research on physical fitness test

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Criterion-Related Validity of Field-Based Fitness Tests in Adults: A Systematic Review

Jose castro-piñero.

1 GALENO Research Group, Department of Physical Education, Faculty of Education Sciences, University of Cádiz, Avenida República Saharaui s/n, Puerto Real, 11519 Cádiz, Spain; [email protected] (J.C.-P.); [email protected] (J.R.F.-S.); [email protected] (F.M.-A.); [email protected] (V.S.-J.); [email protected] (R.I.-G.); [email protected] (M.C.-G.)

2 Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), 11009 Cádiz, Spain

Nuria Marin-Jimenez

Jorge r. fernandez-santos, fatima martin-acosta, victor segura-jimenez, rocio izquierdo-gomez, jonatan r. ruiz.

3 PROmoting FITness and Health through Physical Activity Research Group (PROFITH), Sport and Health University Research Institute (iMUDS), Department of Physical and Sports Education, School of Sports Science, University of Granada, 18007 Granada, Spain; se.rgu@jziur

Magdalena Cuenca-Garcia

Associated data.

We comprehensively assessed the criterion-related validity of existing field-based fitness tests used to indicate adult health (19–64 years, with no known pathologies). The medical electronic databases MEDLINE (via PubMed) and Web of Science (all databases) were screened for studies published up to July 2020. Each original study’s methodological quality was classified as high, low and very low, according to the number of participants, the description of the study population, statistical analysis and systematic reviews which were appraised via the AMSTAR rating scale. Three evidence levels were constructed (strong, moderate and limited evidence) according to the number of studies and the consistency of the findings. We identified 101 original studies (50 of high quality) and five systematic reviews examining the criterion-related validity of field-based fitness tests in adults. Strong evidence indicated that the 20 m shuttle run, 1.5-mile, 12 min run/walk, YMCA step, 2 km walk and 6 min walk test are valid for estimating cardiorespiratory fitness; the handgrip strength test is valid for assessing hand maximal isometric strength; and the Biering–Sørensen test to evaluate the endurance strength of hip and back muscles; however, the sit-and reach test, and its different versions, and the toe-to-touch test are not valid for assessing hamstring and lower back flexibility. We found moderate evidence supporting that the 20 m square shuttle run test is a valid test for estimating cardiorespiratory fitness. Other field-based fitness tests presented limited evidence, mainly due to few studies. We developed an evidence-based proposal of the most valid field-based fitness tests in healthy adults aged 19–64 years old.

1. Introduction

Physical fitness is an integrated measure of all the functions and structures involved in performing physical activity [ 1 ]. Nowadays, physical fitness is one surrogate marker of overall adult health (19–64 years), especially cardiorespiratory fitness and muscular strength. Cardiorespiratory fitness is inversely associated with cardiovascular diseases [ 2 ], obesity [ 3 ], osteoporosis [ 4 ] diabetes [ 5 ], different cancer types [ 6 , 7 ], and is a predictor of all-cause of mortality [ 8 , 9 , 10 , 11 , 12 ] and cardiovascular disease [ 10 , 12 , 13 , 14 , 15 ]. Likewise, in the psychological sphere, high levels of cardiorespiratory fitness are associated with well-being [ 16 , 17 ], improved cognitive function [ 18 ] and a reduced risk of Alzheimer’s disease [ 19 ] and other mental conditions such as anxiety, panic and depression [ 20 ]. Muscular strength demonstrates a protective effect against all-cause mortality [ 21 , 22 ]; and is inversely associated with weight gain and adiposity-related hypertension occurrence and the prevalence and incidence of the metabolic syndrome, [ 22 ] and mental health clinical presentations [ 23 , 24 ]. Consequently, physical fitness assessment is a vital tool of prevention and health diagnoses.

Laboratory testing is an objective and accurate method of assessing physical fitness. However, due to the cost of sophisticated instruments, time constraints and the need for qualified technicians, laboratory testing is limited to sport clubs, schools, population-based studies, and offices or clinical settings. However, field-based fitness testing can offer useful and practical alternatives as screening tools, since they are relatively safe and time-efficient, involve minimal equipment and low cost, and can be easily administered to multiple people simultaneously.

The validity of field-based fitness tests needs to be considered when deciding which test to use [ 25 ]. Criterion-related validity refers to the extent to which a field-based test of a physical fitness component correlates with the criterion measure (i.e., the gold standard) [ 26 ]. Since the early interest in physical fitness testing in the 1950–1960s, many field-based fitness tests have been proposed [ 27 ]. It would be desirable to summarise the criterion-related validity of the existing field-based fitness tests in adults. There have been attempts to summarize the criterion-related validity of a certain test [ 28 , 29 ] or several tests with a common characteristic [ 30 , 31 , 32 ]; however, no attempts have been made to summarise the criterion-related validity of all the existing field-based fitness tests in adults.

Therefore, the aim of the present systematic review was to comprehensively study the criterion-related validity of the existing field-based fitness tests used in adults. The findings of this review will provide an evidence-based proposal for most valid field-based fitness tests for healthy adults, aged 19–64 years old.

2. Materials and Methods

The review was registered in PROSPERO (registration number: CRD42019118482) and the applied methodology followed the guidelines drawn in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [ 33 ].

2.1. Literature Search

The search was performed in the MEDLINE (via Pubmed) and Web of Science electronic databases from inception until July 2020. We screened studies conducted for criterion-related validity in adults, where one or more field-based fitness tests were carried out. Thus, the keywords selected were based on terms related to “criterion-related validity”, “adults” and “field-based fitness test”. The search syntax was adapted to the indexing terms of each database (see Supplementary Material 1 ). Searching was restricted to articles published in humans and the English or Spanish languages.

2.2. Eligibility Criteria

The inclusion criteria for this systematic review were the (1) age criterion: adults (19–64 years old). During this review, we faced the problem that some studies sampled adults and older adults, or adults or adolescents together. In these cases, we observed whether these studies performed stratified analyses by age groups, isolating the adult population from the rest; if so, the study was included and information concerning the adult population reported. In contrast, when the authors analysed the whole sample together, we only included the study if the age of the sample was predominantly within our study age range; (2) participants: the study population was based on a generally healthy population, who did not present any injury, physical and/or mental disabilities, irrespective of body mass index (BMI), diabetes or other cardiovascular risks (i.e., hypertension, hypercholesterolemia, lipid profiles, glucose levels, insulin sensitivity); and (3) study design: original studies or systematic reviews/meta-analysis. The original studies that were selected for the analysis of their criterion-related validity but which were also included in the selected systematic reviews were excluded; (4) language criterion: articles were only published in English or Spanish; (5) topic criterion: studies examining the criterion-related validity of the field-based fitness test. Studies examining the relationship between field-based fitness tests were excluded. Likewise, studies that analysed the criterion-related validity of tests designed for exclusive use in sports or clinical settings were not included.

Two authors (J.C.P. and J.R.F.S.) independently assessed the titles and abstracts of the articles retrieved by the search strategy for eligibility. Then, the full texts of the selected articles were acquired, and the same two researchers independently screened them to determine whether to include the article based on the inclusion criteria. When no consensus was reached between both researchers, a third research (N.M.J.) made the final decision with regard to inclusion. Reasons for the exclusion of identified articles were recorded.

2.3. Data Extraction

Two researchers (N.M.J. and F.M.A.) independently extracted the following information from each eligible original study according to the standardized form: (1) the author’s name; (2) participants (sex and number); (3) age of participants; (4) filed-based test; (5) criterion measure (gold standard); (6) statistical methods; (7) main outcome; and (8) conclusions.

The same researchers independently extracted the following information from the systematic reviews: (1) author´s name, date and years covered by the review; (2) type of review and number of included studies; (3) age of participants; (4) filed-based test; (5) criterion measure (gold standard); (6) main outcome; and (7) conclusions.

Disagreements in the extracted data were discussed between studies until a consensus was reached.

2.4. Criteria for Risk of Bias Assessment

Due to the heterogeneity of statistical methods employed by the original studies selected, the high number of tests included, and the limited number of studies per test, a meta-analysis was not conducted. An assessment of risk of bias in selected original studies and systematic reviews was made for each eligible study by two studies (N.M.J. and F.M.A.) independently. Discrepancies were solved in a consensus meeting. Inter-rater agreement for the risk of bias between researchers was calculated by the percentage agreement (96% (Kappa = 0.962) before consensus, and 100% agreement after consensus meeting).

The assessing risk of bias criteria in original studies were determined according to quality assessment list employed by Castro-Piñero et al. [ 27 ], which include the three following criteria: (1) the adequate number of participants; (2) an adequate description of the study population; and (3) adequate statistical analysis (see Supplementary Table S1 ). Each criterion was rated from 0 to 2, being 2 the best score. For all studies, a total score was calculated by counting up the number of positive items (a total score between 0 and 6). Studies were categorized as very low quality (0–2), low quality (3–4) and high quality (5–6).

The methodological quality of each systematic review was appraised using the ‘Assessment of Multiple Systematic Reviews’ (AMSTAR) rating scale [ 34 ]. AMSTAR contains 11-items to assess the methodological aspects of reviews with items scored as 1 if the answer was “Yes”, and 0 if the answer was “No”, “Cannot Answer” or “Not Applicable” (see Supplementary Table S2 ). The total score ranged from 0 to 11. The item on conflict of interest requires that the systematic review and all primary studies be assessed. We modified this item to only assess the review itself as Biddle et al. [ 35 ] proposed, given that PRISMA does not require a conflict-of-interest assessment for each primary study. The final quality rates were computed by tertiles, where the first tertile ranged from 0 to 3 points (low quality); the second tertile from 4 to 7 points (medium quality); and the third tertile from 8 to 11 points (high quality).

2.5. Levels of Evidence

Three evidence levels [ 27 ] were constructed: (1) strong evidence: consistent findings in three or more high-quality studies; (2) moderate evidence: consistent findings in two high-quality studies; and (3) limited evidence: consistent findings in multiple low-quality studies, inconsistent results found in multiple high-quality studies, or results based on one single study. The degree of criterion-related validity of the field-based fitness test will be discussed for those tests on which we found strong or moderate evidence that the test is (or not) valid. The results of low- or very low-quality studies can be seen in the Supplementary Material 2 .

The literature search yielded 9202 and 27 additional records were identified through other sources (see the PRISMA flowchart in Figure 1 ). After the removal of duplicate references (1805 studies), and the screening of titles and abstracts (7233 studies), we excluded 9038 studies. A total of ▣191 full-text studies were assessed for eligibility, and 85 studies (six systematic reviews) were excluded due to reasons indicated in Figure 1 .

Flow chart of retrieved and selected articles.

Finally, a total of 101 original studies (see Supplementary Table S3 ) addressed the criterion-related validity of field-based fitness tests in adults aged 19–64 years. The sample size involved 10,632 participants (see Supplementary Table S4 ). Eighty-six and seventy-eight original studies reported female ( n = 5539) and male ( n = 4722) sample proportions, respectively; however, in 7 seven studies, sex was not specified.

A total of four meta-analyses [ 28 , 29 , 30 , 31 ] and one systematic review [ 32 ] were included in the present systematic review (see Supplementary Table S2 ). The sample size involved 9985 participants with ages ranging from 19 to 64 years (see Supplementary Table S5 ).

3.1. Quality Assessment

Of the 101 original studies included in the present systematic review, 11 and 40 studies were classified as very low (a total score less than 2) and low quality (a total score of 3 and 4), respectively (see Supplementary Table S3 ). A total of 50 original studies were classified as high-quality (a total score higher than 4). Of these 40, nine and one analysed the criterion-related validity of cardiorespiratory fitness, muscular strength and flexibility field-based fitness tests in adults, respectively. No study of those classified as high quality analysed the criterion-related validity of motor fitness (i.e., speed, agility, balance and coordination).

Two meta-analyses [ 28 , 30 ] and one systematic review [ 32 ] were ranked as high quality (all eight points), and two meta-analyses [ 29 , 31 ] were ranked as medium quality (both seven points) (see Supplementary Table S2 ). Three of them assessed the criterion-related validity of field-based cardiorespiratory fitness tests: the 20 m shuttle run test [ 28 ]; distance and time-based run/walk tests [ 30 ]; and the step tests [ 32 ]—whilst and two of them studied the criterion-related validity of the sit-and-reach [ 31 ] and toe-to-touch tests [ 29 ].

* References of high-quality studies are presented in Supplementary Material 3 .

3.2. Criterion-Related Validity

Table 1 shows a summary of the different levels of evidence found for the criterion-related validity of cardiorespiratory fitness tests.

Levels of evidence of cardiorespiratory fitness tests.

3.2.1. Cardiorespiratory Fitness

Distance and time-based run/walk tests.

Seventeen high-quality studies examined the criterion-related validity of the distance run/walk or walk tests (see Supplementary Table S4 ). Four and two studies showed that the 2 km walk [ 36 , 37 , 38 , 39 ] and 1.5-mile run/walk [ 40 , 41 ] tests, respectively, were valid for assessing cardiorespiratory fitness (r = 0.80–0.93, all p < 0.05). Four studies [ 42 , 43 , 44 , 45 ] observed that the 1-mile walk test was an accurate test for estimating VO 2max (r = 0.81–0.88, all p < 0.05), while another two studies [ 46 , 47 ] showed that it was not a valid test (r = 0.69, 13.3% E, p < 0.05; mean differences range from 2.360 to 9.131 mL/kg/min, all p < 0.001, respectively). The treadmill jogging test reported contradictory results: one study [ 48 ] found it to have high validity for assessing cardiorespiratory fitness (r = 0.84, both p < 0.001); whereas another study [ 41 ] revealed that it was not a valid test (r = 0.50, p < 0.05).

Five high-quality studies investigated the criterion-related validity of the time-based run/walk or walk tests (see Supplementary Table S4 ). These studies showed that the 3 min walk, [ 49 ] 6 min walk, [ 50 , 51 , 52 ] and the 12 min run/walk [ 41 ] tests were valid for assessing cardiorespiratory fitness (r = 0.70–0.95, all p < 0.05). Additionally, one original high-quality study reported that the University Montreal test [ 53 ] was valid for estimating cardiorespiratory fitness (r = 0.71, p < 0.001; mean difference = 0.025 ± 7.445 mL/kg/min., p > 0.05).

