Journal of Biomechanics 45 (2012) 699705

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Journal of Biomechanics
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The minimum required muscle force for a sit-to-stand task

Shinsuke Yoshioka a,n, Akinori Nagano b, Dean C. Hay c, Senshi Fukashiro d
a

Faculty of Sport and Health Science, Ritsumeikan University, Nojihigashi 1-1-1, Kusatsu city, Shiga 525-8577, Japan Department of Computational Science, Kobe University, Japan School of Physical and Health Education, Nipissing University, Ontario, Canada d Department of Life Sciences (Sports Sciences), The University of Tokyo, Japan
b c

a r t i c l e i n f o
Article history: Accepted 27 November 2011 Keywords: Sit-to-stand movement Mechanical threshold Total muscle force Muscle redundancy Optimization

abstract
The purpose of this study was to reveal the minimum required muscle force for a sit-to-stand task. Combining experimental procedures and computational processing, movements of various sit-to-stand patterns were obtained. Muscle forces and activations during a movement were calculated with an inverse dynamics method and a static numerical optimization method. The required muscle force for each movement was calculated with peak muscle activation, muscle physiological cross sectional area and specic tension. The robustness of the results was quantitatively evaluated with sensitivity analyses. From the results, a distinct threshold was found for the total required muscle force of the hip and knee extensors. Specically, two ndings were revealed: (1) the total force of hip and knee extensors is appropriate as the index of minimum required muscle force for a sit-to-stand task and (2) the minimum required total force is within the range of 35.349.2 N/kg. A muscle is not mechanically independent from other muscles, since each muscle has some synergetic or antagonistic muscles. This means that the mechanical threshold of one muscle varies with the force exertion abilities of other muscles and cannot be evaluated independently. At the same time, some kinds of mechanical threshold necessarily exist in the sit-to-stand task, since a muscle force is an only force to drive the body and people cannot stand up from a chair without muscles. These indicate that the existence of the distinct threshold in the result of the total required muscle force is reasonable. & 2011 Elsevier Ltd. All rights reserved.

1. Introduction A sit-to-stand movement, which is dened as a movement of standing up from a chair to an upright posture, is a frequently performed daily task. Nonetheless, there are many elderly people who experience difculty when standing up from a chair (Alexander et al., 1991; Schultz, 1995). As such difculties inuence the quality of daily life and ability to remain independent, research on the sit-to-stand task is important. Mechanical aspects of the sit-to-stand task have been an area of particular focus, since it is one of the most demanding daily activities in mechanical terms (Hodge et al., 1989; Ploutz-Snyder et al., 2002; Rodosky et al., 1989). Rantanen et al. (1994) revealed that there was a signicant difference in muscle strengths between the subjects who could stand up from a chair without difculty and the subjects who had difculties performing the task. Hughes et al. (1996) revealed that, in the case of elderly people, the peak value of the knee joint moment during sit-to-stand movements at their lowest height

Corresponding author. Tel.: 81 77 599 4135; fax: 81 77 561 3761. E-mail address: yoshio-s@fc.ritsumei.ac.jp (S. Yoshioka).

chair reached up to 97% of the maximum isometric knee extensor strength. Lord et al. (2002) revealed that, using multiple regression analysis, muscle strength is the most inuential factor of the performance of a sit-to-stand movement among a variety of factors such as balancing ability, sensorimotor condition and psychological conditions. These ndings indicate that the improvement of muscle strength can contribute to the improvement of sit-to-stand performance of elderly people experiencing difculty when standing up from a chair. To develop an index for exercise or rehabilitation to improve the performance of a sit-to-stand movement, Yoshioka et al. (2007) examined the minimum required joint moment for a sitto-stand task and reported that the total of the peak hip and knee joint moment is an appropriate index. They also found that the minimum required value is 1.53 N m/kg. Their nding, represented in terms of joint moment, is convenient for practical uses such as physical rehabilitation and exercise prescription, since joint moment is used as the index of muscle strength in many muscle strength tests (Runnels et al., 2005). However, joint moment exertion ability varies with joint conditions, including angle, angular velocity, adjacent joint angle and adjacent joint angular velocity (Anderson et al., 2007). These factors affect the physiological and architectural parameters of

