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Topics in Geriatric Rehabilitation • Volume 28, Number 1, 11–16 • Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
DOI: 10.1097/TGR.0b013e31823415fa
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Measurement of Sit-to-Stand Among
Older Adults
Richard W. Bohannon, DPT, EdD, NCS, FAPTA, FAHA, FASNR, CEEAA
Author Affiliation: Program in Physical Therapy, Department of Kinesiol-
ogy, Neag School of Education, University of Connecticut, Storrs.
The author declares no significant relationships with, or financial interest
in, any commercial companies pertaining to this article.
Correspondence: Richard W. Bohannon, DPT, EdD, NCS, FAPTA, FAHA,
FASNR, CEEAA, Program in Physical Therapy, Department of Kinesiology,
Neag School of Education, University of Connecticut, 358 Mansfield Rd,
Storrs, CT 06269 ([email protected]).
The sit-to-stand (STS) maneuver is a common aspect of mo-
bility. In the following review, the mechanics of the maneuver
are briefly reviewed. Thereafter, alternatives for measuring
STS performance are described. The Five-Repetition STS
Test (FRSTST) is discussed in detail. This discussion empha-
sizes the measurement properties of the test. For clinicians
working with older adults, there is considerable support for
using the FRSTST as a measurement of mobility.
Key words: activity limitation, biomechanics, function, geriatrics,
mobility, muscle strength
A
s an endeavor involving the changing of basic body
position, the sit-to-stand (STS) maneuver is a clas-
sical activity of mobility according to the Interna-
tional Classification of Functioning, Disability and Health.
1

Although only one of the many activities of everyday life, it
is performed often by healthy community-dwelling adults;
the mean number of daily STS among such individuals
may be as low as 46 or as high as 60.
2,3
Regardless of the
frequency with which the STS maneuver is completed,
it is a prerequisite to the performance of other activities
(eg, walking)
4
and has implications for other outcomes.
5

Sit-to-stand is a demanding activity, particularly for older
adults,
6
and is often compromised in patients with a variety
of age-related conditions such as stroke,
7,8
Parkinson’s dis-
ease,
9,10
hip fracture,
11,12
arthritis,
13
and joint arthroplasty.
14

These facts render the measurement and interpretation of
STS performance important to those working with older
adults. The primary purpose of this review, therefore, is
to summarize information relevant to the measurement of
STS performance. Before addressing this purpose, how-
ever, a brief review of the mechanics of the STS maneuver
will be provided.
MECHANICS OF SIT-TO-STAND
Knowledge of the mechanics of the STS maneuver provides
a foundation for the measurement of the activity and factors
contributing to its successful completion. Successful perfor-
mance of an STS requires the shifting of weight from the
buttocks and posterior thighs to the feet. This involves an
anterior and then vertical movement of the body’s center of
mass.
7,15,16
This movement is executed primarily by a flexion
of the hips and anterior movement of the head-arms-trunk
segment, followed by an extension of the hips, knees, and
ankles.
16-19
The movement has been described as having
several stages. Schenkman et al
17
and Ikeda et al
20
noted 3
stages: (1) flexion momentum (forward flexion of trunk);
(2) momentum transfer (shift of body displacement from
a primarily anterior to a primarily vertical direction); and
(3) extension (rising to maximum hip, knee, and ankle ex-
tension). Millington et al
21
described 3 comparable phases:
weight shift; transition; and lift. Several STS strategies have
been described for older adults. Hughes et al
22
character-
ized 1 strategy as relying strongly on momentum, another
with a greater emphasis on stability, and a third dependent
on a combination of momentum and stability. Scarborough
et al
23
also described 3 phases: momentum transfer; exag-
gerated trunk flexion; and dominant vertical rise.
Regardless of strategy, considerable range of motion
is needed to egress from sitting to standing. Rising from
a low chair may entail more than 100° of knee flexion,
80° of hip flexion, and 25° of ankle dorsiflexion.
24
The
movements contributing to STS are accomplished by the
generation of torques around the hip, knee, and ankle.
16,25