A meta-analysis [ 30 ] consisting of 102 studies on adults determined that the criterion-related validity of the distance run/walk field tests for estimating cardiorespiratory fitness ranged from low to high, with the 1.5-mile (r p = 0.80; 95% CI: 0.72–0.80) and 12 min run/walk tests (r p = 0.79; 95% CI: 0.71–0.87) being the best predictors (see Supplementary Table S5 ).

Twenty-Metre Shuttle Run Test

Nine high-quality studies analysed the criterion-related validity of the 20 m shuttle run test [ 41 , 54 , 55 , 56 , 57 , 58 ] or modifications of it [ 55 , 57 , 59 , 60 , 61 ] (see Supplementary Table S4 ). Four studies [ 41 , 55 , 56 , 57 ] reported that the 20 m shuttle run was a valid test for assessing cardiorespiratory fitness (r = 0.82–0.94, all p < 0.05). However, one study [ 58 ] concluded that this test was not valid for assessing cardiorespiratory fitness (mean differences range from −0.54 ± 6.23 to −2.94 ± 6.55 mL/kg/min, all p < 0.01). Two studies [ 59 , 60 ] proved that the incremental shuttle walk test was not valid (r = 0.72, 19% E, both p < 0.001), while one study [ 61 ] found that this test was valid for assessing cardiorespiratory fitness (mean difference = 0.14 ± 9.27mL/kg/min, p > 0.05). Moreover, two studies [ 55 , 57 ] reported that the 20 m square shuttle run test was valid (r = 0.95, both p < 0.001).

A meta-analysis [ 28 ] which included 24 studies in adults found that the 20 m shuttle run test had a moderate-to-high criterion-related validity for estimating VO 2max (r p = 0.79–0.94; 95% CI: 0.56–1.00) (see Supplementary Table S5 ).

Eleven high-quality studies analysed the criterion-related validity of the step tests (see Supplementary Table S4 ). Four studies observed that the Danish step [ 62 ], the Queen’s College step [ 63 ], and the 2 min step [ 64 ] tests were not valid for estimating VO 2max (r = 0.034–0.72, all p < 0.05). However, another eight studies proved the validity of the modified Canadian aerobic fitness [ 65 ], 6 min single 15 cm step [ 66 ], YMCA step [ 67 , 68 , 69 , 70 , 71 ], Tecumseh step [ 70 ] and modified Harvard step [ 72 ] tests (r = 0.80–0.91, all p < 0.05).

A systematic review [ 32 ] comprised of 11 studies on adults investigated the criterion-related validity of the step tests (see Supplementary Table S5 ). Validity measures were varied, and a broad range of correlation coefficients were reported across the 11 studies (r = 0.469–0.95; all p < 0.005) with conflicting results in most of the step test protocols. The study concluded that the Chester step test was the best predictor for assessing cardiorespiratory fitness.

3.2.2. Muscular Strength

Table 2 shows a summary of the different levels of evidence found for the criterion-related validity of muscular strength, flexibility and motor fitness tests.

Levels of evidence of muscular strength, flexibility and motor fitness tests.

Maximal Isometric Strength

Four high-quality studies assessed the criterion-related validity of hand maximal isometric strength, using the handgrip strength tests (see Supplementary Table S4 ). Three high-quality studies reported that the TKK dynamometer [ 73 , 74 , 75 ] was valid (mean difference range −0.20, p > 0.05 to 2.02 kg p < 0.001) (r = 0.98, p < 0.001). However, three studies showed inconclusive results about the validity of the DynEx dynamometer [ 73 , 75 , 76 ], and two studies observed that the Jamar dynamometer [ 73 , 76 ] was less accurate than the TKK and DynEx dynamometer for estimating hand maximal isometric strength.

Endurance Strength

Four high-quality studies assessed the criterion-related validity of trunk endurance strength (see Supplementary Table S4 ). Two studies [ 77 , 78 ] suggested that the Biering–Sørensen (r = 0.84–98, p < 0.01) test was valid, whereas another study [ 79 ] reported acceptable validity (r = 0.60–0.71, p < 0.05). One study showed that the prone bridging test [ 80 ] was valid for assessing trunk endurance strength (no mean difference, p > 0.05).

Explosive Strength

Only one high-quality study assessed the criterion-related validity of explosive strength (see Supplementary Table S4 ). This study concluded that the Sargent test [ 81 ] was not valid (mean difference: 4.4 ± 5.1, p < 0.001) for estimating lower body explosive strength.

3.2.3. Flexibility

Only one study [ 82 ] that examined the criterion-related validity of flexibility tests was classified as high quality (see Supplementary Table S4 ). They found that the sit-and-reach was not a valid test (r = 0.44–0.48, p < 0.05).

A meta-analysis [ 31 ] which included 28 studies on adults (see Supplementary Table S5 ) found that the sit-and-reach test and its different versions, had moderate validity for estimating hamstring extensibility (r p ranged from 0.49; 95% CI: 0.29–0.68 to 0.68; 95% CI: 0.55–0.80), but a low validity for estimating lumbar extensibility (r p ranged from 0.16; 95% CI: −0.10–0.41 to 0.35; 95% CI: 0.15–0.54). Moreover, another meta-analysis [ 29 ] carried out on adults (of six studies) reported that the toe-touch test had moderate validity for assessing hamstring extensibility (r p = 0.66; 95% CI: 0.56–1.00).

3.2.4. Motor Fitness

No study investigating the criterion-related validity of motor fitness tests was classified as high quality (see Supplementary Table S3 ).

4. Discussion

The present systematic review comprehensively studied the criterion-related validity of the existing field-based fitness tests used in adults. The findings of this review provide an evidence-based proposal for most valid field-based fitness tests for adult population.

4.1. Cardiorespiratory Fitness

The gold standard to assess VO 2max is the Douglas bag method, although there is agreement that the respiratory gas analyser is a valid method of assessing oxygen uptake [ 83 ]. All high-quality studies measured VO 2max or peak oxygen consumption when performing a submaximal/maximal treadmill or cycle test, except Manttari et al. [ 52 ], who directly measured VO 2max when performing the 6 min walk test.

4.1.1. Distance and Time-Based Run/Walk Tests

The run/walk field tests are probably the most widely used tests [ 27 , 84 ], however, until recently, there was no consensus regarding the most appropriate distance or time to use for these tests [ 85 ]. Mayorga et al. [ 30 ] performed a meta-analysis which examined the criterion-related validity of the 5000 m, 3 mile, 2 mile, 3000 m, 1.5-mile, 1-mile, 1000 m, ½-mile, 600 m, 600 yd, ¼-mile, 15 min, 12 min, 9 min, and 6 min run/walk tests. They found that the criterion-related validity of the run/walk tests, only considering the performance score, ranged from low to high, with the 1.5-mile and the 12 min run/walk tests being the most appropriate tests for estimating cardiorespiratory fitness in adults aged 19–64 years. Sex, age or VO 2max level did not affect criterion-related validity, whereas when multiple predictors (i.e., performance score, sex, age or body mass) were considered, the criterion-related validity values were higher. In this sense, two high-quality original studies reinforced these results, and showed that the 12 min [ 41 ] and the 1.5-mile [ 40 , 41 ] run/walk tests were fairly accurate for estimating cardiorespiratory fitness in adults aged 18–26 years (r = 0.87–0.93, p < 0.05).

Overall, the run/walk tests are not user-friendly tests, due to the difficulty of developing an appropriate pace, which may affect the test outcome (some participants start too fast, so they are unable to maintain their speed throughout the test; others start too slow, so when they wish to increase their speed the test is already finished). These problems are more likely to occur in longer distance tests. Other factors affecting the test outcome include the individual’s willingness to endure the discomfort of strenuous exercise, a short attention span, poor motivation, and limited interest in a monotonous task [ 86 , 87 , 88 ].

The 2 km and 6 min walk tests are probably the most widely used walk tests in adults [ 39 , 51 ]. Both tests require submaximal effort, thus avoiding the problem of enduring the discomfort of strenuous exercise. In addition, it allows to evaluate those people with a low level of physical fitness or is unable to run. Three high-quality studies [ 36 , 37 , 39 ] observed that Oja’s equation derived from the 2 km walk test has high validity (r = 0.80–0.87, all p < 0.05) in untrained and/or overweight/obese adults aged 20–64 years. One high-quality study reported that the 2 km walk test [ 38 ] is a reasonably valid field test for estimating the cardiorespiratory fitness of moderately active adults aged 35–45 years, but not in adults with very high maximal aerobic power.

Many studies developed prediction equations for the 6 min test based on spirometry [ 89 ]. However, only three high-quality studies [ 50 , 51 , 52 ] analysed the criterion-related validity of the 6 min test based on VO 2max in adults. They showed a moderate-to-high validity (r = 0.70–0.93, all p < 0.001) in obese and healthy adults aged 18–64 years. Burr et al. [ 90 ] suggested that, on its own, the 6 min walk test can be useful to discriminate between broad categories of high, moderate and low fitness, but that this approach may be associated with a degree of error, especially in the high fitness group.

According to these findings, the 2 km and 6 min walk tests are valid for use in adults aged 19–64 years with low or moderate fitness levels, but not in adults with a high fitness level.

Regarding the 1 mile walk test, conflicting results were found, especially when examining the accuracy of the Kline’s [ 42 ] and Dolgener’s [ 46 ] equations in adults aged 19–64 years.

4.1.2. Twenty-Metre Shuttle Run Test

The 20 m shuttle run test was developed by Leger at al. [ 91 ] to solve the pace issue of the run/walk tests. The test consists of 1 min stages of continuous running at an increasing speed. Recently, a meta-analysis [ 28 ] showed that the performance score of the 20 m shuttle run test had a moderate-to-high criterion-related validity for estimating VO 2max ( r p = 0.66–0.84) in youth and adults aged 18–64 years, higher than when other variables (i.e., sex, age or body mass) were accounted for ( r p = 0.78–0.95). This study also reported that Leger’s protocol had a greater average criterion-related validity coefficient ( r p = 0.84; 95% CI: 0.80–0.89) than Eurofit, QUB and Dong-HO protocols; and Leger’s protocol was statistically higher for adults ( r p = 0.94, 0.87–1.00) than for children ( r p = 0.78; 95% CI: 0.72–0.85). These values are higher than those reported for the 1500 m and 12 min run/walk tests [ 30 ]. Moreover, the meta-analysis showed that sex did not seem to affect the criterion-related validity values.

On the other hand, Cooper et al. [ 54 ] showed that Brewer’s protocol and equation were not valid for assessing active young people aged 18–26 years (mean difference = 1.8 ± 6.3 mL/kg/min; p = 0.004). In line with these findings, Kim et al. [ 58 ] observed that Leger’s protocol and equation were more accurate than Brewer’s protocol and equation (mean difference −0.54 mL/kg/min; %CV: 1.39 vs. mean difference −2.944 mL/kg/min; %CV: 8.87) in Korean adults, especially in women. Nonetheless, the authors suggested the need to develop new equations for Korean adults.

It is important to note that the 20 m square shuttle run test [ 55 , 57 ] was proposed as an alternative to the 20 m shuttle run test to reduce the test’s turning angle from 180 to 90. This test was the best predictor of VO 2max than the 20 m shuttle run test in young male adults aged 18–25 years.

4.1.3. Step Tests

Step tests are a safe, simple, inexpensive and practical method of assessing cardiorespiratory fitness under submaximal conditions, which require minimum space [ 32 ]; they are also a great alternative to laboratory tests in clinical settings. There are a wide variety of step test protocols which differ in terms of stepping frequency, test duration and number of test stages. Bennett et al. [ 32 ] analysed the criterion-related validity of different step tests (the Chester step test, a personalised step test, the STEP tool step test, the Queen’s College step test, the Skubic and Hodgkins step test, a height-adjusted, rate-specific, single-state step test, the Astrand–Ryhming step test, and a modified YMCA 3 min step test) in adults aged 18–64 years. The validity of these tests ranged from moderate to high, and they suggested that the Chester step test was the most valid step test to evaluate cardiorespiratory fitness in adults. However, this systematic review only included two studies with contradictory results, similarly to the Queen’s College step test.

Analysing the 12 high-quality studies that examined the criterion-related validity of the step tests in adults aged 19–64 years, we can conclude that the YMCA step test [ 67 , 71 ] seemed to be the most appropriate step test to estimate VO 2max in adults aged 19–64 years. However, it is important to note that there is no single equation, since the result of the equation depends on the sample used. Santo and Golding [ 92 ] even altered the protocol by adjusting the step height to the individual participant’s height in order to increase the accuracy of this test.

4.1.4. Levels of Evidence

Strong evidence indicated that (a) the 20 m shuttle run test using Leger’s equation, the 2 km walk using Oja’s equation, the 6 min and the YMCA step tests are valid for estimating cardiorespiratory fitness; and (b) the criterion-related validity of the distance and time-based run/walk tests range from low to high, with the 1.5-mile and 12 min run/walk tests being the best predictors. Moderate evidence indicated that the 20 m square shuttle run test is valid for estimating cardiorespiratory fitness. Due to the inconsistent results found in high-quality studies, limited evidence was found for the validity of the 1-mile walk, treadmill jogging, incremental shuttle walking, Chester, and Queen’s College step tests. Due to the low number of high-quality studies, limited evidence indicated that (a) the 3 min walk, the ¼-mile walk, Mankato submaximal, modified Astrand–Ryhming, University Montreal, modified Canadian aerobic fitness step, 6 min single 15 cm step, Tecumseh step, modified Harvard step and Astrand–Ryhming Step tests are valid for estimating cardiorespiratory fitness; and (b) the YMCA cycle, Ruffier, Danish step, and 2 min step tests are not valid for estimating cardiorespiratory fitness. Due to the consistent results found in multiple low-quality studies, limited evidence supported using the 6 min step test for estimating cardiorespiratory fitness.

