sensors

Article
Evaluating Postural Transition Movement Performance in
Individuals with Essential Tremor via the Instrumented Timed
Up and Go
Patrick G. Monaghan 1 , William M. Murrah 2 , Harrison C. Walker 3,4,5 , Kristina A. Neely 1
and Jaimie A. Roper 1, *

1 School of Kinesiology, Auburn University, Auburn, AL 36849, USA; [email protected] (P.G.M.);

[email protected] (K.A.N.)
2 Department of Educational Foundations, Leadership, and Technology, Auburn University, Auburn, AL 36849,
USA; [email protected]
3 Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
4 Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL 35249, USA
5 Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL 35249, USA
* Correspondence: [email protected]

Abstract: Flexibility in performing various movements like standing, walking, and turning is crucial
for navigating dynamic environments in daily life. Individuals with essential tremor often experience
movement difficulties that can affect these postural transitions, limiting mobility and independence.
Yet, little research has examined the performance of postural transitions in people with essential
tremor. Therefore, we assessed postural transition performance using two versions of the timed up
and go test: the standard version and a more complex water-carry version. We examined the total
duration of the standard and water-carry timed up and go in 15 people with and 15 people without
essential tremor. We also compared the time taken for each phase (sit-to-stand phase, straight-line
walk phase, stand-to-sit phase) and the turning velocity between groups. Our findings revealed
decreased performance across all phases of standard and water-carry timed up and go assessments.
Further, both ET and non-ET groups exhibited reduced performance during the water-carry timed up
Citation: Monaghan, P.G.; Murrah, and go compared to the standard timed up and go. Evaluating specific phases of the timed up and go
W.M.; Walker, H.C.; Neely, K.A.; offers valuable insights into functional movement performance in essential tremor, permitting more
Roper, J.A. Evaluating Postural tailored therapeutic interventions to improve functional performance during activities of daily living.
Transition Movement Performance in
Individuals with Essential Tremor via Keywords: mobility; essential tremor; gait; wearable sensor; functional assessment
the Instrumented Timed Up and Go.
Sensors 2024, 24, 2216. https://
doi.org/10.3390/s24072216

Academic Editor: Thurmon Lockhart 1. Introduction

Essential tremor (ET) stands as one of the most prevalent movement disorders, affect-
Received: 24 February 2024
ing 2.2% of the United States population alone [1]. Traditionally, ET has been viewed as a
Revised: 26 March 2024
Accepted: 27 March 2024
predominantly upper extremity tremor disorder. However, in recent years, the viewpoint of
Published: 29 March 2024
ET being considered a monosymptomatic disorder characterized by upper extremity tremor
has been supplanted. Recent studies have highlighted marked mobility impairments in
individuals with ET [2–9]. These mobility impairments can contribute independently to
functional disability, particularly in elderly patients who take medications that act on
Copyright: © 2024 by the authors. tremors and other neurological symptoms. Therefore, a detailed and thorough examination
Licensee MDPI, Basel, Switzerland. of functional movement performance is warranted in patients with and without ET.
This article is an open access article Various clinical assessment tools are available to evaluate dynamic gait and balance
distributed under the terms and in populations with ET and other movement disorders [10]. The timed up and go (TUG)
conditions of the Creative Commons
test is a well-established clinical assessment of dynamic gait and balance in populations
Attribution (CC BY) license (https://
with movement disorders such as ET [11]. A unique aspect of the TUG assessment is that
creativecommons.org/licenses/by/
it comprises a series of complex activities, which can provide insight into one’s ability to
4.0/).

Sensors 2024, 24, 2216. https://doi.org/10.3390/s24072216 https://www.mdpi.com/journal/sensors

Sensors 2024, 24, 2216 2 of 10

perform critical postural transition movements. The investigation of the phase-specific

performance of the TUG may enhance clinical evaluation. For example, the examination
of the total TUG time does not readily distinguish Parkinson’s disease patients with and
without cognitive impairment [12]. However, an assessment of component phases of the
TUG, such as the duration of the sit-to-stand phase, was able to provide such distinction [12].
Therefore, it is plausible that the examination of component phases of the TUG may provide
additional sensitivity in detecting subtle functional alterations in patients with ET.
Prior work has determined that people with ET display prolonged total TUG time
compared with healthy controls [9,13–16]. While the total duration of the TUG is clinically
useful, few studies in an ET population have examined and compared performance on
each phase of the TUG. Moreover, few studies have compared phase-specific performance
during a more complex version of the assessment. One previous study reported that
individuals with ET took longer to perform the sit-to-stand and turning phases of the TUG.
However, this study did not compare performance to a non-ET population’s [15]. While
the total TUG duration is still a useful outcome metric, measuring the performance of
phases of the TUG may yield more distinct features of the disease. Altered performance
in specific phases of TUG, such as the sit-to-stand or turning phase, may also indicate
deficits in lower extremity strength or dynamic stability, contributing to compromised daily
function. Therefore, a more detailed comparison and examination of phase-specific TUG
performance between a population with and without ET is warranted.
The primary objective of this study is to compare postural transitions via the instru-
mented TUG between people with and without ET. Specifically, we compare performance
during a standard TUG and a more complex water-carry TUG. In addition to total TUG time,
we will also contrast specific phases of the TUG (sit-to-stand, straight-line walk, turning,
and stand-to-sit) in people with and without ET. Based on the previous literature [12,15,17],
we hypothesize that people with ET will display longer total times and decreased per-
formance in the sit-to-stand and turning phases of both the standard and water-carrying
TUG. The outcomes of this study will enhance our understanding of functional mobility
performance in people with ET. Ultimately, it may permit more patient-centered therapeutic
strategies and enhance the performance of activities of daily living in people with ET.

2. Materials and Methods

2.1. Participants
All participants provided written informed consent prior to study participation, as
approved by the Auburn University Institutional Review Board. Fifteen people with ET and
fifteen age-matched people without ET participated in this study. Participants were eligible
to participate in the study if they were aged between 18 and 87 and reported being free from
lower extremity injuries or surgeries in the past 12 months that may have changed their
walking pattern or limited their capacity to complete the protocol. Participants with ET
were recruited from the local area via advertised flyers and word of mouth. Study referrals
from the neurology clinic at the University of Alabama at Birmingham were also part of
the recruitment strategy to maximize the potential number of participants. A convenience
sample of age-matched older adults from the local community was also recruited. The ET
group reported to the study in their optimal therapeutic state. Participant characteristics
can be observed in Table 1.
Sensors 2024, 24, 2216 3 of 11

Sensors 2024, 24, 2216 3 of 10

Table 1. Participant characteristics.

Overall (n =
ET (n = 15) non-ET Tremor (n = 15) p-Value
Table 1. Participant characteristics.30)
Age (years) 66 (15) 66 (16) 66 (15) 0.88
non-ET Tremor
Sex 19 F,
Overall (n 11 M
= 30) 8ETF,(n7 =M15) 11 F, 4 M p-Value
0.14
(n = 15)
Height (m) 1.67 (0.11) 1.71 (0.09) 1.65 (0.1) 0.19
Age (years) 66 (15) 66 (16) 66 (15) 0.88
Mass
Sex (kg) 74.15 (20.26)
19 F, 11 M 84.64 (24.17)
8 F, 7M 65.62
11 F, (12.76)
4M 0.04
0.14
TETRAS-ADL
Height (m) -
1.67 (0.11) 17.43 (10.37)
1.71 (0.09) -
1.65 (0.1) 0.19-
TETRAS-Motor
Mass (kg) -
74.15 (20.26) 21.43
84.64(7.00)
(24.17) -
65.62 (12.76) 0.04-
TETRAS-ADL
Fall History (F, NF) 9 F,- 21 NF 617.43
F, 9(10.37)
NF 3 F, -12 NF -
<0.001
TETRAS-Motor - 21.43 (7.00) - -
MMSE 28 (1) 28 (2) 29 (1) 0.43
Fall History (F, NF) 9 F, 21 NF 6 F, 9 NF 3 F, 12 NF <0.001
ABC
MMSE 85.33
28 (1)(15.61) 80.92(16.61)
28 (2) 89.74 (13.67)
29 (1) 0.12
0.43
FES
ABC 12.93
85.33 (5.41)
(15.61) 14.27(6.57)
80.92(16.61) 11.6(13.67)
89.74 (3.70) 0.19
0.12
FES Values are reported 12.93
Note. as mean(5.41)and standard
14.27(6.57)
deviation (SD).11.6 (3.70)
TETRAS-ADL: The0.19
Essential
Note. Values
Tremor are reported
Rating Assessmentas mean and standard deviation
Scale-Activities of Daily (SD). TETRAS-ADL:
Living The kilograms;
Subscale; kg: Essential Tremor Rating
m: meter;
Assessment Scale-Activities
MMSE: Mini-Mental of Daily
State Exam, Living
TMT: Subscale; kg: kilograms;
Trails-Making m: meter;
Testing; ABC: MMSE: Mini-Mental State
Activities-Specific Exam,
Balance
TMT: Trails-Making Testing; ABC: Activities-Specific Balance Confidence Scale; FES: Fall Efficacy Scale; F: fall
Confidence Scale; FES: Fall Efficacy Scale; F: fall history; NF: no fall history. Bold values indicate
history; NF: no fall history. Bold values indicate differences between essential tremor and non-essential tremor
differences
groups. between essential tremor and non-essential tremor groups.

