8
Rising from a Supine Position to Erect Stance Description of Adult Movement and a Developmental Hypothesis ANN F. VANSANT Standing up from a supine position is important for physical independence. This study was designed to describe movements within specific body regions used to stand up from a supine position. Another purpose was to identify motor devel- opmental sequences for the upper extremities, lower extremities, and axial region for this rising task. Thirty-two young adults were videotaped while rising from a supine position 10 times. Descriptive categories were formed to portray move- ments of the upper extremities, lower extremities, and axial region. Subjects varied greatly in the movement patterns they used to rise. Only 25% of the subjects demonstrated a similar combination of movements during rising. That combination involved symmetrical use of the limbs and trunk while flexing forward from a supine position, moving through sitting to squatting, then standing. An ordering of categories was found for each body region that was proposed as a developmental sequence of movement patterns for this task. The variability of subjects' movements while rising provides clinicians with numerous movement combinations that might be used when teaching patients to stand from a supine position. Key Words: Functional training and activities; Kinesiology/biomechanics, general; Movement; Pediatrics, development. The ability to stand up from the floor is a significant part of physical inde- pendence. Movement patterns used to stand up are a concern of physical ther- apists when evaluating their patients' performances and instructing them to perform this task. The motor reeducation theories and techniques of Bobath and Bobath 1 and Knott and Voss 2 prescribe specific movement patterns to be used when teaching individuals to rise from a su- pine position. No formal studies, how- ever, have been reported in the literature that describe clearly movements used by healthy adults in this task. When train- ing disabled adults to stand up from a supine position, therapists must rely either on these authorities or their own informal observations as a reference for their evaluations and selection of move- ment patterns they will teach. The first purpose of this study was to describe adults' movements in the task of standing up from a supine position. I believed that my method of movement analysis might provide physical thera- pists with a more detailed description of this task that eventually might lead to more refined evaluation and treatment of young adults who experience diffi- culty in standing up. The second purpose of the study was to hypothesize specific developmental sequences for this task. Rising from a supine position is an excellent task for studying life span motor development. From a theoretical perspective, rising from a supine position is a "righting" task. 3,4 Righting encompasses all of the varied movements used in the process of assuming erect stance. Motor abilities such as rolling from a supine to a prone position, moving to sitting, getting up on all fours, and ultimately standing up from a supine position, have been con- sidered righting tasks. 1,3 Development of righting abilities during the first year of life represents progression toward phys- ical independence. The ability to rise from a supine position without pulling up on someone or something is com- monly acquired early in the second year of life 5 and, under normal circum- stances, can be expected to be main- tained until the end of the human life span. The form of movements used to rise from a supine position change during the preschool years. 3-5 Little is known, however, about movement patterns used to right the body after the period of early childhood. Righting movements are assumed to reach mature form and then remain unchanged during later childhood and the adult years. These assumptions, however, have never been studied formally. BACKGROUND Without studies of adults' rising movements reported in the literature, I turned to the published research on righting in infants and young children. Schaltenbrand 3 and McGraw 4 have de- scribed development within the task of rising from a supine position. Both re- searchers implied that developmental change in this task was complete in early childhood. According to Schaltenbrand, the adult form of rising appears by the age of 4 to 5 years and is characterized by symmetry of body action. 3 McGraw's description and illustration of a mature form of rising did not portray symmetry of body action, despite study of children up to 6 years of age. 4 This discrepancy over mature form may have resulted from the varied points of emphasis when describing ris- ing action or from differences in the samples of children studied. Nonethe- less, a single mature form of rising from A. VanSant, PhD, is Associate Professor, Depart- ment of Physical Therapy, Medical College of Vir- ginia, Virginia Commonwealth University, PO Box 224, MCV Station, Richmond, VA 23298-0001 (USA). She was a doctoral candidate, Department of Physical Education and Dance, School of Edu- cation, University of Wisconsin-Madison, Madi- son, WI, when this study was conducted. This study was completed in partial fulfillment of the requirements for Dr. VanSant's doctoral degree, University of Wisconsin-Madison. This study was supported in part by a grant from the Foundation for Physical Therapy and was pre- sented at the Sixty-First Annual Conference of the American Physical Therapy Association, New Or- leans, LA, June 16-20, 1985. This article was submitted June 26, 1986; was with the author for revision 27 weeks; and was accepted April 29, 1987. Potential Conflict of Inter- est: 4. Volume 68 / Number 2, February 1988 185