Greater torques are required, particularly at the knee, for
rising from lower seats.
24,26
Greater torques are also re-
quired at the hip when less knee flexion range is avail-
able.
27
Lesser lower limb torques are used when upper
limb assistance is permitted.
25
Normally, each lower limb provides a comparable
contribution to the STS maneuver. This follows when
weightbearing is symmetrical. Such symmetry, however,
is not the case when range of motion or strength dif-
fers between sides. When 1 foot is placed forward of
the other before STS, the forward foot experiences less
weightbearing.
28
Among patients with hemiparesis ac-
companying stroke, it is typical for more weight to be
placed through the nonparetic limb.
7,29,30
MEASUREMENT OF SIT-TO-STAND
PERFORMANCE
Several options have been described for measuring STS
performance. Most basically, the options can be divid-
ed into those not requiring timing and those dependent
on timing.
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Untimed measurements
Perhaps the simplest way to characterize STS perfor-
mance is to address an individual’s independence in the
activity. At the most basic level, a patient can be labeled
as able (vs unable) to stand without assistance. Such a
dichotomization is capable of denoting status and detect-
ing change over time.
31,32
For more discriminating indica-
tions of assistance required, scales such as the Functional
Independence Measure provide an ordinal rating of in-
dependence that can be applied to the STS maneuver.
33

On the basis of a patient’s contribution to completion of
the task, assistance can be graded (eg, Ͼ75% ϭ minimal
assistance).
Beyond the ability to stand up without assistance, the
conditions under which an STS can be completed can
also be specified. These conditions include, but are not
limited to, use of hands, use of armrests, and height of
seating surface. A distinction between being able to com-
plete the maneuver without hands versus with hands is
meaningful as use of the hands can substantially reduce
the strength necessary to rise independently from a chair.
As a percentage of body weight, the combined strength
of the knee extensors required to stand without the
hands is approximately 40%.
34,35
The combined strength
required to stand with the hands but no armrests is about
31%.
34
If hands are used, it matters whether armrests or
something equivalent is used. Arborelius et al
25
reported
that use of the hands on armrests reduced “the mean
maximum hip moment by about 50%.”
(p1377)
Alexander
et al
36
reported that the percentage of older adults un-
able to rise from a standard-height chair with armrests
decreased from 32% to 1% when hand use was allowed;
the time to stand decreased from a mean 4.6 seconds to
a mean 3.8 seconds. Eriksrud and Bohannon
37
observed
that 8 of the 26 otherwise-dependent patients were able
to egress independently from sitting when they used an
“Easy-up Handle,” a portable device acting much like
an armrest.
37
The height of a seating surface can have
a profound effect on whether a patient will be able to
rise successfully.
36,38,39
Of the older adults observed by
Weiner et al,
39
about twice as many could successfully
stand from a 22-in–high chair as from a 17-in–high chair.
As noted previously, seat height also affects the range of
motion and torques needed during STS; both increase
(particularly at the knee) as seat height gets lower.
26
It
takes longer to stand from lower chairs.
36,40
Regardless of the conditions under which an STS is
completed, patients’ perceived effort can be ascertained.
Doing so can be as simple as asking whether they have
any difficulty with the task.
41,42
Corrigan and Bohannon
42

