Gait & Posture 86 (2021) 38–44

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Gait & Posture

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Full length article

Kinetics, kinematics, and knee muscle activation during sit to stand

transition in unilateral and bilateral knee osteoarthritis
Marina Petrella *, Luiz Fernando A. Selistre, Paula R.M.S. Serrão, Giovanna C. Lessi,
Glaucia H. Gonçalves, Stela M. Mattiello
Department of Physical Therapy, Federal University of São Carlos, Rodovia Washington Luis, Km 235, São Carlos, SP, CEP:13565-905, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The sit to stand transition (STS) is a task performed by those with knee osteoarthritis (KOA) with
Ground reaction force biomechanical modifications that may influence the lower limb load distribution. As a weight bearing task
Total momentum of support mainly performed in the sagittal plane, the presence of unilateral or bilateral KOA may lead to asymmetry during
Electromyography
its performance.
Knee osteoarthritis
Sit-to-stand
Research question: Are the biomechanical and neuromuscular aspects of the sit to stand transition (STS) different
between participants with unilateral and bilateral KOA?
Methods: Twenty-eight participants were allocated as follows: unilateral KOA (OAUNI; n = 12) and bilateral KOA
(OABI; n = 16). All participants were evaluated by means of kinematics (Qualisys Motion Capture System,
Qualisys Medical AB, SUE), kinetics (Bertec Corporation’s model 4060− 08 Mod., USA), and electromyography
(TrignoTM Wireless System, DelSys Inc., USA) during the STS. The variables calculated were the symmetry
indices of the total support moment (TSM) and ground reaction force (ISGRF and ISTSM, respectively), magnitude
of the TSM, individual joint contribution to the TSM, peak trunk flexion, hip, knee, and ankle range of motion,
duration in seconds, the magnitudes of activation of the extensor and flexor muscles, knee extensors: flexor co-
contraction indices and isometric knee extensor peak torques. Participants also answered the WOMAC ques­
tionnaire and performed the 30-second STS test (STS30).
Results: The OABI got up from a chair with a lower TSM magnitude in the most affected limb (p = 0.040), used
greater trunk flexion amplitude (p ≤ 0.034), and presented lower isometric KET (p = 0.039) and worse self-
reported pain (p = 0.011) and physical function (p = 0.015).
Significance: Participants with unilateral and bilateral KOA differ regarding lower limb kinetics and trunk ki­
nematics while getting up from a chair, without modification in the lower limb intersegmental coordination or
symmetry regarding ground reaction force or TSM distribution.

1. Introduction
Knee osteoarthritis (KOA) is a progressive and degenerative joint
disease that compromises articular cartilage, the subchondral bone,
synovial membrane, and periarticular muscles. As a result, knee joint
presents a reduced ability to dissipate loads, minimize friction and
maintain joint congruence during weight-bearing activities [1,2]. The sit
to stand transition (STS) is one of the main weight-bearing activities,
which implies a greater load on the joints of the lower limb when
compared to other tasks, such as walking or going up and down stairs
[3].
As a bipedal task, asymmetry should be expected during the STS
transition, however few studies in which the symmetry during the STS
transition was investigated included both participants with unilateral
and bilateral KOA [4] or only unilateral KOA [5,6]. Regarding unilateral
KOA, participants with early KOA placed more load on their unaffected
side during the intermediate and final stages of the STS [6], while those
with advanced KOA imposed 87 % of load on the non-affected side [5].
When both unilateral and bilateral were evaluated together, participants
with severe KOA presented asymmetry of body weight support during

* Corresponding author at: Federal University of São Carlos, (UFSCar), Department of Physical Therapy, Rodovia Washington Luiz, Km 235, São Carlos, SP, CEP:
13565-905, Brazil.
E-mail addresses: ma.petrella@gmail.com (M. Petrella), lfaselistre@gmail.com.br (L.F.A. Selistre), ppregina@yahoo.com.br (P.R.M.S. Serrão), giclessi@gmail.com
(G.C. Lessi), gauhg.fisio@gmail.com (G.H. Gonçalves), stela@ufscar.com (S.M. Mattiello).

