Clinical Biomechanics 18 (2003) 745–750

www.elsevier.com/locate/clinbiomech

Biomechanical analysis of sit-to-stand movement in normal

and obese subjects
a,*
F. Sibella , M. Galli a, M. Romei a, A. Montesano b, M. Crivellini a

a
Department of Bioengineering, Politecnico di Milano, p.zza Leonardo da Vinci 32, 20133 Milano, Italy
b
Ospedale S. Giuseppe, Piancavallo, Verbania, Italy
Received 16 January 2003; accepted 17 June 2003

Abstract
Objective. Main purpose of this study was to develop a biomechanical model for the analysis of sit-to-stand movement in normal
and obese subjects.
Design. A biomechanical model describing sit-to-stand was developed using kinetic and kinematic experimental data. Trunk
flexion, feet movement, knee and hip joint torques were assumed as sensible indexes to discriminate between normal and obese
subjects.
Background. Sit-to-stand is a functional task that may become difficult for certain patients. The analysis of its execution provides
useful biomechanical information on the motor ability of selected subjects.
Methods. Sit-to-stand was recorded using an optoelectronic system and a force platform in 40 obese patients and 10 normal
subjects. A biomechanical model was developed using inverse dynamics equations.
Results. Kinematic and kinetic indexes evidenced differences in motion strategy between normal and obese subjects. Obese
subjects rise from the chair limiting trunk flexion (mean value: 73.1°) and moving their feet backwards from initial position (mean
deviation: 50 mm). Normal subjects, instead, show a higher trunk flexion (mean value: 49.2°, a lower angular value between trunk
and the horizontal means increased flexion) and fixed feet position (mean deviation: 5 mm). As for kinetics, obese patients show knee
joint torque higher than hip torque (maximum knee torque: 0.75 Nm/kg; maximum hip torque: 0.59 Nm/kg), while normal subjects
show opposite behaviour (maximum knee torque: 0.38 Nm/kg; maximum hip torque: 0.98 Nm/kg).

Relevance
We found differences in motion strategy between normal and obese subjects performing sit-to-stand movement, which may be
used to plan and evaluate rehabilitative treatments.
Ó 2003 Elsevier Ltd. All rights reserved.

Keywords: Obesity; Sit-to-stand; Biomechanics; Optoelectronic system; Force platform; Rehabilitation

1. Introduction to be developed about each body joint. The accurate

analysis of the requirements for STS execution will
Obesity is one of the commonest pathologies in in- provide useful biomechanical information on the motor
dustrialised countries. Many clinical studies (Tagliaferri ability of selected patients. In fact, STS has been a topic
et al., 1998; Brozek et al., 1993) investigated its conse- for many studies (Coglin et al., 1994; Doorenbosch,
quences, but, from a biomechanical point of view, re- 1994; Kathleen, 1991), but it has never been analysed in
search is still poor and no biomechanical models of obese patients using a biomechanical model.
specific movements were found in a literature review. The main aim of this study was to develop a biome-
Sit-to-stand movement (STS) is an important functional chanical model for a quantitative description of STS
task that may become difficult for certain patients. In motion strategy in normal and obese subjects. In fact,
particular, rising from a chair requires adequate torques because of evident differences in mass distribution be-
tween these two populations, correspondent differences
*
Corresponding author. in STS motion strategy are expected both for kinematics
E-mail address: [email protected] (F. Sibella). and kinetics aspects.
0268-0033/$ - see front matter Ó 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0268-0033(03)00144-X
746 F. Sibella et al. / Clinical Biomechanics 18 (2003) 745–750

