Unsupported Sitting Research Articles

Validity and Reliability of Assessment Tools for Measuring Unsupported Sitting in People With a Spinal Cord Injury

Boswell-Ruys CL, Sturnieks DL, Harvey LA, Sherrington C, Middleton JW, Lord SR. Validity and reliability of assessment tools for measuring unsupported sitting in people with a spinal cord injury. Objectives To develop simple tests to assess the abilities of people with spinal cord injury (SCI) to sit unsupported and to assess the construct validity and test-retest reliability of these tests. Design Cross-sectional comparisons, convenience sample. Setting Biomechanical laboratory. Participants People (N=30) with SCI between the C6 and the L2 level of 2 months to 37 years duration before assessment. The sample was stratified by impairment level (at T8) and time since injury (1y postinjury). Interventions Not applicable. Main Outcome Measures On 2 separate occasions, participants performed tests that measured the distance of upper-body sway and maximal torso leaning, errors made during a coordinated stability task, timed dressing/undressing of the upper body and alternating arm reaching, and percentage change in seated upper body/arm reaching. Results All tests showed good construct validity in that they distinguished between participants with higher (C6-T7) and lower (T8-L2) level impairments ( P<.05) and between participants with acute (≤1y) and chronic (>1y) lesions ( P<.05). The tests also showed good to excellent test-retest reliability (intraclass correlation coeffiecient 3,1 range, .51–.91). Conclusions These simple and quick-to-administer tests have both construct validity and test-retest reliability. They would be appropriate for research and clinical purposes to quantify the abilities of people with SCI to sit unsupported.

Training unsupported sitting in people with chronic spinal cord injuries: a randomized controlled trial

Randomized, assessor-blinded trial. To evaluate the effectiveness of a 6-week task-specific training programme on the abilities of people with chronic spinal cord injuries to sit unsupported. NSW, Australia. Thirty adults with spinal cord injuries of at least 1-year duration were recruited. Participants in the training group (n=15) performed up to 1 h of task-specific training three times a week for 6 weeks. Participants in the control group (n=15) did not receive any training or additional therapy. Primary outcome measures were the Canadian Occupational Performance Measure (COPM), and tests of Upper Body Sway, Maximal Balance Range and donning and doffing a T-shirt (the T-shirt test). The between-group mean difference (95% confidence interval) for the maximal balance range was 64 mm (95% confidence interval 20 to 108 mm; P=0.006). There were no significant between-group mean differences for the COPM and the Upper Body Sway and T-shirt tests. This trial shows initial support for intensive task-specific training for improving the abilities of people with chronic spinal cord injuries to sit unsupported, although the real-world implications of the observed treatment effects are yet to be determined.

P047 Natural history of flexed knee gait in diplegic cerebral palsy in children who have not received surgery

Discrepancies between active and passive muscle power are often seen in pre-term infants over the first year. Generally of a transient nature, they are most obvious in the extensor muscles of the trunk where there is a high active muscle power relative to the passive component. While high active muscle power may not be a sign of cerebral palsy, it is our contention that it will impair functions such as unsupported sitting and the ability to rotate in this position. In this study, 20 full-term and 37 healthy pre-term infants were assessed at the (corrected) ages of 39 and 52 weeks for muscle power in the trunk, sitting unsupported and rotation around the body axis while seated. At the age of 39 weeks, all full-term infants could sit without support. In contrast half of the pre-term infants could not sit without support and the majority of them could not rotate the trunk in this position. At 52 weeks the majority of pre-term infants could sit without support, despite having higher active muscle power in the trunk. However this deviant muscle power prevented rotatory movements of the trunk during sitting. The origin of this deviance may reside in the positioning to which pre-term infants are subjected after birth and thus postural management should be directed towards avoidance of extensor positions.

Pelvic Floor Muscle Activity in Different Sitting Postures in Continent and Incontinent Women

Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Objective To determine whether resting activity of the pelvic floor muscles (PFMs) and abdominal muscles varied in different sitting postures in parous women with and without stress urinary incontinence (SUI). Design PFM and abdominal muscle activity was recorded in 3 sitting postures: slump supported, upright unsupported, and very tall unsupported. Spinal curves were measured in slump supported and upright unsupported. Setting A research laboratory. Participants Women (N=17) with a history of vaginal delivery, 8 who were symptomatic of SUI and 9 who were asymptomatic. Interventions Not applicable. Main Outcome Measures Electromyographic activity of (1) the resting PFM recorded per vaginam with surface electrodes and (2) superficial abdominal muscles using surface electrodes. Changes in spinal curves were measured with a flexible ruler. Results Electromyographic activity of the PFM increased significantly from slump supported to upright unsupported postures in both groups ( P<.001) but with lower levels of activity in women with SUI ( P<.05). PFM activity increased further in very tall unsupported sitting in comparison with slump supported sitting ( P<.001). Obliquus internus abdominis electromyographic activity was greater in upright unsupported than in slump supported sitting ( P<.05), and electromyographic activity of other abdominal muscles was greater in very tall unsupported than slump supported. Women with SUI had a trend for greater activity in the abdominal muscles in upright unsupported than asymptomatic women. Asymptomatic women had a greater depth of lumbar lordosis in upright unsupported sitting than women with SUI ( P=.04). Conclusions More upright sitting postures recruit greater PFM resting activity irrespective of continence status. Further investigation should consider the effect of sitting posture in rehabilitation.

Evaluating the effect of electrode location on surface EMG amplitude of the m. erector spinae p. longissimus dorsi

Variations in surface electromyography (SEMG) amplitude have been shown to be dependent on the dislocation of recording electrodes. Yet no literature is available about the effect of electrode dislocation on SEMG amplitude of the lower back muscles. In this project, the aim was to determine this effect by investigating changes in the SEMG root mean square (RMS), induced by a well-defined dislocation of the recording electrodes. Bipolar SEMG of the longissimus dorsi (LD) muscles was measured in 16 healthy subjects undertaking five functional tasks (standing, forward flexion, re-extension, unsupported sitting and arm/leg lifting), and for eight of those subjects the experiment was repeated within two weeks. Intra-class correlation coefficients (ICCs) were used to show the reliability of the RMS in relation to electrode dislocation, the repeatability of the tasks, and the test–retest reliability. Results showed that: (1) lateral dislocation causes a significant decrease (18%, p < 0.001) in RMS; (2) longitudinal dislocation does not change the RMS; and (3) the variability caused by electrode dislocation is comparable to the variability caused by repetitions of tasks or by electrode repositioning. Our conclusion is that positioning in the mediolateral direction should be exact to minimize changes in SEMG amplitude due to dislocation. However, precise longitudinal electrode positioning seems to be less critical in experimental setups which measure the SEMG of the lower back muscles.

Human–seat interface analysis of upper and lower body weight distribution

The human–seat interfaces were analyzed to determine the differential distribution of the body weight to the components of seat. Fifteen volunteers were tested on a simulated seat system with two piezoelectric force platforms, one placed as chair seat pan and the other placed on the floor surface as footrest. The seated configurations included back inclines (75° and 80°), upright (90°) and reclines (95°, 105° and 115°), absence or presence of armrest (adjusted at 62–68 cm of height), forward and backward sloping of the seat pan, and supported and unsupported back. The armrest and backrest assemblies were isolated from the force platforms. The difference in the body weight (kgf) to the sum of forces recorded at seat pan and feet yielded the extent of weight transferred to other features (e.g., backrest and armrest). The weight distributed at seat was 10–12% less at back inclines ( p<0.01) as compared to upright unsupported sitting. With the backrest reclined beyond 95°, the weight at seat gradually decreased by 9% at 115° recline. The load distributed at feet varied narrowly; however, it was significantly greater ( p<0.01) at upright supported back, compared to unsupported back. The height of the armrest was optimized at 68 cm, since the weight distribution at seat pan consistently reduced by 12% at that height, as compared to the absence of armrest ( F (4,524)=8.80, p<0.05). The suggested height of the armrest corresponded to 40% of the body stature of the selected volunteers. The load distributed at feet was 18% greater with the presence of armrest, indicating that a part of the weight of the upper leg fell on the seat pan, when the armrest was absent. The weight fell on the seat in slouch posture was 5% less than in upright sitting, while the weight at feet was marginally higher in slouch than in upright posture. The study maintained that the horizontal as well as 5° forward slope of the seat might be the preferred choice, since the load distributed at seat was highest at backward sloping seat for all conditions of supported and unsupported back. The study reaffirms that the backrest and armrest have conjoint influence in reducing the load distributed at seat, which in turn might help in mitigating stress on the spinal and other paraspinal structures. Relevance to Industry The human–seat interface analysis and understanding of body weight distribution to the components of seat may be beneficial for ergo-design application in optimizing parameters for chair configurations that provide comfort and safety to the user.

