Pattern of Muscle Activation During Sit to Stand Task

in Feet Forward with 80° Knee Flexion using Surface EMG

Taufiq Nashrulloh

, Vitriana Biben

, Farida A Santi

, Rachmat G.Z

, Marina A Moeliono

, Dedy

H.B.Wicaksono

, Nabil el Hasnaoui

Department of Physical Medicine and Rehabilitation, Dr. Hasan sadikin General Hospital

University of Padjadjaran, Bandung, Indonesia.

Department of Biomedical Engineering, Faculty of Life Sciences and Technology,

Swiss German University (SGU) Tangerang, Indonesia

Biomedical Engineering, Delft University of Technology, Delft, Netherland

Keywords: Muscle Activation, sEMG, Sit to Stand

Abstract: The sit-to-stand (STS) in feet forward is one type of STS with a characteristic of delayed contraction of

Tibialis anterior. Surface EMG (sEMG) signals are recorded by non-invasive electrodes and are preferably

used to obtain information about the time or intensity of superficial muscle activation. This study aims to

find the pattern of muscle activation when STS in feet forward. This is a retrospective study using sEMG for

the pattern of muscle activation of 14 males and 14 females in Hasan Sadikin General Hospital Bandung

Indonesia, in March 2019. The average height, weight, body fat, and fat-free mass in men were significantly

different from women participants. The muscle activation of muscle group stabilizer (Rectus Femoris (RF)

and Biceps femoris lateral (BFL)) is bigger than muscle group sequence (Tibialis anterior (TA) and

Gastrocnemius medialis (GM) during STS in this research. Rectus femoris was the muscle that had the

highest mean maximum force in every STS phase. The mean maximum force of RF, BFL, and GM in

Phase II was the highest compared to another phase. On the other hand, the mean maximum force of TA

was the highest in Phase V. Feet Forward with 80° knee flexion is the strategy foot positioning during sit to

stand to increase the force of sequence muscle group than stabilizer muscle group

1 INTRODUCTION

Sit to stand movement is a movement that is

frequently done by people. This ability is an

important skill that is considered as a fundamental

task for daily activities and is a prerequisite for

functional independence. (Carr JH, 1992; Shepherd

RB & Koh HP, 1996; Ng, Shamay S M, et al, 2015).

Sit To Stand (STS) is a movement of the body’s

center of mass (CoM) upward from a sitting position

to a standing position without losing balance.

(Roebroeck et al, 1994) An individual needs to bring

his CoM from a relatively large and stable base of

support in sitting to a considerably smaller base of

support in standing. To achieve this transition, CoM

must first move forward then reach its maximal

velocity at the preparatory phase. At seat-off, CoM

switches into vertical movement and its velocity

continues to accelerate until it reaches a maximum

in the middle of the extension phase. Subsequently,

the CoM velocity decelerates progressively until

reaching zero, when the standing position is

achieved. (Hirschfeld, 1999).

In the literature, two ways to performed STS

define the strategy for implementing the STS task

were found. Defined as the “momentum-transfers

strategy,” the first method implies that the subject in

question makes a small trunk flexion of the weight

transferring forwards and then begins the separation

of the seat, ending with the starting foot. This form

is most common among healthy people. Another

way to make the sequence is increasing trunk flexion

before starting to move from the chair, which is

usually performed by people with muscle weakness

in the legs. If the results obtained in this study are

analyzed, in both groups four muscles act primarily

as stabilizers of motion (tibialis anterior, rectus

abdominis, soleus) and others that are responsible

Nashrulloh, T., Biben, V., Santi, F., GZ, R., Moeliono, M., Wicaksono, D. and Hasnaoui, N.

Pattern of Muscle Activation During Sit to Stand Task in Feet Forward with 80 Knee Flexion using Surface EMG.

DOI: 10.5220/0009064000820087

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 82-87

ISBN: 978-989-758-409-1

for implementing the sequence (quadriceps rectus

femoris, quadriceps vastus medialis and biceps

femoris. (Antoni I, 2013).

STS strategy related determinants such as speed,

foot positioning, trunk positioning, arm movement,

terminal constraint, fixed joint, knee position, and

training. (Lamberts, 2008) Individual normal

healthy, using 100o knee flexion during STS task

and shows muscle activation of stabilizer group

muscle is bigger than sequence group muscle.

