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ResearchReport
Determinantsofthe
Sit-to-StandMovement:AReview
###########################################################################################################################################################################################################################################.
BackgroundandPurpose.Thesit-to-stand(STS)movementisaskillthathelps
determinethefunctionallevelofaperson.AssessmentoftheSTSmovement
hasbeendoneusingquantitativeandsemiquantitativetechniques.Thepurposesofthisstudy
weretoidentify
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thedeterminantsoftheSTSmovementand
todescribetheirinfluenceontheperformanceoftheSTSmovement.Methods.
AsearchwasmadeusingMEDLINE(19802001)andtheScienceCitationIndexExpanded
oftheInstituteforScientificInformation(19882001)usingthekeywordschair,mobility,rising,sit-to-stand,andstanding.Relevantreferencessuchastextbooks,presentations,andreports
alsowereincluded.
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Ofthe160identifiedstudies,onlythose
inwhichthedeterminantsofSTSmovementperformancewereexaminedusingan
experimentalsetup(n!39)wereincludedinthisreview.Results.Theliteratureindicatesthat
chairseatheight,useofarmrests,andfootpositionhaveamajorinfluenceontheabilitytodoanSTSmovement.Usingahigherchair
seatresultedin
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lowermomentsatkneelevel(upto
60%)andhiplevel(upto50%);loweringthechairseatincreased
theneedformomentumgenerationorrepositioningofthefeettolowerthe
neededmoments.Usingthearmrestsloweredthemomentsneededatthehipby50%,probablywithoutinfluencingtherangeofmotionofthejoints.Repositioning
offeetinfluenced
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thestrategyoftheSTSmovement,enabling
lowermaximummeanextensionmomentsatthehip(148.8N!mversus32.7
N!mwhenthefootpositionchangedfromanteriortoposterior).DiscussionandConclusion.
TheabilitytodoanSTSmovement,accordingtotheresearchreviewed,isstronglyinfluencedbytheheightofthechairseat,useofarmrests,
andfootposition.
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Morestudyoftheinteractionamongthe
differentdeterminantsisneeded.Failingtoaccountforthesevariablesmaylead
toerroneousmeasurementsofchangesinSTSperformance.[JanssenWGM,BussmannHBJ,Stam
HJ.Determinantsofthesit-to-standmovement:areview.PhysTher.2002;82:866879.]
KeyWords:Chair,Determinants,Review,Sit-to-standmovement,Variables.
WimGM
Janssen,HansBJ
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Bussmann,HenkJStam
Physical
Therapy.Volume82.Number9.September2002
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################################.
TThe
sit-to-stand(STS)movementisonefunctionpeoplefrequentlyuseastheychange
fromasittingpositiontoastandingposition(andthenoftentowalking).
Theabilitytogofromasittingpositiontoastandingpositionisanimportantskill;inelderlypeople,theinabilitytoperformthisbasic
skillcanlead
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toinstitutionalization,impairedfunctioningandmobilityin
activitiesofdailyliving(ADL),andevendeath.13Changesinabilityto
performtheSTSmovementarefoundinelderlypeopleandpeoplewithdisabling
diseasesandarerelatedtothedeterminantsoftheSTSmovement.417InasurveyofindependentlylivingDutchmenandwomenaged55yearsand
older,25%of
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themenreportedmoderatedisabilityand5%
ofthemenreportedseveredisability(ascomparedwith37.4%and7.8%
ofthewomen,respectively)ontherisingcomponentoftheHealthAssessmentQuestionnaire.1
ThemannerinwhichtheSTSmovementisdefineddependstosomeextentontheaimofthestudy.Roebroecketal,18for
example,definedthe
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STSmovementasmovingthebodyscenter
ofmassupwardfromasittingpositiontoastandingpositionwithout
losingbalance.VanderLindenetal19definedtheSTSmovementasatransitional
movementtotheuprightposture
requiringmovementofthecenterofmassfromastablepositiontoalessstablepositionoverextended
lowerextremities.The
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STSmovementalsocanbedescribedusing
kinematicorkineticvariables,withdefinitionssuppliedforphasesandeventsduring
thismovement.2022Adefinitionofthesephasesthatisusedfrequentlyis
theoneprovidedbySchenkmanetal21andismarkedby4events.PhaseI(flexion-momentumphase)startswithinitiationofthemovementandends
justbeforethe
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buttocksareliftedfromtheseatof
thechair.PhaseII(momentum-transferphase)beginsasthebuttocksarelifted
andendswhenmaximalankledorsiflexionisachieved.PhaseIII(extensionphase)is
initiatedjustaftermaximumankledorsiflexionandendswhenthehipsfirstceasetoextend;includinglegandtrunkextension.PhaseIV(stabilizationphase)begins
afterhipextension
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isreachedandendswhenallmotion
associatedwithstabilizationiscompleted.21
StudyingtheSTSmovement,in
ouropinion,requiresabasicknowledgeofthefactorsinfluencinghowthemovement
isperformed.Thedeterminants,webelieve,shouldbeindependentfromthetechniquesusedtostudymovement.Theextentofthesedeterminantsinfluencecanbesmall
anddetectedonly
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whenusingspecificmeasurementorresearchtechniques
WGMJanssen,MD,isRehabilitationSpecialist,DepartmentofRehabilitation,University
HospitalRotterdam,DrMolewaterplein40,3015GDRotterdam,theNetherlands([email protected]).Addressall
correspondencetoDrJanssen.