https://doi.org/10.1016/j.gaitpost.2021.02.023
Received 8 April 2020; Received in revised form 9 January 2021; Accepted 19 February 2021
Available online 22 February 2021
0966-6362/© 2021 Published by Elsevier B.V.
M. Petrella et al.
the task [4].
The lower limb load distribution during STS transition may be
influenced by movement patterns that has also been previously observed
in those with KOA, such as the lower knee joint moment in the sagittal
plane in the affected limb and higher flexion of the trunk [4,7–10]. A
factor that can also contribute to the load in the tibiofemoral compart­
ment is a higher co-contraction of the agonist and antagonist muscles (e.
g., quadriceps and hamstrings) [11] that may favor a knee stiffening
strategy and result in a reduction of the knee joint moment in the sagittal
plane.
Considering the above, this study aimed to investigate whether there
is a difference in the distribution of the ground reaction force (GRF) and
the kinetic chain synergy, represented by the total support moment
(TSM) of the lower limbs among participants with unilateral and bilat­
eral KOA during STS transition. We also aimed to compare the magni­
tudes of the GRF, TSM, magnitude of activation, co-contraction
magnitude of extensor flexor muscles of the knee, knee extensor torque
(KET) of the affected/more affected lower limb, and trunk flexion. The
main hypothesis of the present study is that participants with unilateral
KOA would present an asymmetric distribution of TSM and GRF
compared to those with bilateral KOA. It is also expected that when
compared with the more affected side of the participants with bilateral
KOA, those with unilateral KOA may exhibit a lower GRF, lower TSM,
higher trunk flexion and lower magnitude of co-contraction of the
extensor and flexor muscles of the knee and higher knee extensor torque
(KET).
2. Methods
2.1. Subjects
This cross-sectional study is a secondary analysis of data from a
previous study in which the trunk flexion, lower limb kinetics, total
support moment, and individual joint contributions to the total support
moment during the sit-to-stand task were compared in participants with
mild and moderate knee osteoarthritis [10]
Estimation of the sample size was based on the study by Turcot et al.
(2012). Considering the measure of the GRF symmetry between the
lower limbs as the main variable, there was a mean difference = 0.08
and a pooled standard deviation = 0.126, with an effect size = 0.63.
Thus, the sample size was estimated as proposed by Cohen (1988), with
an alpha = 0.05, power = 0.80, and effect size = 0.063. The minimum
sample size required for the study was 11 subjects per group. This study
was approved by the Human Research Ethics Committee of the Federal
University of São Carlos and all participants provided written informed
consent.
Participants of both sexes were recruited from the community
through advertisements in the local media. All participants underwent
anteroposterior semiflexed weight-bearing, lateral view, and skyline
view radiographs and were diagnosed with KOA if they met the Amer­
ican College of Rheumatology (clinical, radiographic, and history)
criteria [12]. The KOA severity was classified according to the Kellgren
and Lawrence (KL) criteria and only those with mild (KL grade II) or
moderate (KL grade III) degrees were included [13]. Participants with
bilateral KOA were included as long they had a more affected knee, or
more symptomatic for those in which the KOA degree was the same in
both knees. Twenty-eight participants were grouped as follows: Unilat­
eral KOA (OAUNI), with 12 participants who had unilateral KOA; and
Bilateral KOA (OABI), who had 16 participants with bilateral KOA.
The following non-inclusion criteria were applied: previous ortho­
pedic surgery on lower limbs or spine, medical indication for knee
prosthesis, pain in the spine or other lower limb joint; history of lower
limb trauma, corticosteroid infiltration or physical therapy treatment
within 6 months prior to assessment, use of walking aids, self-reported
allergy to adhesive material, any other rheumatologic disease or any
medical condition that would restrict participation in the study [14]. In
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Gait & Posture 86 (2021) 38–44
addition, participants who did not present ligament integrity, and those
who could not get up from and sit in a chair independently were not
included.
2.2. Procedures
All the participants answered the Western Ontario and McMaster
Osteoarthritis Index (WOMAC) questionnaire [15]. On different days,
they performed the STS, and kinetic, kinematic, and electromyographic
data were acquired, as well as knee extension isokinetic evaluation. For
participants with bilateral KOA, the lower limb in which the knee had a
greater degree of radiographic involvement and worse intensity of
self-reported pain was considered to be the most affected. As part of the
enrollment process, all the participants also had the pain intensity of the
more affected knee evaluated through the Visual Analogue Scale (VAS).
2.3. Sit to stand transition motion assessment
Kinematic data were acquired using the Qualisys Motion Capture
System and acquisition software (QTM - Qualisys Track Manager 2.9,
Medical AB, Sweden), with a sampling frequency of 120Hz [16]. Two
force plates (Bertec Corporation’s, model 4060− 08 Mod. USA)
embedded in the floor, were used to evaluate the kinetics at a frequency
of 1200 Hz. The reflective markers (15 mm diameter) were attached
bilaterally to the following bony prominences: acromia, iliac crests,
anterior and posterior superior iliac spines, greater trochanters of the
femur, medial and lateral femoral epicondyles, medial and lateral mal­
leoli, first, second and fifth metatarsal heads, base of the fifth metatarsal,
and calcaneus. There were single markers placed on the sternal notch
and spinous process at C7, two clusters built with 3 noncollinear markers
positioned on the spinous process at T4 and T12 and four clusters built
with 4 noncollinear markers placed over the lateral side of the right and
left thigh and shank [14].
The affected/more affected limb was evaluated regarding the elec­
tromyographic data, using wireless surface electrodes (TrignoTM
Wireless System, DelSys Inc., USA), amplified by an 8-channel system
(DelSysInc., USA, 40 m range, 2.4 GHz transmission frequency, common
mode rejection>80 dB, 450 Hz bandwidth, total gain 1000 times). For
the electrode placement, the recommendations of the Surface Electro­
MyGraphy for the Non-Invasive Assessment of Muscles (SENIAM) were
followed [17]. Myoelectric activity was recorded from the vastus
medialis (VM), vastus lateralis (VL), rectus femoris (RF), biceps femoris
(BF), medial gastrocnemius (MG), and lateral gastrocnemius (LG) and
normalized to the amplitude of the myoelectric activity obtained during
the maximal voluntary isometric contraction (MVIC) [14].
All the participants were initially positioned with 1/3 of the back of
the thigh supported on the seat of the chair (from an imaginary line
originating from the greater trochanter to the epicondyle lateral of the
femur). The participant initiated the task barefoot, with the arms crossed
in front of the trunk, hips and knees positioned at approximately 90◦ ,
and feet fully supported on the floor. The chair used in this study had no
arms or backrest, and an adjustable height by means of removable seats
with different heights to adapt to the position of each individual. After
familiarization with up to 3 repetitions, three STS repetitions were
performed at a self-selected speed and self-selected foot position [4].
2.4. Kinetic, kinematic and electromyography data analysis
The kinematic data were transferred to Visual 3D software (CMotion,
Inc., Rockville, MD, USA) and filtered with a 4th order Butterworth low
pass filter with zero phase delay and cutoff frequency of 25 Hz. To
determine the center of the hip, knee, and ankle joints, the markers of
anterior and posterior superior iliac spines, the midpoint between the
medial and lateral epicondyles of the femur, and the point between the
lateral and medial malleoli were considered, respectively [14]. The joint
coordinate system was defined as recommended by the International
M. Petrella et al. Gait & Posture 86 (2021) 38–44