(Antonio I et al, 2013; Brunt, 2002) Stroke patients

are reported have weakness in the lower extremity,

making it difficult to do STS. Sit to stand in stroke

patients is reported to have a longer duration than

normal. (Baukadida et al., 2015). It was reported that

in hemiplegia patients, usually using feet forward

strategy 750 knee flexion in foot positioning during

STS. The foot positioning of an uninvolved limb in

feet forward, an extended position (75o of knee

flexion) and normal position (100o of knee flexion)

in involved limb causes the activity muscle of the

sequence group bigger than stabilizer. (Brunt, 2002)

A step foot position during the STS task by

manipulating the foot placement of the unaffected

limb was proved will improving the static and

dynamic postural balance in patients with

hemiplegia (Han Jintae, Kim youngmi, Kim Kyung,

2015). Few studies have described the effect of the

nonparetic foot positioning during STS in patients

but there is no standardization about the degree of

foot positioning. Therefore, in this pilot study, we

want to investigate muscle activity of stabilizers

group muscle and sequence group muscle in STS

task in feet forward position (80o of knee flexion) in

healthy younger adults to add information about foot

positioning impact. Hopefully, the result will be

developed to a bigger study to find out the

standardization method of STS procedure that

effective for patients with stroke to achieve better

performance with their paretic limb.

2 METHODS

Twenty-eight participants, 14 males, and 14 females,

in Hasan sadikin Bandung Indonesia, General

Hospital were recruited in March 2019. Participants

were included if their age between 20-35 years old,

able to walk without an assistive device and had no

heart, vascular, lung or bone/joint problems that may

impaired standing activity from a chair. Participants

were excluded if have a musculoskeletal deformity,

muscle weakness, and pain. The study was approved

by the Faculty of Medicine Universitas Indonesia

ethical committee (No.0438/UN2.F1/ETIK/2018)

and written consent was obtained from all

participants prior take part in this study. Before

measurement was taken, each participant was given

an explanation about the sit to stand (STS) protocol

and make a trial of the movement for familiarization.

All of the participants were instructed to seat with

feet forward (800 knee flexion) in a chair without

arm support (F. R. Goulart and J. Valls-Sol´e, 1999).

Their arms were being folded across their chest in all

of the phases of STS, with their feet being open wide

align with the shoulder. Each subject performed

three times of STS with the speed transition of each

phase of STS indicated by a metronome. The values

considered for statistical analysis were the best score

of maximal voluntary contraction.

The muscle activity (MA) was recorded using

surface electromyography (sEMG) machine

(Gymna, type myo 200, Belgium). Muscles that

evaluated were muscle group sequences such as

Rectus Femoris (RF), Biceps Femoris (BFL), and

muscle group stabilizer such as Tibialis Anterior

(TA), Gastrocnemius (GM). On each muscle three

circular adhesive Ag-AgCl electrodes were placed

based on SENIAM (Surface EMG for non-invasive

assessment of muscles) protocol guidance at a

distance of two inches between the electrode (figure

1) (I Antonio et al, 2013)

Figure 1: Schematic placement of surface electrodes on

each muscle. From MegaWin 3.0.

The STS movement for analysis is classified into

6 phases based on Schenkman et al study. The seat-

off, which refers to the moment when only the feet

Pattern of Muscle Activation During Sit to Stand Task in Feet Forward with 80 Knee Flexion using Surface EMG

are in contact with the grounds and no force is

applied on the seat, is often used to identify STS

phases. Phase I (flexion-momentum phase) starts

with the initiation of the movement and ends just

before the buttocks/thighs are lifted from the seat of

the chair. Phase II (momentum-transfer phase)

begins as the buttocks are lifted and end when

maximal ankle dorsiflexion is achieved (anterior and

upward CoM displacement). The anterior

displacement of the CoM brings it close to the center

of pressure (CoP) to reach a quasi-static stability

position. Phase III (extension phase) is initiated just

after maximum ankle dorsiflexion and ends when

the hips first cease to extend; including leg and trunk

extension. Phase IV (stabilization phase) begins after

hip extensions are reached and end when all motion

associated with stabilization is completed. Phase V

is reverse-phase II and Phase VI is reverse-phase I.

(Janssen et al, 2002; Boukadida A et al, 2015;

Schenkman M, 1990).

