1251
Quantitative Evaluation of Long Sitting in Paraplegic Patients
With Spinal Cord Injury
Osamu Shirado, MD, Masafumi Kawase, RPT, Akio Minami, MD, Thomas E. Strax, MD
ABSTRACT. Shirado O, Kawase M, Minami A, Strax TE.
Quantitative evaluation of long sitting in paraplegic patients
with spinal cord injury. Arch Phys Med Rehabil 2004;85:
1251-6.
Objectives: To evaluate the characteristics of long sitting
(ie, sitting with legs extended) in patients with spinal cord
injury (SCI) and to compare these results with able-bodied
control subjects.
Design: A kinematic study using a video camera and force-
plate with a strain-gauge type load cell.
Setting: A referral center for patients with SCI in Japan.
Participants: Twenty-four subjects, including 11 able-bod-
ied, matched control subjects and 13 SCI patients with com-
plete paraplegia.
Interventions: Not applicable.
Main Outcome Measures: Sitting posture in the sagittal
plane as well as the movement pattern and distance of the
center of pressure (COP).
Results: Patients with SCI kept their pelvis tilted posteriorly
and the lumbar spine was less lordotic during long sitting. The
changing COP pattern during long sitting differed in able-
bodied subjects as compared patients with SCI. During long
sitting with arms outstretched over the thighs, COP movement
in the subjects with SCI was significantly greater than that in
the able-bodied subjects. When the arms were outstretched
over the thighs, the COP shifted anteriorly in the able-bodied
subjects and posteriorly in the patients with SCI.
Conclusions: Long sitting in the paraplegic patients with
SCI was unstable compared with the able-bodied subjects. The
COP distribution pattern differed significantly between the 2
groups. The support and function of the upper extremities may
influence balance during long sitting in the patients with SCI.
The method of seating evaluation using a video camera and
gravicorder was easy to use and appeared to provide an objec-
tive measurement of dynamic seating function in the patients
with SCI.
Key Words: Balance; Posture; Pressure; Rehabilitation;
Spinal cord injuries.
© 2004 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Orthopaedic Surgery, Hokkaido University Graduate
School of Medicine, Sapporo, Japan (Shirado, Minami); Department of Functional
Restoration, Center for Spinal Disorders, Bibai Rosai Hospital, Bibai, Japan (Ka-
wase); and Department of Rehabilitation Medicine, JFK Johnson Rehabilitation
Institute, Edison, NJ (Strax).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Osamu Shirado, MD, Dept of Orthopaedic Surgery, Saitama
Medical School, Morohongo-38, Moroyama-Town, Iruma-Gun, Saitama 350-0495,
Japan, e-mail: oshirado@med.hokudai.ac.jp.
0003-9993/04/8508-8463$30.00/0
doi:10.1016/j.apmr.2003.09.014
S ITTING IS AMONG THE most fundamental activities of
daily living (ADLs) for patients with spinal cord injury
(SCI). Proper, stable sitting is critical for persons with SCI
1,2
from the onset of injury and throughout the patients’ lifetime.
Appropriate assessment, as well as adequate training for sitting,
is essential to improve ADLs and quality of life for patients
with SCI. Information provided by an assessment of sitting
position may play an important role in planning an effective
rehabilitation program and in providing comfortable seating.
This information is important for the selection of spinal instru-
mentation and the vertebrae level to be fused.3,4
Several methods are currently used to evaluate SCI patients’
sitting position.1,3,5-7 One representative method is the descrip-
tion of the sitting status by using the Stoke-Mandeville classi-
fication, which is a qualitative evaluation that depends on direct
visual observation.2,3 Although this method is a static evalua-
tion rather than a dynamic one and is easy to perform and
describe, it is subjective and sometimes difficult to compare
both between patients and between observers. A more objec-
tive method to evaluate the sitting posture in patients with SCI
has been developed.8 Investigators have begun to evaluate
postural control under conditions in which the magnitude and
direction of the perturbing forces change over time.9 This
procedure is costly and is hard to operate, especially in the
clinical environment. From a clinical standpoint, it would be
useful to consider an easier and more objective method to
evaluate sitting posture in patients with SCI.
The purposes of our study were (1) to evaluate and compare
the ability to maintain the sitting posture between able-bodied
control subjects and patients with SCI and (2) to introduce an
easy, objective method to assess sitting posture. Of the various
types of sitting, we paid special attention to long sitting (sitting
with legs extended), which is the primary position for many
patients with SCI when performing their ADLs.
METHODS
Participants
A total of 24 subjects were included in our study. Thirteen
patients with SCI (11 men, 2 women) were studied (table 1).
All 13 patients had fracture dislocation of the spine, and all
underwent surgical stabilization with spinal instrumentations in
our institute or other hospitals. They subsequently underwent a
rehabilitation program in our institute immediately after the
SCI or the surgical procedures. Selection criteria included (1)
complete paraplegia because of trauma, (2) paraplegia lasting
more than 12 months after the SCI, (3) no serious complica-
tions related to the SCI, (4) an absence of pelvic obliquity and
scoliosis (those were evaluated with an anteroposterior [AP]
roentgenogram on sitting), and (5) no contracture and no
marked hypertonus of muscles in the lower extremities. Tight-
ness and contracture of the hip flexor was evaluated with the
Thomas test and the straight-leg raising (SLR) test, and muscle
hypertonus was evaluated with the Ashworth Scale (table 2).
All patients performed ADLs independently, with the use of a
wheelchair. Each patient was capable of independent transfer,
such as to car, bed, tub, or toilet. According to the American
Arch Phys Med Rehabil Vol 85, August 2004
1252 LONG SITTING IN PARAPLEGICS WITH SPINAL CORD INJURY, Shirado