2.2.
2.2. Experimental
Experimental Setup
Setup
Participants
Participants werewere equipped
equippedwith withsixsix wireless
wireless inertial
inertial measurement
measurement unitsunits
(Opal,(Opal,
Gen-
Generation 2, APDM, Inc., Portland, OR, USA), with three-dimensional
eration 2, APDM, Inc., Portland, OR, USA), with three-dimensional sensors placed at the sensors placed at
the sternum
sternum andand lumbar
lumbar spine
spine and
and oneone
at at each
each footand
foot andwrist.
wrist.Participants
Participants then
then completed
a series of instrumented
instrumented TUG TUG assessments
assessments [17–20].
[17–20]. The instrumented TUG objectively
characterizes parameters
parametersduring during postural
postural transitions
transitions (sit-to-stand,
(sit-to-stand, stand-to-stand,
stand-to-stand, walking,
walking, and [18].
and turning) turning)
Each[18]. Eachparameters
of these of these parameters has been previously
has been previously validatedvalidated with
with a motion
aanalysis
motionsystem
analysis system in a gait laboratory [17]. Furthermore, the previous
in a gait laboratory [17]. Furthermore, the previous literature has also literature
has also highlighted
highlighted good test–retest
good test–retest reliability
reliability for assessing
for assessing each ofeach
the of the phases
phases of theofTUG
the TUG
[20].
[20]. Participants
Participants completed
completed two TUGtwo assessments:
TUG assessments:(1) the (1) the standard
standard TUG and TUG andcomplex
a more a more
(2) water-carry
complex TUG (Figure
(2) water-carry TUG1). Participants
(Figure 1). completed
Participantsone trial of each
completed oneassessment.
trial of eachAll
assessments All
assessment. were performedwere
assessments usingperformed
the same armless
using the chair
same(height
armless 37 cm).
chairThe water-carry
(height 37 cm).
TUG assessmentTUG
The water-carry usedassessment
a 14 oz paperboard
used a 14 cup filled with 325
oz paperboard cup mL ofwith
filled water.
325The
mLsame cup
of water.
was used for all participants.
The same cup was used for all participants.

Figure 1. (A) Standard and (B) water-carry TUG assessments. Participants began seated, rose to a
Figure 1. (A) Standard and (B) water-carry TUG assessments. Participants began seated, rose to
standing position, walked 3 m, performed a 180° ◦turn, walked back 3 m, and then returned to a
a standing position, walked 3 m, performed a 180 turn, walked back 3 m, and then returned to a
seated position. For the water-carry TUG assessment, participants performed the same task while
seated position.
carrying For athe
a tray with water-carry
cup filled withTUG assessment,
325 mL of water. participants performed the same task while
carrying a tray with a cup filled with 325 mL of water.
2.3.
2.3. Standard
Standard and
and Water-Carry
Water-Carry TUG
TUG
Participants sat with their backs against
Participants sat with their backs against an
an armless
armless chair.
chair. When
When the
the administrator
administrator
verbally prompted the participant to begin, the participant stood up with their arms
verbally prompted the participant to begin, the participant stood up with their arms across
across
their chest, walked to a piece of tape on the floor three meters away, turned around, and
then walked back three meters and returned to a seated position. For the water-carry TUG,
 Sensors 2024, 24, 2216 4 of 11

Sensors 2024, 24, 2216 their chest, walked to a piece of tape on the floor three meters away, turned around, 4 ofand
10
then walked back three meters and returned to a seated position. For the water-carry TUG,
participants performed the same task; however, this time, they were instructed to carry a
tray with a cup
participants full of water.
performed When
the same prompted,
task; however,participants once
this time, they again
were stood, walked
instructed to carry toaa
piece of tape on the floor three meters away, turned around, and then walked
tray with a cup full of water. When prompted, participants once again stood, walked to a back three
meters
piece of and
tapereturned to a three
on the floor seatedmeters
position, all while
away, turnedcarrying
around,aand
traythen
withwalked
a cup full of water.
back three
For theand
meters water-carry
returned toTUG assessment,
a seated position,a all
table wascarrying
while also placed
a traybeside
with athecupparticipant
full of water. to
place
For thethe tray and the
water-carry TUG water cup if assistance
assessment, a table waswas needed
also during
placed besidethe
thesit-to-stand
participantor to stand-
place
to-sit
the trayphases of the
and the water-carry
water TUG assessment.
cup if assistance was needed during the sit-to-stand or stand-to-sit
phases of the water-carry TUG assessment.
2.4. Data Analysis
2.4. Data
DataAnalysis
were captured (128 Hz) and processed using the Moveo Explorer data collection
Data (APDM
software were captured (128 Hz) OR,
Inc., Portland, and USA).
processed The using
Moveo the Moveo Explorer
Explorer™ softwaredata collection
(version 1.0)
software (APDM Inc., Portland, OR, USA). The Moveo Explorer™
analyzed the raw data from all sensors using an integrated and automatic algorithm software (version 1.0)
to
analyzed
calculate the
the raw data from
durations and all sensorsmeasures
outcome using anofintegrated
the TUG and automatic
phases. The TUG algorithm
can be
to calculate
divided intothe
fourdurations
phases: (1) andsit-to-stand,
outcome measures of the TUG
(2) straight-line walk,phases.
(3) turn,The
andTUG can be
(4) stand-to-
divided into2).
sit (Figure four
Thephases: (1) sit-to-stand,
sit-to-stand time is the(2)time straight-line
required to walk, (3)up
stand turn,
fromand (4) stand-to-sit
a seated position
(Figure 2). The sit-to-stand time is the time required to stand up
at the beginning of the assessment. The straight-line walk time represents the time from a seated position at
the beginning of the assessment. The straight-line walk time represents the
required to walk 3 m to a piece of the tape on the floor plus the time to return to the chair. time required to
walk
Turn3velocity
m to a piece of thethe
indicates tapepeak
on the floor plus
angular the time
velocity to return
of the trunk to the chair.
during Turn velocity
the turns. As two
indicates
turns are involved in the TUG assessment, the average turn velocity wasare
the peak angular velocity of the trunk during the turns. As two turns involved
used in the
in the TUG
analysis. assessment,
Finally, the average
the stand-to-sit turn velocity
duration is the timewas used intothe
required analysis.
transition fromFinally, the
standing
stand-to-sit duration is the time required to transition from standing to
to seated at the end of the trial. Algorithms to detect postural transition movements during seated at the end
of the trial. Algorithms to detect postural transition movements during the instrumented
the instrumented TUG have been shown to display good sensitivity and test–retest
TUG have been shown to display good sensitivity and test–retest reliability [17,21].
reliability [17,21].

