How Balance Matters Can Help Train Sit to Stand

Improve the timing and amplitude of weight shift to decrease loss of balance backwards

No plopping - improve control of stand to sit

I recently listened to a great podcast called "The Therapist Who Said Too Much" from Senior Rehab Project, sponsored by the Academy of Geriatric Physical Therapy.  It really struck a chord with me.  After it was over, I continued to reflect on the cues and feedback I provide to my patients during our sessions together.

While helping a patient with sit to stand, you may have used the cue “nose over toes” to help shift their weight forward. If you have, you know that sometimes it works and other times you need alternate cues or feedback. I tend to explain A LOT. I have even explained the definition of balance (center of mass over base of support) with the hopes that my patient would shift his weight forward better. I have learned through experience though that sometimes less is more.

Is there a way to help provide simple processing with less verbal instruction? Have you ever tried auditory feedback?

When we use our voices, we can say the same word in different ways, expressing different emotions or meanings each time. When using auditory feedback, the click sounds the same every single time it is heard; its meaning never varies. When you hear “click-click” while using the Balance Matters system, you know you performed a movement correctly, motivating you to do it again.

Training Sit to Stand:

Using multi-sensory feedback using the Balance Matters system will improve an individual’s awareness of their starting posture and transitional postures. The auditory feedback in the footpads helps promote improved timing and sequence of the task. Sometimes, an individual’s body awareness is poor due to various reasons and they are unaware of their body position prior to a transfer; this sets them up for failure. Feedback can help engage the patient during all phases of sit to stand transfers (preparatory/ starting alignment, transitional movement and the final standing posture.)   

Verbal Cue: “Activate the back clicker in the footpad.”

This will improve starting alignment by putting weight on the heels with improved anterior pelvic tilt and weight through the legs, activating the quads.

Verbal Cue: “Activate the front clicker in the footpad and stand.”

 This improves the next phase of forward weight shift during sit to stand.

  Verbal Cue: “When standing, keep all clickers quiet.”

At the end phase of standing, all clickers should be quiet. (If there is an increased sway in one direction, the auditory feedback will provide the individual with which way to shift their weight.)

Verbal Cue: “Sit and keep all clickers quiet.”

During stand to sit, try to keep all clickers quiet until they touch the seat with their bottom. This is effective for the temporal (timing) part of the transfer so a “plop” doesn’t occur. This can happen if timing of weight shift is the issue and they shift their weight to their seat too soon and do not keep their COG over their feet. 

Simple instructional cues:

Sit to stand:  Activate back clicker, activate front clicker while you stand, keep all clickers quiet during standing.

Stand to sit: Keep all clickers quiet until bottom is on the seat.

Progressions and intervention ideas to consider depending on patient goal:

You can perform part practice (only one phase of the transfer).

Preparatory phase: Work on good starting posture, activating back clicker to promote anterior pelvic tilt and increased weight bearing through the legs.

Transitional phase: Reach forward with arms and activate front clicker to promote anterior weight shift.

Transitional phase for stand to sit: partial squats to sit down keeping clickers quiet to improve the timing of weight shift and decrease a “plop”.

You can progress by using foam footpads to activate the vestibular system or sit to stand with staggered stance and step to work on step initiation.

You can also perform eyes closed to improve balance in dimly lit environments.

This is important when standing up from bed to walk in order to go to the bathroom at night. An article “Effect of Sitting Pause Times on Balance After Supine to Standing Transfer in Dim Light” mentions that the risk of falling for older adults increases in dimly lit environments. The results of the study suggest that longer sitting pause times may improve adaptability to dimly lit environments, contributing to improved postural stability and reduced risk of fall in older adult women when getting out of bed at night.  This is an important topic on how the speed or timing to adapt in different environments (dim lit or uneven surfaces) can change our overall balance and postural control and should be integrated into balance exercises and goals. 

The starting stance position (feet parallel versus a slight staggered stance) makes a difference during sit to stand transfer speed and initiation of gait. 

Kawagoe et al. demonstrated that forward displacement of CoG during standing up was significantly longer in normal foot placement when compared to posterior foot placement, which was referred to 10 cm behind the normal position

Posterior foot placement in combination with augmented arm position associates with faster FTSTS times in individuals with chronic stroke (Kwong et al 2014)

It may be more desirable for persons with stroke to place the affected foot behind the unaffected foot when performing STS to increase affected ES and GM muscle activation. (Nam et al 2015)

Translating the swing limb ½ foot length backward appears to enhance the interaction between posture and locomotion, which may have therapeutic potential for improving gait initiation performance. (Dalton et al 2011) 

In another blog, I will discuss how to use auditory feedback while training to step at different speeds, stepping to various surfaces and turning.  An individual may have good postural control stepping or turning at one speed but not another; it is important to assess and then train appropriately.

References:

EG Johnson et al. Effect of Sitting Pause Times on Balance After Supine to Standing Transfer in Dim Light J Geriatr Phys Ther. 2017 Jun 01

Podcast: “The therapist who said too much” from Senior Rehab Project sponsored by the Academy of Geriatric Physical Therapy

Cacciatore TW, Gurfinkel VS, Horak FB, Day BL. Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique. Gait & posture. 2011;34(4):496-501.

Hirschfeld H, Thorsteinsdottir M, Olsson E. Coordinated ground forces exerted by buttocks and feet are adequately programmed for weight transfer during sit-to-stand. J Neurophysiol. 1999;82(6):3021–9. [PubMed]

Brunt D, Greenberg B, Wankadia S, Trimble MA, Shechtman O. The effect of foot placement on sit to stand in healthy young subjects and patients with hemiplegia. Arch Phys Med Rehabil. 2002;83(7):924–9.

Kawagoe S, Tajima N, Chosa E. Biomechanical analysis of effects of foot placement with varying chair height on the motion of standing up. J Orthop Sci. 2000; 5(2):124-33.

Kwong PWH, Ng SSM, Chung RCK, Ng GYF. Foot Placement and Arm Position Affect the Five Times Sit-to-Stand Test Time of Individuals with Chronic Stroke. BioMed Research International. 2014;2014:636530. doi:10.1155/2014/636530.

Nam I, Shin J, Lee Y, Lee MY, Chung Y. The effect of foot position on erector spinae and gluteus maximus muscle activation during sit-to-stand performed by chronic stroke patients. J Phys Ther Sci. 2015 Mar;27(3):571-3. doi: 10.1589/jpts.27.571. Epub 2015 Mar 31

Dalton E, Bishop M, Tillman MD, Hass CJ. Simple Change in Initial Standing Position Enhances the Initiation of Gait. Medicine and science in sports and exercise. 2011;43(12):2352-2358