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Movement analysis of sit-to-stand – research informing clinical practice

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 Special Issue Article
Movement analysis of sit-to-stand – research
informing clinical practice
Gunilla E. Frykberg1,2, Charlotte K. Häger2
1
Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Sweden, 2Department of
Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Sweden

Background: Sit-to-stand (STS) is a crucial transfer influencing a person’s independence in daily activities,
as well as safety and quality of life, and is thus vital to evaluate in research and in practice. Clinical STS
tests provide single values in seconds or numbers of STS. There is, however, increasing numbers of
research papers reporting spatial and temporal kinematic and kinetic process STS data.
Objectives: To provide an overview of research findings from laboratory-based movement analyses
regarding phases and determinants of typical STS, characteristics of successful versus failed STS trans-
fers, and finally STS performance in some neurological conditions.
Major Findings: The STS transfer, previously regarded as mainly requiring lower limb muscle strength, is
increasingly recognized as a complex transfer skill. Muscle strength, balance, foot position, chair height
and the movement strategy are major determinants influencing STS performance. Scaling and timing of
momentum generation throughout STS seems critical for success or failure. Sit-to-stand in stroke and
Parkinson’s disease (PD) is characterized by asymmetry in force generation and difficulties in switching
movement direction, respectively. In-depth, knowledge regarding mechanisms of momentum control during
STS sub-phases, STS failures, as well as exploration of variability in normal and atypical STS is still lacking.
Conclusions: Recent research based on instrumented movement analyses has generated better understanding
of movement control during STS, but the specifics are not yet reflected in clinical assessments. There seems to
be a call for clinical tools capturing determinants and process characteristics of the STS transfer for a more com-
prehensive evaluation in rehabilitation.
Keywords: Sit-to-stand, Movement analysis, Momentum control, Kinematics, Kinetics

Background From a biomechanical point of view, STS may be

Rising to stand from a seated position (sit-to-stand,
STS) is a very common task in daily life, and vital
for independence in persons with disability.1 Non-dis-
abled adults perform STS about 60 times per day.2
The importance of STS is particularly evident when
the ability deteriorates and manifests itself as
decreased mobility-related quality of life3 and
increased risk of falls in the elderly4,5 as well as in per-
sons with disabilities, e.g., after stroke.6 Further, STS
performance may contain prognostic information,
e.g., in persons with chronic obstructive pulmonary
disease (COPD).7 In addition, outcomes of STS tests
have proven to be strongly correlated with those
from tests of exercise capacity, e.g., the 6-minute
walk test.8 Thus, STS is a crucial everyday transfer
task and, as such, important to evaluate in clinical
practice as well as in research.
Correspondence to: Gunilla E. Frykberg, Department of Neuroscience,
Rehabilitation Medicine, Uppsala University, Uppsala SE-751 85,
Sweden. Email: gunilla.elmgren.frykberg@neuro.uu.se
defined as a transitional movement from sitting to
upright standing posture, thus requiring horizontal
and vertical displacement of the whole body’s centre
of mass (COM) from a stable to a less stable position
over extended lower extremities.9 Table 1 summarises
some biomechanical concepts9,10 central to research
addressing STS using laboratory-based movement
analysis, included here to clarify and assist in reading
this paper. From such a perspective, it is natural to
approach the understanding of STS in terms of how
forces and movements are generated and controlled
by the brain and how the resulting movement par-
ameters might be captured with technical devices.
In clinical practice, on the other hand, STS ability
is assessed through performance-based tests, which
either report the time it takes to do five or 10 rep-
etitions or the number of repetitions being conducted
during 20 or 30 seconds or 1 minute, i.e., a single
value represents the end result of the task. The five
times sit-to-stand test (FTSST) seems to be the
most frequently used STS protocol11 and this well

ß W. S. Maney & Son Ltd 2015

156 DOI 10.1179/1743288X15Y.0000000005 Physical Therapy Reviews 2015 VOL . 20 NO . 3
 Frykberg and Häger Movement analysis of sit-to-stand

