Balance and Strength Improvement on Elderlies with Limited Mobility Following Elderly Lifter Training Program: A Cohort Study

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So This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7787674/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Late elderlies with mobility restrictions commonly received chair-bound training interventions that are less effective than weight bearing exercises. We developed the elderly lifter prototype with three-axis movement that allows personalized sit-to-stand movement program for participants requiring variety of upper body support to engage in squat exercise. 26 late elderlies with mean age > 84 years with multiple comorbidities were recruited in elderly care home. The participants received six weeks of training using the prototype in a cohort study. Outcome measures were functional performance as measured by number of modified sit-to-stand they can do within thirty seconds, movement quality based on average peak trunk lean before standing up, and postural stability during bilateral standing based on using center-of-mass (COM) total excursion and mean velocity measured pre- and post-intervention. Most participants improved their functional mobility, movement quality and balance based on COM mean velocity. 6 participants dropped out due to unrelated health reasons. Most participants were able to improve on most of the measured outcomes. Further study is needed on the characteristics of the non-responders and how to improve their outcomes. A separate training intervention may be needed to improve COM total excursion during bilateral standing for late elderlies. Trial Registration Ethics Subcommittee of the Hong Kong Polytechnic University No HSEARS2025020301 Health sciences/Health care Health sciences/Medical research aging elderly balance performance postural control strength training Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Approximately one fifth of Chinese population are elderly over retirement age [ 1 ], with greater percentage in Hong Kong [ 2 ]. Elderly on prolonged bed rest would experience significant decrease in leg strength and muscle mass [ 3 ]. Sarcopenia is a progressive loss in skeletal muscle that affects a person’s strength and functional performance [ 4 ]. Elderlies diagnosed with sarcopenia have higher risk of incident falls [ 5 , 6 ], bone fracture [ 7 ], and all-cause mortality [ 8 ]. Approximately 17% of Chinese elderly are diagnosed with sarcopenia [ 9 ]. As sarcopenia affects leg strength, it would also affect elderly’s ability to do stand up from seated position [ 10 ], and decrease in mobility is associated with decrease in mortality and dependence [ 11 ]. More than half of nursing home elderlies have significant decrease in physiological reserve [ 12 ] and unable to complete five repetitions of sit-to stand movement [ 13 ]. Strength training has been shown to be effective in improving functional ability of e [ 14 ], with functional training such as repetitive sit-to-stand shown to improve lower limb strength [ 15 ]. Sit-to-stand is an essential functional movement, with the average sedentary adult performing approximately 60 repetitions per day [ 16 ]. Sit-to-stand test is highly related to functional independence [ 17 ]. The movement itself is requires sufficient lower limb muscle strength [ 18 , 19 ], and balance control [ 18 , 20 , 21 ]. To compensate for the decreased ability of some elderlies to maintain weight bearing positions, seated exercise has been developed to assist mobility constrained elderlies in participating in exercise intervention [ 22 ]. Despite the benefits of seated exercise on the participants’ physical and cognitive functions [ 23 ], seated exercise is not as effective as weight bearing exercise in improving lower limb functional capacity and balance [ 24 , 25 ]. With functional exercise resulting in greater muscular control and coordination relative to seated exercise [ 26 ]. Existing elderly lifting devices have been developed with the focus on decreasing the load of caretakers during weight transfer tasks of moving elderly home residents. The device would execute the main weight bearing task, with no movement contribution requirement from the elderlies [ 27 , 28 ]. The LSCM Elderly Lifter prototype (Fig. 1 ) is a programmable 3-axis movement allowing custom movement for different users, allowing the user to be trained in natural sit-to-stand movement with varying degree of movement speed and support level from the device. The Elderly Lifter prototype was used both by the caretaker to assist in weight transfer tasks, and as weight bearing exercise tool for the elderlies themselves. The aim of this study is to assess the effect of progressive sit-to-stand training with the elderly lifter prototype combined with standard physiotherapy intervention on functional capacity, movement quality and balance of elderlies with lower limb mobility limitations. The hypothesis is that the combined training intervention will allow the participants to improve their functional capacity, movement kinematics and balance relative to baseline measurement. 