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Rising from a Supine Position to Erect Stance Description of Adult Movement and a Developmental Hypothesis ANN F. V A N S A N T

Standing up from a supine position is important for physical independence. This study was designed to describe movements within specific body regions used to stand up from a supine position. Another purpose was to identify motor devel­opmental sequences for the upper extremities, lower extremities, and axial region for this rising task. Thirty-two young adults were videotaped while rising from a supine position 10 times. Descriptive categories were formed to portray move­ments of the upper extremities, lower extremities, and axial region. Subjects varied greatly in the movement patterns they used to rise. Only 25% of the subjects demonstrated a similar combination of movements during rising. That combination involved symmetrical use of the limbs and trunk while flexing forward from a supine position, moving through sitting to squatting, then standing. An ordering of categories was found for each body region that was proposed as a developmental sequence of movement patterns for this task. The variability of subjects' movements while rising provides clinicians with numerous movement combinations that might be used when teaching patients to stand from a supine position.

Key Words: Functional training and activities; Kinesiology/biomechanics, general; Movement; Pediatrics, development.

The ability to stand up from the floor is a significant part of physical inde­pendence. Movement patterns used to stand up are a concern of physical ther­apists when evaluating their patients' performances and instructing them to perform this task.

The motor reeducation theories and techniques of Bobath and Bobath1 and Knott and Voss2 prescribe specific movement patterns to be used when teaching individuals to rise from a su­pine position. No formal studies, how­ever, have been reported in the literature that describe clearly movements used by healthy adults in this task. When train­ing disabled adults to stand up from a supine position, therapists must rely either on these authorities or their own informal observations as a reference for

their evaluations and selection of move­ment patterns they will teach.

The first purpose of this study was to describe adults' movements in the task of standing up from a supine position. I believed that my method of movement analysis might provide physical thera­pists with a more detailed description of this task that eventually might lead to more refined evaluation and treatment of young adults who experience diffi­culty in standing up.

The second purpose of the study was to hypothesize specific developmental sequences for this task. Rising from a supine position is an excellent task for studying life span motor development. From a theoretical perspective, rising from a supine position is a "righting" task.3,4 Righting encompasses all of the varied movements used in the process of assuming erect stance. Motor abilities such as rolling from a supine to a prone position, moving to sitting, getting up on all fours, and ultimately standing up from a supine position, have been con­sidered righting tasks.1,3 Development of righting abilities during the first year of life represents progression toward phys­ical independence. The ability to rise from a supine position without pulling up on someone or something is com­monly acquired early in the second year of life5 and, under normal circum­stances, can be expected to be main­tained until the end of the human life span.

The form of movements used to rise from a supine position change during the preschool years.3-5 Little is known, however, about movement patterns used to right the body after the period of early childhood. Righting movements are assumed to reach mature form and then remain unchanged during later childhood and the adult years. These assumptions, however, have never been studied formally.

BACKGROUND Without studies of adults' rising

movements reported in the literature, I turned to the published research on righting in infants and young children. Schaltenbrand3 and McGraw4 have de­scribed development within the task of rising from a supine position. Both re­searchers implied that developmental change in this task was complete in early childhood. According to Schaltenbrand, the adult form of rising appears by the age of 4 to 5 years and is characterized by symmetry of body action.3 McGraw's description and illustration of a mature form of rising did not portray symmetry of body action, despite study of children up to 6 years of age.4

This discrepancy over mature form may have resulted from the varied points of emphasis when describing ris­ing action or from differences in the samples of children studied. Nonethe­less, a single mature form of rising from

A. VanSant, PhD, is Associate Professor, Depart­ment of Physical Therapy, Medical College of Vir­ginia, Virginia Commonwealth University, PO Box 224, MCV Station, Richmond, VA 23298-0001 (USA). She was a doctoral candidate, Department of Physical Education and Dance, School of Edu­cation, University of Wisconsin-Madison, Madi­son, WI, when this study was conducted.

This study was completed in partial fulfillment of the requirements for Dr. VanSant's doctoral degree, University of Wisconsin-Madison.

This study was supported in part by a grant from the Foundation for Physical Therapy and was pre­sented at the Sixty-First Annual Conference of the American Physical Therapy Association, New Or­leans, LA, June 16-20, 1985.

This article was submitted June 26, 1986; was with the author for revision 27 weeks; and was accepted April 29, 1987. Potential Conflict of Inter­est: 4.

Volume 68 / Number 2, February 1988 185

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a supine position cannot be described on the basis of previous reports.

