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Systematic Review

Two-Minute Step Test of Exercise Capacity: Systematic Review of Procedures, Performance, and Clinimetric Properties

Bohannon, Richard W. PT, DPT, EdD, NCS; Crouch, Rebecca H. PT, DPT, CCS

Author Information
Journal of Geriatric Physical Therapy: April/June 2019 - Volume 42 - Issue 2 - p 105-112
doi: 10.1519/JPT.0000000000000164
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Abstract

INTRODUCTION

Aerobic exercise capacity is a fundamental component of physical fitness. As such, aerobic exercise capacity is often measured in healthy and diseased populations. Treadmills and cycle ergometers can be used to measure exercise capacity, but the devices are not always available outside laboratory settings. As a consequence, other modes of testing have been developed. Among these modes are timed walk tests (eg, 6- or 2-minute walk test),1,2 step-up tests (eg, YMCA step test),3 and sit-to-stand tests (eg, 1-minute chair rise test).4 Each of these modes has a place, but all have limitations as well. Timed walk tests, if performed according to established protocols, require indoor corridors of lengths unavailable in many settings;1,2 step-up tests and sit-to-stand tests are dependent (at least in part) on adequate muscle strength4 and may be painful for individuals with arthritis in their lower limbs.

An alternative exercise capacity test that is easily conducted in almost any setting was introduced in by Rikli and Jones as part of the Senior Fitness Test in 1999.5,6 The test, known as the 2-minute step test (TMST), simply requires that tested individuals march in place as fast as possible for 2 minutes while lifting the knees to a height midway between their patella and iliac crest when standing. Performance on the test is defined as the number of right-side steps of the criterion height completed in 2 minutes. Rikli and Jones5 found the TMST to demonstrate good interday test-retest reliability (intraclass correlation coefficient = 0.90). They also reported convergent validity relative to 1-mile walk time (r = 0.73) and known group validity (differences between age groups and between women who were high active vs low active).5 They have published normative reference values for adults 60 to 94 years old.6

Since the Rikli and Jones papers of the late 1990s,5,6 others have published information on the TMST. Nevertheless, our search revealed no synthesis of information on the test in RehabMeasures7 or in the literature. Such a synthesis is useful to clinicians wanting to make informed decisions regarding test selection, performance, and interpretation. We, therefore, conducted this systematic review of TMST procedures, performance, and clinimetric properties. The clinimetric properties of interest were reliability, validity, responsiveness, and interpretability.

METHODS

Data Sources and Searches

On September 23, 2016, we conducted a search of 3 electronic databases (PubMed, Scopus, and CINAHL). The search string used was “two minute step test” OR “2 minute step test” OR “2 min step test.” Searches were limited, as possible, to adults and English-language publications. The reference lists of identified articles were hand searched. Article titles and abstracts, and then full text, were examined to determine whether each article addressed the standing TMST and did so in English.

Data Extraction and Quality Assessment

We extracted information from each article on the sample tested, test description, and findings. Specifically, the health status, size, and the country of residence of the samples were designated (Table 1). Regarding test description, an indication of knee height during stepping, instructions as to speed, notification as to time elapsed/remaining, and scoring were extracted. Findings involved the number of TMST repetitions, and clinimetric properties. Clinimetric properties included reliability, validity, responsiveness, and interpretability. Reliability focused on the test-retest reproducibility of measures. Validity focused on either convergent validity or known-groups validity. Responsiveness focused on reported significant increases in performance or indices of responsiveness that we calculated using reported summary data (ie, effect size and standardized response mean). Interpretability focused on reference values reported for specific strata of the population.

