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Abstract

BACKGROUND:

Sit-to-stand test is very often used as measure of lower limb strength in elderly adults. However, the recent findings indicate that performance in this test is also influenced by other factors.

OBJECTIVE:

To investigate the association between anthropometric, lower limb strength, and balance variables with the 5-repetition sit-to-stand test (5RSTST) in elderly women.

METHODS:

Forty physically active elderly women $\geqslant$ 60 years underwent the 5RSTST and anthropometric, balance, and lower limb strength assessment. Anthropometric measurements included height and weight. Balance was quantified in the bipedal upright stance on the basis of the centre of pressure sway in the anteroposterior (CoP ${}_{\text{AP}}$ ) and mediolateral (CoP ${}_{\text{ML}}$ ) direction. Bilateral concentric strength of the ankle plantarflexors and dorsiflexors, knee flexors and extensors, and hip extensors was measured.

RESULTS:

The time to complete the 5RSTST was significantly but mildly associated with height ( $r=$ 0.356, $p=$ 0.024), ankle dorsiflexor strength ( $r=-$ 0.413, $p=$ 0.017), knee flexor strength ( $r=-$ 0377, $p=$ 0.030), knee extensor strength ( $r=-$ 0.411, $p=$ 0.017), hip flexor strength ( $r=-$ 0.359, $p=$ 0.040) on dominant limb, and balance in both directions (AP, $r=$ 0.651, $p<$ 0.001; ML, $r=$ 0.647, $p<$ 0.001). Balance control in AP direction and knee extensor strength on dominant limb were the only factors that contributed independently to 5RSTST, accounting for 55% of the variance. Balance control in AP direction alone explained 41% of the variance in 5RSTST.

CONCLUSIONS:

Balance control in AP seems to be the most important factor explaining the 5RSTST performance.

Keywords

Repeated chair standing activity of daily living predictor variable regression analysis

1. Introduction

The ability to stand up from a chair once or repeatedly is a frequent daily locomotion and concurrently an indicator of functional mobility and independence in elderly adults. On average, the sit-to-stand (STS) movement is executed at least 45 times per day by most community-dwelling people [7]. With age-related alterations to the neuromuscular and sensorimotor systems, this transition movement can become progressively more demanding to the extent that standing from a seated position becomes a challenging task for many elderly adults, even for healthy ones [1, 21, 28]. Moreover, limitations in functional mobility of STS are considered as a possible predictor of falls in this group of population [8, 27]. Maintenance of independence and functional mobility is crucial for the quality of life of elderly adults. Thus, sufficient attention is being devoted to this locomotion and to the factors that affect it. Expanding knowledge about these factors is gaining importance considering that the ability to stand up from a seated position is also a prerequisite for many other activities of daily living [16, 23]. These efforts result in the determination of predictor variables associated with STS performance.

Generally, lower limb strength, followed by balance, is the most discussed and assessed STS predictor in community-dwelling elderly adults [6, 12, 25, 34]. In this context, studies are mostly focused on the strength of knee extensors [5, 10, 11, 12]. However, knee extension strength offers an important but incomplete explanation of this performance. Schenkman et al. [32] detailed the kinematic analysis of the STS movement and revealed that during the phase when the buttock is lifted from the chair, higher demand is placed on the ankle dorsiflexors and hip flexors strength. A sufficient level of knee extensor strength is crucial when the body weight is moved off the chair until maximum ankle dorsiflexion is achieved. Strengthened knee and hip extensors provide these joints with sufficient moment to maintain the centre of mass (CoM) line close to the joint centre of rotation and, consequently, keep the entire body balanced as a result of reduced moment arm. An appropriate level of ankle plantarflexor strength is required during stabilisation, that is, when the STS locomotion is complete. These findings enhance the importance of comprehensive analysis of the lower limb strength focusing on all the strategic joints since it is not possible to ignore their relative contributions in the overall STS performance. Contrary to lower limb strength, little is known about the contribution of balance on STS performance [25, 33]. Studies dealing with predictor variables of STS performance in elderly adults indicate that this performance is dependent, in part, on anthropometric factors as well [6].

