Manual Therapy 15 (2010) 88–92

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Original Article

Lumbofemoral rhythm during active hip flexion in standing in healthy

older adults
Yi-Liang Kuo a, c, Elizabeth A. Tully b, *, Mary P. Galea b
a
Department of Physical Therapy, Tzu Chi University, Hualien 97004, Taiwan
b
School of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria 3010, Australia
c
Department of Physical Therapy, Tzu Chi College of Technology, Hualien 97005, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: The 2D PEAK Motus motion analysis system was used to measure the sagittal lumbofemoral rhythm
Received 3 February 2009 during active hip (knee) flexion in standing in 34 healthy older adults whose movement may be influ-
Received in revised form enced by age-related changes in the neuromusculoskeletal system. When the thigh was raised, the
14 July 2009
lumbar spine moved concurrently with the hip joint throughout the movement. Approximately 5! of
Accepted 6 August 2009
initial hip flexion occurred before 1! of lumbar flexion. Overall, the lumbar spine contributed 26.6%
(29.3! ) of the total thigh movement (pelvis þ hip joint) during the upward (110.2! ) movement phase.
Keywords:
Compared to children and young adults, older adults demonstrated some age-related differences in
Spine
Hip sagittal lumbofemoral rhythm, including decreased hip flexion and a large variation in the hip-to-lumbar
Motion analysis movement ratio. Clinicians and exercise instructors need to be aware of the concurrent movement
Ageing interaction between the hip joint and lumbar spine when measuring hip flexion range or when
instructing abdominal, hip, or lumbar exercises. The potential influence of limited range of motion of
either hip or lumbar component on the movement should also be addressed.
! 2009 Published by Elsevier Ltd.

1. Introduction
Scapulohumeral rhythm, or the concurrent movement of the
scapula with the humerus during arm elevation is well documented
in the literature and understood by clinicians. However, this is not
the case with regard to the kinematic contribution of the hip joint,
pelvis and lumbar spine as the thigh is flexed towards the chest. The
current understanding is that the hip joint and pelvis move
sequentially, with the hip joint being flexed first, and the pelvis
commencing to rotate posteriorly once the hip joint has completed
its full range. This is evidenced by the attempt to limit pelvic
movement during the straight leg raising test (Fisk, 1979; Gajdosik
et al., 1993) or to detect the onset of pelvic rotation when
measuring hip flexion range (Norkin and White, 2003), and appears
to indicate that clinicians and researchers believe that ‘thigh
flexion’ occurs solely at the hip joint. Posterior pelvic rotation,
indicative of lumbar flexion in this instance, is considered a ‘trick’ or
compensatory movement.
Using image-based analysis with skin reference markers on
bony landmarks, previous researchers have demonstrated concur-
rent posterior pelvic rotation (Bohannon et al., 1985a; Murray et al.,
* Corresponding author. Tel.: þ61 3 8344 4171; fax: þ61 3 8344 4188.
E-mail address: e.tully@unimelb.edu.au (E.A. Tully).
2002) and lumbar flexion (Tully et al., 2002) during hip (knee)
flexion in supine and standing. Tully et al. (2002) used two-
dimensional (2D) analysis to investigate the effect of age on lum-
bofemoral rhythm and reported a similar pattern of hip-to-lumbar
interaction in healthy children and young adults, with concurrent
lumbar flexion providing approximately 1/3 of the upward move-
ment of the thigh. Although statistical analyses showed no
significant difference between children and young adults, the
phase-angle plots indicated delayed lumbar flexion in some
subjects as they commenced lifting the thigh, and a delay in lumbar
extension in most subjects as the thigh was lowered.
Hip (knee) flexion in standing is a more functional task than hip
flexion in supine, being similar to the activities of stair climbing, and
putting on pants or shoes in standing. It is unclear whether age-
related decline, such as muscle weakness (Skelton et al., 1994) and
decreased range of motion (Roach and Miles, 1991; McGill et al.,
1999;Van Herp et al., 2000), may influence neuromuscular control
and alter the kinematic interaction between the hip joint and lumbar
spine as the thigh is raised in older adults. In a review article, Enoka
(1996) reported that older adults experience less age-related decline
in the maximum force for eccentric contractions compared with
concentric contractions. As it has been suggested that the previously
observed delay in lumbar extension as the thigh was lowered,
especially in children (Tully et al., 2002), may be related to the