HBJBussmann,PT,PhD,isAssistantProfessor,DepartmentofRehabilitation,ErasmusUniversityRotterdam,Rotterdam,theNetherlands.
HJ
Stam,MD,PhD,
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isRehabilitationSpecialist,ProfessorandHeadof
theDepartmentofRehabilitationMedicine,UniversityHospitalRotterdamandErasmusUniversityRotterdam.
Allauthorsprovidedconcept/idea/researchdesignandwriting.DrJanssenprovideddata
collectionandanalysis.DrStamprovidedprojectmanagement,fundprocurement,andfacilities/equipment.DrBussmannandDrStamprovidedconsultation(includingreviewofmanuscriptbeforesubmission).
No
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grantswerereceivedforthisstudy.
ThisarticlewassubmittedJuly19,2001,andwasacceptedMarch
19,2002.
PhysicalTherapy.Volume82.Number9.
September2002Janssenetal.867
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Table1.
Numberof
ExperimentsPerformedinthe39ReviewedStudiesInvestigatingDeterminantsoftheSit-to-Stand
Movementa
Chair-RelatedSubject-RelatedStrategy-RelatedDeterminantsnDeterminantsnDeterminantsn1.
Heightofchairseat121.Age01.Speed112.Witharmrests52.Disease(eg,stroke,arthritis,lowbackpain)02.
Footposition5
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3.Chairspecialtype33.Muscle
force03.Trunkposition/movement34.Withbackrest04.No
footwear04.Armusewitharmrest55.Terminalconstraint16.
Armmovement17.Darkversuslight28.Fixedjoints19.Kneeposition110.Attention011.Training1
a
Insomestudies,
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morethanonedeterminantwasinvestigated.The
constraineddeterminantsareindicatedinTable2(numbersincolumnsunderDeterminant
Constrainedheadingin
Tab.2refertothedetailsofdeterminantslistedinTab.
1).
(eg,momentsassessedbyforceplates).Knowledgeofthedeterminants,wecontend,isnecessaryinordertoconductresearchontheSTS
movementorto
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interpretresultsofreportedstudies,becausethe
resultscanbe,inpart,afunctionofadeterminant.
TheSTSmovementhasbeenstudiedusingstandardizedclinicaltests,whichareused
inepidemiologicalstudies
3,23
andclinicaltesting.128MeasurementsofaspectsoftheSTSmovementhavebeenobtainedusingtechniques
suchas
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useofforceplates,20videoanalysis,17,2931use
of
15,3235
optoelectronicsystems,13goniometry,10,36andaccelerometry.37
Because
themostrecentreviewontheSTSmovementwaspublishedin1991,38we
believedanupdatewasnecessarytogaininsightintostudiesontheeffectsofvariablesontheSTSmovement,especiallyinviewofthenew
technologyavailableto
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studythemovement.Theaimsofour
articlearetoreviewresearchonSTSmovementdeterminantsandtodescribe
thetypeandmagnitudeoftheirinfluenceontheSTSmovement.Inaddition,
weaimedtoexposegapsintheliteratureandmakerecommendationsforfutureresearch.
Methods
AsearchwasmadeusingMEDLINE
(19802001)andthe
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ScienceCitationIndexExpandedoftheInstitute
forScientificInformation(19882001)usingthekeywordschair,mobility,rising,sit-to-stand,andstanding.Referencessuch
astextbooks,presentations,andreportsalsowereincluded.Afterreadingthearticlesor
abstracts,studieswereincludedonlywhenquantitativeinstrumentalanalyzingtechniqueswereusedtostudySTSmovementperformanceinthesubjects(patientsandpeoplewithoutknown
impairments).Thestudies
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inthisreviewwereincludedonthe
basisoftheirdesign(ie,thedesignhadtobeexperimentaland
aimedatelucidatingtheeffectofdeterminantsontheSTSmove
mentbymanipulatingthevariables).Thus,descriptiveandcomparativestudieswereexcluded,butbecauseweincludedtextbooks,presentations,andsimilarmaterials,therewasnota
requirementthatarticles
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bepeerreviewed.
TheSTS
movementdeterminantsarefactorsthatinfluencehowthemovementisperformed.We
categorizedthestudieddeterminantsaschairrelated(eg,seatheight),subjectrelated(eg,
age,muscleforce),orstrategyrelated(eg,speedorlightconditions)(Tab.1).Strategy-relateddeterminantsarethosethatarerelatedtotheexecutionofthe
STSmovement.Although
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subject-relateddeterminantscanbeinvestigatedonlyby
meansofcomparativestudies,whichwasbeyondthescopeofourstudy,
thetypesofpatientsinvestigatedareindicatedinTable2.Wejudgedstudies
accordingtothetechniquesused(eg,useofforceplates,optoelectronicdevices,orgoniometers),numberofmovementsanalyzed,thedeterminantsstudied(ie,chairrelated,subject
related,orstrategy
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related),andthedependentvariables(Tab.2).
STSMovementDeterminantsintheReviewedStudies
Of
the160studiesidentified,wefound39studiesthataddressedtheeffectsof
determinantsontheSTSmovementusinganexperimentaldesign(Tab.2).Wedidnotexaminewhethertheresultscouldbeobtainedconsistentlybymultipleresearchers
(ie,wedid
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notexaminereliabilityofthesejudgments).
