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Human Movement Science 27 (2008) 65–79

www.elsevier.com/locate/humov

Effects of back loading on the biomechanics

of sit-to-stand motion in healthy children
Yasin B. Seven a, N. Ekin Akalan a,b,c, Can A. Yucesoy a,*
a
Biomedical Engineering Institute, Boğazicßi University, Istanbul, Turkey
b
Gait Analysis Laboratory, Physical Therapy Center, Department of Developmental Child Neurology,
School of Medicine Istanbul University, Istanbul, Turkey
c
Department of Orthopedics and Traumatology, School of Medicine, Istanbul University, Istanbul, Turkey

Available online 9 January 2008

Abstract

The goal of the present study was to determine the thus far unstudied effects of back loading on the
kinematics and kinetics of sit-to-stand (STS) motion in healthy children. Fifteen children (8 boys, 7 girls,
mean age 9.6 years, SD 1.2 years) were tested with no back load and with a back load of 10% and 20% of
body weight, respectively. A motion analysis system was used with six infrared cameras and two force
plates. Total STS duration did not change; however, differential effects were shown for the durations of
its phases. Back loading increased ankle dorsiflexion yielding a greater maximal dorsiflexion angle.
Effects on the knee angle were limited except for a significant decrease in final knee flexion. Initial
and maximal hip flexion increased but final hip angle did not change. Initial backward pelvic tilt
decreased and a shift to forward pelvic tilt occurred at an earlier stage of STS motion. Back loading
affected trunk motion: maximal and final forward shoulder tilt increased. Maximal ankle and knee
moments and powers increased; however, hip joint kinetics was not affected significantly. Therefore,
while maintaining the general pattern of STS motion, participants showed selectively significant adjust-
ments to back loading during its different phases. The main kinematic adjustments were increased trunk
flexion and greater ankle dorsiflexion, while the major kinetic adjustment was increased knee extension
moment. Increased back loading yielded more pronounced effects, primarily in the ankle. In sum, back
loading substantially affected the biomechanics of STS motion even for the lower load level studied.
This finding may be of clinical relevance for musculoskeletal disorders, but this needs to be examined.
Ó 2007 Elsevier B.V. All rights reserved.

*
Corresponding author. Tel.: +90 212 359 64 58; fax: +90 212 257 50 30.
E-mail address: can.yucesoy@boun.edu.tr (C.A. Yucesoy).

0167-9457/$ - see front matter Ó 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.humov.2007.11.001
66 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

PsycINFO classification: 4010; 2221

Keywords: Sit-to-stand motion; Back load; Children; Kinematics; Kinetics; Sensory and motor testing

1. Introduction

In the United States, elementary school students are reported to carry on average a
backpack load of 14–17% of their body weight (BW) (Forjuoh, Schuchmann, & Lane,
2004). In Italy the average backpack of school students load is 22% BW, reaching
beyond 30% BW once a week in a third of the students (Negrini, Carabalona, & Sib-
illa, 1999). With back loading, school children perform various activities. Recently,
Chow et al. (2005) studied the gait of adolescent girls with back loading and reported
statistically significant effects including reduced walking speed, altered joint motion,
and greater joint moments and powers. Also Hong and co-workers showed for activ-
ities such as treadmill (Hong & Brueggemann, 2000), prolonged (Hong & Cheung,
2003), and stair walking (Hong & Li, 2005) that back loading in children has marked
effects on the kinematics and kinetics of the motion. Sit-to-stand (STS) is one of the
most frequently performed daily life actions and has been widely studied in adults
(e.g., Doorenbosch, Harlaar, Roebroeck, & Lankhorst, 1994; Goulart & Valls-Sole,
1999; Hirschfeld, Thorsteinsdottir, & Olsson, 1999), healthy children (Hennington
et al., 2004), and children with disabilities (Hennington et al., 2004; Park et al.,
2003; Park, Park, Chang, Choi, & Lee, 2004). However, although school children often
perform STS actions with back loading, the corresponding motions have not yet been
analyzed.
Typically, during rising from the seated position, the lower extremities undergo a wide
range of joint motions in which the BW is transferred from a relatively stable position
with a large support base to an unstable position with a much smaller support base.
Moreover, such activity necessitates a high level of neuromuscular coordination (e.g.,
Papa & Cappozzo, 2000) to regulate the horizontal and vertical transfer of momentum.
Therefore, even unloaded STS is a mechanically demanding motion (e.g., Riley, Schenk-
man, Mann, & Hodge, 1991) and back loading is expected to increase that fact. We
hypothesized that the effects of back loading on the biomechanics of STS motion in
healthy children may be sizable including increased joint motion and loading. In addi-
tion, it is important to understand the detrimental effects of back loading on the imma-
ture musculoskeletal system (e.g., Pascoe, Pascoe, Wang, Shim, & Kim, 1997) and to
determine a critical level of back load above which the biomechanical effects are substan-
tial (e.g., Chow et al., 2005). In our view, such efforts are incomplete without an analysis
of STS motion with back loading.
The goal of the present study was to test our hypothesis and to take an initial step into
assessing the clinical aspects of the biomechanical effects of back loading on STS motion.
For that purpose, we analyzed the temporal, kinematic, and kinetic parameters of STS
motion performed in three conditions: (1) with no back load, (2) with a back load of
10% of BW, and (3) with a back load of 20% of BW.
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 67