1356-689X/$ – see front matter ! 2009 Published by Elsevier Ltd.

doi:10.1016/j.math.2009.08.002
 Y.-L. Kuo et al. / Manual Therapy 15 (2010) 88–92 89

eccentric nature of muscle control, it is possible that this delay may

not be present in older adults. Therefore, the aim of this study was to
quantify the lumbofemoral rhythm during hip (knee) flexion in
standing in healthy older adults whose movement may be influ-
enced by age-related changes in the neuromusculoskeletal system.

2. Materials and methods

Thirty-four healthy community-dwelling older adults aged over

60 years volunteered for this study (Table 1). Volunteers were
screened to exclude those with significant scoliosis, identifiable
movement dysfunction, pain or pathology in the spine or lower
extremities requiring treatment during the preceding 6 months.
Prior to participating in this study, subjects were informed of the
details of this project and signed a written consent form. This study
was approved by the Human Research Ethics Committee of the
university.
The 2D PEAK Motus motion analysis system (PEAK Performance
Technologies, Englewood, CO, USA) was used to investigate the
movement of hip (knee) flexion. Details of camera and lighting set-
up have been reported previously (Tully et al., 2002). Fig. 1 indicates
the placement of the six spherical reflective markers (B&L Engi- Fig. 1. Marker placement and angle calculation. Positive/negative lumbar spine and
hip angles denote flexion/extension.
neering, Tustin, CA, USA) attached to the midline spine, pelvis and
lateral aspect of the right thigh in standing (Tully et al., 2005; Kuo
(20–80%) and late (80–100%) stages (Tully et al., 2002). Then, the
et al., 2008). Good intra-rater reliability of marker placement in
total hip and lumbar spine range (maximum angle minus minimum
standing was established in a pilot study (ICC1,1 (intraclass corre-
angle) and the hip-to-lumbar movement ratios were calculated for
lation coefficient) ¼ 0.85–0.92).
the entire upward and downward movement phases and for each
To ensure safety, participants were instructed to place their
selected movement stage.
hands lightly on a stable support (at waist height) in front of them
The group ensemble average hip joint and lumbar spine angles
while performing the test movement. Participants initiated the
were plotted against time to examine the lumbofemoral rhythm
movement from erect standing, actively flexing the right knee as far
over time, and the group ensemble average angle–angle plot was
as possible towards the chest at their own comfortable speed, and
used to examine the movement interaction between the hip joint
avoiding any forward (transverse) rotation of the pelvis. As soon as
and lumbar spine. Prior to data analysis, normality of the data was
the right knee reached its highest point, participants immediately
examined, and data were summarised accordingly. A paired t-test
lowered the leg to the ground, distributing the weight equally on
was used to compare the total hip and lumbar spine ranges during
both feet before starting the next trial. Following two practise
the entire upward and downward phases. Two-way repeated
attempts, three trials were recorded.
measures analysis of variance was used to investigate the effect of
The best trial was chosen for analysis, based on a combination of
movement phase and movement stage on the angular range. The
(i) the smoothness of the movement, (ii) the largest range achieved,
statistical significance level was set at P < 0.05.
and (iii) the absence of any out-of-plane movement. The location of
each marker was automatically digitised at a frequency of
50 frames/s using the 2D PEAK Motus software program, and 3. Results
smoothed using a fourth order Butterworth (high cut-off) filter
(Winter, 2005) at an optimum cut-off frequency determined by the During hip (knee) flexion in standing, upward movement of the
computer (Jackson, 1979). Then, the video image was converted to thigh was comprised of concurrent hip and lumbar flexion that
kinematic data based on the angle definition illustrated in Fig. 1. reversed as the thigh moved downward to return the lumbar spine
For ease of analysis, the movement of hip (knee) flexion was and hip to their starting position (Fig. 2). Table 2 summarises the
divided into upward and downward phases based on thigh move-
ment. The ‘start’ and ‘end’ events of both movement phases were
defined when the resultant linear velocity of the distal thigh marker
(1/4th) was greater and less than 10 cm/s, respectively. Subse-
quently, the angular data for each movement phase were normal-
ised to 100% total phase duration using KaleidaGraph version 4.0
(Synergy Software, Reading, PA, USA) (Tully et al., 2002), and each
movement phase was further divided into early (0–20%), middle

