Whole body movement strategies during sit-to-stand and stair ascent in individuals with a lower limb amputation: A systematic review

  • Ludovic Miramand
    Corresponding author at: Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), 525, boul. Wilfrid-Hamel, Bureau H-0602, Québec G1M 2S8, Canada.
    Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada

    Faculty of Medicine, Département de kinésiologie, Université Laval, Québec, Canada
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  • Gabriel Moisan
    Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada

    Faculty of Medicine, Département de kinésiologie, Université Laval, Québec, Canada
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  • Vincent Richard
    Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada

    Faculty of Medicine, Département de kinésiologie, Université Laval, Québec, Canada
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  • Bradford J. McFadyen
    Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada

    Faculty of Medicine, Département de réadaptation, Université Laval, Québec, Canada
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  • Katia Turcot
    Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada

    Faculty of Medicine, Département de kinésiologie, Université Laval, Québec, Canada
    Search for articles by this author


      • Stair gait and sit-to-stand are crucial for individuals with lower limb amputation.
      • Trunk and lower limbs need to be investigated during both tasks.
      • This review identified the most relevant parameters underlying movement strategies.
      • Moment and power show that residual joints compensate for the prosthetic joint.
      • Trunk and lower limb need to be more investigated during both tasks.



      Individuals with a lower limb amputation use compensatory strategies during essential tasks such as sit-to-stand and stair ascent leading to secondary physical conditions. The ensuing biomechanical parameters outlining the motion strategies they put in place need to be identified and described.


      We searched three databases (Embase, IEEE Xplore and PubMed) for articles on the spatiotemporal, the kinematics and the kinetics that compared the amputated, the intact lower limbs, or the trunk of individuals with a unilateral transtibial or transfemoral amputation with the limbs of a control group.


      We found twenty articles. During sit-to-stand, individuals with a lower limb amputation increased the trunk inclination angle toward the intact lower limb, explaining higher ground reaction forces and peak knee sagittal power generation. During stair ascent, individuals with a lower limb amputation increased the stance phase duration on the intact lower limb. Moreover, individuals with a lower limb amputation increased both lower limbs hip extension moment and power, and the amputated lower limb knee extension moment. In both tasks, the individuals with a transfemoral amputation presented larger differences than those with transtibial compared to the control group.


      Both lower limbs intact joint moment and power were increased to compensate for the prosthesis passive joint and to ensure stability. Stair gait studies mainly focused on the lower limbs' biomechanical changes in the sagittal plane, while sit-to-stand studies focused on asymmetries without comparing the lower limbs independently. Better methodological descriptions are essential to enhance the external validity of previous results.