0021-9290/$ - see front matter & 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbiomech.2011.11.054

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muscles, including the force-length-velocity relation and moment arm. These strength variations indicate that a joint moment does not necessarily correspond to the load on muscles across the joint. Hoy et al. (1990) developed a musculoskeletal model of the lower extremity and showed that the joint angle where joint moment peaked did not correspond to the angle where muscle force peaked. To conduct the precise evaluation of muscle strength capacity, it is also necessary to focus on muscle force itself. Therefore, the purpose of this study was to reveal the minimum required muscle force to perform a sit-to-stand task.

2. Methods In vivo muscle forces during a sit-to-stand movement cannot be directly measured because of ethical reasons. Two kinds of computational methods to calculate muscle forces during movement (static and dynamic numerical optimization methods) have been developed. There are technical differences between the two methods; however, research has demonstrated that the nal results are essentially similar in cases where movement performance can be evaluated as a time-independent criterion (Anderson and Pandy, 2001). Therefore, from the viewpoint of computational cost, a static numerical optimization method (Crowninshield and Brand, 1981) was adopted in this study. Initially, kinematic data of lower limb joint angles (hip, knee and ankle) during sit-to-stand movements were experimentally collected. This study was performed under the approval of the ethics committee of the University of Tokyo and all subjects gave informed consent to participate in this experiment. Eighty-ve sets of sit-to-stand kinematic data were obtained from human subjects. Using those kinematic data and a link segment model of the human body, 160,086 movements including various kinds of sit-to-stand movements were computationally generated. Joint moments and muscle activations were calculated for all movements. Muscle activations were calculated using a static numerical optimization method and a two-dimensional human lower limb musculoskeletal model. The required muscle forces for each sit-to-stand movement were also calculated. From the required muscle forces of all movements, the minimum required muscle forces for a sit-to-stand task were determined. It has been found that the muscle force result obtained through a static numerical optimization is affected by the kinds of objective function and the parameters used in a musculoskeletal model. Therefore, nally, the robustness of muscle force results was examined through sensitivity analysis. The details of this computational process are explained in the Appendix. Throughout this study, bilateral symmetry was assumed. The process from joint kinematic data collection to computational motion generation was identical to the one used in Yoshioka et al. (2007). Following are the methods we used for this current study after the processes explained in Yoshioka et al. (2007).

Fig. 1. Location of eight muscles implemented in the musculoskeletal model. M. iliopsoas, mm. glutei, mm. vasti, m. soleus and m. tibialis anterior are monoarticular muscles. Hamstrings, m. rectus femoris and m. gastrocnemius are biarticular muscles. The roles of each of the muscles are as follows: m. iliopsoas (hip exion), mm. glutei (hip extension), hamstrings (hip extension and knee exion), m. rectus femoris (hip exion and knee extension), mm. vasti (knee extension), m. gastrocnemius (knee exion and ankle plantar exion), m. soleus (ankle plantar exion) and m. tibialis anterior (ankle dorsi exion).

where ACT is the muscle activation, Fmuscle is the muscle force, f is the function representing the force-length-velocity relations of the contractile element, Lmuscle is the muscle length and Vmuscle is the muscle contractile velocity.

4. Calculation of required muscle forces of each movement The required muscle force for each movement was calculated with the following equation: F MAX _req ACT peak PCSAmuscle ST where FMAX_req is the required muscle force, ACTpeak is the peak muscle activation during the sit-to-stand movement, PCSAmuscle is the physiological cross sectional area value of the muscle and ST is the specic tension (31.5 N/cm2). The results of muscle forces were normalized by the models mass (73.8 kg).

