Gait & Posture 78 (2020) 35–39

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Gait & Posture

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Full length article

Five times sit-to-stand following stroke: Relationship with strength and T

balance
Benjamin F. Mentiplaya,*, Ross A. Clarkb, Kelly J. Bowerc, Gavin Williamsc,d, Yong-Hao Puae
a
La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Australia
b
School of Health and Sport Sciences, University of the Sunshine Coast, Australia
c
Department of Physiotherapy, The University of Melbourne, Australia
d
Department of Physiotherapy, Epworth Healthcare, Australia
e
Department of Physiotherapy, Singapore General Hospital, Singapore

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Rising from a chair is an important functional measure after stroke. Originally developed as a
Chair rise measure of lower-limb strength, the five times sit-to-stand test has shown associations with other measures of
Muscle strength impairment, such as balance ability. We aimed to compare strength and balance in their relationship with the
Rehabilitation five times sit-to-stand test following stroke.
Brain injury
Methods: Sixty-one participants following stroke were recruited from two hospitals in this cross-sectional ob-
servational study. Participants underwent assessment of the five times sit-to-stand (measured with a stopwatch),
bilateral lower-limb muscle strength of seven individual muscle groups (hand-held dynamometry), and standing
balance (computerised posturography). Partial correlations (controlling for body mass and height) were used to
examine bivariate associations. Regression models with partial F-tests (including pertinent covariates) compared
the contribution of strength (both limbs) and balance to five times sit-to-stand time.
Results: The strength of the majority of lower-limb muscle groups (6/7) on the paretic side had a significant
(P < 0.05) partial correlation with five times sit-to-stand time (r = -0.34 to -0.47) as did all balance measures (r
= -0.27 to -0.56). In our regression models, knee extensor strength, total path length, and anteroposterior path
velocity provided the largest contribution to five times sit-to-stand over covariates amongst strength and balance
measures (R2 = 16.6 to 17.9 %). Partial F-tests revealed that both lower-limb strength and balance contribute to
five times sit-to-stand time independent of each other. A regression model containing knee extensor strength and
anteroposterior path velocity accounted for 25.5 % of the variance in five times sit-to-stand time over covariates.
Conclusions: The strength of the knee extensor muscle group along with measures of standing balance ability
(total path length and anteroposterior path velocity) both independently contribute to five times sit-to-stand
time. Further research is required to examine how other important impairments post stroke impact five times sit-
to-stand performance.

1. Background the sit-to-stand movement is effective in improving performance after

Stroke can result in a range of physical impairments and is a leading
cause of disability worldwide [1]. Whilst various impairments need to
be considered, decreased muscle strength and postural control (bal-
ance) are often suggested as major contributors to limitations in ac-
tivities of daily living [2,3]. Standing up from a chair, which is an
important everyday task, is often trained post stroke [4,5]; however,
there is a lack of clarity regarding the key underlying impairments
contributing to this movement. While repetitive task-specific training of
stroke [5], identifying key contributing impairments may guide clin-
icians as to which impairments to prioritise and allow for targeted in-
terventions to optimise outcomes.
Measuring the ability to rise from a chair was developed as a
functional measure of lower-limb strength [6], with one common as-
sessment method being the five times sit-to-stand (5STS) test [7,8]. The
5STS test is reliable in individuals following stroke [9,10], has a po-
tential link with falls [11], and has better clinimetric properties than
assessments with set time limits (e.g. 30-second chair stand) [12].

Abbreviations: 5STS, five times sit-to-stand; BBS, Berg Balance Scale; WBB, Nintendo Wii Balance Board
⁎
Corresponding author at: La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Kingsbury Drive, Bundoora, 3086, Victoria, Australia.
E-mail address: B.Mentiplay@latrobe.edu.au (B.F. Mentiplay).

https://doi.org/10.1016/j.gaitpost.2020.03.005
Received 7 January 2020; Received in revised form 8 March 2020; Accepted 10 March 2020
0966-6362/ © 2020 Elsevier B.V. All rights reserved.
B.F. Mentiplay, et al.