Therefore, the main research interest of this study was to investigate the association between 5RSTST performance with anthropometric, balance, and lower limb strength variables in the elderly women over 60 years of age. The aim was to evaluate the contribution of these variables in the 5RSTST performance. We expected that lower limb strength will be the strongest predictor of 5RSTST performance, followed by balance and anthropometric characteristics.

2. Method

2.1 Participants

Participants were recruited through community service providers, University of the Third Age, and/or through personalised invitation letter. The population targeted was elderly adults (age $\geqslant$ 60 years) who were free of orthopaedic, neurological, and cardiovascular disorders and/or total joint replacement. A total of 40 women (69.5 $\pm$ 6.7 years) met the eligibility criteria and were included in this study. Their characteristics are presented in Table 1. All women were physically active, participating in organized physical activities and sports for at least 2 $\times$ 60 minutes per week, and time spent walking was more than 2 hours per day. The physical activity was screened via interviews; this, however, was not an inclusion criterion. The informed consent was signed by all participants. Study protocol was approved by the local ethics committee and the procedures followed were in accordance with the ethical standards on human experimentation in compliance with the 1964 Helsinki Declaration and its later amendments.

2.2 Outcome measures

All women were evaluated for functional lower limb dominance before balance testing. Limb dominance was determined based on a ball kick test, step up test, and balance recovery test [18]. The limb that was used to kick the ball, descend the stair, or recuperate balance after nudging was considered as the functionally dominant.

2.2.1 Anthropometric data

Anthropometric characteristics like height and weight were obtained in each participant prior to the testing. As a summary, height was measured with an anthropometer to the nearest 0.1 cm (type P-375, Trystom, Czech Republic), and weight was measured to the nearest 0.1 kg (InBody 720).

2.2.2 Five-repetition sit-to-stand test

Participants began this test from sitting position with their feet comfortably on the floor during the whole test and with the back against the upright backrest of the chair. Floor to seat height was 47 cm. They were instructed to cross their arms over their chest and then to stand up all the way and sit down, as fast as possible, five times without using the arms. Timing began on the command ‘go’ and stopped when the subject’s buttocks touched the chair on the fifth repetition. Time to complete the test was recorded as the participant’s score and was used for the analysis.

2.2.3 Standing balance

Participants stood barefoot in comfortable upright posture with their eyes opened and their arms alongside the body on a force platform (AMTI OR6-5, Advanced Mechanical Technology, Inc., Watertown, MA, USA, sampling frequency 200 Hz). They were instructed to minimise postural sway by standing as still as possible for the duration of 30 seconds. Force plate recording began immediately after the participants stabilised their posture. Centre of pressure (CoP) coordinates in the anteroposterior (CoP ${}_{\text{AP}}$ ) and mediolateral (CoP ${}_{\text{ML}}$ ) direction were filtered using the fourth-order low-pass Butterworth filter with a cut-off frequency of 10 Hz. Subsequently, the mean CoP sway in each direction was computed. Data analysis was performed using MATLAB software (v. 2018a, MathWorks, Inc., Natick, MA, USA). The mean CoP sway of two trials in each direction was used for the analysis.

2.2.4 Lower limb strength

Isokinetic bilateral muscle strength was measured using the IsoMed 2000 (D. & R. Ferstl GmbH, Hemau, Germany) dynamometer. Participants underwent an isokinetic familiarization session one week prior to the study. A specially designed warm-up was performed first before the isokinetic testing under the supervision of the researcher. Immediately after the warm-up, participants completed the Concentric isokinetic testing of the knee flexors and extensors (FL ${}_{\text{K}}$ , EX ${}_{\text{K}}$ ), the ankle plantar and dorsal flexors (PF, DF), and the hip flexors and extensors (FL ${}_{\text{H}}$ , EX ${}_{\text{H}}$ ), as stated in this order. Testing was conducted at a velocity of 60 ${}^{\circ}$ /s for the knee and hip joint [9, 13, 20] and at a velocity of 30 ${}^{\circ}$ /s for the ankle joint [29, 35], in agreement with the range of velocities typically studied in elderly participants.

Concentric moment evaluation was performed in the reciprocal concentric-concentric mode. Each subject was instructed to exert maximal voluntary effort as hard and as fast as possible throughout the complete range of motion (ROM). Participants were instructed to hold their arms crossed over the chest during testing to minimise arm support. After the testing protocol, participants underwent supervised stretching exercises focused on the relaxation of the tested muscle groups.