Early researchers described righting movements in quite general terms. That is, a particular aspect of the rising move­ment was selected and used to charac­terize movements of the body as a whole. Schaltenbrand, for example, em­phasized differences in the amount of body rotation used to accomplish right­ing from a supine position,3 and Mc-Graw concentrated on description of the characteristics of automaticity and voli­tion in infants' and young children's righting movements.4 When develop­mental differences are described in terms of action of the whole body, pre­cision is lost.6 Descriptions of move­ments are often incomplete. Movements of the extremities, for example, were not consistently reported when successive developmental levels in the righting task were described.3,4

Roberton tried to classify children's throwing movements by using whole-body descriptions of developmental steps for the task of throwing.6 She found that children might demonstrate upper extremity action corresponding to a description of one level of develop­ment and at the same time demonstrate trunk action corresponding to a differ­ent developmental step. Because de­scriptions of developmental levels for throwing were inadequate, Roberton adopted a "component approach" to movement description.6 She broke total body action down into constituent parts and then described movement within these specific regions of the body. Ap­plying this method in a longitudinal study of development of the overarm throw in children, Roberton discovered that developmental change occurred at different rates in different components of body action.7 That is, the children demonstrated change in the movement pattern used in one component of body action, while the movement pattern used in another component remained stable across the same time interval. In addition, different children developed at different rates within each component of body action.

A major assumption of my study is that motor development is a lifelong process: Developmental or age-related change in movement patterns that may not be directly attributed to learning may occur throughout the human life span. Such an assumption allows the use of adult subjects in a developmental study. Traditionally, the term develop­ment refers to age-related behavioral

change that precedes a mature state. The mature state is characterized by behav­ioral stability.

Change in behavior that occurs in a mature individual is traditionally attrib­uted to learning. Age-related behaviors that are not a result of specific learning experiences, however, possibly may ap­pear in adults. Unless an individual had specific training in a particular motor task, the motor performance demon­strated at a particular point in time as-sumably is representative of naturally occurring, untrained performance. I de­signed this study to describe naturally occurring righting behavior. I did not train the subjects, and I assumed that they were never taught how to rise from the floor.

A survey of individuals of different ages is the most common approach to identifying developmental sequences.8

Cross-sectional research designs are based on the assumption that develop­mental change is age related. The behav­iors of different age groups are used to order a developmental sequence.

An additional assumption is possible, however, that allows study of a single age group for the purpose of identifying developmental sequences. That assump­tion proposes that motor development is an orderly process. Developmental change in motor behavior is believed to occur in a sequence of identifiable steps. A logical corollary predicts that at any point in the life span, individuals should demonstrate motor behavior character­istic of their level within a develop­mental sequence. If an individual is in transition between steps of a develop­mental sequence, behaviors representa­tive of adjacent developmental steps should be evident.6 Individuals who demonstrate variability in motor pat­terns while performing several trials of a task, therefore, may be demonstrating movement patterns that represent adja­cent steps in a developmental sequence.

METHOD Subjects

Thirty-two adults (17 women, 15 men) comprised the study sample. I ac­cepted subjects into the study who were at least 20 years old and no older than 35 years. Their mean age was 28.6 years. The sample was one of convenience, with subjects recruited from the campus of the University of Wisconsin-Madi­son. I eliminated any subject who re­ported acute or chronic physical or med­ical conditions that could limit physical

activity. The protocol for this study was approved by the university's Human Subjects Committee, and written in­formed consent was obtained from each subject.

Design

The research was conducted as a de­scriptive survey. From a developmental perspective, the study represented a sin­gle age-group, cross-sectional design.

Equipment

A Beta format portable videocassette recorder and tuner (VCR) were used in conjunction with a videocamera to record each subject's performance. The videocamera was located 7.6 m from the center of a 1.2- × 1.8-m exercise mat. The camera was positioned on a tripod such that the optical axis was approxi­mately perpendicular to the long side of the mat at a height of 1 m above the floor. The camera obtained a side view of each subject at the beginning of tap­ing. A television monitor was used to view the tapes during data analysis.

Procedure

I recorded each subject performing 10 successive trials of rising from a supine position. I instructed each subject to lie supine on the mat and on my signal "Go" to stand up as quickly as possible. I used the preliminary instruction to stand quickly to facilitate automaticity in the subjects' movements. The sub­jects received no other instructions con­cerning how the movements were to be performed, although I occasionally pro­vided them with indiscriminate praise such as "Good" or "Great" to acknowl­edge their efforts. Intervals between trials were self-paced by the subjects, but in no instance exceeded one minute.