Figure2.
Figure 2. Phases
Phases of
of the
the timed
timed up
upand
andgogoassessment.
assessment.The
TheTUG
TUGcan
canbebe
divided into
divided four
into phases:
four (1)
phases:
sit-to-stand, (2) straight-line walk, (3) turn, and (4) stand-to-sit. The instrumented TUG uses
(1) sit-to-stand, (2) straight-line walk, (3) turn, and (4) stand-to-sit. The instrumented TUG uses
automated algorithms to characterize durations and outcome measures of the TUG phases
automated algorithms to characterize durations and outcome measures of the TUG phases objectively.
objectively.
2.5. Statistical Analyses
2.5. Statistical Analyses
Statistical analyses were performed in IBM SPSS Statistics Version 26 (IBM Corp.,
Armonk,Statistical analyses
NY, USA). Thewere performed
distribution in IBM SPSS
of postural Statistics
transition Versionfrom
outcomes 26 (IBM
both Corp.,
TUG
Armonk, NY,
assessments wasUSA). The using
assessed distribution of postural test,
the Shapiro–Wilks transition outcomes
the inspection of from both TUG
Q–Q plots, and
assessments
the examination wasofassessed
skewnessusing the Shapiro–Wilks
and kurtosis test,comparisons
values. Group the inspection of Q–Q plots,and
of demographic and
the examination
clinical of skewness
characteristics andusing
were made kurtosis values. Group
independent samplecomparisons of demographic
t-tests or chi-square tests of
independence. A Group (ET and non-ET) × Condition (standard TUG and water-carry
TUG) mixed-effects analysis of variance (ANOVA) with repeated measures examined the
effects of Group and Condition and their interaction on postural transition outcomes during
 2
5 TUG Duration Duration
0.5 Duration
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15 # 1.0 -1 3 #1
0.0
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Non- E 5 Non- E
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Sensors 2024, 24, 2216 Sit-to-Stand
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A)
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B) D)Duration C) E) Stand-to-Sit
Duration 0.0
0 Duration -1.0 0 -2
# 5 Non- E Non- E Non- E
15 # 1.0 3 # Sit-to-Stand
Walk
0
Sensors 2024, 24, 2216 A) ET 1.0 T -0.5 B)
ET T
T C)
ET
specific phases of the standard TUG
and Duration
water-carry TUG Duration
(sit-to-stand, Sit-to-Stand
straight-line gait, turning,Duration -1
D) 2 Turn Velocity
A) E) Stand-to-SitB) C)
0.5 -50
and stand-to-sit).
0 If significant TUG
15 0.5 main# effects Duration 1.0 Duration
-1.0or interactions were detected Duration
-2 in the ANOVA 3 #
10 Non- E #
1 Non- E Non- E
models, post hoc ET
comparisons 15
were corrected #
using 1.0 3
0.0
-100 0 T ET the 1.0 Bonferroni
T adjustmentET for multiple
T2
0.0 0.5
Sit-to-Stand Walk
comparisons. If the assumption
Turn
A) Velocity
0 10 of sphericity was violated
Stand-to-Sit
B) according to Mauchly’s
C) test,
-150 D) -50
TUG Duration E) Duration 0.5
2
5
-0.5
Greenhouse–Geisser adjusted degrees10of freedomDuration
were0.5 interpreted. Significance was Duration
1 at
set
# -1 -0.5 0.0 1
-200 15-100
α <0.05 for all analyses.
0
# 1.0 3 #
1.0 0
5 0.0
0 0.0
-1.0 -250 -2 -0.5 2 0
Non- E Non- -150 -1.0
Non- E
Non- E
3. Results -50
E Non- 5 E
0.5
0.5 -1
ET T ET ET T 10 ET T -0.5
T ET T -0.5 1 -1
A comparison
-100 -200 0
of demographic and clinical characteristics
-1.0 of our ET and non-ET groups -2
D) Turn Velocity E) Stand-to-Sit Non- E 0.0 0.0 Non- E Non- E
Duration
can be observed in Table-250
1. ET between0 T Non- ET
-1.0 water-carry
-1.0 T Non- 0 ET -2 T
# Figure 4. A comparison
-150 of performance
5 standard Eand TUGs in individuals
E
Non- E Non- E
0 1.0
with and without essential tremor. D)ET Turn
Positive Velocity
values
T TUG
ETindicate
-0.5
T
-0.5 E)
longer/faster
ET
Stand-to-Sit ET
performance
T duringT the
3.1. Phases of -200
Standard and Water-Carry -1
Duration
Turn Velocity performance during
-50
water-carry TUG, while negative values indicate # D) shorter/slower E) Stand-to-Sit
the standard
0.5
TUG. PanelMean and
(A): total standard
-250TUG task deviation
0 duration, 0 Paneldata (B):for TUG
sit-to-stand outcomes
-1.0 phase,1.0 during
Panel (C): phases Duration
of -2
straight-line a standard
walk
Figure Non- 4. A comparison E of-1.0performance
# Non-betweenEstandard and water-carry Non- TUGsE in i
and water-carry Non- can E observed Non- E stand-to-sit
-100 phase, Panel (D): turn TUG velocity in
ET
with and -50 be
the turning
T in
0
without essential tremor. Table
phase, and2. Panel ET
Positive(E): T 1.0 phase.
values indicate longer/fasterBlue bars
ET performance T
0.0 ET T ET T
represent the non-ET group, while orange bars represent the ET 0.5
group. Black-filled circles indicate
-150 D) TurnTUG,
water-carry Velocity while-50
negative values E) Stand-to-Sit
indicate shorter/slower performance during th
individual
Table data
2. Meanpoints.
andStandard
standard
TUG. error
-100
Panel bars
deviation
(A): are
total dataalsofor
TUG depicted.
TUG
task The symbol
outcomes
duration, Duration
Panelduring # denotes
(B): 0.5
standard
sit-to-stand the and
main
phase, effect
water-carry
Panel
-0.5 Figure 4. A comparison # of performance between standard
0.0
and water-carry TUGs in (C): straigh
individual
-200 of theTUGs
condition.
across ET and non-ET
phase, 0 groups.
Panel (D): turn-100 velocity in the
1.0 turning phase, and Panel (E): stand-to-sit phase
with and without essential tremor. Positive values
-150 indicate longer/faster performance during the
represent the non-ET group, while orange bars represent0.0 the ET group. Black-filled circl
-250 -1.0 water-carry TUG, -50
while negative -150 values indicate shorter/slower
-0.5
performance during the standard
Non- E 3.3. Sit-to-Stand
Non- E Phase individual -200data non-ET (n = 15) ET (n symbol
= 15) # denotes the
TUG. Panel (A): total TUGpoints. Standard
task duration, error
Panel bars
0.5(B): are also depicted.
sit-to-stand phase, Panel The (C): straight-line walk
ET T ET T -0.5
Standard
Our analysis of -100
TUGinvestigating the
(D):condition. -200
phase, Panel -250the
turn sit-to-stand
velocity performance
in the turning phase,-1.0
between
and Panel people
(E): with
stand-to-sit andphase. Blue bars
without Total
ET TUG Duration
represent
during the the(s)non-ET group,
standard andNon-water-carry
while EorangeTUG bars0.0represent
9.25 (1.67) Non-
revealed the
a ET
main E
group.
effect 11.91 (4.59)
Black-filled
of Group circles indicate
Figure 4. A comparison of performance between standard and-150 water-carryETTUGs -250 Tindividuals -1.0 T
(F
Sit-to-Stand
=
Duration
1,27 = 10.1, p individual
0.004, ŋ3.3.
2data
=
(s)
Sit-to-Stand
points.
0.27). Standard Phasein
Specifically, error Non-
people bars1.04
with
(0.253)
are EalsoET
ET
depicted.
took The symbol
longer to
1.16#(0.180)
Non-
complete Ethisthe main effec
denotes
with and without essential tremor. PositiveStraight-Line
values indicate longer/faster (s)performance during ET the T(0.521) ET2.50 (0.657) T
phase of the of
TUGtheWalk Duration
condition.
-200Our to analysis investigating
2.04
-0.5
the(59.8)
sit-to-stand performance between people
water-carry TUG, while negative values indicate
Turn Velocity (◦compared
shorter/slower
/s) performance
Figure their non-ET
4. A during
comparison thecounterparts
standard
of 235.35
performance (Mdiff = 0.209,
between SE = 0.07,
188.48
standard (49.2)
and p=
water-carry TUGs
0.004)
TUG. Panel (A): total TUG task duration, Panel (Figure 3B). No
(B): sit-to-stand
Stand-to-Sit without
significant
Durationphase,
-250 ET
withPanel
(s) during
main(C):
and without effect the of
straight-line
Figure standard
essential Condition
walk
0.75 and
-1.0(0.179)
tremor.
4. A comparison was water-carry
Positive observed TUG
(F
values indicate
of performance revealed
=1.185,
0.924 (0.194)
1,27
between p a
=
longer/faster main
standard and effect
performa
water
phase, Panel (D): turn velocity in the0.29, ŋWater-Carry
