International Journal of Obesity (2000) 24, 14881492 2000 Macmillan Publishers Ltd All rights reserved 03070565/00 $15.

.00 www.nature.com/ijo

Sit-to-stand movement analysis in obese subjects

M Galli1*, M Crivellini1, F Sibella1, A Montesano2, P Bertocco2 and C Parisio2
1

Department of Bioengineering, Polytechnic of Milan, Milan, Italy; and 2Rheumatologic Unit, Scientic Institute Hospital San Giuseppe, Piancavallo, Verbania, Italy

OBJECTIVES: The aim of this study was to evaluate the typical strategies of obese subjects during a sit-to-stand task (a typical daily living activity) and to assess the load conditions of hip, knee and ankle joints. DESIGN: Cross-sectional, controlled (obese patients vs controls) study on sit-to-stand movement analysis SUBJECTS: Ten adult young volunteers (ve men and ve women, mean age 28, s.d. 3 y; mean BMI 22, s.d. 2.3 kgam2) and 30 obese subjects 25 women and ve men, mean age 39.4, s.d. 13.7 y, mean BMI 40, s.d. 5.9 kgam2) suffering from chronic lower back pain were analyzed in a sit-to-stand task (10 trials for each subject). MEASUREMENTS: Angle parameters carried out from a quantitative three-dimensional analysis of sit-to-stand (STS) movement, using an optoelectronic system. RESULTS: STS task in controls was characterized by a fully forward bending strategy of the trunk, while in obese patients at the beginning (rst trial) of the STS task they limited the forward bending in order to protect the vertebral column. When fatigue increased during the execution of multiple STS tasks, the protection of the vertebral column was secondary to the execution of the task. In order to limit the muscle fatigue they increased the forward bending in order to decrease knee joint torque. DISCUSSION: The analysis of the strategy used by obese patients in STS task can be used in the design of future trials to assess the efcacy of rehabilitative treatment. International Journal of Obesity (2000) 24, 14881492 Keywords: obesity; sit-to-stand; biomechanics; optoelectronic system; force platform; rehabilitation

Introduction
Sit-to-stand (STS) movement is an important functional task1,2 that may become difcult for certain patient populations.3 The accurate depiction of the requirements for the execution of this task provides useful biomechanical information on the motor ability of a selected patient. In particular, rising from a chair requires adequate torque to be developed by body joints. Even though the STS movement has been a topic of numerous investigations4 8 related to different patient populations, the STS movement strategy of obese subjects has not been analysed yet. In these patients weight conditions and muscular weakness change motion task strategy and, consequently, the torque distributions of hip, knee and ankle joints. Patients with severe obesity present very frequently with postural changes which can cause chronic low back pain. So far, the association of obesity and chronic

lower back pain is not clear,9 and it is likely to be more evident in the upper quintile of obesity.10 Low back pain can limit the daily activity of obese patients. STS is likely to be a very good model to assess the ability of obese patients to properly execute daily living tasks. The main aim of this study was to compare the analysis of STS movement of normal and obese subjects in order to evidence the motion strategies typical of these patients. In order to evidence the fatigue in execution of the task, the STS strategy was analysed for 10 trials. The kinematic and kinetic analyses of STS in obese might also be useful in designing rehabilitative protocols and to assess their efcacy.

Patients and methods

We carried out a cross-sectional, controlled study. Ten adult young volunteers (ve men, mean age 26, s.d. 3 y and ve women, mean age 28, s.d. 3 y; mean body mass index BMI) 22, s.d. 2.3 kgam2) and 30 obese subjects (25 women mean age 39.4, s.d. 13.7 and ve men, mean age 41.4, s.d. 6 y, mean BMI 40, s.d. 5.9 kgam2) suffering from chronic lower back pain were recruited for this study.

