Seated push-up tests: Reliable and valid measures for older individuals when used by primary healthcare providers

Abstract

BACKGROUND:

Body composition decline, lower limb impairments, and mobility deficits affect independence of older people. The exploration for a practical measure involving upper extremities may offer an alternative tool to be used by primary healthcare (PHC) providers for these individuals.

OBJECTIVE:

To explore reliability and validity of seated push-up tests (SPUTs) among older participants when used by PHC providers.

METHODS:

Older participants ( $n=$ 146) with an average age of $>$ 70 years were cross-sectionally assessed using various demanding forms of SPUTs and standard measures to assess validity of the SPUTs. Reliability of the SPUTs were assessed in nine PHC raters, including an expert, health professionals, village health volunteers, and care givers.

RESULTS:

The SPUTs demonstrated very good agreement, with excellent rater and test-retest reliability (kappa values $>$ 0.87 and ICCs $>$ 0.93, $p<$ 0.001). Moreover, the SPUT outcomes significantly correlated with lean body mass, bone mineral contents, muscle strength and mobility of older participants ( $r$ , $r_{pb}=-$ 0.270 to 0.758, $p<$ 0.05).

CONCLUSION:

SPUTs are reliable and valid for older adults when used by PHC members. The incorporation of such practical measures is particularly important during this COVID-19 pandemic with limited people’s hospital access.

Keywords

Clinical measure community service caregiver primary healthcare mobility

1. Introduction

Older people frequently experience body composition decline, lower limb impairments, and mobility deficits that reduce their independence [1, 2, 3]. The limit hospital services due to healthcare uncertainties – for example, those caused by the ongoing coronavirus disease (COVID-19) pandemic – also have facilitated a healthcare paradigm shift towards increased demand for standard home- and community-based healthcare services for these individuals [4]. Such services are usually distributed through a primary healthcare (PHC) system (i.e., a practical, scientifically sound, and socially acceptable strategy) to enable universal access to individuals’ homes and communities with the aim of providing essential community-based healthcare services [5, 6]. The PHC systems need community health workers (or village health volunteers [VHVs] in Thailand), community residents or caregivers (CGs), and healthcare professionals, as the so-called the PHC providers, working cooperatively to deliver equitable healthcare services and facilitate community participation through multi-sectoral approaches [7]. Nevertheless, the involvement of lay people (e.g., VHVs and CGs) within a healthcare system requires appropriate, simple and practical tools that enable the execution of effective health-related activities in various settings [7, 8].

Existing evidence suggests the use of a hand grip test (HG), which involves the intrinsic muscles of the tested hand that are susceptible to decline with aging, to early detect many aspects relating to independence of older people (e.g., muscle weakness, mobility impairments and health problems) [9, 10]. However, the HG requires a specialized machine that limits clinical application in general community- and home-based settings [1, 10]. Moreover, the HG is performed in an open-kinetic chain, i.e., the tested arm is free in space without the need to overcome the bodyweight, that may reduce the challenging effects of the test [10].

Previous outcome studies and a review article reported the use of a seated push-up test (SPUT) as a practical and demanding measure that can be completed in a small area over a hard and even surface, such as a bed or chair [11, 12, 13]. The ability to complete the test requires the upper limb and upper trunk muscles working cooperatively to increase muscle force, joint torques, and upper limb loading to lift the body from the floor against the bodyweight while maintaining the body balance at the shoulder joints [11, 12]. A recent study found the moderate correlation between upper limb loading during a seated push up test (ULL-SPUT) and skeletal muscle mass (SMM) of older adults, whereby a pass in an SPUT, i.e., the ability of successful lifting the body from the floor, could indicate individuals with optimal SMM (nearly 30% of the bodyweight) [14]. However, that study assessed only the simplest form of SPUT, namely a single time SPUT (1SPUT) along with its ULL-SPUT, to reflect SMM of older people as measured using the Bioelectrical Impedance Analysis (BIA). The findings from BIA are susceptible to errors due to many factors such as electrode placements, skin conductibility, body temperature, and participant preparation (position, overnight fast, bladder voiding) [12, 13, 14]. With their simplicity, the present researchers hypothesised that SPUTs can be used by PHC providers. Furthermore, with their demanding, closed-association of the musculoskeletal system, and global physiological changes throughout the body systems [1, 2, 3], the researchers further hypothesized that the SPUT outcomes would be able to reflect muscle strength, body composition, and mobility relating to independence of older adults variously depending upon the specific characteristics of SPUTs. Therefore, this study examined the reliability (rater and test-retest reliability) and other related psychometric properties of the SPUTs, including the standard error of measurement (SEM) and minimum detectable change (MDC), when used by PHC providers, including health professionals, VHVs and CGs. Moreover, this study assessed the concurrent validity of the SPUT outcomes as verified using standard measures that have already been proven for their validity to reflect muscle strength, body composition, and mobility of older people.

2. Methods

2.1 Study design and participants

This observational study was conducted among participants who were PHC raters and older adults from many rural communities in a developing country. The recruitment criteria are outlined below.

2.1.1 PHC raters

The test-retest and rater reliability was assessed using nine PHC raters who had various working experience as the suggestion from a previous study [15], including health professionals, VHVs, and CGs (three assessors per group). The health professionals included an expert and two health professionals, whereby an expert was a health professional who had experience in using the SPUTs more than three years, and the other two health professional raters were novice and experience health professionals – 1 and 10 years working experience, respectively – both rarely used the SPUTs. The three VHVs graduated from secondary school and had 2 to 11 years of working experience. The three CGs were relatives or caretakers of older adults for more than 10 years [7].

2.1.2 Older participants

Community-dwelling adults aged 65 years and over with a body mass index (BMI) between 18.5 and 29.9 kg/m ${}^{2}$ were recruited in this study. The inclusion criteria were the ability to stand up independently, walk with or without a walking device, and understand the commands used in this study. The exclusion criteria included any signs and symptoms that might affect participation in the study, such as uncontrolled medical conditions (e.g., hypertension or heart disease) and pain in the musculoskeletal system, with a score of more than 5 out of 10 on a visual analogue scale. The estimated minimum number of sample size was 146 older individuals for the validity study when set $R_{0}$ at 0.0 and $R_{1}$ at 0.23 (data from a pilot study, $n=$ 30), with 90% power and an alpha value of 0.05 [16]. Bujang et al. [17] suggested using the minimum number of 30 older participants for a reliability study. All participants signed a written informed consent form approved by the Institutional Ethics Committee for Human Research (HE 611600) prior to participation in the study.

