Assessing Sit-To-Stand for Clinical
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Assessing Sit-to-Stand for Clinical Use Clinical Assessing for Sit-to-Stand Rob van Lummel van Rob Assessing Sit-to-Stand for Clinical Use Rob van Lummel Design: Dominique van Rhee Illustration: Steven van Lummel Printing: Ridderprint Photography: Horizon Creative ISBN: 978 90 5383 234 9 © Rob van Lummel No part of this thesis may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or otherwise without permission of the author. The work in this thesis was sponsored by VRIJE UNIVERSITEIT Assessing Sit-to-Stand for Clinical Use ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. V. Subramaniam, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Gedrags- en Bewegingswetenschappen op donderdag 30 maart 2017 om 13.45 uur in het auditorium van de universiteit, De Boelelaan 1105 door Robert Christiaan van Lummel geboren te ‘s-Gravenhage promotoren: prof.dr. J.H. van Dieën prof.dr. P.J. Beek beoordelingscommissie: prof.dr.dr. A.M. Maier (voorzitter) prof.dr. C. Delecluse prof.dr. P.L. Meurs prof.dr. H.C.W de Vet prof.dr. W. Zijlstra ''If you can't stand up, you can't walk'' CONTENTS 1. Introduction 9 PART I: METHODOLOGICAL ASPECTS 26 2. Automated approach for quantifying the 27 repeated sit-to-stand using one body fixed sensor in young and older adults 3. Validation of seat-off and seat-on in 37 repeated sit-to-stand movements using a single-body-fixed sensor 4. Intra-rater, inter-rater and test-retest 55 reliability of an instrumented Timed Up and Go (iTUG) test in patients with Parkinson’s disease PART II: CLINICAL VALUE 72 5. The Instrumented Sit-to-Stand Test (iSTS) 73 has greater clinical relevance than the manually recorded Sit-to-Stand Test in older adults 6. Older adults with low muscle strength stand 97 up from a sitting position with more dynamic trunk use 7. A new scoring method to quantify the 115 instrumented Sit-to- Stand test in older adults 6 PART III: ASSOCIATION PHYSICAL 136 PERFORMANCE – PHYSICAL ACTIVITY 8. Physical performance and physical activity 137 in older adults: associated but separate domains of physical function in old age PART IV: GENERAL DISCUSSION 160 AND SUMMARY 9. General discussion 161 10. Summary / Samenvatting 171 PART V: APPENDICES 174 11. Acknowledgements / Dankwoord 175 12. List of publications 185 13. Curriculum Vitae 191 7 8 CHAPTER 1 Introduction 9 Chapter 1 INTRODUCTION WHY STUDYING SIT-TO-STAND? GROWING NUMBER OF OLDER ADULTS WITH PROBLEMS STANDING UP In 2015, the Dutch government decided to cut back on long-term care by 3.5 billion euro per year. As a prelude to this decision, the Dutch Central Statistical Office announced in 2014 that the government aims to enable older people to live independently as long as possible, implying that fewer older adults will be admitted to residential care homes. Whether or not this is feasible depends on the health status of those people. It is not so much diseases as such, but rather their ensuing limitations that cause the main obstacles to independent living (https:// www.cbs.nl/nl-nl/achtergrond/2015/18/beperkingen-in-dagelijkse-handelingen- bij-ouderen) (25-07-2016). To date, however, no new policy has been announced to enable older patients to stay mobile and live independently for a longer period. The ability to rise from sitting to standing is critical to an individual’s quality of life, as it is a prerequisite for functional independence. One of the few publications on the hierarchy of disability indicates that problems in standing up become manifest much later than limitations in walking [1]. Disability to stand up has long been seen as a problem of the very old and as a consequence the amount of Sit-To-Stand (STS) research has been smaller and of more recent origin than gait research (Figure 1). There are several reasons why the disability of standing up from sitting increases with age. Above 50 years of age muscle mass reduces at a rate of 1-2% per year while muscle force declines, a process called sarcopenia [2]. It can be expected that a higher life expectancy will result in more people losing motor abilities due to a lack of muscle strength. The Sit-to-Stand (STS) transition is considered one of the most mechanically demanding physical activities in daily life [3], because it requires displacement of body weight against gravity. The loss of muscle mass and muscle force will impact this transfer more than walking. Over the last 100 years the mean life expectancy has increased from 40 to 80 years [4]. By the year 2025, 26 countries are predicted to have a life expectancy at birth of 80 years or older [5]. This implies that more and more people will be confronted with problems standing up. An increase in longevity will lead to an increasing number of older adults with chronic diseases with a potentially negative impact on the ability to stand up. These chronic diseases include respiratory and cardiovascular diseases, osteoarthritis, Parkinson’s disease, stroke, rheumatic disease, vestibular dysfunction, and diabetes. Recent research has shown that limb muscle dysfunction is an essential systemic consequence of Chronic Obstructive Pulmonary Disease, which may have a detrimental effect on the ability to rise from sit to stand [6]. Also patients with Pulmonary Arterial Hypertension present significant peripheral muscle changes [7]. 