Sitting Up, Sitting & Standing Up Flashcards
What is bed mobility important for?
- Pressure relief
- Comfort & rest
- Encourages self care & participation
- Progression to independent mobility
What are the two components of sitting up from supine?
- Rolling over
- Sitting up over the side of the bed
What does rolling include?
Movement from supine to prone, prone to supine or as part of a task
What is the difference between rolling & turning in bed?
- Rolling: Includes lateral displacement of the body
- Turning: Rolling on the spot (no lateral displacement)
What are the difficulties of rolling & turning?
- Rotation of low, flat, wide base
- Considerable force required to shift & stabilise COM
What are the important components of rolling over?
- Rotation & flexion of neck
- Hip & knee flexion
- Flexion & protraction of shoulder
- Rotation of trunk
What are the important components of sitting up over the side of the bed?
- Lateral flexion of neck
- Lateral flexion of trunk & abduction of lower arm
- Legs lifted & lowered over side of bed
How is sitting up measured?
- Time taken to complete task
- Item 1 of MAS (supine to lying on intact side)
- Item 2 of MAS (supine to siting over side of bed)
What are the important components of sitting?
- Feet & knees close together
- Head balanced on level shoulders
- Weight evenly distributed
- Flexion of hips with extension of trunk (shoulders over hips)
What are the important components of reaching in sitting?
- Shifting head, arms & trunk towards object by moving at hips
- Loading the foot ipsilateral to the direction of the reach
What evidence is there for foot positioning during reaching in sitting?
- Compared reaching distance between both feet on floor, one foot off floor, both feet off floor in stroke patients
- Furthest reach achieved with both feet on floor
- Clinical implications: Train reaching with both feet on the floor
What evidence is there for arm positioning during reaching in sitting?
- Study looked at movement of normal healthy adults during reaching
- Observed that head, arms & trunk move towards object by movement at the hips
- Movement duration approx 1s
- Arm never completely straightens to reach the object
- Clinical implications: Look for arm position when assessing reaching in sitting (straight arm may be adaptive strategy)
What evidence is there for loading through the feet during reaching in sitting?
- Examined ground reaction force through feet when performing reaches of varying distances/tasks
- Further reach = greater loading
- Leg muscles activated when reaching beyond arm’s length esp at 140% of arm’s length
- Faster grasp required = greater ground reaction force
- Clinical implications: Train speed & reaching outside arm’s length to improve loading through the feet
What evidence is there for direction of reaching during reaching in sitting?
- Location of target influences amount of force through the feet
- Feet in the direction of the reach have greatest load
- Older subjects activated tib ant, soleus & vastus lateralis bilaterally in all reaches
- Clinical implications: To train loading the foot reach on the same side, for older adults may want to start training on unaffected side to make it easier
What evidence is there for thigh support in reaching in sitting?
- Compared reaching forward, ipsilaterally & across the body with 25%, 50% & 75% thigh support
- Less thigh support = greater load through leg when reaching
- Clinical implications: To progress loading training reduce thigh support
What evidence is there for reaching in sitting after stroke?
- When reaching forwards & sideways:
- Lack of loading of affected foot in all directions & slowness of movement
- Clinical implications: Train speed & loading affected foot
How can you promote loading & muscle activation of the affected side after stroke?
- Reach beyond arm’s length, progress by increasing reaching distance
- Progress reaching to direction of affected leg
- Increase speed & endpoint of reaching
- Reduce thigh support
What does assessment of sitting & reaching in sitting include?
- Observation of sitting alignment & missing important components
- Assessment of patient’s capacity to make preparatory & ongoing postural adjustments e.g. balance
- Observation of adaptive strategies
What are the common observable deviations in sitting?
- ER & abduction of hip
- IR & adduction of hip
- Lack of foot placement on floor
- Inability to reach beyond arm’s length
- Inability to load affected leg
What are the common adaptive behaviours during sitting & reaching in sitting?
- Increased BOS
- Weight shift to intact side
- Forward flexion when task requires sideways shift
- Shuffling feet
- Use of arms
- Minimising challenges of balance by restricting speed & amplitude of movement
- Laterally flexing
- Full elbow extension (voluntary restriction of movement)
- Holding breath
How is sitting & reaching in sitting measured?
- Item 3 of MAS (balanced sitting)
- Amount of thigh support
- Distance reaching without bending
- Speed of reaching to standardised point
What evidence is there for sitting balance training in chronic stroke?
- RCT: sitting balance training vs placebo for stroke patients
- Standardised training protocol: Reaching beyond arm’s length varying distance, direction, speed, thigh support, task & seat height
- Significant improvement in leg loading in all directions (almost normal) & movement speed
What evidence is there for sitting balance training in subacute stroke?
- Same standardised training protocol used for sitting balance training for chronic stroke
- Increased max reach distance & peak vertical force through affected foot (maintained at 6 months)
- Decreased movement time
What are the important components of standing up?