Data Reduction

Body action was divided into three components: 1) the upper extremities (UEs), 2) the axial (head-trunk) region, and 3) the lower extremities (LEs). Con­centrating first on the axial region only, I played back the videotapes using both slow-motion and stop-action capabili­ties of the VCR system and wrote de­scriptions of movements of the head and trunk for each subject's performance during the first trial. I then repeated this procedure for the 2nd through 10th trials in succession and compared my written descriptions for similarities and

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RESEARCH differences. Where similarities of action were apparent, I wrote more general descriptions of head and trunk move­ments that could serve as categorical descriptions of axial component action. I reviewed the videotapes as the cate­gories were formed to ensure their ac­curacy. This process was continued until all trials across all subjects could be clas­sified into one of the categorical descrip­tions of axial component action.

I repeated the process to reduce the data for each of the other two compo­nents, the UEs and the LEs. After action categories were formed for each com­ponent, I reviewed the videotape and used the categories to classify move­ments within each component across all trials and all subjects. Data Analysis

Reliability of categorical descriptions. I trained two raters to analyze righting movements with reference to the com­ponent categorical descriptions. After training, each rater independently clas­sified 50 randomly selected trials of the subjects' performances. I compared the raters' classifications to my original clas­sification of these trials by calculating percentages of exact agreement. If less than 90% of exact agreement was ob­tained for any component, I met with the raters to clarify the reasons for disa­greement. We worked together to refine the categorical descriptions of compo­nent action or to generate decision rules to improve the consistency of classifying component action. I then randomly se­lected another set of 50 trials, and we repeated this process until 90% or greater of exact agreement was obtained for all three components. I also reclas­sified a randomly selected set of 50 trials to determine intrarater agreement.

Description of righting in adults. The percentage of trials observed in each category of component action was cal­culated to portray the frequency of oc­currence of each type of component ac­tion. I also tabulated "profiles," the combinations of UE, LE, and axial com­ponent categories, displayed by each subject on each trial and then deter­mined the mode profile for each subject. The frequency with which different sub­ject mode profiles occurred across the sample was determined, and these data were then used to characterize adult body action in rising.

Developmental sequences. I used the records of those subjects who varied within a component to identify a devel­opmental sequence for that component.

TABLE 1 Number of Trialsa in Each Category of Movement

Subject Number

1 2 3 4 5 6 7 8 9

10 11 12 13

X

8 6 6 4

9 8

1

Category

X'

6 9

4 9

1 3 8 1

XX

4

6 1

XX'

1 2 4 4 6

1 1 7 1 9

Specifically, I constructed a table for each component that included each cat­egory of action and the number of trials each subject demonstrated in each cat­egory (Tab. 1). I then rearranged the categories of action (represented by col­umns of the table) until an order was identified in which each subject varied only between adjacent categories (Tab. 2). Using this method, the reverse order also is always a potential ordering for the developmental sequence. That is, if action categories XX, X', XX', and X are one order in which all subjects vary between adjacent steps, then the order­ing X, XX', X', and XX also is a poten­tial ordering of the developmental se­quence. The researcher either must refer to previous developmental studies of the task or must hypothesize which of the

two possibilities is likely to be the devel­opmental sequence for younger or older individuals. I used this procedure to identify a developmental sequence for each of the three components and then referred to the works of Schaltenbrand3

and McGraw4 to help select the likely developmental sequences for younger subjects.

RESULTS

Categories of Component Action Similarities and differences in the sub­

jects' rising movements resulted in five categories of UE action, four categories of LE action, and four categories of axial movement. The action categories are delineated for the UE, LE, and axial components in Tables 3, 4, and 5, respectively.

Reliability of Categorical Descriptions

I attained greater than 90% of exact agreement with each of the two trained raters when we independently catego­rized component action in a randomly selected set of 50 trials. I attained greater than 95% of exact agreement when I recategorized component action in this same set of 50 trials. The percentages of exact agreement are reported in Ta­ble 6.

Description of Righting in Adults

The frequency with which each cate­gory of movement appeared across trials is presented for the UE, LE, and axial components in Tables 3, 4, and 5, re­spectively. In the UE component, a symmetrical pushing pattern was most common. The most frequently observed action of the axial region was symmet­rical flexion followed by extension. The LEs most commonly demonstrated an asymmetrical squatting pattern.