turning2 = 0.04)
phase,3.3. Sit-to-Stand
(Figure
and
TUG (F1,27(E):
4B)
Panel nor= Phase
Non-
10.1,
was pthere
stand-to-sit E phase.
= with
0.004, ŋ2 without
a significant=Blue
0.27). main
bars Non-
Specifically,
Group E
x people
Condition withinteraction
ET took longer todurin com
water-carry
ET TUG,
T while
and negative values
essential
ET tremor.
indicate shorter/slower performance
T Positive values indicate longer/fas
represent the non-ET group, while orange bars
Total represent
TUG
(F1,27 = 0.597, p = 0.45, Ourŋphase
the
Duration 2analysis
ET group.
(seconds)
= 0.02).
TUG. investigating
Black-filled
of the
Panel TUG (A): circles
compared
total
water-carry the
TUG sit-to-stand
indicate
11.0
towhile
task
TUG, (1.70)
their
duration, performance
non-ET
negative counterparts
Panelvalues between
15.0
(B): sit-to-stand
indicate (6.11)people
(Mdiff
phase, =Panel
shorter/slower with
0.209, (C): and
SE
perforstr=
individual data points. Standard error bars Sit-to-Stand
are also withoutDuration
depicted. The
ET
0.004)(seconds)
symbol
during(Figure
phase, # denotes
the
Panel standard
3B).(D):
TUG. Nothe
turn
Panelmainand
significant 1.02
effect
velocity
(A): total (0.160)
water-carry
inmain
the
TUG TUG
effect
turning
task of revealed
Condition
phase,
duration, 1.29
and
Panel a (0.336)
main
was
Panel
(B): effect
observed
(E): of Group
stand-to-sit
sit-to-stand (F 1,27p=
phase, P
Straight-Line Walk Figure
Duration 4. A (seconds)
comparison of performance 2.28 between standard and
(0.716) 2.97water-carry
(1.09) TUGs in ind
of the condition. 3.4. Straight-Line (F1,27Walk
= 10.1, Phase
0.29,p represent
=ŋ0.004,
2 = 0.04) ŋthe = non-ET
0.27).
2 phase,
(Figure group,
Specifically,
4B)
Panel nor
(D): while
was
turn orange
people
there
velocitya bars
with represent
significant
in the ET took
main
turning the ET
longer
Group
phase, group.
to x
and Black-filled
complete
Condition
Panel this
(E): in
st
with and without essential tremor.
Turn Velocity (degrees/seconds) Positive
162.97 (32.2) values indicate longer/faster
134.34 The(24.5) performance du
1,27individual pdata points.
represent Standard
=the non-ET error bars are also depicted. symbol #0.07,
denotes
phaseofof the TUG compared to =group, ŋwhile orange barsperformance
=represent theduring
=ET group.
2 their non-ET counterparts (Mdiff 0.209,
AStand-to-Sit
main effect Duration (F
water-carry
Group = was
0.597,
(seconds) TUG,
observed=while
0.45, (Fŋ1,28
negative =0.02).
values
5.05,
0.838 indicate
p (0.243)
0.03, 2 shorter/slower
= 0.15). People1.03 with
(0.232) ETSE p=
the
3.3. Sit-to-Stand Phase 0.004) (Figure of the
3B). condition.
No individual
significant data
main points.
effect Standard
of Condition error
TUG. Panel (A): total TUG task duration, Panel (B): sit-to-stand phase, Panel (C): straight- bars
was are also
observed depicted.
(F 1,27 The
=1.185, symb
p=
tookNote.longer
TUG: to timedcomplete
up and go.the walk phases compared to their non-ET counterparts
Our analysis investigating the sit-to-stand performance
0.29, ŋ = 3.4.
2 phase, between
0.04)Straight-Line
(Figure 4B) Walk
Panel (D): of
turn the
people
nor wascondition.
velocity with
Phase in and
there a significant main Group x Condition interactionB
the turning phase, and Panel (E): stand-to-sit phase.
irrespective of Condition 3.3. (Mdiff = 0.574, Phase
Sit-to-Stand SE = 0.23, p = 0.04) (Figure 3C). We found a
without ET during the standard significant
and3.2.
water-carry
main
Total (F
TUG 1,27TUG
=
effect0.597,revealed
represent p A = the
0.45,
main
of Condition (F3.3.
Duration a main
non-ET
ŋ effect
group,of
2 = 0.02).
effect of
1,28 = 8.332,Group pGroup
while
=was
orange 2bars represent the ET group. Black-filled
0.007, observed
ŋ = 0.23). (F1,28 = 5.05, p =of0.03,
Regardless Group, ŋ2 = 0.15). Peoplcircles
individual data
Our points.
analysis Sit-to-Stand
Standard error
investigating Phase
bars are
the also depicted.
sit-to-stand The symbol
performance # denotes
between the m
(F1,27 = 10.1, p = 0.004, ŋ = 0.27). Specifically, people with ET took longer to complete this non-ET peo
2
participants walked
A repeated took
slower
measures longer
during
ANOVA to
the complete
water-carry
compared the
the TUG walk
total phases
compared
TUG duration compared
to the regular
between togroups
their
TUG (ET cou
phase of the TUG compared to their non-ET counterparts
3.4.SE of the
Straight-Line condition.
without
(Mdiff Walk ET
= of
0.209,
Phase duringOur=the
SE analysis
0.07, standard
pNo = investigating
and water-carry the sit-to-stand
TUG performance
revealed a main be
eff
(Mdiff = 0.355, = irrespective
0.12,
and non-ET) across the standard p = 0.007)and Condition
(Figure
water-carry (Mdiff
4C). conditions.= 0.574,
significant SE
The results = 0.23,
Group p
X
revealed = 0.04)
Condition (Figure
a significant 3C). We
0.004) (Figure 3B). No significantinteraction
main effectwas of Condition (F
was = 10.1,
1,27observed without
p =(F 0.004, ET
1,27 =1.185,ŋ 2during
= 0.27).
p = the standard
Specifically, and
people water-carry
with ET TUG
took revealed
longer to
of A main effect ofmain
Group wasofobserved
2 = 0.03).(F(F =hoc5.05, p =p0.03, ŋ =indicated
ŋ0.15). People with ET
2
main effect observed Group significant
(F
(F 1,28 = 0.968,
1,28 = 5.62, ppeffect
= 0.33,
= 0.03, ŋCondition
= 1,281,28 = 8.332, = 0.007, 2 = 0.23). Regardless
0.29, ŋ2 = 0.04) (Figure 4B) nor was there a significant took
3.3.
main
longer
Sit-to-Stand
phase
Group
to
participants complete
Phase
(F
xofCondition
the
walked TUG
1,27
the=slower
10.1,
compared
interaction
walk =0.17).
p during0.004,
phases
Post
ŋcompared
to the 2 =
their
comparisons
0.27).
non-ET
water-carry Specifically,
to counterparts
their
TUG people
non-ET
compared (Mdiff
that
with ET
=the
0.209,
counterparts
to too
reg
irrespective of Condition, Our people with
analysis ET took longer
investigating the to complete
sit-to-stand the TUG assessments
performance between people w
(F1,27 = 0.597, p = 0.45, ŋ2 = 0.02). 3.5. Turning Phase irrespective (Mdiff 0.004)
of = (Figure
Condition
0.355, phase
SE 3B).
(Mdiff= of No the
0.12,= TUG
significant
0.574,
p = compared
SE
0.007) = main
0.23,
(Figure to
effect
p = their
of
0.04)
4C). non-ET
Condition
No (Figure counterparts
significant was
3C). observed
We
Groupfound (MdX(FaC
compared to the without non-ET group ET (Mdiffthe
during = 3.32,
standardSE = 1.40, and p = 0.03) (Figure
water-carry TUG 3A). A significant
revealed a main effect oo
significant main0.29, ŋ was
effect
2 = of 0.004)
0.04)Condition (Figure
(Figure(F4B) (F1,28 3B). No
nor8.332,
1,28==0.968,
significant
was ptherep==0.001, main
a significant
0.007, ŋ2ŋ= =0.55).effect
0.23). main of Condition
Group
Regardless was
x Conditi
main effect
Regarding of
turning interaction
Condition was
velocity, also
we observed
observed
report a (F1,28
main = 34.82,
effect of p<
Group 0.33,(F 1,28 =
=2 7.56,
0.03). p Irrespective
= 0.01, ŋ 2 ofof Group
3.4. Straight-Line Walk Phase participants (F1,27 =walked
(F10.1,
1,27 = p0.597,
= 0.004,
slower0.29, ŋ0.45,
p =during2 0.27).
= 0.04)
ŋ the
2 Specifically,
= (Figure
0.02).
water-carry 4B) nor people
TUG with aET
wascompared
there took
significant longer
tostandard
the mainto Group
regular comp
TUG
group,
= 0.21). Peoplethe water-carry
with ET walked TUGslower assessment than took longer
non-ET to complete
counterparts compared
irrespective ofto the
Condition
A main effect of Group was (Mdiffobserved (F =
(Mdiff
1,28 5.05, phase
=p =
3.5. 0.03,
0.355, of
Turningthe
ŋ
SE 2 == TUG
0.15).
Phase(F
0.12, compared
1,27 =
People
p =0.597, with
0.007) to
p = their
ET0.45,
(Figure non-ET
ŋ 2 = 0.02).
4C). Nocounterparts
significant (Mdiff
Group = 0.209,
X SE
Condition =0
TUG assessment
= 37.7, SE = 13.7, (Mdiffp =3.4. = 2.43,
0.01) SE = 0.41,
(Figure 3D). pWe < 0.001)
also main (Figure
found 4A). No significant
a significant mainwas effect Groupof X (F1,27 =1
