0 0 0 Limited (−)

Lift test, modified Unknown 0 0 Unknown Moderate (+) 0 Moderate (−)

c
Motorized treadmill 0 0 0 0 Limited (+)c 0 Limited (−)
test

Progressive isoinertial Moderate (+) 0 0 Moderate (−) Moderate (+) 0 Moderate (−)
lifting evaluation

Self-paced walking Limited (+)c 0 0 0 Conflicting c 0 Limited (−)c

test

Shuttle walking test Limited (+), 0 0 Unknown 0 0 Limited (+), Limited (+)c
Limited (+)c

Timed “Up & Go” Moderate (+) Unknown 0 Unknown Moderate (+), Limited 0 Limited (+)c
Test (+)c

Treadmill Limited (+)c 0 0 0 0 0 0

examination, 1.2
mphd

Treadmill Limited (+)c 0 0 0 0 0 0

examination,
preferred speed

Treadmill protocol 0 0 0 0 0 Limited (+)c 0

Treadmill walking test 0 0 0 0 Limited (+)c 0 0

Weight-carrying test 0 0 0 0 Limited (+)c 0 0

a
+ = positive result rating; − = negative result rating; 0 = no information
b
50 ft ≈ 15.3 m.
c
The level of evidence marked in italics primarily concerns patients with back-related diagnoses known to severely affect walking capacity (eg, lumbar spinal stenosis,
spondylolisthesis).
d
1.2 miles ≈ 1.9 km.

Of the walking tasks that were specifically investigated for
patients with diagnoses known to severely affect walking
capacity, the Timed “Up & Go” task and shuttle walking
test were the only tasks that displayed positive ratings for
more than 1 measurement property.
Discussion
To our knowledge, this is the first study to determine the
level of evidence for the reliability, validity, and
responsiveness of physical capacity tasks designed to
assess functioning for patients with LBP. The 5-repetition
sit-to-stand, 50-ft walk, 5-minute walk, Progressive
Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks
displayed moderate to strong evidence for positive ratings
for both test-retest reliability and construct validity. These
results suggest that a clinician or researcher can be
confident that the scores of these tasks have a high degree
of reliability and are likely to measure the constructs they
are designed to measure.23 A previous systematic review
investigated the reliability of physical capacity tasks, but
not the validity and responsiveness.58 That review
reported similar results for reliability, despite a different
method for determining the level of evidence.58
The 1-minute stair climbing task, 5-repetition sit-to-stand
task, shuttle walking test, and Timed “Up & Go” displayed
limited evidence for positive ratings for responsiveness.
These results suggest that these tasks appear to have the
ability to detect changes in functioning after a treatment,
although the evidence is limited. In contrast, most
included tasks that were investigated for responsiveness
displayed limited to moderate evidence for negative

2019 Volume 99 Number 4 Physical Therapy  473

Systematic Review of Physical Capacity Tasks
ratings. An important aspect of the definition of
responsiveness in the COSMIN taxonomy is the ability to
detect change over time specifically in the construct to be
measured.29 However, most of the included articles
investigated responsiveness by comparison with global
rating scales of constructs such as “LBP-associated
disability,”51 “general health improvements,”38 and “return
to work,”56 all constructs that are different from those
found in the physical capacity tasks. In contrast, several
authors have recommended using global rating scales of
the same constructs as the outcome measures of interest.23
For instance, the responsiveness of a walking task could
preferably be investigated by comparing the results with a
global rating scale concerning walking ability.23 Future
high-quality studies with a priori hypotheses that include
global rating scales of capacity could show clearer
evidence for the responsiveness of physical capacity tasks.
A moderate to strong level of evidence for negative ratings
for measurement error was displayed by 5 tasks because
the smallest detectable change was larger than the minimal
important change. Similar findings have been reported
previously for PROMs of self-efficacy and health-related
quality of life.59,60 The smallest detectable change (defined
as “the smallest change that can be detected by the
measurement instrument, beyond measurement error”23 )
should be smaller than the minimal important change
(defined as “the smallest change in score that is perceived
as important by patients”23 ) in order to detect changes that
are as small as the minimal important change.61 The data
of the systematic review suggest that the smallest
detectable change of the investigated tasks appears to be
too large to distinguish minimal important change from
measurement error. Nevertheless, all negative ratings of
measurement error were due to comparisons with minimal
important change values determined for 5 tasks in a single
article.51 That article investigated minimal important
change values with a global rating scale of “LBP-related
disability” rather than the constructs that the physical
capacity tasks measure. In contrast, minimal important
change is recommended to be compared with similar
constructs as those in the outcome measures of interest.61
Moreover, the COSMIN 4-point scale is also not designed
to assess the quality of studies that investigate minimal
important change32 and therefore the methodological
quality of the relevant article was undetermined.
We argue that the results of the systematic review are
generalizable to most individuals with chronic LBP.
Research suggests that a representative sample is required
to generalize the results of measurement properties
beyond the research setting.23 The patients in the
systematic review comprise a heterogeneous sample,
which is partly reflected in the differences in levels of pain
and disability seen between the included studies (Tab. 2).
Although we acknowledge that such heterogeneity can
influence the results of physical capacity testing (eg,
meters walked or weight lifted), there seems to be little
474  Physical Therapy Volume 99 Number 4
evidence that the heterogeneity would affect the results of
measurement properties. Not least, this is seen in the
almost unanimous positive results for test-retest reliability
and construct validity regardless of the characteristics of
the study populations. A subset of the results is, however,
primarily generalizable to patients with back-related
diagnoses known to severely affect walking capacity such
as lumbar spinal stenosis and spondylolisthesis (see the
level of evidence marked in italics in Tab. 5).62–64 In the
data synthesis of walking tasks, we therefore did not
combine studies of such patients with other studies.
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Predominantly positive ratings for single measurement
properties were found for walking tasks specifically
investigated for patients with back-related diagnoses
known to affect walking capacity severely. However, only
the Timed “Up & Go” task and shuttle walking test
displayed positive ratings for more than 1 measurement
property. This result appears to be due to a lack of studies
investigating measurement properties with the same test
protocol. For instance, 5 treadmill walking tasks with
similar protocols20,41–43 were evaluated for patients with
lumbar spinal stenosis, but these protocols were
considered too heterogeneous for the results to be
combined in the data synthesis. Physical capacity tasks
investigated in future research might show a stronger level
of evidence considering the promising results reported in
these articles.
Strengths and Limitations
A strength of the present review was the use of the
COSMIN 4-point checklist for assessing the methodological
quality of the included articles.32 To our knowledge, the
checklist is the most widely used consensus-based quality
assessment tool specifically developed for studies on
measurement properties. During the course of this
systematic review, the COSMIN checklist and the data
synthesis procedure were updated.65,66 For instance, poor
studies are included in the new data synthesis
procedure.65,66 After weighing the pros and cons we
decided to proceed with the original methodology as in
our PROSPERO study protocol. In summary, we reasoned
that the changes in the updated COSMIN methodology
would not change the quality of the analysis. Moreover,
breaching the study protocol would have decreased our
trustworthiness in performing the data synthesis.
Another strength is the clearly defined construct that
formed the basis for the selection of articles, ie, “capacity”
in the ICF activity domain.3 This approach generated more
homogeneous test content, which can make the results of
the systematic review easier to interpret. Capacity denotes
a patient’s ability to perform an activity in a standardized
environment and is useful to assess and compare patients’
functioning in a standardized way.3 However, it is
important to note that results from a physical capacity task
are not directly transferable to a patient’s environment
outside the test conditions, but rather signify the patient’s
2019