Within this sample of 32 adults, 21 different combinations of component action appeared across the 320 trials of rising. Thirteen of these combinations, or profiles, occurred as the mode per­formance of at least one subject. The different subject mode profiles and their frequency of occurrence are listed in Table 7.

The most common profile in rising was characterized by symmetry of movement within each component. These subjects pushed symmetrically with the UEs as they flexed their heads

TABLE 2 Order in Which Subjects Vary Among Adjacent Categoriesa

Subject Number

1 2 3 4 5 6 7 8 9

10 11 12 13

XX

4

6 1

Category

X'

6 9

4 9

1 3 8 1

XX'

1 2 4 4 6

1 1 7 1 9

X

8 6 6 4

9 8

1

aEach subject performs 10 trials of the movement task.

a Order of development is proposed to be XX, X ', XX', and X.

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and trunks symmetrically forward and flexed their LEs assuming a symmetrical squat pattern. Extension of the LEs and axial region brought the body to erect stance as the UEs were lifted from the support surface (Fig. 1). Although this profile was most common, it was ob­served as the mode in only 8 of the 32 subjects. Another eight subjects differed from this symmetrical profile only in LE action. These individuals either demonstrated an asymmetrical squat (Fig. 2) or lost their balance when at­tempting to rise from a symmetrical squatting position, which resulted in a stepping action.

Four subjects rose by flexing and ro­tating their trunk to one side, while pushing with one UE and reaching with the other (Fig. 3). The LEs moved through a half-kneeling pattern in as­suming the standing position. Another four subjects rolled to face the support surface, with one UE reaching across the body while the other pushed against the mat keeping the abdomen from con­tacting the surface. The LEs were either brought to an asymmetrical squat pat­tern or moved through a half-kneeling pattern. Both UEs then pushed on the support surface, elevating the trunk to­ward a horizontal position with the ven­tral surface of the trunk facing the mat. The UEs were then lifted as the axial region and LEs were extended vertically.

Of the remaining body action profiles, four were seen as the mode in at least two individuals, and another three were idiosyncratic. Eight additional body ac­tion profiles were observed in the sample but were not the mode performance of any subject.

Developmental Sequences for Each Component

Variability in component action within subjects permitted me to identify a developmental sequence for the LE and axial components. For each com­ponent, the subjects demonstrating var­iability across trials of rising are listed in Table 8. Thirteen subjects demonstrated variability in LE action across their 10 trials. Analysis of this variability re­vealed a sequence in which no subject varied to other than adjacent categories. That sequence is presented in Table 4, with category A proposed to be the ear­liest appearing of the developmental steps identified for LE action in this task. Successive steps follow in alpha­betical order.

TABLE 3 Percentage of Occurrence Across Trials (N = 320) for Upper Extremity (UE) Component Categories

Category

A—Push and reach to symmetrical push

B—Push and reach

C—Symmetrical push to push and reach

D—Symmetrical push

E—Symmetrical reach

TOTAL

Description

One hand is placed on the support surface beside the pelvis. The other UE reaches across the body, and the hand is placed on the support surface. Both hands push against the support surface to an extended elbow position. The UEs are then lifted and used for balance.

One hand is placed on the support surface beside the pelvis. The other UE reaches out to assist in balance throughout the move­ment. The supporting UE pushes into extension and is then lifted, assisting in balance.

Both hands are placed on the sup­port surface, one on each side of the pelvis. Both hands push against the support surface as the trunk moves forward. One hand leaves the support surface before the other to assist in balance.

Both hands are placed on the sup­port surface, one on each side of the pelvis. Both hands push against the support surface be­fore the point when the UEs are lifted simultaneously and used to assist in balance.

The UEs reach forward, leading the trunk, and are used to assist in balance throughout the movement.

Occurrence (%) 12.2

27.5

10.6

46.6

3.1

100.0

The records of nine subjects who demonstrated variability in head-trunk action across 10 trials of rising were analyzed to identify a developmental sequence for this component. The hy­pothesized order of development for the axial component is presented in Table 5, with category A proposed to be the earliest appearing step in the sequence and successive steps labeled in alphabet­ical order.