took longer to complete the walk Condition phases interaction
compared 0.004) to (Figure
theirStraight-Line
3B).
non-ET No Walk Phase
significant
counterparts effect of Condition observed
interactionwas was observed
observed
Regarding (F
(F1,28 = 0.968,
2.60, pp =
1,28 = velocity,
turning = 0.33,
0.12,
we reportŋ =2 = 0.03).
0.09).
a main effect of Group (F1,28 = 7.56, p
irrespective of Condition (Mdiff = 0.574, SE = 0.23, p0.29, = ŋ2 = 0.04)
0.04) A
(Figuremain 3.4.
(Figure Straight-Line
effect
3C). 4B)
We of nor
Group
found wasWalka therePhase
was a significant
observed main
(F1,28counterparts
= 5.05, Group
p = 0.03, x Condition
ŋ2 = 0.15).of int
PC
= 0.21). People with ET walked slower than non-ET irrespective
significant main effect of Condition (F3.3. 1,28 =Sit-to-Stand
8.332, p =Turning
3.5. (F
0.007,
Phase1,27 =
ŋ =0.597,
2took
Phase 0.23). p
longer= 0.45,
Regardlessto ŋ
A
2 = 0.02).
main
complete
of effect
Group, the of Group
walk was
phases observed
compared (F 1,28to= 5.05,
their p = 0.03,
non-ET ŋ
(Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3D). We also found a significant main
participants walked slower during the water-carry Our analysis TUG
Regarding irrespective
compared
investigating turning to took
of
the
the velocity, longer
Condition
regular
sit-to-stand to
TUG
weperformance complete
(Mdiff
report a main = 0.574,
between the walk
SE
effect people =
of Group phases
0.23,
with p
(Fand= compared
0.04)
1,28 =without
(Figure to
7.56, p = 0.01, ŋ the
3C)
3.4.significant
Straight-Line Walk Phase
irrespective ofthanCondition (F(Mdiff
(Mdiff = 0.355, SE = 0.12, p = 0.007)ET(Figure during=4C). No
the standard
0.21). People significant
with ETGroup
and water-carry main
walked effect
X of
Condition
TUG
slower Condition
revealed a main
non-ET effect =of0.574,
1,28 = 8.332,
counterparts Group SE
p =irrespective
0.007, =ŋ20.23,
(F1,27 ofpCondition
==0.23).
10.1, =Regard
0.04) (
interaction was observed (F1,28 = 0.968,pp==0.004,0.33, (Mdiff
ŋ =
2 = 0.03).
0.27). Aparticipants
main
Specifically,
= 37.7, SE effect
= 13.7, people of Group
significant
p walkedwith
= 0.01) ET was
tookobserved
main
slower
(Figure effect
during
longer
3D). We (F
oftoCondition
the = 5.05,
water-carry
1,28
complete
also found this apphase
(F1,28 ==0.03,
8.332,
TUG ofŋcompared
significant
2p==main
the 0.15).
TUG People
0.007,effect
ŋto2 =the
0.2
o
took longer
(Mdiff =to complete
participants
0.355, SE = the
0.12,
compared to their non-ET counterparts (Mdiff = 0.209, SE = 0.07, p = 0.004) (Figure 3B). Nowalk
walked p = phases
slower
0.007) compared
during
(Figure the
4C). to their
water-carry
No non-ET
significant TUG coun
comp
Group
3.5. Turning Phase significant main effect irrespective
interaction
of Conditionof Condition
(Mdiff
was
wasobserved
observed (Mdiff
= 0.355, (FSE
(F = 0.574, 0.12,SEpp===0.33,
==0.968,
1,27 =1.185, p = 0.29,
1,28 0.23,
0.007)ŋp2 = ==(Figure
0.04)(Figure
0.03).
0.04) (Figure
4C). 4B) No3C). We
signific
nor was
Regarding turning velocity, we report there aeffect
a main significant
significant
of Group main
main(FGroup effect
interaction
1,28 = 7.56,
of Condition
x Condition was
p = 0.01,interaction
ŋ 2 (F
observed 1,28 = 8.332,
(F 1,28 = p = 0.007,
0.968, p = ŋ 2 = 0.23).
0.33,
(F1,27 = 0.597, p = 0.45, = 0.02). ŋ 2 = Regardless
0.03). of
3.5.
participants
= 0.21). People with ET walked slower than non-ET counterparts irrespective of Condition Turning
walked Phaseslower during the water-carry TUG compared to the regul
(Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3.4. Straight-Line
3D). We also(Mdiff Walk
found Phase
=a 0.355,
Regarding
significant 3.5.=Turning
SE 0.12,effect
turning
main pPhase
= 0.007)
velocity,
of (Figure
we report4C). a main No effect significantof Group Group(F1,28X= Co 7.
A main effect interaction
of Group was
was observed
observed
= 0.21). People with ET1,28 Regarding(F
(F 1,28 = = 0.968,
5.05,
turning pp == 0.33,
0.03,
velocity, ŋ 2 = 0.03).
=we 0.15).
walked slower than non-ET counterparts irrespectivereport Peoplea main with ET
effect of Grou
took longer to complete(Mdiff the walk phases
= 37.7, SEcompared
= 0.21). =People
13.7, pwith to their
= 0.01) ETnon-ET
walkedcounterparts
(Figure slower
3D). Wethan alsoirrespective
non-ET
found counterpartsof
a significant
Condition (Mdiff 3.5. Turning
= 0.574, SE =Phase p = 0.04)
0.23,(Mdiff (Figure
= 37.7, SE3C). We found
= 13.7, p = 0.01) a significant
(Figure 3D). mainWe effect
alsooffound a
Regarding turning velocity, we report a main effect of Group (F1,28 = 7.56, p =
= 0.21). People with ET walked slower than non-ET counterparts irrespective of Co
(Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3D). We also found a significant main
 0.04) (Figure 4B) nor was 3.4. Straight-Line
there Walk
a significant Phase
main
Sit-to-Stand Group x Condition interaction
Walk
A)p = 0.45, ŋ2 = 0.02).
597, B) C) 2
TUG Duration A main effect of Group was observed (FDuration
Duration 1,28 = 5.05, p = 0.03, ŋ2 = 0.15). People 0.5
with ET 10
15 # took longer 1.0 to complete the walk phases 3 #
compared to their non-ET Sit-to-Stand
counterparts Walk 1
ght-Line Walk Phase A) 7 of 11 B) 0.0 C)
irrespective of Condition (Mdiff = 0.574, TUG SEDuration
= 0.23, p = 0.04) (Figure Duration
3C). We found a Duration
2 0
observed 0.5 # with 5 ET
ain effect of Group wassignificant
10 Sensors 2024, 24, 2216
(F 1,28 = effect
main 5.05, pof=Condition
0.03, ŋ2 = 0.15).
(F151,28 =People
8.332, p = 0.007, ŋ72 =of0.23).
11
1.0 Regardless of Group,
-0.5
3 6 of 10#
ger to complete the walk phases walked compared to during
their non-ET 1 counterparts -1
participants slower the water-carry TUG compared
7 of 11 to the regular TUG 2
0.0 0.5
ive of Condition (Mdiff(Mdiff Sit-to-Stand
= 0.574, = SE = 0.23,
0.355, SE =p 0.12,
= 0.04)p =(FigureWalk
0.007) 3C).
(FigureWe found
4C). 0No a significant Group X Condition
-1.0 -2
B) C) 10 0
Non- E Non- E1
UGmain
nt Duration
5
effect of Condition (F1,28Duration
interaction = -0.5
8.332, pobserved 2 = 0.23).Duration
= 0.007,(Fŋ(F
wasCondition Regardless
1,28 = 0.968, p = 0.33, ofŋ2 Group,
= 0.03).
1,28 = 8.332, p-1= 0.007, = 0.23).ETRegardless T 0.0of Group, participants ET walked T slower
nts # Sit-to-Stand # the regular
Walk TUG
A) walked slower during the water-carry duringTUG compared to
1.0 3
B) the water-carry TUG
C) compared to
D) theTurn Velocity
regular TUG (Mdiff = 0.355,
E) Stand-to-Sit
SE = 0.12, p0 = 0.007)
0.355,0 TUG
A) SE =Duration
0.12, p =Sensors 2024,
3.5. Turning
0.007) 24, 2216
B)-1.0Phase
(Figure Duration
Sit-to-Stand
4C).
(Figure No significant
4C). No significant
2
5
Group
C)
Duration
-2GroupXWalk
Condition
X Condition interaction
-0.5 was observed (F Duration
1,28 = 0.968, p = 0.33,
6
Non-Duration
E Non- E Non- E #
15 TUG
on was observed 0.5
# (F1,28 = 0.968, p = 1.0
0.33, ŋ Duration
2 = 0.03). 3 Duration
# -1
ET T Regarding = 0.03).Tvelocity, we report
ETturning ETa main effect
T 0 of Group (F1,28 = 7.56, p =1.00.01, ŋ2
15 # 1 #
D) Turn Velocity =0.00.21). People
1.0
ET walked slower032than
Stand-to-Sit
with Non-non-ET E counterparts
-1.0
irrespective of Condition -2
0.5E) -50 Non- E Non- E
ing Phase
10 (Mdiff = 37.7, SE Duration
A) = 13.7, p Total
= 0.01)
0 (Figure2 ET3D).
B) WeT alsoSit-to-Stand
found a significant ET main 0.5
C)T effectWalkof ET T
# 0.5 TUG 1
arding
10 0turning velocity, -0.5
we report a
1.0 main effect of Duration
Group (F = Turn
7.56, p = -100 ŋ
Velocity
0.01, Duration
2 Stand-to-Sit Duration
0.0 -1 D)
1,28
1
E) 0.0
counterparts* irrespective Duration
eople5-50
with ET walked slower than0.0non-ET 40
0.5
0 of 2.5
#Condition
-150 * 6 *
37.7,5 SEE= 13.7, p = 0.01)-1.0
on- (Figure 3D).
Non- -0.5 We also found -2a significant
E Non- -1
00
Emain 2.0
effect of 1.0
-0.5
-100 T 30 -200
T ET -0.5 T ET T
0.0 -50
-1 4
0
Turn -150
Velocity -1.0
Stand-to-Sit -2 1.5 0.5
Non- E E) Non- 20 E Non- E-250 -1.0
(s)

