Clinical Biomechanics 61 (2019) 22–30

Contents lists available at ScienceDirect

Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Transitions sit to stand and stand to sit in persons post-stroke: Path of centre T
of mass, pelvic and limb loading – A pilot study
Julie Vaughan-Graham , Kara Patterson, Dina Brooks, Karl Zabjek, Cheryl Cott
⁎

Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, ON M5G 1V7, Canada

ARTICLE INFO ABSTRACT

Keywords: Background: To explore the movement patterns utilized by persons post stroke from the simultaneous per-
Pelvic loading spective of pelvic and limb loading with the path of centre of mass during the movement transitions sit to stand
Limb loading and stand to sit.
Centre of mass Methods: A descriptive pilot study where kinetic and kinematic data were collected and compared between the
Sit to stand
contribution made by the less affected versus more affected lower limb and trunk during sit to stand and stand to
Stand to sit
sit following stroke. Movement analysis was undertaken using force-plates and a 3D VICON motion capture
Hemiparesis
Post-stroke system.
Findings: Data were successfully collected on nine subjects of whom four presented with left side more affected
and eight were male. Two patterns were demonstrated for pelvic loading, four patterns for limb loading and five
patterns for deviation of centre of mass. There were no consistent patterns of movement demonstrated depen-
dent upon the more or less affected side. There was no consistent relationship between pelvic and limb loading
and deviation of centre of mass throughout the movement phases.
Interpretation: In contrast to assumptions often made with respect to limb loading, we found large variability in
movement patterns utilized by person's with a hemiparetic presentation during sit to stand and stand to sit. The
findings suggest that movement problems encountered by persons post-stroke are complex and identifies lim-
itations with respect to current measurement techniques.

1. Introduction impairments (Teasell et al., 2009), and up to 40% have limited to no

Sit to stand (SitTS) is one of the most basic activities of daily living
(Hu et al., 2013), a primary determinant for independence, and equally
as important as ambulation (Camargos et al., 2009; Etnyre and Thomas,
2007). SitTS requires greater lower limb joint torque and range of
motion than either walking or climbing stairs (Lomaglio and Eng,
2005). Performing sitTS requires the generation of force equal to body
mass plus gravity, as well as ensuring appropriate postural control to
transition from a large to small base of support (Boyne et al., 2011;
Chou et al., 2003; Hu et al., 2013; Silva et al., 2013). Infact, sitTS re-
quires more lower limb joint torque and range of motion than either
walking or climbing stairs (Lomaglio and Eng, 2005).
Stand to sit (standTS) is also an essential daily activity but it has
been investigated much less than SitTS, with the primary concern being
how well the individual is able to control the body's downward velocity,
requiring eccentric muscle control (Chen et al., 2010).
Approximately 40% of stroke survivors have moderate to severe
walking ability (Kollen et al., 2006). Whilst there has been considerable
study on the motor behavior involved in gait (Beyaert et al., 2015),
there is less evidence on the motor behavior of sitTS (Boyne et al., 2011;
Camargos et al., 2009; Hu et al., 2013; Lomaglio and Eng, 2005; Silva
et al., 2013) and even less on the motor behavior involved in the
transition of standTS in persons post-stroke (Chen et al., 2010; Dubost
et al., 2005). In the few studies that have been done, asymmetrical limb
loading and modifying the anterior/posterior and lateral displacement
of the centre of mass (CoM) have been identified as common movement
problems in both sitTS and standTS in persons post-stroke (Briere et al.,
2010; Chen et al., 2010; de Souza Rocha et al., 2010; Roy et al., 2007).
A primary focus of neuro-rehabilitation is the recovery of functional
activities with a particular emphasis on movement performance
(Beyaert et al., 2015; Vaughan-Graham et al., 2015). The nature of
neuroscientific research on movement requires that specific aspects of
human movement such as timing, trajectory, coordination, postural
sway, and body configuration need to be identifiable and measurable

⁎
Corresponding author.
E-mail addresses: julie.vaughan.graham@utoronto.ca (J. Vaughan-Graham), kara.patterson@utoronto.ca (K. Patterson), dina.brooks@utoronto.ca (D. Brooks),
k.zabjek@utoronto.ca (K. Zabjek), cheryl.cott@utoronto.ca (C. Cott).