2. METHODS 2.1 Study Design This is a cohort study where all participants received progressive sit-to-stand training assisted with LCSM Elderly Lifter. The training intervention involves twice per week over six-week period. For the first four weeks of intervention, participants executed 15 to 20 repetitions of assisted sit-to-stand. On the fifth and sixth week, they executed 20 to 25 repetitions. Training duration is 20 to 30 minutes, the participants controlling the number of repetitions done per session, including pauses at standing and seated positions to ensure that they trained within their capacity. Registered physiotherapist customized the elderly lifter motion over the 3 axis of movements to ensure suitability with the participant’s trunk and lower limb proportions. Participants are also engaged in regular physiotherapy in the form of leg cycling with THERA-Trainer mobi (medica Medizintechnik GmbH, Hochdorf, Germany) and parallel bar assisted walking five times per week. Participants may experience muscular fatigue or soreness during the training, or within 1–2 days following the training. Residence caregivers at Sik Sik Yuen monitored all participants and regularly update the same registered physiotherapist that first assessed the participants to ensure the training would not cause undue discomfort on the participants. Adverse events were recorded according to Treatment Emergent Symptom Scale (TESS): Adverse Events were collected during every visit at each time point by TESS and using the grading according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. 2.2 Participant demographics Participants were recruited in collaboration with Sik Sik Yuen for the following recruitment criteria: 1) 60 years or older, 2) Proficiency in Chinese and/or English, 3) Requires walking aid and caregiver assistance to walk and stand up from seated position, 4) Currently living at Sik Sik Yuen elderly care center. Exclusion criteria include: 1) Inability to attend all intervention session due to schedule conflict, 2) Lack of capacity to provide informed consent due to cognitive impairment, 2) Absolute contraindication to physical activities, 3) Inability to follow training instructions (due to complete loss of hearing or vision), 4) Inability to complete a single repetition of sit-to-stand with walker support within 30 seconds. A registered physiotherapist with more than 10 years’ experience assessed potential participants to ensure they meet the inclusion and exclusion criteria. This study complied with the Declaration of Helsinki and all the procedures was approved by Subjects Ethics Subcommittee of the Hong Kong Polytechnic University no HSEARS2025020301. Information sheet were provided and all the participants provided written informed consent for this study participation. 2.3 Outcome Measures Noraxon Portable Lab (Noraxon U.S.A. Inc., Scottsdale, Az, United States) Inertial Measurement Units (IMU) were attached on the participant’s upper thoracic, lower thoracic, pelvic, left and right thigh, shank and foot based on the Noraxon myoMOTION Quick Start Guide (Version 30 July, 2024), with Noraxon MyoMOTION version 3.16 was used to process the IMU data and assess participant’s trunk and lower limb kinematic position data. Prior to each data collection, static calibration was done in seated position due to participant’s functional limitations. 2.3.1. Functional Performance and Movement Quality Participants were tasked to execute 30-seconds Sit-To-Stand (30s-STS) where participants were tasked to stand up from seated position as many times as possible within 30 seconds using hand walker as support [ 29 ]. Number of repetitions was considered as the primary functional outcome, with thoracic and lumbar lean needed standing up quantified as the secondary movement quality outcome. Thoracic and lumbar lean Active Range of Motion (AROM) were quantified by the average maximal thoracic and lumbar position prior to standing up subtracted by the thoracic and lumbar position when participants were standing up. 2.3.2. Postural Sway Participants were task to execute bipedal quiet standing with their eyes open for postural sway assessment [ 30 ]. 15 seconds duration was used to ensure that all participants can complete the task at pre-intervention. Center-of-mass (COM) as calculated from the IMU sensors was used to calculate the Total Excursion (TOTEX) and Mean Velocity (MVEL) variables that quantify the participant’s balance during unassisted standing [ 31 ]. 2.4 Statistical Analysis Descriptive statistic of the recruited participant age, sex, weight and height were calculated along with two-tailed paired samples t-test to assess the change in outcome measured pre and post intervention. The level of significance level was set at p < 0.05 for all analysis to balance the type I and II errors. 