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Rising from a Chair: Influence of Age and Chair

Design
Joyce Wheeler, Carol Woodward, Rae Lynn Ucovich,
Jacquelin Perry and Joan M Walker
PHYS THER. 1985; 65:22-26.

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Rising from a Chair


Influence of Age and Chair Design
JOYCE WHEELER,
CAROL WOODWARD,
RAE LYNN UCOVICH,
JACQUELIN PERRY,
and JOAN M. WALKER
We studied the effect of age on the act of rising from a standard armchair in a
younger ( = 24 years) and an older ( = 75 years) group of healthy adult women.
Rising from a standard armchair and an armchair specially designed for comfort
in sitting of the elderly was studied in the older group to determine the influence
of the special chair. We used electrogoniometry, EMG, and videotape analysis to
record the activity for both groups. The older group placed their feet farther back
and showed greater vastus lateralis muscle activity than did the younger group
to rise from the standard chair. These results suggest thatrisingfrom the standard
chair was more difficult for the older than for the younger group. In the special
chair, the older subjects showed even more vastus lateralis muscle activity,
greater knee flexion, and greater trunk forward lean. Rising from the special
chair, therefore, appeared to be more difficult than rising from a standard chair;
this finding suggests that both comfort and function must be considered in chair
selection for certain groups.
Key Words: Age factors, Electromyography, Equipment, Physical therapy.

No evidence exists that the act of rising from a chair has been considered in
reported studies of chair design although
older adults compared with younger
adults often have difficulty rising from
chairs. Suggested dimensions and specifications for chair design have been
based on anthropometric measurements1 and studies that determined the
optimal position to reduce stress on the
lumbosacral spine.2, 3
Ms. Wheeler is Staff Physical Therapist, Good
Samaritan Hospital and Medical Center, 1015 NW
22nd Ave, Portland, OR 97210.
Ms. Woodward is Staff Physical Therapist, San
Jose Hospital, 675 E Santa Clara St, San Jose, CA
95112.
Mrs. Ucovich is Staff Physical Therapist, Mills
Memorial Hospital, 100 S San Mateo Dr, San Mateo, CA 94401.
Dr. Perry is Director, Pathokinesiology Service,
Rancho Los Amigos Medical Center, 7601 E Imperial Hwy, Downey, CA 90242, and Professor of
Orthopaedic Surgery, University of Southern California.
Dr. Walker is Associate Professor, Department
of Physical Therapy and Department of Anatomy
and Cell Biology, University of Southern California,
12933 Erickson Ave, Bldg 30, Downey, CA 90242
(USA).
Address correspondence to Dr. Walker.
Ms. Wheeler, Ms. Woodward, and Mrs. Ucovich
completed this study in partial fulfillment of the
Master of Science degree in the Department of
Physical Therapy, University of Southern California.
This research was funded by the National Institute for Handicapped Research.
This article was submitted February 13, 1984;
was with the authors for revision 10 weeks; and was
accepted July 11, 1984.

Only a few researchers have studied


the activity of standing from a seated
position.4-7 These small sample studies
vary in design and methodology but
lend support to the influence of chair
design on ease of the sit-to-stand act.
Chair seat height can compensate for
limited knee range,4 increased trunk forward lean can decrease knee torque
maximums,7 and arm use can decrease
the knee forces generated.6 Kelley et al
studied a "highly consistent performance," in which subjects did not use
their arms to push-off, and observed
more similarity than differences in
EMG and motion patterns.5 None of
these investigators compared subjects
from different age groups or the use of
different chairs. Some researchers have
documented age changes in muscle
studies that may affect push-off.8-11 Muscular strength apparently peaks in people between 20 and 30 years of age and
then declines. The act of rising from a
chair may be influenced not only by
chair design but also by an individual's
health status, strength, and joint mobility.
In 1977, people 65 years of age or
older comprised 11 percent of the population of the United States; however,
this group represented 29 percent of total personal health-care expenditures.12
Continued increases in health-care costs

