Bohannon, Richard W. DPT, EdD, NCS, FAPTA, FAHA, FASNR, CEEAA
As an endeavor involving the changing of basic body position, the sit-to-stand (STS) maneuver is a classical activity of mobility according to the International Classification of Functioning, Disability and Health.1 Although only one of the many activities of everyday life, it is performed often by healthy community-dwelling adults; the mean number of daily STS among such individuals may be as low as 46 or as high as 60.2,3 Regardless of the frequency with which the STS maneuver is completed, it is a prerequisite to the performance of other activities (eg, walking)4 and has implications for other outcomes.5 Sit-to-stand is a demanding activity, particularly for older adults,6 and is often compromised in patients with a variety of age-related conditions such as stroke,7,8 Parkinson's disease,9,10 hip fracture,11,12 arthritis,13 and joint arthroplasty.14 These facts render the measurement and interpretation of STS performance important to those working with older adults. The primary purpose of this review, therefore, is to summarize information relevant to the measurement of STS performance. Before addressing this purpose, however, a brief review of the mechanics of the STS maneuver will be provided.
MECHANICS OF SIT-TO-STAND
Knowledge of the mechanics of the STS maneuver provides a foundation for the measurement of the activity and factors contributing to its successful completion. Successful performance of an STS requires the shifting of weight from the buttocks and posterior thighs to the feet. This involves an anterior and then vertical movement of the body's center of mass.7,15,16 This movement is executed primarily by a flexion of the hips and anterior movement of the head-arms-trunk segment, followed by an extension of the hips, knees, and ankles.16–19 The movement has been described as having several stages. Schenkman et al17 and Ikeda et al20 noted 3 stages: (1) flexion momentum (forward flexion of trunk); (2) momentum transfer (shift of body displacement from a primarily anterior to a primarily vertical direction); and (3) extension (rising to maximum hip, knee, and ankle extension). Millington et al21 described 3 comparable phases: weight shift; transition; and lift. Several STS strategies have been described for older adults. Hughes et al22 characterized 1 strategy as relying strongly on momentum, another with a greater emphasis on stability, and a third dependent on a combination of momentum and stability. Scarborough et al23 also described 3 phases: momentum transfer; exaggerated trunk flexion; and dominant vertical rise.
Regardless of strategy, considerable range of motion is needed to egress from sitting to standing. Rising from a low chair may entail more than 100° of knee flexion, 80° of hip flexion, and 25° of ankle dorsiflexion.24 The movements contributing to STS are accomplished by the generation of torques around the hip, knee, and ankle.16,25 Greater torques are required, particularly at the knee, for rising from lower seats.24,26 Greater torques are also required at the hip when less knee flexion range is available.27 Lesser lower limb torques are used when upper limb assistance is permitted.25
Normally, each lower limb provides a comparable contribution to the STS maneuver. This follows when weightbearing is symmetrical. Such symmetry, however, is not the case when range of motion or strength differs between sides. When 1 foot is placed forward of the other before STS, the forward foot experiences less weightbearing.28 Among patients with hemiparesis accompanying stroke, it is typical for more weight to be placed through the nonparetic limb.7,29,30
MEASUREMENT OF SIT-TO-STAND PERFORMANCE
Several options have been described for measuring STS performance. Most basically, the options can be divided into those not requiring timing and those dependent on timing.
Perhaps the simplest way to characterize STS performance is to address an individual's independence in the activity. At the most basic level, a patient can be labeled as able (vs unable) to stand without assistance. Such a dichotomization is capable of denoting status and detecting change over time.31,32 For more discriminating indications of assistance required, scales such as the Functional Independence Measure provide an ordinal rating of independence that can be applied to the STS maneuver.33 On the basis of a patient's contribution to completion of the task, assistance can be graded (eg, >75% = minimal assistance).