This research is a descriptive, cross-sectional

study with the convenient sampling method. The

data collection was analyzed using IBM SPSS

statistical software version 20. Independent Samples

Test and Mann Whitney test was used to compare

demographic characteristics between different

gender of the subject.

3 RESULTS

Table 1 showed there were differences in the

anthropometry of the sample between women and

men, except the age.

Table 1: General characteristics of participants.

Characteristics

Men Women

p-Value

Mean(SD) Mean(SD)

Age (years) 30,86(4,52) 30,71(2,46) 0,918

Height (cm) 167,57(4,48) 158,43(6,21) <0,001*

Weight (kg) 71,96(7,52) 59,64(11,79) 0,003*

Body Mass Index

(kg/m

)

25,67(2,99)

23,66(3,82)

0,133

Body Fat (%) 22.08 (4.41) 32.15 (7.04) <0.001*

Fat-free mass

(kg)

52.90 (3.16) 37.29 (4.23) <0.001*

Note: *p-value<0.05 indicates the significant predictors in the model; SD: Standard Deviation

Table 2: The mean maximal force of Rectus Femoris, Biceps Femoris Lateral, Gastrocnemius and Tibialis Anterior muscle

in each phase of Sit-to-Stand.

Note: RF: Rectus Femoris muscle, BFL:Biceps femoris lateral muscle, GM: Gastrocnemius muscle, TA:Tibialis Anterior

muscle

Muscle

Phase I

(µV)

Phase II

(µV)

Phase III

(µV)

Phase IV

(µV)

Phase V

(µV)

Phase VI

(µV)

RF 37,37 73,11 51,60 50,99 61,74 37,28

BFL 19,07 47,97 23,87 27,53 36,90 17,28

GM 11,77 22,77 19,99 20,13 17,95 11,53

TA 17,80 31,05 23,25 23,98 35,87 15,90

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

Figure 2: An overview of muscle activation of RF, BFL,

GM AND TA using sEMG evaluation during all STS

Phases.

In phase II, all muscle group have the biggest

muscle activation compare to another phase, and the

muscle group sequence was bigger than muscle

group stabilizer. The rectus femoris has the biggest

muscle activation in all phases. On the other hand,

the mean maximal activation of TA was the highest

in Phase V. The overview of mean maximal force

for RF, BFL, GM and TA in each phase was also

described in Figure 2.

4 DISCUSSIONS

The subjects of the study were mostly men (90,9%).

Although women could have higher CRP levels than

men due to hormonal factors (O’Connor, 2009),

this condition may not significantly influence the

CRP results.

CRP levels did not change significantly due to

several factors, one of them is the high CRP level

since the beginning, although there was no sign of

infection during the study since the leucocyte count

did not increase. The CRP level could be influenced

by BMI, the level and severity of the lesion and

smoking habits. Most of the subjects in this study

were included in the underweight category with an

average BMI was 18.72 ± 2.173 kg/m2. The BMI

values are related to body fat composition. Low BMI

could be caused by decreased fat-free muscle mass

due to reduction in physical activity and atrophy

caused by paralysis. Greater adipose tissue

composition due to impaired fat and carbohydrate

metabolisms can lead to increased CRP levels

(Wang, 2007).

Lesion levels and severity of SCI itself can

influence the CRP levels. The higher lesion levels

and severe SCI indicate higher CRP levels. Those

with tetraplegia have a greater risk of CVD

compared to those with paraplegia in chronic SCI

Gibson, 2008). SCI lesions of the subjects in this

study were as high as the thoracic cord. Since most

of the subjects had complete SCI, high CRP levels

of the subjects were discovered since the beginning.

The smoking habits were not limited during the

study, these may cause a high of CRP level.

Smoking can increase the release of

proinflammatory cytokines in the blood and lung

circulation. It also can cause oxidative stress and

vascular inflammation occurs marked by increased

IL-6 and CRP levels. A previous study presented

that higher CRP levels were mostly found in the

subjects who smoked (O’Connor, 2009).

Unfortunately, this study did not have any data to

analyaze the correlation between the number of

cigarettes (packs per year) and nicotine levels with

distinctive measurements in each subject.