4.2. Muscular Strength

The specificity of the type of muscular work performed and the use of different energy systems are both major challenges for establishing a gold standard method for maximal, endurance and explosive muscular strength tests [ 93 ]. One repetition maximum (1RM) and repetitions to a certain percentage of 1RM (i.e., 50% of 1RM or 70% of 1RM) [ 27 ], isokinetic dynamometer strength [ 94 , 95 , 96 ], and electromyography [ 78 , 80 ] were used as gold standards.

4.2.1. Maximal Isometric Strength

The TKK dynamometer [ 73 , 74 , 75 ] seemed the most appropriate test to assess maximal isometric strength in adults. All the studies used the “known weights” as the criterion reference.

Several studies examined whether the elbow position (extended or flexed at 90 degrees) affected the hand maximal isometric strength score in children [ 75 ], adolescents [ 97 ] and young adults [ 98 ]. They observed that performing the handgrip strength test with the elbow extended seems the most appropriate protocol to evaluate hand maximal isometric strength in these populations—which is in accordance with the protocol recommended by the American Center for Disease Control and Prevention [ 99 ].

Ruiz et al. [ 100 ] also investigated whether the position (grip span) on the standard grip dynamometer determined the hand maximal isometric strength in adults. They found that when measuring hand maximal isometric strength in women, hand size must be taken into consideration, providing the mathematical equation ( y = x /5 + 1.5 cm) to adapt optimal grip span ( y ) to hand size ( x ). In adult men, optimal grip span could be set at a fixed value (5.5 cm) and is not influenced by hand size.

Importantly, just like the step test, the handgrip strength test can be very useful in clinical settings because it requires minimal equipment and space, is time-efficient and easy to administer.

4.2.2. Endurance Strength

The Biering–Sørensen test, a trunk holding test in an antigravity prone position, is commonly used to measure the back and hip muscle endurance strength, which is associated with lower back pain [ 101 ]. Mannion et al. [ 77 ] and Coorevits et al. [ 78 ] showed that the test endurance time was highly associated with isometric/endurance hip and back musculature strength (r = 0.84–98, p < 0.01). On the other hand, Kankaanpää et al. [ 79 ], found that this association was moderate (r = 0.60–0.71, p < 0.05). However, when BMI (r= −0.49–0.51, p < 0.001) in women and age (r = 0.25–0.29, p < 0.05) in men were accounted for in the prediction model, the explained variance increased considerably. Thus, the Biering–Sørensen test might be considered as valid for measuring back muscle endurance strength.

Assessing abdominal muscle functionality is clinically relevant since it is considered to be related to lower back pain [ 102 , 103 ]. The curl-up test, or its different versions, was the field test originally used to assess this capacity. In the present review, no original studies evaluating the criterion-related validity of this test were classified as high quality. An alternative of the curl-up test could be the prone bridging test, an isometric holding test in prone position which is currently being used to supposedly measure abdominal endurance strength. The prone bridging test time is inversely associated with lower back pain [ 104 , 105 ]. In relation to the validity of this test, De Blaiser et al. [ 80 ] found a higher activation of the abdominal core musculature during the test than for the back and hip musculature, showing a high association between test time and abdominal endurance strength. Future high-quality studies are necessary to clarify the validity of this test.

It should be noted that no study that analysed the criterion-related validity of lower and upper body endurance strength tests were classified as high quality.

4.2.3. Explosive Strength

The standing long jump is proposed in health-related fitness test batteries in preschool children [ 106 ], as well as children and adolescents [ 107 ] to assess lower body explosive strength, given its criterion-related and predictive validity. However, to our knowledge, the criterion-related validity of this test has not been studied. Bui et al. observed that the Sargent jump test [ 81 ] is not appropriate to evaluate lower body explosive strength, because its overestimates the height of a vertical jump and its accuracy is reduced as the jump height increases (mean difference: 4.4 ± 5.1, p < 0.001). Due to the close relationship that lower body maximal/explosive strength has on adult health [ 22 , 23 ], more high-quality studies are required to analyse the criterion-related validity of these tests in future research.

4.2.4. Levels of Evidence

Strong evidence indicated that (a) the handgrip strength test with the elbow extended and with the grip span adapted to the hand size and sex (using the TKK dynamometer) is a valid test for assessing hand maximal isometric strength; and (b) the Biering–Sørensen test offers a valid test for assessing endurance strength of hip and back muscles. Moderate evidence indicated that handgrip strength (Jamar) has acceptable validity for assessing hand maximal isometric strength. Due to (a) the low number of high-quality studies, limited evidence (only one study) was found supporting the use of prone bridging for assessing abdominal endurance strength and the Sargent jump test for assessing lower body explosive strength; (b) the inconsistent results found in multiple high-quality studies, limited evidence was found for the validity of using handgrip strength (DynEx) for assessing hand maximal isometric strength; and (c) the consistent results found in multiple low or very low-quality studies, the curl-up test, or its different versions, are not valid for assessing abdominal endurance strength.

4.3. Flexibility

Radiography seems to be the best criterion measurement of flexibility, but goniometry is also used as a criterion measure [ 108 , 109 ].

Goniometers are relatively easy to obtain; nevertheless, their use requires a certain technical qualification since it is a sensitive method, and thus it is not feasible for use in all settings [ 110 ]. Traditionally, the sit-and-reach test, originally designed by Wells and Dillon [ 111 ], and its different versions, are included in the fitness test batteries for measuring hamstring and lower back flexibility, which are probably the most widely used measures of flexibility [ 27 ].

Mayorga et al. [ 31 ] performed a meta-analysis to analyse the criterion-related validity of the sit-and-reach and its different versions (modified sit-and-reach, back-saver sit-and-reach, modified back-saver sit-and-reach, V sit-and-reach, modification V sit-and-reach, unilateral sit-and-reach and chair sit-and-reach). These tests showed moderate validity for estimating hamstring extensibility, but low validity for estimating lumbar extensibility. They also found that the classic sit-and-reach test had the highest criterion-related validity coefficient in both hamstring and lumbar extensibility, compared to the other test, which does not seem to justify the use of the classic protocol modifications in order to solve the problems attributed to itself (i.e., the length proportion between the upper and lower limbs or the position of the head and ankles).

The toe-touch test is another field-based test for measuring hamstring flexibility, in which the individuals were assessed standing instead of sitting on the floor [ 112 ]. Although this test is easy to administer and can be an alternative to the sit-and-reach test, when the participant has problems being measured sitting, it is not proposed for any filed-based fitness test battery. A meta-analysis [ 29 ] analysed the criterion-related validity of the toe-touch test for measuring hamstring flexibility, reporting similar validity coefficients to those of the classic sit-and-reach.

It is interesting to highlight that Nuzzo [ 113 ] has recently suggested that flexibility should be invalidated as a major component of fitness, due to its lack of predictive and concurrent validity in terms of meaningful health and performance outcomes.

Levels of Evidence

Strong evidence indicated that (a) the sit-and-reach test and its modified versions have moderate validity for estimating hamstring extensibility, but low validity for estimating lumbar extensibility; and (b) the toe-to-touch test has moderate validity for estimating hamstring extensibility.

4.4. Motor Fitness

The validity of motor fitness tests is the least studied in adults. None of the three studies that analysed the criterion-related validity in motor fitness tests were classified as high quality. Given that the motor fitness tests (i.e., gait/walking speed, balance, timed up and go) are associated with all-cause mortality [ 114 , 115 , 116 ], falls and fractures [ 117 ], disability in activities of daily living [ 118 ] and depression [ 119 ], it would be useful to know their criterion-related validity.

Due to the consistent results found in multiple low-quality studies, we found limited evidence that the ten-step test had moderate validity in assessing agility.

5. Conclusions

The systematic review emphasized important major points regarding the criterion-related validity of adult field-based fitness tests ( Figure 2 ):

Major points regarding criterion-related validity of adult field-based fitness tests.

Cardiorespiratory fitness: the 20 m shuttle run tests best assessed cardiorespiratory fitness using Leger’s equation. Alternatively, the 1.5-mile, 12 min run/walk and YMCA step tests were other cardiorespiratory testing options. When low-level cardiorespiratory fitness existed, or if running was possible, the 2 km, then Oja’s equation or 6 min walk tests were appropriate alternatives.

Muscular strength: strong evidence indicated that (a) the handgrip strength test, with the elbow extended and with the grip span adapted to the individual’s hand size (using the TKK dynamometer), offers a valid means to assess hand maximal isometric strength; and (b) the Biering–Sørensen test estimated the endurance strength of hip and back muscles. Limited evidence (only one study) supported the prone bridging and Sargent jump tests as abdominal endurance strength and lower body explosive strength surrogate markers, respectively.

Flexibility: strong evidence supported the sit-and-reach test and its different versions, and that the toe-to-touch tests is not valid for assessing hamstring and lower back flexibility.

Motor fitness: limited evidence about the criterion-related validity of motor fitness existed.

When there are problems of space and time, as in clinical settings, the YMCA step and the handgrip strength tests are good alternatives for assessing cardiorespiratory fitness and isometric muscular strength, respectively.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/jcm10163743/s1 : Supplementary Tables and Supplementary Material.

Author Contributions

J.C.-P. and M.C.-G. conceived the study idea. J.C.-P. led the writing of the review and carried out methodological aspects with N.M.-J., F.M.-A. and J.R.F.-S., F.M.-A., V.S.-J., R.I.-G. and J.R.R. contributed writing—review and editing the final manuscript. All authors discussed the results and contributed to the final manuscript, and agreed with the order of presentation of the authors. All authors have read and agreed to the published version of the manuscript.

This project was supported by Ministry of Economy, Industry and Competitiveness in the 2017 call for R&D Projects of the State Program for Research, Development and Innovation Oriented to the Challenges of the Company; National Plan for Scientific and Technical Research and of Innovation 2017-2020 (DEP2017-88043-R); and the Regional Government of Andalusia and University of Cadiz: Research and Knowledge Transfer Fund (PPIT-FPI19).

Institutional Review Board Statement

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Informed Consent Statement

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The authors declare no conflict of interest.

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Reliability of Field-Based Fitness Tests in Adults: A Systematic Review

Affiliations.

• 1 GALENO Research Group, Department of Physical Education, Faculty of Education Sciences, School of Education, University of Cádiz, Puerto Real, Avenida República Saharaui S/N, 11519, Puerto Real, Cádiz, Spain.
• 2 Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cadiz, Spain.
• 3 GALENO Research Group, Department of Physical Education, Faculty of Education Sciences, School of Education, University of Cádiz, Puerto Real, Avenida República Saharaui S/N, 11519, Puerto Real, Cádiz, Spain. [email protected].
• 4 Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cadiz, Spain. [email protected].
• 5 ACAFYDE Research Group, Faculty of Sport Sciences, University of Extremadura, Caceres, Spain.
• 6 PROFITH "PROmoting FITness and Health Through Physical Activity" Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical and Sports Education, Faculty of Sport Sciences, University of Granada, 18071, Granada, Spain.
• 7 Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
• 8 Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.
• PMID: 35064915
• DOI: 10.1007/s40279-021-01635-2
• Correction to: Reliability of Field‑Based Fitness Tests in Adults: A Systematic Review. Cuenca-Garcia M, Marin-Jimenez N, Perez-Bey A, Sánchez-Oliva D, Camiletti-Moiron D, Alvarez-Gallardo IC, Ortega FB, Castro-Piñero J. Cuenca-Garcia M, et al. Sports Med. 2022 Aug;52(8):1981-1982. doi: 10.1007/s40279-022-01654-7. Sports Med. 2022. PMID: 35150416 No abstract available.

Background: Physical fitness is a powerful predictor of morbidity and mortality, and is therefore a useful indicator for public health monitoring. To assess physical fitness, field-based tests are time-efficient, inexpensive, have minimal equipment requirements, and can be easily administered to a large number of individuals.

Objective: The objective of this systematic review was to examine the reliability of existing field-based fitness tests used in adults aged 19-64 years.

Methods: A systematic search of two electronic databases (MEDLINE and Web of Science) was conducted from inception to 8 June 2021 by two independent researchers. Each study was classified as high, low, or very low quality according to the description of the participants, the time interval between measurements, the description of the results, and the appropriateness of statistics. Three levels of evidence (strong, moderate, and limited) were established according to the number of studies and the consistency of their findings. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO reference number, CRD42019118480).

Results: Of 17,010 records identified, 129 original studies examining the reliability of field-based fitness tests in adults were considered eligible. The reliability was assessed of tests of cardiorespiratory fitness (33 studies: 30 of high quality), musculoskeletal fitness (92 studies: 78 of high quality), and motor fitness (22 studies, all of high quality). There was strong evidence indicating: (i) the high reliability of the cardiorespiratory fitness tests: 20-m shuttle run, 6-min step, and 6-min walk; (ii) the high reliability of the musculoskeletal fitness tests: handgrip strength, back-leg strength, Sorensen, trunk flexion sustained, 5-reps sit-to-stand, sit-and-reach and toe-touch, and moderate reliability bilateral side bridge and prone bridge tests; and (iii) the moderate reliability and low reliability, respectively, of the motor fitness tests T-test and single-leg stand. We found moderate evidence indicating the moderate or high reliability of the following tests: Chester, sit-up, partial curl-up, flexion-rotation trunk, timed stair ascent, pull-up, bent-arm hang, standing broad jump, hop sequence, trunk lift, timed-up-and-go, and hexagon agility. Evidence for the reliability of balance and gait speed tests was inconclusive. Other field-based fitness tests demonstrated limited evidence, mainly due to there being only few studies.

Conclusions: This review provides an evidence-based proposal of the more reliable field-based fitness tests for adults aged 19-64 years. Our findings identified a need for more high-quality studies designed to assess the reliability of field-based tests of lower and upper body explosive and endurance muscular strength, and motor fitness (i.e., balance and gait speed tests) in adults.