and in the proportion of the total population formed by elderly people make
it vital to ensure independence of the
aged. Appropriate chair design is one
factor that will facilitate independence.
The objectives of this descriptive study
were 1) to determine, with electrogoniometry, EMG, and videotape analysis,
if a difference exists in the act of rising
from a standard armchair between
younger and older subjects and 2) to
determine only in the older group, if
differences exist in the same act when
using an armchair specially designed for
the elderly.
This study reports for the first time a
comparison of groupsrisingfrom a standard chair and, thus, contributes to
knowledge of differences between
younger and older people and describes
differences in this activity for older people rising from a standard chair and
rising from a chair specially designed for
the elderly.
METHOD
We studied two age groups (each, n =
10) of adult women volunteers. Younger
subjects had a mean age of 24 years
(range, 22-28 years); the mean age for
older subjects was 75 years (range, 6781 years). The younger group was taller
( =167.1 cm; range, 156.2-179.7 cm)

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PHYSICAL THERAPY
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RESEARCH
than the older group ( = 160.9 cm;
range, 144.0-170.2 cm) (t = 2.01, p =
NS) and had a significantly lower mean
body weight ( =58.1 kg; range, 48.877.6 kg and = 69.1 kg; range, 59.487.5 kg, respectively) (t = 2.41, p < .05).
Subjects were excluded if they had conditions that caused strength or range-ofmotion (ROM) limitation that produced abnormal patterns of rising from
a chair (eg, severe arthritis).
We recorded each subject's height,
weight, and limb dominance (writing
hand and foot used to kick a ball). Skin
markers (4-cm diameter circles with 2cm white centers) were taped bilaterally
on the following bony landmarks: 3 cm
anterior to the posterior edge of the
greater trochanter, 2 cm anterior to the
posterior edge of the acromion process,
and the lateral femoral epicondyle. We
measured femoral shaft length (greater
trochanter to lateral epicondyle).

iometer was set at maximal extension


and the end ROM measured with a
manual goniometer. Electrogoniometric
and EMG data were stored on analog
tape* with a visicorderprintout.
A standard armchair and an armchair
designed specifically for the elderly
were used (Fig. 1). The height and width
of the seat and width between armrests
were similar in measurements between
the two chairs. Differences in seat depth,
posterior seat slant, height of armrests,
backrest incline, and clearance under
front of chair were noted (Fig. 2). Tape
marks (2 cm wide and 2 cm apart) were
placed on the floor parallel to the front
edge of the chair and on the chair armrests as well as the seat (Fig. 3). Subjects
were positioned between a grid (a 10- by
10-cm square) and the stationary videotape system.**

up as you normally would." Muscular


activity and joint motion were recorded
on one side of the body during the activity with a simultaneous videotape recording. Testing of right and left sides
was randomly ordered for each subject,
as was the starting chair for the elderly
subjects. Three trials were recorded on
each side of the body using the same
procedure for both groups. The older
group, however, performed trials in both
chairs, a total of 12 trials with rest periods between trials. Thefirsttrial began
with the subject's hands on her lap so
that arm use was optional and gave us a
single record of spontaneous arm use.
In all subsequent trials, a standardized
starting position was used with all sub-

Procedure
Each subject was instructed to sit back
against the chair backrest and then to
rise on the verbal request: "Please stand

Equipment
We used 50-m dual wire electrodes
to record the activities of the vastus
lateralis (VL) and the medial head of
triceps brachii (MT) muscles. We used
indwelling electrodes instead of surface
electrodes to eliminate the action of the
rectus femoris muscle, which also functions as a hip flexor and may show
activity during trunk forward lean in the
initial stage of rising from a chair. Burke
et al showed in the cat that the same
motor units span the bulk of the muscle;
thus, a sample of any spot is representative of the entire muscle.13 We used the
insertion technique described by Basmajian with the electrode placement
confirmed by electrical stimulation.14
Myoelectric signals were relayed by an
FM-FM telemetry system. Maximal isometric strength using standard manual
muscle testing techniques for VL and
MT muscles was recorded with EMG.
We recorded joint motion by a double
parallelogram electrogoniometer (mean
error for 0 to 90 of knee flexion was
<7).15 Electrogoniometers were set at
zero with the subject standing. Knee
extension was confirmed by alignment
of a straight edge with the greater trochanter (3 cm anterior to posterior
edge), the lateral femoral epicondyle,
and the lateral malleolus. The elbow
goniometer was set similarly at zero with
alignment of bony landmarks. For subjects with elbow flexion contractures (n
= 2, maximum limitation 15), the gon-