Table 1
Descriptive information for participants (n ¼ 34).

Characteristics Mean $ SD or median (IQR) Range

Age (year) 64 (6) 60–75
Weight (kg) 74.1 $ 12.6 52–109
Height (cm) 167.7 (11.7) 159–187.5
BMI (kg/m2) 25.5 $ 3.2 18.8–31.4
Fig. 2. Group ensemble average sagittal angles of the hip joint and lumbar spine
Values are mean $ standard deviation for normally distributed data or median during the upward (0–100%) and downward (100–200%) phases of hip (knee) flexion
(interquartile range) for skewed data. BMI ¼ body mass index. in standing. Grey area indicates $1 standard deviation of the mean.
90 Y.-L. Kuo et al. / Manual Therapy 15 (2010) 88–92

hip and lumbar spine ranges during the entire movement and at
each selected movement stage.

3.1. Hip joint

The hip joint started from 1.5! of flexion in upright standing

(Fig. 2), and as the thigh moved upward, flexed to a maximum of
82.4! . On reaching the highest thigh position, the hip joint reversed
the direction of movement and extended to 1.0! of flexion at the
end of the downward phase. Because the hip joint started and
finished in a similar position (Fig. 3), no significant difference was
found in the total hip joint range during both movement phases
(t33 ¼ 0.62, 95% CI ¼ %1.0 to 1.8, P ¼ 0.5).
Movement of the hip joint (Table 2) was affected by the main
effect of movement stage (F2,41 ¼1073.92, P < 0.001) and the
interaction effect of movement phase and stage (F2,54 ¼ 16.2,
P < 0.001). The hip joint range used during the early upward phase
was significantly greater than that in the late downward phase
(t33 ¼ 4.72, 95% CI ¼ 2.0–5.1, P < 0.001), and that in the late upward
phase was significantly smaller than that during the early down-
ward phase (t33 ¼ %6.82, 95% CI ¼ %3.6 to %2.0, P < 0.001). This
finding was reflected in the slope of the hip trajectory (Fig. 3),
which was steeper in the middle movement stages, and in the
discrepancy between the movement trajectories in both phases. No
significant difference was found in the hip joint range at the middle
stage during both upward and downward phases (t33 ¼ %0.31, 95%
CI ¼ %1.9 to 1.4, P ¼ 0.8).

3.2. Lumbar spine

At the start of hip (knee) flexion the lumbar spine was in 12.7! of
extension. As the hip flexed, the lumbar spine started to flex (Fig. 2).
On average, approximately 5! of initial hip flexion occurred before
1! of lumbar flexion. At the end of the upward phase, the lumbar
spine reached its maximum flexion angle of 16.6! . During the
downward phase, the lumbar spine returned to 10.4! of extension. Fig. 3. Group ensemble average angle–time plots of the hip joint (top) and lumbar
Compared to the consistent start and end positions of the hip joint, spine (bottom) during the upward and downward phases of hip (knee) flexion in
standing.
the lumbar spine did not return to its starting position and
remained slightly flexed by 2.3! (Fig. 3). Therefore, the total lumbar
spine range during the upward phase was significantly greater than P ¼ 0.002). During the other movement stages, the lumbar spine
that during the downward phase by 3.5! (t33 ¼ 4.44, 95% CI ¼ 1.9– range during the upward phase was significantly greater than that
5.1, P < 0.001). during the downward phase (P & 0.001).
Further analyses showed that the lumbar spine range was
affected by the main effects of movement phase (F1,33 ¼ 37.45, 3.3. Hip-and-lumbar spine movement interaction
P < 0.001) and movement stage (F2,40 ¼ 240.23, P < 0.001) and the
interaction effect (F2,66 ¼ 15.94, P < 0.001). The lumbar spine range Positive slopes of the trajectory in the hip-lumbar spine angle–
during the early upward phase was significantly smaller than that angle plot (Fig. 4) indicate that the hip joint and lumbar spine
during the late downward phase (t33 ¼ %3.38, 95% CI ¼ %2.0 to %0.5, moved concurrently and towards the same direction during hip