Although the 5STS is often used as a functional measure of strength,
research has shown factors other than muscle strength influence 5STS
performance [13,14]. One large study in 669 community-dwelling,
non-stroke affected older adults was undertaken to examine the re-
lationship between the 5STS test and a range of sensorimotor, balance,
and psychological measures [13]. Interestingly, despite finding many
measures to have a significant relationship with the 5STS test (in-
cluding balance), knee extensor strength had the strongest relationship
[13], indicating that strength does indeed play a large part in de-
termining 5STS performance in older adults.
Similar to older adults, research in stroke has shown a strong re-
lationship between muscle strength and the 5STS test [9,15,16].
However, given that balance impairments are common post stroke, they
may have a stronger association with the 5STS test compared with older
adults. Conflicting evidence on whether balance has a relationship with
the 5STS test following stroke has been shown in two relatively small
studies; one [9] finding no significant correlation between balance
(measured with the Berg Balance Scale (BBS) and limits of stability test)
and the 5STS (n = 12) and one [16] finding balance (measured via
weight bearing asymmetry) to have significant correlations with the
5STS (n = 22). A larger study of 68 community-dwelling participants
after stroke examined the relationship that lower-limb strength and
balance have with the 5STS test [10]. A very strong, significant corre-
lation was found between balance (measured with the BBS) and 5STS
time (r = -0.837), whilst a composite measure of bilateral lower-limb
strength showed a weaker, yet still significant correlation with the 5STS
(r = -0.577) [10]. Further, a linear regression model showed that
balance was independently associated with 5STS time, whilst muscle
strength was not. Therefore, the researchers [10] concluded that bal-
ance, and not muscle strength, influences performance of the 5STS test.
However, the use of a composite measure of muscle strength, that
combined the strength of the knee extensors, ankle dorsiflexors, and
ankle plantarflexors (without appropriate weighting of each muscle
group or towards those important in the sit-to-stand movement), may
be problematic and impact the correlation between muscle strength and
the 5STS test. Additionally, the use of the BBS to reflect balance im-
pairment may have increased the magnitude of association, given that
three of the 14 BBS components include sit-to-stand movements (sit-to-
stand, stand-to-sit, and inter-chair transfers). While the BBS assesses a
variety of aspects of both static and dynamic balance, it uses a limited
scoring scale and has known floor and ceiling effects [17], which may
have impacted the results of this previous study [10].
Due to this conflicting evidence on the relationships that balance
and strength have with the 5STS following stroke, further research is
required to understand the underlying impairments that contribute to
sit-to-stand ability. Therefore, this study aimed to examine the re-
lationship that standing balance and muscle strength have with the
5STS test following stroke.
2. Methods
This cross-sectional observational study recruited a convenience
sample of participants following stroke from two major hospitals in
Australia and Singapore. Selection criteria were: ≥21 years old, ≥3
months after a non-cerebellar stroke, ability to walk ≥10 m without
any assistance or gait aids, no significant cognitive impairments (≥7 on
the Abbreviated Mental Test Score), and no other comorbidities that
could impact upon the assessment of strength or balance. This study
was a secondary analysis of previous work examining gait velocity after
stroke [18,19]. All participants provided written informed consent prior
to any assessments and the study had approval from ethics committees
at each hospital (637-14 and 2015/2562). Participants attended one
testing session at the hospital where they were receiving treatment.
Procedures were consistent across the two hospitals with the same as-
sessor (BFM) performing all testing. This study was reported according
to the strengthening the reporting of observational studies in
36
Gait & Posture 78 (2020) 35–39
epidemiology (STROBE) guidelines [20] (see Supplementary File).
The 5STS test was performed using a standard chair height (45 cm),
similar to previous research [10,13], with participants instructed to not
use their arms. Instructions to the participants were to “stand up from
the chair and then sit down as quickly as possible for five repetitions
and do not use your hands during the test”. The assessor ensured par-
ticipants stood up completely (i.e. full extension) and sat down (i.e.
touched the chair) between each repetition. One trial of the 5STS test
was performed with the time taken to complete the 5STS recorded with
a stopwatch. The stopwatch recording started and ended with the
participant in sitting with their back against the chair. Trials were re-
peated if the participants used their arms, did not stand up completely,
or did not sit down between repetitions.