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Reliability of Field-Based Fitness Tests in Adults: A Systematic Review

• Systematic Review
• Published: 22 January 2022
• Volume 52 , pages 1961–1979, ( 2022 )

Cite this article

• Magdalena Cuenca-Garcia   ORCID: orcid.org/0000-0002-8510-9253 1 , 2 ,
• Nuria Marin-Jimenez   ORCID: orcid.org/0000-0002-0687-7554 1 , 2 ,
• Alejandro Perez-Bey   ORCID: orcid.org/0000-0002-9849-5544 1 , 2 ,
• David Sánchez-Oliva   ORCID: orcid.org/0000-0001-9678-963X 1 , 2 , 3 ,
• Daniel Camiletti-Moiron   ORCID: orcid.org/0000-0002-8856-5967 1 , 2 ,
• Inmaculada C. Alvarez-Gallardo   ORCID: orcid.org/0000-0002-1062-8251 1 , 2 ,
• Francisco B. Ortega   ORCID: orcid.org/0000-0003-2001-1121 4 , 5 , 6 &
• Jose Castro-Piñero   ORCID: orcid.org/0000-0002-7353-0382 1 , 2  

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A Correction to this article was published on 12 February 2022

This article has been updated

Physical fitness is a powerful predictor of morbidity and mortality, and is therefore a useful indicator for public health monitoring. To assess physical fitness, field-based tests are time-efficient, inexpensive, have minimal equipment requirements, and can be easily administered to a large number of individuals.

The objective of this systematic review was to examine the reliability of existing field-based fitness tests used in adults aged 19–64 years.

A systematic search of two electronic databases (MEDLINE and Web of Science) was conducted from inception to 8 June 2021 by two independent researchers. Each study was classified as high, low, or very low quality according to the description of the participants, the time interval between measurements, the description of the results, and the appropriateness of statistics. Three levels of evidence (strong, moderate, and limited) were established according to the number of studies and the consistency of their findings. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO reference number, CRD42019118480).

Of 17,010 records identified, 129 original studies examining the reliability of field-based fitness tests in adults were considered eligible. The reliability was assessed of tests of cardiorespiratory fitness (33 studies: 30 of high quality), musculoskeletal fitness (92 studies: 78 of high quality), and motor fitness (22 studies, all of high quality). There was strong evidence indicating: (i) the high reliability of the cardiorespiratory fitness tests: 20-m shuttle run, 6-min step, and 6-min walk; (ii) the high reliability of the musculoskeletal fitness tests: handgrip strength, back-leg strength, Sorensen, trunk flexion sustained, 5-reps sit-to-stand, sit-and-reach and toe-touch, and moderate reliability bilateral side bridge and prone bridge tests; and (iii) the moderate reliability and low reliability, respectively, of the motor fitness tests T -test and single-leg stand. We found moderate evidence indicating the moderate or high reliability of the following tests: Chester, sit-up, partial curl-up, flexion-rotation trunk, timed stair ascent, pull-up, bent-arm hang, standing broad jump, hop sequence, trunk lift, timed-up-and-go, and hexagon agility. Evidence for the reliability of balance and gait speed tests was inconclusive. Other field-based fitness tests demonstrated limited evidence, mainly due to there being only few studies.

Conclusions

This review provides an evidence-based proposal of the more reliable field-based fitness tests for adults aged 19–64 years. Our findings identified a need for more high-quality studies designed to assess the reliability of field-based tests of lower and upper body explosive and endurance muscular strength, and motor fitness (i.e., balance and gait speed tests) in adults.

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Cuenca-Garcia, M., Marin-Jimenez, N., Perez-Bey, A. et al. Reliability of Field-Based Fitness Tests in Adults: A Systematic Review. Sports Med 52 , 1961–1979 (2022). https://doi.org/10.1007/s40279-021-01635-2

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DOI : https://doi.org/10.1007/s40279-021-01635-2

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SYSTEMATIC REVIEW article

Field-based health-related physical fitness tests in children and adolescents: a systematic review.

• 1 CIPER, Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal
• 2 ISAMB, University of Lisbon, Lisbon, Portugal
• 3 Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal
• 4 Faculty for Sport and Physical Education, University of Montenegro, Niksic, Montenegro
• 5 Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
• 6 Cognitive Aging Lab, Department of Psychology, University of Geneva, Geneva, Switzerland
• 7 Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland
• 8 Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, Lausanne and Geneva, Switzerland

Physical fitness (PF) is a multi-component construct and a biomarker of health. Worse PF is related to vulnerability and predicts worse academic achievements. Thus, assessing PF is important to monitor health in youth. This systematic review aimed to identify and inform physical education, health professionals and entities about existing PF batteries and field-tests that can be used in school settings. A comprehensive literature search was carried out in five electronic databases (Academic Search Complete, Education Resources Information Center, PubMed, Scopus, and Web of Science) to identify PF battery protocols that can be carried out in the school setting. Overall, 24 PF batteries were identified. Regarding the PF components assessed, only cardiorespiratory fitness and upper body strength were contemplated in all batteries. Middle-body strength and lower body strength were presented in most batteries (21 and 19 of 24, respectively). Agility (16 of 24) and body composition (16 of 24) were also considered in several batteries, although to a lesser extent. Flexibility (14 of 24) and speed (12 of 24) were the PF components less represented in the batteries. Among the 24 identified PF batteries, 81 PF tests assessing the different PF components were encountered. The advances in the PF field-based assessment in school settings and health in youth resulted in the amplification of the number of existing batteries. Considering the connection between PF and health and the opportunity that the school setting provides to assess fitness in children and adolescents, there is a need for standardization and a consensus of PF assessments in this specific setting.

Introduction

Physical fitness (PF) is a multi-component construct and a biomarker of health ( 1 , 2 ). Worse PF is related to vulnerability ( 3 ) that can negatively affect human development, such as cognitive functioning ( 4 , 5 ). This has important consequences children and adolescents. For instance, it has been shown that worse PF predicts substantially reduced improvements in academic achievement over time ( 6 ). PF is influenced by genetic and external factors ( 7 ). The genetic heritage has an essential role in trainability and describes the magnitude of the physiologic response to physical stress ( 2 , 8 ). External factors such as regular PA, sleep, nutrition also have an impact on PF components ( 9 – 11 ). Assessing PF through specific and validated test protocols allows monitoring the biological and physiological adaptations that are achieved through natural development or training ( 12 ). Health-related PF components include body composition measures (i.e., body mass index [BMI], waist circumference), cardiorespiratory fitness (CRF), muscular fitness, speed, agility, balance, and coordination ( 13 , 14 ). These components have been consistently associated with indicators of obesity, cardiovascular health, metabolic health, bone health, and mental health ( 1 ).

Assessing PF reflects the impact of genetic and environmental factors on health-related PF components and consequently on health indicators ( 15 ). In light of this, assessing PF is a simple, safe, and low-cost tool that allows examining several health indicators. Based on the PF level of children, pedagogical, and public health strategies and policies can be developed. However, to correctly and accurately assess PF, the validity, reliability, and feasibility of PF assessment tools are essential. This is especially true when health and government entities aim to monitor a variety of health indicators in local, regional, national, or worldwide populations to guide policy actions.

Previous systematic reviews identified a large number of test batteries available worldwide to test children's and adolescents' PF levels ( 16 – 18 ). These reviews showed that different tests address different components of fitness such as cardiorespiratory fitness, musculoskeletal fitness, body composition, and central body fat. Although the selected tests are extensively used and recognized, they do not determine all physical fitness aspects. Moreover, a large number of field-based fitness tests presented in these systematic reviews have limited evidence ( 16 , 18 ). Furthermore, previous reviews sought to identify physical fitness tests that could be used with children and adolescents. However, some of the contexts identified for the application of some batteries were the sport context. This context is elitist because few children and adolescents practice physical activity in the sports context.

So far no systematic review that provides a summary of all existing fitness test batteries for children and adolescents that can be carried out in the school setting under the specific circumstances of the school (e.g., time constraints, equipment at schools, the scope of testing, costs) has been carried out. Therefore, this systematic review aimed to identify and summarize the existing field-based health-related PF batteries that can be performed in children and adolescents to monitor and improve their health status.

Data selection, collection, and analyses were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement ( 19 ).

Search Strategy and Data Sources

Five international databases (Academic Search Complete [ASC], Education Resources Information Center [ERIC], PubMed, Scopus, and Web of Science) were searched for scientific articles published in peer-reviewed journals until the 30th of April 2020 containing PF battery protocols. In each database, a search was conducted taking into account a predefined combination of keywords. The combination of keywords used in each database was the following: “field-based test” OR “fit * ” OR “physical performance” OR “sport performance” OR “physical condition” OR “aerobic capacity” OR “maximum oxygen consumption” OR “strength” OR “flexibility” OR “motor” OR “endurance” OR “speed” OR “agility” OR “balance” OR “body composition” OR “anthropometry” OR “body mass index” OR “BMI” OR “skinfolds” OR “waist circumference” AND “batter * ” OR “protocol * ” OR “assess * ” OR “valid * ” OR “reproduct * ” OR “feasab * ” OR “measur * ” AND “adolescent * ” OR “child * ” OR “young * ” OR “school age” OR “school-aged” OR “youth”. The keywords were selected and defined by consensus from all authors. Furthermore, the reference lists of individual studies that reported results or used PF batteries in their methodologies but did not present the protocol were searched for records containing those protocols. Records identified through this method were added as records identified through other sources.

Inclusion Criteria

This systematic review includes scientific articles from peer-reviewed journals that contained PF battery protocols published until the 30 th of April 2020. Only records presenting PF batteries comprising field-based health-related PF tests for children and adolescents that could be performed in the school setting were included. Thus, inclusion criteria were the following: (1) presenting results on the identification, structure, validity, reliability or feasibility of PF batteries, or parts of it (including specific tests), assessing health-related PF components in children and adolescents; (2) containing PF batteries comprising field-based tests that can be performed in the school setting; (3) having a cross-sectional, prospective, observational, experimental, or narrative review study design; (4) being written in English, French, German, Spanish, or Portuguese. Records presenting findings on motor skills, other populations that were not children or adolescents, or not meeting all inclusion criteria were excluded.

Data Extraction and Selection

The data extraction process was conducted based on PRISMA guidelines ( 19 ). After downloading the records from the databases to a reference managing software and integrating further records identified through other sources, duplicates were removed. Two authors (DHN and MP) screened the remaining records for title and abstract to identify studies that met the inclusion criteria. Relevant articles were retrieved for a full read. Then, the two authors reviewed the full text of potential studies, and decisions to include or exclude studies in the review were made by consensus. Disagreements were solved by consensus and, when necessary, a third reviewer served as a judge (AM). Agreement between reviewers was assessed using k statistics (k=0.96) for full-text screening and rating of relevance.

Data Analysis

Each identified PF battery was entered into a Microsoft Excel (Microsoft Corp., Redmond, Washington, DC, USA) spreadsheet, including information on author and year of publication; country; setting and age range of application; PF components assessed, and the PF tests used for each assessed component. The considered components of PF were body composition, CRF, upper body strength, lower body strength, middle-body strength, speed, agility, and flexibility. Also, a narrative synthesis was performed to describe each field-based health-related PF test in the identified PF batteries.

Study Selection

A total of 10223 records (1506 from ASC; 167 from ERIC; 1559 from PubMed; 2610 from Scopus; 4358 from Web of Science; and 23 from other sources) were identified. After removing duplicates ( n =5,838), 4,385 records were screened based on title and abstract, resulting in 4,154 records excluded. A total of 231 records were assessed for eligibility by full-text reads. Finally, 33 articles matched all inclusion criteria and were included in the qualitative synthesis. The flow chart of records selection is presented in Figure 1 .

Figure 1 . Flow diagram of study selection.

Summary of the Identified Physical Fitness Batteries

Table 1 presents a summary of the PF batteries identified in the included records, showing author, year, country, setting, age-range, and test for the following PF components: body composition, CRF, upper body, middle-body and lower body strength, endurance and power, speed, agility, and flexibility. From the 33 included records, 25 PF batteries were identified. Nine PF batteries were from America (six from the United States, two from Canada, one from Brazil) ( 20 – 28 ), nine were from Europe (two from the Czech Republic, one from each of the following countries Norway, Slovenia, Portugal, Italy, France, and Spain, one from the European Union) ( 15 , 23 , 24 , 27 , 28 , 30 , 32 , 41 , 42 ), four were from Asia (one from each of the following countries: Japan, Singapore, China, and Russia) ( 33 , 34 , 38 , 40 ), two were from Oceania (one from Australia, one from New Zealand) ( 22 , 36 ), and one from the Middle East (Bahrain) ( 31 ).

Table 1 . Presentation and summary of the physical fitness batteries identified in the included records.

Most PF batteries (21 of 25) are exclusively for children and adolescents, while four of them are also extended to young adults ( 33 ) and adults ( 26 , 40 , 42 ). Also, even though all PF batteries can be performed in the school setting with the purpose of monitoring health-related indicators, some of them can be used in other settings such as sports and the army to assess physical performance. Two examples are the National Youth Physical Program from the United States Marines Youth Foundation (NYPFP) and the Ready for Labour and Defense (GTO) from Russia that is usually used to monitor PF for military purposes.

Regarding the PF components assessed in the batteries, only the CRF and the upper body strength, endurance and power were contemplated in all PF batteries. Middle-body and lower body strength, endurance and power were presented in most of the PF batteries, 21 of 25 and 20 of 25, respectively. Other components as agility (17 of 25) and body composition (16 of 25) were also contemplated in most PF batteries, although to a lesser extent. Flexibility (14 of 25) and speed (13 of 25) were the PF components less represented in the batteries, notwithstanding they were present in at least 50% of the identified PF batteries.

Among 25 identified PF batteries, a total of 87 PF tests, assessing the different PF components, were encountered. The PF component with the widest variety of different tests, that is, with 23, was CRF. It was followed by upper body strength, endurance and power with 21, speed with 10, middle-body strength and endurance with nine, body composition with eight, agility with seven, lower body endurance and power with five and flexibility with four different tests.