Neurological Examination at 6 to 9 Months in Infants with Cystic Periventricular Leukomalacia

The Hammersmith Infant Neurological Examination was performed in 24 infants with cystic periventricular leukomalacia whose gestational age ranged between 26-38 weeks. The infants were examined between 6 and 9.5 months corrected age. The aim of the study was to establish the different patterns of neurological abnormality as well as the optimality scores that predict the severity of motor sequelae at 2 years. Increased neck and trunk extensor tone, and a posture of flexed arms and extended legs between 6 and 9 months were always associated with the inability to sit unsupported at 2 years, whilst truncal hypotonia and extended arms and legs were associated with unsupported sitting but not walking. Optimality scores between 41 and 60 were generally associated with sitting but not walking at 2 years whilst scores below 40 were always associated with the inability to sit independently at 2 years. All infants who did not develop cerebral palsy at 2 years had scores > 60. Our results suggest that the pattern of findings on neurological examination performed between 6 and 9 months as well as the calculated optimality score helps to predict motor impairment in infants with PVL.

Sitting posture affects pelvic floor muscle activity in parous women: An observational study

Do different sitting postures require different levels of pelvic floor and abdominal muscle activity in healthy women? Observational study. Eight parous women with no pelvic floor dysfunction. Bilateral activity of pelvic floor muscles (assessed vaginally) and two abdominal muscles, obliquus internus abdominis and obliquus externus abdominis, during three sitting postures. There was a significant increase in pelvic floor muscle activity from slump supported sitting (mean 7.2% maximal voluntary contraction, SD 4.8) to both upright unsupported sitting (mean 12.6% maximal voluntary contraction, SD 7.8) (p = 0.01) and very tall unsupported sitting (mean 24.3% maximal voluntary contraction, SD 14.2) (p = 0.004). Activity in both abdominal muscles also increased but did not reach statistical significance. Both unsupported sitting postures require greater pelvic floor muscle activity than the supported sitting posture.

Effect of elbow flexion contractures on the ability of people with C5 and C6 tetraplegia to lift.

It is commonly assumed that minor elbow flexion contractures prevent people with C5-C6 tetraplegia and paralysis of the triceps brachii muscles from bearing full body weight through their upper limbs. The aim of the present study was to determine the effect of simulated bilateral elbow flexion contractures on the ability of these individuals to bear weight through their upper limbs and to determine whether full passive elbow extension is truly critical for lifting body weight. A biomechanical study was performed. Body weight lifted was measured under conditions that simulated bilateral elbow flexion contractures. Five people with motor complete C6 tetraplegia and one person with motor complete C5 tetraplegia, all with bilateral paralysis of the triceps brachii muscles, were recruited to the study. Subjects were fitted with bilateral elbow splints that restricted elbow extension but did not restrain elbow flexion nor prevent the elbow from collapsing, and were seated on an instrumented platform that measured vertical forces under the buttocks. Subjects pushed down through their hands and lifted under five different conditions, namely: with no elbow splints; with bilateral elbow splints adjusted to restrict elbow extension by 5-10 degrees; by 15-20 degrees; by 25-30 degrees and with bilateral elbow splints adjusted to allow unrestricted movement of the elbow joint. Maximal weight lifted from under the buttocks, for each condition, was expressed in relation to weight under the buttocks during unsupported sitting (that is, 'seated body weight'). Subjects lifted progressively less weight from under their buttocks as passive elbow restriction was progressively restricted. However, one subject lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and another lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and 15-20 degrees. Minor elbow flexion contractures will not alone prevent people with tetraplegia and paralysis of the triceps brachii muscles from lifting. Full passive elbow extension is not critical for the performance of this task.

Low back joint loading and kinematics during standing and unsupported sitting

The aim was to examine lumbar spine kinematics, spinal joint loads and trunk muscle activation patterns during a prolonged (2 h) period of sitting. This information is necessary to assist the ergonomist in designing work where posture variation is possible—particularly between standing and various styles of sitting. Joint loads were predicted with a highly detailed anatomical biomechanical model (that incorporated 104 muscles, passive ligaments and intervertebral discs), which utilized biological signals of spine posture and muscle electromyograms (EMG) from each trial of each subject. Sitting resulted in significantly higher (p< 0.001) low back compressive loads (mean±SD 1698±467 N) than those experienced by the lumbar spine during standing (1076±243 N). Subjects were equally divided into adopting one of two sitting strategies: a single ‘static’ or a ‘dynamic’ multiple posture approach. Within each individual, standing produced a distinctly diVerent spine posture compared with sitting, and standing spine postures did not overlap with flexion postures adopted in sitting when spine postures were averaged across all eight subjects. A rest component (as noted in an amplitude probability distribution function from the EMG) was present for all muscles monitored in both sitting and standing tasks. The upper and lower erector spinae muscle groups exhibited a shifting to higher levels of activation during sitting. There were no clear muscle activation level diVerences in the individuals who adopted diVerent sitting strategies. Standing appears to be a good rest from sitting given the reduction in passive tissue forces. However, the constant loading with little dynamic movement which characterizes both standing and sitting would provide little rest/change for muscular activation levels or low back loading.