* Ampex FR-1300, Ampex Corp, 401 Broadway,


Redwood City, CA 94063.
12106 Visicorder, Honeywell Corp, 4800 E Dry
Creek Rd, Denver, CO 80217.
Lumex 5811, Lumex, Division of Lumex, Inc,
100 Spence St, Bay Shore, NY 11706.
** JVC Model CR-6060U video cassette recording system, Japan Victor Corp, 1011 W Artesia,
Compton, CA 90220.

Fig. 1. Lateral views of standard (left) and


special (right) armchairs.

Fig. 2. Lateral and oblique view of a representative chair with arms showing dimensions
measured (values for standard and special chairs used, but not shown, are given, respectively):
A, seat height (44.0 cm,'44.4 cm); B, seat width (45.1 cm, 45.0 cm); C, width between armrests
(44.4 cm, 45.0 cm); D, seat depth (47.3 cm, 45.0 cm); E, posterior slant (1.5 cm, 7.1 cm); F,
height of armrests (24.0 cm, 13.6 cm); G, backrest incline (15, 20); H, clearance under front
of chair (34.5 cm, 29.5 cm).

Volume 65 / Number 1, January 1985


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23

TABLE 1
Videotape and Goniometric Analysis of the Activity of Rising from the Standard Chair,
with Body Weight as a Covariate

RESULTS

Younger
Group
(n = 10)

Variable

Older Group
(n = 10)
s

Trunk forward lean ()


Hand placement (cm)
Foot placement (cm)
Ratio of supported femoral
shaft to total femoral length
(%)
Knee flexion ()
Elbow flexion ()
a

Rising from the Standard Chair

75.0
6.0
-0.4

4.90
2.11
2.67

78.1
5.9
-4.6

5.65
1.45
2.01

5.64a
0.69
4.43a

74.3
75.5
81.6

5.95
3.66
5.27

76.2
72.8
76.7

6.88
5.63
7.50

3.45
2.02
0.44

p.05

ject's hands on the arms of the chair


(Fig. 3).
The EMG was quantified and nor
malized with the aid of a minicompu
ter. To exclude the influence of a
nonnormalized sample, all functional
measurements obtained with one elec
trode were related to the EMG obtained
with maximal effort. Values for inte
grated EMG (IEMG) were obtained
from a series of 0.1-second samples dur
ing the activity cycle and are expressed
as percentages of maximum. We defined
peak and average muscular activities
within the cycle. The point where mus
cle activity began, peaked, and ended
was expressed as a percentage of the
cycle.

Data Analysis
We calculated means and standard
deviations for all quantitative data. The
t test for paired observations was used
to examine differences in mean values
between sides of the body and between
chairs in the older group. For clarity of
results, data from both sides of the body
were combined because analyses
showed minimal differences. Differ
ences between groups rising from the
standard chair were analyzed with an
analysis of covariance, with body weight
as a covariate, using the General Linear

We took measurements from the vi


deotape screen at the point when the
subject's buttocks began to rise from the
chair. Position of the subject in the chair
was calculated as ratio of supported fem
oral shaft length (front of chair to greater
trochanter) to total femoral length (A/P
position). We measured the angle of
trunk forward lean with a goniometer
using the anatomical landmarks for
shoulder, hip, and knee defined earlier.
Hand and foot placement measure
ments were taken from chair arm and
floor marks, respectively. Foot place
ment in front of the zero mark (even
with the front edge of the chair) was
recorded as positive and behind the zero
mark as negative. Maximum joint flex
ion was measured from the visicorder
printout.
Model 960A, Texas Instruments, PO Box
2500, Lubbock, TX 79408.

Models procedure of SAS.16 The level of


significance used was p < .05.