Eight subjects demonstrated variabil­ity in UE action. The movement cate­gories could not be arranged into an order in which each subject varied only between adjacent steps. A sequence was found in which two subjects varied be­tween categories B and D without dem­onstrating category C. At this point, I reinspected the categorical descriptions and videotapes of all subjects demon­strating categories B, C, or D in the UE component. Individuals demonstrating

category C appeared to be using a com­bination of action seen in categories B and D. That is, they began the move­ment by pushing symmetrically, as in category D, but then switched to push­ing with just one UE later in the move­ment as in category B. I interpreted category C as a transitional pattern that may appear in individuals moving be­tween categories B and D, but believed category C was not necessarily a devel­opmental step. I, therefore, merged cat­egory C with category B. Combining categories B and C into a single descrip­tive category enabled me to hypothesize a developmental sequence in which no individual varied between other than adjacent steps. The proposed four-step sequence of development for UE action in the rising task is presented in Table 9. This sequence presents a revised de­scription of UE category B that incor­porates asymmetrical movements of the

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RESEARCH

TABLE 4 Percentage of Occurrence Across Trials (N = 320) for Lower Extremity (LE) Component Categories

Category

A—Half kneel

B—Asymmetrical squat

C—Symmetrical squat with balance step

D—Symmetrical squat

TOTAL

Description

The LEs are brought toward the trunk assuming an asymmetrical crossed-leg position with one foot and the opposite thigh contacting the sup­port surface. Body weight is trans­ferred from the thigh to the knee of the same LE, as the body is ro­tated over the LEs into a half-kneel­ing position. Weight is then trans­ferred to the opposite foot as the LEs extend.

One or both LEs are brought toward the trunk, assuming an asymmetri­cal or crossed-leg position with the soles of the feet contacting the support surface. The LEs (or LE if one remained extended) push(es) up to an extended position. Cross­ing or asymmetry may be corrected during the extension phase by cir­cumduction or stepping action.

The LEs are flexed synchronously and symmetrically, placing the soles of the feet on the support surface. Foot placement is adjusted before extension or at the end of straightening by stepping or hopping.

The LEs are brought symmetrically into flexion with the heels approxi­mating the buttocks. Weight is transferred from buttocks to the feet, and the LEs then extend vertically.

Occurrence (%) 15.9

40.9

16.9

26.3

100.0

UEs, including those that begin with a symmetrical push pattern but end with asymmetrical use of the UEs.

DISCUSSION

Utility of Component Approach The results of this study illustrate the

usefulness of using the component method of movement analysis for de­scription of motor behavior in tasks of interest to physical therapists. The level of detail in description seems to be ap­propriate as a beginning step toward characterizing movement patterns used to accomplish such fundamental motor tasks as rising from a supine position, assuming a sitting position, or rolling. This method may lead to more precise descriptions of body movements for tasks that previously have been de­scribed only in general terms. For phys­ical therapists, such detail is necessary

when faced with the task of retraining individuals to perform these functional motor skills. In addition, the component method could be used more extensively in pathokinesiology to describe and characterize movement disorders result­ing from neuromuscular or musculo­skeletal dysfunction. Indeed, Brunns-trom has proposed that recovery from stroke may proceed at different rates within different regions of the body.9

The results of the study also imply that biomechanical studies of motor tasks such as rising from a supine posi­tion would best be performed within component action categories or a single body action profile. The kinesiological differences between the various cate­gories of component action are too great to be ignored, particularly if movements are to be described in terms of kinematic variables such as angular displacements, velocities, and accelerations of body segments.

Implications for Clinical Practice

The relatively high degree of intersub-ject variability, evidenced by 21 differ­ent combinations of component action, demonstrates the many forms of rising that are possible. The results of my study refute the notion that all adults perform the rising task using the same movement patterns. From a practical perspective, this variability provides the physical therapist with options when selecting movement patterns to be used when teaching the task of rising. Which com­bination of movements might be an ap­propriate set for a specific patient is now a question of interest. Should a patient be trained to perform the rising task using the profile most commonly en­countered in their age group? Is one form of rising more "efficient" than an­other? Are certain body dimensions re­lated to the use of component move­ment categories? Do biomechanical constraints restrict an individual's choice of combinations of component action during the rising task? Surely, knowing the answers to such questions could provide a degree of specificity for physical therapists concerned with mo­tor reeducation that is yet unrealized.

Developmental Implications Theoretically, the component ap­

proach offers a more insightful model of motor development than previous ap­proaches. Previous studies of rising were based on a model that views neuromo­tor development as a process of heir­archical integration of reflexes that ultimately come under volitional or cor­tical control.3,5 When the cortex exerted control over motor behavior, develop­ment was considered to be complete. The model of neuromotor organization suggested by the studies of Kuypers and colleagues proposes that axial and limb regions may be primarily con­trolled through medial and lateral neu-roanatomical structures, respectively.10

Subsequent primate studies based on Kuypers' model suggested that motor development may be viewed as progres­sive dissociation of limb movements from an early linkage with axial move­ment.11 The component method of movement analysis is ideally suited to examination of the relationship between movement patterns occurring in differ­ent regions of the body during the proc­ess of development.