Chair-RelatedDeterminants
Theliteratureindicatesthatthechairhas
aninfluenceontheperformanceoftheSTSmovement(eg,theheightof
theseatcanmakeanSTSmovementimpossible).39Mostresearchhasbeenfocusedontheheightoftheseat,andfewstudiestriedto
clarifytheinfluence
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of
868.Janssenet
alPhysicalTherapy.Volume82.Number9.September2002
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PhysicalTherapy.Volume82.
Number9.September2002Janssenetal.869
Table
2.
DetailsoftheExperimentalStudiesThatAddressedDeterminantsofthe
Sit-to-Stand(STS)Movementa
SubjectsDeterminantConstrainedbAuthorsYearPublishedStudyTechniqueRepNTypeAge(y)XRangeChairRelatedSubjectRelatedStrategy
RelatedDeterminantDependent
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VariablesAlexanderetal461991Video(3
samplesintotal)HandledynamometryChairinstrumented3(1)5117y
23o11o/d23.272.484.41931638675921,2,4
42,4With/withoutarmuseMovementtime,kinematicdata,phaseduration,handforcesArboreliusetal441992Forceplate(feet)Video(digitized)sEMGBorg
Scale29
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9m262334243
chairheights(kh,kh"1/3upperleg,kh"2/3upperleg)ArmrestDifficultyBorg
Scaleestimationofeffort,load-bearingseat,jointmoments,sEMGBurdettetal401985
ForceplateCinecamera(digitized)11410m4m/d33.352254119672,342,42typesofchair(with/withoutarm
use)Kinematicdata,
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jointmomentsCarr571992Forceplate(feet)
Video(digitized)666m203012,4,63
armmovementconditionsMovementtime,COMpositionandhorizontalandverticallinearmomentum,
supportmoment,angulardisplacementanklejointDoorenboschetal491994Forceplate(feet)Cinefilm,motionanalyzersEMG5(2)93m,6f27
11,2,
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4Trunkmovement(naturalvsfullflexion)
Movementtime,kinematicdata,jointmoments,sEMGFleckensteinetal591988Cinecamera
(digitized)1105m,5f25.4144,92
kneeangles(75,105)Movementtimekinematicdata,jointmoments,phasedurationGoulartandVallsSole371999AccelerometrysEMGChairswitch52012m,8
f34.72545
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12,3,46typesSTS
(trunkstraight,flexionoftrunk,feetanterior,kneesfirst,headsupported,reference)
EMGphases
########################.
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870.JanssenetalPhysical
Therapy.Volume82.Number9.September2002Table2.
Continued
SubjectsDeterminantConstrainedbAuthorsYearPublishedStudyTechnique
RepNTypeAge(y)XRangeChairRelatedSubjectRelatedStrategyRelatedDeterminantDependentVariablesGrossetal501998Forceplates(2,feet/chair)Motion
analysissystemsEMG
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Dynamometry1repetitionmaximum3(1)38
12f/y26f/o24.270.1648411,42speeds
(normal,asfastaspossible)Movementtime,moments,torquehip/knee,groundreaction
forces,kinematicsHankeetal291995Forceplates(2,feet/chair)2video5199m10f32.431.12538273611,2,
43speeds
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(normal,asslowandasfastas
possible)Movementtime,COMmomentum,phasedurationHesseetal541996Force
plates(2,feet/chair)5209m,11f27.8194012,4
3speeds(natural,asslowandasfastaspossible)Movementtime,COMdisplacementHesseetal601998Forceplates(2,feet/chair)153517
m/h18f/h
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64.8597912Pretraining/posttrainingMovement
time,timeseat-off,bodyweightdistribution,COMvelocity/displacementHughesandSchenkman151996
Forceplate(feet)Motionanalysissystem11818o/d74.814
42chairheights(khandlowestpossible)Movementtime,hipflexionvelocity,COM/baseofsupportseparationatlift-offHughesetal3919941video
(digitized)122
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22o/a/d72.064105442,
46chairheights(43.255.9cmwithanintervalof2.5cm)
Movementtime,COMmovement/velocityHughesetal321996Forceplate(feet)Motionanalysis
systemDynamometer1215m,5f/y5m,6f/o/d25782,43chairheights(58cm,khandlowestpossible)Joint
moments,isometricquadriceps
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femorismuscleforceItokazuetal361998
ForceplateChairswitchGoniometers(3)346tka16oa30
artncs1Kneeflexion#100and$1002chairheights(100%,120%
ofkh)Movementtime,hip/kneeflexionangleandangularvelocity
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PhysicalTherapy.Volume82.