Table 1: Demographic Data of the Patients With SCI

Neurologic Sitting Fused

Case Age Level of Injury Height Weight Height Motion Duration After
No. (y) Sex (ASIA) (cm) (kg) (cm) Segments the Injury (mo)

1 28 M T5 172 70 87 1 13
2 28 M T5 174 62 89 2 15
3 29 M T5 168 65 86 2 19
4 39 M T5 166 66 85 1 17
5 32 M T8 170 72 87 2 12
6 28 M T8 176 75 88 2 38
7 33 M T8 169 60 88 3 19
8 30 M T10 175 64 85 3 21
9 31 F T10 160 63 83 2 18
10 22 M T10 173 61 87 2 25
11 34 M T10 175 75 86 2 15
12 29 M T12 178 77 91 2 19
13 25 F T12 166 58 85 2 23

Mean 29.8 170.9 66.8 86.7 2.0 19.5

SD 4.2 5.0 6.3 2.1 0.6 6.7

Abbreviations: ASIA, American Spinal Injury Association; F, female; M, male; SD, standard deviation.

Spinal Injury Association system, the neurologic level of injury
was T5 in 4 patients, T8 in 3, T10 in 4, and T12 in 2. Seated
height was measured in the supine position, with the knee and
hip flexed at 90°. The distance between the ischium and vertex
was measured. The average seated height was 88.5⫾4.7cm for
the able-bodied subjects and 86.7⫾2.1cm for the patients with
SCI. The period after the injury ranged from 12 to 38 months
(mean, 19.5⫾6.7mo). Table 1 describes the demographic data
of the patients with SCI. In all patients, there was no voluntary
contraction of any lower-extremity muscles. The function of
the trunk muscles of each patient was evaluated by the same
person (MK) and is detailed in table 3.
Eleven able-bodied control subjects (6 men, 5 women) vol-
unteered for the study. The able-bodied subjects were recruited
Table 2: Muscle Spasm and Tightness
of Hip Flexor and Hamstrings
Ashworth
Case No. Scale* Thomas Test† SLR (deg)
by the authors as the matched controls. All able-bodied sub-
jects had no known history of any neurologic problems and
were well motivated to perform this study. The average height
and weight of individuals in the control group was
172.5⫾7.1cm and 64.3⫾8.3kg, respectively. Ages ranged from
24 to 36 years (mean, 32.3⫾5.5y).
Written informed consent was obtained from all subjects.
The procedures for the study were reviewed by an institutional
review board.
Experimental Devices and Procedures
A gravicorder G6100a was used to evaluate the long-sitting
position in each subject. The gravicorder consisted of a force-
plate that was 55⫻60cm, and was connected to a computer that
was programmed to display and record in real time the center
of gravity (COG) during long sitting.10 Weight was detected by
using a strain-gauge type load cell in the forceplate. The
measuring range of the load cell was 10 to 300kg. The accuracy
of the COG and of the measured weight were shown