2.2 Research protocols

2.2.1 Reliability study

Prior to the SPUT measurements, all raters were trained regarding the measurement protocols, instructions and outcome recording of the SPUTs by the expert. Then, they practiced the SPUT assessments using the video data of five non-participants. Subsequently, the PHC raters assessed the participants’ SPUT outcomes from the video data for two times with a seven-day interval. The data from the expert of both assessment periods were used to represent test-retest reliability. The SPUT data of all raters from the first measurement were used to report the inter-rater reliability of the SPUTs, and the data of the first and second assessments of each rater was analysed for intra-rater reliability [7, 15].

2.2.2 Outcomes measures

Older participants were interviewed and assessed for their demographics. Then, they were assessed for the outcomes of the study, including the SPUTs, as well as standard measures to reflect body composition, muscle strength and mobility needed for the independence and safety of older individuals [18, 19]. Details of the measurements are outlined below.

2.2.3 Seated push-up tests

Many forms of SPUTs are clinically available, including untimed and timed SPUTs [11, 12, 13]. This study applied simple with increasingly demanding forms of SPUTs, including 1SPUT along with its ULL-SPUT, a five-time (5SPUT), a 10-time (10SPUT), and 1-minute SPUT (1minSPUT), were applied according to the participants’ abilities, with no pressure to complete all the tests if they were unable to demonstrate feasibility of the tests. A recent study [14] reported the optimal outcomes of SPUT when performed in a ring sitting position ( $r=$ 0.457–0.608, $p<$ 0.005). Therefore, participants were assessed for the SPUTs in a ring sitting position [14]. Before and after the SPUTs, the participants were provided with a warm-up and stretching session to reduce the risk of musculoskeletal injury that might occur after completing such demanding activities. Details of each SPUT method are as follows:

•
1SPUT: The test was executed using push-up loading devices with the size of standard clinical push-up boards (18 cm in height) to quantify ULL-SPUT while completing a 1SPUT (Fig. 1) [12]. The devices were developed from digital load cells (Model L6E3-C, 50-kg 3G, with the standard calibration method based on UKAS LAB 14: 2006 mini-patent application No. 2103001612), with the outcome’s accuracy up to $<$ 0.1 kg and a measurement uncertainty of $\pm$ 0.2 kg. The participants were in a ring sitting position and placed their hands on the push-up loading devices, slightly anteriorly towards their hips (Fig. 1A and B). Then, they pushed both hands against the devices, lifted their body up from the floor while slightly bending the trunk forwards and depressing both scapulars, and gradually bent their elbows to sit down on the floor. The participants who could lift their body up from the floor successfully in at least two of the three trials were assigned to the ‘pass’ group (Fig. 1); otherwise, they were assigned to the ‘fail’ group. In addition, the average data of the maximum ULL-SPUT obtained from the push-up loading devices over the three trials was recorded [12, 14].

Figure 1.
Protocols of a seated push up test. (A) Starting position with push-up loading devices. (B) Position indicates “Pass” with push-up loading devices. (C) Starting position with push-up broads. (D) Position while lifting the body up from the floor.

The participants who passed a 1SPUT proceeded to be assessed using the 5SPUT, 10SPUT and 1minSPUT, while the participants who failed terminated the SPUT and continued with the standard measures.
•
5SPUT: This test was modified from the five times sit-to-stand test (FTSST) [20]and completed using standard clinical push-up boards (Fig. 1C and D). The participants were in a starting position similar to that in a 1SPUT. Then, they were instructed to complete the five push-up repetitions at their fastest and safest speed. The time was recorded from the command ‘start’ until the participant’s buttocks touched the floor on the fifth repetition. The mean duration over the three trials was recorded.
•
10SPUT: Participants were in a starting position and performed the test similarly to that of the 5SPUT; however, they were required to complete 10 push-up repetitions, and the average duration over the three trials was recorded.
•
1minSPUT: The participants were in a starting position similar to that of the 1SPUT. Then, they were assessed for the maximum number of push-up repetitions in a minute over one trial [21]. During the test, the participants could take a period of rest as needed and continue the test as soon as they could or terminate it if they were unable to continue.

Subsequently, older participants were assessed using standard measures for muscle strength, including the HG and the back and leg strength test. Furthermore, they were assessed using mobility measures, consisting of the FTSST, the timed up-and-go test (TUG), the 10-meter walk test (10MWT), and the 2-minute step test (Table 1) to represent lower limb muscle strength, dynamic balance control and walking ability that are the ability needed for independent living [18, 19, 20]. These measures were performed in a random order by an experienced assessor. Participants wore a lightweight safety belt around their waist so that the assessor could provide assistance as needed. The participants could take a period of rest between the tests and trials as required (or at least 30 s) to minimise learning effects and fatigue that might occur due to sequences of the tests. Within seven days, the participants were at a hospital for the assessments of their body composition, including lean body mass (LBM), bone mineral content (BMC), and fat mass (FM), using dual-energy X-ray absorptiometry (Table 1).

Table 1
Details of the standard measures used to report muscle strength, mobility, and body compositions

Outcome measure Aims of the assessments/psychometric properties Measurement details

Muscle strength tests

Handgrip test Upper limb muscle strength, physical frailty, and disability in older individuals. Excellent test–retest reliability (ICC $=$ 0.912–0.954) [9]. In a sitting position, the participants squeezed the handle as much as they could during 3 trials per hand with a sufficient rest period (at least 30 s) between the trials, and the maximum force was recorded [10].

Back and leg strength test Back and leg extensor muscle strength. Excellent intra-rater reliability (ICC $=$ 0.97) [21]. The participants stood on the base of a back-leg-chest dynamometer with the chain adjusted according to their height and the protocols for the trunk or leg extensor muscles explained previously [22]. Then, they pulled the chain with their maximum force, holding it for 3 s. A rest period between the trials was allowed as needed (at least 30 s). The average force in the 3 trials for each method was recorded in kilograms [21, 22].