did so and found that older community-dwelling wom-
en were progressively more likely to report difficulty in
rising from a dining chair, toilet, easy chair, and couch.
Perceived exertion can be graded more specifically by
using a perceived exertion scale.
25,42
Using a Borg scale
of perceived exertion, subjects studied by Arborelius
et al
25
reported greater exertion when standing from
lower heights.
Timed measurements
When an individual is able to rise from a standard chair
without assistance or use of the upper limbs, performance
can be quantified while accounting for the time required to
complete the task 1 or more times. This can be accomplished
with a stopwatch or more sophisticated equipment.
8,10,42
The time for a single STS is informative. Corrigan and
Bohannon
42
reported mean and median times of 1.5 and
1.4 seconds, respectively, for community-dwelling older
women. Their finding of significant, albeit-only moder-
ate, correlations (Ϫ0.32 to Ϫ0.53) between STS time and
knee extension force lends some support to the validity
of STS time as an indicator of lower limb strength. Known
groups validity of the measure is upheld by the greater
time required by patients with stroke (3.1 seconds) than
for matched controls (1.9 seconds).
8
Such validity has also
been demonstrated for patients with Parkinson’s disease
whose STS times were longer when they were in their
off state (1.97 seconds) than when in their on state (1.86
seconds).
10
The STS times of patients during their off state
were also longer than those of matched controls.
Timed STS tests usually involve more than a single rep-
etition. Timed tests incorporating multiple repetitions re-
quire either counting the number of repetitions that can be
completed in a given period of time or determining how
long it takes to complete a given number of repetitions.
The most common times over which repetitions are
counted are 10,
43-46
30,
47-49
and 60
50,51
seconds. For tests
documenting the number of repetitions completed in 10
seconds, criterion and/or convergent validity are demon-
strated by research showing correlations between repeti-
tions and knee extension force (0.41-0.65),
43,45
comfortable
and maximum walking speed (0.41 and 0.73),
45
and stair-
climbing performance (0.56 and 0.57).
43
Known groups
validity for the test is confirmed by the observation that
patients on hemodialysis completed approximately 50%
fewer STS repetitions in 10 seconds than matched healthy
subjects.
46
The test-retest reliability is supported by an
intraclass correlation coefficient (ICC) of 0.84.
43
Respon-
siveness is illustrated by research showing that patients
undergoing kidney transplants performed fewer repeti-
tions 1 month posttransplant than they did before their
transplant.
44
For tests noting the number of repetitions completed
in 30 seconds, validity is demonstrated by correlations
(Ͼ0.70) between repetitions and weight-adjusted “leg-
press” strength and differences in repetitions between age
and activity groups.
47
Test-retest reliability across sessions
is supported by research reporting an ICC of 0.84 for men
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and an ICC of 0.92 for women.
47
Normative values have
been published as well.
48
For the number of repetitions completed in 60 sec-
onds, convergent validity is supported by correlations
between repetitions and 6-minute walk distance covered
by patients with chronic obstructive pulmonary disease
(r ϭ 0.75) and by healthy individuals (r ϭ 0.54).
51
Known
groups validity of the 60 seconds measure is evidenced
by differences in the mean repetitions between a group
with chronic obstructive pulmonary disease and matched
healthy individuals
51
and by a group of healthy subjects
and a group of patients on hemodialysis whose perfor-
mance was about 50% worse.
50
Five-Repetition Sit-to-Stand Test
Some literature describing the timing of multiple repeti-
tions of STS describes the use of either 2
52,53
or 10
13,54

repetitions. However, the “Five-Repetition STS Test”
(FRSTST) is by far the most widely employed STS test
with older adults. It has been used in more than 50 pub-
lished studies and is a component of several test batter-
ies, including the Short Physical Performance Battery,
55