Static standing balance was measured with a Nintendo Wii Balance
Board (WBB; Nintendo, Kyoto, Japan) while the participant stood
barefoot in a comfortable position on both legs “as still as possible” for
30 s with eyes open. The WBB has shown strong reliability and validity
[21]. Measures taken from the WBB were the total path length (distance
the centre of pressure travelled during the test) as well as mediolateral
and anteroposterior sway amplitude (range of movement) and velocity
(speed of movement). Two trials were performed, with a third trial used
if the sway velocity of the first two trials differed by > 0.3 m/s. The
average of two, or median of three, was used for analysis. Data analysis
was performed using techniques described previously [22].
Isometric strength was measured with hand-held dynamometry –
the Lafayette Manual Muscle Testing System Model-01165 (Lafayette
Instrument Company, Lafayette IN, USA). Seven lower-limb muscle
groups on both the paretic and non-paretic side were assessed: hip
flexors, knee extensors and knee flexors (seated); ankle plantarflexors,
ankle dorsiflexors and hip abductors (supine); and hip extensors
(prone), as per a previously described protocol [23]. The assessor pre-
viously demonstrated acceptable reliability in both healthy and stroke
cohorts [18,23]. Participants performed two trials for each muscle
group on each side and were instructed to push/pull as hard as they
could against the dynamometer. The highest amount of force (measured
in Newtons) recorded across the two trials was used for analysis. For
descriptive reporting, strength data were normalized to lever arm
length and body mass. For statistical analyses, strength data were kept
in Newtons, with body mass and height used as covariates.
2.1. Statistical analysis
Descriptive statistics were used to report the demographics and test
results of participants. To examine differences between Australian and
Singaporean cohorts, Mann-Whitney U and Chi-Squared tests were used
(continuous and categorical variables respectively). Partial correlations,
controlling for body mass and height, were used to examine the asso-
ciations between our measures of 5STS, strength, and balance.
Separate multivariable linear regression models were used to ana-
lyse the contribution of strength and balance to the 5STS, similar to
previous work [19]. All models were adjusted for pertinent covariates
of age, height, body mass, gender, time since stroke (log transformed),
and country recruited (Australia or Singapore). To avoid overfitting of
the models, principal component analysis was used to combine gender,
time since stroke, and country recruited into one variable [24]. It
should be noted that the first principal component (PC1) was used,
which explained 42 % of the variance in the three covariates. The re-
gression models were first created with a base model of covariates (PC1,
age, height, and body mass), with 5STS time as the dependent variable.
Then strength of both limbs for one muscle group (entered into the
same model as two variables) or one balance measure was entered into
the model as independent variables and the change statistics (adjusted
R2 values) examined to determine the incremental value of strength and
balance variables over the covariates. This process was repeated for
each muscle group for strength and each measure for balance. For each
muscle group, the combined R2 values after entering both paretic and
B.F. Mentiplay, et al. Gait & Posture 78 (2020) 35–39

non-paretic strength into the model was evaluated, as 5STS is a bilateral Table 2
task and this procedure allows for collinear variables to combine in- Regression results for the contribution of isometric strength and balance to
stead of competing against each other for outcome variance. 5STS time.