https://doi.org/10.1016/j.clinbiomech.2018.11.004
Received 25 July 2018; Accepted 8 November 2018
0268-0033/ © 2018 Elsevier Ltd. All rights reserved.
J. Vaughan-Graham et al.
Table 1
Inclusion/exclusion criteria.
Inclusion criteria
30–70 years of age
1st episode of stroke or acquired brain injury resulting in hemiparesis
> 12 weeks < 24 months post neurological injury
Attending community based neuro-rehabilitation
Able to sitTS and standTS independently without the use of the upper limbs, an
assistive device or orthosis
Able to maintain independent standing for at least 60 s
Passive ankle dorsiflexion to 90°
Able to understand instructions in English
Ability to provide informed consent
(Powell and Williams, 2015; Vaughan-Graham et al., 2018), whereas
clinicians require a broad holistic understanding that integrates all as-
pects of movement and are primarily interested in the movement pat-
terns utilized (Harbourne and Stergiou, 2009; Vaughan-Graham et al.,
2017).
No studies to date have specifically described the movement pat-
terns utilized by persons post stroke from the simultaneous perspective
of pelvic and limb loading with the path of COM during these move-
ment transitions. This pilot study was developed to provide important
information on (i) feasibility; (ii) protocol procedures; (iii) refining
measurement and data collection procedures; and (iv) data quality to
facilitate planning of a larger scale study (Brooks and Stratford, 2009).
In this pilot study, we explored movement patterns utilized by persons
post-stroke during sitTS and standTS through the simultaneous inter-
pretation of pelvic and foot centre of pressure (CoP) measures and the
deviation of CoM from midline. This information will further clinicians'
understanding of sitTS and standTS movement impairments due to
stroke thereby guiding remediation of these movement transitions to
enhance outcomes.
2. Methods
This was a descriptive pilot study where kinetic and kinematic data
were collected and compared between the contribution made by the
less affected vs more affected lower limb and trunk during sitTS and
standTS following stroke. Movement analysis was undertaken using
force-plates and a 3D VICON motion capture system. Ethics approval
was granted for this study by the Health Sciences Research Ethics
Board, University of Toronto (protocol reference #29399).
Table 2
Operationalization of pelvic/limb loading and deviation of COM (refer to Supplemental Tables 5, 6 & 7).
Pelvic and limb loading (N)
Towards more affected side
Similar loading
Towards less affected side
Deviation of centre of mass (CoM) (mm)
Towards more affected side
No deviation
Towards less affected side
Clinical Biomechanics 61 (2019) 22–30
Exclusion criteria
Previous history of neurologic disease, such as Parkinson's disease, pontine and/or
cerebellar lesions, peripheral neuropathies
Botox injection to the lower limb within 12 weeks of study enrollment
Receptive aphasia
Orthopedic lower extremity pathology or rheumatoid conditions which affect sitTS and
standTS
Auditory or visual deficits that could prevent data collection
2.1. Sample size justification and recruitment
All participants were community-dwelling adults aged between 35
and 70 years who had sustained adult-onset of 1st stroke or acquired
brain injury with resulting hemiparesis (Table 1). Ten participants were
recruited from community rehabilitation clinics who were participating
in out-patient physiotherapy. This sample size is consistent with similar
studies whose samples were between 12 and 18 participants with
stroke. For example, Roy et al. (2007), and Camargos et al. (2009),
investigated lower limb asymmetry and the effect of foot position in 12
stroke patients. Duclos et al. (2008), evaluated the effect of foot posi-
tion on sitTS in 18 stroke subjects, Chen et al. (2010), investigated leg
load sharing strategies and sitting impact forces in the standTS transfer
with 18 stroke subjects, and de Souza Rocha et al. (2010) investigated
the effect of constraint of the non-paretic lower limb, using a step, with
12 stroke subjects.
2.2. Experimental protocol and data collection
Each participant attended for a single evaluation comprising five
successive sitTS and standTS transitions with a 1 minute rest period
between each sitTS. The participants were barefoot, dressed in shorts
and sleeveless T-shirt and were seated in a standardized position on a
bench (armless and backless) at standard chair height (45 cm) in which
two force plates were embedded. The participants placed themselves
into the sitting position and were provided with instruction on the
standard sitting position as follows: sitting on the bench with each is-
chial tuberosity located on a separate force plate and with two thirds of
the femurs supported, arms positioned as close as possible to body, feet
placed symmetrically, each foot placed on a force plate embedded in
> than ± 1 standard deviation on the more affected side
Means of both limbs within ± 1 standard deviation of each other
> than ± 1 standard deviation on the less affected side
Mean > than ± 1 standard deviation from 0 towards the more affected side
Mean within ± 1 standard deviation of 0
Mean > than ± 1 standard deviation from 0 towards the less affected side
23
J. Vaughan-Graham et al. Clinical Biomechanics 61 (2019) 22–30

Table 3
Participant demographics.
Subject ID Sex M/F Age (Yrs) Diagnosis Time since onset (months) More affected side R/L Brace Y/N Gait aid

#2 M 69 Benign meningioma 15 L N None

#3 M 60 Aneurysm 11 R N None
#4 M 26 Neurocytoma 10 L N None
#5 M 56 Left CVA 9 R N Single point cane
#6 M 58 Hemorrhagic left basal ganglia CVA 20 R N Quad cane with supervision
#7 F 52 Left CVA 19 R N Trekking pole indoors only
#8 M 66 Right CVA 25 L N Single point cane
#9 M 51 Right CVA 21 L Y Quad cane
#10 M 56 Left CVA 20 R Y Trekking pole

Legend: male (M); female (F); years (Yrs); cerebrovascular accident (CVA); right (R); left (L); yes (Y); no (N).