Table 1 Definitions of some biomechanical concepts9,10 70–79 years olds; 14.8 seconds for 80–85 years olds.27
reported in studies investigating sit-to-stand transfer with
Similarly, reference values have been presented from
laboratory-based movement analysis
the 1-minute STS test (i.e., the number of STS transfers
Concept Definition being conducted during 1 minute) from a range of
Centre of mass, An abstract point age groups (20–79 years) in an adult population in
COM representing the weighted Switzerland (n56926),28 in order to facilitate identifi-
average of COM cation of persons with reduced muscle strength in the
of each body
segment in 3D lower limbs and with impaired endurance. Reference
space values ranged from 27 minute{1 (in women 75–
Centre of pressure,
COP
The point location
of the vertical
79 years olds) to 50 minute{1 (in men 20–24 years olds).
ground reaction force Thus, there is extensive material including refer-
vector, which represents ence data regarding the FTSST and similar tests
a weighted average
of all pressures capturing essentially only the movement time of
over the base the task, but telling us very little about how the
of support transfer was accomplished in terms of movement
Momentum The quantity of
motion possessed by quality including strategies. The time to perform
an object; a five or 10 STS or the number of STS conducted
vector quantity; body
during a specified time period, might serve as
mass times velocity
(m|v; unit in quick information guiding rehabilitation. However,
kg ms{1 for linear momentum) a deeper understanding of control parameters and
Kinematic Referring to a
description of motion
process skills might be necessary for physiothera-
in terms of pists in order to successfully train individuals with
position, velocity and impaired STS ability. An increasing number of
acceleration
Kinetic Relating to motion, research reports focus on kinematic and kinetic pro-
a description that cess data of STS performance in individuals of
includes consideration of different ages as well as in different patient
force as the
cause of motion groups. Consequently, there is a need to summarise
these research results regarding the STS transfer and
discuss clinical implications.
described and standardised test has, for instance,
been used in studies with the elderly,12 in persons Objectives
with stroke,13,14 multiple sclerosis (MS),15 incomplete The present narrative review provides an up-to-date
spinal cord injury,16 vestibular dysfunction,17 overview of what we know from biomechanical
Parkinson’s disease (PD),3 low-back pain,18 COPD19 research studies regarding phases and determinants
and in children with cerebral palsy (CP).20 The FTSST of typical STS, characteristics of successful versus
was first introduced in 1985 as a test of lower limb failed STS transfers, features of STS performance
muscle strength.21 Its psychometric properties have in neurological conditions, mainly in persons with
been extensively investigated. Test–retest reliability of stroke and PD, and finally, some information about
FTSST in adults22 and in subjects with neurological other related everyday transfers.
disorders11 as well as intra-14 and inter-rater3,16,23
reliabilities have shown good to high intra class corre- Review Method
lation values (ICC). Concurrent validity of FTSST The databases PubMed and Scopus were searched
when compared to muscular strength,14,15 walking for scientific papers investigating the STS transfer
speed,17 walking endurance20 and different balance with focus on descriptive analysis. Key words used
tests3,15,24,25 has, irrespective of patient group, been were: sit-to-stand, sit-to-stand transfer, sit-to-stand
demonstrated to be moderate. A clinically significant movement, sit-to-stand in combination with stroke,
change of FTSST performance, excluding measurement and Parkinson. Over 1000 articles were found. The
error, has been estimated to be 2.5 seconds in older papers most relevant for the present aim were then
females24 and to be i2.3 seconds in persons with or selected. Predominantly, articles where the concept
without balance disorders.17 Cut-off points for the sit-to-stand was part of the title were selected. Refer-
test’s ability to discriminate between subjects with or ence lists from the selected articles further contribu-
without balance impairments have been shown to be ted with additional papers.
10 seconds in young adults and 14.2 seconds in the When the wording ‘significant’ is used in the text,
elderly.26 Reference values for the FTSST for different it implies a statistical difference with a P value of
age groups have been reported, for example, v0.05 regarding the chosen dependent variables in
11.4 seconds for 60–69 years olds; 12.6 seconds for the respective study.