(s)

(s)
0 ET Duration
-1.0 ET -100
-2 Non- E Non- E
# Non- T
E T ET 1.0 T
Non-
-0.5 E Non- E ET T0.0 2 ET T
-200
D) ET Turn Velocity
T 1.0 Stand-to-Sit
E) ET 10 T -150 ET T
0.5
-250 Turn Velocity Duration
Stand-to-Sit
D) Non-
#
E
E)
-1.0 Figure 4. A comparison -0.5 of performance between standard and water
0.5 Non-
Duration
0 E -200 0.0 0
0 1.0 with and without essential tremor. Positive values
ET # T ET T
Standard Water Carry Standard Water Carry Standard Water Carryindicate longer/fast
0 1.0 TUG TUG
-250 water-carryTUG TUG, TUG while
-1.0 negative TUG indicate
values TUG shorter/slower perfor
-50 0.0 Non- E Non- E
0.5 D) E) TUG. Panel (A): total TUG task duration, Panel (B): sit-to-stand phase, P
Figure
-50 4. A comparison of performance between standard and water-carry ET TUGs T in Stand-to-Sit
individuals ET T
-100
with and without essential
0.5 Turn Velocity phase, Panel
Duration(D): turn velocity in the turning phase, and Panel (E): st
-0.5tremor. 0.0 Positive values indicate longer/faster performance during the
-100
water-carry
-150 TUG, while negative values indicate shorter/slower
0.0
400
*Figureperformance represent
2.0during the
4. A comparison
individual
the
* points. Standard
non-ET
standard
of performance
data walk
group, while orange bars represent the ET group.
between standard and water-carry TUGs in i
error bars are also depicted. The symb
TUG.-150
Panel (A): total TUG task
-1.0 duration, Panel (B): sit-to-stand phase, Panel (C): straight-line
with and without essential tremor. Positive values indicate longer/faster performance
Non- E -0.5
-200 Panel
phase, (D): turn velocityNon- in the turningE 300
phase, and Panel (E): stand-to-sit
water-carry TUG, 1.5of thephase.
while
condition.
Blue bars
negative values indicate shorter/slower performance during th
ET T ET -0.5 T
-200
represent the non-ET group, while orange bars represent the ET group. Black-filled circles indicate
TUG. Panel (A): total TUG task duration, Panel (B): sit-to-stand phase, Panel (C): straigh
(°/s)