3. Calculation of muscle activations A two-dimensional human lower limb musculoskeletal model was developed based on Gerritsens model (1997). Eight Hill-type (Hill, 1938) muscles were implemented in this model (Fig. 1). The mathematical expression of a muscle model was derived from previous researches (Nagano and Gerritsen, 2001; van Soest and Bobbert, 1993). Muscle parameter values were also derived from previous researches (Brown et al., 1998; Friederich and Brand, 1990; Gerritsen, 1997; Matsubayashi et al., 2008) (Table 1). In a static numerical optimization, the optimal set of solutions (eight muscle forces) was searched with Bremermanns (1970) method. The following function was used as the objective function. The value of muscle activation was constrained between 0 and 1: J
8 X muscle 1

5. Sensitivity analysis It has been found that the result obtained through a static numerical optimization is affected by the objective function (Crowninshield and Brand, 1981; Kaufman et al., 1991) and the parameters used in a musculoskeletal model such as physiological cross sectional area (Brand et al., 1986), force-length relation of muscle contractile element (Scovil and Ronsky, 2006), optimal length of muscle contractile element (Hoy et al., 1990; Redl et al., 2007), slack length of series elastic element (Hoy et al., 1990; Redl et al., 2007; Scovil and Ronsky, 2006) and muscle moment arm length (Hoy et al., 1990; Maganaris, 2004; Raikova and Prilutsky, 2001). Therefore, sensitivity analyses were conducted in these points. The settings of the analyses were determined based on the ndings of previous researches (Burkholder and Lieber, 2001; Erdemir et al., 2007; Klein Horsman et al., 2007; Maganaris et al., 1998; Pierrynowski, 1995; Tsaopoulos et al., 2006).

ACT 3 muscle

0 r ACT muscle r 1

where J is the objective function and ACTmuscle is the muscle activation. This optimization was executed at all time steps of all movements. Muscle activation was calculated with the following equation: ACT F muscle f Lmuscle , V muscle

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Table 1 Muscle parameter values used in this study. PCSA: physiological cross sectional area. Lslack: slack (unloaded) length of the series elastic element. Lceopt: optimal length of the contractile element. L0deg: muscle length at full extension of the joints. Width: maximum length range of force production relative to Lceopt. MAankle: moment arm length about the ankle joint. MAknee: moment arm length about the knee joint. MAhip: moment arm length about the hip joint. PCSA (cm2) m. iliopsoas mm. glutei hamstrings m. rectus femoris mm. vasti m. gastrocnemius m. soleus m. tibialis anterior 49.03 59.79 96.94 42.96 213.28 64.90 186.69 34.97 Lslack (m) 0.142 0.157 0.297 0.361 0.223 0.440 0.245 0.317 Lceopt (m) 0.102 0.200 0.104 0.081 0.093 0.055 0.055 0.082 L0deg (m) 0.248 0.271 0.346 0.437 0.271 0.424 0.201 0.464 Width (%Lceopt) 129.8 62.5 119.7 144.3 62.7 88.8 103.9 44.2 MAankle (m) MAknee (m) MAhip (m) 0.050 0.062 0.072 0.034

0.053 0.053 0.037

0.034 0.050 0.042 0.020

Fig. 2. Average and standard deviation of (a) the vertical position and (b) the vertical velocity of center of mass of the model. (c) The average and standard deviation of the vertical component of ground reaction force. They were obtained from the 160,086 computed movements. 0 and 100% of the time, respectively, indicate the start and nish time of the movement. The dashed line in (c) shows the body weight level.

Fig. 3. Typical examples of (a) postures during the sit-to-stand movement, (b) joint moments, (c) muscle forces and (d) muscle activations. 0 and 100% of the time, respectively, indicate the start and nish time of the movement. Joint moments of hip extension, knee extension and ankle plantar exion are dened as positive. Muscle activation is dened as not activated (0) and maximally activated (1.0).