Mobility assessments

Five times sit-to-stand test Functional lower extremity muscle strength and dynamic balance control while changing postures [20, 23]. Test-retest reliability (ICC $=$ 0.81; SEM $=$ 0.9 s) [23, 24]; MDC95 $=$ 2.5 s [24]; concurrent validity with the TUG test; $r=$ 0.64, $p<$ 0.001 [24]. The participants’ time to complete the 5 chair-rise cycles at the fastest and safe speed possible without using their arms was recorded. The average time for the 3 trials was reported [19].

Timed up-and-go test Mobility, dynamic balance control, and risk of falling in older individuals [25, 26]. Test-retest reliability (ICC $=$ 0.97) [27]. Inter-tester reliability (ICC $=$ 0.99) [25]. The time the participants took to stand up from a standard armrest chair, walk around a traffic cone placed 3 m from the chair, and walk back to sit down in a chair at the fastest and safe speed was recorded. The average time for the 3 trials was reported [19, 26].

10-metre walk test Overall quality of gait, community participation, health condition, morbidity, and mortality rates [28]. Test-retest reliability (ICC $=$ 0.92) and MDC $=$ 0.10 m/s [29]. The participants’ time to walk at a comfortable pace along the middle 4 m of a 10-m walkway. The average time for the 3 trials was converted to walking speed [29].

Two-minute step test Functional capacity and physical endurance [30]. Test-retest reliability (ICC $=$ 0.90) and concurrent validity with 1-mile walking time ( $r=$ 0.73) [31]. The participants raised their knee to a mid-thigh level – that is, the mid distance between the iliac crest and the patella, marking the point on the wall. The total number of steps in place – that is, the number of times the right knee reached the target level in 2 minutes over one trial was recorded [30].

Body compositions

Dual-energy X-ray absorptiometry (DXA) Body composition (lean body mass [LBM], bone mass content [BMC], and body fat mass [FM]) [32]. Inter- and intra-tester reliability (ICC $=$ 0.97–0.98) [33]. The participants were in a supine position on the DXA table, with their arms placed at their sides, legs extended, and toes facing upwards according to the standard protocols recommended by the GE Healthcare. The body composition data, including LBM, BMC, and FM, was automatically generated by the machine in kilograms .

Note: ICC, intraclass correlation coefficient; SEM, standard error of measurement; MDC, minimal detectable change.

2.3 Statistical analysis

Outcome measure	Aims of the assessments/psychometric properties	Measurement details
Muscle strength tests
Handgrip test	Upper limb muscle strength, physical frailty, and disability in older individuals. Excellent test–retest reliability (ICC $=$ 0.912–0.954) [9].	In a sitting position, the participants squeezed the handle as much as they could during 3 trials per hand with a sufficient rest period (at least 30 s) between the trials, and the maximum force was recorded [10].
Back and leg strength test	Back and leg extensor muscle strength. Excellent intra-rater reliability (ICC $=$ 0.97) [21].	The participants stood on the base of a back-leg-chest dynamometer with the chain adjusted according to their height and the protocols for the trunk or leg extensor muscles explained previously [22]. Then, they pulled the chain with their maximum force, holding it for 3 s. A rest period between the trials was allowed as needed (at least 30 s). The average force in the 3 trials for each method was recorded in kilograms [21, 22].
Mobility assessments
Five times sit-to-stand test	Functional lower extremity muscle strength and dynamic balance control while changing postures [20, 23]. Test-retest reliability (ICC $=$ 0.81; SEM $=$ 0.9 s) [23, 24]; MDC95 $=$ 2.5 s [24]; concurrent validity with the TUG test; $r=$ 0.64, $p<$ 0.001 [24].	The participants’ time to complete the 5 chair-rise cycles at the fastest and safe speed possible without using their arms was recorded. The average time for the 3 trials was reported [19].
Timed up-and-go test	Mobility, dynamic balance control, and risk of falling in older individuals [25, 26]. Test-retest reliability (ICC $=$ 0.97) [27]. Inter-tester reliability (ICC $=$ 0.99) [25].	The time the participants took to stand up from a standard armrest chair, walk around a traffic cone placed 3 m from the chair, and walk back to sit down in a chair at the fastest and safe speed was recorded. The average time for the 3 trials was reported [19, 26].
10-metre walk test	Overall quality of gait, community participation, health condition, morbidity, and mortality rates [28]. Test-retest reliability (ICC $=$ 0.92) and MDC $=$ 0.10 m/s [29].	The participants’ time to walk at a comfortable pace along the middle 4 m of a 10-m walkway. The average time for the 3 trials was converted to walking speed [29].
Two-minute step test	Functional capacity and physical endurance [30]. Test-retest reliability (ICC $=$ 0.90) and concurrent validity with 1-mile walking time ( $r=$ 0.73) [31].	The participants raised their knee to a mid-thigh level – that is, the mid distance between the iliac crest and the patella, marking the point on the wall. The total number of steps in place – that is, the number of times the right knee reached the target level in 2 minutes over one trial was recorded [30].
Body compositions
Dual-energy X-ray absorptiometry (DXA)	Body composition (lean body mass [LBM], bone mass content [BMC], and body fat mass [FM]) [32]. Inter- and intra-tester reliability (ICC $=$ 0.97–0.98) [33].	The participants were in a supine position on the DXA table, with their arms placed at their sides, legs extended, and toes facing upwards according to the standard protocols recommended by the GE Healthcare. The body composition data, including LBM, BMC, and FM, was automatically generated by the machine in kilograms .

Descriptive statistics were used to explain the participants’ characteristics and study findings. Cohen’s kappa coefficient was used to analyse the agreement of the 1SPUT outcomes that provides dichotomous data, i.e., pass and fail. The kappa strength of agreement was interpreted as poor ( $<$ 0.2), fair (0.2 to 0.4), moderate (0.4 to 0.6), good (0.6 to 0.8), and very good (0.8 to 1.0) [37]. The intraclass correlation coefficient (ICCs) were applied to analyse the reliability of the SPUTs with continuous outcomes, i.e., ULL-SPUT, 5SPUT, 10SPUT and 1minSPUT. The ICC values were interpreted as very low ( $<$ 0.26), low (0.26 to 0.49), moderate (0.5 to 0.69), high (0.7 to 0.89), and very high (0.9 to 1.0) reliability [38]. Fitzpatrick et al. [39] suggest that a reliability level of $\geqslant$ 0.90 is required for a clinical measure. The Bland-Altman plots – the data plotting between the mean values on the $x$ -axis against the different outcomes between the sessions on the $y$ -axis – were utilized to analyse the outcome agreement between the two sessions of the test-retest reliability. Then the SEM, i.e., the absolute reliability or the possible margin of measurement errors in an original unit, was determined using the formula SEM $=$ SD $\times\surd$ 1 $-$ ICC, where SD is the standard deviation. The MDC – the smallest change that represents a real change beyond the measurement errors in the result of the test – was calculated using the formula MDC $=$ 1.96 $\times\surd$ 2 $\times$ (SEM) [36]. The Pearson correlation coefficient was used to analyse the concurrent validity of the SPUTs, i.e., the amount of correlation between two different measures, including a measure to be validated for its outcome benefit (SPUT) and the well-established validity measures for muscle strength, mobility and body composition. The level of statistical significance was set to $p<$ 0.05.