2. Materials and methods

2.1. Participants

Fifteen healthy primary school children (eight boys and seven girls) participated in the
experiment (see Table 1 for participant characteristics). The reports of routinely performed
medical examination of the children included in the study confirmed that they had no pedi-
atric or general neurological abnormality. In addition, before the experiments, a video
based observational gait analysis of the participants was performed to ensure the absence
of movement disorders. All participants were able to clearly hear and understand the
instructions given. After a full explanation of the experimental purpose and procedures,
the participants provided their informed assent to participate while informed consent
was obtained from their parents.

2.2. Methods

A motion analysis system (Elite Eliclinic, BTS, Milan, Italy) with six infrared cameras
and two force plates (Kistler Instrumente AG, Winterthur, Switzerland) was used to
record the STS motions of the participants. Reflective markers were placed onto the seg-
ments using the Helen Hayes Marker Placement Protocol (Davis, Ounpuu, Tyburski, &
Gage, 1991). Bilateral marker locations were the metatarsal head II, the heel, the malleous,
the tibial wand, the femoral epicondyle, the femoral wand, and the anterior superior iliac
spine (ASIS), and a single marker was placed onto the sacrum. In addition to the standard
marker set, a marker on the seventh cervical vertebrae (C7) was used (1) to detect initia-
tion of STS motion, and (2) to quantify shoulder tilt relative to horizontal in combination
with two shoulder markers (on the flat portions of the acromion).
Participants were asked to wear tight shorts and were tested barefoot. A backless seat of
fixed height and depth (43 cm and 25 cm, respectively) representing the dimensions of a
standard primary school bench was used. The participants’ feet were positioned on sepa-
rate force plates to measure the ground reaction forces beneath each foot.
The initial seating position was controlled carefully within certain constraints. To con-
trol initial foot position, the anteroposterior heel position on each force plate was kept
identical for all participants: the distance between the heels and the front of the seat
was 20 cm. The distance between the feet equaled the participants’ pelvic width. To control
initial buttock position, care was taken to ensure that the participants’ buttocks were
safely placed on the seat such that the buttock position ranged within the posterior half
of the depth of the seat and never corresponded to its back edge. Note that the changes
in initial joint angles were considered part of the effect of back loading.

Table 1
Participant (n = 15) characteristics
Age (years) Mass (kg) Height (m)
Mean (SD) 9.6 (1.2) 34.2 (5.1) 1.38 (0.09)
Range 6.6–11.6 28–42 1.24–1.50
68 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