Lastly, to compare strength and balance in their relationship with R2 increment P-value of Total
5STS time, a regression model with a partial F-test was performed increment adjusted R2
[19,24]. The muscle group (both limbs) and balance measure that de-
Strength Ankle 0.030 0.11 0.340
monstrated the largest incremental change over the base model of
(paretic and dorsiflexors
covariates were chosen in this head-to-head comparison. A full re- non-paretic) Ankle 0.096 0.01* 0.406
gression model was created with the covariates, strength, and balance plantarflexors
measures. To assess whether balance added incremental value to a Hip abductors 0.056 0.04* 0.366
Hip extensors# 0.008 0.30 0.264
model that included strength measures and covariates, the balance
Hip flexors 0.113 < 0.01* 0.423
measure was removed from the full model and the decrement in ad- Knee extensors 0.179 < 0.01* 0.489
justed R2 values was computed. This process was repeated for the Knee flexors 0.063 0.03* 0.373
strength measure to understand which measure provided significant Balance Total path 0.166 < 0.01* 0.476
contributions to the model. length
ML amplitude 0.092 < 0.01* 0.402
The regression residuals were examined to determine if they ade-
ML velocity 0.121 < 0.01* 0.431
quately met the assumptions for least squares regressions. Significance AP amplitude 0.107 < 0.01* 0.417
was set at P < 0.05 for analyses, with all analyses performed using the AP velocity 0.168 < 0.01* 0.478
Statistical Package for Social Sciences, version 25 (IBM Corp., Armonk
NY, USA). Results from linear regression models, with analyses adjusted for age, height,
body mass as well as one variable (created using principal component analysis)
that combined gender, time since stroke (log transformed) and country re-
3. Results cruited. R2 increment is the change in R2 of each variable (either strength of
both sides or one balance measure entered into the model) over a base model of
Sixty-three participants were recruited [18,19]; however, two par- covariates (the base model of covariates R2 was 0.310 for all models, except for
ticipants were unable to perform the 5STS and thus were removed. Of hip extensors which was 0.256 due to the lower participant numbers for that
the 61 included participants, 20 were from Australia and 41 from measure). The P-value of increment is the significance level of the R2 increment.
Singapore (Table 1). There were no significant differences between Total adjusted R2 is the total combined model with covariates (base model R2)
Australian and Singaporean participants (Table 1), except for the Sin- and the independent variables (R2 increment). Significant increments
gaporean participants performing the 5STS faster (P < 0.01). Hip ex- (P < 0.05) are highlighted bold with an asterisk. # = assessment of hip ex-
tensor strength was measured in 49/61 participants due to an inability tensors only performed in 49/61 participants. Non-paretic ankle plantarflexors
and all balance measures were log transformed to reduce the influence of
to lie prone for testing. Descriptive data for strength and balance
outliers. ML = mediolateral; AP = anteroposterior; 5STS = five times sit-to-
measures are provided in Appendix Table 1.
stand.
Upon inspection of the data, large (but real) outliers were visually
observed for the strength of the non-paretic ankle plantarflexors and all
over the covariates in their contribution to 5STS time for the knee ex-
balance measures. As such, these measures were log transformed prior
tensors, hip flexors, ankle plantarflexors, knee flexors, and hip abduc-
to all analyses to reduce the impact of these outliers on results.
tors. Strength of the knee extensors had the largest contribution to 5STS
Significant partial correlations were found between paretic and non-
time with 17.9 % over the covariates.
paretic lower-limb strength for all muscle groups (r = 0.28 to 0.76,
Linear regression models (Table 2) showed all balance measures to
P < 0.05; Appendix Table 2). For the most part, paretic side strength
have significant incremental value over the covariates in their con-
had significant correlations with balance, whilst non-paretic side
tribution to 5STS time (P < 0.01). Anteroposterior velocity and total
strength did not (Appendix Table 3).
path length had the largest R2 increments, contributing 16.8 % and 16.6
There were significant partial correlations between 5STS time and
% to the variance in 5STS respectively.
the strength of paretic side muscle groups (r = -0.34 to -0.47; P < 0.05;
Lastly, partial F-tests (Table 3) were used to compare the strongest
Appendix Table 4) except for the hip extensors (P > 0.05). Significant
strength (knee extensor strength) and balance measures (ante-
partial correlations were observed between 5STS time and non-paretic
roposterior velocity and total path length) in their contribution to 5STS
ankle plantarflexor strength (r = -0.34; P < 0.05) and all standing
time. The partial F-test revealed that both strength and balance had
balance measures (r = -0.27 to -0.56; P < 0.05; Appendix Table 4).
significant contributions to 5STS time, independent of each other. For
Linear regression models (Table 2) showed that strength of the
example, a regression model that contained covariates, knee extensor
paretic and non-paretic side (both entered into the same model as in-
strength, and anteroposterior velocity had a total R2 value of 56.5 %
dependent variables) provided significant incremental value (P < 0.05)

Table 1
Participant characteristics.