Society of Biomechanics [18]. The proximal hip, knee, and ankle seg­
ments were used to calculate the angles of each of these joints and the
global coordinate system was used to calculate the angle of flexion of the
trunk.
The magnitude of the internal extensor moments of the hip, knee,
and ankle were calculated through the inverse dynamics and normalized
by the body weight and height of participants [14]. The internal
extensor moment of the knee was considered positive, while the internal
extensor moment of the hip and flexor momentum of the ankle were
considered negative [19].
The electromyographic data were filtered using a Butterworth
bandpass filter of the fourth order of 20− 400 Hz and rectified by a full
wave using a 50-millisecond moving window, the RMS linear envelope.
The maximum amplitudes of the MVIC represented 100 % of the
muscular electrical activity and the normalized average electromyog­
raphy data of the three STS repetitions were expressed as a percentage of
the MVIC. Using the hip kinematics, the beginning and end of each phase
of the STS were determined as detailed in Bouchouras et al. (2012). The
STS transition was analyzed in three phases: Phase1: from the beginning
of the task until the maximum angle of hip flexion; Phase2: from the
maximum hip flexion angle to the maximum flexion angle of the ankle;
Phase3: from the point that represents the maximum flexion angle of the
ankle to the end of the movement [20].
The magnitudes of the peak of the GRF were obtained using a Matlab
algorithm and the TSM by means of the sum of the average of the in­
ternal extensor moments of the hip, knee, and ankle [19,21]. Next, the
independent variables, symmetry index of the magnitude of the GRF
(SIGRF) and symmetry index of the TSM (SITSM), were calculated. For the
OAUNI, the symmetry indices of the affected limb were divided by the
non-affected limb, while for the OABI the values of the affected limb
were divided by the less affected limb. A SIGRF and SITSM of 1 was
considered as perfect symmetry, while values above one represent a
movement pattern that prioritizes the affected or more affected limb
[22]. Regarding each phase of the STS, dependent variables were also
considered, the magnitude of the TSM, the peak trunk flexion angle, the
range of motion of the hip, knee, and ankle, the time duration, and the
individual joint contributions to the TSM, representing the proportional
contribution of hip, knee, and ankle joints (%hip, %knee, and %ankle,
respectively) [19].
The electromyographic variables obtained were the magnitudes of
activation of the extensor (VL, BF, VM) and flexor (BF, MG, LG) muscles
of the knee and the following co-contraction indices: VL:BF (Covl:bf) and
(VL, BF, VM): (BF, LG, MG) (Coext:flx). For each co-contraction index,
values closer to "0" represent greater magnitude [20].
Except for the SIGRF and SITSM variables, all the dependent variables
were obtained in relation to the affected limb for OAUNI and the most
affected for OABI, for each of the phases of the task (Phase1, Phase2, and
Phase3).
kilograms was considered (PTiso_ext).
2.6. Statistical analysis
Data distribution and homogeneity were tested using the Shapiro-
Wilk and Levene tests, respectively. Age, body mass, height, and BMI
were compared between the groups (OAUNI x OABI) using the t-test. The
chi-square test was utilized to compare the distribution of the partici­
pants in each group regarding sex, radiographic degree of KOA, and pain
in the contralateral side. The scores of the pain and physical function
subscales of the WOMAC questionnaire and the pain intensity evaluated
throughout VAS in the affected/more affected side during the enroll­
ment process were compared using t-tests for independent samples.
The individual joint contributions to TSM were compared with the
Mann-Whitney U test The kinematics and duration of the task variables
were compared using analysis of covariance (ANCOVA), with body mass
index as covariate. The TSM and PTiso_ext were previously normalized by
the weight of the participant and compared using independent t-tests.
The mean difference (MD) and 95 % confidence interval (95 % CI) for
the parametric variables are reported. For the non-parametric variables,
the confidence interval was obtained by the Hodges-Lehman estimator.
The ES was calculated to determine the relevance of the differences
[24]. Statistical analysis was performed using the statistical software
SPSS (version 17.0; SPSS, Inc., USA). A level of significance ≤5% was
considered for all comparisons.
3. Results
Both groups had a similar age and height (p = 0.921 and p = 0.936,
respectively), however the OABI presented higher values for body mass
and BMI (p = 0.016 and p = 0.002, respectively). The groups were not
different regarding KOA severity(p = 0.126), sex(p = 1.00). All the
participants of the OABI presented contralateral knee pain while none of
the participants of OABI reported this symptom. The pain intensity
evaluated throughout VAS in the affected/more affected side was higher
in the group of participants with bilateral KOA (p = 0.016) (Table 1).
Participants with bilateral KOA reported higher pain and worse
physical function throughout WOMAC questionnaire. They also had a
lower PTiso_ext than those with unilateral KOA (Table 2). The OAUNI
and OABI groups presented similar SIGRF and SITSM (Table 3). Partic­
ipants with bilateral KOA presented a lower magnitude of MTS only
during Phase3 of the STS when compared to OAUNI (F(1.27) = 4.672;
p = 0.040; MD = 0.08; 95 % CI=(0.004; 0.154); ES = 0.86). There were
no differences in relation to the individual joint contributions to the TSM
(Fig. 1).
Regarding the magnitudes of activation of the knee extensor and
flexor muscles and co-contraction indices, there were no significant