This systematic review provides a summary of existent PF batteries from around the world containing field-based health-related tests that can be performed by children and adolescents and used to monitor health status. A total of 25 different PF batteries from European, American, Asian, and Oceanian countries were identified. This knowledge can be useful for selecting standardized and validated PF tests and batteries, adjusted for the school setting and considering different PF components, and simultaneously, allows direct comparison between peers of the same age from different geographic locations.

Among children and adolescents, PF is associated with numerous health indicators, thus assessing PF has been suggested to be a reliable tool to monitor health in youth ( 1 ). Furthermore, PF batteries are considered a valid, simple, precise, and low-cost health monitoring tool ( 44 ). Given that in several countries, such as Australia, Bahrain, Brazil, Canada, Czech Republic, China, France, Italy, Japan, Norway, Portugal, New Zealand, Russia, Singapore, Slovenia, Spain, and the USA, the military, sport, health, and education sectors have been implementing and using PF batteries. Findings from this review corroborate the popularity of PF assessments, once 25 PF batteries from four different continents were identified.

Being a multi-component construct, examining PF as a whole, using only one or two tests is a misconception, as different associations between PF components and health indicators are observed ( 1 , 45 ). Because of that, the existence of detailed PF batteries is of importance. Such batteries allow taking into account a cluster of PF tests that are validated for each PF component, and that together it is possible to monitor complementing indicators of health and vulnerability. In this review, body composition, CRF, and muscular fitness (MF) were identified as the components of PF most frequently assessed in PF batteries.

Assessing body composition is usually the result of different anthropometric measures and their relation, such as height, weight, or waist circumference, as well as methodologies to analyse the % of body fat, muscle mass, and hydration ( 44 ). The measures of body composition, used in PF batteries, identified in this review were BMI, waist circumference, % of body fat (skinfolds), height to waist ratio, waist to hip ratio, wingspan, and bioelectrical impedance analysis. Requiring only height and weight, the BMI is a non-invasive, inexpensive, practical, and a largely applicable anthropometric indicator of obesity ( 48 , 49 ). On the other hand, BMI does not differentiate fat mass from lean mass and is thus an insufficient indicator of body fat or abdominal adiposity ( 50 ). In this line, to avoid misclassifications international experts have been suggesting waist circumference, which is a better indicator of central adiposity, as an alternative to BMI ( 50 , 51 ). More precise measures of body composition, namely the % of body fat were also present in some batteries, assessed by skinfolds or bioelectrical impedance analysis. Skinfolds allow calculating the % of fat mass and fat-free mass, through specific equations and are a low-cost methodology but specific and intensive training is required to minimize potential measurement error ( 52 ). Bioelectrical impedance analysis is more precise and allows to examine the % of fat mass, muscle mass or hydration status, however, it requires specific equipment, individual calibration and is more difficult to operationalize ( 53 ).

The CRF is the most studied component of PF among children and adolescents ( 54 ), and not surprisingly was assessed in each of the PF batteries identified in this systematic review. Higher levels of CRF are associated with a lower risk of several health outcomes, namely obesity, cardiovascular diseases, and mental health ( 1 ). The importance of assessing CRF was also reflected in a large number of tests observed, and among these tests, the PACER and the 1-mile run/walk seemed to be present in the most PF batteries. Both, the PACER and 1-mile run /walk are widely validated and reliable for assessing the CRF in young populations ( 15 , 55 ). From these test results, maximum aerobic capacity can be estimated. From all equations to estimate maximum aerobic capacity through these field-based PF tests, the equations proposed by Cureton et al. ( 56 ) for the 1-mile run/walk test and Barnet et al. ( 57 ) for the PACER had the strongest evidence of validity with Léger equation ( 56 – 59 ). However, recently some issues have been raised regarding the estimation of maximum aerobic capacity considering that a multitude of factors (e.g., sex, adiposity) have an influence, emphasizing that estimations should be carefully interpreted to avoid misconceptions ( 60 – 62 ). Also, using test results in terms of the number of laps, stages, or time may provide a clearer picture of the individual's CRF.

Muscular fitness, another important PF component, was also assessed in each of the PF batteries identified. However, different components of MF (i.e., upper body, middle-body and lower body strength, endurance and power, agility, speed, and flexibility) were assessed across the batteries. Similar to CRF, MF is also associated with several health outcomes in youth ( 45 , 46 ). A total of 56 different tests to assess the several components of MF were identified. For the upper body, the most common tests were the handgrip, push-ups or bent arm hang test, which assessed endurance and power. Regarding the lower body, the standing broad jump and the vertical jump, both assessing power, were the most usual tests. Lastly, for the middle-body, curl-ups and sit-ups were the most common tests, assessing endurance. Most of these tests require minimum equipment and are easily applied within a school or class setting. Agility, speed, and flexibility were present in fewer PF batteries than the other components of muscular fitness. This may be because there is more evidence observing the associations of lower, upper, and middle body strength with health indicators ( 47 ).

A total of 25 PF batteries were identified in this systematic review and across them 87 different PF tests for body composition, CRF, and MF. A previous systematic review focused on PF tests indicated that the PACER (or 20-meter shuttle run), the handgrip strength and standing broad jump tests, the 4 × 10m shuttle run test, weight, BMI, skinfolds, circumferences, and % body fat estimated from skinfold thickness were the most reliable field-based PF tests for children and adolescents ( 63 ). In this review, the aforementioned tests are among the most used in the identified PF batteries, which also corroborates previous research on this topic ( 17 ). Notwithstanding, when selecting a measurement/ protocol test of body composition, CRF or MF to perform factors such as staff training, equipment cost and time should be considered, as they heavily influence data collection, validity, and feasibility. Also, to avoid data contamination and misinterpretations, all protocols should be clear and performed by trained personnel, such as physical education teachers and other specialists ( 44 ). Despite being beyond the scope of this paper, it is important to acknowledge that physical education, sport, and health professionals should have a pedagogical approach in the application of PF batteries. This means that the application of the PF batteries must be aligned with the promotion of meaningful, relevant, and positive experiences for children and adolescents ( 64 ).

This systematic review is not without some limitations. Firstly, the large number of articles and protocols for the same PF test may have resulted in an overlap of tests. Secondly, the terms selected to identify investigations and other documents describing the PF batteries, although highly thorough nevertheless may have excluded documents not matching the inclusion criteria. Also, the search was conducted in only five databases. Lastly, because of the different study designs and the integration of gray literature (not following a scientific structure, such as protocols) the risk of bias and study quality assessment was unfeasible. Yet, most importantly, the major strength of this review is the ample number of articles reviewed and time interval search, which resulted in the identification of a rich set of PF batteries from around the globe.

The advances in the PF field-based assessment on school settings and health in youth resulted in the amplification of the number of existing batteries. On the one hand, diversity allows choosing the battery that most fits the specific purpose and setting of the assessment. On the other hand, it somehow complicates the comparability of data from different contexts, countries, or regions. Therefore, considering the connection between PF and health and the opportunity that the school setting provides to assess fitness in children and adolescents, we highlight the need for standardization and a consensus of PF assessments in this specific setting. In the European Union, a unique and actualized European PF battery would allow comparisons between European children and adolescents from different countries, to contribute to adequate and specific education and health public policies in the future.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

AM and MP: conception and design and drafting the manuscript. DH-N, MP, JM, and FG: data acquisition. AM, SP, and BM: data analysis and interpretation. YD, AS, JM, DH-N, and AI: critical revision for intellectual content. DH-N and FG: administrative, technical or material support. All authors read and approved the final manuscript.

This work was supported by the Swiss National Centre of Competence in Research LIVES – Overcoming vulnerability: life course perspectives, granted by the Swiss National Science Foundation (grant number: 51NF40-185901). AI acknowledges support from the Swiss National Science Foundation (grant number: 10001C_189407). The funder had no role in the collection of data, their analysis and interpretation, and in the right to approve or disapprove publication of the finished manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: body composition, cardiorespirarory fitness, fitness testing, musculoskeletal, physical education, vulnerability

Citation: Marques A, Henriques-Neto D, Peralta M, Martins J, Gomes F, Popovic S, Masanovic B, Demetriou Y, Schlund A and Ihle A (2021) Field-Based Health-Related Physical Fitness Tests in Children and Adolescents: A Systematic Review. Front. Pediatr. 9:640028. doi: 10.3389/fped.2021.640028

Received: 10 December 2020; Accepted: 15 February 2021; Published: 05 March 2021.

Reviewed by:

Copyright © 2021 Marques, Henriques-Neto, Peralta, Martins, Gomes, Popovic, Masanovic, Demetriou, Schlund and Ihle. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Miguel Peralta, mperalta@fmh.ulisboa.pt

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• Published: 18 September 2023

The long-term impact of the COVID-19 pandemic on physical fitness in young adults: a historical control study

• Jeffrey W. Ripley-Gonzalez 1 ,
• Nanjiang Zhou 1 ,
• Tanghao Zeng 1 ,
• Baiyang You 1 , 2 ,
• Wenliang Zhang 1 , 2 ,
• Jie Liu 3 ,
• Yuchen Dong 4 ,
• Ying Guo 3 ,
• Yaoshan Dun 1 , 2 , 5 &
• Suixin Liu 1 , 2  

Scientific Reports volume  13 , Article number:  15430 ( 2023 ) Cite this article

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The strength of evidence regarding long-term changes to fitness resulting from the coronavirus disease 2019 (COVID-19) lockdowns is deficient. This two-site retrospective study aimed to investigate the long-term changes in physical fitness among young adults a year after the onset of the pandemic using a robust historical control. University freshmen who underwent physical fitness tests in 2019 and completed a follow-up in 2020 (study group) were included. The primary focus was to compare the current cohort with a historical control group who completed the same tests a year prior (2018). A total of 5376 individuals were recruited, of which 2239 were in the study group. Compared with the control, the study group exhibited a decrease in anaerobic fitness, with an overall difference of −0.84 (95% confidence interval [CI], [−1.33 to −0.36]); declines in aerobic fitness, with a difference of −2.25 [−3.92 to −0.57] for males and −4.28 [−4.97 to −3.59] for females; a reduced explosive fitness (−2.68 [−3.24 to −2.12]); and a decreased upper-body strength in females (−1.52 [−2.16 to −0.87]). The fitness of young adults has been considerably compromised by COVID-19 lockdowns, highlighting the importance of promoting physical activity to prevent long-term health implications.

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Physical fitness plays a crucial role in maintaining overall health and well-being and is associated with a range of health benefits, including a reduced risk of cardiovascular disease and metabolic disorders and lower overall mortality rates 1 , 2 . In view of these, multinational guidelines recommend regular physical activity and exercise across all age groups, while also highlighting the need to limit sedentary behaviours 3 .

However, the coronavirus disease 2019 (COVID-19) pandemic and the accompanying measures implemented to mitigate its spread have posed significant challenges in maintaining optimal physical fitness levels, leading to increased sedentary behaviour and decreased exercise participation among many individuals 4 , 5 . Multiple published research have reported on the wide-ranging effects of lockdowns. For example, our previous research has documented acute self-reported weight gain, reduced overall physical activity and exercise, and increased sedentary behaviour, which aligns with findings reported elsewhere during the pandemic 6 , 7 . Additionally, our research has revealed an increase in psychological issues associated with COVID-19 mitigation measures affecting young individuals 8 . It is worth noting that these effects might have been influenced by baseline fitness levels 9 . However, there is a limited body of research exploring the long-term effects of the pandemic on physical fitness. While some studies have investigated the effects of COVID-19 on physical fitness in children 10 , research focusing on standardised fitness testing in adult populations is scarcer due to insufficient data. Moreover, most studies that have examined this topic have relied on subjective fitness questionnaires to assess acute changes 11 , 12 . Although qualitative research has provided valuable insights into how individuals’ behaviours might be affected by the pandemic and lockdowns, it falls short of providing an accurate representation of fitness changes compared with objective measurements. Recent research by Yu et al. suggested that changes in physical activity over time could be associated with decreased fitness after the pandemic, however, this study only offers a snapshot in time as it lacks baseline data from before the pandemic 13 . Lastly, a prevalent issue in the existing evidence is the lack of control groups in studies involving young adult populations, significantly limiting the strength of the evidence 14 , 15 .

The current study aimed to investigate the long-term changes in objectively measured fitness parameters among young adults, a year after the onset of the COVID-19 pandemic to address this gap in the literature. A robust historical control group was used to evaluate these changes, allowing us to make inferences regarding the effect of the COVID-19 lockdowns by comparing the study group to a similar group of individuals who were unaffected by COVID-19 lockdowns. This novel approach will allow for a comparison between groups which can contribute to a more complete understanding of the long-term impact of the COVID-19 pandemic and aid in developing effective measures against future epidemics.

Materials and methods

Study design and participants.

From December 2019 to January 2021, data collection was conducted at two centres (in Central and Central-East China, respectively) to assess the longitudinal changes in the physical fitness of university-aged students. Participants were recruited from the Chinese Medical College, Hunan, China, and the Medical College of Jinhua Polytechnic, Zhejiang, China. These institutions conducted the inaugural Chinese National Student Physical Fitness Standard (CNSPFS) battery between 1 December 2019 and 20 January 2020 before the implementation of national lockdowns. After a year, these participants were followed up, and the CNSPFS battery was administered again between 1 December 2020 and 20 January 2021. At the time of enrolment all participants involved in this study had begun their first year of higher education, with a mean age of 18 (standard deviation (SD): 1). Participants were excluded from physical fitness tests if they had a pre-existing medical condition which would impede their ability to perform exercise safely.

Baseline data was retrieved from the CNSPFS system, and data from both time points were linked using each participant's university student identity number. This research was approved by the Institutional Review Board of Xiangya Hospital of Central South University (approval no. 202005126). Written informed consent was obtained from all participants, and the study was performed in accordance with the principles of the Declaration of Helsinki. This manuscript follows the reporting guidelines set by STROBE.

Historical control

A group was required for comparison to fully understand the effect of the pandemic on objective measurements of fitness and weight changes. The historical control group was established by obtaining the physical fitness records of students who had enrolled in the same two universities in 2018 and had completed the CNSPFS battery a year prior to the study. The first visit of the historical control group was between 1 December 2018 and 20 January 2019, while their second visit was between 1 December 2019 and 20 January 2020, before the implementation of nationwide lockdowns. This control group was selected to provide a baseline for comparing the findings with current study participants.