1 1 Negative 110
2 1 Negative 105
Table 3: Function of Trunk Muscles, Based on Manual
3 1 Negative 115 Muscle Testing
4 1 Negative 110
5 1 Negative 115 Manual Muscle Testing
6 1 Negative 115 Case Trunk Trunk Elevator Hip
7 1 Negative 115 No. Flexor Extensor of Pelvis Flexor
8 1 Negative 115 1 — Trace — —
9 0 Negative 120 2 — Trace — —
10 0 Negative 125 3 — Trace — —
11 1 Negative 110 4 — Trace — —
12 1 Negative 110 5 — Trace — —
13 0 Negative 120 6 — Trace — —
7 — Trace — —
*The scale for assessing severity of hypertonus. It is a 5-point rating
scale (0, normal; 1, slight hypertonus, a “catch” when limb is moved; 8 Trace Poor — —
2, mild hypertonus, limb moves easily; 3, moderate hypertonus, 9 Trace Poor — —
passive limb movement difficult; 4, severe hypertonus, limb rigid). 10 Trace Poor — —
†
The test for detecting a hip flexion deformity. When examining the
11 Trace Poor — —
range of flexion of a hip, the opposite hip must be flexed fully on the
patient’s abdomen and held there. If the hip automatically exposes a 12 Fair Fair Trace —
flexion deformity, the test is positive. If no hip flexion deformity is 13 Fair Poor Trace —
found, the test is negative.

Arch Phys Med Rehabil Vol 85, August 2004

 LONG SITTING IN PARAPLEGICS WITH SPINAL CORD INJURY, Shirado
Fig 1. The 2 types of long sit-
ting with legs extended, using
a representative posture of
the patients with SCI (subject
8): (A) long sitting with both
hands on the thighs, and (B)
long sitting with arms out-
stretched over the thighs.
by the manufacturer to be less than 1mm and 1.0%, respec-
tively. The analog data from the load cell was converted
through a 16-channel analog-to-digital converter and was sub-
sequently stored on the computer hard drive. The sampling rate
was 90Hz.
Subjects were asked to sit on the forceplate in a comfortable
fashion with their eyes open. Two types of long sitting with
legs extended were performed by each subject: (A) long sitting
with both hands on the thighs and (B) long sitting with arms
outstretched over the thighs (fig 1). For all subjects, trial A was
always followed by trial B. Subjects were asked to gaze at a
marker 3m directly in front of them and to maintain the same
sitting posture for 20 seconds.
In addition to using the quantitative evaluation from the
gravicorder, a qualitative evaluation of long sitting was per-
formed simultaneously with a video-recorder.b The following
analyses were performed: (1) the observation of long sitting in
the sagittal plane using the video camera, (2) the pattern of the
trace of the center of pressure (COP), (3) the distance the COP
1253
moved during the long sitting, and (4) the deviation of the COP
in the sagittal plane. Before data acquisition, each subject had
enough practice to be familiar with each procedure and sat on
the platform for 10 seconds before the recording. In the qual-
itative evaluation with a video recorder, pelvic tilt and spinal
curve were evaluated to observe the markers placed at the
anterior-superior iliac spine, posterior-superior iliac spine, and
the spinous processes of C7, T7, T12, L3, and L5 vertebrae.
Statistical Analysis
Statistical analysis was done by using the Student t test to
compare the different sitting data sets. The 95% confidence
interval (P⬎.05) of the data sets of the different subjects was
determined. The pattern of trace with COP was classified for
each subject, based on the Tokita classification (fig 2).11 The
types of COP tracing during sitting could be divided into 5
categories: AP, central, diffused, bilateral, and multicentral
types.
Fig 2. The 5 trace pattern classifi-
cation of the COP, based on the
Tokita reports.
Arch Phys Med Rehabil Vol 85, August 2004
1254 LONG SITTING IN PARAPLEGICS WITH SPINAL CORD INJURY, Shirado