Table 2
Demographics and outcomes for reliability and concurrent validity study

Variable	Reliability ( $n=$ 44)	Validity
		Total ( $n=$ 146)	Fail ( $n=$ 66)	Pass ( $n=$ 80)
Demographics
Age: years ${}^{\text{a}}$	72.1 $\pm$ 6.0 (70.3–73.9)	75.5 $\pm$ 7.0 (74.3–76.6)	76.1 $\pm$ 7.7 (74.2–78.0)	74.9 $\pm$ 6.4 (73.5–76.3)
Gender: $n$ (%)
Female	33 (75)	98 (67.1)	58 (87.9)	40 (50.0)
Body mass index: kg/m ${}^{2\text{a}}$	23.3 $\pm$ 3.6 (22.1–24.4)	22.8 $\pm$ 3.4 (22.2–23.3)	22.6 $\pm$ 3.6 (21.8–23.5)	22.9 $\pm$ 3.2 (22.2–23.8)
Underlying disease ${}^{{\dagger}}$ : $n$ (%)	16 (36.4)	77 (52.7)	41 (62.1)	36 (45.0)
Walking devices: $n$ (%)
Cane	5 (11.4)	24 (16.4)	20 (30.3)	4 (5.0)
Walker	1 (2.3)	4 (2.7)	4 (6.1)	–
Seated push-up tests: SPUTs ${}^{\text{a}}$
ULL–SPUT: %BW	82.3 $\pm$ 8.1 (79.8–84.7)	80.5 $\pm$ 12.3 (78.5–82.5)	75.7 $\pm$ 14.6 (70.1–77.2)	86.2 $\pm$ 5.5 (85.0–87.4)
5SPUT: s	9.7 $\pm$ 2.3 (8.9–10.6)	9.5 $\pm$ 2.3 (9.0–10.1)
10SPUT: s	19.0 $\pm$ 3.5 (17.8–20.3)	18.2 $\pm$ 3.3 (17.4–19.0)
1minSPUT: times	29.7 $\pm$ 7.7 (26.9–32.6)	29.3 $\pm$ 8.1 (27.4–31.2)
Muscle strength ${}^{\text{a}}$
Hand grip: kg	20.5 $\pm$ 5.5 (18.3–22.0)	18.5 $\pm$ 5.1 (17.6–19.4)	15.4 $\pm$ 4.1 (14.4–16.4)	21.0 $\pm$ 4.9 (19.9–22.1)
Back: kg	27.8 $\pm$ 15.0 (22.4–32.6)	23.2 $\pm$ 14.6 (20.8–25.7)	16.6 $\pm$ 9.6 (14.0–19.1)	28.3 $\pm$ 15.3 (24.8–31.8)
Leg: kg	32.3 $\pm$ 17.4 (25.1–38.9)	26.0 $\pm$ 18.8 (22.9–29.2)	16.7 $\pm$ 11.1 (13.8–20.0)	33.0 $\pm$ 19.5 (28.6–37.4)
Mobility measures ${}^{\text{a}}$
Five times sit-to-stand test: s	13.2 $\pm$ 2.5 (11.7–14.0)	14.6 $\pm$ 3.5 (13.9–15.2)	16.9 $\pm$ 4.3 (15.7–18.0)	12.9 $\pm$ 2.9 (12.2–13.5)
Timed up and go test: s	15.9 $\pm$ 4.3 (12.9–18.2)	15.8 $\pm$ 6.3 (14.5–17.9)	18.7 $\pm$ 9.9 (16.3–21.1)	13.2 $\pm$ 2.8 (12.6–13.9)
10-meter walk test: m/s	0.93 $\pm$ 0.23 (0.82–0.99)	0.89 $\pm$ 0.20 (0.85–0.93)	0.77 $\pm$ 0.26 (0.71–0.83)	1.0 $\pm$ 0.17 (0.95–1.0)
Two-minute step test: times	53.8 $\pm$ 13.4 (47.6–58.0)	50.9 $\pm$ 16.9 (48.1–53.6)	44.8 $\pm$ 17.1 (40.2–49.3)	55.3 $\pm$ 14.4 (52.1–58.5)
Body compositions ${}^{\delta}{\text{a}}$
Lean body mass: kg	16.6 $\pm$ 5.0 (14.2–18.1)	14.8 $\pm$ 3.1 (14.2–15.5)	13.4 $\pm$ 3.1 (12.4–14.5)	15.7 $\pm$ 2.8 (15.0–16.4)
Bone mass contents: kg	1.8 $\pm$ 0.6 (1.5–2.0)	1.8 $\pm$ 0.5 (1.7–1.9)	1.6 $\pm$ 0.45 (1.4–1.7)	1.9 $\pm$ 0.59 (1.8–2.1)
Fat mass: kg	15.9 $\pm$ 7.7 (12.5–18.7)	16.6 $\pm$ 5.9 (15.5–17.8)	16.1 $\pm$ 6.2 (14.1–18.2)	17.0 $\pm$ 5.6 (15.5–18.4)

Note: ${}^{\text{a}}$ The data are presented using mean $\pm$ standard deviation (95% confidence interval). ${}^{{\dagger}}$ Underlying disease, including hypertension, diabetes mellitus, hyperlipidemia, gout, heart failure, chronic kidney disease, asthma, and osteoarthritis. ${}^{\delta}$ This variable was additionally included after initiation of the study, there were 102 participants in this variable, whereby 64 participants passed and 38 participants failed the 1SPUT. Abbreviation: ULL-SPUT $=$ upper limb loading a seated push-up test.