Number9.September2002Janssenetal.871
Table
2.ContinuedAuthorsYearPublishedStudyTechniqueRepSubjectsNTypeAge(y)
XRangeDeterminantConstrainedbChairRelatedSubjectRelatedStrategyRelatedDeterminantDependentVariablesKawagoeetal55Khemlanietal65Kotakeetal22Moureyetal48
Moureyetal53
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Munroetal30Muntonetal10Pai
andLee3520001999199319982000199819841994Forceplates
(2,feet)MotionanalysissystemsEMGForceplate(footright)sEMGVideoPressure-sensitive
chairswitchMotionanalysissystemIsometricdynamometerForceplate(feet)Motionanalysissystem,3camerasForceplate(feet)Motionanalysissystem,2camerasForceplate
(feet)VideoArmrest
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loadcellCinecameraGoniometersEMGForceplate
(stool)Motionanalysissystem562333(1)1
510912137129910m9m
12m7y5o4m/y,3f/y7o12o/f/ra54art4m,5f30.22930.722.873.222.8
75.165.5ncs
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2035224020257182202571822739
1111,41,42,3,414
422,3,41,2,44,73,4,7
3,42,453chairheights(30,40,50cm)3footpositionsMovementtime,temporaldata,kinematics,center-of-gravityposition,groundreactionforce
2footpositions
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(anterior/posterior)Movementtime,EMGphasing,extensionmoments,
temporaldata3speeds(natural,fast,slow)Movementtime,kinematicdata,phase
duration,jointmomentsYoungvselderly,darkandlight,2speeds(normal,fast)
Movementtime,kinematicdata,headstabilityYoungvselderly,darkandlight2speeds(normal,fast)Movementtime,kinematicdataHigh(54cm)vslow
(45cm)chair
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seatEjectvsnonejectuseMovementtime,
kinematics,armrestforce,exertion(BorgScale),pain(VAS)2chairseatheights
(42and59.5cm)With/withoutarmuse2footpositions(normal,posterior)sEMG
pattern3speeds(natural,asfastaspossible,fast"fall)Movementtime,temporalparameters,COMdisplacement,moments########################.
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872.JanssenetalPhysical
Therapy.Volume82.Number9.September2002Table2.
Continued
SubjectsDeterminantConstrainedbAuthorsYearPublishedStudyTechnique
RepNTypeAge(y)XRangeChairRelatedSubjectRelatedStrategyRelatedDeterminantDependentVariablesPaiandRogers131991Forceplates(2,feet/chair)Motion
analysis58
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4m,4f263811,
43speeds(natural,slow,fast)Movementtime,kinematicdata,jointmoments
systemPaiandRogers341990Forceplates(2,feet/chair)Motionanalysissystem5
105m,5f263811,43speeds(natural,slow,fast)Movementtime,COMmovement,impulsemomentumPaietal331994Force
plates(2,feet/chair)
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WATSMARTLEDmotionanalysissystem5(3)
328m/y,8f/y8m/o,8f/o31.972.12538
63841
1,43speeds(natural,slow,fast)Movementtime,COMmomentum,
COMmovement,phasedurationPapaandCappozzo521999Forceplate(feet/chair)Loadcell5126m,6f223411,2,3,
42speeds
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(selfselected/maximal)Movementtime,kinematicdata,rotational/linear
actuatorPapaandCappozzo512000Forceplate(feet/chair)Loadcell5
517m/y,9f/y12m/o,23f/o2234658111,
2,3,42speeds(selfselected/maximal)Movementtime,kinematicdata,rotational/linearactuatorRodoskyetal421989ForceplateMotionanalysissystem2left2
right105
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m,5f25.5203542,
44chairheights(65%,80%,100%,115%ofkh)Kinematicdata,
jointmomentsSchenkmanetal141996Forceplates(2,feet)Motionanalysissystem
22111y10o28.967.32536617941,2,44chairheights(65%,80%,100%,and115%ofkh)Kinematic
data,phaseduration
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ScholzandSchoner581999Motionanalysissystem
2cameras1095m,4f222812,3,
4,83conditions(normal/rigidboots/narrowbase)COM,head,handtrajectorySeedhomand
Terayama451976Forceplate(feet)CinecameraUVoscillograph22ncsncs1,2,4With/withoutarmuseMoments,force(quadricepsfemoris,hamstring,calfmuscles)
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PhysicalTherapy.Volume82.
Number9.September2002Janssenetal.873
Table
2.
Continued
SubjectsDeterminantConstrainedbAuthorsYearPublishedStudy
TechniqueRepNTypeAge(y)XRangeChairRelatedSubjectRelatedStrategyRelatedDeterminantDependentVariablesShepherdandKoh171996Forceplate(feet)Pressure
switchVideoncs
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66f21.3182512,
43footpositionsMovementtime,kinematicdata,jointmoments,momentof
supportShepherdandGentile311994Forceplate(stool)VideoChairswitch66
6m2030142,43trunkpositionsKinematicdata,phaseduration,jointmoments,momentofsupportStevensetal561989Forceplate
Photographic1sEMG
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82ncsncs12,4
Legpositionguided/unguidedGroundreactionforces,headmovement,sEMGpatternSuet
al431998Forceplates(2,feet)Motionanalysissystemncs3812tka,
4m,8f12o,5m,6f14oa,2m,12f64.861.7ncs5775547544chairheights
(65%,80%,100%,
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115%kh)Movementtime,kinematicdata,COM
displacement,jointflexionmomentsVanderLindenetal191994ForceplateMotion
analysissystemsEMG5(4)81m,7f68.861771
1,2,42speeds(selfselected,fast)2footpositions(18or5dorsiflexion)Movementtime,kinematicdata,phaseduration,groundreactionforces,sEMGpattern
Weineretal41
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1993MotionanalysissystemVAS122
o/a/dncs442,46chairheights(1722in,interval
1in)Kinematicdata,difficulty(VAS),STSsuccessratioWheeleretal471985
Video1manual(1sample)ElectrogoniometerEMG32010f/y10f/o2475222867811,442typesofchairMovement
time,kinematicdata,
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sEMGpattern,hand/footplacement
a
Rep!repetitions(numberanalyzedinparentheses),m!male,f!female,y!young,o!old,a!able,d!disabled,h!hemiplegia,
art!arthritis,ra!rheumatoidarthritis,oa!osteoarthritis,tka!total-kneearthroplasty,ncs!notclearlystated,sEMG!surfaceelectromyography,kh!kneeheight,
COM!centerofmass,VAS!visualanalogscale,WATSMART!WaterlooSpatialMotionAnalysisRecordingTechnique,LED!light-emittingdiode;UV!ultraviolet.bNumbersrefertodeterminantslistedinTable1.