the floor, knees positioned as close to 105° flexion as possible, with the
distance between the lateral malleoli corresponding to hip width. Foot
placement was marked to ensure consistency between trials. The in-
struction provided to the participant was: “You may stand-up at a
comfortable speed, remain standing for three seconds and then sit
down”. Limb loading and path of centre of mass (CoM) were recorded
continuously throughout the five trials as described below.
2.2.1. Limb loading
Two AMTI BP400600-OP (Advanced Mechanical Technology Inc.,
Watertown, USA) force-plates, placed side by side and embedded in the
bench measured pelvic loading. Two AMTI OR6-7000 (Advanced
Mechanical Technology Inc., Watertown, USA) multi-axial force-plates,
placed side by side and embedded in the floor measured limb loading.
Initial measurement of the participant's body mass was made in
standing for 10 s on each floor force plate. Centre of pressure measures
were recorded throughout the sitTS and standTS movement transitions.
Force-plate data was acquired at a sampling frequency of 1000 Hz and
stored for further analysis offline. Post signal processing of the data
included filtering the data using a 6 Hz dual low pass Butterworth filter.
Additional feature extraction was performed in Matlab (Mathworks,
Natick, USA).
2.2.2. Path of the centre of mass
A VICON motion analysis system (Vicon LA, Culver City, USA) was
used to attain a 3D movement model using a 14 link segment model
involving placing reflective markers (diameter = 14 mm) to create an
anthropometric model (Winter et al., 2003). The 3D motion capture
data was acquired at a sampling frequency of 100 Hz. A modified
“Winter” model using 32 markers was utilized to specifically identify
movement of the thorax, pelvis and lower limbs. Using this anthropo-
metric model, anterio-posterior/medial-lateral trunk and pelvic dis-
placement, initial/transitional and terminal positions of the upper,
lower limbs and head were established. The midline of the base of
support was defined as the mid-point between the lateral borders of the
feet. The position of the markers were reconstructed to estimate the
mean maximal displacement of the CoM from midline during the sitTS
and standTS movement transitions.
2.3. Data analysis
Descriptive statistics (mean and one standard deviation) were cal-
culated from trials 2, 3 and 4 for pelvic and limb loading and maximal
displacement of the CoM. Kinematic and kinetic data were averaged
over these 3 trials.
The sitTS and standTS movement transitions were analyzed and
described with respect to distribution of loading and path of CoM.
Associated analysis/calculations of measures of interest were analyzed
at five time points during the sitTS and standTS movements: (i) initial
sitting; (ii) mid-point between sitTS; (iii) stationary stand; (iv) mid-
point between standTS; and, (v) terminal sitting. Pelvic and limb
loading, and deviation of CoM were operationalized with respect to
‘towards more affected side’, ‘towards less affected side’, or ‘similar
loading/no deviation from midline’ (Table 2). Plots for limb/pelvic
loading and deviation of CoM were created with respect to the phase of
movement. Participants were classified based on the similarity of the
plots.
3. Results
Ten participants successfully completed five successive sitTS and
standTS transitions with a 1 minute rest period between each sitTS.
Data were successfully collected on nine subjects. Data were incomplete
for participant #1 due to post-processing issues with force-plate data
and were not included in the analysis. Four participants presented with
the left side more affected and eight were male (Table 3).
3.1. Distribution of pelvic loading (Fig. 1)
Eight of the nine participants presented with no change in pelvic
loading at intial and terminal sit (Pattern I). Of those eight, four [#02,
03, 04, 08] demonstrated higher pelvic loading towards the more af-
fected side (Pattern I-i), one [#07] demonstrated similar loading
(Pattern I-ii), and three [#06, 09, 10] demonstrated pelvic loading to-
wards the less affected side (Pattern I-iii). Only one participant [#05]
demonstrated a change in pelvic loading from similar loading at initial
sit to increased loading on the less affected side at terminal sit (Pattern
II) (Table 5 Supplemental data).

24
J. Vaughan-Graham et al.
Paern I
Fig. 1. Pelvic loading patterns.
3.2. Distribution of limb loading (Fig. 2)
There were four patterns of limb loading demonstrated. Five of the
nine participants [#02, 05, 06, 9, 10] demonstrated pattern I, in which
limb loading is towards the more affected limb or similar loading at
initial sit, shift towards the less affected limb during the movement
transition and then shift back towards the more affected limb or similar
loading at terminal sit. Two participants [#04, 08] demonstrated pat-
tern II, in which limb loading is towards the more affected limb, shifts
towards the less affected limb at mid-point up, shifts to similar loading
25
Clinical Biomechanics 61 (2019) 22–30
Paern II
in standing and shifts to the more affected limb at terminal sit. One
participant [#03] demonstrated pattern III, in which limb loading was
shifted to the less affected side at initial sit, shifted to similar loading at
mid-point up, shifted towards the less affected side in standing, shifted
to similar loading at mid-point down and finally shifted to the less af-
fected side at terminal sit. One participant [#07] demonstrated pattern
IV, presenting with similar loading at initial sit, shifted to the less af-
fected side at mid-point up, shifted to similar loading in standing and
mid-point down and shifting to the less affected side at terminal sit
(Table 6 Supplemental data).
J. Vaughan-Graham et al. Clinical Biomechanics 61 (2019) 22–30

Pa ern I Pa ern II

Pa ern III & IV

Fig. 2. Limb loading patterns.