3. Results

One hundred forty-six older participants, with a mean age of $>$ 70 years, were included in this study. The data of 44 participants were recorded to attain a total of at least 30 participants for reliability data of each SPUT method. Most participants were female with a normal BMI, well-functioning, physically active, and able to perform daily activities independently without mobility devices ( $>$ 80%; Table 2). Of all, 80 participants could complete a 1SPUT (55%) or pass the test with a mean ULL-SPUT of 86% of their bodyweight (Table 2) and proceeded with the other SPUTs. On the contrary, the rest of the participants were unable to lift their body from the floor or failed a 1SPUT, and thus they only had 1SPUT data along with their ULL-SPUT data (approximately 76% of bodyweight; Table 2). None of the participants reported adverse effects after the SPUTs. Their SPUT and standard measure data are presented in Table 2.

All forms of SPUT demonstrated very good agreement, or excellent rater and test-retest reliability (kappa values for 1SPUT $=$ 0.87–1.00, $p<$ 0.001; ICCs for other forms of SPUTs $=$ 0.93–1.00, $p<$ 0.001; Tables 3 and 3). Moreover, the 5SPUT, 10SPUT, and 1minSPUT data showed small ranges of SEM and MDC (Table 3). Figure 1 illustrates the Bland-Altman plot for the differences between the two measurements from the test-retest sessions of 5SPUT, 10SPUT, and 1minSPUT. The mean differences or biases (95% limit of agreement) between the two measurement sessions were 0.03 s ( $-$ 1.42 s to 1.49 s), 0.57 s ( $-$ 2.45 s to 3.58 s), and $-$ 0.77 times ( $-$ 6.35 to 4.82 times) for the 5SPUT, 10SPUT, and 1minSPUT, respectively. The data of most participants ( $n=$ 28 to 29) were within the 95% limit of agreement (Fig. 2A to C).

Figure 2.

Bland-Altman plot of seated push up test (SPUT) outcomes between test and retest sessions. (A) five-time SPUT (5SPUT). (B) 10-time SPUT (10SPUT). (C) 1-minute SPUT (1minSPUT).

Table 3 presents the correlation between the SPUT data and the standard measures (concurrent validity). All SPUT forms demonstrated low-to-moderate correlations to muscle strength and mobility measures ( $r$ , $r_{pb}=-$ 0.270 to 0.560, $p<$ 0.05) and low-to-strong correlation to LBM and BMC ( $r$ , $r_{pb}=$ 0.273 to 0.785, $p<$ 0.001), but not to the FM ( $p>$ 0.05; Table 3).

4. Discussion

Older people face with many system decline and lower limb deficits affecting their independence. The ongoing COVID-19 pandemic also facilitates the need for the distribution of standard and effective community-based and home healthcare services for older adults. The present study examined the rater and test-retest reliability of the SPUTs when used by PHC providers, as well as their benefit. After training and practicing with a few older adults, the SPUT outcomes of PHC raters showed excellent agreement and intra- and inter-rater reliability compared to the expert (kappa and ICC values of $\geqslant$ 0.87, $p<$ 0.001; Tables 3 and 3). The outcomes of the SPUTs also demonstrated excellent test-retest reliability with small SEM and MDC, and the differences between the two measurement sessions were within the 95% limit of agreement (Table 3 and Fig. 2).

The excellent test-retest reliability of the SPUTs, with the small SEM and MDC found in the present study, suggest the internal validity of the SPUTs and ensure that the outcome obtained are representative and stable over time. The excellent rater reliability lies in the fact that the outcomes indicate the extent to which the data collected correctly represents the real ability not by any possible extraneous variables [37]. Therefore, these findings suggest the use of SPUTs among PHC providers for older people.

The present findings further confirmed the association between outcomes of the SPUTs and standard measures for the muscle strength of the upper limbs, trunk,

Table 3
Rater reliability of the seated push up tests (SPUTs)

SPUTs			Expert (HP1)	Health professionals (HP)		Village health volunteer (VHV)			Care giver (CG)
				HP2	HP3	VHV1	VHV2	VHV3	CG1	CG2	CG3
Intra-rater reliability	1SPUT	Kappa	1.00	0.93	1.00	1.00	0.93	0.93	0.93	0.93	1.00
	5SPUT	ICC (95% CI)	1.00 (0.99–1.00)	0.99 (0.99–1.00)	1.00 (0.99–1.00)	0.99 (0.98–1.00)	0.99 (0.98–1.00)	0.99 (0.98–1.00)	0.99 (0.97–0.99)	0.98 (0.96–0.99)	0.99 (0.97–0.99)
	10SPUT	ICC (95% CI)	1.00 (0.99–1.00)	1.00 (0.99–1.00)	1.00 (0.99–1.00)	1.00 (0.99–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
	1minSPUT	ICC (95% CI)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Inter-rater reliability	1SPUT	Kappa		0.87	0.87	1.0	1.0	0.93	0.93	0.93	1.00
	5SPUT	ICC (95% CI)		0.99 (0.99–1.00)	1.00 (0.99–1.00)	1.00 (1.00–1.00)	1.00 (0.99–1.00)	1.00 (0.99–1.00)	1.00 (0.99–1.00)	0.98 (0.96–0.99)	1.00 (0.99–1.00)
	10SPUT	ICC (95% CI)		1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
	1minSPUT	ICC (95% CI)		1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)

Note: ICC $=$ Intraclass correlation coefficient; 95% CI $=$ 95% confidence interval.

akecaption mmaketablecaption Test-retest reliability, standard error of measurement (SEM), and minimal detectable of change (MDC) of the seated push up tests (SPUTs)

SPUTs	1 ${}^{\text{st}}$ session	2 ${}^{\text{nd}}$ session	Reliability	SEM	MDC ${}_{90}$	$P$ -value
1SPUT ${}^{\delta}$ (pass/fail)	16/14	16/14	1.00 (N/A)	N/A	N/A	$<$ 0.001
5SPUT (s) ${}^{{\dagger}}$	9.7 $\pm$ 2.3 (8.9–10.6)	9.7 $\pm$ 2.2 (8.9–10.5)	0.97 (0.94–0.99)	0.14	0.39	$<$ 0.001
10SPUT(s) ${}^{{\dagger}}$	18.9 $\pm$ 3.4 (17.8–20.3)	18.5 $\pm$ 3.2 (17.3–19.6)	0.94 (0.88–0.97)	0.28	0.78	$<$ 0.001
1minSPUT (times) ${}^{{\dagger}}$	29.8 $\pm$ 7.8 (26.9–32.6)	30.5 $\pm$ 7.3 (27.8–33.2)	0.96 (0.92–0.98)	0.52	1.44	$<$ 0.001

akecaption mmaketablecaption The correlation between the seated push up tests (SPUTs) and standard measures to reflect muscle strength, functional mobility and body compositions