Total (n = 61) Australia (n = 20) Singapore (n = 41) Difference between cohorts (P-value)

Age 59 ± 13 59 ± 16 59 ± 11 0.93
Gender (male/female) 32/29 8/12 24/17 0.17
Height (cm) 163 ± 10 166 ± 9 162 ± 10 0.35
Mass (kg) 66 ± 14 71 ± 19 64 ± 11 0.33
Time since stroke (months) 39 ± 52 58 ± 72 30 ± 35 0.20
Stroke paretic side (left/right) 31/30 9/11 22/19 0.53
Type of stroke (haemorrhage/ischaemic) 15/46 8/12 7/34 0.05
Assistive devices used outdoors (yes/no) 37/24 13/7 24/17 0.63
Habitual gait velocity (m/s) 0.87 ± 0.36 0.78 ± 0.30 0.91 ± 0.38 0.11
5STS (seconds) 18.51 ± 9.65 24.62 ± 13.55 15.53 ± 4.97 < 0.01*

Data reported as mean ± standard deviation for continuous variables and frequencies for categorical variables. Differences between the Australian and Singaporean
cohorts examined with Mann-Whitney U tests for continuous variables and Chi-Squared tests for categorical variables. 5STS = five times sit-to-stand.

37
B.F. Mentiplay, et al.
Table 3
Partial F-test comparing isometric strength and balance in their contribution to
5STS time.
Total R2 Reduction in R2 P-value
Balance vs Strength 0.565
Remove KE both sides 0.087 < 0.01*
Remove AP velocity 0.076 < 0.01*
Balance vs Strength 0.558
Remove KE both sides 0.082 < 0.01*
Remove total path length 0.069 < 0.01*
Total R2 column reflects the total model containing the covariates (age, height,
body mass, and one variable that combined gender, time since stroke and
country recruited; base model R2 of 0.310 as per Table 2) and measures of knee
extensor strength (both the paretic and non-paretic sides) and balance (either
anteroposterior velocity or total path length). The reduction in R2 column is the
impact of removing either strength or balance from the model, with the cor-
responding P-value reported. As removing either strength or balance from the
model has a significant P-value, this indicates that both strength and balance
have significant and independent contributions to 5STS time. Significant re-
ductions in R2 (P < 0.05) are highlighted bold with an asterisk. Both balance
measures were log transformed to reduce the influence of outliers. AP =
anteroposterior; KE = knee extensor strength; 5STS = five times sit-to-stand.
(strength and balance contributed 25.5 % of the total variance over
covariates). In that model, both strength and balance measures in-
dependently contributed to 5STS time; increment values of strength and
balance measures over each other were 8.7 % (P < 0.01) and 7.6 %
(P < 0.01), respectively.
4. Discussion
Our findings suggest that both strength and standing balance have
significant relationships with 5STS time, independent of each other.
Although conflicting evidence exists in the literature, these findings
support previous research [10,13] that has found significant contribu-
tions of both strength and balance to the 5STS test in older adults and
those after stroke. The results of this study agree with the notion that
5STS time is not solely a measure of muscle strength.
Whilst chair rise ability was developed as a functional measure of
lower-limb strength [6], our current results, together with previous
findings, indicate that the 5STS may in fact be an assessment that also
examines balance ability. Measures of total path length and ante-
roposterior velocity provided the largest contribution of balance mea-
sures to 5STS time (just under 17 % of the variance). Previous research
in stroke has suggested balance, and not strength, determines 5STS time
[10]; however, it should be noted that we used differing methodology.
The previous study [10] utilised the BBS, a 14-item test that combines
both static and dynamic balance tasks (including three items directly
assessing sit-to-stand movements). We focused on a more specific aspect
of balance, being a simple static balance task using clinically feasible
and accurate technologies, which may represent a ‘true’ measure of
balance that is less impacted by other impairments compared with
dynamic measures. Dynamic balance measures (e.g. timed up and go,
step tests, functional reach) may have a larger contribution to the 5STS
test [10,14] and may be more functionally relevant with regard to falls
risk; however, these measures are themselves influenced by a range of
other impairments irrespective of balance ability (e.g. muscle strength).