26
J. Vaughan-Graham et al.
3.3. Deviation of centre of mass (CoM) (Fig. 3)
There were five patterns of deviation of CoM demonstrated. Three
primary patterns (I, II & III) represent seven of the nine participants'
[#02, 04, 05, 07, 08, 09, 10] movement behavior. Three participants
[#04, 09, 10] demonstrated pattern I, in which there was no change in
the deviation of CoM throughout the movement transition, two parti-
cipants [#09, 10] were consistently deviated towards the less affected
side, pattern I-i, whilst one participant [#04] was consistently deviated
Paern I
Paern III
Fig. 3. Deviation of centre of mass.
27
Clinical Biomechanics 61 (2019) 22–30
towards the more affected side, pattern I-ii. Three participants [#02,
07, 08] demonstrated pattern II, in which the CoM is deviated towards
the more affected side at initial sit, becoming less deviated during the
movement transition and deviates back to the more affected side at
terminal sit. One participant [#05] demonstrated pattern III, in which
the CoM deviates from midline towards the less affected side and back
towards midline. One participant [#03] demonstrated pattern IV, in
which the CoM is deviated towards the less affected side until standing
and then shifts towards midline at mid-point down and terminal sit.
Paern II
Paern IV and V
J. Vaughan-Graham et al. Clinical Biomechanics 61 (2019) 22–30

One participant [#06] demonstrated pattern V, in which the CoM is 4. Discussion

deviated towards the more affected side until standing, becomes mid-
line at mid-point down and deviated to the less affected side at terminal
sit.
In summary, five of the nine participants [#02, 04, 06, 07, 08]
demonstrated their CoM deviated towards the more affected side at
initial sit, only one participant [#05] demonstrated no deviation at
initial sit, the remaining three participants [#03, 09, 10] were deviated
towards the less affected side at initial sit. Of the five participants
[#02,04,06,07,08] whose CoM was deviated towards their more af-
fected side at initial sit; four [#02, 06, 07, 08] deviated their CoM to-
wards midline during the mid-point up to mid-point down phases; three
[#02, 07, 08] deviated their CoM back towards the more affected side
at terminal sit; and one [#04] remained deviated to the more affected
side throughout the entire movement transition (Table 7 Supplemental
data).
3.4. Combined pelvic/limb loading and COM patterns (Table 4)
At ‘initial sit’ three of nine participants [#02, 04, 08] presented with
pelvic/limb loading and deviation of CoM to the more affected side.
One of the participants [#05] presented with similar limb/pelvic
loading and no deviation of the CoM.
At ‘mid-point up’, three of nine participants [#05, 09, 10] presented
with limb loading and deviation of CoM to the less affected side.
In standing, four of nine participants [#03, 05, 09, 10] presented
with limb loading and deviation of CoM to the less affected side.
At ‘mid-point down’, two of nine participants [#09, 10] presented
with limb loading and deviation of CoM to the less affected side, and
three of nine participants [#02, 03, 08] presented with similar limb
loading and no deviation of the CoM.
At ‘terminal sit’, three of nine participants [#02, 04, 08] presented
with pelvic/limb loading and deviation of CoM to the more affected
side.
There does not appear to be more of a relationship between de-
viation of CoM with initial limb or pelvic loading. However, there ap-
pears to be less of a relationship between deviation of CoM and limb
loading during mid-point up than during standing and mid-point down,
as well as less of a relationship between deviation of CoM with terminal
sit limb load than pelvic load.
The purpose of this study was to describe and characterize pelvic
and limb loading simultaneously with the path of the CoM during sitTS
and standTS movements in persons post-stroke. The results of this study
demonstrate tremendous variability in pelvic and limb loading and
deviation of the CoM during the functional activity of sitTS and standTS
despite all participants having a hemiparetic presentation.
The SitTS and standTS movement transitions place significant bio-
mechanical, postural and muscular demands on an individual, thus it is
not surprising that these activities are significantly compromised in
persons post-stroke (Boyne et al., 2011; Silva et al., 2013). Asymme-
trical limb loading and difficulty in controlling the CoM during the
movement transitions are common movement problems associated with
both sitTS and standTS (Briere et al., 2010; Chen et al., 2010; de Souza
Rocha et al., 2010; Roy et al., 2007).
Centre of pressure (CoP) measures, derived from force-plates, pro-
vide information on the centre of the distribution of the total force
applied by the body segment on the supporting surface (Shumway-Cook
and Woollacott, 2012). Unfortunately, CoP measures do not provide
information on the role of the whole foot in contact with the floor,
therefore only providing a limited view, as the alignment of the foot
and the interaction of the whole foot with the floor has the potential to
influence weight-bearing, postural control and balance (Bourane et al.,
2015; Fraser et al., 2016; Kelly et al., 2012; McKeon and Hertel, 2007;
Parsons et al., 2016; Thompson et al., 2011).
CoP measures are traditionally interpreted as an indication of the
amount and variability in limb loading and, therefore, an assumption is
that the more affected limb of the person post-stroke will register a
lower CoP, as well as increased variability, due to reduced motor
control (Parsons et al., 2016; Roy et al., 2006). However, the results of
this study suggest a more complex presentation. A number of our par-
ticipants demonstrate higher pelvic and limb loading on the more af-
fected side at initial and terminal sit, in addition to the CoM being
deviated to the more affected side. If this increased limb loading on the
more affected side was due to the inactivity of the limb, the passive
weight of the limb as a result of the stroke, one would expect the in-
creased loading to be consistently higher throughout the movement
transitions. However, this is not the case, as often the increased limb
loading shifts to the less affected limb during the mid-point up and mid-
point down phases. This is contrary to the prevailing assumption that
loading and deviation of CoM would be towards the less affected side at