Table 1. - Summary of Studies Describing the Use of the 2-Minute Step Test
Study Sample [Country] Test Description Findings
Alosco et al9 Older adults with heart failure (n = 145)
[United States]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of times right knee met marked target
Mean TMST reps: 58.9
Validity: TMST reps correlated significantly with global cognitive function, executive function, language, attention, age, and depression
Alosco et al10 Older adults with heart failure (n = 122)
[United States]
Knee height: midway between hip and knee
Instructions: NS
Time notifications: NS
Score: number of times right knee met target
Mean TMST reps: 61.5
Validity: TMST reps correlated significantly with ambulation, driving, and housekeeping
Alosco et al11 Older adults with heart failure (n = 157)
[United States]
Knee height: midpoint between knee cap and iliac crest
Instructions: march in place
Time notifications: NS
Score: number of times right knee met target
Mean TMST reps: 58.8
Validity: TMST reps correlated significantly with attention, executive function, and language
Alosco et al12 Adults with heart failure (n = 69)
[United States]
Knee height: midpoint between patella and iliac crest
Instructions: march in place
Time notifications: NS
Score: number of times right knee met target
Mean TMST reps: 70.3 (men), 57.3 (women)
Validity: TMST reps correlated significantly with brain volume and thickness and with age and education
Aoike et al13 Sedentary, overweight patients with chronic kidney disease (n = 29)
[Brazil]
Knee height: NS
Instructions: maximum number
Time notifications: NS
Score: number of steps achieved
Mean TMST reps: 189.5 (control), 180.0 (exercise)a
Responsiveness: TMST reps ↑ significantly in exercise group (effect size = 1.08)b
Aoike et al14 Overweight patients with chronic kidney disease (n = 10)
[Brazil]
Knee height: NS
Instructions: maximum number
Time notifications: NS
Score: number of steps achieved
Mean TMST reps: 190.5a
Responsiveness: TMST reps ↑ significantly after 12 wk of training (effect size = 1.15)b
Arabaci and Topsaç15 Older women with osteoporosis (n = 24)
[Turkey]
Knee height: NS
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 76.9 (strength group), 110.8 (balance group)
Responsiveness: TMST reps ↑ significantly after 12 wk of strength training (effect size = 1.42)b
Bates et al16 Older community-dwelling adults (n = 109)
[Australia]
Knee height: NS
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 94.7
Responsiveness: TMST reps ↑ significantly after 10 wk of strength training (standardized response mean = 0.80)b
Brito et al17 Older healthy women (n = 37)
[Brazil]
Knee height: midway between patella and iliac crest
Instructions: alternate steps
Time notifications: NS
Score: number of times right knee reached required height
Mean TMST reps: 61.9
Validity: TMST reps correlated significantly with Veteran's Specific Activities Questionnaire
Cancela et al18 Patients with Parkinson's disease (n = 30)
[Spain]
Knee height: halfway between iliac crest and middle of patella
Instructions: NS
Time notifications: NS
Score: number of times step in place
Mean TMST reps: 23.8 (men), 21.1 (women)c
Chang et al19 Older community-dwelling adults (n = 628)
[Taiwan]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of repetitions
Mean TMST reps: 87.4
Cicioglu20 Older physically independent men (n = 849)
[Turkey]
Knee height: per Senior Fitness Test manual
Instructions: per Senior Fitness Test manual
Time notifications: per Senior Fitness Test manual
Score: per Senior Fitness Test manual
Mean TMST reps: 66.8
Validity: TMST reps significantly different between most age groups
Norms: presented for men in 60-64 y, 65-69 y, 70-74 y, 75-79 y, 80+ y groups
Freene et al21 Middle-aged sedentary community-dwelling adults (n = 158
[Australia]
Knee height: NS
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 89.2 (home-based exercise), 95.0 (group exercise)
Garcia et al22 Older patients with heart failure (n = 41)
[United States]
Knee height: midway between knee cap and iliac crest
Instructions: walk in place
Time notifications: NS
Score: number of steps
Mean TMST reps: 69.6
Validity: TMST reps correlated significantly with stress test metabolic equivalents and with attention and executive function
Holmerová et al23 Older adults in residential care facilities (n = 52)
[Czech Republic]
Knee height: height between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of repetitions
Mean TMST reps: 35.3 (experimental),
30.0 (control)
Responsiveness: change in TMST reps significantly different between experimental and control groups
Lee et al24 Older women (n = 54)
[Korea]
Knee height: as described in Senior Fitness Test Manual
Instructions: as described in Senior Fitness Test Manual
Time notifications: as described in Senior Fitness Test Manual
Score: as described in Senior Fitness Test Manual
Mean TMST reps: 74.1 (virtual reality group), 68.5 (group exercise group)
Responsiveness: TMST reps ↑ significantly after 8 wk of virtual reality training (standardized response mean = 0.86) and group exercise (standardized response mean = 1.06)b
Lee et al25 Adults with chronic stroke (n = 68)
[Korea]
Knee height: halfway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of times lifted
Mean TMST reps: 29.1
Validity: community ambulators completed significantly more steps than limited community ambulators. Area under curve = 0.81
Milanović et al26 Older physically independent adults (n = 1288)
[Serbia]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of full steps
Mean TMST reps: 95.1 (men 60-69 y), 84.7 (men 70-80 y), 82.5 (women 60-69 y), 81.7 (women 70-80 y)