-250 -1.0 200

(s)

Non- E Non- 1.03.3. Sit-to-Stand Phase

individual data points. Standard error bars are alsoEdepicted. phase, The symbol Panel # (D):
denotes turn the main effect
velocity in the turning phase, and Panel (E): stand-to-sit phase
-250
A comparison ET of performance
T -1.0
between standard
ET and
T water-carry TUGs in individuals
Non-
of the condition. E Non- E represent the non-ET Our
group, analysis
while investigating
orange bars the sit-to-stand
represent the ET group.performance
Black-filled circlbe
without essential tremor. Positive valuesET 100
indicate longer/faster performance0.5 during the
ET T T
ry TUG, while negative values indicate shorter/slower performanceindividualduring datathe points.
without
standard Standard
ET duringerror thebars standard
are also depicted.
and The symbolTUG
water-carry # denotes the
revealed
Figure 4. A comparison of performance between standard and water-carry TUGs in individuals
3.3. Sit-to-Stand
el (A):and total TUG
Phase
task duration, Panel (B):between 0
sit-to-stand phase,and of the(C):
Panel condition. 0.0(F1,27 walk
straight-line = 10.1, p =the 0.004, ŋ2 = 0.27). Specifically, people with ET took
with
Figure 4. Awithout
comparison essential tremor.
of performance Positive valuesstandard
indicate
Standard longer/faster
Water Carry
water-carry performance
TUGsStandardin during
individuals
Water Carry
nel (D):
water-carry
with Our
and turnanalysis
velocity
TUG,
without while investigating
in negative
essential thetremor.
turning
valuesthe
Positive sit-to-stand
phase, and Panel
indicate
values performance
TUG(E): stand-to-sit
shorter/slower
indicate TUG between
performance
longer/faster phase. people
phase
Blue
during
performance bars
the
TUG with
ofduring
the TUG
standard and
TUG compared to their non-ET counterparts (Md
the
without
the non-ET
TUG. Panel (A): ET during
group, totalwhile the
TUG standard
orange bars
task duration, and water-carry
represent the
Panel (B): ET TUG
group. 3.3. Sit-to-Stand
revealed
Black-filled
sit-to-stand phase, a main
circles
Panel (C):
Phase
effect
indicate
0.004) of
(Figure
straight-line Group
walk No significant main effect of Condition was o
3B).
water-carry TUG, while negative values indicate shorter/slower performance during the standard
lTUG.
data points. Standard error bars are also Figure 3. The
depicted. Between-group
symbol # differences
denotes
Our the
analysismainin theeffect standard and
investigating water-carry
the sit-to-stand TUG assessments in
performance people people
(F
phase,Panel
1,27 = 10.1,
Panel(A): p = 0.004,
(D):total
turnTUG ŋ 2 =
velocity 0.27). Specifically,
in the turning
task duration, Panel phase, people with
andFigure
(B): sit-to-stand ET
Panelphase,
3.(E):took longer
Panel (C):0.29,
stand-to-sit
Between-group to
phase. complete
ŋ = Blue
2
differences
straight-line 0.04)walk
bars
inthis
(Figure
the 4B) norand
standard waswater-carry TUGbetween
there a significant main Group
assessments in p
dition. with and without essential
without tremor. (A)
ETessential shows the total duration of each respective TUG, (B) displays
represent
phasePanel
phase, ofthethenon-ET
(D):TUG turngroup,
compared
velocity while orange
in to
the their bars
non-ET
turning represent
phase, the
andwith
counterparts ET
Panel andgroup.
without
(E):(Mdiff =during
Black-filled
stand-to-sit 0.209, phase.
(F1,27 =the
circles
tremor.
SE standard
indicate
=Blue
0.597, (A)
0.07, =shows
pbars = and
p0.45, ŋ2water-carry
the =total
0.02).durationTUG revealed
of each respective a main
TUG, effect
(B) dis
ndividual
represent data
the
0.004) (Figure points.
non-ET Standard
3B). group,
No whileerror
significant orangebarsthe
main are
bars sit-to-stand
also depicted.
represent
effect phase,
the
of Condition The
ET (C)
(Fgroup. =represents
symbol
sit-to-stand
was
1,27 # denotes
phase,
Black-filled
10.1, the
(C)(F
p = 0.004,
observed straight-line
the1,27ŋmain
represents
circles effect
the
2 =indicate
0.27).
=1.185, pwalk phase, (D)
=straight-line
Specifically, depicts
walk
people the(D)
phase,
with turn velocity
ETdepicts
took theinturn
longer toveloc
com
of-Stand
the
ndividual Phase
condition.
data points. Standard error bars
0.29, ŋ = 0.04) (Figure 4B) nor was there a significant main
2 the
areturning
also phase,
the
depicted. and
turning
The
phase(E) represents
phase,
symbol
Group of the# and
denotes
TUG the
(E) stand-to-sit
represents
the
compared main
3.4. Straight-Line
x Condition phase.
the
effect
interaction toWalk The
stand-to-sit
theirPhaseleft side
phase.of the
The graphs
left side indicates
of
non-ET counterparts (Mdiff = 0.209, SE = the the
graphs indicat
of(F the
analysiscondition.
investigating standard TUG assessments,
standard TUG with solid
assessments, blue bars
with indicating
solid bluemain the non-ET
bars indicating group
the and
non-ETsolidgroup
orange andbars
solid (F
orang
1,27 = 0.597, p = 0.45, ŋ2the sit-to-stand
= 0.02). performance between
0.004) people
(Figure with
3B). NoA and significant
main effect of effect
Group wasof observed
Condition (Fwas observed 1,27 =
1,28 = 5.05, p = 0.03, ŋ
3.3. Sit-to-Stand Phase indicating the indicating
ET group. the
The ET
rightgroup.
side The
of the right side
graphs of the
indicates graphs
the indicates
water-carry the
TUG water-carry
assessments, TUG assessm
ET during the standard and water-carry TUG revealed 0.29, a main ŋ2 =effect of
0.04) (Figure
tookGroup 4B)
longer nor was
to non-ET there
complete a significant
theand walk main
phases Group x
comparedCondition
to the in
3.3. Sit-to-Stand Phase with striped, with
blue bars striped,
indicatingbluethe bars indicating
non-ET group the
and striped, group
orange bars striped,
indicating orange
the ETbars indicating
group. th
.1, p Our
= analysis
0.004, ŋ 2 =
3.4. Straight-Line Walk Phase investigating
0.27). Specifically, the sit-to-stand
people with performance
ET took longer between
(FIndividual to complete people
1,27 = 0.597, p = 0.45, ŋ = 0.02). this
irrespective
2with and
of Condition (Mdiff = Standard
0.574, SEerror= 0.23, pare=also
0.04)
Individual data group.
points are shown data
as points
solid blackare shown
circles. as solid black
Standard error circles.
bars are also depicted. barsThe dep(
the Our
without TUG
A mainanalysis
ET effectinvestigating
during
compared the standard
oftoGroup wasthe
their non-ET and sit-to-stand
observed (F1,28 performance
water-carry
counterparts = TUG
(Mdiff
5.05, prevealed
== between
0.209,
0.03, ŋ a main
2 SE
= =
0.15).
The main effect of the significant
people
effect
0.07,Peoplep
group is denoted=with
of with
mainand
Group ETeffect
by of Condition
an asterisk (*). (F1,28 = 8.332, p = 0.007, ŋ = 0.2 2
without
(F 1,27 =3B).
gure ETNo
10.1, pduring the
=significant
0.004, ŋ2 standard
=main
0.27).effect main
andofwater-carry
Specifically, effect
people
Condition ofTUG
the
with
was group ET is
revealed
3.4.
observed denoted
took alonger
main
Straight-Line
(F 1,27
by to an
=1.185, asterisk
effect
complete
Walk pPhase (*).this
=of Group
took longer to complete the walk phases compared to their non-ET counterparts
participants walked slower during the water-carry TUG compa
F 1,27 =(Figure
phase
0.04) 10.1,
of thep TUG
=of0.004,
4B) nor ŋ2 = 0.27).
compared
was there toaSpecifically,
their non-ET
significant people
main with
counterparts
Group p =ET took
(Mdiff
x 0.04)
Condition
A main longer
= 0.209, to SE
complete
interaction
effect of We == 0.07,
Group this
p =SE
was aobserved
irrespective Condition (Mdiff = 0.574, SE
3.5. Turning = 0.23,
Phase (Figure 3C).
(Mdiff found
0.355, = 0.12, p(F1,28 = 5.05,(Figure
= 0.007) p = 0.03,4C).
ŋ2 = 0.15). Peopl
No signific
phase
0.004)
597, p =of the
(Figure
0.45, ŋTUG
23B).
= compared
No
0.02). significant to their
main
significant main effect of Condition (F1,28 = Regarding non-ET
effect counterparts
of Condition
8.332, p = 0.007, took
ŋ (Mdiff
was2 =longer
0.23).=
observed0.209,
to (FSE
complete
Regardless
interaction = 0.07,
1,27 =1.185,
of thep
Group,
was = walk
observed phases
(F = compared
0.968, p = to
0.33, their
ŋ non-ET
2 = 0.03). cou
turning velocity, we report a main effect of Group (F1,28 = 7.56, p = 0.01, = 0.21).
1,28
0.004)
0.29, ŋ2(Figure
participants 3B).
= 0.04)walked Noslower
(Figure significant
4B) wasmain
norduring there
the effect of Condition
awater-carry
significant main
TUG was
Group observed
irrespective
compared x Condition
ofto (F1,27regular
Condition
the =1.185,
interaction p = = 0.574, SE = 0.23, p = 0.04) (Figure 3C). We
(Mdiff
TUG
People with ET walked slower than non-ET counterparts irrespective of Condition (Mdiff = 37.7,
ght-Line
0.29,
(F(Mdiff
1,27 = =Walk
ŋ20.597,
=0.04)pPhase
(Figure
SE =ŋ4B)
= 0.45, norpwas
2 = 0.02). there a(Figuresignificant main Group x Condition
significant main effect Xinteraction
of
0.355, 0.12, = 0.007) SE = 13.7, p4C). = 0.01) No significant
(Figure 3D). We 3.5.
Group
also Turning
found aCondition
Phase (F
Condition
significant 1,28 = 8.332, p = 0.007, ŋ2 = 0.23). Regardless
main effect of Condition (F1,28 = 60.18,
Finteraction
1,27 = 0.597, p = 0.45, ŋ = 0.02).
ain effect ofwas Group was
2
observed (F = 5.05, p = 0.03, ŋ 2 = 0.15). People with ET
observed (F1,28 = 0.968,pp<=0.001,
1,28 0.33, ŋ = 2
0.68).participants
= 0.03). Regardless of walked
Group, slower during
participants
Regarding thevelocity,
turned
turning water-carry
slowerwe TUG
during
reportthecompared
a water-carry
main effect to of
theGrou
reg
3.4.
ger Straight-Line
to completeWalk thePhase
walk phases compared to their non-ET
(Mdiff counterparts
= 0.355, SE = 0.12, p = 0.007) (Figure 4C). No significant Group X C
TUG compared to the regular TUG (Mdiff = 63.2, SE = 8.2, p < 0.001) (Figure 4D).
= 0.21). People with ET walked slower than non-ET counterparts No significant
3.4.
3.5.Straight-Line
ive A
of main effect
Condition
Turning PhaseWalk
(MdiffPhase
of Group was observed
= 0.574, SE =Group 0.23,(F1,28
p == 5.05,
0.04) p = 0.03,
(Figure ŋ 2 = 0.15). People with ET
3C).
interaction We
was found
observed a (F = 0.968, p = 0.33, ŋ 2 = 0.03).
X Condition interaction was(Mdiff observed (F1,28SE
= 37.7, 1,28
= 13.7,pp==0.28,
= 0.1.24, = 0.04). 3D). We also found a s
0.01) (Figure
took
nt mainAlonger
main
effecteffect
Regarding to of Group
complete
of Condition
turning (F was
the
1,28 =
velocity, observed
walk
8.332,
we report p = (F
phases 0.007, = ŋ5.05,
compared
a1,28main p = of
2 = 0.23).
effect 0.03,
to ŋ2 = non-ET
their
Regardless
Group 0.15). People p with
counterparts
of=Group,
(F1,28 7.56, = 0.01,ETŋ2
ook
nts longer
rrespective
walked
= 0.21). PeopleoftoCondition
slower complete
with during
ET walked the water-carry
(Mdiff walk
slower phases
= 0.574, 3.6.
than SETUG=compared
0.23,
Stand-to-Sit
non-ET pPhase
compared to Turning
=3.5.
0.04)
counterparts their
to the non-ET
(Figure Phase
regular3C).TUG
irrespective counterparts
We found a
of Condition
rrespective
significant
0.355, SE =of
main Condition
effect
0.12, p =of (Mdiff
Condition
0.007) =
(Figure 0.574,
(F 1,28 =
4C). SE
8.332,
No = 0.23,
Regardingp = p
0.007,
significant = 0.04)
ŋ (Figure
2 = 0.23).
Group
stand-to-sit 3C).
Regardless
X Condition
duration, we We of
reportfound
Group,
a mainaofwe effect of Group
a main(Feffect p = 0.002,
(Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3D). We also foundRegarding
a significant turning
main velocity,
effect report 1,27 = of
11.8,
Group (F1,28 = 7.56, p
significant
participants main
walkedeffect of
slowerCondition
during
on was observed (F1,28 = 0.968, p = 0.33, ŋ = (Fthe
1,28 2 = 8.332,
water-carry
= 0.03). p = 0.007,
TUG
0.30). People with ŋ2 = 0.23). Regardless
compared
ET walked
= 0.21). to
People with the
slower of
regular
ETthan Group,
walked TUG
non-ET counterparts
slower than non-ET irrespective of Condition
counterparts irrespective of C
participants
(Mdiff = 0.355, walked SE =slower
0.12, pduring= 0.007) the(Mdiff
water-carry
(Figure 4C).SE
= 0.18, TUG
No compared
significant
= 0.05,
(Mdiff p = =0.002)
37.7,to
Group the= regular
(Figure
SE X3E).
13.7, p =TUG
Condition
No effect
0.01) of Condition
(Figure 3D).was We observed
also found (F1,27 = 2.71,
a significant main
ing
Mdiff Phase
nteraction= 0.355, SE = 0.12,
was observed p == 0.968,
(F1,28 0.007) pp(Figure
= 0.11, ŋ4C).
= 0.33, No significant
2 = 0.03).
= 0.09). No significant GroupGroup X XCondition
Condition interaction was observed (F1,27 = 0.02,
nteraction
arding was velocity,
turning observedwe (F1,28 = 0.968,
report a main pp == 0.33,
effectŋ of=
0.90, 2 = 0.03).
0.001) (Figure
Group 4E). p = 0.01, ŋ2
(F1,28 = 7.56,
3.5. Turning Phase
eople with ET walked slower than non-ET counterparts irrespective of Condition
3.5.
37.7,Turning
RegardingPhase
SE = 13.7, turning
p = 0.01)velocity,
(Figure we 3D).report
We also a mainfound effect of Group main
a significant (F1,28 =effect
7.56, pof= 0.01, ŋ2
= 0.21).Regarding
People with turning velocity,
ET walked we report
slower a main effect
than non-ET of Group
counterparts (F1,28 = 7.56,
irrespective ofpCondition
= 0.01, ŋ2
=(Mdiff
0.21). =People
37.7, SEwith ET walked
= 13.7, p = 0.01) slower
(Figure than3D). non-ET We alsocounterparts irrespectivemain
found a significant of Condition
effect of
Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3D). We also found a significant main effect of
Sensors 2024, 24, 2216 7 of 11
Sensors 2024, 24, 2216 7 of 10

Sit-to-Stand Walk
A) B) C)
TUG Duration Duration Duration
15 # 1.0 3 #

2
0.5
10
1
0.0
0
5
-0.5
-1

0 -1.0 -2
Non- E Non- E Non- E
ET T ET T ET T

D) Turn Velocity E) Stand-to-Sit

Duration
#
0 1.0

-50
0.5
-100
0.0
-150

-0.5
-200

-250 -1.0
Non- E Non- E
ET T ET T

Figure 4. A comparison of performance between standard and water-carry TUGs in individuals

Figure 4. A comparison of performance between standard and water-carry TUGs in individuals
with and without
with and without essential
essential tremor.
tremor. Positive
Positive values
values indicate
indicate longer/faster
longer/fasterperformance
performanceduring
duringthe the
water-carry TUG, while negative values indicate shorter/slower performance during
water-carry TUG, while negative values indicate shorter/slower performance during the standard the standard
TUG.Panel
TUG. Panel(A):
(A):total
totalTUG
TUGtask
taskduration,
duration,Panel
Panel(B):
(B):sit-to-stand
sit-to-standphase,
phase,Panel
Panel(C):
(C):straight-line
straight-linewalk
walk
phase, Panel (D): turn velocity in the turning phase, and Panel (E): stand-to-sit phase.
phase, Panel (D): turn velocity in the turning phase, and Panel (E): stand-to-sit phase. Blue bars Blue bars
represent the non-ET group, while orange bars represent the ET group. Black-filled circles
represent the non-ET group, while orange bars represent the ET group. Black-filled circles indicateindicate
individual
individualdata
datapoints.
points.Standard
Standarderror
errorbars
barsare
arealso
alsodepicted.
depicted.TheThesymbol
symbol##denotes
denotesthethemain
maineffect
effect
of the condition.
of the condition.