Exercise can decrease inflammatory cytokines in

the blood (Alves, 2013). Muscle contractions can

stimulate the release of IL-6 from muscle cells,

namely muscle derived IL-6.

 IL-6 has important

anti-inflammatory effects since it plays a role in the

formation of anti-inflammatory cytokines such as

interleukin-1 receptor antagonist (IL-1ra) and

interleukin-10 (IL-10).

The appearance of IL-10 and

IL-1ra in the circulation contributes to mediating the

anti-inflammatory effects of exercise and induces a

reduction in CRP levels and suggests that physical

activity may suppress systemic low-grade

inflammation.

The increased plasma IL-6 is related to exercise

intensity, duration, the mass of muscle recruited and

one’s endurance capacity (Peterson, 2005). Physical

activities with moderate intensity are recommended

to reduce CRP levels (Zonneveld, 2014). IS exercise

in this study counted as moderate intensity based on

Borg scale 11-13. Most of the subjects had the same

occupation as a craftsman and did their daily

activities independently, but still there were no

complete data and objective assessment of physical

activities collected.

The IS exercise given in this study had not

decreased the inflammation marker of CRP. This

study given different result from the previous studies

that after 4 weeks of physical training was

associated with significantly improved plasma

concentrations of adiponectin and CRP (Oberbach,

2006), IS exercise for 4 weeks (twice daily, 30

breaths a set for 30 days) in COPD patients was

Pattern of Muscle Activation During Sit to Stand Task in Feet Forward with 80 Knee Flexion using Surface EMG

already showed a significant result in reducing IL-6

and TNF-α inflammatory cytokines

(Leelarungrayub, 2017), IMT combined with aerobic

training provides additional benefits in functional

and serum biomarkers of inflammation (CRP) in

patients with moderate CHF (Adamapoulos, 2014).

The differences in the type of exercise, the mass of

muscle recruited, the intensity and duration of

exercise compared with the previous study, the

markers of inflammation which had been examined

may make the differences of the result.

The study has shown that IS exercise can

improve lung function in an individual with chronic

SCI. The similar results showed in another previous

study (Kim, 2017). The study has not shown

significant change in the circulating level of CRP

however, a potential local effect of IS on

diaphragmatic myocyte cytokine production cannot

be excluded. Whether there was a reduction in local

diaphragmatic muscle inflammation marker after IS

was not tested in this study.

The IS exercise given in this study had influenced

fat metabolism marked by the significant reduction

of LDL/HDL ratio. IL-6 is the first cytokine

released into the circulation during exercise, derived

from the contracting muscle. This cytokine will

activate lipolysis independently of elevations in

Growth Hormone (GH) and/or cortisol and become a

potent catalyst for fat oxidation in muscle cells

(Peterson, 2005). The present study was given

different result from the previous studies that IMT

with low inspiratory loading fails to demonstrate any

significant improvements in blood glucose levels,

serum lipids, and/or HOMA-IR in female patients

with type 2 diabetes (Ahmad, 2017) and after 7 days

of IMT had not able to change metabolic variables

(blood glucose and lipid profile) in women with

metabolic syndrome (Feriani, 2017).

There are some limitations to this study that can

be improved in future research. Firstly, the present

study did not measure other cytokines, such as IL-10

and IL-1ra may be needed to confirm that the

observed increase in IL-6 is muscle derived and not

due to other factors, such as the existence of a

catabolic/inflammatory state due to exercise training

(Peterson, 2005). Secondly, this study did not have

any data regarding the number of cigarettes (packs

per year) and nicotine levels with distinctive

measurements in each subject which can correlate

with the inflammatory state. Thirdly,

 there was no

complete data and objective assessment of physical

activities and nutritional intake collected.

Further study can be conducted by giving longer-

term IS exercise intervention or with other exercise

combinations including aerobics. Assessment of

detail physical activity level, other routine activity

(such as smoking), nutritional status and other anti-

inflammatory cytokine levels should be done in

further study.

5 CONCLUSIONS

A 4 weeks incentive spirometry breathing exercise

resulted in improvement in lung function and lipid

ratio. Improvement in lung function has not

influenced the systemic inflammatory level (CRP),

although a beneficial influence on LDL/HDL ratio

was recorded. Further follow up and studies are

required to establish the role of inspiratory muscles

in improving the systemic inflammatory status of

patients with chronic spinal cord injury.

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