2. Methods

Ten volunteers subjects [seven men and three women;

mean age (SD): 26.5 years (2.5)] were enrolled as control
group (CG). Forty obese subjects [all women mean age
(SD): 48.5 years (13.5)], recovered at the Auxologico
hospital, (Piancavallo, Verbania, Italy), were selected
for the study. The hospital ethical committee gave its
approval for the study. Inclusion criteria for normal
subjects were: no musculoskeletal pathologies, body
mass index (BMI; calculated as weight [kg]/height2
[m2 ]) <25 kg/m2 , no previous skeletal fractures, no low
back pain. Mean BMI (SD) of CG group was: 23 kg/m2
(2.2). Inclusion criteria for obese subjects were:
BMI > 30 kg/m2 , able to stand from an armless chair,
patients scheduled for a rehabilitative treatment. Mean
BMI (SD) of the obese group was: 37.9 kg/m2 (4.9).
Rehabilitative treatment included: low-fat diet, gym-
nastic sessions for 2 h twice a week, a 5 km walk each
day, massages and stretching lessons. The treatment was
2 week long. All subjects were enrolled before the
treatment. Fig. 1. Biomechanical model of STS movement (four segments).
A motion optoelectronic measurement system
(E L I T E , B.T.S. S.p.A., Milano, Italy), 6 TVC, acquisi-
tion frequency set at 50 Hz, provided the three-dimen- horizontal coordinates ðX Þ of markers positioned over
sional coordinates of reflective passive markers; a force both lateral malleola were analysed and the difference
platform (A M T I , Newton, MA, USA), acquisition fre- between left and right side anterior–posterior absolute
quency set at 500 Hz provided the ground reaction displacement (diff ¼ jX left
X rightj mm) was calcu-
forces. lated. Since marker diameter is 15 mm, a difference less
than 7.5 mm was considered negligible and the move-
2.1. Experimental setup ment symmetric.
A comparison between the first and last trial was
Sixteen reflective passive markers (diameter: 15 mm) made for each subject to find differences (if existing) due
were positioned on bony landmarks as follows: over the to repeated movements.
spinosus process of C7, over the sacrum midway be-
tween the posterior superior iliac spines and, bilaterally, 2.3. Biomechanical model
over the acromion, the anterior superior iliac spine, the
great trochanter, the femoral condyle, the lateral mal- STS movement was assumed to be a symmetric
leolus, the fifth metatarsal head and the heel. An office movement in frontal and horizontal plane as found in
chair, armless and backless, was adjusted vertically for literature (Ludin et al., 1995) and this hypothesis was
each subject to obtain the same knee flexion angle (fixed verified through the symmetry analysis of feet move-
at 90°). A reference marker was placed on the chair. ment. A simplified biomechanical model of the human
Each subject was asked to stand up at self-selected speed body was developed to investigate dynamic interactions
with arms crossed over the trunk and with the feet self- at knee and hip joint considering only the sagittal plane.
positioned over the force platform (no fixed distance The model is based on a 4-segment representation of the
between the feet was imposed) for 10 acquisition trials. body. Each segment is modelled as a rigid non-extensible
Interval time between each trial was fixed at 30 s. one-dimensional segment and it is linked with the next
through an ideal joint (Fig. 1). The first segment repre-
2.2. Kinematic analysis sents the head, trunk and upper limbs (HAT), the second
represents the thighs (THIGH), the third represents the
STS strategy was first analysed taking into account legs (LEG) and the fourth represents the feet (FOOT).
trunk movement: the vertical coordinates of shoulder The developed model was implemented using Matlab. It
markers (Y coordinate) were extracted and trunk angle was used first to calculate torques at hip ðMhip Þ, knee
ðaÞ defined as the angle between the horizontal line and ðMknee Þ and ankle ðMankle Þ joints for normal subjects, then
the segment representing the trunk was calculated (Fig. it was refined to correctly explain the movement strategy
1). Asymmetry in feet movement was investigated: the of obese population. The fat mass of obese subjects was
 F. Sibella et al. / Clinical Biomechanics 18 (2003) 745–750 747