SPUTs	Muscle strength			Mobility measures				Body compositions
	HG	Back	Leg	FTSST	TUG	10MWT	2MST	LBM	BMC	FM
1SPUT: (pass/fail)	0.523 ${}^{\ast\ast}$	0.407 ${}^{\ast\ast}$	0.443 ${}^{\ast\ast}$	$-$ 0.493 ${}^{\ast\ast}$	$-$ 0.362 ${}^{\ast\ast}$	0.453 ${}^{\ast\ast}$	0.319 ${}^{\ast\ast}$	0.349 ${}^{\ast\ast}$	0.347 ${}^{\ast\ast}$	0.070
	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	0.484
ULL-SPUT (kg)	0.560 ${}^{\ast\ast}$	0.375 ${}^{\ast\ast}$	0.342 ${}^{\ast\ast}$	$-$ 0.270 ${}^{\ast\ast}$	$-$ 0.418 ${}^{\ast\ast}$	0.455 ${}^{\ast\ast}$	0.316 ${}^{\ast\ast}$	0.785 ${}^{\ast\ast}$	0.688 ${}^{\ast\ast}$	$-$ 0.483
	$<$ 0.001	$<$ 0.001	$<$ 0.001	0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001
5SPUT	$-$ 0.477 ${}^{\ast\ast}$	$-$ 0.322 ${}^{\ast\ast}$	$-$ 0.287 ${}^{\ast}$	0.439 ${}^{\ast\ast}$	0.485 ${}^{\ast\ast}$	$-$ 0.319 ${}^{\ast\ast}$	$-$ 0.358 ${}^{\ast\ast}$	$-$ 0.423 ${}^{\ast\ast}$	$-$ 0.294 ${}^{\ast}$	0.149
	$<$ 0.001	0.008	0.020	$<$ 0.001	$<$ 0.001	0.008	0.003	0.001	0.022	0.276
10SPUT	$-$ 0.367 ${}^{\ast\ast}$	$-$ 0.328 ${}^{\ast\ast}$	$-$ 0.305 ${}^{\ast}$	0.451 ${}^{\ast\ast}$	0.476 ${}^{\ast\ast}$	$-$ 0.383 ${}^{\ast\ast}$	$-$ 0.352 ${}^{\ast\ast}$	$-$ 0.303 ${}^{\ast}$	$-$ 0.178	0.264
	0.002	0.007	0.013	$<$ 0.001	$<$ 0.001	0.001	0.003	0.018	0.170	0.052
1minSPUT	0.401 ${}^{\ast\ast}$	0.490 ${}^{\ast\ast}$	0.477 ${}^{\ast\ast}$	$-$ 0.538 ${}^{\ast\ast}$	$-$ 0.316 ${}^{\ast\ast}$	0.362 ${}^{\ast\ast}$	0.239 ${}^{\ast}$	0.337 ${}^{\ast\ast}$	0.273 ${}^{\ast}$	$-$ 0.196
	0.001	$<$ 0.001	$<$ 0.001	$<$ 0.001	0.010	0.002	0.046	0.008	0.034	0.140

and lower limbs; mobility; and body composition ( $r$ , $r_{pb}=$ 0.239 to 0.785, $p<$ 0.05; Table 3). The findings reflect characteristics of the SPUTs, closed association of the musculoskeletal system, and global physiological changes of the body systems [1, 2, 3]. The ability to lift the body from the floor successfully using the upper limbs or pass a 1SPUT requires a ULL-SPUT of $>$ 85% of the participant’s bodyweight (Table 2). Such ability requires complex interaction of many upper limb and upper trunk muscles, as well as the perceptual information necessary to generate adequate force and joint torque to increase upper limb loading while lifting the body from the floor against the bodyweight and maintaining body balance at the shoulder [12, 14]. This ability requires the SMM, a major part of the LBM, to enable the muscles to convert chemical energy into mechanical energy for force and power generation to produce movements and maintain body balance at the shoulder joints [12, 13]. Then, the global physiological changes throughout the body enable the association between the outcomes of the SPUTs involving upper body with the outcomes of standard measures involving other parts of the body [1, 2]. Consequently, the ability to increase the ULL-SPUT and pass a 1SPUT showed significant correlation with the muscle strength and mobility, particularly the FTSST that reflects functional lower extremity motor strength of the participants (Table 3).

The significant correlation with LBM also suggests the benefit of the ULL-SPUT because the LBM is associated with protection against frailty and physical dysfunction, as well as with favourable cardiometabolic profiles driven mainly by increased insulin sensitivity in older adults [40, 41, 42]. The SMM is the largest reservoir of protein in the body and a source of amino acids for protein synthesis in other vital tissues during periods of stress, disease, malnutrition, or starvation. A low SMM is also associated with sarcopenia, frailty, risk of underlying diseases, and dependence of older people [3, 40, 41]. Therefore, the findings may suggest the use of low ULL-SPUT for the early detection of older adults at risk for sarcopenia, frailty, and metabolic syndromes. Moreover, mechanical loading while attempting to complete the SPUTs attributes compressive force to the bones and cardiovascular functions [3, 12, 14]. Thus, the 1SPUT and ULL-SPUT outcomes were also significantly associated with BMC ( $r$ , $r_{pb}=$ 0.347 and 0.688, respectively, $p<$ 0.001; Table 3).

However, in those who passed a 1SPUT, the data may face a ceiling effect – that is, scenarios where older participants obtained the upper limit of the ULL-SPUT and 1SPUT outcomes [43]. Thus, the outcomes cannot represent alterations over time. In such situations, the timed-based SPUT measures (5SPUT, 10SPUT, and 1minSPUT) are needed to inform further changes. However, the findings from these timed-based SPUTs showed similar weak-to-moderate correlation with the standard measures ( $r=$ 0.239 to $-$ 0.538, $p<$ 0.05; Table 3). Such similarity may suggest the use of a timely and more simple measure, 5SPUT, to determine the muscle strength, mobility, and body composition of older people. Nonetheless, the higher correlation between the results of the 1minSPUT and muscle strength tests – namely, back and leg strength, and the FTSST – may reflect characteristics and the effects of a demanding measure of the 1minSPUT that enables the outcomes to determine strength in other parts of the body, including the trunk and leg muscles ( $r=$ 0.477–0.490, $p<$ 0.001; Table 3).