The primary outcomes were measured in an open-air track field, which included changes in several performance and fitness scores. These scores were derived from various tests, including a 50-m sprint 16 , an 800-m run for females and a 1000-m run for males 17 , a standing long jump 18 , timed 1-min sit-ups for females and pull-ups for males 19 , a sit and reach test, and vital lung capacity measurement 20 . These tests assessed various aspects of fitness, such as anaerobic capacity, aerobic endurance, explosive power, muscular strength, flexibility, and pulmonary function.

The CNSPFS was conducted according to the standard operating procedures, under the supervision of trained physical education teachers. The assessment commenced with the collection of anthropometric data, including height measured using a portable stadiometer and weight measured using an electronic weight scale. Body mass index (BMI) was then calculated for each participant by dividing their weight in kilograms by the square of their height in meters. All physical fitness tests were conducted in the track-fields within the grounds of each respective university. Throughout the COVID-19 period, all students had to take bi-weekly nucleic acid testing as part of the “zero-COVID” governmental policy. During the testing period, there were no COVID-19 infections amongst the participant populations or testing staff of either university. As a result all tests were conducted as scheduled.

Secondary outcomes included the frequency of aerobic and strength training (prior to the lockdown, during the lockdown, and at the 2-year follow-up (1 year after the second CNSPFS visit) in the study group. Daily sedentary time and computer usage were recorded at three time points: during the first CNSPFS assessment, during the lockdown and a year after the second CNSPFS assessment).

Standardisation of the CNSPFS battery

Physical fitness measurements were obtained by administering the CNSPFS battery and the scores were calculated using a nationally standardised scoring system that adjusted each fitness indicator score for age- and sex-specific percentages. The scores were categorised into four groups: low fitness (< 60), moderate fitness (60–79), high fitness (80–89), and excellent fitness (≥ 90). An intraclass correlation coefficient of > 0.90 was achieved to ensure consistency between assessments. The details regarding performing CNSPFS have been described previously 21 , 22 .

Sample size

Based on previous research 23 that reported a mean difference between groups in the change of total fitness score of 2.84, with a standard deviation of 9.3, we conducted a sample size calculation via a two-sided two-sample t-test with an alpha level at 0.05 and a power of 0.90. PASS version 15.0.5 software (Utah, USA) was used to calculate. The estimated required sample size was 456 participants, with 228 per group. Anticipating a 20% failure to attain complete physical testing data, a minimum of 570 participants were required, which was considerably less than was finally attainable for this research study.

Statistical analysis

The normality of continuous variables was assessed using the Shapiro–Wilk test. Normally distributed continuous variables are presented as means ± SD, while non-normally distributed variables are presented as the median (interquartile range). Categorical variables are presented as numbers (percentages). Baseline data were compared using independent samples t -test and the chi-square test. For the primary outcomes and secondary outcomes analyses, linear mixed models were pre-specified. The models adjusted for schools, age, sex, location, regional disposable income, and the value of the outcome and at baseline differences. Subgroup analyses were conducted for male and female, urban and rural subgroups to examine the consistency of the primary outcome across different areas. Statistical significance was set at p  < 0.05. All statistical analyses were performed using SPSS 26.0 (IBM Inc., Chicago, USA).

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Xiangya Hospital of Central South University (approval no. 202005126).

Informed consent

Written informed consent was documented during the baseline, and digital informed consent was given upon initiating the survey.

Demographics

A total of 5376 individuals were included in the analysis, with 2239 participants in the study group and 3137 participants in the control group, recruited from two universities. The study flow chart is presented in Fig.  1 . The baseline demographics of both groups are presented in Table 1 . Female participants constituted a higher proportion of the population. In the study group, 61.5% of the participants resided in urban areas, while 38.5% resided in rural communities. In the historical control group, these percentages were 64.5% and 35.5%, respectively. Age in both groups was a median of 18 years (interquartile range (IQR) of 18–19), with a mean age of 18 years (SD:1) in both groups ( P  = 0.45 ) . No differences were observed in baseline height, weight, or socioeconomic conditions between the two groups. Furthermore, no significant difference was observed at baseline for BMI, with the Study group mean BMI of 20.6 kg/m 2 (SD: 3) and Historical Control of 20.7 kg/m 2 (SD: 3), median (IQR) of 20.0 kg/m 2 (18.6–22) in the study group and 20.1 kg/m 2 (18.7–22) in the historical control. However, significant differences were observed between the groups in terms of baseline sit-and-reach tests and 1-min sit-ups.

Flow chart showing the study processes of both groups. Chinese National Student Physical Fitness Standard (CNSPFS).

Change in fitness

The changes in fitness measures between the study group and the historical control group are presented in Table 2 , Figs.  2 and 3 . Figure S1 illustrates the changes in fitness as proportions of the population. The statistical results remained consistent across subgroup analysis (Supplementary Table S1 ).

Changes in physical fitness performance within each group. BMI, body mass index. (*) used to show the confidence interval. G, Female participants completed an 800 m run, and Male participants completed a 1000 m run. H, Female participants’ measure of strength was the maximum number of sit-ups completed in a single minute, for male participants this was the maximum number of pull-ups completed in one minute.

Changes in physical fitness between study and historical groups. (*) used to show the confidence interval. Fitness was weighed according to the standardised system that weighted each fitness indicator score by age- and sex-specific percentage. Scores were grouped into: low fitness (below 60), moderate fitness (60 to 79), high fitness (80 to 89), and excellent fitness (90 and above). The consistency between assessments was ensured through an intraclass correlation coefficient (ICC) that was greater than 0.90. The graph shows mean changes in scores: ( A ) Total composite score; ( B ) Aerobic score (males); ( C ) Aerobic score (females); ( D ) Anaerobic score; ( E ) Explosive fitness (score); ( F ) Upper-body strength (male); ( G ) Upper-body strength (female); ( H ) Flexibility.

Aerobic and anaerobic fitness

In the follow-up period compared to the baseline, the study group experienced a 0.5% decrease in the 50-m run performance. Notably, this decrease was more pronounced in men, with a 0.8% decline, compared to women who showed a 0.4% decrease (Table 2 ). In contrast, over the same period, the mean time for the 50-m run decreased by 0.09 s for males and 0.05 s for females. The difference in the changes between the two groups was statistically significant 0.07 (95% CI: 0.04 to 0.10) ( P  < 0.001). These results indicate a decline in anaerobic fitness in the study group, while the historical control group exhibited an increase in anaerobic fitness (Fig.  3 ).

The decline in aerobic fitness, as indicated by changes in middle-distance run performance, was more prominent in the study group. In the study group, the mean time for the 1000-m run increased by 2.41 s, whereas in the control group, it decreased by 3.88 s, resulting in a significant between-group difference of 4.43 s (95% CI: 1.4 to 7.46) ( P  = 0.004). This suggests a decrease in aerobic fitness of approximately 2% in males and 4.7% in females in the study group (Fig.  3 ). Similarly, for the 800-m run, the mean time decreased by 1.95 s in the control group, while it increased by 4.22 s in the study group, resulting in a significant between-group difference of 7.36 s (95% CI: 6.33 to 8.38) ( P  < 0.001). Furthermore, the study group exhibited a greater decline in aerobic fitness as a proportion of the population compared with the control group, which showed a greater increase in aerobic fitness (Fig. S1 ).

Muscular strength

Contrary to the effects on aerobic and anaerobic fitness, the impact of the lockdown on upper body strength was not consistent. Among male participants, the study group demonstrated a slight improvement in the number of achieved 1-min pull-ups, with a positive difference between baseline and follow-up indicating a performance increase of 3.33%. In contrast, the control group exhibited a negative change of 24.29%. The between-group difference was significant, with a value of 2.16 (95% CI: 1.58 to 2.74) ( P  < 0.001). For female participants, the study group showed an increase in the number of completed sit-ups in 1 min, resulting in a change of 5.65%. However, this increase was smaller than that observed in the control group (11.67%). When examining fitness change as population proportions (Fig. S1 ), it was evident that the study group experienced a lower decrease in fitness levels compared with the control group, although there was a greater increase in this fitness measure as a proportion in the control group.

Explosive fitness

Regarding explosive fitness, the standing long jump test revealed a significant difference between the study and control groups. Participants in the study group had a mean jump distance of 176.51 cm (SD: 25.05), which increased by 0.71 cm (0.4%) after a year. In contrast, the control group had a mean jump distance of 175.98 cm (SD: 25.8), which increased by 4.82 cm (2.7%). The difference between the two groups was −3.43 (95% CI: −4.07 to −2.79), indicating that the control group experienced a greater increase in jump distance ( P  < 0.001). This trend was consistent for females and males (Table 2 ) and was reflected by a greater increase in explosive fitness in the control group (Fig.  3 ).

Flexibility and vital capacity

In the sit-and-reach test, a greater improvement was observed in the study group, indicating enhanced flexibility. The mean change in the study group was 2.8 (SD: 5.05), corresponding to a 17% increase, while the control group showed a mean change of 1.36 (SD: 4.75) and an increase of 8.5%. The between-group difference was statistically significant, with a mean difference of 1.5 cm (95% CI: 1.26 to 1.73, P  < 0.001). These results were consistent among females and males. Regarding vital capacity, no significant difference was observed between the groups, although there was a slight tendency towards a better performance in the study group.

Weight and BMI

Regarding changes in BMI, a statistically significant difference was observed between the study group and the control group, with a between-group difference of 0.24 kg/m 2 (95% CI: 0.17 to 0.32, P  < 0.001). The observation group exhibited a small overall decrease in BMI (0.1%), while the historical control showed a more significant decrease (1.8%). Among females, the study group and the historical control group experienced a decrease in BMI (0.5% and 1.6%, respectively). In contrast, male participants in both groups showed an increase in weight, with the study group exhibiting a greater increase compared with the control group (1.8% increase and 0.1% increase, respectively).

Sedentary time and exercise habits

In Fig. S2 A, the mean sedentary time (in h/day) for all participants in the study group are presented for three periods. A significant increase was observed in both of these measures from the first assessment (prior to lockdown) to the second assessment (during the lockdown), as well as an increase from the second assessment to the third assessment (follow-up). In Fig. S2 B and C, the changes in habitual exercise at two time points (before lockdown and follow-up) are illustrated. A decrease in exercise frequency, as well as in aerobic and strength training, was observed between the two time points.

Our study presents a novel approach to assess the impact of the COVID-19 pandemic on physical fitness. A historical control study design was used to investigate the longitudinal changes in fitness in a large population of young adults, a year after the onset of the pandemic. By comparing these changes to robust historical controls, strong evidence was provided regarding the effects of COVID-19 on the fitness levels of young adults. Our findings indicate that the pandemic-induced lockdown significantly undermined several dimensions of physical fitness, including aerobic and anaerobic capacities, explosive power, and weight, a year after the lockdowns. These changes have important implications for health, as they are associated with an increased risk of chronic conditions such as cardiovascular disease and type 2 diabetes, as well as heightened premature mortality risk 24 , 25 .

Preliminary studies on COVID-19 mitigation strategies have highlighted immediate effects on weight and psychological health. Subsequent studies have suggested that increased sedentary behaviour and reduced physical activity could result in a population-wide fitness decline 26 , 27 . For instance, research has demonstrated that confinement measures and the suspension of physical education classes could result in decreased cardiorespiratory fitness among adolescent elite football players, with oxygen consumption decreasing by up to 9%. Similarly, in children, these measures have been associated with significant weight gain and reduced cardiorespiratory fitness 10 , 28 . The closure of fitness facilities and limitations on outdoor activities are significant barriers to maintaining physical activity levels, particularly for adults who might have fewer resources and opportunities to engage in physical activity. These findings are concerning not only for younger populations experiencing diminished fitness but also for adults and older adults who might lack structured exercise routines or face greater challenges in staying physically active.

Building upon existing evidence, our study confirms notable discrepancies in weight and fitness trajectories between lockdown-affected and unaffected groups. Among males subjected to lockdown, a pronounced average weight gain of 1.3 kg was observed, despite increased activity post-lockdown, compared with a 0.7 kg gain in the control group. Although female participants from both groups experienced a decrease in annual weight, the decline was more significant among those unaffected by lockdowns. Moreover, significant declines in aerobic and anaerobic fitness were documented, along with lower body explosive fitness, 8 months after the relaxation of pandemic restrictions. These findings contrast with the improvements observed in these fitness measures among the historical control group during the same period. While adults might recover from temporary shifts in BMI and fitness as a result of resuming regular physical movement and dietary habits, this might not apply to a substantial subset of the population, particularly those lacking regular or mandatory exercise regimens.

The decline in fitness observed in our study is potentially due to a combination of disrupted physical activity routines, altered dietary habits, and pandemic-induced psychological stressors. Measures implemented to mitigate the spread of COVID-19 resulted in a significant disruption of daily life, including the closure of recreational and exercise facilities, which in turn led to reduced physical activity levels and increased sedentary behaviour 13 , 29 . This effect was particularly pronounced in areas with higher deprivation levels and among individuals who were previously inactive 6 , 30 . Concurrently, the pandemic-related stress and anxiety further exacerbated sedentary behaviours among young adults 31 . Interestingly, our study revealed a slight increase in lower body explosive fitness, as assessed by the standing long jump, within the study group affected by the pandemic. However, this increase was significantly lower than the standard reached by the control, aligning with trends observed in other studies, albeit with smaller and younger populations. Prolonged periods of sedentary behaviour, such as sitting, significantly reduce energy expenditure and muscle activation 32 , potentially leading to disuse atrophy 33 characterised by a significant loss of skeletal muscle mass due to inactivity. These cumulative effects of increased inactivity and sedentary behaviour likely contribute to the poorer performance of the study group in fitness tests requiring lower body muscle activation 34 , such as the 100-m sprint, middle-distance run, and long jump.