Beyond the ability to stand up without assistance, the conditions under which an STS can be completed can also be specified. These conditions include, but are not limited to, use of hands, use of armrests, and height of seating surface. A distinction between being able to complete the maneuver without hands versus with hands is meaningful as use of the hands can substantially reduce the strength necessary to rise independently from a chair. As a percentage of body weight, the combined strength of the knee extensors required to stand without the hands is approximately 40%.34,35 The combined strength required to stand with the hands but no armrests is about 31%.34 If hands are used, it matters whether armrests or something equivalent is used. Arborelius et al25 reported that use of the hands on armrests reduced “the mean maximum hip moment by about 50%.”(p1377) Alexander et al36 reported that the percentage of older adults unable to rise from a standard-height chair with armrests decreased from 32% to 1% when hand use was allowed; the time to stand decreased from a mean 4.6 seconds to a mean 3.8 seconds. Eriksrud and Bohannon37 observed that 8 of the 26 otherwise-dependent patients were able to egress independently from sitting when they used an “Easy-up Handle,” a portable device acting much like an armrest.37 The height of a seating surface can have a profound effect on whether a patient will be able to rise successfully.36,38,39 Of the older adults observed by Weiner et al,39 about twice as many could successfully stand from a 22-in–high chair as from a 17-in–high chair. As noted previously, seat height also affects the range of motion and torques needed during STS; both increase (particularly at the knee) as seat height gets lower.26 It takes longer to stand from lower chairs.36,40
Regardless of the conditions under which an STS is completed, patients' perceived effort can be ascertained. Doing so can be as simple as asking whether they have any difficulty with the task.41,42 Corrigan and Bohannon42 did so and found that older community-dwelling women were progressively more likely to report difficulty in rising from a dining chair, toilet, easy chair, and couch. Perceived exertion can be graded more specifically by using a perceived exertion scale.25,42 Using a Borg scale of perceived exertion, subjects studied by Arborelius et al25 reported greater exertion when standing from lower heights.
When an individual is able to rise from a standard chair without assistance or use of the upper limbs, performance can be quantified while accounting for the time required to complete the task 1 or more times. This can be accomplished with a stopwatch or more sophisticated equipment.8,10,42
The time for a single STS is informative. Corrigan and Bohannon42 reported mean and median times of 1.5 and 1.4 seconds, respectively, for community-dwelling older women. Their finding of significant, albeit-only moderate, correlations (−0.32 to −0.53) between STS time and knee extension force lends some support to the validity of STS time as an indicator of lower limb strength. Known groups validity of the measure is upheld by the greater time required by patients with stroke (3.1 seconds) than for matched controls (1.9 seconds).8 Such validity has also been demonstrated for patients with Parkinson's disease whose STS times were longer when they were in their off state (1.97 seconds) than when in their on state (1.86 seconds).10 The STS times of patients during their off state were also longer than those of matched controls.
Timed STS tests usually involve more than a single repetition. Timed tests incorporating multiple repetitions require either counting the number of repetitions that can be completed in a given period of time or determining how long it takes to complete a given number of repetitions.
The most common times over which repetitions are counted are 10,43–46 30,47–49 and 6050,51 seconds. For tests documenting the number of repetitions completed in 10 seconds, criterion and/or convergent validity are demonstrated by research showing correlations between repetitions and knee extension force (0.41–0.65),43,45 comfortable and maximum walking speed (0.41 and 0.73),45 and stair-climbing performance (0.56 and 0.57).43 Known groups validity for the test is confirmed by the observation that patients on hemodialysis completed approximately 50% fewer STS repetitions in 10 seconds than matched healthy subjects.46 The test-retest reliability is supported by an intraclass correlation coefficient (ICC) of 0.84.43 Responsiveness is illustrated by research showing that patients undergoing kidney transplants performed fewer repetitions 1 month posttransplant than they did before their transplant.44
For tests noting the number of repetitions completed in 30 seconds, validity is demonstrated by correlations (>0.70) between repetitions and weight-adjusted “leg-press” strength and differences in repetitions between age and activity groups.47 Test-retest reliability across sessions is supported by research reporting an ICC of 0.84 for men and an ICC of 0.92 for women.47 Normative values have been published as well.48
For the number of repetitions completed in 60 seconds, convergent validity is supported by correlations between repetitions and 6-minute walk distance covered by patients with chronic obstructive pulmonary disease (r = 0.75) and by healthy individuals (r = 0.54).51 Known groups validity of the 60 seconds measure is evidenced by differences in the mean repetitions between a group with chronic obstructive pulmonary disease and matched healthy individuals51 and by a group of healthy subjects and a group of patients on hemodialysis whose performance was about 50% worse.50
Five-Repetition Sit-to-Stand Test
Some literature describing the timing of multiple repetitions of STS describes the use of either 252,53 or 1013,54 repetitions. However, the “Five-Repetition STS Test” (FRSTST) is by far the most widely employed STS test with older adults. It has been used in more than 50 published studies and is a component of several test batteries, including the Short Physical Performance Battery,55 Index of Mobility Limitation,56 and Physical Performance Examination of the National Health and Nutrition Examination Survey.57 Thus, the rest of this section will address only the FRSTST.