modelled through a hemisphere positioned on the ab- Fourth segment––FOOT (Fig. 2):
domen. The hemisphere was supposed to be homoge-
neous and fat density value was set at 0.99 g/cm3 . An Mankle þ ðD
G4 ÞKðP4 Þ þ ðD
P ÞKðFy Þ ¼ 0 ð8Þ
ideal BMI value was fixed at 23 kg/m2 (this value coin-
cides with the mean value of CG); from this value an where Mankle ¼ unknown moment; P4 ¼ weight vec-
‘‘ideal weight’’ for each obese subject was calculated as tor ¼ mðfootÞ  g, ðD
G4 Þ ¼ G4 centre of mass position
follows: 23 ¼ ideal weight [kg]/(effective height2 ) [m2 ] and with respect to D, ðD
P Þ ¼ P ground reaction position
the difference between the effective weight of each obese with respect to D, Fy ¼ vertical component of ground
patient and her ideal weight represented the fat mass that reaction force, inertial vector not significant.
had to be modelled through the hemisphere. Since all our Third segment––LEG (Fig. 2):
obese patients are women, the fat mass was distributed Mknee
Mankle þ ðD
G3 ÞKðP3 Þ
40% on the abdomen and 60% on the thighs (‘‘pear
shape’’ distribution); therefore only 40% of the calcu- þ ðD
CÞKðRLEGx þ RLEGy Þ ¼ 0 ð9Þ
lated fat mass was considered to calculate the hemisphere
where Mknee ¼ unknown knee moment, Mankle ¼ ankle
dimension. From mass and density values, the radius ðRÞ
moment, P3 ¼ weight vector of the third seg-
of the hemisphere for each obese patient was calculated
ment ¼ mðlegÞ  g, ðD
G3 Þ ¼ G3 centre of mass position
as follows: R ¼ (mass (g)/density [g/cm3 ])1=3 and from R
with respect to D, ðD
CÞ ¼ C position with respect to
value, the position of the fat centre of mass Gs with re-
D, RLEGx and RLEGy ¼ horizontal and vertical component
spect to hip joint was extracted. Then, inertial moments
of the reaction force on C, inertial vector not significant.
with respect to the axial centre of mass, which is per-
pendicular to the sagittal plane, were evaluated to write
the equilibrium equations of the model. Anthropometric
parameters came from the measures obtained by Winter
(1979). Each segment length was calculated using the
distance between the sagittal projections of the corre-
spondent markers coordinates. The origin of the abso-
lute reference system was positioned on the left
malleolus, horizontal and vertical components of HAT-
segment centre of mass acceleration were calculated
using the following equations (Fig. 1):
XG1 ¼ L3 cos c
L2 cos b þ d1 cos a ð1Þ
YG1 ¼ L3 sin c þ L2 sin b þ d1 sin a ð2Þ
By deriving
X€G1 ¼ aG1 x
c þ L2 cos bb_ 2
¼
L3 cos cc_ 2
L3 sin c€
þ L2 sin bb€
d1 cos aa_ 2
d1 sin a€
a ð3Þ
Y€G1 ¼ aG1 y
¼
L3 cos c€c
L3 sin cc_ 2 þ L2 cos bb€
þ L2 sin bb_ 2
d1 cos a€a
d1 sin aa_ 2 ð4Þ

where Li ¼ ith-segment length; d1 ¼ distance between G1

and B (Fig. 1).
For each segment, dynamic equilibrium equations
along the horizontal and vertical axes and torques
equilibrium equation were written
F x ¼ m  ax ð5Þ
F y ¼ m  ay ð6Þ
C_ c ¼ Mc ð7Þ
Only the equations used to obtain joint moments are
reported in the following: Fig. 2. Foot, shank and HAT model.
748 F. Sibella et al. / Clinical Biomechanics 18 (2003) 745–750