Table 4
Combined pelvic/limb loading and deviation of centre of mass per movement phase.
Phase of Initial sit Mid-point up Standing Mid-point down Terminal sit
movement
Participant
#/more Deviation Pelvicl Limb Deviation Limb Deviation Limb load Deviation Limb Deviation Pelvic Limb load
affected side CoM load load CoM load CoM CoM load CoM load
#02/L A A A A S A S O S A A A
#03/R LA A LA LA A LA LA O S O A A
#04/L A A A A LA A S A S A A A
#05/R O S S LA LA LA LA LA S O LA S
#06/R A LA A A LA A LA O LA LA LA S
#07/R A S S O LA A S A S A S LA
#08/L A A A O LA O S O S A A A
#09/L LA LA S LA LA LA LA LA LA LA LA A
#10/R LA LA S LA LA LA LA LA LA LA LA A

L: left.
R: right.
CoM: centre of mass.
A: loading towards the more affected limb.
S: similar loading between limbs (within 1 SD).
LA: loading towards the less affected limb.
Red = loading towards more affected side; Blue = loading towards less affected side; Green = similar loading and no deviation of COM.
O: no deviation (mean < 1 SD either towards or away from more affected limb).

28
J. Vaughan-Graham et al.
all times for person's post-stroke.
Although higher loading was recorded on the more affected limb in
both sitting and standing for some participants, this higher loading
shifted to the less affected limb during the sitTS and standTS movement
transition phases. This suggests that the participants maybe using force
generation through their more affected limb differentially between the
static and dynamic phases of movement. Although the participants
were generating a higher loading through their more affected limb,
specifically in the static postures of sitting and standing, this loading
was not utilized to assist the sitTS or standTS movement transitions,
hence contributing to the asymmetrical nature of post-stroke movement
(Roy et al., 2007).
These results raise a number of questions for research and clinical
practice. Specifically, with respect to CoP measures, it would appear
that the loading measured does not differentiate between functional
weight-bearing and non-functional load-bearing. Clinically, functional
weight-bearing implies that the person is able to appropriately organize
the alignment of body segments with respect to gravity and the body
segment in contact with the supporting surface such that the appro-
priate muscular activity is generated to complete the movement, or
maintain a posture, whilst controlling the CoM within the base of
support (Vaughan-Graham et al., 2018). In contrast, non-functional
load-bearing implies the ability to maintain a force with respect to the
body segment in contact with the supporting surface, however, this
force generation does not functionally contribute to the maintenance of
a posture or movement performance and is not necessarily congruent
with the location of the CoM.
Higher pelvic and limb loading, and deviation of the CoM towards
one side of the body is generally interpreted as the individual has a
greater degree of weight-bearing to that side. However, whilst the force
plate measures higher loading, for example to the more affected side,
this may be interpreted as above, or alternatively it could be due to: (a)
passive loading of those body segments because there is insufficient
motor control to maintain a symmetrical posture; or (b) atypical force
generation primarily through the more affected limb, or in fact a
combination of both (a) and (b).
In clinical practice it is quite common to observe a person post-
stroke in which the pelvis and trunk are deviated to the more affected
side in sitting. Since the CoM is a virtual point at the centre of the total
body mass and is dependent upon body segment alignment (Wu and
MacLeod, 2001), it is conceivable that this is why the CoM is also de-
viated to the more affected side. Clinically, this is not interpreted as
appropriate weight transfer and weight-bearing to the more affected
side but is explained as a result of loss of truncal and pelvic motor
control due to the CNS lesion.
We also observed pelvic loading at initial sit as similar or more
towards the less affected side whilst the CoM remained deviated to the
more affected side. Or conversely, increased pelvic loading to the more
affected side at initial sit whilst the CoM was deviated to the less af-
fected side. This suggests that despite a homogenous hemiparetic pre-
sentation the organization of pelvic loading and deviation of CoM is
considerably heterogenous.
Perhaps a more difficult question to resolve is why some of the
participants are generating a higher force through their more affected
limb in sitting. Some possible explanations could include that the
person is seeking sensory information through their more affected limb