Validity: men 60-69 y completed significantly more TMST reps than men 70-80 y
TMST reps correlated significantly with physical activity level
Norms: presented for men 60-69 y and 70-80 y, women 60-69 y, 70-80 y
Nascimento et al27 Older adult women (n = 540)
[Brazil]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of times right knee reached target
Mean TMST reps: 79.4 (aquatic training group), 84.4 (multifunctional fitness training group), 71.1 (sedentary group)
Validity: women in training groups completed significantly more TMST reps than sedentary women. Older women completed significantly fewer reps than younger women
Pedrosa and Holanda28 Older hypertensive women (n = 32)
[Brazil]
Knee height: midpoint between patella and anterior superior iliac spine
Instructions: as many as possible without running
Time notifications: When 1 min completed and 30 s remaining
Score: number of right knee raises
Mean TMST reps: 62.7
Validity: TMST reps correlated significantly with 6-min walk test distance and Timed Up and Go time
Rikli and Jones5 Older adults residing in community, ambulatory without device (total n = 190; reliability n = 82)
[United States]
Knee height: midway between patella and iliac crest
Instructions: complete as many steps as possible, rests allowed
Time notifications: 1 min and 30 s
Score: number of times right knee reaches the minimum height
Mean TMST reps: 100.4 (60-69 y), 92.6 (70-79 y), 83.5 (80-89 y)
Validity: TMST reps correlated significantly with 1-mile walk time and treadmill performance
TMST reps significantly different between age groups (60-69 y, 70-79 y, and 80-89 y), between high-active and low-active groups and between men and women
Reliability: test-retest ICC = 0.90
Rikli and Jones6 Older adults residing in community, ambulatory without device (n = 3309)
[United States]
Knee height: midway between patella and iliac crest
Instructions: complete as many steps as possible without overexertion, rests allowed
Time notifications: 1 min and 30 s
Score: Number of times right knee reaches target
Mean TMST reps: 93 (men), 83 (women)
Validity: TMST reps significantly different between some age groups
Norms: presented for men and women in 60-64 y, 65-69 y, 70-74 y, 75-79 y, 80-84 y, 85-89 y, and 90-94 y age groups
Sannicandro et al29 Older women (n = 74)
[Italy]
Knee height: NS
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 102.9
Responsiveness: TMST reps ↑ significantly after a 12-wk training program (effect size = 0.72)b
Tanaka et al30 Patients with heart failure (n = 16)
[United States]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 50.0
Responsiveness: TMST reps ↑ significantly after intra-aortic balloon pump placement and exercise (effect size = 4.89)b
Taylor-Piliae et al31 Older adults with chronic stroke (n = 145)
[United States]
Knee height: nonaffected side halfway between middle of patella and iliac crest
Instructions: as many times as possible
Time notifications: NS
Score: number of steps with nonaffected side
Mean TMST reps: 37.9 (Tai Chi group), 44.4 (Silver Sneakers group), 41.1 (usual care group)
Responsiveness: TMST reps ↑ significantly in Tai Chi (effect size = 0.31) and Silver Sneaker (effect size = 0.65) groupsb
Taylor-Piliae et al32 Older adults with chronic stroke (n = 100)
[United States]
Knee height: nonparetic side halfway between middle of patella and iliac crest
Instructions: as many times as possible with nonparetic side
Time notifications: NS
Score: number of steps with nonparetic side
Mean TMST reps: 39.7
Validity: TMST reps correlated significantly with gait velocity, modified Rankin score, lower limb strength and balance
Toraman and Yildirim33 Older retirement home residents (n = 60)
[Turkey]
Knee height: Senior Fitness Test protocol applied
Instructions: Senior Fitness Test protocol applied
Time notifications: Senior Fitness Test protocol applied
Score: number of steps
Median TMST reps: 51.0
Validity: TMST reps correlated significantly with Berg Balance Test scores and unipedal stance time.
Węgrzynowska-Teodorczyk et al34 Men with heart failure (n = 168)
[Poland]
Knee height: midway between patella and iliac crest
Instructions: as many steps as possible
Time notifications: time left till end of trial
Score: number of steps
Mean TMST reps: 88.0
Validity: TMST reps for patients with NYHA class I or II significantly more for patients with NYHA class III or IV. TMST reps correlated significantly with 6-min walk test distance, peak oxygen consumption, exercise time, and quadriceps strength
Zanco et al35 Older adults with major depression (n = 20), Alzheimer disease (n = 17), good health (n = 20)
[Brazil]
Knee height: midway between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of times right knee reaches target
Median TMST reps: 41 (major depression), 34 (Alzheimer disease), 60 (healthy)
Validity: TMST reps significantly greater for healthy than for depression and Alzheimer groups (but not when adjusted for mental status)
Zhao and Chung36 Older adults with no falls in previous 12 months (n = 78)
[Hong Kong]
Knee height: midlevel between patella and iliac crest
Instructions: NS
Time notifications: NS
Score: number of steps
Mean TMST reps: 82.7 (risk of falling), 92.3 (no risk of falling)
Validity: TMST reps were significantly higher for adults with no risk of falling. For all groups together TMST reps correlated significantly with Veterans Specific Activities Questionnaire scores
Abbreviations: ICC, intraclass correlation coefficient; NS, not stated; NYHA, New York Heart Association; TMST, 2-minute step test.
aBoth left and right steps counted.
bCalculated rather than reported.
cOne-minute time.