First segment––HAT (Fig. 2): calculated in the first and last trial of the experimental
session for each group. Significance level was set at P ¼
Mhip þ ðB
G1 ÞKðP1 Þ þ ðB
G1 ÞKðF1x þ F1y Þ
JG1  a€ ¼ 0
0:05.
ð10Þ
where Mhip ¼ unknown hip moment, P1 ¼ weight vec- 3. Results
tor ¼ mðHATÞ  g ¼ ðmðtrunkÞ þ mðheadÞ þ mðupper-
limbsÞÞ  g, ðB
G1 Þ ¼ centre of mass G1 position with 3.1. Symmetry analysis
respect to B, F1x and F1y ¼ horizontal and vertical com-
ponent of the inertial vector ðm1  aG1 Þ, JG1 ¼ centre of Differences between left and right side anterior–pos-
mass inertial moment with respect to the perpendicular terior displacement of malleolus markers were calcu-
from the sagittal plane. lated for each analysed subject of both groups. For all
First segment obese––HAT modified adding the vir- subjects we found a difference <7 mm [mean diff (SD):
tual belly 5.3 mm (1.4)].
Mhip þ ðB
G1 ÞKðP1 Þ þ ðB
G1 ÞKðF1x þ F1y Þ
JG1  a€
3.2. Kinematic results
þ ðB
Gs ÞKðPGs Þ þ ðB
Gs ÞKðF1sx þ F1sy Þ

JGs  a€ ¼ 0 ð11Þ Control group of healthy subjects. 90% of the analysed
CG subjects use a rising strategy characterised by a high
where (B
Gs ) ¼ centre of mass Gs position (of the vir-
degree of trunk flexion and a feet movement near to zero
tual belly) with respect to B, PGs ¼ weight vector of the
mm (see Table 1 for numerical data). In Fig. 3 the Y
fat mass ¼ mðfat massÞ  g, F1sx and F1sy ¼ inertial vector
coordinate of shoulder marker is plotted vs movement
horizontal and vertical component ðms  aGs Þ [fat mass],
cycle to give a qualitative idea of the movement strategy.
JGs ¼ centre of mass inertial moment with respect to the
Comparison between the first and the tenth trial shows a
perpendicular from the sagittal plane [fat mass].
slight decrease of trunk flexion (that means an increased
All calculated joint moments were normalised divid-
angle value), but again no feet movement in 100% of the
ing them by height and weight of each subject to permit
analysed cases. No differences between men and women
inter-subject comparisons and they were analysed vs
were found during this analysis.
movement cycle. Movement cycle was defined using a
Obese subjects. 100% of the analysed subjects limit
angle according to Millington et al. (1992). In detail,
their trunk flexion. This strategy (In Fig. 4 the Y coor-
motion cycle begins when a decreases of 0.5° in 20 ms
dinate of shoulder marker is plotted) results different
and it ends when the variations of a value remain within
from that adopted by CG subjects (Fig. 3). A feet
0.5° and the analysed subject is in standing position.
movement backwards from the initial position is always
Standing position was evaluated considering the vertical
to observe (Fig. 4). The comparison between first and
coordinate of shoulder markers. Knee and hip joint
last trial does not evidence any change in motion strat-
moments were plotted in graphs and their maximum
egy during the experimental session. All data relative to
values were extracted for the first and last trial of each
kinematic analysis of both groups are summarised in
subject. Two more indexes representing fatigue ðM  %Þ
Table 1. t-Test performed on CG vs obese group for all
and work ðP  %Þ of each joint were calculated (Nigg and
kinematic parameters confirmed statistical significance
Herzog, 1995)
of the results ðP < 0:05Þ.
R
 motioncycle
ðMi Þ2 dt
Mi % ¼ R P3  100 ð12Þ 3.3. Kinetic results
2
motioncycle k¼1 Mk dt
R 2 The analysis was mainly focused on the torques

ðP Þ dt
motioncycle i
Pi % ¼ R P3  100 ð13Þ generated at lower limb joints. Particular attention was
2
motioncycle k¼1 Pk dt given to knee and hip joint moments.
where Pi ¼ Mi  wi , Pi ¼ muscular power in the ith joint,
Mi ¼ moment at the ith joint, wi ¼ angular velocity for Table 1
the ith joint. Kinematic results: ðaÞ angle, X coordinate deviation of malleola
markers: mean (SD)
2.4. Statistical analysis Mean a (°) X coord. deviation
of the malleola (mm)
Statistical analysis of the results was performed using Control group (1st trial) 49.2 (0.5) 5 (1.7)
StudentÕs t-test between CG and obese group parameters Control group (10th trial) 56.1 (0.1) 5 (1.5)
and considering separately the first and last trial of STS. Obese group (1st trial) 73.1 (1.2) 50 (2.3)
Obese group (10th trial) 75.3 (2.0) 47.2 (1.6)
The same test was also used to compare the parameters
 F. Sibella et al. / Clinical Biomechanics 18 (2003) 745–750 749