Low back joint loading and kinematics during standing and unsupported sitting

The aim was to examine lumbar spine kinematics, spinal joint loads and trunk muscle activation patterns during a prolonged (2 h) period of sitting. This information is necessary to assist the ergonomist in designing work where posture variation is possible—particularly between standing and various styles of sitting. Joint loads were predicted with a highly detailed anatomical biomechanical model (that incorporated 104 muscles, passive ligaments and intervertebral discs), which utilized biological signals of spine posture and muscle electromyograms (EMG) from each trial of each subject. Sitting resulted in significantly higher (p< 0.001) low back compressive loads (mean±SD 1698±467 N) than those experienced by the lumbar spine during standing (1076±243 N). Subjects were equally divided into adopting one of two sitting strategies: a single ‘static’ or a ‘dynamic’ multiple posture approach. Within each individual, standing produced a distinctly diVerent spine posture compared with sitting, and standing spine postures did not overlap with flexion postures adopted in sitting when spine postures were averaged across all eight subjects. A rest component (as noted in an amplitude probability distribution function from the EMG) was present for all muscles monitored in both sitting and standing tasks. The upper and lower erector spinae muscle groups exhibited a shifting to higher levels of activation during sitting. There were no clear muscle activation level diVerences in the individuals who adopted diVerent sitting strategies. Standing appears to be a good rest from sitting given the reduction in passive tissue forces. However, the constant loading with little dynamic movement which characterizes both standing and sitting would provide little rest/change for muscular activation levels or low back loading.

Prevention of Fixed, Angular Kyphosis in Achondroplasia

Transient kyphotic deformity arises in most infants with achondroplasia. In a minority, a fixed and angular kyphosis develops, which can cause serious neurologic sequelae later in life. We assessed a protocol for preventing development of such fixed kyphosis in a sequential, unselected series of 66 infants with achondroplasia. This study demonstrates the efficacy of early prohibition of unsupported sitting and, in those in whom such prohibition proves insufficient, use of bracing. When the proposed algorithm was followed, none of the infants had development of a progressive kyphotic deformity. On this basis, it appears that the secondary risks of angular kyphosis, previously estimated to be between 10 and 15% in individuals with achondroplasia, can be completely eliminated.

Muscle power, sitting unsupported and trunk rotation in pre-term infants.

Discrepancies between active and passive muscle power are often seen in pre-term infants over the first year. Generally of a transient nature, they are most obvious in the extensor muscles of the trunk where there is a high active muscle power relative to the passive component. While high active muscle power may not be a sign of cerebral palsy, it is our contention that it will impair functions such as unsupported sitting and the ability to rotate in this position. In this study, 20 full-term and 37 healthy pre-term infants were assessed at the (corrected) ages of 39 and 52 weeks for muscle power in the trunk, sitting unsupported and rotation around the body axis while seated. At the age of 39 weeks, all full-term infants could sit without support. In contrast half of the pre-term infants could not sit without support and the majority of them could not rotate the trunk in this position. At 52 weeks the majority of pre-term infants could sit without support, despite having higher active muscle power in the trunk. However this deviant muscle power prevented rotatory movements of the trunk during sitting. The origin of this deviance may reside in the positioning to which pre-term infants are subjected after birth and thus postural management should be directed towards avoidance of extensor positions.

The effect of seat back inclination on spine height changes

The effect of backrest inclination on spinal height changes was tested during static sitting and seated whole-body vibrations. The vibration input was sinusoidal with a frequency of 5 Hz and an acceleration of 0.1 g rms. The backrest inclinations tested were 110° and 120°. The 110° backrest caused less shrinkage than did the 120° during static sitting, whereas the opposite was true when vibration was present, although the differences between the backrests were not statistically significant. Only when the results were compared with results from exposure to unsupported sitting were the differences statistically significant for both static sitting and seated vibrations when the 110° backrest was used and for vibration with the 120° backrest. Thus we conclude that an inclined backrest reduces the effects of vibration. More importantly, emphasis should be placed upon seats and seat materials that can attenuate vibration.