Procedures for completing the FRSTST vary somewhat.58 Although armless chairs are typically used, their heights vary slightly. Tested individuals are usually prohibited from using their upper limbs, with some protocols calling for them to be folded across the chest. While timing generally begins on the command “go,” it sometimes ends with the achievement of the fifth stand and sometimes ends with the return to the seat after the fifth stand. I recommend the following:
1. Use a slightly padded armless chair with a seat height of about 17 inches.
2. Stabilize the chair, preferably against a wall.
3. Have the patient come forward on the chair seat until the feet are flat on the floor.
4. Have the patient fold the upper limbs across the chest if possible.
5. Instruct the patient to stand up all the way and sit down once without using the upper limbs.
6. If the patient is able to complete the maneuver without the upper limbs or physical assistance, instruct him or her to stand up all the way and sit down landing firmly, as fast as possible, 5 times without using the arms. Guard the patient as necessary.
7. Begin timing on the command “go” and cease timing on landing after the fifth stand up.
8. Abort the test and start over again if the patient fails to stand up all the way or sit down firmly.
The FRSTST has been shown to have good measurement properties. These include validity, reliability, and responsiveness. There are normative values for the test.
Often considered a measure of functional strength, the criterion validity of the FRSTST is supported by correlations of FRSTST time with lower limb force or torque. Bohannon et al reported correlations of −0.48 to −0.57 between knee extension force or torque and the FRSTST times of healthy community-dwelling individuals 50 to 85 years of age.59 The correlations were slightly better when knee extension strength was normalized against body weight. Multiple regression analysis supported knee extension strength as a key determinant of FRSTST time, particularly when the curvilinear nature of the relationship was addressed. McCarthy et al,60 who measured the isokinetic strength of 6 lower limb muscle actions, found 5 to correlate significantly with FRSTST performance. Combined, the strengths explained 48% of the variance in FRSTST time. Mong et al61 also looked at the relationship between lower limb muscle strength and FRSTST performance. However, they tested patients with stroke. They found correlations of −0.01 to −0.75 on the affected side and −0.48 to −0.83 on the unaffected side. The highest correlations were with knee flexor strength of each side. Also testing patients with stroke, Ng62 reported a significant correlation (−0.58) between a muscle strength index and FRSTST results. Significant correlations between strength and FRSTST times notwithstanding, much of the variance in FRSTST performance is left unexplained by measures of muscle strength. Lord et al63 identified sensation, speed, balance, and psychological status as variables adding to the explanation of STS performance provided by knee muscle strength. They, therefore, questioned the use of the FRSTST as a “proxy measure of lower limb strength.”
Seen as a measure of balance, the criterion validity of FRSTST times is affirmed by moderate to strong correlations with other balance measures. In patients with stroke, correlations of −0.55 and −0.84 with Berg Balance Test scores have been reported.61,62 The FRSTST measures also correlate (−0.59) with scores on the Activities-Specific Balance Confidence Scale in patients with stroke.62 Among patients undergoing vestibular rehabilitation, low but significant correlations have been reported between FRSTST results and multiple balance-related measures: Activities-Specific Balance Confidence Scale (−0.32), Dizziness Handicap Inventory (0.28), and Dynamic Gait Index (−0.36).64 For a mixed sample of younger and older individuals with and without balance disorders, correlations between FRSTST time and the Activities-Specific Balance Confidence Scale (−0.58) and Dynamic Gait Index (−0.68) were higher.65
There are important variables other than strength and balance, with which performance on the FRSTST correlates. Among healthy community-dwelling people, FRSTST time has convergent validity with self-reported physical functioning (−0.47),66 Timed Up and Go test times (0.73) and gait speed (−0.82).67 A moderate correlation (0.53) has been documented between FRSTST time and Timed Up and Go performance in patients undergoing vestibular rehabilitation.64 A moderate correlation (−0.60) has also been noted between FRSTST time and the distance walked in 6 minutes by patients with hemiparesis following stroke.62
Known groups' validity is well-established for the FRSTST. Bohannon68 demonstrated a significant difference in the time for patients seen in a home care setting (15.8 seconds) and healthy matched individuals (12.1 seconds). Whitney et al65 found that the FRSTST could discriminate between individuals with and without balance or vestibular disorders. Discrimination was better for individuals younger than 60 years (15.3 seconds vs 8.2 seconds).65 Kim et al69 showed that the FRSTST distinguished between older women at low risk of frailty versus high risk of frailty. The age-adjusted odds ratio was 6.29; the area under the receiver operating characteristic curve was 0.79. These indicators of validity were slightly less than those for usual and rapid gait and the Timed Up and Go. Obese older adults have been observed to require significantly longer (nonsarcopenic 10.6 seconds and sarcopenic 10.7 seconds) than nonobese older adults (nonsarcopenic 11.3 seconds and sarcopenic 12.3 seconds) to complete the FRSTST.70 Curb et al71 reported the FRSTST to be good at discriminating between individuals functioning at different levels. The FRSTST was comparable with the 10-repetition STS test in this regard. For patients with peripheral arterial disease, Atkins et al72 found those with low ankle-brachial indexes to require significantly more time to complete the FRSTST than those with moderate ankle-brachial indexes (mean, 15.9 seconds vs 13.5 seconds).