Table 2
Range (degrees) and movement ratio during the entire upward and downward phases and at each selective movement stages.

Age group Movement phase/stage Upward Downward

Range Ratio Range Ratio

Hip Lumbar H/L Hip Lumbar H/L

Childrena Overall 79.9 $ 7.2 29.1 $ 9.8 3.0 $ 2.0 80.2 $ 8.2 20.9 $ 10.7 4.7 $ 3.5
Young adultsa Overall 94.0 $ 7.3 33.8 $ 7.3 3.0 $ 1.9 95.5 $ 8.1 29.6 $ 8.2 3.2 $ 1.3

Older adults Early 12.2 $ 4.6 2.0 (2.2) 6.3 (7.3) 6.2 $ 2.6 3.7 (3.4) 1.5 (2.2)
Middle 65.8 $ 10.6 21.3 $ 6.5 3.0 (1.6) 66.0 $ 9.8 18.1 $ 7.1 3.7 (2.7)
Late 3.4 $ 2.1 6.2 $ 2.9 0.5 (1.2) 8.6 $ 3.3 3.1 (4.1) 2.9 (2.5)
Overall 81.2 $ 11.3 29.6 $ 9.6 2.7 (1.7) 80.8 $ 11.5 25.8 $ 9.1 3.1 (1.7)