Biomechanical measurements of back shape and interface pressures in unsupported sitting

The paper describes the use of two non-invasive techniques to provide simultaneous measurements of interface pressures and back shape in the seated posture. A modified wheelchair was used to provide adjustments of various seating parameters. The effects of varying seat angulation with four normal subjects are reported. The lumbar lordosis, evident in the standing position, was absent in the sitting position. The changing of seat base angulation affected the balance between the main areas of seating support. For example, forward inclination of the seat reduced pr posterior thigh.

Disc pressure measurements.

By measurement of intradiscal pressure in vitro, the hydrostatic properties of the nucleus pulposus of normal lumbar intervertebral disc were proven. The hydrodynamic properties seem to exist also in the somewhat degenerated disc, but not in the more severely deranged ones. Intravitally-performed measurements of disc pressure over the last 20 years in more than 100 individuals have demonstrated how the load on the lumbar disc varies with the position of the subject's body and during the performance of various tasks, both in standing and in sitting. Compared with the pressure of load in the upright standing position, reclining reduces the pressure by 50-80%, while unsupported sitting increases the load by 40%, forward leaning and weight lifting by more than 100%, and the position of forward flexion and rotation by 400%. Large augmentations in pressure were also observed in subject performing various commonly prescribed strengthening exercises.

The Sitting Posture: An Electromyographic and Discometric Study

The disc pressure of the third lumbar disc and the myoelectric activity of several muscles of the back were measured. Three standing and nine unsupported sitting positions were studied as well as eight support parameters and six sedentary tasks. 1. Myoelectric activity is about the same in standing and in relaxed unsupported sitting. In the unsupported sitting positions the highest level of activity is found in anterior sitting and the lowest in posterior sitting. In the muscles of the cervical and lumbar regions the activity is always lower than in the muscles of the thoracic region. The disc pressure is considerably higher in unsupported sitting than in standing. In the unsupported sitting positions the highest disc pressure is found in anterior sitting and the lowest in sitting straight. 2. Both the myoelectric activity and the disc pressure decrease when the back is supported. Of the support parameters, the backrest inclination is the most important, myoelectric activity and disc pressure both decreasing with an increase in inclination. The disc pressure is considerably reduced also when the lumbar support is increased and when armrests are used. 3. Myoelectric activity and disc pressure are both comparatively low in writing, higher in typing, and still higher in lifting. In the car driver's seat the disc pressure increases both when the gear is shifted and when the clutch pedal is depressed. When the gear is shifted, there is also an increase in myoelectric activity.

Towards a better understanding of low-back pain: a review of the mechanics of the lumbar disc.

By measurement of intradiscal pressure in vitro, the hydrostatic properties of the nucleus pulposus of normal lumbar intervertebral disc was established. The stress distribution within normal discs subjected to vertical load was also explained, demonstrating the high tangential strains occurring in the posterior part of the annulus fibrosus. Intravitally performed measurements of disc pressure have demonstrated how the load on the lumbar disc varies according to the position of the subject's body. Compared to the pressure or load in the upright standing position, reclining reduces the pressure by 70%, while unsupported sitting increases the load by 40% and forward leaning and weight lifting by more than 100%. Similar relatively large augmentations of the load were observed in subjects performing various commonly used muscle-strengthening exercises. Measurement of intradiscal pressure is instrumental in explaining, from a mechanical point, the occurrence of posterior ruptures in the lumbar discs, and provides a basis for the rational treatment of patients with low-back pain in so far as these exhibit increase of pain on increased mechanical loads. For the majority of patients with low-back pain, the cause is unknown, although most evidence so far presented links the lumbar intervertebral disc to the pain syndromes. Results of recent studies have shown that both chemical and mechanical factors are probably of importance. So far we cannot successfully treat the chemical part of the disc syndrome. Since all our patients exhibit more pain when the spine is mechanically loaded, knowledge gained from intravital disc-pressure measurements provides a basis for successfully treating the mechanical part of the condition. Since none of the frequently prescribed and more spectacular remedies has ever been proved statistically superior to any of the others, it is most fair to our patients and to ourselves to use simpler, less expensive, and less dangerous programmes, such as bed-rest, administration of salicylates, and proper ergonomic advice. Based on a scientific approach, the low-back-pain school is intended to help the patient to be able to cope with these back troubles, to avoid excess therapy, and to decrease the cost both for the individual and for Society.