Functional Motor Task

Sit to Stand

Prepared
By
Mohammad Bin Afsar Jan
BSPT, MSPT,GCRS,MAPA,MNPA
 Headings

Essential Components
Bio- Mechanical Analysis
Muscle activity
Analysis of sit to stand in stroke
patients
Clinical and methodological
implications
Retraining program
STS requires ability to move the body mass
forward from over a large BOS to small BOS and
to extend lower limb joints to raise body mass
over feet
STS is one of class of action in which the lower
limb extend and flex over feet which form a fixed
BOS i.e. STS, sitting down, stance phase of walk,
walking up and down stairs, squat, initial phase of
jumping and hoping
Lack of practice of STS is associated with
weakness of lower limbs and short calf muscles
 Essential components
Pre-Extension phase
Initial foot placement backward (approx 10 cm
behind the knee joint)
This position augment backward horizontal motion to
propel body mass forward
Inclination of the trunk forward by the flexion at
hip with knees forward and extended neck and
spine
Movement of thigh and shank augment ankle DF
together with trunk rotation moves body mass forward
as part of horizontal momentum
 Essential components
Extension phase
a sequence of lower limb extension
(knee, hip and ankle)
Shoulder traces a path horizontally then
vertically with some overlap at thigh off
There is no pause between horizontal and
vertical phase forming one continuous
forward and upward movement
Angular displacement at hip (flexion) and
ankle (DF) in pre-extension phase has
dynamic effect on extension phase
Bio-mechanical analysis
Kinematics
Generation of horizontal linear momentum of
body mass to move the body mass forward
over the new BOS
Translation of horizontal momentum to vertical
momentum which propels the body mass
upward to the standing position
Horizontal movement results from clockwise rotation
of the trunk at hips and of shank segment at the
ankles
Vertical movement results from extension at hips,
knees and ankle i.e. counter clockwise rotation of
trunk and shank segment and clockwise rotation of
thigh at hip and knee- it also extends knee with
counter clockwise rotation of shank
Bio-mechanical analysis
Kinematics
Horizontal and vertical movements of the body mass
overlap – sequential onset of knee, hip and ankle,
knee extending at the time of hip flexion
Trunk (pelvis, spine and head) rotate forward as one
segment in pre-extension and backward in extension
phase – little movement occurs at spine
Extent of angular displacement in STS will very
depending on starting position of feet and trunk,
height of stool, type of seat and position of upper
limbs
Timing relationship is critical between horizontal
movement and extension phase
 kinematics
Pattern of movement
1. Trunk inclination ~ 80 hor/ 10 vert axis
2. Neck segment ~ 63 hor/ 27 vert axis
3. Pelvic segment ~ 116 hor/ 26 vert axis
4. Hip flexion ~135 –flex 40%,ext 60%
5. Knee flexion ~ 95 – Extension
throughout the pattern
6. Ankle DF ~ 106 deg – 45% of the
movement cycle
 kinetics
Major force generation occurs at thigh off when
body is accelerated to vertical position from
horizontal
In ADLs the distribution of WB through lower
limbs depends on goal of action and
environmental demand
Decrease in force at one joint is compensated
by increase at other joints to ensure limb does
not collapse e.g flexion at knee at thigh off
result in increase extension at ankle with
magnitude force remaining same
 kinetics
TA is first muscle activated in bringing feet
back (shank moving forward on ankle) along
with activation of Hip and knee extensor
Peak activity in hip and knee occurs at thigh
off
Biarticular rectus femoris and bicep femoris
contribute to control hip flexion in trunk
inclination with RF flexing and BF exerting
braking force
 Muscle activity
kinetics
Phase 1- beginning of trunk flexion
R.A
G.M
T.A
E.S
Quad & Ham
Phase 2 – Thighs and Buttocks off seat
Gastro
T.A & Quad deactivated at the end of this
phase
A separate distinct of E.S was seen in some
subjects
 Muscle activity
Phase 3 – Beginning of stance
Gastro
Ham
G.M
E.S
R.A
Phase 4 – End of stance and beg of trunk flexion
T.A
Quad
Ham
G.M
ES
R.A
 Muscle activity
Phase 5- Thighs and buttocks down and
trunk extension
ES deactivates at start
Ham deactivates sec
G.M
R.A
Phase 6- End of the movement
G.M & R.A both deactivated
 Kinetics
Contribution of initial foot position to
lower limb extension
Further the feet are, flexion at trunk increase
with velocity
Hip extensor force increased with decrease
in knee and ankle moment force with feet
placed forward
Increase amplitude of hip flexion and
strength in hip extensor with feet forward will
be difficult to cope by stroke patients and
THR
Optimal position is 10 cm behind knee
 Kinetics
Contribution of trunk segment to lower limb
extension
Trunk is a major contributor to horizontal linear
momentum facilitating limb extension with thigh
segment being major contributor to vertical
momentum
High level of overall muscle force over longer period
of time is required with STS from fully flexed position
Generation of extension force can be optimized by
starting trunk flexion from erect position, increasing
speed and starting extension as the trunk is flexing
not after stopping flexion
 kinetics
Speed of movement
Increased velocity of trunk flexion resulted in
short burst of overall extensor force
Patients with movement disorder needs
encouragement to move faster
Practice range of speeds for ADLs
 kinetics
Contribution of upper limb to balance
and propulsion
– When arm is constrained there is increased time
spent with overall extensor force increased,
decrease horizontal displacement and horizontal
and vertical linear momentum
– Shank moves forward on foot approx 28% of
extension phase
– Subjects move less forward and with less speed
when arm is free to move – to improve stability
Analysis of sit to stand in stroke
patients
Difficulty generating and timing sufficient force
Failure to place one or both feet backwards due to
weak DF or Hamstring or tight soleus results in
hip extensor movement increases
knee and ankle extensor moments decreases
stands with weight shifted laterally to the intact side
Adduction and IR of paretic leg to gain effective ext
shoulder path moves downwards from the horizontal
instead of upward
Stronger foot placed behind paretic foot
Analysis of sit to stand in stroke
patients
Inability to move body mass forward due to lack of
vigour, loss of stabilizing effect of paretic leg or
fear of falling forward results
Propel body backward instead of forward
Prolong extension phase
High value of extensor phase
Weak ankle DF & KE – foot is not stabilized on floor-
prevents shank from moving forward on foot- lack of
horizontal momentum in pre-extension phase
Lack of balance and stability due to difficulty
generating and timing force
Use of hands
Widen the base of support
 Clinical and methodological
implications
Forward placement of feet increases
hip extensors moments making sit to
stand difficult for individual with weak
hip extensors
Extension of the lower limbs with the
CBM behind the heel would propel
the person backward not forward
 Clinical and methodological
implications
Arm should be free to move in individuals
who have difficulty generating muscles
force in lower limb extensors
With increased velocity of trunk flexion
there is relatively short burst of over all
extensor force to propel the body pass
vertically rather than more sustained effort
when subject moves slowly
 Retraining program
Arranging suitable environment
Seat height
Increase seat height with assistance of arm
decrease forces in relation to knee and hip
seat should be flat not sloped backward
start with increase height and progress to lower
seat should not have arms
Seat design
Standard chair Vs Special chair
Preparatory components for STS