Physical Therapy Reviews 2015 VOL . 20 NO . 3 157

Frykberg and Häger Movement analysis of sit-to-stand
Major Findings and Some Reflections
Phases of typical sit-to-stand performance
The STS transfer has been divided into four phases,29
which is often referred to in the literature30–32 – see
Fig. 1. Bending forward of the trunk and pelvis
prior to the instant when the buttocks leave the
base of support (BoS) (i.e., seat-off) is called Flexion
Momentum (Phase I). Phase II, Momentum Transfer,
lasts from seat-off to maximum ankle dorsiflexion.
During this phase, the momentum from the upper
body is transferred to the total body and contributes
to the forward and upward movement of the
whole body. Extension (Phase III) lasts until the
hips are straight. Lastly, Stabilisation (Phase IV) is
defined as the end of the transfer. According to the
authors, the end point of this last phase is difficult
to identify.
Another definition of two STS phases has been
presented based on information recorded simul-
taneously from four force plates positioned beneath
the buttocks and feet.30 The Preparatory phase was
identified from the first detectable change of the
anterior–posterior (AP) force generation beneath
the buttocks to seat-off, i.e., anticipatory actions
were registered here before the visible STS move-
ments, something that had not previously been
described. The Rising phase lasted from seat-off to
where the vertical velocity of total body COM
decreased to zero. The role of the feet was more of
a ‘damping drive’ in order to smoothly control for
the subsequent rising to stand.
Additionally, 11 events from horizontal and verti-
cal ground reaction forces (GRF) have been pro-
posed to standardise STS in future studies.33
Timing and scaling of these events were surprisingly
similar in this kinetic study as compared to earlier
research studies including different numbers of ident-
ified events.34,35
Total movement time for one discrete STS transfer
has been reported to range from 1.51 to 2.97 seconds
depending on age and when rising to stand is
Figure 1 Illustration of four suggested phases during
the sit-to-stand transfer. From Schenkman et al. 199029
(Reprinted from Phys Ther 1990;70:638–648, with permission
of the American Physical Therapy Association. q 1990
American Physical Therapy Association.)
158 Physical Therapy Reviews 2015 VOL . 20 NO .
considered to start and end, respectively.30,36–41 Thus,
in order to facilitate comparisons between STS studies
and to allow meta-analysis, an agreement on how to
define critical events and phases would be beneficial.
Determinants of the sit-to-stand transfer
Several suggested STS determinants have been demon-
strated to influence the performance regarding
self-reported outcome measures as well as kinematic
and kinetic outcome measures. The content in Table 2
originates from a review article by Janssen et al. pub-
lished in 2002,31 but has been modified to incorporate
the extensive research results during the last decade.
Some of the subject-related determinants in Table 2
have a strong influence on the STS performance,
e.g., body weight, which pronouncedly influences
which rising strategy to use.42 Muscle strength in
the lower limbs is also considered as one important
subject-related STS determinant;43–46 however, con-
tradictory opinions exist about which muscles are
the strongest predictors. (e.g.,43,45) Interaction from
other determinants such as age, disability and
motor strategy used for rising to stand likely have
impacts on muscle activation patterns. Balance abil-
ity has been highlighted as a determinant of STS in
the elderly43,47 and in subjects with impairments,46
but is probably of less importance in non-disabled
young adults. Further, in the elderly, many interact-
ing determinants, e.g., sensation and psychological
status, are reported to influence STS performance.43
Chair height is considered to be the most important
chair-related STS determinant, where an increased
chair height positively influences self-reported, kin-
ematic and kinetic outcome measures.48–50
A continuum of strategies has been suggested ran-
ging from rising with an almost vertical trunk to a
pronounced forward leaning of the trunk where stab-
ility and safety seem to be prioritised.51–53 Explora-
tion of underlying mechanisms for strategy-related
determinants is on-going and the peak of the COM
acceleration prior to seat-off has been proposed to
be a critical variable.54 Further, a posterior foot pos-
ition before onset of STS has been reported to have
several temporal and kinetic advantages32 during
rising to stand. The role of arm movements has on
the other hand rarely been considered as in most
studies the arms have been constrained and held
across the chest for standardisation purposes. How-
ever, use of the arms might facilitate horizontal and
vertical momenta generation during STS.55
Characteristics of successful and failed
sit-to-stand trials
The ability of STS in children develops from the age
of 12–18 months in terms of decreased time for
execution, kinematic changes such as reduced ankle
and trunk flexion peaks during the performance,
3
 Frykberg and Häger Movement analysis of sit-to-stand

Table 2 Determinants of sit-to-stand performance and their influence on self-reported, kinematic and kinetic outcome
measures

Determinants Influence on STS performance

Subject-related
Age Young adults (41 years) performed STS significantly faster than old adults
(73 years)26
No influence on time for STS in age groups w 60 years26
Gender Young women (22 years) used less time to perform STS than men; however,
proportions between STS events did not differ33
No gender difference in old adults (75 to 90z)43 and in subjects with or without
balance disorders26 when performing the clinical test FTSST
Weight & height Subjects with obesity (BMI w30 kg/m2) demonstrated an STS motor strategy with
very high knee moments42
Body weight accounted for 21.9% of the variance in STS in old adults (75 to 90z)43
Height: explained only 2% of variance in subjects with balance impairments
performing FTSST26
No correlation between total STS time and height in 75 to 90z year old adults43
Muscular strength Lower limb strength could explain 48% of variance in the FTSST and 35% in the
30 seconds chair stand test, respectively, in non-disabled sexagenarian women44
Hip muscle strength was more important than knee extensor strength in elderly
(70 years) with functional limitations45
Quadriceps strength explained 16.5% of STS variance in old adults (75 to 90z)43
Balance ability Increased instability (i.e., longer time to achieve stability and increased COP sway)
during the stabilisation phase of STS in older adults (74 years)47
Body sway with eyes open (quiet standing on a foam mat) was a predictor of STS
performance in old adults (75 to 90z)43
High negative correlation (r5{0.84) between scores on Berg Balance Scale and
time for FTSST in subjects with stroke46
Sensitivity Visual contrast sensitivity, lower limb proprioception, and peripheral tactile sensitivity
were independent predictors of STS performance in old adults (75 to 90z)43
Psychological status Anxiety scores from SF12 predicted STS performance in old adults (75 to 90z)43