The younger group did not place their


feet back as far as the older group (4.2cm difference, p < .05). Neither group
moved forward in the chair before ris
ing. We found no significant differences
between the two age groups in hand
placement, A/P position, knee flexion,
or elbowflexionin rising from the stan
dard chair; however, the elderly group
showed greater trunk forward lean (Tab.
1). Eight younger andfiveolder subjects
used their arms spontaneously to rise
from the chair during the first trial,
which was the only trial with optional
arm use. Two older subjects lacked full
elbow extension. One with a right 10degree limitation did not spontaneously
use her arms; the other with a right 5degree and left 15-degree limitation did
spontaneously use her arms.
Both the average and peak activities
of the VL muscle were greater in the
older group (differences: average =
21.3%, peak = 43.2%, both p < .01).
The activity cycle duration, however,
did not show significant difference be
tween the two age groups (Fig. 4). Nei
ther muscle demonstrated significant
differences in the timing (begin, peak,
or end time) of their activity between
the two subject groups whenrisingfrom
the standard armchair (Tab. 2). The pat
terns of activity for both VL and MT
muscles of the older and younger sub
jects were similar although older sub
jects showed greater variability in peak
and average activity.

Standard versus Specially


Designed Chair

Fig. 3. Markers for videotape analysis; sub


ject in the standard armchair, electrogoniometer in place.

When the older subjects rosefromthe


specially designed chair, most videotape
and goniometric measurements were
significantly different from those meas
urements whenrisingfromthe standard
chair (Tab. 3). Subjects placed their feet
2.7 cm farther forward (p < .001) in the
special chair and attained greater trunk
forward lean during rising (11.4; p <
.001). These individuals, however, did
not move forward in either chair before
starting to rise. Less of the femur was
supported in the special chair (4.2%; p
< .01). Differences in hand placement
and elbow flexion -were not significant

24

PHYSICAL THERAPY
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RESEARCH

between the two chairs despite the increased trunk forward lean in the special
chair.
The older subjects showed significantly greater VL muscle activity when
rising from the special chair than from
the standard chair (differences: peak =
16.6%, p < .05; average = 13.3%, p <
.01). When subjects rose from the special chair, MT muscle activity occurred
earlier than that of VL muscle (differences: onset = 8.0%, p < .05; peak =
12.7%, p < .05; end = 9.9%, p < .01).
With the exception of trial one (optional
arm use), subjects started with their
hands on the arms of the chair, and they
used their arms to initiate rising from
both chairs. Table 4 and Figure 4 show
that MT muscle activity ceased as the
hands left the armrests, and this event
occurred earlier in the special chair (difference: 2.3% of cycle, p < .01).

ACTIVITY CYCLE (PERCENT)


Fig. 4. Activity cycle for vastus lateralis and medial triceps brachii muscles.

TABLE 2
Values for Integrated EMG Muscle Activity While Rising from the Standard Chair with
Body Weight as a Covariate

DISCUSSION
Based on observations, we anticipated
that older subjects would rise from a
standard armchair differently than
younger subjects and would rise differently from a chair specially designed for
their age group than from a standard
armchair. In the small sample studied,
the special chair did not facilitate the act
of rising from a chair. To the contrary,
rising from this chair was a more difficult task for subjects.
Because the older subjects performed
twice as many trials as the younger subjects, a fatigue effect cannot be ruled
out; however, rest periods were given
and the starting chairstandard or specialwas randomized.
The standard chair had a 5-cm greater
foot clearance than the special chair,
which allowed the subjects to place their
feet farther back. Open space below the
chair seat should facilitate movement of
the center of gravity over the feet during
rising if the person is sitting back in the
chair and does not move forward before
rising.3 None of the subjects in this study
moved forward in either chair before
rising.
Triceps brachii muscle activity reflects use of the arms to lift and propel
the center of gravity forward. In the
special chair, MT muscle activity commenced and peaked later but ended
sooner than when subjects rose from the
standard chair. Potential assistance from
the abdominal or hip flexor muscles in
the act of rising was not assessed. The

Muscle
Variable

Older Group
(n = 10)

Younger Group
(n = 10)
s

Cycle duration (sec)


Vastus lateralis
Begin timea
Peak timea
End timea
Peak activityb
Average activityb
Medial triceps brachii
Begin timea
Peak timea
End timea
Peak activityb
Average activityb