Throughout the measurements, participants were asked to look at a fixed point (located
2 m above the ground and 4 m ahead of the seat). Their hands were crossed on the chest
and holding the shoulders (initially and throughout the motion) to standardize the inertial
effects of arm motion.
Following an explanation of the procedure to the participants and the performance of a
test motion, actual trial and data collection was started. Two seconds after motion capture
initiation participants were instructed to stand up. The same phrasing was used for the
instructions in each trial and care was taken that the same voice level was maintained.
STS motion was performed at the participant’s own preferred speed. Upon completion
of standing up, the participants were asked to maintain the standing posture for 2 s, after
which data collection was terminated. Each participant performed eight STS trials for
each loading condition.
To study the effects of back loading on the biomechanics of STS motion, the same mea-
surement procedure was repeated for three different conditions in a fixed order: (1) with no
back load (referred to as the unloaded condition); (2) with a backpack containing a load of
10% of the participants’ BW (referred to as the 10% load condition); (3) with a backpack
containing a load of 20% of the participants’ BW (referred to as the 20% load condition).
Between the different loading conditions, the participants were given a 5-min resting per-
iod to avoid fatigue and to minimize conditioning for the altered back load. Note that for
the 10% and 20% load conditions, participants wore both strands of the backpack. There-
fore, both shoulders were involved in carrying the back load. Plates of known weight were
placed in the backpack for back loading. This avoided localization of the load at the bot-
tom of the backpack. The accuracy of actual back load compared to the desired back load
was determined by the mass of the lightest plate (250 g). Therefore, the maximal error
between the actual and the desired back load was ±125 g (i.e., approximately 0.4% of aver-
age BW). The position of the center of mass of the back load was approximately aligned
with vertebra T9.

2.3. Definition of STS phases used

For the analysis of kinematic and kinetic data, STS motion was studied in different
phases which were defined by using four critical points representing important phases of
the motion: (1) the point of motion initiation (marker C7 starts to move forward), (2)
the point at which buttocks are lifted (the hip joint center starts to move in vertical direc-
tion), (3) the point of maximal ankle dorsiflexion, and (4) the point at which shoulder rise
is complete (the shoulder markers cease to move upward). Note that the last point repre-
sents the achievement of standing posture and therefore the end of STS motion. The three
consecutive phases, defined between these critical points, are: Phase I: flexion-momentum
phase, Phase II: momentum-transfer phase, and Phase III: extension phase.

2.4. Data analysis and statistics

The smoothest three of the eight STS trials (i.e., the trials with minor or the least data
discontinuity due to occlusion of markers) were analyzed for each loading condition. The
total duration of STS motion (time between the first critical point and the last critical
point) was converted into a 100% scale (referred to as% STS). The kinematic data were
sampled at 100 Hz and filtered by a second order Butterworth filter. BTS Elite Eliclinic
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 69

software was used to compute the kinematics and kinetics from the measured trial data
and participant anthropometrics. The kinematic (ankle, knee and hip joint angles as well
as pelvic and shoulder tilt) and kinetic (ankle, knee and hip joint moments and powers)
variables were computed based on a 3 D model including eight segments (feet, shanks,
thighs and pelvis, as well as an additional segment to study shoulder tilt). However, the
analysis was focused exclusively on the sagittal plane (see Fig. 1 for joint angle definitions).
Joint moments and powers were normalized for body mass. For the discontinuities in the
kinematic and kinetic data, cubic spline interpolation was used to determine the values for
each% STS with missing data. The temporal variables included in the analysis were the
total duration of STS motion and the durations of the individual phases of STS motion.
At each% STS and for each load condition, an average of the kinematic and kinetic
data of the three trials selected per participant was calculated using data from both limbs.

Fig. 1. Joint angle definitions in the sagittal plane. Ankle angle: angle between the normal to the sole axis and the
shank axis. Knee angle: angle between the shank axis and the thigh axis. Hip angle: angle between the normal to
the pelvis axis and the thigh axis. Pelvic tilt: angle between the horizontal axis and the pelvis axis. Shoulder tilt:
angle between the horizontal and shoulder axis. The axes (i.e., the sole, shank, thigh, pelvis and shoulder) used in
joint angle definitions are shown. Note that the sole axis is defined by the heel and metatarsal head II markers.
Pelvic plane is defined by the right and left ASIS markers and the sacrum marker. The pelvis axis is on the pelvic
plane and passes through the mid-point between the right and left ASIS markers and the sacrum marker.
Shoulder plane is defined by the right and left shoulder markers and the C7 marker. The shoulder axis is on the
shoulder plane and passes through the mid-point between right and left shoulder markers and C7 marker. Note
that the figure shows a hypothetical configuration of joint angles in the momentum transfer phase of STS motion
including a forward pelvic tilt and forward shoulder tilt. Note also that no segment is considered between the
pelvis and shoulder segments.
70 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