Chair-related
Chair height Decreased perceived effort in elderly when chair height increased from 42.5 to
55 cm48
Angular velocities for most lower extremity joints increased when standing up from a
chair of 80% of knee height compared to 100% in 64 years old adults130
Reduced hip and knee angles as well as force moments when a higher chair was
used in male subjects (39 years)131
Lower moments at knee (up to 60%) and at hip level (up to 50%) when increased
chair height49
No significant effect for low to normal seat heights neither on 30 seconds chair
stand test in older adults (70 years)132 nor on peak hip and knee joint moments in
young subjects (26 years)133
Longer time for FTSST when seat height was lower than knee height in subjects with
stroke50
Chair design Elderly (84 years) had longer STS duration, but more positive perception, when the
chair seat was tilted backward, and with a foam cushion134
Arm rests No effect of arm rests on rising ability in elderly (84 years)134
Reduced hip extension moments by approximately 50%131

Strategy-related
Knee strategy/kinetic
strategy/momentum transfer strategy
Hip and trunk strategy/semi-static
strategy/zero-momentum stabilisation
Continuum of motor strategies
COM acceleration profiles
Foot position
High knee moments and small hip and low-back moments and rising with a
relatively vertical trunk utilising trunk momentum in young men51
High kinetic energy from trunk momentum was converted into rising work52
Elderly with impairments utilised horizontal momentum53
High hip- and pelvis-trunk moments and decreased knee moments with more
forward flexion of the trunk in young men51
COM was transferred more forward at a slower velocity and with more flexed trunk52
Repositioning of the base of support and position of COM53
Elderly displayed a movement pattern more split up in separate consecutive
sequences135
Even distribution of moments and powers at specific joints in subjects with low-back
pain51
Combination of the momentum transfer and stabilisation strategies53
Similar COM momentum at seat-off in young (22 years) and old (71 years,
non-disabled, and 74 years, with difficulties in STS) adults, but different peak
COM accelerations prior to seat-off across groups54
A posterior foot position implies a shorter distance between COM and COP, which
suggests optimal efficiency with respect to muscle activity. The lower the chair
height, the stronger the influence from the foot position32
Asymmetrical foot position post-stroke implied:
Longer duration of STS sub phases79
Longer total movement time76

Physical Therapy Reviews 2015 VOL . 20 NO . 3 159

Frykberg and Häger Movement analysis of sit-to-stand

Table 2 Continued

Determinants Influence on STS performance

Placing the paretic foot behind implied:

Reduced asymmetry of trunk position77,136
Decreased medio-lateral displacement of COP136
Increased weight-bearing symmetry77,78
Increased knee-moment symmetry77
Increased vertical force production79
Arm movements A strong temporal linkage between shoulder flexion and lower limb extension as well
as potentiation of horizontal and vertical momenta due to arm movements in
young adults (24 years)55