########################.
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thearmrestposition,useofarmrests,
orthetypeofchairontheSTSmovement.
Seat
height.LoweringtheheightoftheseatmakestheSTSmovementmoredemanding
orevenunsuccessful
accordingtotheliteraturewereviewed.10,14,30,3943Theminimumheightforsuccessfulrisingforelderlypeople(community-dwellingandnursing
homeresidents64105
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yearsofage)withchairrisedifficulties
appearstobe120%oflowerleglength.41Alowerseatapparently
leadstoincreasedangularvelocityofthehipinordertostand14,30,39,42and
tomorerepositioningofthefeet(alsocalledthestabilizationstrategy).14,39Inyoungsubjects(2536yearsofage)withoutimpairments,loweringtheseatofthe
chairfrom115%
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to65%ofkneeheightresultsin
anincreaseintrunkflexionangularvelocityofalmost100%inorder
tostand.14Alowerseathasbeenshowntoincreasetrunk,knee,and
ankleangulardisplacement.30,42,43Changingtheseatheightaffectsthemaximummomentneededatthehipandknee.15,4244Differencesforhipandkneemomentscan
beaslarge
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as50%to60%,withseatheight
havingagreaterinfluenceonthemomentsneededatthekneethan
atthe
hip.15,4244
Thechangesinseatheightcan
resultinchangingbiomechanicaldemands(eg,theneedtomovethebodyscenterofmassoveralargerdistance)orinanalteredstrategy(eg,
stabilizationstrategy,due
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totheimposedbiomechanicaldemandsbya
differentfoot,trunk,orarmposition).
Armrests.Issuesrelatedto
thearmrestuseincludepositioningofthehandsonthearmrests,heightof
thearmrests,andthemomentsexerted.Thereisnoresearchontherelationshipamongtheheightofthearmrests,seatheight,handpositioning,andtheir
cumulativeeffecton
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performanceoftheSTSmovement.
Usingarmrests,accordingtothearticleswereviewed,resultsinlowermoments
atkneeandhip;atthehip,areductionofabout50%of
theextensionmomentneededtoperformtheSTSmovementhasbeencalculated.40,44,45Burdettetal40foundnoinfluenceoftheuseofarmson
jointanglesin
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subjectswithoutimpairments(2541yearsofage).
InastudybyAlexanderetal,46youngandoldsubjectswithout
impairmentsusedahandbarpositionedinfrontofthemtoperformthe
STSmovement.Theyfoundnodifferencesinbodysegmentrotationsintheyoungsubjects(1931yearsofage).Adifferenceintrunkrotationwasobserved
intheold
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subjects(6386yearsofage),althoughthis
movementwasanalyzedonlyatthemomentofmaximumanteriorheaddisplacement.46
Chairtype.Wefoundonly3studiesontheinfluenceof
speciallydesignedchairs.30,40,47DifferenttypesofchairsdesignedtoeasetheSTSmovementwerestud
874.Janssenetalied.30,40,47Wheeleret
al47suggesteda
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negativeinfluenceofseatposteriorslantbecause
oftiltingthebodyscenterofmassfartherbackward.Useofan
ejectormechanismloweredverticalimpulsesappliedtothearmrestsby47%inpatients
witharthritis,butnodifferenceswerefoundforkneeandanklemoments.30
Backrests.Wefoundnoexperimentalstudiesconcerningtheinfluenceofbackrests
onSTSmovement.
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Inonly
8studies30,39,41,42,45
48wasachairwithabackrestused.Whenabackrestwas
used,itwastostandardizetheSTSmovementstartingposition.Theinfluenceof
trunkpositionhasbeenstudied;however,thisinfluencecannotnecessarilyberelatedtobackrestuseorbackrestposition,becausethetrunkpositionstudiedwasnot
comparabletothe
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trunkpositionusingabackrest.31
Strategy-RelatedDeterminants
Speed.IncreasingspeedoftheSTSmovementincreases
thehipflexion,kneeextension,andankledorsiflexionjointmoments.13Toincreasereproducibility
andcomparabilityoftheresultsoftheirstudies,some
authors14,18,49
didnotallowsubjectstoriseattheirself-selectedspeeds.Subjects
hadtorise
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atapresetspeedindicatedby,for
example,ametronome.18Otherresearchersstudiedtheinfluenceofspeedonstrategy,
peakjointmoment,phasechanges,andlateraldisplacement.Paiandcolleagues33,34reportedthat
afasterSTSmovementinfluencesthepeakverticalmomentumofthecenterofmasswhilethepeakhorizontalmomentumremainsrelativelyunchanged(dataweregiven
ingraphs).A
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fasterSTSmovementgaveashorterflexion
andmomentum-transferphase.19,29VanderLindenandcolleagues19reportednoinfluenceofspeed
onjointexcursions.Grossetal50andPapaandCappozzo,51,52however,describedless
hipflexionatthemomentofseat-offinelderlysubjectswhostoodrapidly.Inseveralstudies,48,50,53,54elderlysubjects(6484yearsofage)wereless
abletoincrease
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thespeedoftheirSTSmovement.