During knee flexion and extension testing, participants were seated with the hip joint at about 75 ${}^{\circ}$ (0 ${}^{\circ}$ $=$ full extension). The pelvis, the tested lower limb, and the shoulders were strapped. The ROM for testing was set from 20 ${}^{\circ}$ to 90 ${}^{\circ}$ of the knee FL (0 ${}^{\circ}$ $=$ full knee extension).

Ankle plantarflexion and dorsiflexion were measured with patients in supine position with hip and knee in full extension. The foot was placed on the foot adapter. The waist and thigh of the tested limb and the shoulders were fixed. The contralateral limb was flexed to $\approx$ 90 ${}^{\circ}$ in the knee joint and foot placed on the table. The ROM was set from 10 ${}^{\circ}$ of the ankle DF to 35 ${}^{\circ}$ of the ankle PF (0 ${}^{\circ}$ $=$ neutral position of the talocrural joint).

Table 1
Correlation analysis of the association of 5RSTST with independent variables

	Mean (SD)		$r$	$p$
5RSTST (s)	12.0	(3.1)
Anthropometric characteristics
Weight (kg)	70.6	(11.4)	0.207	0.200
Height (cm)	163.0	(6.9)	0.356	0.024
Standing balance (mm)
CoP ${}_{\text{AP}}$	4.5	(1.4)	0.651	$<$ 0.001
CoP ${}_{\text{ML}}$	2.2	(1.1)	0.647	$<$ 0.001
Lower limb strength (Nm.kg ${}^{-1}$ )
Dominant limb
FL ${}_{\text{K}}$	0.78	(0.17)	$-$ 0.377	0.030
EX ${}_{\text{K}}$	1.34	(0.34)	$-$ 0.411	0.017
PF	0.96	(0.26)	$-$ 0.269	0.130
DF	0.32	(0.09)	$-$ 0.413	0.017
FL ${}_{\text{H}}$	1.08	(0.26)	$-$ 0.359	0.040
EX ${}_{\text{H}}$	1.71	(0.55)	$-$ 0.236	0.187
Non-dominant limb
FL ${}_{\text{K}}$	0.77	(0.19)	$-$ 0.152	0.398
EX ${}_{\text{K}}$	1.35	(0.28)	$-$ 0.205	0.252
PF	0.93	(0.24)	$-$ 0.309	0.081
DF	0.34	(0.08)	$-$ 0.168	0.349
FL ${}_{\text{H}}$	1.01	(0.26)	$-$ 0.310	0.079
EX ${}_{\text{H}}$	1.66	(0.51)	$-$ 0.333	0.058

Note: 5RSTST $=$ Five-repetition sit-to-stand test; $r=$ Pearson’s correlation coefficient; CoP ${}_{\text{AP}}$ $=$ sway in the anteroposterior direction; CoP ${}_{\text{ML}}$ $=$ sway in the mediolateral direction; FL ${}_{\text{K}}$ $=$ knee flexors; EX ${}_{\text{K}}$ $=$ knee extensors; PF $=$ plantarflexors; DF $=$ dorsiflexors; FL ${}_{\text{H}}$ $=$ hip flexors; EX ${}_{\text{H}}$ $=$ hip extensors. Bold values indicate statistical significance.

Table 2

Stepwise regression analysis with 5RSTST performance as the dependent variable

	Standardized $\beta$ coefficient	$\beta$ significance	$R^{2}$	Adjusted $R^{2}$	Model significance
Model 1			0.424	0.409	$<$ 0.001
CoP ${}_{\text{AP}}$	0.651	$<$ 0.001
Model 2			0.569	0.546	$<$ 0.001
CoP ${}_{\text{AP}}$	0.643	$<$ 0.001
EX ${}_{\text{K}}$ (dominant limb)	$-$ 0.380	0.001

Note: CoP ${}_{\text{AP}}$ $=$ sway in the anteroposterior direction; EX ${}_{\text{K}}$ $=$ knee extensors. $R^{2}=$ coefficient of determination. Bold values indicate statistical significance.