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        • Actis J.A.
        • Nolasco L.A.
        • Gates D.H.
        • Silverman A.K.
        Lumbar loads and trunk kinematics in people with a transtibial amputation during sit-to-stand.
        J. Biomech. 2018; 69: 1-9
        • Agrawal V.
        • Gailey R.
        • Gaunaurd I.
        • III R.G.
        • O’Toole C.
        Weight distribution symmetry during the sit-to-stand movement of unilateral transtibial amputees.
        Ergonomics. 2011; 54: 656-664
        • Aldridge Whitehead J.M.
        • Wolf E.J.
        • Scoville C.R.
        • Wilken J.M.
        Does a microprocessor-controlled prosthetic knee affect stair ascent strategies in persons with transfemoral amputation?.
        Clin. Orthop. 2014; 472: 3093-3101
        • Aldridge J.M.
        • Sturdy J.T.
        • Wilken J.M.
        Stair ascent kinematics and kinetics with a powered lower leg system following transtibial amputation.
        Gait Posture. 2012; 36: 291-295
        • Alimusaj M.
        • Fradet L.
        • Braatz F.
        • Gerner H.J.
        • Wolf S.I.
        Kinematics and kinetics with an adaptive ankle foot system during stair ambulation of transtibial amputees.
        Gait Posture. 2009; 30: 356-363
        • Andriacchi T.P.
        • Mündermann A.
        • Smith R.L.
        • Alexander E.J.
        • Dyrby C.O.
        • Koo S.
        A framework for the in vivo pathomechanics of osteoarthritis at the knee.
        Ann. Biomed. Eng. 2004; 32: 447-457
        • Aulivola B.
        • Hile C.N.
        • Hamdan A.D.
        • Sheahan M.G.
        • Veraldi J.R.
        • Skillman J.J.
        • Campbell D.R.
        • Scovell S.D.
        • LoGerfo F.W.
        • Pomposelli F.B.
        Major lower extremity amputation: outcome of a modern series.
        Arch. Surg. Chic. Ill. 2004; 1960 (discussion 399): 395-399
        • Burger H.
        • Kuželički J.
        • Marinček Č.
        Transition from sitting to standing after trans-femoral amputation.
        Prosthetics Orthot. Int. 2005; 29: 139-151
        • Bussmann J.B.
        • Grootscholten E.A.
        • Stam H.J.
        Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease.
        Arch. Phys. Med. Rehabil. 2004; 85: 240-244
        • Collins T.D.
        • Ghoussayni S.N.
        • Ewins D.J.
        • Kent J.A.
        A six degrees-of-freedom marker set for gait analysis: repeatability and comparison with a modified Helen Hayes set.
        Gait Posture. 2009; 30: 173-180
        • Costigan P.A.
        • Deluzio K.J.
        • Wyss U.P.
        Knee and hip kinetics during normal stair climbing.
        Gait Posture. 2002; 16: 31-37
        • Dawes D.
        • Iqbal S.
        • Steinmetz O.K.
        • Mayo N.
        The evolution of amputation in the province of Quebec.
        Can. J. Diabetes. 2010; 34: 58-66
        • de Laat F.A.
        • Rommers G.M.
        • Dijkstra P.U.
        • Geertzen J.H.
        • Roorda L.D.
        Climbing stairs after outpatient rehabilitation for a lower-limb amputation.
        Arch. Phys. Med. Rehabil. 2013; 94: 1573-1579
        • Devan H.
        • Carman A.
        • Hendrick P.
        • Hale L.
        • Ribeiro D.C.
        Spinal, pelvic, and hip movement asymmetries in people with lower-limb amputation: systematic review.
        J. Rehabil. Res. Dev. 2015; 52: 1-19
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J. Epidemiol. Community Health. 1998; 52: 377-384
        • Ephraim P.L.
        • Dillingham T.R.
        • Sector M.
        • Pezzin L.E.
        • Mackenzie E.J.
        Epidemiology of limb loss and congenital limb deficiency: a review of the literature.
        Arch. Phys. Med. Rehabil. 2003; 84: 747-761
        • Esquenazi A.
        Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration.
        Disabil. Rehabil. 2004; 26: 831-836
        • Ferrari A.
        • Benedetti M.G.
        • Pavan E.
        • Frigo C.
        • Bettinelli D.
        • Rabuffetti M.
        • Crenna P.
        • Leardini A.
        Quantitative comparison of five current protocols in gait analysis.
        Gait Posture. 2008; 28: 207-216
        • Gaffney B.M.
        • Murray A.M.
        • Christiansen C.L.
        • Davidson B.S.
        Identification of trunk and pelvis movement compensations in patients with Transtibial amputation using angular momentum separation.
        Gait Posture. 2016; 45: 151-156
        • Gaffney B.M.
        • Christiansen C.L.
        • Murray A.M.
        • Davidson B.S.
        Trunk kinetic effort during step ascent and descent in patients with transtibial amputation using angular momentum separation.
        Clin. Biomech. Bristol Avon. 2017; 48: 88-96
        • Gailey R.S.
        • Roach K.E.
        • Applegate E.B.
        • Cho B.
        • Cunniffe B.
        • Licht S.
        • Maguire M.
        • Nash M.S.
        The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee’s ability to ambulate.
        Arch. Phys. Med. Rehabil. 2002; 83: 613-627
        • Gailey R.
        • Allen K.