Table 1
2.5. Isokinetic knee extension evaluation Participants Characteristics.
(OAUNI) (OABI) p
The concentric and eccentric KET were evaluated at 60◦ /s using an
(n = 12) (n = 16)
isokinetic dynamometer (Biodex Multi-Joint System 3, Biodex Medical
Incorporation, New York, NY, USA) with an acquisition frequency of Age (years) 56.75 ± 6.88 56.50 ± 6.28 0.921
Height (m) 1.67 ± 0.07 1.67 ± 0.09 0.936
100 Hz. The participant was placed in the chair of the dynamometer, Body Mass (kg) 73.27 ± 11.30 84.36 ± 8.16 0.016 *
stabilized with belts crossing the trunk and pelvic belt, with the knee BMI (kg/m2) 26.28 ± 2.90 30.47 ± 3.53 0.002 *
flexed at 90◦ . All participants performed three submaximal repetitions Female (%) 50 % 50 % 1.00
and two maximal repetitions for familiarization with both concentric KOA severity (mild/moderate) 8/4 6/10 0.126
Report of pain (yes/no) in the 0% 100 % p<
and eccentric contractions. After a rest of two minutes, they performed
non affected / less affected 0.001*
five isokinetic contractions with a rest period of five minutes between knee (%)
each contraction. During the tests, participants were instructed to keep Pain intensity in the more 425 671 0016*
their arms crossed in front of the trunk and verbal encouragement was affected knee (VAS)
provided. The range of motion at which contractions were performed Abbreviations: OAUNI, Unilateral Knee Osteoarthitis; OABI, Bilateral Knee
was 20◦ to 90◦ (0◦ =complete knee extension) [23]. For the comparison Osteoarthitis; KOA, knee osteoarthritis; VAS, visual analogue scale.
between groups, the first and last contractions were excluded and the *
p ≤ 0.05 for comparisons between OAUNI and OABI with independent t-test
average of the peak of isometric KET normalized by body mass in or chi-square.