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Fig. 4. (a) Required muscle forces for each movement. The results are shown in ascending order of the total force of all muscles. The forces of hip and knee extensors (mm. glutei, hamstrings, m. rectus femoris and mm. vasti) were relatively invariant, as were the total forces of those muscles. (b) The ten results of (a) from the rst to tenth lowest total force. The forces of m. iliopsoas, m. gastrocnemius, m. soleus and m. tibialis anterior were noticeably smaller than those of hip and knee extensors.

6. Results Figs. 2a and b show the average and standard deviation of (a) the vertical position and (b) the vertical velocity of center of mass of the model. Fig. 2c shows the average and standard deviation of the vertical component of ground reaction force. Fig. 3 shows typical examples of the result about (a) postures during a movement, (b) joint moments, (c) muscle forces and (d) muscle activations. The resultant moments of eight muscle forces corresponded to the joint moments calculated with the inverse dynamics method. Differences of less than 1.0 10 3 N m/kg between the total muscle and joint moments were found in all movements. This result indicates that the optimization of this study was successful. Fig. 4a shows the required muscle forces for each movement (the results are shown in ascending order of the total force of all muscles). Fig. 4b shows the ten results of Fig. 4a from the rst to tenth lowest total force. The average required muscle forces (standard deviation) were as follows: m. iliopsoas: 2.2 (2.2), mm. glutei: 5.6 (0.5), hamstrings: 7.8 (2.3), m. rectus femoris: 2.9 (0.6), mm. vasti: 33.6 (2.6), m. gastrocnemius: 4.7 (3.9), m. soleus: 8.5 (3.8) and m. tibialis anterior: 3.3 (2.4) (N/kg). The forces of hip and knee extensors (mm. glutei, hamstrings, m. rectus femoris and mm. vasti) were relatively invariant, as was the total force of those hip and knee extensors (minimum total force was 44.7 N/kg). On the other hand, the forces of m. iliopsoas, m. gastrocnemius, m. soleus and m. tibialis anterior did vary, and the lowest forces of these four muscles were all zero (N/kg). In the sensitivity analysis, the results of each factor were qualitatively similar to those of the base settings of this study, although there were quantitatively some differences in the details (Table 2a). This trend (qualitatively similar and quantitatively different) was identical to that of previous studies (Brand et al., 1986; Raikova and Prilutsky, 2001). This result indicates that it is necessary to take the variation of calculated muscle forces (which was attributed to the variation of each parameter) into consideration when forces are quantitatively discussed. Table 2b shows the variation range of the results of each factor to the results of the basic settings. The variation range of hip and knee extensors was from 21 to 11%.

7. Discussion The purpose of this study was to reveal the minimum required muscle force for a sit-to-stand task. It was found that the total