as well as increased knee and trunk extension at the end of
STS.56 Thus, movement strategies that are more energy
efficient are gradually emerging and improved postural
orientation with better stabilisation of COM has been
suggested to be the underlying mechanism refining STS
performance.56 In a comparison between 6 to 7-year-
old children and 28-year-old adults the movement form
of STS, defined as the sequence of joint onsets, were
demonstrated to be similar.57 The children, however, dis-
played almost twice as high coefficients of variation in
kinematic data, reflecting an inability to control inter-
segmental dynamics. Further, the children’s coordi-
nation of horizontal and vertical momenta during the
STS transition was performed with less refined motor
control. Similar results have been reported in an earlier
STS study where children 12–18 months, 4–5 years and
9–10 years were compared.58 With increasing age, the
capability to control horizontal momentum and thereby
to balance increased.
During typical adult STS, the points of force appli-
cation are beneath the buttocks (thighs) and feet.30 The
forward movement of the whole body accelerates to a
peak and then decelerates before the rising starts, i.e.,
there is a braking impulse acting to coordinate the first
part of the transfer.30 The timing of peak horizontal
acceleration has been proposed to be invariant with
different speeds of rising and across age groups.59 The
velocity of the vertical momentum of COM, on the
other hand, has been reported to be reduced in elderly
persons (mean age 72+ 6 years) as compared with
young adults (mean age 32+ 4 years).60 The head-,
arm- and trunk-segments are the main contributors to
the body’s forward propulsion prior to seat-off during
STS, whereas the thighs predominantly contribute to
the upward momentum of the body.61 Recent research
highlights potential asymmetry during STS in non-dis-
abled adults, measured with joint moment and joint
power variables.62 Typically, during the STS transfer,
the COP is initially displaced in a backward direction63
and the transfer is effectuated by the use of lower limb
muscles acting in close temporal relation.64
There are only a few research studies that report data
of failed trials of rising to stand. In one of these, 13
elderly persons with disabilities of either neuromuscular
or musculoskeletal origin presented 20 failures to rise.65
The disabled elderly persons either sat back or took a
step after rising up compared to the elderly without dis-
ability, and significant group differences were demon-
strated with regard to scaling and timing of horizontal
and vertical momenta. In another study, successful
and non-successful trials of STS were compared in one
subject with a traumatic brain injury.66 The variable
that differed between these trials was the peak vertical
velocity of the whole-body COM, being too low in the
trials, which resulted in a failure to stand up. Likewise,
in 28 persons with PD, 14 failed and 18 successful
trials of STS67 indicated that in the failed trials, there
was a reduced peak of COM velocity in the vertical
direction. Regression analyses showed that COM for-
ward velocity and height of the hip at the moment of
COM peak vertical velocity could be the best predict
whether the STS transfer would result in a failure or a
success. Variables of dynamic stability [e.g., AP position
of the body’s COM relative to the BoS] did not differ
between failed and successful trials and the authors con-
cluded that ‘limb collapse’, rather than instability, was
the reason behind the failed STS.
In another study, the maximum vertical velocity of
COM was chosen as the primary outcome measure in
motor-impaired elderly persons and trunk bending
momentum and lower limb extensor muscle strength
were identified as major predictors of STS perform-
ance.12 After a rehabilitation program (RP), focussing
on strength training, the vertical velocity of COM
during STS increased significantly, as shown in Fig. 2.
To summarise, in research aimed at finding the
most important predictor of a successful STS, differ-
ent determinants have been considered. Speed of
execution during the STS transfer with an increase
in hip flexion velocity prior to seat-off has been
suggested to be the most important factor to over-
come STS difficulty.68 Indeed, a reduced upward vel-
ocity of COM is a critical factor behind a failed STS
trial.66 The reasons behind the reduced vertical vel-
ocity of COM could be several, such as insufficient
momentum transfer, impaired postural orientation
and/or non-optimal biomechanical conditions.
These mechanisms and their interactions remain to
be investigated. Further, research investigating mech-
anisms of momentum transfer from horizontal to