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M. Petrella et al. Gait & Posture 86 (2021) 38–44

Table 2
Pain and physical function WOMAC scores and isometric knee extensor torque expresses as mean ± standard deviation.
OAUNI OABI p MD 95 % IC ES

WOMACpain 6.25 ± 3.95 10.44 ± 3.48 0.006* − 4.19 (-7.08 ; -1.29) 1.15
WOMACphysical_function 16.67 ± 15.63 31.5 ± 11.72 0.008* − 14.83 (-25.44 ; -4.22) 1.12
PTEXT_ISO 18,127 ± 4100 14,474 ± 4612 0.039* 1681 (196 ; 7108) 0.84

Abbreviations: OAUNI, Unilateral Knee Osteoarthritis; OABI, Bilateral Knee Osteoarthritis; p, significance level; MD, mean difference; 95 % CI, 95 % confidence interval
(lower bound; upper bound); ES, effect size.
ES interpretation:
Small effect size: 0.0 ≤ ES ≥ 0.49.
Medium effect size: ES ≥ 0.50.
Large effect size: ES ≥ 0.80.
*
p ≤ 0.05.

Table 3
Symmetry Index (SI) of the total support moment (SITSM) and Symmetry Index of the ground reaction force (SIGRF) in the STS phases expresses as Mean ± standard
deviation.
SI OAUNI 95% IC OABI 95% IC F p MD Lower Bound Upper Bound ES

SITSM1 0.98 ± 0.26 0.94 ± 0.23 0.007 0.936 0.04 − 0.26 0.24 0.000
SITSM2 0.94 ± 0.21 1.03 ± 0.22 0.934 0.343 − 0.09 − 0.32 0.12 0.037
SITSM3 1.04 ± 0.23 0.95 ± 0.23 1.219 0.280 0.09 − 0.11 0.36 0.048
SIGRF1 0.98 ± 0.19 1.01 ± 0.23 0.042 0.840 − 0.03 − 0.18 0.22 0.002
SIGRF2 0.97 ± 0.19 1.03 ± 0.27 0.031 0.861 − 0.06 − 0.25 0.21 0.001
SIGRF3 0.93 ± 0.10 0.96 ± 0.22 0.011 0.918 − 0.03 − 0.18 0.16 0.000