4. Discussion
3.3. Sit-to-Stand Phase
Thisanalysis
Our study compared postural
investigating thetransitional
sit-to-standmovements
performance in people
betweenwith and without
people with andET
during aET
without standard
during and progressively
the standard more complex
and water-carry measure
TUG revealedof mobility.
a main effectWe report two
of Group
main
(F 1,27 = findings: (1) people
10.1, p = 0.004, with Specifically,
ŋ2 = 0.27). ET showed people
decreased
withperformance
ET took longerin each phase ofthis
to complete the
TUG compared to people without ET and (2) task complexity did not
phase of the TUG compared to their non-ET counterparts (Mdiff = 0.209, SE = 0.07, p =differentially impact
TUG performance
0.004) (Figure 3B). inNopeople with ET.
significant mainThese results
effect support our
of Condition washypothesis
observed (F that
1,27people
=1.185,with
p=
ET would
0.29, exhibit
ŋ2 = 0.04) differences
(Figure 4B) norin TUG
was phases
there compared
a significant to those
main Group without ET. This
x Condition is among
interaction
the
(F 1,27first studies
= 0.597, to examine
p = 0.45, phase-specific differences during a standard and complex TUG
ŋ2 = 0.02).
assessment in ET. Our study provides additional insight indicating particular functional
movement
3.4. alterations
Straight-Line in people with ET.
Walk Phase
Our study is novel as we corroborate and expand upon previous studies by comparing
A main effect of Group was observed (F1,28 = 5.05, p = 0.03, ŋ2 = 0.15). People with ET
the TUG subcomponent phases to patients without ET [9,13,15,22]. People with ET exhib-
took longer to complete the walk phases compared to their non-ET counterparts
ited decreased performance in each phase of the standard and water-carry TUG assessment
irrespective of Condition (Mdiff = 0.574, SE = 0.23, p = 0.04) (Figure 3C). We found a
compared to those without ET. For instance, during the standard TUG assessment, com-
significant main effect of Condition (F1,28 = 8.332, p = 0.007, ŋ2 = 0.23). Regardless of Group,
pared to the non-ET group, people with ET took 0.12 s longer to complete the sit-to-stand
participants walked slower during the water-carry TUG compared to the regular TUG
phase, 0.46 s longer to complete the straight-line walk phase, and 0.45 s longer to complete
(Mdiff = 0.355, SE = 0.12, p = 0.007) (Figure 4C). No significant Group X Condition
the stand-to-sit phase, while turning velocity was 45◦ /s slower. Similarly, regarding the
interaction was observed (F1,28 = 0.968, p = 0.33, ŋ2 = 0.03).
complex TUG assessment, the ET group took 0.27 s, 0.46 s, and 0.19 s longer to complete
the sit-to-stand phase, the straight-line walk phase, and the stand-to-sit phase, while turn-
3.5. Turning Phase ◦
ing velocity was 19 /s slower. Our study findings support previous research on TUG
Regarding
performance inturning
ET, whichvelocity,
showswe report a main
decrements effectTUG
in overall of Group (F1,28and
duration = 7.56, p = 0.01, ŋ2
phase-specific
=performance
0.21). People [9,13,15,22].
with ET walked Ourslower
outcomesthanalso
non-ET counterparts
align with Mostilleirrespective of Condition
et al.’s, who reported
(Mdiff = 37.7, SE = 13.7, p = 0.01) (Figure 3D). We also found a significant main effect of
Sensors 2024, 24, 2216 8 of 10

differences in the TUG’s sit-to-stand, turning, and stand-to-sit phases [15]. However, this
study exclusively examined ET and failed to compare performance to a non-ET population.
Therefore, our study is novel and expands upon these findings by comparing the TUG
subcomponent phases to participants without ET.
Each phase of the TUG task represents crucial postural transition movements necessary
for everyday activities of daily living. Altered performance in specific TUG phases may
indicate functional deficits that may compromise daily function. For example, we report
decreased performance during the sit-to-stand and turning phase, which may signify
movements requiring lower extremity strength, and dynamic balance may be impacted
in people with ET [23–25]. Critically, decreased performance in these assessments has
been associated with disability [26,27] and decreased quality of life [28]. Focusing solely
on total TUG duration may limit the interpretative capacity of the assessment, as it fails
to provide quantitative outcomes describing components of the assessment that may
be most compromised in populations with mobility impairments. Therefore, our study
emphasizes the significance of examining individual TUG phases. Examining phase-
specific performance may provide more targeted therapeutic approaches to address specific
functional performance alterations in people with ET.
Task complexity, introduced by adding a water-carrying task during the TUG, did
not differentially affect overall or phase-specific TUG performance in people with ET.
Compared to the standard and regardless of group, the complex TUG resulted in a 2.43 s
longer total TUG time, 0.37 s longer straight-line walk phases, and a 63.2◦ /s slower turning
velocity. The sit-to-stand and stand-to-sit phases showed no differences between the stan-
dard and complex TUG assessments. Our study aimed to replicate real-life environments
and enhance the sensitivity of detecting postural transition deficits in people with ET by
incorporating a secondary manual task. This approach builds upon previous research
introducing secondary tasks to increase task complexity [29–33]. For example, Lundin and
colleagues introduced a water-carrying task during the TUG in frail older adults. They
found that a difference of 4.5 s between the standard TUG and the water-carry TUG was
sensitive at detecting those frailer and those at fall risk [29]. While previous studies have
investigated TUG and phase-specific performance [9,13,15,22], to our knowledge, we are
among the first to explore the impact of a secondary manual task on TUG performance
in individuals with essential tremor. Despite the typical clinical characteristics of upper
extremity tremor and cognitive impairment in ET, both ET and non-ET groups performed
similarly during the water-carry TUG assessment. However, our study did not reveal such
differences. Therefore, it is plausible that people with ET may have gained assistance from
adding the manual task or that it perhaps did not provide a challenging enough stimulus.
There are limitations in our study that should be considered when interpreting the
results. First, our measures for the TUG assessment were somewhat limited. We analyzed
the timed duration and velocity of the turn for our first aim. However, future studies should
explore specific kinematic differences in each phase of the TUG to better explain alterations
in performance. Additionally, our assessments only incorporated the 3 m TUG, and we
could not detect spatiotemporal metrics of gait during the straight-line walk phases using
our inertial sensors. Future studies should consider extending the walkway length to 7 or
10 m to capture additional gait metrics [17]. Furthermore, it is important to acknowledge
that medication used by patients with ET might alter their motor performance; however,
we consistently ensured that all participants were tested in their therapeutic optimal state.
The limited sample size of 30 individuals (15 with ET and 15 without ET) may have
affected our outcomes. While this limitation may have influenced our ability to identify
interaction effects between group and condition, we believe this limited dataset addresses
critical gaps in the existing ET literature. Further, it is important to consider that there are
other factors not included within the scope of this study that may have impacted TUG
performance (Supplementary Materials), such as depression, anxiety, cognitive impairment,
musculoskeletal deconditioning, obesity, and other age-associated comorbidities. Study
outcomes provide a necessary first step at enhancing our understanding of functional
Sensors 2024, 24, 2216 9 of 10

mobility performance in people with ET. Further, it offers valuable evidence supporting the
selection of sensitive clinical measures of functional mobility. Future work should expand
current study findings in a larger, more robust sample of people with ET. Despite these
limitations, our study outcomes contribute significantly to understanding walking and
functional mobility performance in ET.

5. Conclusions
People with ET exhibit decreased performance in all phases of the TUG compared
to those without ET, indicating functional movement alterations in tasks requiring lower
extremity strength and dynamic balance. Our study outcomes provide insight into specific
aspects of functional movements that may be most compromised in ET. Ultimately, study
outcomes may provide patient-centered therapeutic approaches, increasing one’s ability to
complete everyday activities of daily living and improve quality of life.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/s24072216/s1.
Author Contributions: P.G.M. and J.A.R. conceived and designed the research; P.G.M. analyzed
data; P.G.M. prepared the figures; P.G.M. drafted the manuscript; P.G.M., J.A.R., W.M.M., K.A.N.
and H.C.W. edited and revised the manuscript; J.A.R., W.M.M., H.C.W. and K.A.N. approved the
final version of the manuscript. All authors have read and agreed to the published version of
the manuscript.
Funding: Research was supported by the National Center for Advancing Translational Research of
the National Institutes of Health under award number UL1TR003096-03.
Institutional Review Board Statement: This study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Institutional Review Board of Auburn University
(21-598 EP 2201, 1 November 2023).
Informed Consent Statement: Informed consent was obtained from all subjects involved in this study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: The authors would like to thank those who participated in this study and all
those who helped distribute and spread awareness of our study.
Conflicts of Interest: The authors declare no conflicts of interest.

References
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