The findings of this study raise several additional issues. First, applying the

Volume 68 / Number 2, February 1988 189

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TABLE 5 Percentage of Occurrence Across Trials (N = 320) for Axial Component Categories

Category

A—Full rotation, abdomen up

B—Partial rotation

C—Symmetrical, interrupted by rotation

D—Symmetrical

TOTAL

Description

The head and trunk flex and ro­tate to the side. Rotation con­tinues until the ventral surface of the trunk faces, but does not contact, the support sur­face. The pelvis is then ele­vated to or above the level of the shoulder girdle. The back extends from this position vertically, with or without ac­companying rotation of the trunk.

Flexion and rotation of the head and trunk bring the body to a side-facing position, with the trunk inclined slightly forward of the vertical plane. The trunk extends vertically, with or without accompanying rotation.

The head and trunk begin to flex forward symmetrically. The symmetrical movement is in­terrupted by rotation to one side or by extension with ro­tation. Forward movement then continues until the head and trunk are forward of the vertical plane. The trunk may rotate counterclockwise dur­ing extension to the upright position. A frontal or diagonal facing may result.

The head and trunk move for­ward symmetrically past the vertical plane; the back then extends symmetrically to the upright position.

Occurrence (%) 14.4

19.7

19.7

46.2

100.0

adjacent criterion to order action cate­gories demonstrated by adults into developmental sequences has not been reported previously. Although Roberton successfully used this criterion to iden­tify developmental sequences within components for the task of throwing, she initially identified the movement patterns that were to become develop­mental steps by using children as sub­jects.6 Whether the component action categories evident in adult subjects are representative of developmental steps in movement used to right the body and whether the proposed sequences are or­dered correctly can only be answered by further study. Although longitudinal study is the ultimate validation proce­dure for the sequences, a more practical approach might be a cross-sectional study of individuals of different ages. The purpose of a cross-sectional study would be to determine whether the ac­tion categories rise and fall in frequency in the order predicted.8

Assuming that these categories do rep­resent developmental differences, an­other issue arises. Do these various forms of component action observed in

TABLE 6 Percentages of Exact Agreement Across Trials (N = 50) by Component

Rater

1 vs 2 1 vs 3 1 vs 1

UE (%) 92 94 98

Component

LE Axial (%) (%) 94 100 94 100 96 96

Fig. 1. Most common form of rising to a standing position: upper extremity component, symmetrical push; axial component, symmetrical; lower extremity component, symmetrical squat.

Fig. 2. Second most common form of rising to a standing position: upper extremity component, symmetrical push; axial component, symmetrical; lower extremity component, asymmetrical squat.

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RESEARCH adults possibly represent lack of progress to advanced symmetrical form in rising or might they represent developmental regression? Are these movement pat­terns specific to young adults and, there­fore, different from those seen in younger and older individuals? Studies of both older and younger subjects could begin to answer these questions.

CONCLUSIONS

The component approach to move­ment description is a useful method of describing fundamental movement pat­terns of interest to physical therapists for both theoretical and practical reasons. Great variability exists in the patterns of movement used by adults in the rising task. Differences in adult movements used in rising from a supine to a stand­ing position may well represent different developmental steps within components of body action. Only further cross-sec­tional and longitudinal studies of this movement task in individuals of various ages will support or refute the proposed component developmental sequences. Until additional studies are performed to further identify factors that might affect which component action pattern is most appropriate for any patient, physical therapists are faced with select­ing from a wide range of possible move­ment pattern combinations when teach­ing patients to rise from the floor.

Acknowledgments. I thank Mary Baldwin, MS, and Randy Richter, MS, for their assistance in determining the objectivity of the component categories.