due to the loss of cutaneous and proprioceptive feedback. This would be
consistent with some recent findings suggesting that postural sway is
exploratory rather than an error correcting strategy (Carpenter et al.,
2010; McKeon and Hertel, 2007) and, that cutaneous information
through the feet is integral to balance and postural control in persons
post-stroke (Parsons et al., 2016). An alternative possible explanation
could be the loss of reciprocal innervation between both sides of the
body as a result of the cortical lesion. Although the most apparent loss
of motor control is contra-lesional, particularly in the limbs, the con-
tribution of the ipsi-lesional pathways particularly in the lower limbs
29
Clinical Biomechanics 61 (2019) 22–30
and trunk are becoming more evident in motor control research
(Mochizuki et al., 2006; Silva et al., 2012; Silva et al., 2013).
The corticoreticulospinal pathways comprise ipsilateral and bi-
lateral pathways and contribute to the generation of anticipatory
(feedforward) postural control (Darian-Smith, 2009; Klous et al., 2011;
Santos et al., 2010; Schepens et al., 2008). There is clear evidence
supporting the theory of ipsilateral feedforward stability for con-
tralateral limb movement (Krishnan et al., 2011; Krishnan et al., 2012).
Therefore, it is conceivable that higher loading through the more af-
fected limb is an atypical response to stabilize the body due, in part, to
the loss of ipsilesional truncal postural stability. Another possible ex-
planation is the involuntary recruitment of inappropriate motor activity
of the more affected lower limb in order to either maintain sitting and/
or to complete the sitTS/standTS task. However, irrespective of the
mechanism resulting in increased limb loading of the more affected
limb in sitting, this was often not translated into higher loading of the
more affected limb during the mid-point up, standing and mid-point
down phases. Thus, loading responses of the pelvis and limbs in sitting
do not appear to be a good indication of how the limbs and trunk will
actually respond in movement. Therefore, if limb loading measures are
used alone to indicate possible improvements in weight-bearing,
loading during dynamic phases of movement, in particular the mid-
point up of sitTS, may be the most optimal indicator of improvement.
Additionally, consideration of using pressure mapping of the feet, in
addition to CoP measures, may provide useful information on pressure
distribution of the entire sole of the foot furthering our clinical un-
derstanding on the differences between weight-bearing vs. non-func-
tional load-bearing.
Participation in experimental studies investigating the effectiveness
of various neuro-rehabilitation interventions typically revolves around
grouping participants by their medical diagnosis. This assumes that
persons with a similar diagnosis, such as right or left cerebrovascular
accident (CVA), present with similar movement problems and, there-
fore, it is assumed that such persons will respond in a similar manner to
the interventions. However, this study highlights the inherent hetero-
geneity in the clinical presentation of persons with cortical lesions and
contradicts the assumption that participants with cortical lesions will
demonstrate increased pelvic and limb loading as well as deviation of
the CoM towards the less affected side. This degree of heterogeneity
may be one explanation why grouping persons in studies by their
medical diagnosis alone when investigating the effectiveness of inter-
ventions produces inconclusive results as differences in functional
weight-bearing vs. non-functional loading as well as the control of the
CoM will ultimately influence the persons response to interventions.
Therefore, stratifying person's post-stroke with respect to movement
diagnosis, in addition to medical diagnosis, may assist in identifying
those persons who may benefit the most from specific interventions.
The patterns described in the current study warrant further investiga-
tion as a potential basis for movement diagnosis for sitTS and standTS.
This study has a number of limitations including: (i) A small sample
size with a broad inclusion criteria. However, this sample size is con-
sistent with similar studies (Roy et al., 2007) (Camargos et al., 2009;
Chen et al., 2010; de Souza Rocha et al., 2010; Duclos et al., 2008); (ii)
the study participants had been participating in neuro-rehabilitation for
differing amounts of time which may have contributed to the diversity
in the results; (iii) all study participants were required to be able to
sitTS and standTS independently for data collection purposes, therefore
the results are likely not reflective for persons requiring assistance for