Data across all participants were then ensemble-averaged for the qualitative analysis of the
time courses of the variables.
In determining the maximal values of kinematic and kinetic data, the greatest value
obtained for the two limbs in each trial was considered exclusively, whereas, for the initial
and final kinematic and kinetic values, data from both limbs were averaged. For each par-
ticipant and load condition, average initial, maximal and final values of kinematic and
kinetic data as well as averaged temporal data were obtained from the three trials selected.
These values were then used in the statistical analyses.
A one-way repeated measures analysis of variance (ANOVA) was performed to test for
the effects of back load on kinematic and kinetic parameters. A two-way repeated mea-
sures ANOVA was performed to test for the effects of interaction of back loading and
phases of STS motion on (1) phase durations and (2) differences between phase durations.
Significant effects were analyzed further using Tukey’s Honestly Significant Difference test.
Differences were considered significant at p < .05.

3. Results

3.1. Phase durations

The total duration of STS motion was independent of back loading (Table 2). However,
the durations of the individual phases were altered if the participants were loaded: (1) the
flexion-momentum phase duration shortened significantly for the 10% load condition but
was not altered for the 20% load condition, (2) the extension phase duration increased sig-
nificantly for both the 10% and the 20% load condition compared to the unloaded condi-
tion, whereas (3) the momentum-transfer phase duration remained unaffected. Note that
the interaction effects between back load and phase on phase durations regarding flexion-
momentum and extension were consistent: the difference between durations of these
phases increased significantly for both the 10% and the 20% load conditions with respect
to the unloaded condition.

3.2. Kinematics

General patterns of variation of sagittal plane joint angles during STS motion were similar
for all conditions (Fig. 2). However, for a large part of the motion, a sizable increase in ankle
dorsiflexion was observed with back loading (Fig. 2a): (1) 20% load caused a significant
increase in the initial angle of dorsiflexion with respect to both the 10% load and the unloaded
conditions, (2) 10% load increased the maximal dorsiflexion significantly and 20% load
Table 2
Phase durations of sit-to-stand (STS) motion
Unloaded 10% Load %20 Load
*
Phase I (flexion-momentum) 0.47 (0.15) 0.41 (0.08) 0.43 (0.10)
Phase II (momentum-transfer) 0.36 (0.19) 0.33 (0.12) 0.33 (0.09)
Phase III (extension) 0.52 (0.20) 0.56 (0.16)* 0.61 (0.24)*
Total duration of STS motion 1.34 (0.31) 1.31 (0.23) 1.38 (0.26)
Values are in second: mean (SD).
*
p < .05 when compared to the unloaded condition.
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 71

Fig. 2. The effects of back loading on the kinematics of STS motion. The ensemble-averaged data for (a) ankle,
(b) knee, (c) hip, (d) pelvic tilt, and (e) shoulder tilt angles are shown as a function of% of sit-to-stand motion (%
STS) for the unloaded condition (—), the 10% load condition and the 20% load condition (- - -). The
transitions between flexion-momentum and momentum-transfer phases () as well as momentum-transfer and
extension phases (d) are indicated on the curves with matching line segments for the load conditions. Note that
the positive values show ankle dorsiflexion, knee and hip flexion, forward pelvic tilt and forward shoulder tilt.

caused a further significant increase (Table 3). No significant back load dependent change
was found for the final ankle angle. Effects of back loading on the knee angle were limited
(Fig. 2b); however, the final knee angle was affected significantly: 10% load decreased the
knee flexion significantly and 20% load caused a further significant decrease (Table 3). For
the first half of STS motion, both load conditions increased hip flexion (Fig. 2c) yielding a
significant increase in initial and maximal hip angles with respect to the unloaded condition
(Table 3). However, for the remainder of the motion, back load effects were minor (Fig. 2c)
and the difference in the final hip angle between load conditions was not significant (Table 3).
Almost throughout the entire STS motion, back loading affected pelvic tilt angle
greatly, causing a shift in the curves towards greater forward tilt (Fig. 2d). As a conse-
quence, both load conditions decreased initial backward pelvic tilt significantly (Table
72 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