Our results indicate that a simple static balance task provides relevant
information about the 5STS after stroke.
Lower-limb muscle strength showed significant relationships with
5STS time, independent of balance measures. We examined a range of
muscle groups, with the knee extensors showing the largest magnitude
of contribution to 5STS (just under 18 % of the variance). Table 2 also
suggests a relationship between 5STS time and the strength of the ankle
plantarflexors, hip abductors, hip flexors, and knee flexors. Previous
research has suggested the knee extensors [13,15], knee flexors [9,13],
38
Gait & Posture 78 (2020) 35–39
ankle plantarflexors [25], and ankle dorsiflexors [13] to have a strong
relationship with 5STS. One previous study in stroke [10] created a
composite score for lower-limb strength by combining multiple muscle
groups without appropriate weighting, which may have resulted in the
score being dominated by stronger lower-limb muscle groups (e.g. knee
extensors) or the score being diluted by muscle groups that contribute
little to the sit-to-stand movement. As the current study has suggested a
relationship between knee extensor strength and 5STS time, this com-
posite score [10] may be a reason for the finding that strength does not
have a significant relationship with 5STS time. We believe a composite
score of lower-limb strength is not desirable in most instances; however,
if a composite score of multiple muscle groups is required, weighting
should be provided to ensure muscle groups with less strength (or less
available torque) provide a similar contribution to the composite score
[26].
There has been a relatively recent shift towards undertaking
strength training in neurological rehabilitation; however, it remains
unclear what the best combination of interventions are for improving
functional outcomes [27,28]. Our results highlight the importance of
both strength and balance in contributing to 5STS time, although given
the cross-sectional nature of our study, further research is needed to
confirm the optimal combination of interventions to improve sit-to-
stand ability following stroke.
This study is not without limitations. We examined only two im-
pairments, with the results of our regression analyses revealing rela-
tively small contributions of strength and balance to 5STS time
(Table 3); suggesting that 5STS has many contributors to performance
(e.g. motor control, muscular endurance, or cardiorespiratory fitness).
Psychological domains have also shown relationships with 5STS, such
as anxiety, vitality, and pain [13], while fear of falling has shown a link
to sit-to-stand ability in Parkinson’s disease [29]. Further research is
needed post stroke to examine the role of other impairments in 5STS
time.
We used a standard chair height [10,13]; however, our results may
have differed if we normalised chair height to participant character-
istics (e.g. limb length or knee flexion angle in sitting). This study in-
cluded a relatively high functioning cohort, as our selection criteria
required participants to be able to walk ≥10 m without assistance or
gait aids (used for our original studies [18,19]). Despite this criterion,
there was a large range in 5STS time from 5 to 61 s; however, our
results may not be generalisable to those who can perform the 5STS test
but are not independently ambulant. The average 5STS time was 18.5 s,
which is higher than previously used cut-off scores, such as 12.6 s used
to discriminate community ambulation (> 0.80 m/s gait velocity) post
stroke [30], and 12.2 s used to discriminate between older adults and
adults post stroke [9].
5. Conclusions
This study suggests that both balance and strength contribute to
5STS time after stroke. Knee extensor strength, along with measures of
static standing balance ability (total path length and anteroposterior
path velocity), provided the largest magnitude of association with 5STS
time. Further research is needed to examine other impairments post
stroke that may impact performance of the 5TS.
Authors’ contributions
All authors were involved in the study design. BFM collected and
analysed data and created software for data analysis. RAC created
software for data collection and analysis. BFM and YHP performed the
statistical analyses. BFM drafted the initial manuscript. All authors
contributed to the revision of the manuscript and have read and ap-
proved the final version.
B.F. Mentiplay, et al.