Hip flexion and extension were measured with patients in lying supine position with fixed waist and shoulders. The contralateral limb was flexed to $\approx$ 90 ${}^{\circ}$ in the knee joint and foot placed on the table. The ROM was set from 10 ${}^{\circ}$ to 100 ${}^{\circ}$ of the hip FL (0 ${}^{\circ}$ $=$ full hip extension).

Prior to each test, subjects performed three submaximal practice trials. Afterwards, the four trials were executed for each muscle/group at dominant and non-dominant limb. The peak moment was normalised to body weight.

2.2.5 Statistical analysis

The Shapiro-Wilk test was used to test data distribution and revealed that the data met the assumptions of a normal distribution. The association between 5RSTST as the dependent variable and anthropometric characteristics, balance, and lower limb strength as the independent variables was assessed using Pearson’s correlation coefficient. The magnitude of the correlations was determined using the modified scale according to Hopkins et al. [19]: $r<$ 0.1 trivial; 0.1–0.3 small; $>$ 0.3– $>$ 0.5 moderate; $>$ 0.5–0.7 large; $>$ 0.7–0.9 very large; $>$ 0.9 nearly perfect; and 1 perfect. Only the independent variables that correlated significantly with the dependent variable (5RSTST) were included in the regression analysis. The proportion of variance in the dependent variable explained by the dependent variables was reported with adjusted R squared (Adjusted $R^{2}$ $\times$ 100). Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) for Windows, version 25 (SPSS, IBM Corporation, Armonk, NY, USA). An alpha level of 0.05 was considered statistically significant for all analyses. The variables were presented as mean $\pm$ standard deviation.

3. Results

The main outcome characteristics are presented in Table 1. No significant differences were detected between the lower limbs in terms of strength.

Performance in 5RSTST was significantly but mildly associated with height and knee flexor strength, knee extensor strength, ankle dorsiflexor strength and hip flexor strength of the dominant limb. A fairly strong correlation was observed between the 5RSTST and balance control in AP and ML direction (Table 1).

Using stepwise regression analysis, the variables of balance control in AP direction and knee extensor strength of the dominant limb were found to be significant predictors of 5RSTST accounting for 55% of the variance. Balance control in AP direction alone explained 41% of the variance in 5RSTST (Table 2).

Based on the reference values of ‘healthy’ elderly adults obtained by Bohannon [4], about 43% of our participants achieved higher time than the upper limit of these values.

4. Discussion

In this study we have performed a multifactorial assessment of the 5RSTST (e.g. anthropometric, balance, and lower limb strength factors) in elderly women over 60 years of age. Among all the factors, balance control in AP direction and knee extensor strength of the dominant limb were the only significant predictors of 5RSTST performance and revealed 55% of the variance in this test. Balance control in AP direction alone explained 41% of the variance in 5RSTST.

We hypothesised that among all the factors, lower limb strength will be the strongest predictor of 5RSTST performance followed by balance in healthy and physically active elderly adults. Performance on this test is often used as an indicator or proxy measure for lower limb strength in elderly adults [3]. Lord et al. [25] found that in community-dwelling elderly adults, 5RSTST performance is dependent on standing balance and other factors in addition to lower limb strength. On the other hand, Tiwari et al. [34] found no association between 5RSTST and standing balance in such cohort. These seemingly contrasting findings comply with each other better when one considers the mean age of participants. As far as the current findings are concerned, it seems that the dependence of 5RSTST performance on balance increases with increasing age. Even though no significant differences in strength were found between the dominant and non-dominant limb, our results indicate that lower limb dominance has impact on the 5RSTST. Previous literature has shown lower limb loading asymmetries during balance tasks in older adults towards the dominant side [2]. Thus, the potential explanation of our finding could be that the elderly women rely more on the dominant lower limb while performing test.

Kinematic studies commonly divide STS movement into 2–5 phases, wherein the last phase is stabilisation characterised by reaching quiet standing [14, 15, 22, 26, 30, 32]. However, studies that assess STS performance in elderly adults tended to ignore this phase despite the fact that STS failure is due to the inability to stop in a stable position once the standing posture is achieved [1]. In the detailed analysis of 5RSTST performance in elderly fallers and non-fallers, the mean standing times accounted for about 6.7% and 6.5% of the total time [14]. Another study has indicated that the stabilisation phase accounted for 27% of one STS cycle in healthy females and males aged between 20 and 78 years [22]. During the STS transition, the CoM of the body is moving forward and upward. For elderly adults, it may be a challenge to control and stabilise repeatedly and dynamically the moving CoM, especially at the end of the STS movement. Mainly, the CoP forward motion must be precisely controlled to successfully maintain anteroposterior stability and, therefore, to prevent falls [1].