Index of Mobility Limitation,
56
and Physical Performance
Examination of the National Health and Nutrition Ex-
amination Survey.
57
Thus, the rest of this section will
address only the FRSTST.
Procedures for completing the FRSTST vary some-
what.
58
Although armless chairs are typically used, their
heights vary slightly. Tested individuals are usually pro-
hibited from using their upper limbs, with some protocols
calling for them to be folded across the chest. While tim-
ing generally begins on the command “go,” it sometimes
ends with the achievement of the fifth stand and some-
times ends with the return to the seat after the fifth stand.
I recommend the following:
1. Use a slightly padded armless chair with a seat
height of about 17 inches.
2. Stabilize the chair, preferably against a wall.
3. Have the patient come forward on the chair seat
until the feet are flat on the floor.
4. Have the patient fold the upper limbs across the
chest if possible.
5. Instruct the patient to stand up all the way and sit
down once without using the upper limbs.
6. If the patient is able to complete the maneuver
without the upper limbs or physical assistance,
instruct him or her to stand up all the way and sit
down landing firmly, as fast as possible, 5 times
without using the arms. Guard the patient as
necessary.
7. Begin timing on the command “go” and cease
timing on landing after the fifth stand up.
8. Abort the test and start over again if the patient
fails to stand up all the way or sit down firmly.
The FRSTST has been shown to have good measure-
ment properties. These include validity, reliability, and
responsiveness. There are normative values for the test.
Validity
Often considered a measure of functional strength, the
criterion validity of the FRSTST is supported by correla-
tions of FRSTST time with lower limb force or torque.
Bohannon et al reported correlations of Ϫ0.48 to Ϫ0.57
between knee extension force or torque and the FRSTST
times of healthy community-dwelling individuals 50 to
85 years of age.
59
The correlations were slightly better
when knee extension strength was normalized against
body weight. Multiple regression analysis supported
knee extension strength as a key determinant of FRSTST
time, particularly when the curvilinear nature of the rela-
tionship was addressed. McCarthy et al,
60
who measured
the isokinetic strength of 6 lower limb muscle actions,
found 5 to correlate significantly with FRSTST perfor-
mance. Combined, the strengths explained 48% of the
variance in FRSTST time. Mong et al
61
also looked at the
relationship between lower limb muscle strength and
FRSTST performance. However, they tested patients with
stroke. They found correlations of Ϫ0.01 to Ϫ0.75 on
the affected side and Ϫ0.48 to Ϫ0.83 on the unaffect-
ed side. The highest correlations were with knee flexor
strength of each side. Also testing patients with stroke,
Ng
62
reported a significant correlation (Ϫ0.58) between
a muscle strength index and FRSTST results. Significant
correlations between strength and FRSTST times notwith-
standing, much of the variance in FRSTST performance is
left unexplained by measures of muscle strength. Lord et
al
63
identified sensation, speed, balance, and psychologi-
cal status as variables adding to the explanation of STS
performance provided by knee muscle strength. They,
therefore, questioned the use of the FRSTST as a “proxy
measure of lower limb strength.”
Seen as a measure of balance, the criterion validity
of FRSTST times is affirmed by moderate to strong cor-
relations with other balance measures. In patients with
stroke, correlations of Ϫ0.55 and Ϫ0.84 with Berg Bal-
ance Test scores have been reported.
61,62
The FRSTST
measures also correlate (Ϫ0.59) with scores on the
Activities-Specific Balance Confidence Scale in patients
with stroke.
62
Among patients undergoing vestibular re-
habilitation, low but significant correlations have been
reported between FRSTST results and multiple balance-
related measures: Activities-Specific Balance Confidence
Scale (Ϫ0.32), Dizziness Handicap Inventory (0.28), and
Dynamic Gait Index (Ϫ0.36).
64
For a mixed sample of
younger and older individuals with and without balance
disorders, correlations between FRSTST time and the
Activities-Specific Balance Confidence Scale (Ϫ0.58) and
Dynamic Gait Index (Ϫ0.68) were higher.
65
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There are important variables other than strength and
balance, with which performance on the FRSTST cor-
relates. Among healthy community-dwelling people,
FRSTST time has convergent validity with self-reported
physical functioning (Ϫ0.47),
66
Timed Up and Go test
times (0.73) and gait speed (Ϫ0.82).
67
A moderate corre-
lation (0.53) has been documented between FRSTST time
and Timed Up and Go performance in patients under-
going vestibular rehabilitation.
64
A moderate correlation
(Ϫ0.60) has also been noted between FRSTST time and
the distance walked in 6 minutes by patients with hemi-
paresis following stroke.
62
Known groups’ validity is well-established for the
FRSTST. Bohannon
68
demonstrated a significant difference
in the time for patients seen in a home care setting (15.8 sec-
onds) and healthy matched individuals (12.1 seconds).
Whitney et al
65
found that the FRSTST could discriminate
between individuals with and without balance or vestibular
disorders. Discrimination was better for individuals young-
er than 60 years (15.3 seconds vs 8.2 seconds).
65
Kim et
al
69
showed that the FRSTST distinguished between older
women at low risk of frailty versus high risk of frailty. The
age-adjusted odds ratio was 6.29; the area under the re-
ceiver operating characteristic curve was 0.79. These in-
dicators of validity were slightly less than those for usual
and rapid gait and the Timed Up and Go. Obese older
adults have been observed to require significantly longer
(nonsarcopenic 10.6 seconds and sarcopenic 10.7 seconds)
than nonobese older adults (nonsarcopenic 11.3 seconds
and sarcopenic 12.3 seconds) to complete the FRSTST.
70