Table 3
Initial, maximal and final values of joint angles
Unloaded 10% Load 20% Load
Ankle Initial angle 3.99 (7.10) 5.26 (6.80) 7.61 (7.06)*,**
Maximal angle 12.12 (5.73) 14.85 (6.27)* 17.08 (7.02)*,**
Final angle 3.91 (5.08) 2.93 (4.76) 2.81 (5.21)
Knee Initial (maximal) angle 76.93 (9.25) 79.37 (8.99)* 78.09 (9.15)
Final angle 7.01 (9.52) 5.29 (9.39)* 0.20 (9.56)*,**
Hip Initial angle 53.77 (10.09) 61.87 (8.19)* 61.92 (7.92)*
Maximal angle 70.64 (12.89) 76.16 (11.88)* 77.37 (9.87)*
Final angle 8.60 (10.29) 8.50 (10.70) 10.76 (12.03)
Pelvic Tilt Initial angle 20.89 (7.54) 12.29 (7.72)* 9.76 (6.64)*
Final angle 6.29 (5.80) 6.49 (7.32) 11.59 (9.13)
Shoulder Tilt Initial angle 33.23 (12.83) 39.53 (12.05) 42.32 (14.13)
Maximal angle 50.98 (14.17) 62.55 (12.20)* 66.90 (12.66)*
Final angle 25.24 (13.15) 33.85 (12.30) 35.78 (12.95)*
Values are in degrees: mean (SD).
Positive values show ankle dorsiflexion, knee and hip flexion, forward pelvic tilt and forward shoulder tilt.
*
p 6 0.05 compared to the unloaded condition.
**
p 6 0.05 compared to the 10% load condition.

Fig. 3. The effects of back loading on the joint moments. The ensemble-averaged data for (a) ankle, (b) knee and
(c) hip moments are shown as a function of% of sit-to-stand motion (% STS) for the unloaded condition (—), the
10% load condition and the 20% load condition (- - -). The transitions between flexion-momentum and
momentum-transfer phases () as well as momentum-transfer and extension phases (d) are indicated on the
curves with matching line segments for the load conditions. Note that the positive values show ankle plantar
flexor, knee and hip extensor moments.
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 73

3) and pelvic tilt became neutral (0°) at an earlier stage of STS motion (Fig. 2d). However,
the final pelvic tilt (forward) was unaffected by back loading. Additionally, back loading
caused an increased forward shoulder tilt (Fig. 2e): both load conditions increased maxi-
mal shoulder tilt and 20% load increased final shoulder tilt significantly with respect to the
unloaded condition (Table 3).

Table 4
Maximal values of joint extension moments and power generation
Unloaded 10% Load 20% Load
Ankle Moment 0.33 (0.10) 0.35 (0.12) 0.44 (0.11)*,**
Power 0.12 (0.10) 0.17 (0.14) 0.20 (0.17)*
Knee Moment 0.28 (0.14) 0.34 (0.21)* 0.37 (0.19)*
Power 0.54 (0.37) 0.68 (0.46)* 0.77 (0.57)*
Hip Moment 0.80 (0.24) 0.79 (0.38) 0.85 (0.37)
Power 1.37 (0.85) 1.44 (1.04) 1.36 (0.96)
Moment and power values are in Nm/kg or W/kg, respectively: mean (SD).
Positive moment values show ankle plantar flexor, knee and hip extensor moments, positive power values show
generation.
*
p 6 0.05 compared to the unloaded condition.
**
p 6 0.05 compared to the 10% load condition.