Footpositioning.Shepherdandcolleagues17studiedtheeffectoffootposition
(posterior,preferred,andanteriorpositions)priortothestartoftheSTSmovement,
andtheyshowedashortermovementtimewithfeetplacedposterior.Withtheposteriorplacementofthefeet,hipflexionandhipflexionspeedwere
lowered,whereasanterior
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placementofthefeetincreasedthepre-extension
phase.17Kawagoeetal55alsoshowedaninfluenceofposteriorfootplacement.
Positioningthefeetmoreposteriorlyenabledlowermaximummeanextensionmomentsatthe
hip(148.8N!mversus
32.7N!m)tobeusedfortheSTSmovement.55Hughesetal39describedrepositioningofthefeetasa
movementstrategyto
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lowermomentsusedfortheSTSmovement,
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########################.
whichthey
calledstabilizationstrategy.Muntonetal10foundnodifferenceinelectromyographic(EMG)
activityof6largelower-extremitymusclegroupswithfeetplacednormalorposterior.
Stevensetal56studiedtheeffectoftheinitiallower-extremityposture,includingfootposture,ontheSTSmovementandreportedthatthepreferredlower-extremityposition
giveslesshead
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movementandlowergroundreactionforces.
Trunkpositioning/movement.AccordingtoShepherdandGentile,31changingtheinitialtrunk
positiontohavemoreflexiondidnotchangethepeaksupportmoment,but
thedurationofmaximumsupportmomentdidincrease.Thedurationoftheextensionphasealsobecamelongerwhenthetrunkinitiallywasmoreflexed.31Starting
fromatrunk
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positiondifferentfromerectaltersthekinematics
andkineticsoftheSTSmovement.Fortheconditionflexionofthe
trunk(first
flexthetrunktowardtheknees,beforerisingfromthechair),
GoulartandValls-Sole37describedalongermovementtimethanfornormalSTSmovementconditionanddelayedseat-off,withoutjointangularchanges.Thisobservationwassupported
bySchenkmanet
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al,21whodescribedamomentumtransferstrategy
inwhichthemomentumgeneratedbytheupperbodyisusedduring
theextensionphase.
Doorenboschetal49studiedtheeffectofan
STSstrategyaimedatmaximumflexionofthetrunkduringtheSTSmovement.Thisstrategyresultedinkinematicchangesaroundthehip,buttherange
ofmotionof
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thekneeandankledidnotchange.
Usingthemaximumflexionstrategy,27%lower(net)kneejointmomentsthan
innaturalrisingwerefound.49
Armmovement.StudyoftheSTS
movementisoftendonewithconstraintsontheuseofthearms.57Inmoststudies,useofthearmsduringtheSTSmovementwasnot
allowed.Subjectswere
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ofteninstructedtostandupwiththeir
handsintheirlap,folded,sideways,placedontheknees,orfixating
anobject.Someauthors16,47havereportedthatuseofthearmsduringthe
STSmovementisverycommonamongelderlypeopleandevenamongyoungpeople.OnlyCarr57studiedtheeffectofarmmovementstrategyonthebodys
centerofmass.
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ArmpositionduringtheSTSmovementappears,
basedontheliterature,toinfluencethepositionofthebodyscenter
ofmass.57Thebodyscenterofmassmovesforwardattheendof
theSTSmovementwhensubjectspointwiththeirarms.57Restrictingthearmsleadstoadifferentpatternofankleangulardisplacement,withamuchhigher
meanstandarddeviation
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thanoccurswiththearmsfree.This
findingsuggeststhatmoreadjustmentofthestrategyofrisingisneeded,
usingongoingadjustmentattheanklejointduringrestrictedarmmovement.57
Terminalconstraint.TheterminalconstraintistherequiredbodypositionoractivityattheendoftheSTSmovement.TheSTSmovementhasbeenstudied
whilethemotion
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wasaimedatstandingquietlyatthe
endofthemovement.PaiandLee35conductedastudywitha
constrainttofallafterthemovementinsteadofstandingquietlyattheend.
Nostudyhasquantitativelyexploredthesit-to-walkmovement.
Darkversuslight.VisualcontrolwasmanipulatedwhilesubjectsperformedtheSTSmovementinlight
anddarknessat
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2speeds.48,53Noeffectonmovementtime
wasfoundinyoung(2025yearsofage)andelderly(7182years
ofage)peoplewhenvisualcontrolwasvaried.48,53Thespeedofthecenter
ofmass,however,waslowerintheblindfoldedconditionfortheelderlysubjects.53
Fixedjoints.Onlyonestudy58concernedtheinfluenceof
jointfixationon
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thelevelofcontrolofSTSmovement
performanceusingtheso-calleduncontrolledmanifoldconcept(acyberneticconcepttodescribe
results).Thisanalysisshowedthatthepositionofthecenterofmassin
thesagittalplaneiscontrolled.Nodataonjointangleorangularvelocityweregiven.Anotherstudy36analyzedtherelationshipbetweentheactivelimitationin
rangeofmotion
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ofthekneefollowingtotalkneearthroplasty
andtheheightoftheseatwhenrisingfromaseatedposition.