sitTS; (iv) the bench was not height adjustable and this may have af-
fected pelvic and limb loading at initiation and termination of the
movement transitions; and, (v) inconsistency in marker placement
could influence the construction of the anthropometric model from
which the deviation of CoM was determined. This was minimized
through application of the markers by the same person in addition to
the accuracy of the VICON spatial model being < 1 mm (Winter et al.,
2003). However, this proof of concept with respect to simultaneously
J. Vaughan-Graham et al.
investigating pelvic/limb loading and deviation of CoM in persons post-
stroke warrants further investigation.
5. Conclusion
We explored pelvic and limb loading concurrently with the devia-
tion of the CoM from midline, in persons post-stroke, during the sitTS
and standTS movement transitions. The findings highlight the heter-
eogeneity in the clinical presentation by identifying differences in
pelvic and limb loading patterns, with some participants demonstrating
increased loading on the more affected side particularly at the initial
and termination of the movement transitions. The findings are in con-
trast to assumptions often made with respect to limb loading in persons
with hemiparesis. Likewise, a number of patterns emerged with respect
to the deviation of CoM suggesting that movement problems en-
countered by persons post-stroke are complex and identifies limitations
with respect to current measurement techniques.
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.clinbiomech.2018.11.004.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
References
Beyaert, C., Vasa, R., Frykberg, G., 2015. Gait post-stroke: pathophysiology and re-
habilitation strategies. Clin. Neurophysiol. 45 (4–5), 335–355.
Bourane, S., Grossmann, Katja S., Britz, O., Dalet, A., Del Barrio, Marta G., Stam, Floor J.,
Garcia-Campmany, L., Koch, S., Goulding, M., 2015. Identification of a spinal circuit
for light touch and fine motor control. Cell 160 (3), 503–515.
Boyne, P., Israel, S., Dunning, K., 2011. Speed-dependent body weight supported sit-to-
stand training in chronic stroke: a case series. J. Neurol. Phys. Ther. 35 (4), 178–184.
Briere, A., Lauziere, S., Gravel, D., Nadeau, S., 2010. Perception of weight-bearing dis-
tribution during sit-to-stand tasks in hemiparetic and healthy individuals. Stroke 41
(8), 1704–1708.
Brooks, D., Stratford, P., 2009. Pilot studies and their suitability for publication in phy-
siotherapy Canada. Physiother. Can. 61 (2), 66-66.
Camargos, A.C.R., Rodrigues-de-Paula-Goulart, F., Teixeira-Salmela, L.F., 2009. The ef-
fects of foot position on the performance of the sit-to-stand movement with chronic
stroke subjects. Arch. Phys. Med. Rehabil. 90 (2), 314–319.
Carpenter, M.G., Murnaghan, C.D., Inglis, J.T., 2010. Shifting the balance: evidence of an
exploratory role for postural sway. Neuroscience 171 (1), 196–204.
Chen, H.-B., Wei, T.-S., Chang, L.-W., 2010. Postural influence on stand-to-sit leg load
sharing strategies and sitting impact forces in stroke patients. Gait Posture 32 (4),
576–580.
Chou, S.-W., Wong, A.M.K., Leong, C.-P., Hong, W.-S., Tang, F.-T., Lin, T.-H., 2003.
Postural control during sit-to stand and gait in stroke patients. Am. J. Phys. Med.
Rehabil. 82 (1), 42–47.
Darian-Smith, C., 2009. Synaptic plasticity, neurogenesis, and functional recovery after
spinal cord injury. Neuroscientist 15 (2), 149–165.
de Souza Rocha, A., Knabben, R.J., Michaelsen, S.M., 2010. Non-paretic lower limb
constraint with a step decreases the asymmetry of vertical forces during sit-to-stand
at two seat heights in subjects with hemiparesis. Gait Posture 32 (4), 457–463.
Dubost, V., Beauchet, O., Manckoundia, P., Herrmann, F., Mourey, F., 2005. Decreased
trunk angular displacement during sitting down: an early feature of aging. Phys.
Ther. 85 (5), 404–412.
Duclos, C., Nadeau, S., Lecours, J., 2008. Lateral trunk displacement and stability during
sit-to-stand transfer in relation to foot placement in patients with hemiparesis.
Neurorehabil. Neural Repair 22 (6), 715–722.
Etnyre, B., Thomas, D.Q., 2007. Event standardization of sit-to-stand movements. Phys.
Ther. 87 (12), 1651–1666.
Fraser, J.J., Feger, M.A., Hertel, J., 2016. Midfoot and forefoot involvement in lateral
30
Clinical Biomechanics 61 (2019) 22–30
ankle sprains and chronic ankle instability part 1: anatomy and biomechanics. Int. J.
Sports Phys. Ther. 11 (6), 992–1005.
Harbourne, R.T., Stergiou, N., 2009. Movement variability and the use of nonlinear tools:
principles to guide physical therapist practice. In: Physical Therapy, (2009/03//
:267+).
Hu, P.-T., Lin, K.-H., Lu, T.-W., Tang, P.-F., Hu, M.-H., Lai, J.-S., 2013. Effect of a cane on