Several studies have examined the predictive validity of the FRSTST. Both Tiedemann et al73 and Buatois et al74 focused on the prediction of falls in their studies. Tiedemann et al73 investigated the ability of 8 mobility tests to predict multiple falls over a subsequent year. The time required to complete the FRSTST was significantly less in nonmultiple fallers (mean, 12.5 seconds) than in multiple fallers (mean, 14.8 seconds). For the prediction of falls, an FRSTST time of 12.0 seconds was associated with a relative risk of 2.0 and a likelihood ratio of 1.47. Buatois et al74 looked at the value of 3 tests to predict recurrent falls over a period 18 to 36 months. Only the FRSTST was independently associated with risk of such falls after adjustment for relevant covariates. Using a criterion of 15 seconds, a risk ratio of 1.74 was calculated. Wang et al75 examined the usefulness of 7 performance measures for predicting mobility disability 2 years later. After adjusting for age and gender, the FRSTST was the only measure identified as a significant predictor of future mobility disability.
The test-retest reliability of the FRSTST has been studied widely. Bohannon76 recently summarized the findings of 10 studies reporting reliability coefficients for measurements obtained across sessions. The coefficients ranged from 0.64 to 0.96. The adjusted mean for the reported coefficients was 0.81.
There is very little literature that specifically addresses the responsiveness of the FRSTST. Schaubert and Bohannon77 reported technical errors of measurement for repeated measures obtained from community-dwelling older adults over 6- and 12-week intervals. The values ranged from 1.6 to 2.8 seconds. Follow-up measurements of FRSTST time would have to change more than these amounts to conclude that a real change had taken place. For a sample of individuals, including, but not limited, to older adults, Bohannon et al78 calculated a method error of 0.5 seconds for FRSTST measurements obtained 4 to 10 days apart. A difference between sessions greater than this value would be required to conclude that a real change had occurred. The responsiveness of the FRSTST is illustrated by its ability to detect declines in lower limb function accompanying aging. Forrest et al79 noted that FRSTST time of older women increased by 22% over a 10-year period. This exceeded the 17% decline in gait speed over the same period. Meretta et al64 addressed the responsiveness of the FRSTST among patients undergoing vestibular rehabilitation. The patients demonstrated a 2.7-second reduction in FRSTST time. The standardized response mean associated with the change was 0.58 (moderate). A change of at least 2.3 seconds was determined to be clinically meaningful.
Numerous studies have provided data for FRSTST performance that can be used for normative purposes. Bohannon58 has summarized the information from 14 such studies in a descriptive meta-analysis. He calculated mean values for use as standards for older adults aged 60 to 69 years (11.4 seconds), 70 to 79 years (12.6 seconds), and 80 to 89 years (12.7 seconds).
The STS maneuver is important to everyday functioning. It can be quite demanding, particularly for older adults with pathologies resulting in impaired strength, balance, and range of motion. While there are several options for measuring STS performance, the FRSTST is probably the most widely employed. The simplicity of the test along with its sound-measurement properties and the availability of normative values for comparison are a compelling reason to utilize the test to describe mobility among older adults.
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activity limitation; biomechanics; function; geriatrics; mobility; muscle strength
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