TABLE 7 Profiles Demonstrated as Mode Performance by Subjects (N = 32)

UE

Symmetrical push Symmetrical push Asymmetrical push and

reach Symmetrical push

Asymmetrical push and reach to symmetrical push

Asymmetrical push and reach to symmetrical push

Symmetrical push to push and reach

Symmetrical reach Asymmetrical push and

reach

Asymmetrical push and reach

Asymmetrical push and reach

Asymmetrical push and reach

Asymmetrical push and reach

Component

Axial

symmetrical symmetrical partial rota­

tion symmetrical

full rotation, abdomen up

full rotation, abdomen up

symmet­rical, in­terrupted by rota­tion

symmetrical symmet­

rical, in­terrupted by rota­tion

symmet­rical, in­terrupted by rota­tion

full rotation, abdomen up

partial rota­tion

symmet­rical, in­terrupted by rota­tion

LE

symmetrical squat asymmetrical squat half kneel

symmetrical squat, with balance steps

half kneel

asymmetrical squat

asymmetrical squat

asymmetrical squat symmetrical squat

asymmetrical squat

asymmetrical squat

symmetrical squat with balance steps

symmetrical squat with balance steps

Number of Subjects

8 5 4

3

2

2

2

1 1

1

1

1

1

Fig. 3. Third most common form of rising to a standing position: upper extremity component, asymmetrical push and reach; axial component, partial rotation; lower extremity component, half kneel.

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TABLE 8 Individual Patterns of Variability in Body Action Components

Component

UE

Axial

LE

Subject Number

4 7

14 23b

25 26 29 31b

1 4 7

12 13 14 23 25 31 4 7 9

10 13 14 20 22 27 28 30 31 32

A

9

1 1

6

4

6 1

Number of Trials in Category

B

1 3 1 3 1 9 9 1

4

4

6 9

4 9

1 3 8 1

C

2 9

3

2

5 6 2 1 3 3 1

1 2 4 4 6

1 1 7 1 9

D

5

7 6

9 8

5

8 9 7 7 9

8 6 6 4

9 8

1

Ea

TABLE 9 Proposed Developmental Sequence for the Upper Extremity (UE) Component

Proposed Order of Categories

A—Push and reach to symmetrical push

B—Push and reacha

C—Symmetrical push

D—Symmetrical reach

Description

One hand is placed on the support surface beside the pelvis. The other UE reaches across the body, and the hand is placed on the support surface. Both hands push against the support surface to an ex­tended elbow position. The UEs are then lifted and used for balance.

One or both hands are placed beside the pelvis on the support surface. One hand continues to support and push against the support surface as the other reaches forward to assist in balance.

Both hands are placed on the support sur­face, one on each side of the pelvis. Both hands push against the support surface before the point when the UEs are lifted synchronously and used to assist in balance.

The UEs reach forward, leading the trunk, and are used to assist in balance throughout the movement.

REFERENCES 1. Bobath B, Bobath K: Cerebral palsy. In Pear­

son PH, Williams CE (eds): Physical Therapy Services in the Developmental Disabilities. Springfield, IL, Charles C Thomas, Publisher, 1972, pp 31-177

2. Knott M, Voss DE: Proprioceptive Neuromus­cular Facilitation: Patterns and Techniques, ed 2. Baltimore, MD, Williams & Wilkins, 1968

3. Schaltenbrand G: The development of human motility and motor disturbances. Archives of Neurology and Psychiatry 18:720-730, 1927

4. McGraw MB: Neuromuscular Maturation of the Human Infant. New York, NY, Hafner Press, 1945

5. Bayley N: The development of motor abilities during the first three years. Monogr Soc Res Child Dev 1:1-26, 1935

6. Roberton MA: Stability of stage categorizations across trials: Implications for the "stage theory" of overarm throw development. Journal of Hu­man Movement Studies 3:49-59, 1977

7. Roberton MA: Longitudinal evidence for devel­opmental stages in the forceful overarm throw. Journal of Human Movement Studies 4:167-175,1978

8. Roberton MA, Williams K, Langendorfer S: Pre-longitudinal screening of motor development sequences. Research Quarterly for Exercise and Sport 51:724-731, 1980

9. Brunnstrom S: Movement Therapy in Hemiple­gia: A Neurophysiological Approach. New York, NY, Harper & Row, Publishers Inc, 1970

10. Kuypers HGJM: Anatomy of the descending pathways. In Brooks VB (ed): Handbook of Physiology, Section 1: The Nervous System: Motor Control. Baltimore, MD, Williams & Wil­kins, 1981, vol 2, pp 597-666

11. Lawrence DG, Hopkins DA: The development of motor control in the Rhesus monkey: Evi­dence concerning the role of corticomotoneu-ronal connections. Brain 99:235-254, 1976

a Category E does not apply to the axial or the LE component. b Subject varied to nonadjacent steps in this proposed ordering of categories.

a Category B represents a combination of categories B and C presented in Table 3. Category A is the same as presented in Table 3. Categories C and D were labeled as categories D and E, respectively, in Table 3.

192 PHYSICAL THERAPY