160 Physical Therapy Reviews 2015 VOL . 20 NO . 3


Figure 2 Horizontal and vertical velocities of centre of mass (COM) during sit-to-stand in motor-impaired elderly before
(A) and after (B) a rehabilitation program (RP). (Horizontal velocity-continuous line; vertical velocity-dashed line).
From Bernardi et al.12 (reprinted with permission from the publisher).
vertical momenta is rare and might reveal important
information regarding the success of STS.
Sit-to-stand performance in stroke and
Parkinson’s disease
The STS transfer has been investigated in several
pathological conditions. To exemplify the impact of
disability on STS performance some findings in
stroke and PD will be presented below.
During STS, persons with stroke demonstrate
reduced weight-bearing ability on the paretic side of
the body, approximately 37.5% instead of about
50%.69 Further, decreased force production post-
stroke resulting in a prolonged STS transfer has
been reported.70,71 On the other hand, the muscles
in the non-paretic leg produce excessive activity.72,73
Similarly, anticipatory postural adjustments during
STS, defined as activation timing of tibialis anterior
and soleus muscles, have been demonstrated to
differ in both limbs post-stroke as compared to typi-
cal performance.74,75 An asymmetrical foot position
with the non-paretic foot placed behind the paretic
during STS is often observed clinically after stroke
and this foot-position is associated with an increased
duration of STS.75,76 Studies have been performed
where the paretic affected foot has been placed
behind (Table 2). This strategy significantly reduces
weight-bearing asymmetry77,78 and increases force
production as well as activity in involved lower
limb muscles.79 The possibility for therapy-induced
improvements regarding STS post-stroke, in terms
of, e.g., time taken to perform the transfer or sym-
metry during rising, has been demonstrated in a
recently published Cochrane Review.80 However,
insufficient evidence to reach conclusions was
revealed regarding effect on other outcome measures,
such as vertical GRF,81 functional ability82,83 and
falls.81–84
Frykberg and Häger Movement analysis of sit-to-stand
In persons with PD 44% subjectively report diffi-
culties during rising to stand.85 Furthermore, the
STS transfer has been identified as an important
determinant for independence and quality of life for
those with PD.86 The anticipatory postural control
during STS was studied in 10 male subjects with
PD and in 10 age and gender matched controls.87
The results demonstrated an exaggerated, rather
than the expected reduction in, movement prep-
aration. The subjects with PD used a hip flexion
strategy with greater COM displacement and reduced
knee extensor moments as compared to controls.
This strategy may be due to a need for greater pos-
tural stability during the lift-off phase, as well as to
decreased knee extensor strength. Similar results
with generation of larger COM forward momentum
was reported in a study with six persons with PD
where the motor strategy supposedly aimed to
reduce the time spent in the unstable transitional
phase of STS.88 Further, subjects with PD have
exhibited slowness during the STS transfer,89–91
with a prolonged Flexion Momentum phase possibly
caused by impaired recruitment of the tibialis
anterior muscles.89 A study of STS at matched
speeds between persons with PD and controls
revealed that the only significant group difference
was that the controls used a shorter transition time
between COM peak forward velocity and seat-off.92
The researchers concluded that subjects with PD
probably have difficulties to switch between different
movement directions, i.e., to switch between forward
and upward whole-body movements.
In summary, persons with neurological dysfunc-
tions, such as stroke and PD, use disability-specific
motor strategies while rising to stand according to
prerequisites and specific needs. Scaling and timing
characteristics of the trunk movements as well as
the foot position, which influence lower limb
muscle activation, are considered important factors.
Physical Therapy Reviews 2015 VOL . 20 NO . 3 161
Frykberg and Häger Movement analysis of sit-to-stand
Related everyday transfers
Sit-to-walk (i.e., gait initiation from sitting) is a clo-
sely related complex everyday transfer. Here, as
during STS, the central nervous system is challenged
to simultaneously handle locomotion and balance.
The typical STW performance is that the first step
is initiated before the body is fully extended.63
Characteristics of how the STS transfer is modified
when gait is initiated (i.e., STW) has been examined
in 10 male subjects (mean age 28+ 6 years),63 where
the whole body’s momentum increased in both hori-
zontal and vertical directions. Older adults (mean age
63 years)93 and persons with PD94 are proposed to