force of hip and knee extensors is appropriate as the index of minimum required muscle force, with a range of 35.349.2 N/kg. To ensure that the kinematics and kinetics of all movements computed in this study are within the natural range of sit-tostand movements, the trajectories and velocities of center of mass and the vertical component of ground reaction force were compared with the results obtained from real human subjects. Riley et al. (1991) and Roebroeck et al. (1994) examined the kinematics of sit-to-stand movements performed by human subjects and showed that the trajectory of center of mass was a nearly straight path with a bell-shaped velocity prole after the buttocks lost contact with the chair. The trajectories of this study were also nearly straight paths with a bell-shaped velocity prole (Figs. 2a and b). As for the vertical ground reaction force, it has been revealed that the force rstly becomes higher, then lower than body weight (Hesse et al., 1994). This is theoretically reasonable. The force proles within this study were similar to that of previous studies (Fig. 2c). These similarities indicate that the data computed in this study were within natural kinematic and kinetic ranges and provided valid movements for analysis. The physiological validity of the results of this study was evaluated through the comparisons of the results of previous studies. Finni et al. (2000) directly measured patellar tendon force during a submaximal squat jump with an invasive optic ber method. They revealed that the patellar tendon force at the time of initial static squat posture was approximately 32 N/kg. In this study, the total force of m. rectus femoris and mm. vasti was similar at 29.7 N/kg (Fig. 4). Yoshioka et al. (2009) revealed that, in the case of a slow sit-to-stand movement lasting more than 2.5 s, the mechanical load on a lower limb joint was equivalent to that in the case of a static condition, since inertial load was negligible. From this nding, it can be said that the mechanical load on a knee joint at the time of initial static squat posture in Finni et al. is equivalent to that at the time of buttocks liftoff during a slow sit-to-stand movement. In the sit-to-stand movement in this study where minimum required joint moment was obtained, the movement time was 3.78 ss. In this trial, peak knee extensor force occurred at the time of buttocks liftoff. In other words, the similarity between the patellar tendon force in Finni et al. and the total force of m. rectus femoris and mm. vasti in this study is mechanically valid and supports the physiological validity of the results of this study. Shelburne and Pandy (2002) simulated muscle loading during a fast sit-to-stand movement with a muculoskeletal model and a dynamic numerical optimization method. They found that the peak value of quadriceps muscle

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Table 2 (a) Results of the sensitivity analysis. Each value is an average value of required muscle forces of the one thousand sit-to-stand movements. (b) Change ratio of the results of each factor to the results of the basic settings. (a) m. iliopsoas mm. glutei hamstrings m. rectus femoris mm. vasti m. m. gastrocnemius soleus m. tibialis anterior Total of hip and knee extensors [mm. glutei, hamstrings, m. rectus femoris, mm. vasti] 49.8

Base settings 1. Objective function Sum of muscle activation Sum of muscle activation squared Sum of muscle stress squared Sum of muscle stress cubed

2.4

5.6

7.9

2.8

33.5

5.0

8.5

3.3

1.6 1.8 1.8 2.3

5.7 4.5 3.9 4.7

9.4 7.9 7.8 7.8

0.3 1.1 0.5 1.7

37.4 36.1 37.0 35.0

5.5 5.3 5.2 5.0

9.8 9.0 9.0 8.6

3.3 3.3 3.3 3.3

52.8 49.6 49.2 49.2

2. Physiological cross sectional area Klein Horsman et al., 2007 1.7 Pierrynowski, 1995 1.6 3. Force-length relation 80% maximum ability 100% maximum ability

9.1 4.7

5.7 8.0

2.1 2.7

30.9 33.8

5.8 5.8

8.3 7.6

3.3 3.4

47.7 49.2

3.1 2.4

5.5 4.4

9.2 7.4

2.3 1.8

32.1 25.8

6.1 4.9

10.3 8.3

3.6 2.9

49.1 39.4

4. Muscle moment arm length 90% arm length 2.7 110% arm length 2.3 (b) m. iliopsoas

5.4 6.4

8.6 7.5

2.5 3.7

32.4 37.7

5.5 4.7

9.6 8.2

3.3 10.6

48.9 55.4 (N/Kg)

mm. glutei

hamstrings m. rectus femoris

mm. vasti

m. m. gastrocnemius soleus

m. tibialis anterior

Total of hip and knee extensors [mm. glutei, hamstrings, m. rectus femoris, mm. vasti] 0 6 0 1 1 4 1 1 21 2 11 (%)

Base settings

0 2 19 30 16 62 16 1 21 3 14

0 20 0 1 1 28 1 17 6 9 4

0 91 60 82 39 25 5 19 36 13 31

0 12 8 11 5 8 1 4 23 3 13

0 11 6 5 0 16 17 23 2 11 6

0 15 6 6 0 3 11 21 3 13 4

0 0 0 0 1 0 2 8 14 1 219

1. Objective function Sum of muscle activation 34 Sum of muscle activation 23 squared Sum of muscle stress 22 squared Sum of muscle stress cubed 2 2. Physiological cross sectional area Klein Horsman et al., 2007 29 Pierrynowski, 1995 34 3. Force-length relation 80% maximum ability 100% maximum ability 29 3