Values are mean $ standard deviations for normally distributed data or median (interquartile range) for skewed data.
H/L are hip-to-lumbar movement ratios.
a
Data for children and young adults are based on the study of Tully et al. (2002).
 Y.-L. Kuo et al. / Manual Therapy 15 (2010) 88–92
Fig. 4. Group ensemble average angle–angle plot of the hip-and-lumbar spine during
hip (knee) flexion in standing.
(knee) flexion. On average, the lumbar spine contributed to 26.6%
(29.3! ) and 24.1% (25.6! ) of the total thigh movement (pelvis þ hip
joint) during the upward (110.2! ) and downward (106.4! ) phases.
The relative contribution from the hip joint and lumbar spine to
the thigh movement varied throughout the total hip (knee) flexion
duration, and was reflected in the hip-to-lumbar movement ratios
(Table 2). The finding that the hip-to-lumbar movement ratio
continuously decreased throughout the upward phase shows that
the hip joint was dominant in moving the thigh towards the chest
during the early and middle upward phases but the lumbar spine
became the prime contributor towards the end of the upward
phase. The lumbofemoral rhythm during the downward phase was
not simply the reverse of what occurred during the upward phase.
In the early downward phase, the hip joint and lumbar spine both
extended through a small range with a greater contribution from
the hip joint. Both joints, especially the hip joint, increased their
extension range during the middle downward phase, which
resulted in an increasing hip-to-lumbar movement ratio. In the late
downward phase, as the thigh returned to its starting position in
standing the hip joint and lumbar spine decreased their extension
range. Although the hip joint remained the prime contributor, the
hip extension movement decreased, and as a result the lumbar
spine increased its relative contribution during this movement
stage. Therefore, the hip-to-lumbar movement ratio (2.9) at the late
downward phase was smaller than that at the middle downward
phase (3.7).
4. Discussion
4.1. Hip joint
The mean total hip joint range achieved by older adults during
hip (knee) flexion was similar to that used by children but smaller
by 13.1! and 14.8! than that reported for young adults during the
upward and downward phases, respectively (Tully et al., 2002)
(Table 2). One possible explanation is decreased strength in the hip
flexor and abdominal muscles associated with ageing (Skelton
et al., 1994; Taaffe and Marcus, 2000). During active hip flexion in
healthy subjects, the abdominal muscles flex the lumbar spine and
rotate the pelvis posteriorly, thereby maintaining an optimal
length–tension relationship in the hip flexors (Kendall and
McCreary, 1983). Thus, lack of abdominal strength may have
contributed to the decline in active hip flexion range in these
elderly subjects. Alternatively, although this group was not cat-
egorised as ‘obese’ (BMI > 30) (Australian Government Department
91
of Health and Ageing), many of these older adults were observed to
have a bulging lower abdomen that could have limited upward
movement of the thigh and thus affected the maximal hip flexion
angle. However, despite the limitation in the hip joint, the available
range of active thigh flexion in this group of older adults remained
adequate for daily activities.
4.2. Lumbar spine
The total lumbar spine range in this study was close to the value
reported for young adults during both movement phases and the
value for children during upward phase (Tully et al., 2002) (Table 2).
The finding of a similar lumbar flexion range rules out weak
abdominal action with active insufficiency of the hip flexors as
a possible mechanism for decreased hip flexion range. However,
although not tested, the hip flexors may have been weaker in this
age group. As a result of the decreased total hip joint range and
similar total lumbar spine range, the relative contribution from the
lumbar spine to the thigh movement became greater in older adults
compared to young adults and children (Tully et al., 2002). The
clinical implication of these findings is that mobility of the lumbar
spine is important in this age group. Various scenarios emerge. For
example, older adults who have a stiff lumbar spine may experi-
ence difficulty placing the foot on a high step because they do not
have sufficient lumbar flexion to compensate for their decreased
hip joint flexion. For elderly people with severe hip stiffness, for
example hip osteoarthritis, the mobility of the lumbar spine
becomes essential for maintenance of a reasonable level of func-
tional ability. Unfortunately, many elderly subjects likely have
degenerative changes in both hip and lumbar spine with the result
that activities requiring significant thigh flexion, including stepping
up or sitting on a low chair or toilet for example could be seriously
impaired.
4.3. Hip-and-lumbar spine movement interaction
Age-related differences were observed in the hip-to-lumbar
movement ratios when compared to those of Tully et al. (2002).
Except during the early upward phase and middle downward
phase, older adults had smaller hip-to-lumbar movement ratios,
primarily due to their decreased hip movement. On the other hand,
the larger hip-to-lumbar movement ratio in older adults during the
early upward phase indicates a possible delay in initiating lumbar
flexion. One explanation is poorer neuromuscular control between
abdominals and hip flexors, a suggestion previously made by Tully
et al. (2002) with respect to some children. Not previously reported
for children and young adults was the large between-participant
variation in hip-to-lumbar movement ratio, especially at the early
and late movement stages, which may have been due to the diverse
ageing process in older adults.