Table 4: Pelvic Tilt and Lumbar Lordosis in the Sagittal Plane, With the Video-Camera Observation

Direction of Pelvic Tilt Change of Lumbar Lordosis

Case
No. Trial A Trial B Trial A Trial B

1 Posterior Posterior Decreased Decreased

2 Posterior Posterior Decreased Decreased
3 Posterior Posterior Decreased Decreased
4 Posterior Posterior Decreased Decreased
5 Posterior Posterior Decreased Decreased
6 Posterior Posterior Decreased Decreased
7 Posterior Posterior Decreased Decreased
8 Posterior Posterior Decreased Decreased
9 Posterior Posterior Decreased Decreased
10 Posterior Posterior Decreased Decreased
11 Posterior Posterior Decreased Decreased
12 Posterior Anterior Decreased Increased
13 Posterior Anterior Decreased Increased

NOTE. Trial A: both hands on the thighs (fig 1A). Trial B: upper extremities outstretched over the thighs (fig 1B).

RESULTS
All subjects completed this study without any problems.
Qualitative Observation of Long Sitting in the Sagittal
Plane Using the Video Camera
In all able-bodied subjects, physiologic curvature of the
spinal column was maintained in both trials A and B. On the
other hand, posterior pelvic tilt and decreased lumbar lordosis
in trial A were found in all patients with SCI (fig 1). In trial B,
the long-sitting posture in patients with SCI was divided into 2
types. In the SCI patients with T5-10 functional levels, poste-
rior pelvic tilt and decreased lumbar lordosis became more
dominant, and thoracic kyphosis increased (fig 1). In contrast,
anterior pelvic tilt and lumbar lordosis increased, and thoracic
kyphosis decreased in the patients with SCI of T12 functional
level (table 4).
Quantitative Analysis of Long Sitting Using the
Gravicorder
Two observers (MK, OS) independently evaluated each
COP tracing pattern during long sitting with legs extended. The
results were consistent between both observers (table 5). Dur-
ing long sitting with both arms on the thighs, all able-bodied
subjects revealed a pattern resembling the central type, based
on the Tokita classification. In contrast, a bilateral type was
observed in all patients with SCI. No patients with SCI showed
the central type or any other types of sitting patterns. During
long sitting with the upper extremities outstretched over the
thighs, both groups showed the same pattern, which was the
central type.
Variability of the COP moving distance during long sitting.
Figure 3 shows the distance the COP moved during long sitting
in both groups. During long sitting with both arms on the
thighs, the distance was 5.95⫾1.02cm and 9.38⫾0.34cm in the
able-bodied and the SCI groups, respectively. The distance the
COP moved in the subjects with SCI was significantly longer
than that found in the able-bodied subjects (P⬍.05). During
long sitting with the upper extremities outstretched over the
thighs, the distance was 6.93⫾2.01cm for the able-bodied
subjects and 26.42⫾2.46cm for the SCI group. The distance
moved was also significantly greater in the patients with SCI
than for the able-bodied subjects (P⬍.05).

Table 5: The Variability of the COP Moving Distance, and the Type of COP Tracing During Long Sitting in Patients With SCI

Translation of COP (cm) Type of COP Tracing

Case
No. Trial A Trial B Trial A Trial B

1 9.32 26.49 Bilateral Central

2 9.86 23.67 Bilateral Central
3 9.32 25.43 Bilateral Central
4 9.22 25.03 Bilateral Central
5 9.94 27.22 Bilateral Central
6 9.33 31.67 Bilateral Central
7 9.95 27.83 Bilateral Central
8 9.43 26.41 Bilateral Central
9 9.29 25.96 Bilateral Central
10 8.99 29.08 Bilateral Central
11 9.18 28.22 Bilateral Central
12 8.85 22.49 Bilateral Central
13 9.32 24.02 Bilateral Central

Mean 9.38 26.42

SD 0.34 2.46

NOTE. Trial A: both hands on the thighs (fig 1A). Trial B: upper extremities outstretched over the thighs (fig 1B).