4. Muscle moment arm length 90% arm length 14 110% arm length 3

force was 2850 N. The total force of m. rectus femoris and mm. vasti of this study was 2192 N ( 29.7 N/kg 73.8 kg) and 0.77 times as much as the muscle force revealed by Shelburne and Pandy. Using the relationship between joint moment and movement time (Yoshioka et al., 2009), the difference of the mechanical load between both studies attributed to the movement time (Shelburne and Pandys study, 0.59 s; this study, 3.78 s) was roughly estimated to be 0.7 times. Considering the difference of the mechanical load, the results of both studies were similar. Ellis et al. (1984) calculated the muscle forces of quadriceps, hamstrings and gastrocnemius during a sit-to-stand movement using the movement data obtained from nine male subjects and a quasi-static musculoskeletal model under four kinds of extreme

conditions; the condition of hamstrings and gastrocnemius alone (non-activation of gluteus and soleus was assumed), the condition of hamstrings and soleus alone, the condition of gluteus and gastrocnemius alone and the condition of gluteus and soleus alone. It was revealed that the average values of the maximum forces of quadriceps, hamstrings and gastrocnemius under the four conditions were, respectively, 5.50, 2.22 and 0.71 ( body weight). However, it was noted that these values were obtained under extreme conditions. In other words, they are the average values of the upper limits of estimated muscle forces. In this study, the average values of quadriceps (m. rectus femoris and mm. vasti), hamstrings and gastrocnemius forces of all movements were, respectively, 3.72, 0.80 and 0.48 ( body weight);

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values that can be considered within a valid physiological range and less than the extreme limits found by Ellis et al.. The total force of the knee extensors (m. rectus femoris and mm. vasti) was larger (more than two times) than that of the hip extensors (mm. glutei and hamstrings) (Fig. 4a). This result suggests that the potential of knee extensors to become a limiting factor of the sitto-stand task is larger than that of hip extensors, since both joints have similar force exertion abilities. Isokinetic peak extensor moment of the knee joint ranges from 90 to 230 N.m (Larsson et al., 1979; Runnels et al., 2005), and those of the hip joint ranges from 70 to 220 N m (Cahalan et al., 1989; Markhede and Grimby, 1980). Hughes et al. (1996) compared the knee extension moment during a sit-to-stand movement with that during an isometric muscle strength test. In the case of the young, the knee extension moment during a sit-to-stand movement was less than one-half of the value during an isometric muscle strength test. In the case of the elderly, both moments had similar values. From their results, the authors concluded that knee extension ability was the limiting factor of sit-to-stand task. Their conclusion is similar to the ndings of this study. Doorenbosch et al. (1994) measured electromyography levels during a sit-to-stand movement as a percentage of the value during maximum voluntary isometric contractions. Similar to our study, they reported that the knee extensors, m. rectus femoris and especially mm. vasti, had higher activation levels than the hip extensors (m. gluteus max and hamstrings). Waters et al. (1974) examined the relative strength of hamstrings to mm. glutei during an isometric hip extension and revealed that the strength ratio of hamstrings to mm. glutei was approximately 3354%. In this study, the ratio was 3866% (calculated from Table 2a). The nding of Waters et al. was obtained from real human subjects, so the similar values calculated from static numerical optimization in this study suggest that the muscle distribution results are valid. The minor discrepancy could be explained by the fact that movement used in Waters et al. was an isometric strength test, and not a sit-to-stand test. Overall, the similarities between the results of this study and previous studies support the physiological validity of our results. The muscle forces of ankle plantar exors and dorsiexors (m. gastrocnemius, m. soleus and m. tibialis anterior) were not necessarily required (Figs. 4a and b). On the other hand, in all movements, the muscle forces of hip and knee extensors (mm. glutei, hamstrings, m. rectus femoris and mm. vasti) were required. These results indicate that the hip and knee extensors were necessary actuators of a sit-to-stand movement, but ankle plantar and ankle dorsi exors were not. From the view point of joint moment, Yoshioka et al. (2007) reported similar results that the hip and knee extension moments were required in all movements, while the ankle moments were not necessarily required. Therefore, the hip and knee extensors are given specic focus in the following discussion. A muscle is not mechanically independent from other muscles, since each muscle has some synergistic or antagonistic muscles. This means that the mechanical threshold of one muscle varies with the force exertion abilities of other muscles and cannot be evaluated independently. At the same time, some kinds of mechanical thresholds necessarily exist in the sit-to-stand task, since muscle forces are required to elevate the body. In this study, the threshold could be clearly determined from the total force of the hip and knee extensors (44.7 N/kg) (Fig. 4a). Therefore, instead of individual muscle forces, the total force of the hip and knee extensors was adopted as the index to show the minimum required muscle force for a sit-to-stand task. Also, considering the variation range of the total force derived from the sensitivity analysis ( 21 to 10%) (Table 2b), it could be calculated that the minimum required muscle force for a sit-tostand task is within the range of 35.349.2 N/kg. The lower and