Based on the previously reported reference values for the 5RSTST in elderly adults at various ages [4], only 57% of participants in our study achieved ‘normal performance’. The rest have surpassed the upper limits of the reported norms, indicating worse than average performance, with a scoring over 15 seconds. Elderly adults who needed more than 15 seconds to complete the test had a 74% greater risk of recurrent falls than those who needed a shorter time, independently of the other main risk factors, including history of falls [8]. These findings point out to the importance of targeted physical activity. Participants in our study were physically active, however, their physical activity had predominantly aerobic character (i.e. jogging, walking, cycling, and hiking). Thus for eliminating the risk of falls in the elderly, exercise should be focused not only on better exercise tolerance, but also on balance and strength improvement.

Generally, there are a number of studies dealing with STS performance and its determinants in elderly adults. However, they include participants with various clinical backgrounds. This is probably the reason for the contradictory findings. On the other hand, only a few studies were conducted in healthy and well-functioning elderly adults [5, 6, 24, 34]. A lack of studies conducted in elderly adults in an apparently good state of health and physical condition rendered it difficult to compare and discuss our results with the other studies.

The findings of this study raise the importance of application of balance and strength training with advancing age, including high-functioning elderly adults. The ability to safely control balance during standing from a seated position and immediately after, is important for everyday life without falls. It should be noted that falls due to sit-to-stand transition occur not only in the weak and disabled elders but even in the relatively healthy physically active individuals [17, 31].

Two limitations of this study concern the failure to include lower limb length as one of the anthropometric factors while the 5RSTST was not performed on force platform and thus balance control was evaluated separately. Testing women only limits the conclusions to this gender only.

5. Conclusions

Balance control in AP direction and knee extensor strength were the main factors for predicting 5RSTST performance in elderly women with the former being the single best predictor of 5RSTST performance. However, 5RSTST performance was mostly unexplained, suggesting that other important variables may also be involved in this test.

Author contributions

CONCEPTION: Zuzana Kovacikova.

PERFORMANCE OF WORK: Zuzana Kovacikova, Javad Sarvestan, Zuzana Gonosova and Petr Linduska.

INTERPRETATION OR ANALYSIS OF DATA: Zuzana Kovacikova, Javad Sarvestan, Zuzana Gonosova and Petr Linduska.

PREPARATION OF THE MANUSCRIPT: Zuzana Kovacikova and Javad Sarvestan.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Zuzana Kovacikova, Javad Sarvestan, Zuzana Gonosova, Petr Linduska, Erika Zemkova and Miroslav Janura.

SUPERVISION: Zuzana Kovacikova, Erika Zemkova and Miroslav Janura.

Ethical considerations

The study was prepared within the project entitled “Postural stability and its relationship to the muscle strength of selected muscle groups”. The project was approved by the ethics committee of Faculty of Physical Culture UP in Olomouc No.24/2017 (29.3.2017). The committee of Faculty of Physical Culture evaluated the project and found no contradictions with the principles, procedures and international guidelines for medical research involving human subjects.

Funding

This study was supported through the scientific grant of the Czech Science Foundation (GA CR, No. 18-16107Y). The authors also thank the Slovak Research and Development Agency under the contract No. APVV-15-0704.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors report no conflict of interest.

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The association between anthropometric,lower limb strength,and balance variables with 5-repetition sit-to-stand test performance in physically active elderly women

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Method

2.1 Participants

2.2 Outcome measures

2.2.1 Anthropometric data

2.2.2 Five-repetition sit-to-stand test

2.2.3 Standing balance

2.2.4 Lower limb strength

Table 1 Correlation analysis of the association of 5RSTST with independent variables

3. Results

4. Discussion

5. Conclusions

Author contributions

Ethical considerations

Funding

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Correlation analysis of the association of 5RSTST with independent variables