have problems in merging the two STW sub tasks,
rising and starting to walk. Three95 or four96,97
STW phases have been suggested, mainly based on
kinematic data. Kinetically, different strategies of
AP force generation beneath buttocks and feet were
demonstrated when subjects with stroke and matched
controls were compared.98 However, the amount of
total AP force generated did not differ significantly.
Discussions are on-going regarding which STW vari-
ables are the most critical and clinically relevant to
study, e.g., COP displacement,99 total COP
paths,100 AP COM-ankle angle,101 and movement
fluency in terms of hesitation, coordination and
movement smoothness.102
In the context of the STS transfer, the reversed
pattern of stand-to-sit is also worth mentioning.
Dubost et al.103 compared movement patterns
during sitting down in young (mean age 27 years;
SD + 5) and old (mean age 76 years; SD + 3)
adults without known impairments. No group differ-
ence was found regarding trunk and shank angles.
However, during sitting down the older adults signifi-
cantly reduced the forward displacement of the
trunk, a strategy probably used in order to avoid
falling. The researchers emphasised the different
roles of the trunk while standing up (i.e., responsibil-
ity for momentum generation) and sitting down (i.e.,
stability controller). Displacements of the shoulder
and the upper part of the thigh were registered in
two groups of healthy adults of different ages.104
The young (23+ 2 years) and old (73+ 6 years) partici-
pants exhibited similar movement patterns during
rising to stand. The trajectories of the shoulders
were similar, irrelevant of direction. However, the tra-
jectories of the thighs differed depending on direction,
being displaced further back during sitting down.
Both groups used more time in sitting down compared
to standing up, with the older adults using signifi-
cantly more time than the younger.
Methodological Issues
An important aspect to consider when interpreting
results from research of STS in laboratories is that
162 Physical Therapy Reviews 2015 VOL . 20 NO .
more or less as a rule, strict standardisation with
respect to seat height, foot position, the allowance
of arm use or not, etc. has been applied.
In addition, the studies often comprise relatively
few subjects, but include large data sets. The possi-
bility to generalise to everyday activities is thereby
reduced and the ecological validity is questioned.105
A recent study illustrated how strict standardisation
might influence motor performance and the problem
of what should be considered a typical motor strat-
egy in 26 subjects with unilateral knee arthroplasty,
where both self-selected and constrained lower limb
positions were used.106 Mobility as well as force gen-
eration at the hip and knee joints in the operated
limb improved when self-selected positions were
applied.
Another methodological issue to consider is
biological variability, which has been demonstrated
to be a fundamental principle for central nervous
system function.107 In studies regarding everyday
activities, such as STW97 and multi-joint hand move-
ments,108 variability between measurements has been
quantified, which is considered important.109 How-
ever, in a standardised set-up efforts are made to
reduce variability. This issue needs to be taken into
consideration when conclusions are drawn from
STS studies in research laboratories.
Most of the included STS studies in this review
used data based on high-speed camera systems
and/or force plates. This not only implies advantages
such as objective collection of 3D data from multi-
joint human movements but also problems such as
marker placements and filtering of data, difficulties
of interpretation110,111 and, perhaps most of all, lim-
ited ecological validity.105 During recent years, porta-
ble body-fixed-sensors comprising gyros and
accelerometers have been utilised to study timing
and scaling of STS variables in more natural environ-
ments. These sensors provide information such as
STS duration, maximal velocity, acceleration and
jerk and peak power.112 Variability measures (such
as coefficient of variation) are also proposed as
they may indicate deterioration of automation.113
Psychometric properties of sensor-worn systems
have been established showing excellent test-retest
reliability in both young and old adults (ICC
i0.90 and i0.91, respectively).114 A study of discri-
minative validity of a body-fixed system revealed sig-
nificant differences regarding STS duration, velocity,
and variability parameters between young (20 years)
and old (88 years) adults.113 Regarding concurrent
validity, fair to excellent relationships of peak
power have been reported from a comparative
study of sensor-based versus force plate-based data
with sensors worn on different locations of the
trunk.115 Further, sensor-based data demonstrated
3