        • Castles J.
        • Kucharik J.
        • Roeder M.
        Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use.
        J. Rehabil. Res. Dev. 2008; 45: 15-29
        • Gauthier-Gagnon C.
        • Grisé M.C.
        • Potvin D.
        Enabling factors related to prosthetic use by people with transtibial and transfemoral amputation.
        Arch. Phys. Med. Rehabil. 1999; 80: 706-713
        • Hendershot B.D.
        • Bazrgari B.
        • Nussbaum M.A.
        Persons with unilateral lower-limb amputation have altered and asymmetric trunk mechanical and neuromuscular behaviors estimated using multidirectional trunk perturbations.
        J. Biomech. 2013; 46: 1907-1912
        • Hicks G.E.
        • Sions J.M.
        • Coyle P.C.
        • Pohlig R.T.
        Altered spatiotemporal characteristics of gait in older adults with chronic low back pain.
        Gait Posture. 2017; 55: 172-176
        • Hicks-Little C.A.
        • Peindl R.D.
        • Hubbard T.J.
        • Scannell B.P.
        • Springer B.D.
        • Odum S.M.
        • Fehring T.K.
        • Cordova M.L.
        Lower extremity joint kinematics during stair climbing in knee osteoarthritis.
        Med. Sci. Sports Exerc. 2011; 43: 516-524
        • Highsmith M.J.
        • Kahle J.T.
        • Carey S.L.
        • Lura D.J.
        • Dubey R.V.
        • Csavina K.R.
        • Quillen W.S.
        Kinetic asymmetry in transfemoral amputees while performing sit to stand and stand to sit movements.
        Gait Posture. 2011; 34: 86-91
        • Honegger J.D.
        • Actis J.A.
        • Gates D.H.
        • Silverman A.K.
        • Munson A.H.
        • Petrella A.J.
        Development of a multiscale model of the human lumbar spine for investigation of tissue loads in people with and without a transtibial amputation during sit-to-stand.
        Biomech. Model. Mechanobiol. 2021; 20: 339-358
        • Horak F.B.
        Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?.
        Age Ageing. 2006; 35 (ii7–ii11)
        • Imam B.
        • Miller W.C.
        • Finlayson H.C.
        • Eng J.J.
        • Jarus T.
        Incidence of lower limb amputation in Canada.
        Can. J. Public Health Rev. Can. Santé Publique. 2017; 108: 374-380
        • Jacobs J.V.
        A review of stairway falls and stair negotiation: lessons learned and future needs to reduce injury.
        Gait Posture. 2016; 49: 159-167
        • Kent J.
        • Franklyn-Miller A.
        Biomechanical models in the study of lower limb amputee kinematics: a review.
        Prosthetics Orthot. Int. 2011; 35: 124-139
        • Kulkarni J.
        • Adams J.
        • Thomas E.
        • Silman A.
        Association between amputation, arthritis and osteopenia in British male war veterans with major lower limb amputations.
        Clin. Rehabil. 1998; 12: 348-353
        • Kulkarni J.
        • Gaine W.J.
        • Buckley J.G.
        • Rankine J.J.
        • Adams J.
        Chronic low back pain in traumatic lower limb amputees.
        Clin. Rehabil. 2005; 19: 81-86
        • Litwic A.
        • Edwards M.
        • Dennison E.
        • Cooper C.
        Epidemiology and burden of osteoarthritis.
        Br. Med. Bull. 2013; 105: 185-199
        • Lura D.J.
        • Wernke M.W.
        • Carey S.L.
        • Kahle J.T.
        • Miro R.M.
        • Highsmith M.J.
        Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control.
        Gait Posture. 2017; 58: 103-107
        • Major M.J.
        • Kenney L.P.J.
        • Twiste M.
        • Howard D.
        Stance phase mechanical characterization of transtibial prostheses distal to the socket: a review.
        J. Rehabil. Res. Dev. 2012; 49: 815-829
        • McFadyen B.J.
        • Winter D.A.
        An integrated biomechanical analysis of normal stair ascent and descent.
        J. Biomech. 1988; 21: 733-744
        • Miller L.A.
        • Childress D.S.
        Problems associated with the use of inverse dynamics in prosthetic applications: an example using a polycentric prosthetic knee.
        Robotica. 2005; 23: 329-335
        • Murray A.M.
        • Gaffney B.M.
        • Davidson B.S.
        • Christiansen C.L.
        Biomechanical compensations of the trunk and lower extremities during stepping tasks after unilateral transtibial amputation.
        Clin. Biomech. Bristol Avon. 2017; 49: 64-71
        • Nadeau S.
        • McFadyen B.J.
        • Malouin F.
        Frontal and sagittal plane analyses of the stair climbing task in healthy adults aged over 40 years: what are the challenges compared to level walking?.
        Clin. Biomech. Bristol Avon. 2003; 18: 950-959
        • Nolasco L.A.
        • Morgenroth D.C.
        • Silverman A.K.
        • Gates D.H.
        Effects of anterior-posterior shifts in prosthetic alignment on the sit-to-stand movement in people with a unilateral transtibial amputation.
        J. Biomech. 2020; 109
        • Norvell D.C.
        • Czerniecki J.M.
        • Reiber G.E.
        • Maynard C.
        • Pecoraro J.A.
        • Weiss N.S.