1.5

0.16

1.9

0.68

0.51

13.9
49.9
97.0
46.5
19.4

6.37
12.58
5.56
25.48
11.30

10.8
46.2
99.4
89.7
40.7

6.05
11.23
1.58
33.72
11.86

0.87
0.25
0.84
7.17c
8.72c

3.4
31.1
88.8
80.0
28.0

10.75
10.07
11.37
38.38
16.65

2.7
34.2
91.5
102.2
39.8

4.81
8.11
9.41
50.77
24.91

0.00
0.65
0.17
1.07
2.01

Expressed as % of cycle.
Expressed as % of maximum.
c
p<.01.
b

TABLE 3
Videotape and Goniometric Analysis of the Activity of Rising from the Standard and
Special Chairs in the Elderly Group (n = 10)
Variable

Standard
Chair

Special Chair
s

Trunk forward lean ()


Hand placement (cm)
Foot placement (cm)
A/P position (%)
Knee flexion ()
Elbow flexion ()
a
b

78.1
5.9
-4.6
76.2
72.8
76.7

5.65
1.45
2.01
6.88
5.63
7.50

66.7
5.4
-1.9
72.0
78.5
71.7

4.79
2.07
1.66
7.56
5.66
11.22

13.69a
0.68
-6.38 a
4.36b
-10.58a
2.24

p<.001.
p<.01.

Volume 65 / Number 1, January 1985


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25

TABLE 4
Values for Integrated EMG Muscle Activity in the Older Group (n = 10) While Rising from
the Standard and Special Chairs

Muscle
Variable
Cycle duration
Vastus lateralis
Begin timea
Peak timea
End timea
Peak activityb
Average activityb
Medial triceps brachii
Begin timea
Peak timea
End timea
Peak activityb
Average activityb
a
b

Standard Chair

Special Chair

1.9

0.68

2.2

1.06

-1.96

10.8
46.2
99.4
89.7
40.7

6.05
11.23
1.58
33.72
11.86

9.2
44.2
98.7
106.3
54.0

4.61
11.87
3.77
35.88
15.75

-1.11
-0.76
-1.00
2.74c
4.15d

2.7
34.2
91.5
102.2
39.8

4.81
8.11
9.41
50.77
24.91

1.2
31.5
88.8
115.5
44.9

2.30
11.14
10.28
49.02
21.86

-0.99
-0.80
-2.83 e
1.78
1.57

Expressed a s % of cycle.
Expressed as % of maximum.

p<.05.
p<.01.
e
p<.02.
d

increased forward lean of the trunk on


initiation of rising from the special chair
may relate to the greater posterior slant
of the chair seat. This slant would tilt
the body's center of mass farther back.
As expected, MT muscle activity
ceased when the hands left the armrests.
Armrests, considered essential for the
elderly,17 may be used for assistance in
lifting, propelling body weight forward,
and balance during the activity. This use
is influenced by height of the armrests
relative to an individual's height and
arm length. The special chair had armrests that were 10 cm lower than those
in the standard armchair and 10 cm
lower than the height found most suitable for patients in a recent study.17 The
lower armrests of the special chair may
account for subjects' apparent necessity
to lean farther forward on rising, which
was attained without a larger amount of
elbow flexion. Bajd et al showed on one
healthy subject that increased trunk lean
decreases knee torque maximum.7
Generally, the older subjects used a
greater percentage of maximum muscular activity than the younger subjects
to rise from the standard chair. Strength
differences between age groups may
contribute to thisfinding.11Asignificant
mean weight disparity of 11 kg existed
between the two groups; however, the
differences in VL muscle activity remained when we controlled for body
weight. Older subjects required more

force to move because they were heavier.