Nevertheless, no significant association between the outcomes of the SPUTs and body FM ( $p>$ 0.05; Table 3) may suggest the influence of participants’ recruitment criteria. This study recruited participants with a BMI between 18.5 and 29.9 kg/m ${}^{2}$ , with a mean BMI of 22.8 $\pm$ 3.4 kg/m ${}^{2}$ (Table 2). Such a small BMI distribution range might have limited the association between the outcomes of SPUTs and body FM of the participants ( $p>$ 0.05; Table 3).

The present findings confirmed the reliability and validity of the SPUTs to be used by PHC providers for older people. VHVs are community members who are trained as lay health workers and considered to be the backbone of healthcare providers. Caregivers are people who provide direct care to older people [5, 7]. The present findings suggest the use of SPUTs as simple quantitative measures to promote the two cornerstones of PHC – namely community participation in the healthcare system and empowerment that leads to self-determination [36]. The ULL-SPUT and 1SPUT could be applied with all participants in the present study, whereas the time-based measures (5SPUT, 10SPUT, and 1minSPUT) could be completed by only those who passed a 1SPUT. None of the participants experienced adverse events after the tests. These findings suggest the clinical applicability of SPUTs in older people.

However, the findings have some limitations. The data were cross-sectionally collected from mostly well-functioning older adults with normal BMI. The generalisability of the findings might be limited to use in frail and obese older people. Furthermore, more than half of older participants were females, and the convenient sampling may contain selection bias. Nonetheless, the gender proportion was coherent with an existing study from the same country [44]. In addition, this study applied the standard clinical protocols of SPUTs [9, 15], whilst many factors could influence outcomes of the tests, such as elbow flexion angle, position of push-up devices, and size of the individuals. Therefore, a further prospective study with systemic sampling should be conducted in both healthy and frail older people with a wide range of BMIs to assess the factors affecting the outcomes of SPUTs, as well as their responsiveness when used by novice and experience raters to extend the clinical utility of SPUTs in older adults.

5. Conclusion

Demands for effective community-based rehabilitation and home healthcare services, particularly during the ongoing COVID-19 pandemic, have increased the need for a standard practical measure that can be performed in various settings. The present findings suggest the use of SPUTs by PHC providers to reflect muscle strength, mobility, LBM, and BMC in well-functioning older people. The ULL-SPUT and 1SPUT could be applied in all older adults, whereas the 5SPUT, 10SPUT and 1minSPUT could be used to increase the difficulty of the test for older people with good physical ability. The incorporation of such tests may promote standard screening, monitoring, and data transfer among PHC providers in various clinical, community, and home-based settings.

Ethics statement

The research protocols of this study were approved by the Institutional Ethics Committee for Human Research (HE 622255). Participants needed to sign a written informed consent form prior to participation in the study.

Funding

This study was supported by funding from the National Research Council of Thailand (NRCT) (5/2564 KKU-NRCT) and the Fundamental Fund (2023), Khon Kaen University, Thailand.

Author contributions

All authors were responsible for the research conceptualization, study design, and final approval of the manuscript. PC, PP and RI were involved in the data collection. PC and PP were engaged in the statistical analysis, data interpretation, and drafting of the the manuscript. SA was responsible for the funding application, research management, data interpretation, and finalized the manuscript.

Footnotes

Acknowledgments

The authors sincerely thank the National Research Council of Thailand and Fundamental Fund for the funding support.

Conflict of interest

The authors declare no potential conflicts of interest.

References

Amarya

Singh

Sabharwal

. Changes during aging and their association with malnutrition. J Clin Gerontol Geriatr. 2015; 6(3): 78-84.

Colon-Emeric

Whitson

Pavon

Hoenig

. Functional decline in older adults. Am Fam Physician. 2013; 88(6): 388-394.

Frontera

Ochala

. Skeletal muscle: A brief review of structure and function. Calcif Tissue Int. 2015; 96(3): 183-195.

Rawlinson

Connell

. Out-patient physiotherapy service delivery post COVID-19: Opportunity for a re-set and a new normal? Physiotherapy. 2021; 111: 1-3.

Shoultz

Hatcher

. Looking beyond primary care to primary health care: An approach to community-based action. Nurs Outlook. 1997; 45(1): 23-26.

Declaration of Alma-Ata. International Conference on Primary Health Care [Internet]. 1978 [cited 25 July 2021]. Available from: http://whqlibdoc.who.int/publications/1978/9241541288_eng.pdf.

Suwannarat

Kaewsanmung

Thaweewannakij

Amatachaya

. leThe use of functional performance tests by primary health-care providers to determine walking ability with and without awalking device in community-dwelling elderly. Physiother Theory Pract. 2019; 1-9.

Kauffman

Myers

. The changing role of village health volunteers in northeast Thailand: An ethnographic field study. Int J Nurs Stud. 1997; 34(4): 249-255.

Bohannon

Schaubert

. Test-retest reliability of grip-strength measures obtained over a 12-week interval from community-dwelling elders. J Hand Ther. 2005; 18(4): 426-427, quiz 428.

10.

Roberts

Denison

Martin

Patel

Syddall

Cooper

, et al. A review of the measurement of grip strength in clinical and epidemiological studies: Towards a standardised approach. Age Ageing. 2011; 40(4): 423-429.

11.

Short

Winnick

. Test items and standards related to muscle strength and endurance on the brockport physical fitness test. Adapt Phys Activ Q. 2005; 22(4): 371-400.

12.

Wiyanad

Amatachaya

Sooknuan

Somboonporn

Thaweewannakij

Saengsuwan

, et al. The use of simple muscle strength tests to reflect body compositions among individuals with spinal cord injury. Spinal Cord. 2022; 60(1): 99-105. doi: 10.1038/s41393-021-00650-4.

13.

Contreras

Schoenfeld

Mike

Tiryaki-Sonmez

Cronin

Vaino

. The biomechanics of the push-up: Implications for resistance training programs. Strength Cond J. 2012; 34(5): 41-46.

14.