upper limits (35.3 and 49.2 N/kg) were, respectively, obtained by multiplying the minimum value of total forces (44.7 N/kg) by the sensitivity analysis result of total force ( 21 and 10%) as follows: 44.7 (10.21) 35.3, 44.7 (1 0.10) 49.2. Friederich and Brand (1990) reported physiological cross sectional areas of lower limb muscles of an elderly female cadaver (63 yrs). Assuming that the specic tension is 31.5 N/cm2 (Brown et al., 1998), the force exertion capacity of the cadaver can be estimated as 65 N/kg. The minimum required muscle force obtained in this study corresponds to approximately 70% of the force exertion capacity. From the viewpoint of a joint moment, Hughes et al. (1996) revealed that the force exertion capacities (the ratio of the knee extension moment during a sit-to-stand movement at knee height chair to that during an isometric muscle strength test) of the elderly was 78%. This result is similar to the result of this study and support the result of the minimum required muscle force (35.349.2 N/kg). It has been revealed that upper limbs and trunk exion during the initial phase of a sit-to-stand movement can facilitate a sit-tostand movement (Ellis et al., 1984; Riley et al., 1991). The contribution of the upper limbs to the sit-to-stand performance was not taken into consideration in this study. In daily life, there are many cases in which people have to stand up from a chair without upper limb support, for example, when they are carrying objects in both hands. Therefore, the general usefulness of this study is not reduced by limiting upper limb movements. However, as the upper limbs can modify the standing movement due to additional muscle usage (Ellis et al., 1984) or altering balance ability (Schultz et al., 1992), future studies would benet from considering the contribution of the upper limbs during sit-to-stand movements. The contribution of the trunk exion was also not taken into consideration. It has been revealed that trunk exion during the initial phase of a sit-to-stand movement contributes to the generation of the vertical momentum of the upper body in a fast movement by the young (Riley et al., 1991). This was not applicable to the case of this study, since the sit-to-stand movements on which this study focused were slow and the momentum was small. Hughes et al. (1994) revealed that, in the case of a slow movement, trunk movement only contributed to the displacement of the center of mass of a body from a chair seat to a foot support range. Therefore, it was not taken into consideration. Conict of interest statement There were no nancial or personal relationships with other people or organizations that could have inappropriately inuence our work. Acknowledgments This project was supported by Ministry of Education, Culture, Sports, Science and Technology in Japan (No: 16300205) and The Uehara Memorial Foundation.

Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at doi:10.1016/j.jbiomech.2011.11.054.

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