- Feet placed back so ankles are behind knees (approx 15 deg DF)
- Forward translation of trunk by flexion at hip with extension of trunk
- DF of ankles to bring knees forward (approx 27-28 deg DF)
- Sequence of lower limb extension at knees, hips & ankles
What are the common observable deviations in standing up?
- Difficulty generating/timing sufficient force in lower limb extensors to propel body vertically
- Failure to place feet far enough back
- Failure to move body far enough forward for thighs off
- Poor balance
What are the common adaptive behaviours in standing up?
- Increase BOS
- Use of hands
- Falls backwards
- Weight shift laterally to intact side
- Flexion of trunk
- Intact foot placed posterior to affected foot
- Adduction &/or IR of affected leg (locking joints together to increase stability)
- Final alignment flexed
What evidence is there for the kinematics of sit to stand?
- Looked at healthy population STS kinematics
- Movement duration 1.5s
- COM moves in 2 phases, horizontal & vertical
- Ankle at 15 deg DF
- Thighs off occurs at 30% movement duration
- Knees move forward then back to start position
What evidence is there for loading the legs in sit to stand?
- At thighs off force through the feet is 150% BW
- Allows body to be propelled upward to standing
- Clinical implications: Loading the legs is important, need to aim for 75% BW for each leg when training standing up
What evidence is there for muscle activity during standing up?
- Ankle DF active before movement begins
- Muscles that propel body upwards are active just before thighs off
- Clinical implications: Need to train whole movement, not just components otherwise preparatory activation won’t happen
What evidence is there for foot placement during standing up?
- Study examined 3 foot positions
- Feet further forward
= > distance BM needs to move
= > movement time
= > hip movement
= < knee/ankle movement - Clinical implications: Need to train bringing the feet back for STS
What evidence is there for elevation of feet during standing up?
- Examined effects of 3 different foot positions (normal, unaffected extended, unaffected elevated) in stroke patients
- Peak vertical force & rate of development of peak force greater in affected foot when unaffected foot was forward or elevated
- Affected tib ant & quads require greater force production when unaffected foot placed forward
- Clinical implications: Train both feet back initially, progress by putting unaffected foot forwards or elevated
What evidence is there for initial alignment during standing up?
- Compared active trunk inclination with no inclination in horizontal phase of STS (healthy young adults)
- Max force in all muscles sustained for longer when no forward trunk inclination
- Peak acceleration of forward trunk inclination coincides with onset of hip & knee extension
- Clinical implications: Need to train forward translation of trunk, ensure you’re not blocking patient’s forward translation
What evidence is there for seat height & standing up?
- Compared effects of standing up with seat at knee height: alone; plus use of arms; plus 1/3 thigh length; plus 2/3 thigh length
- Joint movements around hip & knee decreased as seat height increased
- Amount of muscle activity decreased as seat height increased
- Muscle activity in lower limbs reduced by 50% when arms used
- Clinical implications: No arm use in training, have seat at correct height
What assessment is used for standing up?
- Observation
- Note deviations from important components & adaptive behaviours
- Determine impairments most likely contributing to deviations
What measurement is used for standing up?
- Item 4 MAS (sitting to standing)
- Time taken to perform 5 reps STS
- Seat height
- Weight taken through affected foot
What are the principles of training standing up?
- Address underlying impairments
- Do not use upper limbs
- Use demonstration & feedback
- Use manual guidance
- Repetitive practice (5x20 reps daily)
What evidence is there for standing up interventions?
- Cochrane systematic review of standing up interventions for sub-acute & chronic stroke patients
- Interventions included repetitive STS practice alone; exercise programs; augmented feedback during STS training
- Moderate quality evidence that STS interventions may improve speed & lateral symmetry of STS
- Improvement maintained at follow-up
What evidence is there for training STS with auditory feedback?
- Compared to STS training with no feedback
- Trained 45 mins, 5 days/week for 6 weeks
- Significant improvement in weight distribution in standing up
- Clinical implications: Need to use feedback in training
What evidence is there for biofeedback in lower limb activities after stroke?
**Use in viva
- Systematic review of effects of biofeedback in LL activities
- Activities included sitting, STS, standing & walking
- Biofeedback & physio tended to improve standing up more than physio alone
What evidence is there for using feedback for foot position in standing up?
- Pilot study (no control)
- Used a square rule to provide feedback on foot position (no verbal)
- Increased speed & quality of standing up
- Improved performance outside of therapy (foot position correct 2/3 of the time)
What are the common adaptive strategies of rolling over in bed?
- Wriggling instead of turning
- Pulling over with intact hand
- Failure to move affected arm (may indicate inattention or neglect)
What are the common adaptive strategies of sitting up over the side of the bed?
- Rotation & flexion of neck forward
- Excessive pushing through intact arm to compensate for lack of trunk side flexion
- Hooking intact leg under affected leg
- Falling backwards