Abbreviations: OAUNI, Unilateral Knee Osteoarthritis; OABI, Bilateral Knee Osteoarthritis; p, significance level; MD, mean difference; 95 % CI, 95 % confidence interval
(lower bound; upper bound); ES, effect size.
*p ≤ 0.05.
ES interpretation.
Small effect size: 0.0 ≤ ES ≥ 0.49.
Medium effect size: ES ≥ 0.50.
Large effect size: ES ≥ 0.80.

Fig. 1. A: Mean and standard deviation of the magnitude of total support moment (TSM); B:Hip, knee and ankle joint contribution to the TSM presented as per­
centage (%).
Abbreviations: OAUNIUnilateral Knee Osteoarthritis; OABI Bilateral Knee Osteoarthritis
* significance level (p) ≤ 0.05

differences between groups (p ≥ 0.05) (Fig. 2). 4. Discussion

There were no differences for the hip, knee, or ankle range of motion
or time duration during any STS phases (p ≥ 0.05). In Phase3, the OABI
presented greater trunk flexion (p = 0.034; MD = 6.84; ES = 0.89). The
duration of each phase of the STS was similar between groups
(p > 0.05). The results concerning kinematic data are presented in
Table 4.
As bilateral involvement and progression of the disease are observed
over time [25], understanding whether participants with unilateral or
bilateral KOA differ regarding the STS movement pattern is important
for planning research and rehabilitation involving KOA. In this study,
those with unilateral or bilateral KOA did not differ in relation to the
SIGRF and SITSM during the STS. In addition, when the affected/more

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M. Petrella et al. Gait & Posture 86 (2021) 38–44

Fig. 2. A: Magnitudes of activation of the extensors (vastus medialis (VM), vastus lateralis (VL), rectus femoris (RF)) and flexors (biceps femoris (BF), medial
gastrocnemius (MG), and lateral gastrocnemius (LG)) during Phases 1,2 and 3 of the sit to stand transition expressed as percentage of the maximal voluntary iso­
metric contraction (%MVIC). B: Co-contraction indices: VL:BF (Covl:bf) and (VL, BF, VM): (BF, LG, MG) (Coext:flx) during Phases 1,2 and 3 of the sit to stand transition.
Abbreviations: OAUNI, Unilateral Knee Osteoarthritis; OABI, Unilateral Knee Osteoarthritis

Table 4
Peak flexion ankle of the trunk, hip, knee and ankle range of motion in the three phases of the STS task presented in degrees (o).
OABI Mean ± SD 95 % CI OAUNI Mean ± SD 95 % CI MD 95 % CI F p ES

