SIT-TO-STAND

The patient is an 83 yo male who was taken to the ER after a fall at home. The patient lives alone and apparently, he has been on the ground for a few days. He was found to have elevated CK, encephalopathy and COVID-19. After getting medically stable, he insisted on going home after 5 days, and declined SNF placement. While at home, he tried to get up to use the bathroom and, apparently, his legs "gave out from under him." He was taken back to the ER after the fall, and was discharged to the SNF. I treated the patient on a weekend and he initially required moderate assistance with sit-to-stand. By the end of the treatment session, he just required CGA for cuing.

The 2 videos present novel interventions to address sit-to-stand. Next to the videos are images of the equipment used for performing the task. The first is that of an elastic suspended from the door jamb using a C-clamp. The harness that I put on the patient is on the walker. The second is that of a kitchen-chair I found in a "Carol Wright" catalog.

The first uses elastic attached to a harness on the patient. The elastic pulls the harness (i.e. patient's pelvis) forward and upward. This frees the therapist from physically assisting the patient into the standing position. This allows the therapist to be a therapist and not a "patient lifter." This allows the therapist to observe the patient perform the task, looking for missing components (see discussion below), and providing manual cues to correct movement impairments.

I prefer using the first set-up but, as the image shows, it uses a C-clamp on a closet door jamb. When the room is full of patients, I am unable to keep the closet doors open. The second set-up is an alternative, but not as ideal because a bar on the chair limits correct positioning of the patient's ankles.

ASSUMPTIONS:

1. For a previously ambulatory older adult who,  after a few days of hospitalization, requires extensive assistance with sit-to-stand, mechanics in performing the task is the problem and not muscle strength.

From my experience, strengthening the quads is a "red herring"  when addressing sit-to-stand in this situation. Although concentric contraction of the quads (i.e. seated knee extension using ankle weights) has some value, if the mechanics of performing the task is not addressed, we are prolonging the patient's disability. And, the longer the patient is unable to perform the task independently, the greater the chance of the patient not regaining independence in performing this task.

There seems to be 3 primary components of sit-to-stand which are problematic for the institutionalized older adult.

PROPER ANKLE POSITIONING

The ankle joint has to be positioned posterior to the knee joint. Correct positioning is important to achieve positioning of the COG over the BOS. Tightness of the soleus muscle can limit the patient's ability to position the ankle properly.

ANTERIOR PELVIC TILT

We are all guilty of slouching when we sit. For the older adult who sits most of the day, a posteriorly tilted pelvis in sitting becomes the norm.

FORWARD TRANSLATION OF THE UPPER BODY

Even before the knee and the hips go into extension,  sit-to-stand has to begin with forward translation of the upper body. This "counters" the posterior shift in the COG brought about by the knee extension. The absence or insufficiency of forward translation of the upper body is one of the primary reasons why some patients "fall back" into the chair when attempting to stand-up. This is the reason why you will often hear "nose over your toes" in the SNF. I prefer using "chest over your toes." Pelvic tilt is an important requisite in this forward translation (i.e. a posteriorly tilted pelvis makes forward translation difficult).

The 2 strategies illustrated above allows the therapist to observe for these components and to manually provide cues to correct movement impairments.

2. In pediatrics, there is a treatment principle of giving the child the opportunity to experience "normal" movement for skill acquisition. I think this is also a pertinent treatment principle when providing intervention to older adults.

We ascribe to "the body forgetting how to perform a task" when patients have difficulty performing basic transfers after a short hospitalization. If this is the case, then maybe we should "remind" the body how to perform the task. We have to provide the older adult the sensation of "normal" movement. And, the more repetitions performed, the faster the re-acquisition of skill. The 2 strategies illustrated above do not limit the number of repetitions according to "therapist fatigue." Instead, the number of repetitions is determined by patient fatigue.

3. There is less guarding when the patient is being moved by an inanimate object versus being moved by another person.

Have you experienced being pushed while sitting on a wheelchair? Children have fun pushing each other while sitting on a wheelchair, but I contend that this activity causes  anxiety as we get older. During transfer from sit-to-stand, when the assistance is provided by another person, the older adult performing the task cannot gauge the amount of assistance provided by the other person because it will fluctuate between repetitions, and fluctuates even within a single repetition. Assistance provided by an inanimate object (i.e. ELASTIC) is consistent. The patient can therefore predict the amount of force they need to exert more consistently. This allows them to focus on the mechanics of the task.