Thesubjectswithlargerlimitationsinactivekneeflexion(#100ofkneeflexion)
requiredahigherangularvelocityofthehiptoliftthetrunkforwardthandidthosewithlesslimitationofkneeflexion($100ofknee
flexion).36
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Kneeposition.Positioningthekneeinmore
extensionthanpreferredpriortotheSTSmovementappearedtoleadto
anincreaseofthehipjointangulardisplacement,withanincreaseofhip
extensionmomentsof77%.59Thisexperimentalsetupistosomeextentcomparabletothefoot-forwardsetupasusedbyShepherdandKoh17becausefootforward
willresultin
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morekneeextension.
Attention.No
experimentalstudyaddressingtheinfluenceofattentionontheperformanceofthe
STSmovementinsubjectswithoutimpairmentscouldbefound.
Training.Training
canbeadeterminantinanexperimentalstudy.Hesseetal60studiedtheinfluenceof4weekstraining(4-weekinpatientrehabilitationprogram;thephysicaltherapists
trainedthepatients
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todistributeequalweightonbothlegs
andtoavoidlateralcompensatorytiltofthetrunk)onthetemporal
andspatialvariablesoftheSTSmovement.Onlyinasubgroupofpeople
withlefthemipareticstrokeswasadifferencenoted.
PhysicalTherapy.Volume82.Number9.September2002Janssenetal.
875
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DiscussionandConclusions
Method
General.Inourreview,weincludedonlyexperimentalstudies.In
anexperimentalstudyoftheSTSmovement,thedeterminantsaremanipulatedinorder
toexploretheirinfluenceonperformance.Notallofthestudiesreviewed,however,werecompletelyexperimental.Somearticlesincludedcomparativeordescriptivedata.Webelieve
thatexperimentalstudies
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areimportantbecausetheyprovidethestrongest
evidenceconcerningtheinfluenceofthedeterminants.Inthesestudies,onlyone
determinantisusuallymanipulatedwhileothersarekeptconstant.Incomparativestudies,we
believeconclusionsaredifficulttomakebecauseofthenonexperimentaldesign.Therelationshipbetweensubject-relateddeterminants(eg,age,muscleforce)andSTSmovementperformance,in
ourview,is
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seldomunambiguousbecausesubject-relateddeterminantsaregenerally
examinedinnonexperimentalstudies.Forexample,theinfluenceofageonthe
abilitytodoanSTSmovementisoftenstudied,46,48,51,53,6163withageaccountingfor
smalldifferencesinSTSmovementperformanceandadecreasedabilitytodecreasemovementtime.WhetherthesedifferencesintheSTSmovementaretheresultof
increasedageor
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ofcovariatessuchasmuscleforce,balance
disturbances,neuromusculoskeletalchanges,orchangedmotorcontrolisnotclear.Anotherexample
concernsmuscularforceasadeterminantofSTSmovementperformance.Lessquadricepsfemoris
muscleforcewillaffecttheperformanceoftheSTSmovement,andthetimetodotheSTSmovementwillincrease.32,50,61,64Relatedneuromusculoskeletalchanges(eg,loss
oftrunkmuscle
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force,lossofbalance)mayinfluencethe
performanceoftheSTSmovementtothesamedegree.Whentheserelated
changescannotbecontrolledforinastudy,theycanbecomeconfoundingfactors
influencingtheconclusionstobedrawnfromthesestudies.
Validity.OurreviewofstudiesonthedeterminantsofwhatmakestheSTSmovement
possibleledus
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tobelievethatmanystudieshavegood
internalvalidity,butwedidnotuseevaluativecriteriaorexaminationby
multipleauthors.Thereis,inourview,alsoevidenceforconstructvalidityfor
themeasuresused,becauseclinicaltestsforSTSmovementperformanceappeartoustobehighlycorrelatedwithphysicalfunctioninginelderlypeople.2,3Wequestion,
however,whetherthe
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reviewedstudiesareexternallyvalidforpredicting
changesinstandingup.Standingupfromachairisalmostnever
aimedatstandingalonebutispartofagoal-orientedbehavior,suchas
goingforawalkorpickingupanobject.Nevertheless,thereareexamplesinwhichstandingupis
aimedatsimplestanding(eg,
inchurch,watching
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sports).
Variability.Thereisintrasubject
andintersubjectvariabilityintheperformanceoftheSTSmovement.Variabilitycan
betheresultofproblemsindefiningtheSTSmovementevents,technicalproblems,
oranalysisofalownumberofSTSmovements,oritcanbeconsideredasasignofflexibilityofperformanceduringtheSTSmovement.
Tolowervariability
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andtoeaseanalysisofthedeterminants,
manyconstraintswereusedintheSTSmovementstudiesthatwereviewed
(Tab.2).Wecontendthatonlyinclinicalphysicalperformanceistestingof
thenaturalSTSmovementimitated(withself-selectedspeedandstrategy).9,23,24OtherexplanationsforvariabilitymayincludealearningeffectduringperformanceoftheSTSmovement,
fatigueinrepeating
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fastandfrequentSTSmovements,anderroneous
instructionsleadingtomisinterpretation.