Funding
BFM was funded by an Endeavour Research Fellowship from the
Australian Government, Department of Education and Training; RAC
was funded by a National Health and Medical Research Council Career
Development Fellowship; and GW was funded by a National Health and
Medical Research Council Translating Research into Practice
Fellowship. The funding bodies had no involvement in the study.
Ethics approval and consent to participate
This study was approved by the institutional ethics committee at
each site (Epworth HealthCare 637-14; Singapore General Hospital
2015/2562) and all participants provided written informed consent.
Availability of data and material
The datasets used and analysed during the current study are avail-
able from the corresponding author on reasonable request.
Consent for publication
Not applicable.
Declaration of Competing Interest
The authors declare that they have no competing interests.
Acknowledgements
The authors would like to acknowledge Dr Brooke Adair and Dr
Dawn Tan for their assistance with this study.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.gaitpost.2020.03.005.
References
[1] V.L. Feigin, M.H. Forouzanfar, R. Krishnamurthi, G.A. Mensah, M. Connor,
D.A. Bennett, et al., Global and regional burden of stroke during 1990-2010: find-
ings from the Global Burden of Disease Study 2010, Lancet 383 (2014) 245–255.
[2] A.C.H. Geurts, M. De Haart, I.J.W. Van Nes, J. Duysens, A review of standing bal-
ance recovery from stroke, Gait Posture 22 (2005) 267–281.
[3] R.W. Bohannon, Muscle strength and muscle training after stroke, J. Rehabil. Med.
39 (2007) 14–20.
[4] S. Barreca, C.S. Sigouin, C. Lambert, B. Ansley, Effects of extra training on the
ability of stroke survivors to perform an independent sit-to-stand: a randomized
controlled trial, J. Geriatr. Phys. Ther. 27 (2004) 59–68.
[5] D.G. de Sousa, L.A. Harvey, S. Dorsch, B. Varettas, S. Jamieson, A. Murphy, et al.,
Two weeks of intensive sit-to-stand training in addition to usual care improves sit-
to-stand ability in people who are unable to stand up independently after stroke: a
randomised trial, J. Physiother. 65 (2019) 152–158.
[6] M. Csuka, D.J. McCarty, Simple method for measurement of lower extremity muscle
strength, Am. J. Med. 78 (1985) 77–81.
[7] J.M. Guralnik, E.M. Simonsick, L. Ferrucci, R.J. Glynn, L.F. Berkman, D.G. Blazer,
et al., A short physical performance battery assessing lower extremity function:
39
Gait & Posture 78 (2020) 35–39
association with self-reported disability and prediction of mortality and nursing
home admission, J. Gerontol. 49 (1994) M85–M94.
[8] R.W. Bohannon, Measurement of sit-to-stand among older adults, Top. Geriatr.
Rehabil. 28 (2012) 11–16.
[9] Y. Mong, T.W. Teo, S.S. Ng, 5-Repetition sit-to-stand test in subjects with chronic
stroke: reliability and validity, Arch. Phys. Med. Rehabil. 91 (2010) 407–413.
[10] S.S.M. Ng, Balance ability, not muscle strength and exercise endurance, determines
the performance of hemiparetic subjects on the timed-sit-to-stand test, Am. J. Phys.
Med. Rehabil. 89 (2010) 497–504.
[11] Y. Goto, Y. Otaka, K. Suzuki, S. Inoue, K. Kondo, E. Shimizu, Incidence and cir-
cumstances of falls among community-dwelling ambulatory stroke survivors: a
prospective study, Geriatr. Gerontol. Int. 19 (2019) 240–244.
[12] Y.H. Pua, J. Thumboo, R.A. Clark, Correspondence: time-based versus repetition-
based sit-to-stand measures: choice of metrics matters, J. Physiother. 64 (2018)
200–201.
[13] S.R. Lord, S.M. Murray, K. Chapman, B. Munro, A. Tiedemann, Sit-to-stand per-
formance depends on sensation, speed, balance, and psychological status in addi-
tion to strength in older people, J. Gerontol. A Biol. Sci. Med. Sci. 57 (2002)
M539–M543.