Trunk1 50.46 ± 7.18 (46.19 ; 54.73) 44.96 ± 7.00 (41.36 ; 48.57) 5.50 (-0.55 ; 11.55) 3.49 0.073 0.75
Hip1 22.87 ± 6.90 (18.77 ; 26.97) 26.27 ± 6.73 (22.81 ; 29.73) − 3.40 9-9.21 ; 2.41) 1.45 0.240 0.48
Sagital Plane Kinematics(o)
Phase1 Knee1 3.39 ± 0.75 (1.84 ; 4.93) 4.34 ± 0.63 3.00 ; 5.65 − 0.96 (-3.14 ; 1.23) 0.02 0.88 0.06
Ankle1 7.8 ± 3.14 (5.94 ; 9.67) 8.13 ± 3.06 (6.56 ; 9.71) 0.34 (-2.98 ; 2.31) 0.07 0.796 0.11
Time duration (s) Time1 0.48 ± 0.30 (0.31 ; 0.66) 0.52 ± 0.25 (0.37 ; 0.67) − 0.04 (-0.29 ; 0.22) 0.08 0.774 0.11
Trunk 2 53.43 ± 7.79 (48.80 ; 58.06) 47.46 ± 7.59 (43.55 ; 51.37) 5.97 (-0.59 ; 12.53) 3.51 0.073 0.75
Hip2 10.51 ± 7.10 (6.29 ; 14.73) 11.14 ± 6.92 (7.58 ; 14.71) − 0.63 (-6.61 ; 5.35) 0.05 0.830 0.09
Sagital Plane Kinematics (o)
Phase2 Knee2 11.72 ± 6.56 (7.82 ; 15.62) 12.14 ± 6.39 (8.85 ; 15.43) − 0.42 (-5.94 ; 5.10) 0.02 0.876 0.06
Ankle2 3.79 ± 1.97 (2.62 ; 4.96) 3.53 ± 1.92 (2.54 ; 4.52) 0.26 (-1.4 ; 1.91) 0.10 0.750 0.13
Time duration (s) Time 2 0.22 ± 0.10 (0.16 ; 0.28) 0.25 ± 0.09 (0.19 ; 0.30) − 0.03 (-0.11 ; 0.06) 0.45 0.511 0.26
Trunk 3 50.35 ± 7.47 (45.91 ; 54.79) 43.50 ± 7.28 (39.76 ; 47.26) 6.84 (0.55 ; 13.14) 5.02 0.034* 0.89
Hip3 76.68 ± 11.51 (74.40 ; 88.08) 81.65 ± 11.22 (70.91 ; 82.46) 4.56 (-5.14 ; 14.25) 0.94 0.343 0.39
Sagital Plane Kinematics (o)
Phase3 Knee3 64.67 ± 13.22 (56.82 ; 72.53) 61.58 ± 12.89 (54.95 ; 68.22) 3.09 (-8.04 ; 14.23) 0.33 0.573 0.23
Ankle3 9.64 ± 4.49 (6.98 ; 12.32) 10.29 ± 4.38 (8.03 ; 12.54) − 0.64 (-4.43 ; 3.15) 0.12 0.731 0.14
Time Duration (s) Time 3 0.99 ± 0.34 (0.79 ; 1.19) 1.15 ± 0.28 (0.98 ; 1.31) − 0.15 (-0.44 ; 0.13) 1.28 0.270 0.45

Abbreviations: OAUNI, Unilateral Knee Osteoarthritis; OABI, Bilateral Knee Osteoarthritis; SD, standard deviation; CI 95 %, confidence interval of 95 % (lower bound ;
upper bound); p, significance level; ES, effect size.
ES interpretation:
Small effect size: 0.0 ≤ ES ≥ 0.49.
Medium effect size: ES ≥ 0.50.
Large effect size: ES ≥ 0.80.
*
p ≤ 0.05.

affected limb was compared between groups, lower magnitude of TSM
and greater trunk flexion were observed in OABI while performing the
body extension to reach the vertical position (Phase3).
To the best of our knowledge, the biomechanical aspects of the STS
have not been previously compared between those with unilateral or
bilateral KOA. However, previous studies in which the symmetry be­
tween the lower limbs was investigated contribute to the discussion of
our results. When previously compared to controls, unilateral or bilat­
eral KOA placed more load on their unaffected/less affected lower limb
while standing [4–6]. Although a sample consisting of a greater
proportion of participants with bilateral symptoms of KOA was sug­
gested as a limitation in a previous study that evaluated the load
asymmetry in the lower limb in individuals with KOA and contrary to
the hypothesis of the present study, participants with unilateral and
KOA were symmetrical in relation to the lower limb load distribution
during STS transition.
Despite the similarity regarding body weight and lower limb load
distribution, there were some differences in the biomechanical aspects
of the STS transition between those with unilateral and bilateral KOA.
Participants with bilateral KOA exhibit lower magnitude of TSM on the