GeneralConclusions
Inour
review,wefoundthatinmoststudies(27ofthe39studies),a
combinationofforceplate(s)andamotionanalysissystem(varyingfromvideotoatypeofoptoelectronicsystem)wasused.SurfaceEMGanalysiswasused
in10of
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the39studies.Thenumberofanalyzed
STSmovementspersubjectrangedfrom1to15.In7of
the39studies,onlyonetrialwasusedforstatisticalanalysis.Thenumber
ofsubjectsstudiedrangedfrom2to51.Webelieve,however,thatgeneralconclusionscanbedrawn.Theheightofthechairseat,theuse
ofarmrests,and
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footpositioninghaveamajorinfluenceon
STSmovementperformance.Ahigherchairseatresultsinlowermomentsat
hipandkneelevel(upto60%and50%,
respectively).10,14,30,39,40,42
44Loweringthechairseatwillincreasetheneedforgenerationofmomentumorrepositioningofthefeettolowerthemomentsneeded.14Comparison
oftheresults
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ofthestudiesisdifficultbecauseof
differencesinstudydesignandthefactthatchairseatheightis
notalwaysbasedonlower-extremitylength.Usingarmrestswilllowerthemomentsneeded
atthekneeby50%,probablywithoutinfluencingtherangeofmotionofthejoints.40,44,46Therewerenoreportsontheinteractionbetweentheheight
ofthearmrests,
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chairseatheight,orhandpositioningand
theircumulativeeffectonSTSmovementperformance.Repositioningoffeetappearsto
influencetheSTSmovementstrategy,enablinglowerpeakmomentsatthe
hipandknee.17,19,39,55,65
Noexperimentalstudywasfoundthataddressedtheinfluenceoftheuseofabackrest.Theinfluenceoftrunkposition
hasbeenstudied;
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however,trunkpositioncannotberelatedto
backrestposition,becausethestudiedtrunkpositionisnotcomparabletothe
trunkpositionusingabackrest.31
876.JanssenetalPhysical
Therapy.Volume82.Number9.September2002
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########################.
ClinicalSignificance
TheabilitytoperformanSTSmovementisanimportant
skill.Inelderlypeople,theinabilitytoperformthisbasicskillcanlead
toinstitutionalization,impairedADLfunctioning,andimpairedmobility.2,3Consequently,thismovementisfrequentlyassessedinclinicalpractice.KnowledgeofdeterminantsoftheSTSmovement,therefore,
isimportantfor
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cliniciansinterestedinevaluatingtheabilityto
doanSTSmovement.ForaproperevaluationoftheSTSmovement
inaclinicalsetting,wecontendthatstandardizationoftheevaluationshouldbe
doneinregardtotypeofchair,chairseatheight,positioningoffeet,andtheuseofarmrests.Resultsofexperimentalstudiesshowthatthese
variablesinfluencethe
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performanceoftheSTSmovement.Neglectingthese
variablesmayresultinaninabilitytomeasureactualchangesinSTS
movementperformanceofapatient.Furthermore,problemsinSTSmovementperformancemaybe
obscuredwithoutstandardization.Anotherconsequencemaybethatapparentchangesordiscrepanciesmaynotactuallybepresent.Allofthesefactorscanleadtosuboptimal
choicesanddecisions
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withrespecttoprognosis,planning,andtherapy.
Recommendations
Webelievethatinbothexperimentaland
comparativeSTSmovementstudies,thereneedstobecontrolofvariablesthatcan
influenceSTSmovementperformance.Somedeterminants(eg,chairseatheight,speed,positionoffeet)havebeenstudiedextensively.Others(eg,theeffectsoffootwearon
STSmovementperformance)
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havenotbeenwellstudied(althoughthe
footweartypedoesinfluencetheperformanceoftheTimedUp&Go
Test66).Theinteractionamongdeterminants
extent.19,30,48,53,55
hasbeenstudiedto
someMoreresearchisneeded,however,ontheinteractionofvariablessuchasuseofarmrests,chairseatheight,andfootpositioning.
All
ofthestudies
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weexaminedweredirectedatthelevel
ofimpairment.Studyingfunctionalperformance,inouropinion,shouldalsoincludetesting
atthelevelofskills.67,68Toanalyzetheskillofasubjectto
performtheSTSmovement,itmaybenecessarytoevaluatetheabilitiesofthatsubjecttocopewithchangingconstraints(eg,STSmovementatdifferent
speeds,atdifferent
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chairseatheights,STSmovementversussit-to-walk
movement,lightversusdarkness).Togaininsightintotheinfluenceofthe
determinantsontheSTSmovementmayentailusingotherbiomechanicalmodelsorparadigms.68,69
Newtechniques(eg,ambulatorytechniquesthatregisterbodypostureandmovementsinthereal-lifeenvironmentofthesubject)raisenewresearchquestions.Toenhancethe
validityofdata
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obtainedinfuturestudiesandthegeneralizability
oftheresults,newmethodsof
PhysicalTherapy.Volume
82.Number9.September2002
research(whichcanbe
usedoutsidethegaitlaboratory70),webelieve,shouldbeevaluated.
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