        The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees.
        Arch. Phys. Med. Rehabil. 2005; 86: 487-493
        • Nuzik S.
        • Lamb R.
        • VanSant A.
        • Hirt S.
        Sit-to-stand movement pattern. A kinematic study.
        Phys. Ther. 1986; 66: 1708-1713
        • Özyürek S.
        • Demirbüken İ.
        • Angın S.
        Altered movement strategies in sit-to-stand task in persons with transtibial amputation.
        Prosthetics Orthot. Int. 2014; 38: 303-309
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • Boutron I.
        • Hoffmann T.C.
        • Mulrow C.D.
        • Shamseer L.
        • Tetzlaff J.M.
        • Akl E.A.
        • Brennan S.E.
        • Chou R.
        • Glanville J.
        • Grimshaw J.M.
        • Hróbjartsson A.
        • Lalu M.M.
        • Li T.
        • Loder E.W.
        • Mayo-Wilson E.
        • McDonald S.
        • McGuinness L.A.
        • Stewart L.A.
        • Thomas J.
        • Tricco A.C.
        • Welch V.A.
        • Whiting P.
        • Moher D.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372n71
        • Powers C.M.
        • Boyd L.A.
        • Torburn L.
        • Perry J.
        Stair ambulation in persons with transtibial amputation: an analysis of the Seattle LightFoot.
        J. Rehabil. Res. Dev. 1997; 34: 9-18
        • Ramstrand N.
        • Nilsson K.-A.
        A comparison of foot placement strategies of transtibial amputees and able-bodied subjects during stair ambulation.
        Prosthetics Orthot. Int. 2009; 33: 348-355
        • Rusaw D.
        • Ramstrand N.
        Sagittal plane position of the functional joint Centre of prosthetic foot/ankle mechanisms.
        Clin. Biomech. Bristol Avon. 2010; 25: 713-720
        • Rusaw D.
        • Ramstrand N.
        Motion-analysis studies of transtibial prosthesis users: a systematic review.
        Prosthetics Orthot. Int. 2011; 35: 8-19
        • Sagawa Y.
        • Turcot K.
        • Armand S.
        • Thevenon A.
        • Vuillerme N.
        • Watelain E.
        Biomechanics and physiological parameters during gait in lower-limb amputees: a systematic review.
        Gait Posture. 2011; 33: 511-526
        • Sansam K.
        • Neumann V.
        • O’Connor R.
        • Bhakta B.
        Predicting walking ability following lower limb amputation: a systematic review of the literature.
        J. Rehabil. Med. 2009; 41: 593-603
        • Schenkman M.
        • Berger R.A.
        • Riley P.O.
        • Mann R.W.
        • Hodge W.A.
        Whole-body movements during rising to standing from sitting.
        Phys. Ther. 1990; 70 (discussion 648-651): 638-648
        • Schmalz T.
        • Blumentritt S.
        • Marx B.
        Biomechanical analysis of stair ambulation in lower limb amputees.
        Gait Posture. 2007; 25: 267-278
        • Serrien B.
        • Goossens M.
        • Baeyens J.-P.
        Statistical parametric mapping of biomechanical one-dimensional data with Bayesian inference.
        Int. Biomech. 2019; 6: 9-18
        • Shepherd R.B.
        • Gentile A.M.
        Sit-to-stand: functional relationship between upper body and lower limb segments.
        Hum. Mov. Sci. 1994; 13: 817-840
        • Sinitski E.H.
        • Hansen A.H.
        • Wilken J.M.
        Biomechanics of the ankle-foot system during stair ambulation: implications for design of advanced ankle-foot prostheses.
        J. Biomech. 2012; 45: 588-594
        • Slajpah S.
        • Kamnik R.
        • Burger H.
        • Bajd T.
        • Munih M.
        Asymmetry in sit-to-stand movement in patients following transtibial amputation and healthy individuals.
        Int. J. Rehabil. Res. Int. Z. Rehabil. Rev. Int. Rech. Readapt. 2013; 36: 275-283
        • Stevermer C.A.
        • Gillette J.C.
        Kinematic and kinetic indicators of sit-to-stand.
        J. Appl. Biomech. 2016; 32: 7-15
        • Struyf P.A.
        • van Heugten C.M.
        • Hitters M.W.
        • Smeets R.J.
        The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees.
        Arch. Phys. Med. Rehabil. 2009; 90: 440-446
        • Wagner K.E.
        • Nolasco L.A.
        • Morgenroth D.C.
        • Gates D.H.
        • Silverman A.K.
        The effect of lower-limb prosthetic alignment on muscle activity during sit-to-stand.
        J. Electromyogr. Kinesiol. Off. J. Int. Soc. Electrophysiol. Kinesiol. 2020; 51102398
        • Wolf E.J.
        • Everding V.Q.
        • Linberg A.A.
        • Czerniecki J.M.
        • Gambel J.M.
        Comparison of the power knee and C-leg during step-up and sit-to-stand tasks.
        Gait Posture. 2013; 38: 397-402
        • Yack J.
        • Nielsen D.H.
        • Schurr D.G.
        Kinetic patterns during stair ascent in patients with transtibial amputations using three different prostheses.
        J. Prosthet. Orthot. 1999; 11: 57-62
        • Zachazewski J.E.
        • Riley P.O.
        • Krebs D.E.
        Biomechanical analysis of body mass transfer during stair ascent and descent of healthy subjects.
        J. Rehabil. Res. Dev. 1993; 30: 412-422