10 Introduction NUMBER OF PUBLICATIONS ABOUT STS Clinical movement analysis has long been dominated by the analysis of walking, or ‘gait analysis’. This dominance is reflected in the number of publications on ‘gait analysis’ vis-à-vis other motor activities in MEDLINE. The number of publications with the search term ‘gait analysis’ generated over 9 times more hits than the search term ‘sit-to-stand’ (Figure 1). ((http://www.ncbi.nlm.nih.gov/ pubmed/?term=gait+analysis and term=sit+to+stand)(28-08-2016)) Publications in PubMed Figure 1. Number of PubMed publications per year using the search terms ‘gait analysis’ and ‘sit- to-stand’. The blue/dashed line represents the number of gait analysis publications and the orange/ points line represents the STS publications. Walking is obviously a very basic motor activity, but the question arises whether these numbers are proportionate to the importance of research in these two mobility domains. Most knowledge about the biomechanics of STS has been generated in motion laboratories with complicated, expensive and time-consuming measurement systems. In this thesis we aim to develop a method to analyze the STS that is easier to use, cheaper and less time consuming. EFFECTS OF AGEING ON SITTING BEHAVIOR Losing the ability to stand up may lead to avoidance of moving around, further inactivity and longer sitting. A recent not yet published study involving 884 subjects revealed a significant increase in sitting duration with ageing in the 81- 100 age group compared to the 71-80 age group (Figure 2). 11 Chapter 1 Duration of sitting Figure 2. Cross-sectional age differences in sitting duration. Data collected in the Gray Power study of the Vrije Universiteit Amsterdam. https://www.vumc.nl/afdelingen/Amsterdam-Center-on-Aging/ nieuws/8362866/ Recent studies have suggested that breaking up prolonged sitting may improve glucose metabolism and could represent an important public health and clinical intervention strategy for reducing cardiovascular risk [8–11] and mortality [12], which underscores the importance of maintaining the ability to stand up from a sitting position. AGEING AND FALLS Risk of falling and fear of falling are common causes of becoming inactive at older age. In a study in Bayern, the largest state in Germany, more than 70,000 falls from residents of Bavarian nursing homes were analyzed. Serious falls resulting from walking and standing up, in particular during the morning hours, were compared. Unsuccessful transfers from sitting to standing accounted for 41% of all falls [13]! Several mechanisms in older adults can lead to instability and thus jeopardize the ability to remain stable while standing up. An important cause of falls during transitions in the morning might find its origin in dizziness. Blood pressure control medication can lead to lower blood pressure in the morning with orthostatic hypotension and dizziness as potential side effects. Furthermore, 35.4% of US adults aged 40 years and older were found to have vestibular dysfunction. Participants with vestibular dysfunction who were clinically symptomatic (reported dizziness) had a 12-fold increase in the odds of falling [14]. Confidence and ability to stand up from sitting in a safe and automatic manner is an important prerequisite for independent living and active and healthy ageing. 12 Introduction PHYSICAL PERFORMANCE TESTS Since the 1970s several Physical Performance (PP) tests have been introduced, during which the subject is asked to engage in a series of physical activities like walking different distances, standing up and sitting down, turning and balancing. In general, these tests are standardized to allow comparison within and between subjects. In some cases a cognitive task is added, for instance counting down to determine how this additional task affects the motor task. Furthermore, the task can be performed at a self-chosen speed or as fast as possible. In clinical practice a supervisor typically explains the test, monitors whether the performance is correct, records the outcome by counting, timing with a stopwatch or measuring distance, and writes down the results. A well-known and often used test in the geriatric domain is the Short Physical Performance Battery (SPPB). This test includes three common physical activities: maintaining balance, walking a short distance (4 meter), and performing repeated sit-to-stand transitions.