The delay observed in lumbar extension throughout the
downward phase in children and young adults was also present in
the older group. Previously, Tully et al. (2002) speculated that
delaying extension, or holding the lumbar spine in a relatively
flexed position during the downward phase may have been asso-
ciated with the challenge of eccentric contraction. As the maximum
force for eccentric contractions has been shown to be less affected
by ageing (Enoka, 1996), a similar finding of delayed extension in
older adults, during the middle and late downward phases, was not
anticipated. The reason for this phenomenon seen in the wide
range of age groups studied so far remains unclear.
The finding that the lumbar spine moved concurrently with the
hip joint during hip (knee) flexion in standing is in agreement with
the results for young adults reported by Tully et al. (2002), and is
inferred by the results for pelvic rotation by previous researchers
92 Y.-L. Kuo et al. / Manual Therapy 15 (2010) 88–92
(Bohannon et al., 1985b; Murray et al., 2002; Dewberry et al., 2003).
The cause of this posterior pelvic rotation/lumbar flexion is not
clear. On first thought, contraction of the abdominal muscles, acting
as lumbar flexors and stabilising synergists for the hip flexor
muscles, would appear as the most likely cause during active
movement. However, Bohannon et al. (1985b) found that posterior
pelvic rotation occurred in a similar manner during passive as well
as active hip flexion. It is clear that the flexed knee removes
hamstring muscle length as the cause of posterior pelvic rotation. In
support, Dewberry et al. (2003) reported that although the pelvis
rotated posteriorly during hip flexion with a flexed knee, the
hamstrings significantly increased the amount of rotation when the
knees were extended, particularly in subjects with shorter
hamstrings. It seems unlikely that there would be sufficient tension
in the posterior capsule or other one-joint antagonist muscles such
as glutaeus maximus to cause pelvic rotation so early during
movement. However, the continuous fascial connections between
the thigh, glutaeus maximus, ligaments of the pelvis, and the
thoracolumbar fascia are complex (Vleeming et al., 1995) and may
provide the answer.
With respect to measurement of hip flexion it becomes apparent
that observation or palpation of the pelvis, the methods commonly
used in the clinical setting, have not been sensitive enough to
detect the early onset of posterior pelvic rotation or lumbar flexion
until the late upward stage of the thigh movement. For example,
Fisk (1979) indicated that the pelvis does not rotate until the thigh
nears 90! . This phenomenon can be explained by the angle–angle
plot (Fig. 4), which shows that the lumbar spine steeply increased
its contribution as the hip joint reached approximately 70! of
flexion. Thus, the current practise recommended for measuring hip
flexion as the thigh angle relative to the horizontal plane at the
point of perceived onset of posterior pelvic rotation (Norkin and
White, 2003) or attempting to forcefully prevent posterior pelvic
rotation (Nonaka et al., 2002) is incorrect. True hip flexion range
can only be determined by measurement of the femur with respect
to the pelvis, and without any attempt to restrict pelvic/lumbar
movement.
Another clinical implication is the application to exercise.
Clinicians and Pilates exercise instructors frequently teach lumbar
(core) stabilisation exercises for the deep abdominal muscles
(transversus and internal oblique). These abdominal exercises are
practised by patients with low back pain and also by healthy people
for prophylactic purposes. The instruction to eliminate or reduce
movement in the pelvis and lumbar spine is considered critical to
selectively activate the deep abdominal muscles in the early stage
of rehabilitation (O’Sullivan et al., 1997; O’Sullivan, 2000). However,
our results suggest that the same instruction, i.e. to maintain
a ‘neutral’ lumbar lordosis, is incorrect when the exercises progress
to the next stage, for example alternatively flexing the legs in
supine or progressing to functional activities involving hip flexion.
Clinicians and exercise instructors sometimes use the term ‘disas-
sociation’ in this regard, however the attempt to disassociate the
movement between the hip joint and lumbar spine demonstrates
a lack of understanding of the concurrent hip-and-lumbar spine
movement interaction during hip flexion. It is even questionable
whether trained subjects can effectively alter or eliminate pelvic
motion/lumbar flexion during hip flexion (Elia et al., 1996). Exercise
instructions need to be adjusted accordingly, so that the correct
hip–spine movement interaction is facilitated and practised by
patients and healthy people.
5. Conclusions
In older adults, hip and lumbar flexion occurs concurrently
during hip flexion in standing in a similar manner to that reported
previously for children and young adults. As the thigh is lowered,
the elderly similarly demonstrate a delay in lumbar extension. The
large variability in the hip-to-lumbar movement ratio throughout
the total hip (knee) flexion duration appears to reflect the diverse
ageing process. Clinicians and exercise instructors need to be aware
of the concurrent lumbofemoral rhythm when measuring hip
flexion range or instructing lumbar stabilisation exercises. As thigh
flexion is dependent on hip-and-lumbar movement, older adults
who have a stiff lumbar spine may experience difficulty in func-
tional activities involving significant flexion. The potential influ-
ence of limited range of motion of either hip or lumbar component
on the movement should be addressed.
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