Where Do You Stand on the Sitting-Rising Test?

Medscape

3 days ago

Medscape recently published an article mentioning our latest research on physical fitness and overall health. In this paper, we described significant association between low scores on the sitting-rising test (SRT) and higher mortality due to natural and cardiovascular causes in men and women aged 46-75 years. Medscape readers posted several interesting and pertinent comments about the findings, which deserve a response. But before providing my thoughts about these comments, let's go back in time for a bit of context.
The Evolution of Fitness Metrics
I was a teenager when I first read the book Aerobics , by Dr Kenneth Cooper. Motivated to try out what I had learned, I convinced our high-school PE teacher to apply Cooper's 12-minute test to our class by running laps around the basketball court to estimate aerobic fitness. A few years later (1974), when entering medical school, I was fortunate to have my VO 2 effectively measured in a maximal test undertaken in the university's exercise physiology laboratory. Soon I was working in the same lab as a research assistant.
It did not take too long to realize that fitness involved more than 'just' aerobic capacity. I first studied flexibility and proposed the Flexitest as an assessment tool to evaluate the maximal physiologic passive range of motion in several joint movements. But it was only in the late 1990s, after several brainstorming sessions with my wife, Denise Sardinha (who holds a PhD in physical education), and many trials, that the SRT became ready for application. For scientific purposes, my 1999 publication describing the SRT established its birth date.
Anatomy of the Sitting-Rising Test
Teaching and mentoring graduate students and practicing sports and exercise medicine in CLINIMEX in Rio de Janeiro, Brazil, has provided me with the opportunity to experiment with the SRT in different scenarios and types of populations, and to formally determine its concurrent validity and interobserver/intraobserver reliability. In July 1998, we formally introduced the assessment as part of the CLINIMEX evaluation protocol and, since then, we have safely applied it to over 9000 individuals ranging in age from 6 to 102 years with a wide variety of clinical and fitness-related conditions.
The CLINIMEX exercise cohort has provided us the opportunity to propose sex- and age-reference data from our assessment tools and, in combination with the official data from the state, to conduct several observational studies on nonaerobic fitness and mortality. From its birth in 1999 to now, the SRT has emerged as a tool to simultaneously assess all nonaerobic fitness components — muscle strength and power, flexibility, balance, and body composition — and SRT performance across these components has proven to be a significant predictor of mortality.
The main features of the SRT are:
It's safe, simple, and quick to apply.
The protocol of evaluation is well standardized.
The evaluator has standardized verbal instructions to present to test-takers.
Scoring is simple (0-10 scale), and even self-scoring can be reliable for many adults.
Scores are easily understood by the individual being tested.
Scores are reliable and validly assess nonaerobic fitness.
No equipment is needed to perform the test or assess the result.
Time does not need to be measured and speed of execution is not a factor.
The test can be performed by people of any age, from preschoolers to the super-aged.
The limitations and contraindications for its application are clearly specified.
Good scientific evidence supports its association with mortality.
Traditionally, men have had greater strength and power than women, but women tend to be more flexible than men, which somewhat balances scores for men and women in similar age groups.
Responding to Reader Reactions
I'll now address some additional issues brought by Medscape readers.
'What information does the score add? Compared to vital signs, clinical impressions, medical history, executive function, and other clinical measures, is there additional value in the score? Compared to grip strength, serum albumin, or creatinine, does the new score improve reliable estimation of mortality risk? I would like to know more before I ask my patients to sit on the floor.'
Nonaerobic fitness does have prognostic implications for survival in middle-aged and older adults who were able to be evaluated by the SRT, even after controlling for several clinical covariates, such as presence of coronary artery disease, arterial hypertension, dyslipidemia, obesity, and diabetes. The hazard ratio obtained with SRT scores exceeds those obtained with each one of the components of nonaerobic fitness in our other studies, and it is by far higher than those relating to many of the classical risk factors or basic clinical signs (eg, resting heart rate), making the SRT a very powerful clinical tool. Indeed, I have suggested several times in lectures and interviews that the SRT can be easily incorporated into all health consultations.
"None had physical or clinical limitations that restricted their participation in the fitness tests."
As with most studies using fitness tests (eg, treadmill studies), we have excluded those with major locomotor or neurologic limitations from our mortality studies. However, other researchers found the SRT clinically useful for some specific cases, such as post-total knee arthroplasty, multiple sclerosis, or chronic stroke. Although we have not specifically studied healthspan, health-related quality of life, or autonomy, in my clinical experience scores on the SRT are strongly related to a better or positive profile in these areas.
"I think that cultures where people squat often would excel at this. Not so much for people who were raised to sit in chairs their entire lives."
Of course, our latest study has several limitations, as it was a single-center study and restricted to a specific population. Crossing the legs (or ankles) to sit and to rise is not mandatory, but most individuals feel that this is the best way to perform the SRT. Some individuals, especially young children, can prefer to sit down without crossing their legs and do very well with it; this is perfectly OK with the protocol. I agree that people in Asian cultures will likely have more facility to obtain comparable higher SRT scores. Squatting and sitting on the floor seems to be much easier and common to some specific populations in Asia and, coincidentally or not, they tend to live longer.
"Yet another 'test' which proves that physically fit people tend to live longer — something doctors haven't known for the past 100 years!"
A final thought about how the SRT compares with other 'similar' fitness tests. The 'five times sit-to-stand test' (FTSTS test), presumably first proposed in 1985, is quite well known and similar assessments have been advocated by the US Centers for Disease Control and Prevention. However, several relevant issues differentiate the two tests.
The FTSTS test requires a 'standard height' chair and an evaluator trained to adequately and precisely time the execution of the tasks with a stopwatch, which makes it more complicated to administer and introduces potential for error. The SRT is also much simpler to score and interpret, as the FTSTS depends on mean power in five executions. The FTSTS does not depend much on body flexibility or balance, while SRT scoring is very much influenced by these components of nonaerobic fitness. And importantly, no situation in daily life demands an individual stand and sit in a chair five times as fast as possible, while sitting and rising from the floor at 'natural speed' is a common action that we learn early and routinely practice over the course of our life.
Beauty in Simplicity
We all know physicians have a large array of advanced clinical tools at their disposal, including imaging, laboratory testing, and genetic testing. Over the years, I have studied, admired, and used sophisticated technology, as appropriate, for diagnosing and prognosing in my medical practice. I am fully receptive to these concerns and understand how challenging it can be to recognize that a simple test requiring zero equipment has significant utility in identifying middle-aged and older individuals who are at higher risk for premature death.
However, I urge readers to remember the amazing (and likely unreplaceable) merits of observing and examining the patient. These "basics" are a foundational pillar of medicine. The SRT is another great example of how a simple, yet science-backed, test can be so informative and powerful.
So, why don't you try it? What is your SRT score? Get your friends and family to join in and compare their SRT scores to sex- and age-reference values. Perhaps after getting acquainted with the SRT, you will consider including it as an assessment tool in your daily clinical practice.