higher sensitivity for effects of an eight-week RP than
did data from more common clinical instruments
such as isometric quadriceps strength, Timed Up
and Go Test, and Berg Balance Scale.112 However,
studies performed using portable movement analysis
systems often differ in methods and analyses, which
make comparisons of results difficult. Issues regard-
ing filtering of sensor-based data are under discussion
and must be considered.116
In addition to the aforementioned dependent vari-
ables, parameters describing movement smoothness
(such as fractal dimension) and local energy of
trunk dynamics are proposed to be calculated in
studies with sensor-based measurements, recognising
that the STS transfer is a non-linear and non-stationary
movement.117 Further, the latter mentioned outcome
variables seemed to capture subtle functional
changes between the non-disabled and frail elderly fol-
lowing a RP that might be essential in detecting early
decline.
The clinical method FTSST has demonstrated to
be a predictor of falls.118,119 However, the cut-off
time regarding high falls risk is under discussion
and accelerometer data (e.g., AP spectral edge fre-
quency) seem promising for providing comprehensive
and objective information of STS performance.120
Several mathematical models, using different
optimisation principles, have been applied to regener-
ate joint trajectories in order to improve the under-
standing of human movement control. With the
assumption that STS is a complex transfer skill, a
new model, the multiphase cost model, was applied
to STS data from six young non-disabled subjects.121
This new model sufficiently and accurately could pre-
dict joint trajectories throughout the STS transfer
why it was concluded that the brain and nervous
system appear to apply different strategies for differ-
ent phases of STS.122
Clinical Implications of Research Findings
in Sit-To-Stand Studies
An expanding body of knowledge of typical and
atypical STS performance based on detailed movement
analysis shows that the STS task represents a most com-
plicated transfer skill with a multitude of factors influen-
cing even each sub phase.122 The step from the
knowledge generated in movement laboratories to
what is reflected in the assessment tools that are used
in the clinics seems nevertheless still quite large.
A deeper understanding of the different sub phases
is necessary for clinically observing and analysing an
atypical STS transfer. During the Flexion Momentum
phase the preparation for an effective push-off30 might
be critical. Research studies are scarce where the con-
tribution from each buttock and foot generating
propulsive and braking impulses to coordinate the
Frykberg and Häger Movement analysis of sit-to-stand
body into an effective rising is explored.30 Four
force plates is a necessary prerequisite for this infor-
mation, highlighted further during recent years
where typical asymmetry during STS has been
reported.62 Mechanisms of an effective momentum
transfer from the trunk to the lower limbs during
and after the critical event seat-off are rarely reported,
but essential to explore. During the Extension phase,
generation of sufficient vertical momentum has been
demonstrated to be critical for a successful STS.65,66
At the end of STS, when the whole body’s COM is
stabilising over a significantly decreased BoS, children
display an increased variability compared to young
adults.57 This variability is suggested to be a key prin-
ciple for the central nervous system’s function107 and
needs to be further explored.
Among the multitude of determinants to consider
when assessing STS, some appear potentially more
important. Muscle strength and balance ability
have been proven to be major subject-related STS
determinants in the elderly43,45 and in subjects with
disabilities.46 Further, a somewhat posterior foot
placement facilitates momentum transfer from the
trunk into the lower extremities in order to produce
the upward movement of the body.32 Thus, foot pos-
ition and other STS determinants such as chair
height and chair design should be documented by
clinicians when STS is assessed. Movement speed as
well as optimal timing and scaling of momentum
during STS execution seem critical for a successful
STS.65,66,92 To capture data of such variables in the
clinic, integration of observation-based and body-
fixed sensor-based movement analysis might be fruit-
ful. Further subject-related determinants such as
psychological factors regarding fear of falling,
anxiety or pain43 are scarcely reported. These subjec-
tive determinants need to be put into focus in future
STS clinical practice and research.
Considering balance ability, COM is at its most
posterior location relative to the ankle joints at the
critical event seat-off and the difference between the
locations of COG and COP is greatest.123 Here, it
is important to guarantee safety as balance is jeopar-
dised. Moreover, the distance between COG and
COP has been suggested to be a critical variable
regarding postural stability,124,125 and this variable
needs to be investigated in STS studies.
Another aspect of the STS transfer is which motor
strategy the patient is using and this should be docu-
mented. Interestingly, non-disabled subjects have
demonstrated both kinetic strategies and semi-static
strategies,51,53 probably reflecting the possibility to
choose strategy based on demands of the task and
in the environment. The continuum of strategies
suggested51,53 might show the variability of neuromo-
tor processes ready to be used to fulfil the same task.
Physical Therapy Reviews 2015 VOL . 20 NO . 3 163
Frykberg and Häger Movement analysis of sit-to-stand
For standardisation purposes research subjects
have most often held their arms still across the
chest. There may be a great potential in using the
arms, either to push off with or to swing in order
to facilitate generation of both horizontal and verti-
cal momenta. Similarly, in the debate of why and
how the arms swing during gait, some researchers
have recently highlighted the potential of using arm
movements during gait training for the purpose of
facilitating leg movements.126
Studies regarding STS failures are rare.65–67 Insuf-
ficient vertical velocity, and thereby too small vertical
momentum, has been reported to be the cause for
failure.65,66 The underlying mechanisms to this,
whether too small horizontal momentum being
generated prior to seat-off, an ineffective momentum
transfer, a bad aligned foot position or something
else remain to be studied in depth.
Persons with neurological dysfunctions demon-
strate disability-specific STS motor strategies, such
as asymmetric force generation (stroke; low force
production in the paretic leg70,71 and excessive com-
pensatory force generation in the non-paretic leg72)
and problems with switching from forward to
upward movement direction (PD92). Specific inter-
ventions need to be tailored to meet the demands in
diverse patient populations with different underlying
causes for STS disability.
Altogether, there are important considerations to
make throughout each of the sub phases of the STS
transfer in patients with disabilities. As a conse-
quence of the increasing body of knowledge regard-
ing STS and the assumption that it is a complex
transfer skill, and not merely a single motor task
requiring muscle strength, there is a need to develop
clinical tools able to capture process information
about the different sub phases as well as of the
whole transfer. This information is essential for
understanding impaired STS ability and thereby
facilitating clinical decision making. Similar clinical
assessment instruments, i.e., capturing the process
and thereby quality of a motor task, have been
suggested from researchers in physiotherapy, e.g.,
the Fluidity Scale for the rise-to-walk task127,128
and the Reaching Performance Scale.129 In the pro-
cess of developing comprehensive clinical tools
regarding the STS transfer, several systematic reviews
of research findings including careful evaluation of
intervention studies in different pathological con-
ditions are warranted.
Conclusions
Recent research highlights STS as a multifactorial
transfer skill, which not is reflected in the clinical
assessment of this rising task. This discrepancy
between a single value documenting STS ability in
164 Physical Therapy Reviews 2015 VOL . 20 NO .
the clinic and the comprehensive information pro-
vided in research might be bridged by development
of clinical tools capturing various determinants and
the process characteristics of STS.
Disclaimer Statements
Contributors
Both authors have been fully involved in the manu-
script and have made substantial contributions to
the different steps of the review process. Each of
the authors has read and concurs with the content
in the final manuscript
Funding
None
Conflicts of interest
The authors declare that they have no conflict of
interest.
Ethics approval
Not applicable.
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