*Correspondence: M Galli, Dipartimento di Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milano, Italy. E-mail: galli@biomed.polimi.it Received 25 November 1999; revised 10 May 2000; accepted 7 June 2000

Analysis of movement M Galli et al

The inclusion criteria for the control group were: no muscular-skeletal pathologies; BMI ` 25 kgam2; no previous skeletal fractures; no lower back pain (evaluated with a questionnaire in which the subjects were asked to indicate their lower back conditions); for obese subjects the inducing, criteria were: BMI b 30 kgam2; able to stand from an armless chair, postural chronic lower back pain (evaluated with a questionnaire in which the subjects were asked to indicate their lower back condition and for how long they had been suffering from it). A motion measurement system (ELITE, bts@, IT), 6 TV, 50 Hz, provided the three-dimensional coordinates of reective markers and a force platform (AMTI, Newton, MA) provided the ground reaction forces. In particular, reective markers were placed over (Figure 1): the spinosus process of C7; the sacrum midway between the posterior superior iliac spines; and, bilaterally, the acromion; the anterior superior iliac spine; the greater trochanter, the femoral condyle; the lateral malleolus; the head of the fth metatarsal; and the heel. Another reference marker was placed on the chair. A wooden chair, armless and backless, was adjusted vertically for each subject in order to obtain the same knee exion angle (xed to 110 ). The subjects were asked to stand with a self-selected speed with arms crossed with the feet over the force platform. The subjects were asked to perform 10 trials (each one separated by a pause of 1 min) of STS. The strategy used was analysed taking into account the quantitative data coming from the vertical coordinates of the shoulder markers. The asymmetrical movement of the feet (ie if a foot is moving and the other is not) was evaluated analysing the horizontal

coordinate of markers positioned over the both lateral malleula (Figure 2). In order to quantify the strategy used by control and obese subjects the angles a and g (shown in Figure 3a) were computed. The angle a is formed by the horizontal axis and the link connecting the shoulder and greater trochanter

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Figure 1 Marker position for STS analysis.

Figure 2 Evaluation of trunk and feet strategy during STS . International Journal of Obesity

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Figure 3 (a) kinematic analysis of sit-to-stand task; (b) strategy indexes; (c) four-segment planar model (HAT: head, arm, trunk). Figure 4 Strategy indexes of obese and controls (mean and s.d.).

markers; the angle g is formed by the horizontal axis and the link connecting femoral condyle and lateral malleulus markers in the sagittal plane. In particular, two strategy indexes were analyzed: amin, representing the maximal trunk exion; and gmin, representing the leg exion during STS task (Figure 3b). When the movement was symmetrical, in sagittal plane the angles a and g were evaluated using the marker positioned on the right side. If movement presented an asymmetry, the angles a and g were computed as a mean values of the angles computed for the left and the right sides. By using a four-segment planar model from kinetic and kinematic data the torques acting on the hip (M1), knee (M2) and ankle (M3) joints (Figure 3c) were computed11 and normalized to body weight and height of each subject. In particular the maximal torques of hip (M1max) and knee (M2max) joints were considered. The STS movement was analysed both in kinematic and in kinetic trial to trial (rst to tenth). The statistical t-test (P  0.05) was used for comparison. In order to evaluate the reproducibility of the analysed parameters, both for kinematics and kinetics, three volunteers and three obese patients were analysed in two different sessions and the results were compared.

Table 1 Maximal values of momenta at hip (M1max) and knee joint (M2max) M1max (Nmakg), mean (s.d.) 0.604 (0.076) 0.363 (0.022)* M2max (Nmakg), mean (s.d.) 0.312 (0.043) 0.749 (0.119)*

Patients Control Obese

*P ` 0.05, control vs obese.

ment in the sagittal plane was veried in all analysed subjects. The obese mainly (84% of analysed subjects) used a strategy characterized by a limited trunk exion. This strategy produced a high momentum on knee joint (M2max) but limited the torque on the hip joint (M1max) and consequently at the lower back (Table 1). The symmetry of the movement, in the sagittal plane, was veried in 80 of analysed obese subjects.
Tenth STS trial

Results
The results of the two sessions of three obese subjects and three volunteers demonstrated a high reproducibility (P 0.8) of the data.
First STS trial

Figure 5 shows the results of the angle amin corresponding to the maximal trunk exion of obese and control groups during the rst and the tenth trials. Trial-by-trial strategy movement of trunk did not change in the control group as it did in the obese group.