Arch Phys Med Rehabil Vol 85, August 2004

 LONG SITTING IN PARAPLEGICS WITH SPINAL CORD INJURY, Shirado
Fig 3. Variability in the moving distance with the COP during long
sitting for trial A (both hands on the thighs) and trial B (upper
extremities outstretched over the thighs). Abbreviation: NS, not
significant. *P<.05.
Among the able-bodied subjects, there was no statistical
significance in the change in COP distance between the 2 arm
positions in each trial. These distances became longer when the
patients with SCI stretched their upper extremities over the
thighs (P⬍.05).
Shift in COP in the sagittal plane during long sitting. The
shift of COP in the sagittal plane was evaluated when subjects
lifted their arms over the thighs. At this time, the COP shifted
forward in the able-bodied subjects but backward in the pa-
tients with SCI. The shifted distance was 1.56⫾1.13cm for-
ward and 2.04⫾1.42cm backward, for the able-bodied controls
and for the patients with SCI, respectively. There was no
significant difference between the 2 groups.
DISCUSSION
Patients with SCI need a stable and comfortable sitting
posture to perform ADLs. Sitting in a wheelchair is crucial to
maximize the ability to perform most tasks for patients with
SCI.1,2,7,12 The evaluation of wheelchair sitting is very impor-
tant to plan a rehabilitation program and to provide more
comfortable seating devices for these patients. Many investi-
gators4,5,7,9,12,13 have been interested in studying wheelchair
sitting to improve ADLs in patients with SCI.
Wheelchair sitting evaluation has been performed by using
various types of measuring devices. Kamper et al9 investigated
the lateral postural stability of people with SCI subjected to
dynamic perturbations. In that study, the equipment to evaluate
sitting stability was costly and too complicated to use in the
clinical setting. Our earlier study10 using this device provided
reliable and accurate data regarding dynamic side-shifts in
patients with idiopathic scoliosis. In our current study, we
evaluated the COP pattern and COP distance variability by
using the gravicorder. The classification pattern used was that
reported and developed by Tokita et al.11 They reported, in
their study regarding the righting reflex, that the COP trace
pattern during sitting was divided into 5 types. They also
pointed out that many able-bodied subjects revealed AP, cen-
tral, and diffused types. No bilateral type was observed in any
able-bodied subjects. They also noted that the findings were
reliable enough to compare the patients with the able-bodied
subjects. The changes in COP distance measured the sitting
balance of the patient’s body posture.
Performance of ADLs requires many types of sitting; ride
sitting, crook sitting, long sitting, side sitting, stoop sitting, and
1255
fallout sitting.1-3 Long sitting with legs extended on the floor is
among the most basic and common sitting postures in SCI
patients. For instance, the long-sitting position is necessary
when patients learn dressing techniques and when they must
move their lower limbs in preparation for transfers and bed
activities. The literature on evaluation of this type of sitting is
surprisingly sparse. We chose to evaluate the characteristics of
long sitting rather than wheelchair sitting.
Balance during stable sitting in paraplegic patients with SCI
is provided by (1) the 3-point supports provided by the bilateral
ischium and sacrum, (2) posterior pelvic tilting, (3) anterior
spinal support with increased intrathorax and intra-abdominal
pressure, and (4) the locking effect of bones and various
ligaments.2,3 Our study using video observation of the sagittal
sitting posture confirmed that all patients with SCI showed
posterior pelvic tilting and a less lordotic lumbar spine shape
than able-bodied controls. This posture seems to provide a
mechanism for stable balance in paraplegic patients with SCI.
Nawoczenski et al1 also recommended that the lower back not
be stretched when attempting to balance in this position.
Quantitative analysis performed by using the gravicorder
showed that balance in long-sitting SCI patients was signifi-
cantly more unstable than in the able-bodied subjects. This
difference between the able-bodied and the SCI groups was
unrelated to arm position. Balance while in the long-sitting
position was significantly more unstable when the SCI patients’
arms were outstretched over the thighs. Subjects were asked to
sit comfortably on the forceplate with their eyes open. At this
time, the subjects put their hands on their thighs in a relaxed
fashion. For these patients with SCI, the function and support
provided by their arms on their thighs may have played an
important role in maintaining balance while sitting. During
rehabilitation and ADL training of patients with SCI, balance
activities in the long-sitting position should be emphasized,
both with and without using the arms for support.1-3
The pattern of COP movement during long sitting in the SCI