Fig. 4. The effects of back loading on the net joint powers. The ensemble-averaged data for (a) ankle, (b) knee
and (c) hip powers are shown as a function of% of sit-to-stand motion (% STS) for the unloaded condition (—),
the 10% load condition and the 20% load condition (- - -). The transitions between flexion-momentum and
momentum-transfer phases () as well as momentum-transfer and extension phases (d) are indicated on the
curves with matching line segments for the load conditions. Note that the positive values show power generation.
74 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

3.3. Kinetics

General patterns of joint moments were similar across the different loading conditions
(Fig. 3). However, back loading caused (1) the increase in ankle plantar flexor moment in
the momentum-transfer and extension phases to be more pronounced (Fig. 3a) and (2) the
knee extensor (positive) moment to attain higher values; therefore, a greater maximal
value in the momentum-transfer phase (Fig. 3b). The maximal ankle plantar flexor
moment was significantly higher for the 20% load condition compared to the unloaded
condition (Table 4). Both load conditions increased the maximal knee extensor moment
significantly; however, the maximal hip extensor moment was unaffected (Table 4).
Regarding joint powers (Fig. 4), the 20% load condition increased maximal ankle power
generation and both load conditions increased knee power generation significantly with
respect to the unloaded condition. However, no significant change in maximal hip power
generation was shown (Table 4).

4. Discussion

4.1. Effects of back loading on the biomechanics of STS motion

4.1.1. Increased trunk flexion

Despite the lack of a detailed quantification of trunk motion (i.e., lumbar flexion) in the
present study, trunk flexion from vertical was related to forward tilt of the shoulders. The
results showed a sizable increase in forward shoulder tilt during most of the STS motion
due to back loading, indicating that back loading substantially increased the trunk flexion
during the STS motion. Note that the participants flexed their hips more with back loading
and adjusted their pelvic tilt. In all likelihood, those adjustments accounted for a large
proportion of the increased trunk flexion, with the remainder of the increase possibly com-
ing from lumbar flexion.
In a study of STS motion in healthy elderly, Schultz, Alexander, and Ashton-Miller
(1992) suggested that increased trunk flexion allowed the participants to locate the body
weight vector near the middle of the foot support area after seat-off, providing greater sta-
bility. In the present study the center of mass was not computed. However, with back load-
ing, the center of mass of body + load was expected to shift posteriorly compared to the
unloaded condition. Increased trunk flexion can shift the center of mass of body + load (1)
anteriorly and (2) downward. The former may help keeping it close to its position in the
unloaded condition (a center of mass outside the hip-seat contact area and foot support
area is avoided when seated and after seat-off, respectively). The latter may help limiting
back load-induced instability.

4.1.2. Increased ankle dorsiflexion

The present results showed that back loading increases ankle dorsiflexion yielding a
greater maximal angle. In STS motion, the center of mass is typically in a statically unsta-
ble position immediately after seat-off and must be propelled forward to reach the feet to
avoid a fall. Back loading renders this more difficult due to the increased mass and poster-
ior shift of the center of mass. However, increased ankle dorsiflexion (initially in part by
sitting more forward on the seat especially for the higher load condition) may be under-
stood as a strategy that allows participants to overcome such difficulty because (1) it short-
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 75

ens the distance that the center of mass needs to be propelled forward, and (2) in combi-
nation with increased trunk flexion it may help to keep the center of mass within the sup-
port base and thus to limit the load-induced instability.
In addition, as a consequence of increased maximal angle of ankle dorsiflexion (shown
presently to increase from approximately 12° to maximally 17°) and unchanged final ankle
angle, a major effect of back loading was the increased ankle excursion during the exten-
sion phase. As regards the activity of the plantar flexor muscles, this was expected to be
kinetically advantageous. Using in vivo dynamometry-based moment measurements and
ultrasound-based calculations of moment arms, Maganaris (2003) showed that human
medial and lateral gastrocnemius muscles can exert much higher forces in the dorsiflexion
to neutral position range compared to the neutral position to plantar flexion range. More-
over, he reported higher muscle forces and moments for 20° dorsiflexion compared to 10°
dorsiflexion. This suggests that the plantar flexors were capable of producing more
moment during the extension phase in the loaded conditions.