Curb et al
71
reported the FRSTST to be good at discriminat-
ing between individuals functioning at different levels. The
FRSTST was comparable with the 10-repetition STS test in
this regard. For patients with peripheral arterial disease,
Atkins et al
72
found those with low ankle-brachial indexes
to require significantly more time to complete the FRSTST
than those with moderate ankle-brachial indexes (mean,
15.9 seconds vs 13.5 seconds).
Several studies have examined the predictive validity of
the FRSTST. Both Tiedemann et al
73
and Buatois et al
74
fo-
cused on the prediction of falls in their studies. Tiedemann
et al
73
investigated the ability of 8 mobility tests to predict
multiple falls over a subsequent year. The time required to
complete the FRSTST was significantly less in nonmultiple
fallers (mean, 12.5 seconds) than in multiple fallers (mean,
14.8 seconds). For the prediction of falls, an FRSTST time
of 12.0 seconds was associated with a relative risk of 2.0
and a likelihood ratio of 1.47. Buatois et al
74
looked at the
value of 3 tests to predict recurrent falls over a period 18 to
36 months. Only the FRSTST was independently associated
with risk of such falls after adjustment for relevant covari-
ates. Using a criterion of 15 seconds, a risk ratio of 1.74
was calculated. Wang et al
75
examined the usefulness of
7 performance measures for predicting mobility disability
2 years later. After adjusting for age and gender, the FRSTST
was the only measure identified as a significant predictor
of future mobility disability.
Reliability
The test-retest reliability of the FRSTST has been studied
widely. Bohannon
76
recently summarized the findings of
10 studies reporting reliability coefficients for measure-
ments obtained across sessions. The coefficients ranged
from 0.64 to 0.96. The adjusted mean for the reported
coefficients was 0.81.
Responsiveness
There is very little literature that specifically addresses the
responsiveness of the FRSTST. Schaubert and Bohannon
77

reported technical errors of measurement for repeated
measures obtained from community-dwelling older adults
over 6- and 12-week intervals. The values ranged from 1.6
to 2.8 seconds. Follow-up measurements of FRSTST time
would have to change more than these amounts to con-
clude that a real change had taken place. For a sample
of individuals, including, but not limited, to older adults,
Bohannon et al
78
calculated a method error of 0.5 seconds
for FRSTST measurements obtained 4 to 10 days apart. A
difference between sessions greater than this value would
be required to conclude that a real change had occurred.
The responsiveness of the FRSTST is illustrated by its ability
to detect declines in lower limb function accompanying ag-
ing. Forrest et al
79
noted that FRSTST time of older women
increased by 22% over a 10-year period. This exceeded the
17% decline in gait speed over the same period. Meretta
et al
64
addressed the responsiveness of the FRSTST among
patients undergoing vestibular rehabilitation. The patients
demonstrated a 2.7-second reduction in FRSTST time. The
standardized response mean associated with the change
was 0.58 (moderate). A change of at least 2.3 seconds was
determined to be clinically meaningful.
Normative values
Numerous studies have provided data for FRSTST per-
formance that can be used for normative purposes.
Bohannon
58
has summarized the information from 14
such studies in a descriptive meta-analysis. He calculated
mean values for use as standards for older adults aged 60
to 69 years (11.4 seconds), 70 to 79 years (12.6 seconds),
and 80 to 89 years (12.7 seconds).
SUMMARY
The STS maneuver is important to everyday functioning. It
can be quite demanding, particularly for older adults with
pathologies resulting in impaired strength, balance, and
range of motion. While there are several options for mea-
suring STS performance, the FRSTST is probably the most
widely employed. The simplicity of the test along with its
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sound-measurement properties and the availability of nor-
mative values for comparison are a compelling reason to
utilize the test to describe mobility among older adults.
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