potential of performing the activity outside the test
conditions.
This review also has a few limitations. First, the COSMIN
4-point checklist was originally developed for PROMs,32
which could compromise its validity for assessing physical
capacity tasks. However, we argue that the checklist is
indeed appropriate for physical capacity tasks because the
items of the checklist are phrased in a general manner and
draw upon the researchers’ knowledge of the test at hand,
such as the appropriate time interval between the first and
second administrations in a reliability study. The checklist
has also been successfully used in previous systematic
reviews of physical capacity tasks for other patient
groups.33,35
Another possible limitation is the exclusion of so-called
functional capacity evaluations because we could not
obtain the original test manuals for these tests due to
copyright issues. Functional capacity evaluations are test
batteries commonly used for return-to-work evaluations
and could potentially have added value to this systematic
review. However, we could not reliably determine the
quality of the tests because we could not review the
detailed procedures. Also, many of the excluded functional
capacity evaluation articles appeared to focus on either
the composite scores of the batteries or constructs such as
“level of effort,” “work capacity,” and “safe lifting,” which
would have led to the exclusion of several articles.
A final possible limitation is that the data extraction was
not performed completely independently, as 1 author
(M.J.) extracted the data and a second author (A.G., M.L.,
or R.S.) double-checked it for accuracy. In contrast, at least
2 authors independently performed all other
methodological steps of the review. We decided on the
current data extraction procedure because of the high
accuracy of the first author in the pilot of this
methodological step. We therefore argue that having a
second author double-checking all data extracted was
almost equivalent to having 2 authors independently
performing the data extraction.
Conclusion
In conclusion, the 5-repetition sit-to-stand, 5-minute walk,
50-ft walk, Progressive Isoinertial Lifting Evaluation,
Timed “Up & Go,” and 1-minute stair-climbing tasks are
promising physical capacity tasks for the measurement of
functioning in patients with chronic LBP. However, more
research on the measurement error and responsiveness of
these tasks is needed to be able to fully recommend them
as outcome measures in research and clinical practice for
patients with LBP.
Author Contributions and Acknowledgments
Concept/idea/research design: M. Jakobsson, A. Gutke, L.B. Mokkink, R.
Smeets, M. Lundberg
2019
Systematic Review of Physical Capacity Tasks
Writing: M. Jakobsson, A. Gutke, L.B. Mokkink, R. Smeets, M. Lundberg
Data collection: M. Jakobsson, M. Lundberg
Data analysis: M. Jakobsson, A. Gutke, L.B. Mokkink, R. Smeets, M. Lundberg
Project management: M. Jakobsson, M. Lundberg
Fund procurement: M. Lundberg
Providing facilities/equipment: M. Lundberg
Providing institutional liaisons: R. Smeets, M. Lundberg
Consultation (including review of manuscript before submitting): A. Gutke,
L.B. Mokkink, R. Smeets, M. Lundberg
The authors of the systematic review would like to acknowledge the medical
librarians Anders Wändahl and Klas Moberg at Karolinska Institutet
University Library for their valuable help in developing the search strategy
and performing the search.
Downloaded from https://academic.oup.com/ptj/article/99/4/457/5252375 by guest on 19 January 2021
Funding
This review was supported by AFA Försäkring 120216, the Eurospine
Research Grants 8-2014, the Health and Medical Care Executive Board of the
Västra Götaland Region, and Vetenskapsrådet 2015-02511.
Clinical Trial or Systematic Review Registration
The study protocol was registered at the International Prospective Register of
Systematic Reviews (PROSPERO; http://www.crd.york.ac.uk/PROSPERO;
registration number: CRD42016042011).
Disclosures
The authors completed the ICJME Form for Disclosure of Potential Conflicts
of Interest. A. Gutke reported a grant received by her institution from the
Swedish Research Council. No other authors reported any conflicts of
interest.
DOI: 10.1093/ptj/pzy159
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