Trunk stabilization (hip ext & abd)

Side lying
Selective activation of gluteals by pushing
through foot in groin
Remove hand in side lying for added abd
control
sweep tap, finger stretches etc along with
verbal cueing
Preparatory components for STS

Supine lying
inner range hip control by bridging over the
edge of bed on stool
progress to outer range with feet on mat
rhythmic stabilization for stability. Add
compression from knee to foot awareness
Bridging with affected leg crossed over good
leg
Progress to good leg crossing over the affected
leg
One leg in SLR
Stretching the calf to maintain length and
flexibility
Preparatory components for STS

Sitting
Facilitatory techniques to stimulate
DF/PF i.e. sweap tapping , vibration,
quick ice, FES, Biofeedback
Standard strengthening of DF with knee
bent initially and progressing to knee
straight
eccentric & concentric contractions of
quad with compressions through heels
stepping on the block
 Standing
Activation through loading and symmetrical
WB
Stepping up on the block with unaffected
leg
progress to amount of self support patient
allowed
amount of manual support from therapist
amount of verbal cueing
height of block
Standing on block with affected leg . Drop
unaffected leg on side, raise and lower
pelvis
 Standing
Stepping up on less stable object e.g.
cone, ball
Activities on single limb i.e kicking
balls
Rhythmic stabilisation in lunge
position for co-contraction of
hamstrings
Small knee bends
Wall squats
 Prepare to stand

Practice foot placement in sitting

Add compression towards heel for
Awareness
Placing the foot on a towel on a low
friction surface and practicing moving it
backward and forward
Lines on floor or targets can provide
visual cues and goals
Stretch the calf
 Prepare to stand

Practice trunk inclination forward at

hips with erect trunk and forward knee
movement
Practice with momentum
Aim to push down and back through feet
Give proper instructions
 Prepare to stand
Practice sit to stand
Stand from a higher chair and progress to lower
Even weight distribution
Add compression for awareness
Stopping the movement at various points
Placing affected leg posterior during practice
Stopping in different range, reversing, changing
direction & altering speed
 Prepare to stand
Practicing sitting down improves control
Repeat sit to stand many times
Practice whole action to develop timing
and co ordination
 Manual Guidance

Passive movement of the limb by

therapist
Guiding shoulder movement by
therapist
Physical restriction of a segment
 Demonstrations

Saggital plane
Video replay
Balance performance monitor
Pressure sensitive foot pad
 Home/ward program

Practice sit to stand in a structured

environment
Repeat, stop and reverse movements
Progress to hand free
Can use weighing scales
Bed exercises