Post-lockdown, upper-body strength was resilient, with male participants, in particular, showing improvements that surpassed the historical control group. Female participants also experienced some improvement, albeit lesser than the control group. This indicates a lockdown-induced shift towards resistance and body-weight exercises, particularly among males, possibly influenced by limited mobility and exercise preferences favouring intense strength training 35 . Research conducted in the United Kingdom indicated persistently low physical activity levels post-lockdown 36 . Our study expands on this finding by demonstrating that while sedentary behaviours returned to pre-pandemic levels, exercise habits remained low, which likely contributed to enduringly low cardiorespiratory and anaerobic fitness levels 8 months post-lockdown.

The findings of our study, focusing on young adults, extend to older populations with even greater significance. Older adults typically exhibit lower baseline fitness levels, and their ability to regain physical capacity after sedentary periods is often slower and more challenging due to age-related physiological changes and comorbidities 37 . Moreover, the detrimental effects of sedentary behaviour, such as insulin resistance and muscle atrophy, might manifest more acutely and rapidly in older adults, increasing their susceptibility to chronic conditions and functional decline 38 . Therefore, the potential for increased weight gain and decreased physical fitness during prolonged periods of inactivity, as indicated by our findings, could further exacerbate health risks and impede functional recovery in this demographic.

Limitations

This study has limitations. First, despite our analysis suggesting a connection between reduced physical activity during lockdown and fitness and weight changes, further research is necessary to compare these findings with individuals who were unaffected by the lockdown. Second, it is important to note that our study focused on a large group of Han Chinese young adults, which might limit the generalisability of our findings to other populations. Lastly, while our historical control group from the same two universities shared similar age and weight baseline characteristics, some inherent differences between the two groups might have persisted. Furthermore, while we accounted for schools, age, sex, location, regional disposable income, and the value of the outcome and at baseline difference, it is important to note that the retrospective observational study design has inherent limitations, which means that complete elimination of resulting bias may not be feasible. However, considering the available options, this historical control group provided the most comparable basis for our analysis.

This study provides relatively strong evidence that the COVID-19 pandemic and its mitigation measures significantly affected various aspects of physical fitness in young adults. These effects persist even a year after the implementation of lockdowns. The findings underscore the importance of continued efforts to promote physical activity during and beyond pandemics to prevent long-term detrimental consequences on health.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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This work is funded by the National Natural Science Foundation of China (82172549 to S.L., and 82272613 and 82002403 to Ys.D.), the Natural Science Foundation of Hunan Province (2021JJ70073 to S.L. and 2021JJ40981 to Ys.D.).

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Ripley-Gonzalez, J.W., Zhou, N., Zeng, T. et al. The long-term impact of the COVID-19 pandemic on physical fitness in young adults: a historical control study. Sci Rep 13 , 15430 (2023). https://doi.org/10.1038/s41598-023-42710-0

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Research Article

Physical fitness cognition, assessment, and promotion: A cross-sectional study in Taiwan

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – original draft

Affiliation Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan

Roles Conceptualization, Investigation, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliation Health Management Center, National Taiwan University Hospital, Taipei, Taiwan

Roles Data curation

Roles Conceptualization, Funding acquisition, Project administration, Resources, Writing – review & editing

Affiliations Health Management Center, National Taiwan University Hospital, Taipei, Taiwan, Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan

• Te-Wei Ho, 
• Hsing-Hua Tsai, 
• Jui-Fen Lai, 
• Sue-Min Chu, 
• Wan-Chung Liao, 
• Han-Mo Chiu

• Published: October 6, 2020
• https://doi.org/10.1371/journal.pone.0240137
• Reader Comments

Introduction

Many health organizations have promoted the importance of the health-related benefits of physical fitness and physical activity. Studies have evaluated effective public health practice aiming to understand the cognition of physical activity among youths and adolescents. However, studies investigating the level of cognition and knowledge of physical fitness among Asian adults are lacking.

This study aimed to investigate the self-awareness level of physical fitness and exercise prescription and the demand for physical fitness assessment among Taiwanese adults.

In January–July 2019, a cross-sectional anonymous survey was conducted using Research Electronic Data Capture to gather data on demographic data, cognition investigation of physical fitness and exercise prescription, cognitive test of physical fitness and exercise prescription, and demand for physical fitness assessment.

The questionnaire was answered by 200 respondents. The rating for cognition investigation of physical fitness was 2.63–3.13 (unclear to mostly clear) and for exercise prescription was 2.05–2.76 (unclear) (rated on a 5-point Likert scale). Results show that lack of awareness was highest for health-related physical fitness, exercise prescription, and exercise progress planning. 98% of subjects did not know the latest recommended guidelines for physical activity, despite most agreeing that physical fitness and exercise are good for health. Most subjects (72%) indicated a willingness to accept self-pay service for physical fitness assessments.

Conclusions

This is the first study to report on the demand for cognition, assessment, and promotion of physical fitness among Taiwanese adults. The study shows that the subjects widely lack knowledge in the cognition of physical fitness and exercise prescription. Furthermore, a self-pay service for the physical fitness assessment and individualized exercise prescription were acceptable to most subjects, especially those undergoing regular health examinations. The findings are encouraging and will aid support for health organizations and professionals in the development and management of promotion strategies on health-related physical fitness in preventive medicine and health promotion.

Citation: Ho T-W, Tsai H-H, Lai J-F, Chu S-M, Liao W-C, Chiu H-M (2020) Physical fitness cognition, assessment, and promotion: A cross-sectional study in Taiwan. PLoS ONE 15(10): e0240137. https://doi.org/10.1371/journal.pone.0240137

Editor: Sabine Rohrmann, University of Zurich, SWITZERLAND

Received: June 11, 2020; Accepted: September 20, 2020; Published: October 6, 2020

Copyright: © 2020 Ho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This study was supported by an Asia number one grant from the National Taiwan University Hospital (grant numbers 107-A142, 108-A142, and 109-A142), which had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ACSM, American College of Sports Medicine; CDC, Centers for Disease Control and Prevention; NTUH, National Taiwan University Hospital; REDCap, Research Electronic Data Capture; HTTPS, Hypertext Transfer Protocol Secure; IP address, Internet Protocol address; Cis, confidence intervals; AHA, American Heart Association; WHO, World Health Organization; NHI, National Health Insurance

Physical fitness, a state of good health and strength, which is a comprehensive ability, is a multifactorial concept covering five components: muscular strength, muscular endurance, flexibility, body composition, and especially cardiorespiratory fitness [ 1 , 2 ], all of which are related to the body’s ability to adapt to life and the environment [ 3 , 4 ]. In general, individuals with better physical fitness have better energy and adaptability to carry out daily tasks or work, especially physical activity or exercise [ 5 ]. Moreover, a number of evidence-based studies have consistently indicated that moderate physical and cardiorespiratory fitness could create a protective effect for some cancers [ 6 ] and reduce the risks of cardiovascular diseases and metabolic syndrome [ 7 , 8 ], especially risks of all-cause and cardiovascular mortality [ 9 – 15 ]. Health organizations such as the American College of Sports Medicine (ACSM), in collaboration with the Centers for Disease Control and Prevention (CDC), started to propose a guideline of physical activity in 1995 to increase public awareness of the importance of the health-related benefits of physical activity [ 16 ]. The latest guidelines state that to achieve health benefits in adults aged >18 years, one must engage in at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous exercise per week, or an equivalent combination of moderate and vigorous exercise [ 16 , 17 ]. To encourage students to adopt lifelong exercise habits, in 1999, the Ministry of Education in Taiwan initiated a project entitled “Physical Fitness 333 Plan,” where students (aged 6–15 years) were encouraged to exercise for 30 minutes at least three times per week, with heart rate during exercise reaching at least 130 bpm or higher [ 18 ]. This protocol, however, is proposed mainly for students and does not take age, health profile, and other issues in the general population into account, making it unsuitable for elderly people or patients with diseases. Most people in Taiwan still consider it as the latest exercise guideline for the general population around the world, despite that the main purpose of the 333 Plan is to advocate establishing regular exercise habits; also, people usually do not know the difference between moderate-intensity and vigorous exercise and the intensity of different forms of physical activity. Furthermore, many reports have indicated that to achieve high compliance and achievement of goals, plans for fitness-related activities must be individualized and personalized according to the individual’s specified purpose and his/her unique needs and interests [ 19 – 23 ]. In the past decades, the effects of physical fitness on quality of life, health, and life expectancy have been proven by number of studies and reports. To the best of our knowledge, cognition of physical fitness and physical activity recommendations are pivotal prerequisites for actual change in behavior and action [ 24 , 25 ]. Significant associations between cognition of physical activity recommendations and activity behavior have been well documented [ 26 – 28 ], and educational exposure to physical activity recommendations had a significantly positive effect on the improvement of activity behavior [ 29 ]. Another study also reported that increasing cognition of physical activity recommendations may be an effective promotional strategy to develop and augment intentions to engage in physical activity [ 30 ]. A great deal of previous researches has been directed at understanding the cognition of physical activity among youths and adolescents [ 29 , 31 – 33 ]. However, there is a lack of studies investigating the level of cognition and knowledge of physical fitness in Asian adults. To address these issues, this study aimed to investigate the cognition of physical fitness and exercise prescription and the demand for physical fitness assessment among adults in Taiwan.

Materials and methods

Participants and data collection.

In this cross-sectional study, an anonymous questionnaire was used for the survey, which was conducted from January 2019 to July 2019 at the Health Management Center of the National Taiwan University Hospital (NTUH) and public websites. We put up flyers with an introduction and a website link for a questionnaire investigation on these public study fields. No inclusion and exclusion criteria were defined for the subject recruitment. When participants learned about the recruitment, they joined voluntarily and were assured confidentiality and that they were free to withdraw from the survey at any time. A double-checked button was used to signify that the participant was done answering the questionnaire. No compensation was provided to the participants for their time. Of 268 responses during the study period, 68 questionnaires with missing data were excluded from the study. A total of 200 individuals voluntarily answered the anonymous questionnaire, along with complete records, which were included in this study for further data analysis. The institutional review board of the NTUH approved the study protocol (201908044RINC).

Survey development and procedures

Research Electronic Data Capture (REDCap), a web-based platform hosted at the NTUH, was used to develop, collect, and manage the anonymous questionnaire. REDCap, which is a compatibility, scalability, and security data collection tool, along with built-in analysis tools was developed at Vanderbilt University in 2004 for the purpose of clinical research [ 34 ]. REDCap was designed to meet Health Insurance Portability and Accountability Act compliance standards. REDCap is widely used in the academic research community: currently, it has 3,719 partner institutions in 131 countries, supports more than 735,000 projects with 1 million end-users, and has been cited in 7,136 journal articles [ 35 ].

The custom-designed REDCap online survey can be accessed and filled out by participants using a smartphone, tablet, or computer with internet connection. The Hypertext Transfer Protocol Secure (HTTPS) protocol for secure internet communication transmits the feedbacks automatically into the hospital database. NTUH maintains the research database, and to access the management tool, researchers must enter their username and password. The hospital portal system, along with one‐time password from email or Google Authenticator Application, validates the login session. User behavior and manipulation on the platform are tracked as log messages into database. The data format of REDCap fulfills the Clinical Data Interchange Standards Consortium standard. The researchers could use automatic export procedures for seamless data downloads including raw data and variable schema to common data types such as CSV, Excel, SPSS, SAS, R, Stata, and XML.

Questionnaire design

A research team that specialized in exercise physiology, medicine, and health management developed the questionnaire material in a roundtable conference for fulfilling the need of investigation (the study questionnaire is presented in S1 File ). An introduction paragraph in the questionnaire stated the purpose of the study, that is, to investigate the cognition and demand of the people for physical fitness. To address the purpose of this study, survey questions broadly fell into the following categories: basic demographic data (four items), cognition investigation of physical fitness (nine items), cognition investigation of exercise prescription (seven items), cognitive test of physical fitness and exercise prescription (nine items), and demand for physical fitness assessment (six items). Content validity of the study questionnaire has been verified, with a mean Cronbach’s α of 0.912 (minimum = 0.905; maximum = 0.922) for cognition investigation of physical fitness and 0.920 (minimum = 0.911; maximum = 0.926) for cognition investigation of the exercise prescription, both of which indicate excellent internal consistency. All sensitive information, such as name, identification number, telephone number, email, and Internet Protocol address (IP address) of the electrical devices were not collected in this study. A 5-point Likert scale (1 = very unclear, 2 = unclear, 3 = mostly clear, 4 = clear, and 5 = very clear) was used to rate the cognition items. Higher scores indicate positive cognition. The true-or-false tests were presented as positive and negative statements. Finally, the questionnaire was divided into five pages on the REDCap online survey, with each page having an intuitive interface for the validation of data entry without any missing item. The study team conducted complete checks for content typo and interactive buttons before starting the survey. Although this was an anonymous questionnaire, the participants still had to click a button to accept and continue with the survey at the beginning of the questionnaire.

Outcome and demographic variables

We calculated the average score of the cognition items based on the 5-point Likert scale and the accuracy of true-or-false tests as study outcomes, both of which represent the levels of cognition of physical fitness and exercise prescription. We assessed the following demographic data: gender, age (20−29, 30−39, 40−49, 50−59, 60−69, and ≥70 years), undergoing regular health examination and frequency (once every year, once every 2 years, once every 3 years, and casual). In addition, the following data were gathered to determine the demand for physical fitness assessment: factors that affected the choose of a physical fitness test service, willingness to accept self-funded physical fitness tests and the acceptable price, having undergone a physical fitness test in the past 5 years, and having received guidance related to exercise prescriptions in the past. Furthermore, we evaluated the distribution of the demand for physical fitness assessment stratified by subjects with and without regular health examinations.

Data analysis

To calculate numbers and percentages for all question items among respondents, descriptive statistics were initially performed in REDCap. Figures were generated using Microsoft Office Excel 2019. The results of cognition items are presented as means with 95% confidence intervals (CIs). Further statistical analysis was conducted using SPSS software (Version 23; IBM Corp., Armonk, NY). Chi-square test or Fisher exact test was used for comparisons of willingness between men and women among different age groups, as appropriate. Statistical significance was set at P < 0.05. Reliability analysis was evaluated by Cronbach’s alpha for the content validity of questionnaire.