Control group of healthy subjects. The curve repre-

senting hip and knee joint moments (Mhip and Mknee ) is
shown in Fig. 5 (upper part) for a single subject taken as
example. 100% of the analysed subjects show a high
value of Mhip maximum that leads to the minimisation
of Mknee maximum for the first trial. The parameters
calculated for last trial, instead, show a decreased Mhip
maximum and consequently an increased Mknee maxi-
mum. The same results can be observed from the fa-
tigue and work indexes (M  % and P  %) calculated for
both joints. Numerical comparisons can be seen in
Table 2.
Obese subjects. A qualitative curve of hip and knee
moment is plotted in Fig. 5 (bottom part) for a single
subject taken as example. Two differences arise from the
comparison between CG and obese group graphs: first,
in obese patients the higher peak corresponds to knee
and not to hip joint moment as in the CG; second, for
obese group the comparison between the first and the
last trial shows no changes in motion strategy. M  % and
P  % confirm kinetic results: if compared to CG, obese
group shows higher values of both indexes at the knee
and, consequently, lower values at the hip (for numerical
data see Table 2). t-Test performed on CG vs obese
group for all kinetic parameters confirmed statistical
significance of the results ðP < 0:05Þ.
Fig. 3. CG rising strategy: Y shoulder coordinate (left) and X malleolus
coordinate (left).

Fig. 4. Obese group rising strategy: Y shoulder coordinate (left) and X Fig. 5. CG and obese group rising strategy: hip (light grey) and knee
malleolus coordinate (left). (black) joint moments.
750 F. Sibella et al. / Clinical Biomechanics 18 (2003) 745–750

Table 2
Kinetic results for control and obese group: mean (SD)
Mean Mhip maximum Mean Mknee maximum M  % hip M  % knee P  % hip P  % knee
(Nm/kg) (Nm/kg)
Control group (1 trial) 0.98 (0.04) 0.38 (0.08) 76.6 11.7 62.5 24.7
Control group (10th trial) 0.88 (0.02) 0.45 (0.03) 70.3 17.5 57.5 36.7
Obese group (1st trial) 0.59 (0.04) 0.75 (0.08) 52.5 35.2 33.8 64.6
Obese group (10th trial) 0.57 (0.06) 0.77 (0.08) 50.3 36.4 33.5 65.1

4. Discussion 5. Conclusions

4.1. Kinematic results We suggested a biomechanical model for the com-

prehension of STS movement in normal and obese
Kinematic analysis permitted to evaluate the differ- people. In particular a model of the belly was introduced
ences in STS motion strategy between normal (CG) and to underline the role of the fat mass in the impairment
obese population. In particular, normal people rise from of obese people during STS movement. STS movement
the chair by flexing the trunk forward and keeping the was chosen because of its high repeatability in normal
feet in their initial position; on the contrary, obese subjects and because it is one of the commonest move-
subjects rise from the chair by limiting the forward ments in daily activities. Our findings may be useful to
trunk flexion and moving the feet backwards from the evaluate the effect of rehabilitative treatments, which
initial position. In the CG, from the first to the last trial are expected to modify STS strategy. The proposed
a small decrease in forward trunk flexion is to notice, model is very simple and it can be further developed.
even though the flexion degree remains always sensibly Nevertheless it was able to explain the differences be-
higher than that of the obese group. Vice versa, no tween normal and obese subjects during STS mo-
changes in forward trunk flexion values are visible for tion, both from a kinematic and from a kinetic point of
the obese group. view.

4.2. Kinetic results

Kinetic analysis confirms and explains kinematic re-

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