Few differences between dominant
and nondominant sides were observed.
Although recording was made one side
at a time, these results suggest further
studies could confine the analysis to one
side alone.
The special chair design was based on
data from an older age group (50-69
years). The investigators of that study,
however, only made design recommendations for comfort in sitting.18 Our
findings suggest that the effect chair design will have on the functional act of
rising from the seated position must be
considered if independence of individuals, such as the disabled and the elderly,
is to be facilitated. Failure to consider
this aspect is a weakness of reported
studies on chair design. Physical therapists, who are often consulted on the
design of equipment to be purchased,
should be aware of the advantages and
limitations of such equipment to ensure
that scarce funds are well-spent. Further
studies are ongoing to determine if similar findings are seen in male subjects.
Additional investigation may include
whether "assist" mechanisms in chairs
facilitate stable rising from a chair in
healthy subjects and patient samples.
CONCLUSION
The implication of this study to physical therapists is that specially designed

chairs for groups such as the elderly may


be comfortable to sit in but may not
facilitate rising from these chairs. Results also suggest that rising from the
standard chair was more difficult for the
older than for the younger group.
Acknowledgments. We thank Jim
Brinkmann, RPT, for his assistance, and
Lumex, Division of Lumex, Inc, for the
loan of the special chair.
REFERENCES
1. Roberts DF: Functional anthropometry of elderly women. Ergonomics 3:321-327,1960
2. Andersson BJG, Ortengren R, Nachemson A,
et al: Lumbar disc pressure and myoelectric
back activity during sitting: 1. Studies on an
experimental chair. Scand J Rehabil Med
6:104-114,1974
3. Keegan JJ: Alterations of the lumbar curve
related to posture and seating. J Bone Joint
Surg [Am] 35:589-603,1953
4. Laubenthal KN, Smidt GL, Kettelkamp DB: A
quantitative analysis of knee motion during
activities of daily living. Phys Ther 52:34-42,
1972
5. Kelley DL, Dainis A, Wood GK: Mechanics and
muscular dynamics of rising from a seated
position. In Komi PV (ed): Biomechanics VB.
Baltimore, MD, University Park Press, 1976,
pp 127-134
6. Seedhom BB, Terayama K: Knee forces during
the activity of getting out of a chair with and
without the aid of arms. Biomedical Engineering 11:278-282,1976
7. Bajd T, Kralj A, Turk R: Standing-up of a
healthy subject and a paraplegic patient. J
Biomech 15:1-10,1982
8. Timiras PS: Developmental Physiology and Aging. New York, NY, Macmillan Publishing Co,
1972, p 417
9. Carlson KE, Alston W, Feldman DJ: Electromyographic study of aging in skeletal muscle.
Am J Phys Med 43:141-145,1964
10. Shafiq SA, Lewis SG, Dimino LC, et al: Electron
microscopic study of skeletal muscle in elderly
subjects. In Kaldor G, DiBattista WJ (eds):
Aging: Aging in Muscle. New York, NY, Raven
Press, 1978, vol 6, pp 65-83.
11. Larsson L: Morphological and functional characteristics of the ageing skeletal muscle in
man. A cross-sectional study. Acta Physiol
Scand [Suppl] 457:1-36,1978
12. Gibson RM, Fisher CR: Age differences in
health care spending, fiscal year 1977. Soc
Secur Bull 42:3-16,1979
13. Burke RE, Levine DN, Salcman M, et al: Motor
units in cat soleus muscle: Physiological, histochemical and morphological characteristics.
J Physiol (Lond) 238:503-514,1974
14. Basmajian JV: Muscles Alive, ed 4. Baltimore,
MD, Williams & Wilkins, 1979, pp 34-35
15. Siebert S: The dynamic Rancho knee goniometer. Downey, CA, Rancho Los Amigos Hospital, Orthopedic Seminar 7:275-283, 19741975
16. SAS User's Guide: Statistics, 1982 Edition.
Cary, NC, SAS Institute Inc, 1982, pp 139-199
17. Finlay OE: Rehabilitation chair. Physiotherapy
67:207,1981
18. Agricultural Experimental Station: Basic design
measurements for sitting, quoted in Diamond
B (ed): Furniture Requirements for Older People. New York, NY, National Council on Aging,
1963, pp 38-39

PHYSICAL THERAPY

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Rising from a Chair: Influence of Age and Chair


Design
Joyce Wheeler, Carol Woodward, Rae Lynn Ucovich,
Jacquelin Perry and Joan M Walker
PHYS THER. 1985; 65:22-26.

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