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more affected limb and a higher trunk flexion during the body extension
to reach the vertical position (Phase3). In a previous study of our
research group that aimed to compare biomechanical aspects of the STS
transition among the different KOA degrees [10], a possible influence of
unilateral or bilateral KOA in the results was also reported as a limitation
of the study. However, in this previous study those with moderate KOA
presented lower TSM in Phase1 and Phase2 of the STS transition, while
those with bilateral KOA used this strategy in the Phase3. Thus, the
findings of the present study may represent specific movement adapta­
tions of those with bilateral KOA.
Among the clinical factors that could explain this modified move­
ment pattern adopted by those with KOA is pain, muscle weakness, and
the need to unload the affected lower limb [4,26,27]. In the present
study, the participants of the OABI group reported more pain and were
weaker than the OAUNI. Although the higher trunk flexion amplitude
maintained for a longer period by those with bilateral KOA at the end of
the task may be considered a compensatory strategy for knee pain and
quadriceps weakness, there are other strategies that should be consid­
ered, such as a larger peak trunk lateral lean to less-affected side in the
frontal plane. Thus, future studies should investigate the relationship
between pain and muscle weakness and the biomechanical strategies
that differ from those with unilateral and bilateral KOA.
Alongside the trunk kinematics and TSM modifications, there were
no differences for lower limb joint moments in the sagittal plane or in­
dividual joint contributions to the total support moment between those
with unilateral or bilateral KOA. Thus, there is a decrease in the demand
on the affected knee joint during Phase3 without modifying contribu­
tions of hip, knee, and ankle joints to the TSM, representing a balanced
intersegmental coordination. The groups were also similar regarding the
magnitude of knee muscle activation or co-contraction, suggesting an
absence of greater demand on the neuromuscular system on the
affected/more affected lower limb.
Together, the results of the present study suggest that having uni­
lateral or bilateral KOA influence the movement pattern of the STS
transition without implying an asymmetric load distribution between
the lower limbs or in intersegmental incoordination during the task. For
rehabilitation, this is an important finding, as STS transition is per­
formed daily and is present in rehabilitation protocols.
The absence of differences in the magnitude of GRF distribution
between those with unilateral and bilateral KOA has also been previ­
ously reported during gait [28]. The authors suggested a possible asso­
ciation with biomechanical adaptations that do not have origins related
only to the physiological characteristics of the knee affected by the KOA,
such as similar biomechanical gait adaptations between limbs due to
cortical or subcortical alterations originated by knee joint degeneration,
even when only one knee is symptomatic. In this line of reasoning,
another study reported that participants with moderate or severe KOA
modified the cortical representation of the knee during isometric
extension of this joint [29]. However, future studies are needed to un­
derstand whether there is modification of motor cortex activity of par­
ticipants with unilateral and bilateral KOA during STS and its
relationship to changes in the pattern of movement while rising from the
chair.
It is also important to mention that in the present study participants
with bilateral KOA had a worse perception of physical function and
higher intensity of knee pain in the affected lower limb, both observed
during the enrollment process. Although bilateral KOA is considered a
risk factor for worse physical function [30], a similar self-reported
physical function between participants with unilateral and bilateral
KOA was previously observed, however the authors didn’t report knee
pain assessment [31]. Knee pain could influence the evaluation of
physical function through the participant’s self-report, so that those with
greater pain intensity in the contralateral lower limb presented worse
performance [32].
The absence of knee pain evaluation of knee pain intensity before,
during or after the STS task should be mentioned as limitation of the
43
Gait & Posture 86 (2021) 38–44
present study, as this variable was not considered as a contribution to
altered mechanics. The knee pain information refers to the period of
72 h before the initial evaluation (WOMAC) or the perceived pain dur­
ing the initial evaluation (EVA). Although all the participants with
bilateral KOA presented pain on the less affected side, the absence of the
pain intensity assessment in the contralateral knee may also be reported
as a limitation, as this was not possible to compare the pain intensity
between the affected and less affected side. The unilateral electromyo­
graphic evaluation is a limitation of this study and bilateral EMG could
help in the analysis of the STS task performed by those with unilateral
and bilateral KOA, however no difference was observed between the
lower limbs EMG in participants with moderate KOA during gait [33].
5. Conclusion
Participants with unilateral and bilateral KOA differ regarding lower
limb kinetics and trunk kinematics, without modification in the lower
limb intersegmental coordination or symmetry regarding ground reac­
tion force or total support moment distribution in order to successfully
complete the sit to stand transition. Thus, these differences should be
considered when interpreting the results of studies that include both
participants with unilateral and bilateral KOA.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgements
To all volunteers that took part in this study. This work was sup­
ported by the Coordination for the Improvement of Higher Education
Personnel (CAPES) and National Council for Scientific and Technolog­
ical Development (CNPq)
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