At the beginning of the experimental test (rst trial), kinematic and kinetic results showed that the STS strategy in obese subjects is different (P ` 0.05) from that of the control group. Figure 4 compares the strategy indexes of obese patients and controls. Controls mainly (78%) used a strategy characterized by a fully forward exion of the trunk (Figure 4). This strategy produced high momentum at the hip joint and lower back (M1max) and small net momentum at the knee (M2max) (Table 1). The symmetry of the moveInternational Journal of Obesity

Figure 5 Comparison of obese and controls during the rst and tenth trials (mean and s.d.).

Analysis of movement M Galli et al Table 2 Maximal values of momenta at hip (M1max) and knee joint (M2max) (t-test yes P ` 0.05, no P b 0.05) First trial M1max (N makg) mean (s.d.) 0.604 (0.076) 0.363 (0.022) yes yes no M2max (N makg), mean (s.d.) 0.312 (0.043) 0.749 (0.119) yes yes no Tenth trial M1max (N makg), mean (s.d.) 0.630 (0.082) 0.828 (0.091) no M2max (N makg) mean (s.d.) 0.293 (0.035) 0.430 (0.061) no

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Patients Controls Obese t-Test, controls vs obese t-Test, First vs Tenth trial, obese t-Test, First vs Tenth trial, controls

In fact, while at the beginning the obese limited the trunk exion, at the end (tenth trial) they used a fully forward exion as we observed in controls. As far as the kinematic is concerned (Table 2) the controls maintained the same strategy during the whole trial. At the tenth trial there was in the obese group a decrease in the momentum of the knee joint (M2max) related to an increase in the momentum of the low back (M1max). Although the strategy of obese subjects at the end of the task execution paralleled the controls (P b 0.05), the load situation on the lower back was different because weight conditions and consequently the mass of the trunk were substantially different. Comparing the kinematic and kinetic results of men and women no signicant differences (P 0.7) were observed.

Discussion
STS is an important functional task that may become difcult to execute in obese patients because of weight conditions, muscular weakness and low back pain. Although STS has been the topic of numerous investigations, no study was found in the literature about the STS task in obese patients. The aim of this study was to evaluate the typical strategies of obese subjects and the load conditions of hip, knee and ankle joints. Kinematic data show that normal subjects used a strategy characterized by fully forward trunk exion in order to minimize knee joint torque, as demonstrated by kinetic results. This strategy did not change during the whole experimental session. However, obese patients, at the beginning of experimental session, used a strategy characterized by a limited trunk exion in order to minimize the momentum on the lower back. At the end of the experimental session they changed their rising strategy and increased trunk exion, leading to a minimization of knee joint torque. The lower back pain that occurs in these patients limits the trunk exion in order to decrease the vertebral column torque. Unfortunately, this strategy produces a high momentum on knee joints. The load conditions of the knee joints related to the use of this strategy should be taken into account when planning a rehabilitative treatment.

The results show that for the control group the criteria imposed at the beginning of the trial are conserved trial-by-trial. The obese group, however, trial-by-trial, change their initial strategy because of fatigue into the one used by the controls and characterized by a forward exion that minimizes knee joint load. Doing so they are able to stand up but they overload the vertebral column, worsening their lower back pain. At the beginning of STS task, when obese patients were asked to stand up, they tried to protect the vertebral column. When fatigue increased, during the execution of multiple STS, the protection of vertebral column was secondary with respect to the aim of standing up and this why they changed their rising strategy. The relevance of these results is that the analysis of strategy used by obese patients in the STS task is likely to be used in future trials to assess the efcacy of rehabilitative treatment.
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