4.1.3. Final knee angle

In contrast to the insignificant effects of back loading on knee kinematics in general, a sig-
nificant change was found for the final knee angle, indicating that with back loading, the par-
ticipants chose to extend their knees more. Such trend became even more pronounced for the
20% load condition: the averaged final knee angle computed for this condition attained a
negative value. Therefore, our results showed that with increasing back load, the partici-
pants tended to approximate full knee extension. This trend suggests that a further increase
in back load may result in knee hyperextension. Hard and soft tissue deformity due to pro-
longed genu recurvatum was shown to lead to pain, weakness, and knee instability, as well as
disturbed gait (e.g., Choi, Chung, Cho, & Park, 1999; Moroni, Pezzuto, Pompili, & Zinghi,
1992; Segev, Hendel, & Wientroub, 2002). However, the extent to which higher back loading
than that studied here affects knee joint motion remains to be tested.

4.2. Limitations and implications of the present study

4.2.1. Present maximal joint moments compared to those representing children’s capability
The results showed that back loading caused substantial and significant changes on the
kinematics and kinetics of STS motion of children even for the lower load level studied.
Back load carriage was shown to affect both kinematic and respiratory parameters (e.g.,
increased trunk inclination angle and breathing frequency) in children during walking
(Li, Hong, & Robinson, 2003). In addition, back loading was shown to correlate positively
with low back pain (e.g., Sheir-Neiss, Kruse, Rahman, Jacobson, & Pelli, 2003). Conceiv-
ably due to such adverse effects, the gait of children with back load has been studied with
the specific aim of determining a ‘‘critical level” of back load above which the effects on the
kinematic and kinetic parameters are significant (e.g., Chow et al., 2005; Pascoe et al.,
1997). Chow et al. (2005) suggested for healthy adolescent girls that such critical load is
approximately 10% BW.
In the present data, the knee joint was affected kinetically most in that even the 10%
load had significant effects on both maximal knee extension moment and power genera-
tion. This indicates that a primary adaptation to back load was an alteration in knee kinet-
ics. It should be noted that the presently determined maximal knee extension moment for
the 10% load condition, normalized for body mass, was approximately 31% greater than
76 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

that reported by Chow et al. (2005) for the gait of healthy adolescent girls with a back load
of 10% BW. This suggests that the peak values of kinetic variables of STS motion with
back loading may be greater than those encountered in other common activities at least
for certain joints. However, new systematic studies are necessary to test whether the effects
of back loading on STS motion are actually more pronounced. Moreover, taking into
account the biomechanical parameters exclusively, our present results imply that the crit-
ical load for the STS motion of healthy children should be lower than 10% BW. This needs
to be tested in a new study performed using finer back load increments.
However, to assess the ‘‘criticalness” of the effects of back loading, not only biomechan-
ical but also clinical relevance of the present results needs to be addressed. Fosang and
Baker (2006) performed dynamometer assisted isometric strength measurements of major
muscle groups of the lower extremities in healthy children at ages similar to our partici-
pants (6.7–11.0 years old, mean 9.0, SD 1.4). When compared to their findings obtained
using ‘‘break” tests, the presently determined maximal ankle plantar flexion, knee exten-
sion and hip extension moment values are 36%, 29% and 44%, respectively, of what the
children are capable of. This suggests for the load range studied presently that STS motion
with back loading is not necessarily detrimental to the musculoskeletal system considering
the lower extremities. Nevertheless, the back load that seems safe for the lower extremities
may not be safe for other parts of the body, for example, for the low back. However, the
lumbar moments were not determined in the present study. This limits implications of our
findings. Therefore, new studies that focus on the details of trunk motion are indicated for
STS motion with back loading.

4.2.2. Effects of nonzero seat-thigh contact forces during flexion momentum phase
In the present experiment, the participants’ buttocks were positioned within the poster-
ior half of the seat. The contact forces between the seat and the thighs were therefore prob-
ably nonzero. STS motion is commonly analyzed using force plates to measure the ground
reaction forces beneath the feet exclusively (e.g., Doorenbosch et al., 1994; Sibella, Galli,
Romei, Montesano, & Crivellini, 2003). However, such nonzero contact forces acting on
the thighs are then not accounted for. Therefore, in the present results, an overestimation
of the internal hip flexion moment is plausible at the onset of motion and during the flex-
ion momentum phase: the external hip flexion moment created by the contact force acting
on the thighs that is neglected in the inverse dynamics calculations is included instead as
part of the internal hip flexion moment.
In studies focused specifically on coordination of ground reaction forces among the feet
and the buttocks (Hirschfeld et al., 1999) and asymmetry of vertical forces (Roy et al.,
2006), the reaction forces on the buttocks were measured using extra force plates. Hirsch-
feld et al. (1999) suggested that buttocks play an important role in preparing for seat-off:
the buttocks generate the rising forces, whereas the feet apply damping control. It is likely
that this role becomes even more pronounced for participants with back loading. How-
ever, the methodology used here does not allow testing this hypothesis. A new study using
extra force plates that can avoid hip moment errors is needed to examine the specific effect
of back loading on the flexion-momentum phase.