Quality was assessed using a hybrid 6-item (12-point instrument) similar to one used previously in systematic reviews of measurements of physical performance.8 Specifically, 1 point was given for indicating each of the following: type of sample (eg, convenience), consecutive enrollment, inclusion criteria, exclusion criteria, knee lift height, speed of stepping, scoring of steps, statistical summary statistics (eg, mean and standard deviation) for steps completed, and the validity, reliability, responsiveness, and normative reference values for stepping measurements.

RESULTS

Thirty articles (Table 1) were identified as appropriate based on inclusion and exclusion criteria (Figure).5,6,9–36 The samples described in the articles consisted of older adults without reference to health status (eg, community dwelling) or adults with specific pathologies; these included heart failure, chronic kidney disease, osteoporosis, Parkinson's disease, stroke, hypertension, depression, and Alzheimer disease. Study sample sizes ranged from 10 to 3309. Most samples incorporated residents of the United States (n = 10), but residents of 11 other countries were studied as well.

F1
Figure.:
Prisma flow diagram for systematic review of the 2-minute step test.

Authors' descriptions of how the TMST was conducted varied widely in regard to thoroughness. Some authors simply indicated that the TMST was conducted according to the original description provided by Rikli and Jones.5 Some included no specifics other than to note that the number of steps was counted. Only a few studies addressed knee height, instructions, time notifications, and scoring.

All authors used means or medians to summarize the number of TMST steps completed by study participants. For studies in which steps for 1 side were counted over a full 2 minutes, the mean number of steps ranged from 29.1 for a sample patient with chronic stroke24 to 110.8 for a sample of older women with osteoporosis.15

The results of numerous studies support the validity of the TMST. Specifically, its convergent validity is delineated by significant relationships between TMST steps and exercise/activity history or fitness levels.5,17,22,26,28,34,36 Further evidence for validity is provided by the relationship between TMST steps and psycho/cognitive measures,9–11,22 activity performance,12,24 training and health status,27,34,35 and age.6,9,10,20,27

Only 1 study addressed the reliability of the TMST. In that study, Rikli and Jones5 reported a test-retest reliability coefficient of 0.90.

No reviewed study focused on the responsiveness of the TMST test. Nevertheless, 8 studies demonstrated that TMST repetitions increased with training.13–16,23–25,30,31 For most of these studies, we calculated effect sizes or standardized response means that would be considered strong (>0.80).

Presumptively, normative data were presented in 3 studies.6,20,26 The reference values provided therein are stratified by age and gender.

Table 2 shows the results of our quality assessment. The scores ranged from 2 to 9 out of a possible 12 points. Only 2 studies explicitly indicated the type of sample (eg, convenience) and specifics of enrollment (eg, consecutive). All but 3 studies were clear as to inclusion and exclusion criteria. Most studies did not thoroughly describe the stepping task, usually lacking was an indication of the speed at which participants were to step. Some studies made reference to the Senior Fitness Test of which the TMST is a component, but this did not ensure adherence to the test protocol. One study actually employed a 1-minute test period.18 Only 2 studies failed to indicate how the test was scored. All but 2 studies provided summary statistics (eg, mean and standard deviation) for the number of steps completed. Of 4 measurement properties of interest, 2 or fewer were addressed in the summarized studies.