Poncumhak

Wiyanad

Siriyakul

Kosura

Amatachaya

. Validity and feasibility of a seated push-up test to indicate skeletal muscle mass in well-functioning older adults. Physiother Theory Pract. 2022; 6: 1-8. doi: 10.1080/09593985.2021.2023931.

15.

Saito

Sozu

Hamada

Yoshimura

. Effective number of subjects and number of raters for inter-rater reliability studies. Stat Med. 2006; 25(9): 1547-1560.

16.

Mohamad

Nurakmal

. Sample size guideline for correlation analysis. World J Soc Sci Res. 2016; 3(1): 37-46.

17.

Bujang

Omar

Baharum

. A review on sample size determination for cronbach’s alpha test: A simple guide for researchers. Malays J Med Sci. 2018; 25(6): 85-99.

18.

Lusardi

Pellecchia

Schulman

. Functional performance in community living older adults. J Geriatr Phys Ther. 2003; 26(3): 14-22.

19.

Thaweewannakij

Wilaichit

Chuchot

Yuenyong

Saengsuwan

Siritaratiwat

, et al. Reference values of physical performance in Thai elderly people who are functioning well and dwelling in the community. Phys Ther. 2013; 93(10): 1312-1320.

20.

Whitney

Wrisley

Marchetti

Gee

Redfern

Furman

. Clinical measurement of sit-to-stand performance in people with balance disorders: Validity of data for the Five-Times-Sit-to-Stand Test. Phys Ther. 2005; 85(10): 1034-1045.

21.

Bethards

Everitt-Smith

Roberts

Scarborough

Tate

Bandy

. Intrarater test-retest reliability of an instrument used to measure back and leg strength. Isokinet Exerc Sci. 1995; 5(1): 31-35.

22.

Ten Hoora

Muscha

Meijerb

Plasquia

. Test-retest reproducibility and validity of the back-leg-chest strength measurements. Isokinet Exerc Sci. 2016; 24(3): 209-216.

23.

Bohannon

. Test-retest reliability of the five-repetition sit-to-stand test: A systematic review of the literature involving adults. J Strength Cond Res. 2011; 25(11): 3205-3207.

24.

Goldberg

Chavis

Watkins

Wilson

. The five-times-sit-to-stand test: Validity, reliability and detectable change in older females. Aging Clin Exp Res. 2012; 24(4): 339-344.

25.

Podsiadlo

Richardson

. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991; 39(2): 142-148.

26.

Shumway-Cook

Brauer

Woollacott

. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80(9): 896-903.

27.

Steffen

Hacker

Mollinger

. Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002; 82(2): 128-137.

28.

Studenski

Perera

Patel

Rosano

Faulkner

Inzitari

, et al. Gait speed and survival in older adults. JAMA. 2011; 305(1): 50-58.

29.

Amatachaya

Kwanmongkolthong

Thongjumroon

Boonpew

Amatachaya

Saensook

, et al. Influence of timing protocols and distance covered on the outcomes of the 10-meter walk test. Physiother Theory Pract. 2020; 36(12): 1348-1353.

30.

Haas

Sweeney

Pierre

Plusch

Whiteson

. Validation of a 2-minute step test for assessing functional improvement. Open J Ther Rehabil. 2017; 5: 71-81.

31.

Rikli

Jones

. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act. 1999; 7(2): 129-161.

32.

Choi

. Dual-Energy X-Ray Absorptiometry: beyond bone mineral density determination. Endocrinol Metab (Seoul). 2016; 31(1): 25-30.

33.

Bakkum

Janssen

Rolf

Roos

Burcksen

Knol

, et al. A reliable method for measuring proximal tibia and distal femur bone mineral density using dual-energy X-ray absorptiometry. Med Eng Phys. 2014; 36(3): 387-390.

34.

Blake

Fogelman

. The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgrad Med J. 2007; 83(982): 509-517.

35.

Koo

. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016; 15(2): 155-163.

36.

Portney

Watkins

. Foundations of clinical research applications to practice. New Jersey: Prentice Hall Inc; 2000.

37.

McHugh

. Interrater reliability: The kappa statistic. Biochem Med (Zagreb). 2012; 22(3): 276-282.

38.

Amatachaya

Wongsa

Sooknuan

Thaweewannakij

Laophosri

Manimanakorn

, et al. Validity and reliability of a thoracic kyphotic assessment tool measuring distance of the seventh cervical vertebra from the wall. Hong Kong Physiother J. 2016; 35: 30-36.

39.

Fitzpatrick

Davey

Buxton

Jones

. Evaluating patient-based outcome measures for use in clinical trials. Health Technol Assess. 1998; 2(14): i-iv, 1-74. PMID: 9812244.

40.

Fielding

Vellas

Evans

Bhasin

Morley

Newman

, et al. Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011; 12(4): 249-256.

41.

Rizzoli

Reginster

Arnal

Bautmans

Beaudart

Bischoff-Ferrari

, et al. Quality of life in sarcopenia and frailty. Calcif Tissue Int. 2013; 93(2): 101-120.

42.

Peppa

Koliaki

Boutati

Garoflos

Papaefstathiou

Siafakas

, et al. Association of lean body mass with cardiometabolic risk factors in healthy postmenopausal women. Obesity (Silver Spring). 2014; 22(3): 828-835.

43.

Wang

Zhang

McArdle

Salthouse

. Investigating ceiling effects in longitudinal data analysis. Multivariate Behav Res. 2009; 43(3): 476-496.

44.

Phetsitong

Vapattanawong

Sunpuwan

Völker

. State of household need for caregivers and determinants of psychological burden among caregivers of older people in Thailand: An analysis from national surveys on older persons. PLoS One. 2019 Dec 11; 14(12): e0226330. doi: 10.1371/journal.pone.0226330.

Seated push-up tests: Reliable and valid measures for older individuals when used by primary healthcare providers

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Study design and participants

2.1.1 PHC raters

2.1.2 Older participants

2.2 Research protocols

2.2.1 Reliability study

2.2.2 Outcomes measures

2.2.3 Seated push-up tests

Table 2 Demographics and outcomes for reliability and concurrent validity study

Table 3 Rater reliability of the seated push up tests (SPUTs)

Ethics statement

Funding

Author contributions

Footnotes

Acknowledgments

Conflict of interest

References

Table 2
Demographics and outcomes for reliability and concurrent validity study

Table 3
Rater reliability of the seated push up tests (SPUTs)