[14] D. Tiwari, S.A. Talley, B. Alsalaheen, A. Goldberg, Strength of association between
the five‑times‑sit‑to‑stand test and balance, knee extensor strength and lower limb
power in community‑dwelling older adults, Int. J. Ther. Rehabil. 26 (2019) 1–10.
[15] R.W. Bohannon, Knee extension strength and body weight determine sit-to-stand
independence after stroke, Physiother. Theory Pract. 23 (2007) 291–297.
[16] M.J. Lomaglio, J.J. Eng, Muscle strength and weight-bearing symmetry relate to sit-
to-stand performance in individuals with stroke, Gait Posture 22 (2005) 126–131.
[17] L. Blum, N. Korner-Bitensky, Usefulness of the Berg Balance Scale in stroke re-
habilitation: a systematic review, Phys. Ther. 88 (2008) 559–566.
[18] B.F. Mentiplay, D. Tan, G. Williams, B. Adair, Y.H. Pua, K.J. Bower, et al.,
Assessment of isometric muscle strength and rate of torque development with hand-
held dynamometry: test-retest reliability and relationship with gait velocity after
stroke, J. Biomech. 75 (2018) 171–175.
[19] B.F. Mentiplay, G. Williams, D. Tan, B. Adair, Y.-H. Pua, C.W. Bok, et al., Gait
velocity and joint power generation after stroke: contribution of strength and bal-
ance, Am. J. Phys. Med. Rehabil. 98 (2019) 841–849.
[20] E. Von Elm, D.G. Altman, M. Egger, S.J. Pocock, P.C. Gøtzsche, J.P. Vandenbroucke,
et al., The Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) statement: guidelines for reporting observational studies, J. Clin.
Epidemiol. 61 (2008) 344–349.
[21] R.A. Clark, B.F. Mentiplay, Y.H. Pua, K.J. Bower, Reliability and validity of the Wii
Balance Board for assessment of standing balance: a systematic review, Gait Posture
61 (2018) 40–54.
[22] R.A. Clark, Y.H. Pua, SeeSway – a free web-based system for analysing and ex-
ploring standing balance data, Comput. Methods Programs Biomed. 159 (2018)
31–36.
[23] B.F. Mentiplay, L.G. Perraton, K.J. Bower, B. Adair, Y.H. Pua, G.P. Williams, et al.,
Assessment of lower limb muscle strength and power using hand-held and fixed
dynamometry: a reliability and validity study, PLoS One 10 (2015) e0140822.
[24] F.E. Harrell Jr., Regression Modeling Strategies: With Applications to Linear
Models, Logistic and Ordinal Regression, and Survival Analysis, Springer, New
York, United States of America, 2015.
[25] E.K. McCarthy, M.A. Horvat, P.A. Holtsberg, J.M. Wisenbaker, Repeated chair
stands as a measure of lower limb strength in sexagenarian women, J. Gerontol. A
Biol. Sci. Med. Sci. 59 (2004) 1207–1212.
[26] M. Schenkman, M.A. Hughes, G. Samsa, S. Studenski, The relative importance of
strength and balance in chair rise by functionally impaired older individuals, J. Am.
Geriatr. Soc. 44 (1996) 1441–1446.
[27] G. Williams, M. Kahn, A. Randall, Strength training for walking in neurologic re-
habilitation is not task specific: a focused review, Am. J. Phys. Med. Rehabil. 93
(2014) 511–522.
[28] S. Dorsch, L. Ada, D. Alloggia, Progressive resistance training increases strength
after stroke but this may not carry over to activity: a systematic review, J.
Physiother. 64 (2018) 84–90.
[29] M.R. Landers, M. Lopker, M. Newman, R. Gourlie, S. Sorensen, R. Vong, A cross-
sectional analysis of the characteristics of individuals with Parkinson disease who
avoid activities and participation due to fear of falling, J. Neurol. Phys. Ther. 41
(2017) 31–42.
[30] G.C. Lee, S.H. An, Y.B. Lee, D.-S. Park, Clinical measures as valid predictors and
discriminators of the level of community ambulation of hemiparetic stroke survi-
vors, J. Phys. Ther. Sci. 28 (2016) 2184–2189.