Table 2. - Summary of Article Quality Using a Hybrid Instrument
Study Sample Describeda (2) Inclusion/Exclusion (2) Task Describedb (2) Scoring Described (1) Summary Statisticsc (1) Measurement Propertiesd (4) Total (12)
Alosco et al12 2 2 1 1 1 1 8
Alosco et al10 1 2 1 1 1 1 7
Alosco et al11 2 2 1 1 1 1 8
Alosco et al9 1 2 1 1 1 1 7
Aoike et al13 0 2 1 1 1 1 6
Aoike et al14 0 2 0 1 1 1 5
Arabaci and Topsaç15 0 2 0 0 1 1 4
Bates et al16 0 2 0 1 0 1 4
Brito et al17 1 2 1 1 1 1 7
Cancela et al18 0 2 1 1 1 0 5
Chang et al19 0 2 1 1 1 0 5
Cicioglu20 0 2 2 1 1 2 8
Freene et al21 1 2 0 1 1 0 5
Garcia et al22 0 2 1 1 0 1 5
Holmerová et al23 1 2 1 1 1 1 7
Lee et al25 0 2 0 0 1 1 4
Lee et al24 0 2 1 1 1 1 6
Milanović et al26 1 2 1 1 1 2 8
Nascimento et al27 0 2 1 1 1 1 6
Pedrosa and Holanda28 0 2 2 1 1 1 7
Rikli and Jones5 0 2 2 1 1 2 8
Rikli and Jones6 0 2 1 1 1 2 7
Sannicandro et al29 0 0 0 1 1 0 2
Tanaka et al30 1 1 1 1 1 1 6
Taylor-Piliae et al31 1 2 2 1 1 2 9
Taylor-Piliae et al32 1 1 2 1 1 1 7
Toraman and Yildirim33 0 2 0 1 1 1 5
Węgrzynowska-Teodorczyk et al34 0 2 2 1 1 1 7
Zanco et al35 1 2 1 1 1 1 7
Zhao and Chung36 0 2 0 1 1 1 5
aType, enrollment.
bKnee lift, speed.
cMeasure of central tendency and dispersion.
dValidity, reliability, responsiveness, reference values.

DISCUSSION

Aerobic exercise capacity is a key component of physical fitness. Although the measurement of exercise capacity is commonplace, established protocols are often impracticable because of the space, time, or equipment they require. The TMST is a notable exception. We undertook a systematic review to synthesize what has been published regarding TMST procedures, performance, and clinimetrics.

Our review revealed that the TMST, which requires no expensive equipment and only a few square meters of space, has been used internationally with both healthy and diseased individuals. The procedures for the TMST, although thoroughly described by Rikli and Jones,5,6 have not necessarily been followed by subsequent investigators. This makes it difficult to interpret the TMST performance across studies.

There is considerable evidence for the validity of the TMST, both convergent and known groups. However, a low correlation between the TMST and peak oxygen consumption does not support its criterion validity—at least not in patients with heart failure.34 Only 1 study addressed the reliability of the TMST.5 Although the reliability coefficient in that study (0.90) was good, further research with other populations is necessary. Information on absolute reliability (eg, minimal detectable change) and responsiveness is also needed. The effect sizes and standardized response means we calculated do not provide much help for interpreting changes in TMST performance over time.

Rikli and Jones6 provide useful normative data for the TMST for residents of the United States. Their summary data include not only mean and standard deviations but percentile values for age and gender strata as well. Normative data provided by others are for Serbian men and women or Turkish men.20,26 The stratified mean values for the older Serbians are slightly lower than those of Rikli and Jones; the stratified mean values for the Turkish men are 24% to 41% lower than those of Rikli and Jones.

Using the criteria of our quality checklist, none of the studies we reviewed met all standards. We intentionally did not employ a cut score for study inclusion. This decision was based on a desire to capture all literature addressing the TMST. Using a hybrid checklist as we did is a limitation, but similar checklists have been used previously. They allow us to capture test-specific criteria of importance.

CONCLUSIONS

As a whole our review provides support for use of the TMST. Nevertheless, further research is required regarding the validity, reliability, and responsiveness of the test. This applies to essentially healthy adults as well as adults with pathology.

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Keywords:

exercise capacity; step test; systematic review

© 2017 Academy of Geriatric Physical Therapy, APTA.