We collected data from a total of 200 respondents (114 men and 86 women) for further analysis. Age distributions, in order, were as follows: 40–49 years (n = 84, 42%), 50–59 years (n = 45, 22.5%), and 30–39 years (n = 42, 21%). Most subjects were educated at the university (n = 104, 52%) and postgraduate or above (n = 88, 44%) level. Seventy-nine percent of the subjects receive regular health examinations and usually undergo examination once a year ( n = 64, 40.5%) (distribution of regular health examination stratified by gender is presented in S2 File ). Table 1 summarizes the subject characteristics.

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https://doi.org/10.1371/journal.pone.0240137.t001

Cognition investigation of physical fitness and exercise prescription

With regard to cognition of physical fitness, subjects’ replies using the 5-point Likert scale ranged from 2.63 to 3.13, indicating that the general cognition of physical fitness is “unclear” to “mostly clear.” Higher scores were found for cognition for flexibility (5-point Likert mean, 3.13; 95% CI, 3.00–3.25), impact of cardiopulmonary function on life and work (5-point Likert mean, 3.08; 95% CI, 2.95–3.21), and muscle and muscular endurance (5-point Likert mean, 2.98; 95% CI, 2.85–3.11). Physical fitness items that had the highest response rates of “very unclear” and “unclear” are health-related physical fitness ( n = 101, 50.5%), what diseases people with poor cardiopulmonary functions will easily contract ( n = 99, 49.5%), and body mass index ( n = 92, 46%). Results of the investigation of cognition of physical fitness in this study are presented in Fig 1 , along with rank ordering according to the distribution of responses of “very unclear” and “unclear.”

https://doi.org/10.1371/journal.pone.0240137.g001

For cognition of exercise prescription, the results show that participant responses on the 5-point Likert ranged from 2.05 to 2.76, indicating that the cognition of exercise prescription among subjects is, in general, “unclear.” Results show that cognition for exercise intensity (5-point Likert mean, 2.76; 95% CI, 2.62–2.89), the relationship between duration of exercise and effective exercise (5-point Likert mean, 2.63; 95% CI, 2.49–2.76), and the relationship between exercise intensity and effective exercise (5-point Likert mean, 2.47; 95% CI, 2.33–2.60) had higher ratings. The items with the highest rates of “very unclear” and “unclear” ratings are exercise progression planning ( n = 159, 79.5%), exercise prescription ( n = 156, 78%), and impacts of different types of activity/exercise on physical fitness ( n = 136, 68%). Results of the investigation on cognition of exercise prescription, along with rank ordering according to the distribution of “very unclear” and “unclear” responses, are presented in Fig 2 .

https://doi.org/10.1371/journal.pone.0240137.g002

Cognitive test of physical fitness and exercise prescription

With regard to cognitive test of physical fitness, results indicate that all subjects know ( a ) that understanding one’s own physical fitness is important to self-management of health and ( b ) that, because the activity content of each person is different, the design of exercise prescription varies from one person to another. However, results show that subjects lack knowledge in the following areas: (1) a single vigorous exercise can make up for the inadequacy of regular exercise if a person has not exercised for a long time (accuracy rate, 83%); (2) engaging in vigorous or intensive exercise can greatly improve the body’s immune system (accuracy rate, 70.5%); and (3) having good physical fitness means that the body must be healthy (accuracy rate, 67.5%). In addition, although the 333 Plan had already been considered out-of-date, up to 98% of respondents consider it as the latest exercise recommendations. Fig 3 shows the results of cognitive test for physical fitness along with rank ordering according to accuracy.

https://doi.org/10.1371/journal.pone.0240137.g003

Demand for physical fitness assessment

Overall, 144 (72%) subjects are willing to accept a self-pay service for physical fitness assessments, with more men (79%) than women (63%) agreeing to this ( P = 0.017). In the comparison of sexes in each age category, significant differences were found only in subjects between 40 and 49 years ( P = 0.006; men, 84%; female, 56%). The distribution of willingness to accept a self-pay service for physical fitness assessment by sex, according to different age groups, is displayed in Fig 4 . With regard to the acceptable price for a single physical fitness assessment service, the price ranges acceptable according to participant responses were as follows (in order, in NT $): $500–$1,000, n = 42 (29%); $1,001–$1,500, n = 36 (25%); $1,501–$2,000, n = 24 (17%); $2,001–$2,500, n = 20 (14%); under $500, n = 11 (8%); and greater than $2,500, n = 11 (8%). Fig 5 illustrates the distribution of expected price for self-pay service of physical fitness according to age groups.

https://doi.org/10.1371/journal.pone.0240137.g004

https://doi.org/10.1371/journal.pone.0240137.g005

With regard as to why participants were willing to accept a self-pay service, the main reasons were the provision of (1) individualized exercise prescription according to physical fitness examination results ( n = 160, 80%), (2) individualized report according to the physical fitness examination results ( n = 151, 75.5%), and (3) reasonable and achievable health-related physical fitness goals ( n = 144, 72%). In contrast, the underlying reasons for not choosing a self-pay service for physical fitness assessment are the following: (1) does not want to pay for physical fitness tests ( n = 27, 13.5%), (2) no time ( n = 14, 7%), (3) feeling that one is healthy ( n = 13, 6.5%), and (4) does not know any place that provides physical fitness examinations ( n = 12, 6%).

This article presents the first findings regarding the cognition of physical fitness and exercise prescription and the demand of physical fitness assessment among adults in Taiwan. The present experimental results show ranges of 2.63–3.13 for cognition investigation of physical fitness and 2.05–2.76 for exercise prescription, rated on a 5-point Likert scale, indicating that the subjects’ cognition level of physical fitness is between “unclear” to “mostly clear” and exercise prescription is “unclear.” In addition, results show that the items health-related physical fitness, exercise prescription, and exercise progress planning were the areas that most participants lack an awareness of, all of which are terms unfamiliar to the public. Although approximately all subjects agreed that physical fitness and exercise are good for the health, up to 98% of subjects do not know the latest recommended guidelines for physical activity, a finding that is in accordance with previous large-scale studies. In a cross-sectional national survey (n = 4,281) conducted in the United States, only 36.1% of US adults had ever received messages regarding government physical activity guidelines from any type of media, of which only 1% were aware that for substantial health benefits, the recommended volume of exercise was at least 150 minutes of moderate-intensity exercise per week [ 36 ]. A cross-sectional study in the United Kingdom reported that in 2013, 18% of 1,797 adults accurately recalled the physical activity guidelines, compared with 11% of 2,860 adults in 2007 [ 37 ]. Similarly, another national survey conducted on 10,992 adults between December 2013 and September 2014 in the United Kingdom showed that only 15% of adults accurately reported the recommendation guideline on physical activity [ 38 ]. Despite many organizations such as the ACSM, CDC, American Heart Association (AHA), and World Health Organization (WHO) focus on global health and widely promote the benefits and guidelines of physical fitness, keeping the right cognition in mind is still difficult for most people, especially putting it into action. In addition, several studies have reported that the multitude of physical activity recommendations released over the years may have caused confusion among people [ 39 – 41 ]. This once again highlights the importance of promoting the right knowledge.

In Taiwan, life expectancy for the general population is 80.4 years, with rates of 77.3 and 83.7 years among men and women, respectively [ 42 ]. With regard to the proportionate increase in the elderly population each year, the main purpose of health organizations in Taiwan is to advocate “Healthy Life Expectancy,” which promotes initiatives that focus on healthy lifestyle, including no tobacco, healthy diet, stress relief, regular exercise, and physical fitness. The first step for medical and health care institutions with regard to primary prevention is to make individuals aware and knowledgeable of physical fitness, which is necessary for making health-related decisions [ 43 ]. In the past, assessment and counseling for physical activity were generally not a focus of most health professionals’ training programs [ 44 , 45 ]. A scientific statement from AHA described lifestyle counseling during medical school training and indicated a low percentage of primary care providers who discuss lifestyle and physical activity issues with patients during clinic visits [ 46 ]. A recent study showed that most physicians provided counseling and prescription for exercise in only less than 10% of appointments [ 47 ]. In a cohort study for patients with obesity, primary care providers provided counseling on exercise and physical activity in only 20% of office visits [ 48 ]. However, most of subhealth people and patients, especially individuals who have an inactive lifestyle or who are in a particularly urgent need of moving more, need recommendations or interventions for activity and exercise. All medical practitioners, including physicians, nurses, physical and occupational therapists, exercise physiologists, dieticians, and any healthy lifestyle providers, should routinely integrate the concept of physical fitness and exercise into their practice. Despite the possibility that assessment and intervention will vary greatly across them, attempts to ask several simple health-related fitness questions in counseling should at least be made; for example, if the patient reveals characteristics of inactive activity or a completely sedentary lifestyle, the importance of physical activity should be emphasized. In addition, medical professionals should appropriately refer patients to other members of the multidisciplinary team for further health-related fitness assistance. Previous studies also mentioned that a more attractive approach to improve healthy lifestyle behaviors is health care practice across multidisciplinary professionals [ 49 , 50 ].

For public health organizations such as government agencies and nongovernmental organizations, the main purpose of health dissemination is carried out through multiple channels to raise general public awareness on the importance of the health-related benefits of physical fitness, especially in physical activity and moderate-intensity exercise. In addition, physical inactivity and sedentary lifestyle are global adverse health effects, which have been identified to contribute to the burden of many chronic diseases and premature mortality [ 51 – 53 ]. The concept of “exercise is medicine” or “movement is medicine” (i.e., taking more daily steps as possible, sitting as little as possible, and having regular exercise habit) should be more widely advocated in developing individual healthful living behavior. Both physical educators and health promoters should assume leadership to be a model for the public and apply effective public health campaign and behavioral strategies, such as social support and enrichment sport activities, to foster recommendation adherence [ 30 , 54 ]. It has also been reported in recent studies that attractive environments could influence physical activity behavior and the health profile of community residents [ 55 – 58 ].

In this study, a self-pay service for physical fitness assessments was acceptable to most subjects (72%). The most acceptable price for a self-pay service for physical fitness assessments was approximately $500−$1,500 New Taiwan Dollars (NTDs) (30 NTDs = 1 US dollar). In Taiwan, the prices of visiting a clinic, undergoing a labor health examination, and undergoing a health examination package generally are approximately $150−$350, $1,000−$1,500, and $20,000−$150,000, respectively. Providing this augmentation service in health examination packages would require the setting of an affordable price. Moreover, compared with subjects who did not go for regular physical examinations, individuals who undergo regular health examinations were more accepting of a self-pay service for physical fitness assessments (57% vs. 76%; P = 0.02; S3 File ). More importantly, 92.4% of subjects who go for regular health examinations did not receive any physical fitness evaluation in the past 5 years ( S4 File ). This indicates that the identification of any possible signs or symptoms of a medical condition is the main focus of current regular health examinations, and the concept of health-related physical fitness is still not integrated into preventive healthcare services. The preliminary results of this study indicate that people are eager to receive and know their health-related physical fitness profile and to obtain further personalized suggestions and exercise prescriptions. Generally, medical practitioners are often swamped with clinical responsibilities that they do not have enough time to conduct a routine assessment, discussion, and plan of physical fitness for patients. Fortunately, with information and communication technologies progressing and developing, facilities with internet of things technology such as wearable devices and smartphones have carried out appropriate approaches, along with objective quantitative data, for measurement and management in physical fitness and physical activity [ 59 – 62 ].

This cross-sectional study had some limitations that should be mentioned. First, because of the limited number of participants, the present findings are limited to represent the ideas of the general population in Taiwan, which may affect the inference to various Asian peoples of different nationalities or ethnicities. Second, most of the responses presented were that of having regular health check-ups and theoretically more concerned about their own health, which may overestimate the demand of physical fitness assessment for adults in Taiwan. Similarly, recruitment at a health care facility and on websites may have increased the possibility of bias in this cross-sectional study. People who were concerned about their health may voluntarily prefer to answer the study questionnaire, which may also result in an over-estimated investigation. In contrast, the level of cognition of physical fitness for adults may be overestimated due the abovementioned issue. Third, some potential confounding factors, such as social-economic level, residential area, marriage status, and health-related status, were not collected in this survey owing to the anonymous nature of the questionnaire. To achieve a discussion from multiple perspectives and perspectives based on further results, future studies should consider designs that include a more personal profile.

Our next goal is to focus on advocating, through multidisciplinary professionals, the importance of self-awareness of health-related fitness to the general public and determine whether the assessment and intervention of physical fitness could actually affect people’s behavior and health condition.

Our study is the first to report on the urgent demand for cognition, assessment, and promotion of physical fitness among adults in Taiwan. This cross-sectional investigation showed that many subjects lacked cognition of physical fitness and exercise prescription. A self-pay service for the physical fitness assessment and individualized exercise prescription were acceptable to most subjects, especially to individuals who were undergoing regular health examinations. The findings in this study may have pivotal implications for the lack of promotion and implementation of health-related physical fitness plans. Health organizations and professionals can use the insights in this study to aid in the development of strategies, promotion of correct augmented knowledge, and conduct of effective practical guidelines in the fields of preventive medicine and health promotion.

Supporting information

S1 file. study questionnaire..

https://doi.org/10.1371/journal.pone.0240137.s001

S2 File. Distribution of regular health examinations stratified by gender.

https://doi.org/10.1371/journal.pone.0240137.s002

S3 File. Distribution of accepting self-pay service for physical fitness assessments stratified by those who had/did not undergo regular health examinations.

https://doi.org/10.1371/journal.pone.0240137.s003

S4 File. Distribution of receiving physical fitness evaluation in the past 5 years stratified by those who had/did not undergo regular health examinations.

https://doi.org/10.1371/journal.pone.0240137.s004

S1 Checklist. PLOS ONE clinical studies checklist.

https://doi.org/10.1371/journal.pone.0240137.s005

Acknowledgments

The authors would like to thank all members of the Health Management Center at the National Taiwan University Hospital for their efforts and contributions. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation.

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