4.2.3. Possible effects of crossed hand position on the chest

To standardize the STS motion across participants they were instructed to hold their
hands crossed on the chest. However, this procedure had differential effects on the location
 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79 77

of center of mass and therefore on the stability in the three cases studied: (1) in the
unloaded case such hand position causes the body center of mass to shift upward and ante-
riorly; (2) if back loading is then added, the center of mass (of body + load) shifts further
upward but also posteriorly. Therefore, in the unloaded condition the crossed hand posi-
tion on the chest itself may increase instability, whereas in the loaded conditions this con-
straint may have an effect opposite to that of back loading. Analysis of the center of mass
position was outside the scope of the present study. A new study on the effects of back
loading on the trajectory of the resultant center of mass and its time rate of change
may provide insight into the strategies employed by the participants to avoid instability.

4.2.4. Not randomized testing of different loading conditions

A learning effect may have been caused by not randomizing the different loading con-
ditions: the alterations in initial joint angles shown as a function of back loading may in
part be due to adaptation of the participants’ execution of their sit-to-stand task. How-
ever, the 5-min resting period given to the participants between loading conditions was
expected not only to minimize the effects of fatigue but also to limit such learning effects.

4.2.5. Potential interactions of back loading and initial seated position on the joint kinetics
In the present study the initial seating position was controlled carefully within certain
constraints such that initially the anteroposterior position of the heels was fixed and the
buttock position was within the posterior half of the seat. Therefore, initial body position
may have varied due to variations in buttock position alone within a range of 12.5 cm
only. The changes in initial joint angles under such constraints were considered to repre-
sent adjustments to back loading. Nevertheless, interaction effects of back loading and ini-
tial position on joint kinetics may have occurred. Changes in ankle joint kinetics that
occurred after participants altered their initial ankle position for the 20% load condition
may be ascribable in part to such interactions. In addition, the change in initial position
may also be a reason that the peak knee extension moments did not differ between the
10% and 20% load conditions.

4.2.6. Clinical relevance of STS motion with back load remains to be investigated
An important finding of the present study was that the total duration of STS motion
did not change significantly as a result of back loading for the range of loads studied.
On the other hand, the durations of individual phases of STS motion were altered. Similar
results were reported also by Hennington et al. (2004), who found that the total duration
of STS motion in healthy children did not change following a change in seat height; how-
ever, using a lower seat prolonged the extension phase. These results suggest that healthy
children may control the total duration of STS motion regardless of alterations in mechan-
ical conditions. On the other hand, whether back loading will produce differential tempo-
ral, kinematic and kinetic effects in STS motion of children with musculoskeletal disorders
remains to be investigated in new studies. If large enough and reliable, these effects may
help to gain insight into the etiology of such disorders in the future.
In conclusion, back loading affects the biomechanics of STS motion substantially even at
low loads. In spite of this, the different levels of loading did not cause a significant change in
the total duration of STS motion. The present results showed that the children stayed
within the general pattern of STS motion, but made selective adjustments including changes
in initial joint angles, timing and magnitude of critical kinematic parameters and increasing
78 Y.B. Seven et al. / Human Movement Science 27 (2008) 65–79

joint moments during different phases of the motion. The main kinematic adjustments were
increased trunk flexion and greater ankle dorsiflexion, while the main kinetic adjustment
was increased knee extension moment. Increasing amounts of back loading yielded increas-
ingly pronounced effects at the ankle. The effects of back loading on the biomechanics of
STS motion may be clinically relevant, but this remains to be investigated.

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