patients was different from that in the able-bodied subjects.
During long sitting with both hands on their thighs, all able-
bodied subjects revealed a central pattern. A bilateral pattern
was observed in the patients with SCI. No patients with SCI
showed the central COP pattern during both trials A and B.
Tokita11 concluded that the bilateral type was not observed in
able-bodied subjects. This is a characteristic of patients with
SCI in the long-sitting position and might be caused by trunk
muscle imbalance and postural inability to maintain the stable
sitting position in the frontal plane.3,5,6,14 The upper extremities
might prevent trunk motion or sway in the sagittal plane.
However, both groups showed the same central pattern on the
COP trace during long sitting with their arms outstretched over
their thighs (trial B). The upper extremities raised over the
thighs might aid balancing in the long-sitting position in SCI
patients.5,14 With the arms raised, the average change in the
distance of COP in the patients with SCI was significantly
greater than in the able-bodied subjects. This implies that long
sitting in patients with SCI was more unstable without the
support of their upper extremities.
When the arms were raised over the thighs from the relaxed
position, the COP shifted in both groups. The COP moved
anteriorly in the able-bodied subjects and posteriorly in the
patients with SCI. The anterior shift in COP in the able-bodied
subjects was caused by an increase in anterior moment when
the arms were raised over the thighs. The mechanism of the
posterior shift in the patients with SCI could be speculated as
follows. The intrathoracic and intra-abdominal pressure de-
creased with the elevation of the arms, followed by an increase
in anterior instability.5 Moreover, the anterior moment in-
Arch Phys Med Rehabil Vol 85, August 2004
1256 LONG SITTING IN PARAPLEGICS WITH SPINAL CORD INJURY, Shirado
creased with the elevation of the arms. The COP moved pos-
teriorly to compensate for the anterior instability to maintain
the stable long-sitting position.
Because there was a small number of patients, we could not
conclude that there were any significant differences in the
ability to maintain a stable long-sitting position between pa-
tients with different functional levels and fusion length. Trunk
muscle function varied in each patient, although there was no
voluntary contraction of any lower-extremity muscles in any
patient with SCI. Sitting balance should have differed, accord-
ing to functional level in each patient. Many factors influence
balance during the long-sitting posture. These include skill,
experience, body habitus, tight hip flexors, and knee flexion
contracture. Further study, including motion analysis and elec-
tromyography of various muscles in the trunk and lower ex-
tremities, are needed to clarify the difference of sitting balance
in different functional levels of SCI.
More dynamic and complicated postures may need to be
evaluated to improve sitting posture for ADLs in these patients
with SCI. Movements are usually accompanied by trunk bend-
ing and rotation, such as lifting up items from the floor and
moving objects. Under those circumstances, balance might be
influenced by the level of injury and fusion length. In an earlier
investigation of trunk mobility and ADLs in SCI patients after
both conservative and surgical treatments, we found that trunk
mobility was better maintained in patients with conservative
treatment and 1- or 2-level fusion than in those with the
multilevel fusion associated with more complex surgery.4
Trunk balance was also more stable in the conservatively
managed group. Moreover, the patients with multilevel fusion
surgery were less able to perform ADLs, especially the trunk
flexion and rotation. The local factors affecting sitting balance
might be the level of injury and severity of impaired trunk
muscle control, a change in spinal alignment after the fusion
surgery, the length of fused segments, and muscular spastici-
ty.9,13,15 One has to consider all these factors when evaluating
more dynamic and complicated postures.
CONCLUSIONS
We investigated the characteristics of able-bodied subjects
and paraplegic patients with SCI in maintaining the long-sitting
position by using video-camera observations and gravicorder
measurement. Patients with SCI tilted their pelvis posteriorly,
and the lumbar spine became less lordotic in the long-sitting
posture. The pattern of the COP trace during long sitting
differed between groups. During long sitting with both arms
outstretched over the thighs, the change in COP distance in
subjects with SCI was significantly greater than in able-bodied
subjects. This analysis, using a video camera and a gravicorder,
Arch Phys Med Rehabil Vol 85, August 2004
was a useful method to evaluate balance and sitting posture in
different groups of patients at other institutions.
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