sit-to-stand transfer in subjects with hemiparesis. Am. J. Phys. Med. Rehabil. 92 (3),
191–202.
Kelly, L.A., Kuitunen, S., Racinais, S., Cresswell, A.G., 2012. Recruitment of the plantar
intrinsic foot muscles with increasing postural demand. Clin. Biomech. 27 (1), 46–51.
Klous, M., Mikulic, P., Latash, M.L., 2011. Two aspects of feedforward postural control:
anticipatory postural adjustments and anticipatory synergy adjustments. J.
Neurophysiol. 105 (5), 2275–2288.
Kollen, B., Kwakkel, G., Lindeman, E., 2006. Longitudinal robustness of variables pre-
dicting independent gait following severe middle cerebral artery stroke: a prospective
cohort study. Clin. Rehabil. 20 (3), 262–268.
Krishnan, V., Aruin, A., Latash, M., 2011. Two stages and three components of the pos-
tural preparation to action. Exp. Brain Res. 212 (1), 47–63.
Krishnan, V., Latash, M.L., Aruin, A.S., 2012. Early and late components of feed-forward
postural adjustments to predictable perturbations. Clin. Neurophysiol. 123 (5),
1016–1026.
Lomaglio, M.J., Eng, J.J., 2005. Muscle strength and weight-bearing symmetry relate to
sit-to-stand performance in individuals with stroke. Gait Posture 22 (2), 126–131.
McKeon, P.O., Hertel, J., 2007. Diminished plantar cutaneous sensation and postural
control. Percept. Mot. Skills 104 (1), 56–66.
Mochizuki, G., Semmler, J.G., Ivanova, T.D., Garland, S.J., 2006. Low-frequency common
modulation of soleus motor unit discharge is enhanced during postural control in
humans. Exp. Brain Res. 175 (4), 584–595.
Parsons, S., Mansfield, A., Inness, E., Patterson, K., 2016. The relationship of plantar
cutaneous sensation and standing balance post-stroke. Top. Stroke Rehabil. 23 (5),
326–332.
Powell, D., Williams, D., 2015. Athletes trained using stable compared to unstable sur-
faces exhibit distinct postural control profiles when assessed by traditional and
nonlinear measures. Hum. Mov. Sci. 44, 73–80.
Roy, G., Nadeau, S., Gravel, D., Malouin, F., McFadyen, B.J., Piotte, F., 2006. The effect of
foot position and chair height on the asymmetry of vertical forces during sit-to-stand
and stand-to-sit tasks in individuals with hemiparesis. Clin. Biomech. 21, 585–593.
Roy, G., Nadeau, S., Gravel, D., Piotte, F., Malouin, F., McFadyen, B.J., 2007. Side dif-
ference in the hip and knee joint moments during sit-to-stand and stand-to-sit tasks in
individuals with hemiparesis. Clin. Biomech. 22 (7), 795–804.
Santos, M.J., Kanekar, N., Aruin, A.S., 2010. The role of anticipatory postural adjustments
in compensatory control of posture: 1. Electromyographic analysis. J. Electromyogr.
Kinesiol. 20 (3), 388–397.
Schepens, B., Stapley, P., Drew, T., 2008. Neurons in the pontomedullary reticular for-
mation signal posture and movement both as an integrated behavior and in-
dependently. J. Neurophysiol. 100 (4), 2235–2253.
Shumway-Cook, A., Woollacott, M., 2012. Motor Control: Translating Research into
Clinical Practice, 4th ed. Lippincott Williams & Wilkins, Baltimore.
Silva, A., Sousa, A.S.P., Pinheiro, R., Tavares, J., Santos, R., Sousa, F., 2012. Soleus ac-
tivity in post-stroke subjects: movement sequence from standing to sitting.
Somatosens. Mot. Res. 29 (3), 71–76.
Silva, A., Sousa, A.S., Pinheiro, R., Ferraz, J., Tavares, J.M.R., Santos, R., Sousa, F., 2013.
Activation timing of soleus and tibialis anterior muscles during sit-to-stand and stand-
to-sit in post-stroke vs. healthy subjects. Somatosens. Mot. Res. 30 (1), 48–55.
Teasell, R., Meyer, M.J., Foley, N., Salter, K., Willems, D., 2009. Stroke rehabilitation in
Canada: a work in progress. Top. Stroke Rehabil. 16 (1), 11–19.
Thompson, C., Bélanger, M., Fung, J., 2011. Effects of plantar cutaneo-muscular and
tendon vibration on posture and balance during quiet and perturbed stance. Hum.
Mov. Sci. 30 (2), 153–171.
Vaughan-Graham, J., Cott, C., Wright, F.V., 2015. The Bobath(NDT) concept in adult
neurological rehabilitation: what is the state of the knowledge? A scoping review part
I : conceptual perspectives. Disabil. Rehabil. 37 (20), 1793–1807.
Vaughan-Graham, J., Patterson, K., Zabjek, K., Cott, C., 2017. Conceptualizing movement
by expert Bobath instructors in neurological rehabilitation. J. Eval. Clin. Pract. 23 (6),
1153–1163.
Vaughan-Graham, J., Patterson, K., Zabjek, K., Cott, C., 2018. Mind The Gap: Important
Movement Concepts - Clinical vs. Neuroscience perspectives. Mot. Control (Accepted
for publication).
Winter, D.A., Patla, A., Ishac, M., Gage, W.H., 2003. Motor mechanisms of balance during
quiet standing. J. Electromygr. Kinesiol. 13 (1), 49–56.
Wu, G., MacLeod, M., 2001. The control of body orientation and center of mass location
under asymmetrical loading. Gait Posture 13 (2), 95–101.