3. RESULTS 26 participants were recruited with 6 drop out due to prolonged hospitalization not related to musculoskeletal issues. Out of the 20 participants completed the study, most (18) have hypertension, 12 participants have diabetes mellitus, 9 have cerebrovascular incident (stroke), and 6 have liver disease either hyperlipidemia or fatty liver. Other conditions where less than 5 participants experience includes hypercholesterolemia, osteoporosis, ischemic heart disease, Parkinson’s, gout and other conditions. Demographics of participants that completed the study are shown in Table 1 . Table 1 Participant Demographics Variable Participants (n = 20) Age (Years) Mean (SD) 85.6 (5.6) Sex (male n (%): female n (%)) 12 (60%): 8 (40%) Height (cm) Mean (SD) 161.6 (6.9) Weight (kg) Mean (SD) 60.5 (10.4) Body Mass Index (kg/m 2 ) Mean (SD) 23.1 (3.1) SD : Standard Deviation Based on the 30sSTS outcomes, the participants increased the number of repetitions done within 30 seconds (t = 2.26, p = 0.013), decreases thoracic (t = 2.306, p = 0.020) and lumbar (t = 2.306, p = 0.001) lean before standing up, and decreased postural sway as quantified by TOTEX (t = 2.306, p = 0.007) and MVEL (t = 2.306, p = 0.004) during 15 seconds bipedal quiet standing. Detailed results are available on Table 2 . Table 2 Training Effect on Participants Variable Pre-intervention (Mean ± SD) Post-Intervention (Mean ± SD) Significance (t, p ) 30s-STS (repetitions) 4.1 ± 3.25 5 ± 4.32 2.09, 0.007 Lumbar Lean AROM (°) 22.0 ± 78.49 14.8 ± 34.66 2.09, 0.016 Thoracic Lean AROM (°) 28.6 ± 562.02 12.4 ± 30.52 2.09, 0.008 TOTEX (mm) 50.6 ± 1120.16 46.8 ± 7257.93 2.09, 0.868 MVEL (mm/s) 22.4 ± 135.41 8.9 ± 28.98 2.09, < 0.001 30s-STS : thirty seconds sit-to-stand; SD : Standard Deviation; AROM : Active Range of Motion; TOTEX : Total Excursion; MVEL : Mean Velocity Large variation in the TOTEX was observed as some participants. Participant 16 has hypertension, diabetes mellitus, suffered acute right ischemic stroke and swayed his COM up to the edge of his base of support as seen on Fig. 2 during 15 seconds bilateral standing at post intervention. At pre-intervention participant 16 has TOTEX of 19.9 mm and MVEL of 8.4 mm/s while at post-intervention has TOTEX of 398.7 mm and MVEL of 2.9 mm/s. Participant 20 has hypercholesterolemia, thyroid disease, hypertension, diabetes mellitus, suffered cerebrovascular incident and swayed his COM significantly closer to the starting point as seen in Fig. 3 . Participant 20 had TOTEX of 38.1 mm and MVEL of 14.5 mm/s at pre-intervention and TOTEX of 16.8 and MVEL of 12.0 mm/s. 4. DISCUSSION Seated based exercise are compromise for people unable to either maintain prolonged weight bearing position or stand up from seated position unassisted such as those classified as late elderly [ 32 ] recruited in this study, recovering from injury or having specific disability. Late elderly unable to stand up from seated position without arm supports may experience functional mobility and balance improvements following assisted sit-to-stand exercise using the elderly lifter on their functional capacity, movement quality and balance. Within the recruited demographics of this study, participants require significant thoracic and lumbar flexion prior to standing up possibly as they need to first shift their center of mass forward closer to the walker support prior to extension to stand up position at pre-intervention. The large value of standard deviation when compared to post intervention may indicate that at pre-intervention, there was a varying degree of reliance on arm support for standing up movement that became more uniform during the training period. Over the 6 weeks of training, there was a decrease in both the average lumbar and thoracic lean AROM and related standard deviation, indicating the participant’s decreased reliance on the arm support that could be due to improved leg strength. Increasing movement pattern uniformity based on trunk leaning angle at post-intervention may indicate a ceiling on the improvement over prolonged period using the current training module. Participants balance also significantly improved as indicated by decrease in postural sway during 15 seconds bipedal quiet standing as measured by MVEL which is supported by prior study showing leg strength training improved balance[ 33 ] among geriatric patients. Our study did not result in balance improvement based on TOTEX measurement possibly as the elderly lifter training and the existing physiotherapy program given to the participants did not include specific balance or trunk muscle training component. The elderly lifter training program also involve the participants using arm support the whole time, that could limit the benefit on lower limb proprioception. MVEL and TOTEX may be measuring different aspects of balance and advance elderly (mean age > 85 years) recruited in our study, all with various forms of chronic disease or past surgeries, may experience significant decrease in trunk and lower limb proprioception not affected by leg strengthening protocol. Future study should include a control group, with both training and control group receiving a standard physiotherapy intervention, or both training and control group not receiving any training other than the intervention receiving the elderly lifter training. Such research design can verify the independent effect of the training. Larger sample size would also allow more detailed analysis on potential confounding factors that can affect training effectiveness. More outcome measures such as knee and hip extensor and flexor strength measurement can provide more insight on the improvement mechanism from the training program. The modified sit-to-stand protocol used in this study, and the elderly lifter prototype itself assumed that arm support would always be needed for the participants to stand up from seated position, while an ideal training progression and related outcome measure should be one that aims to have participants stand up only using their legs. Improvements on the elderly lifter prototype can be in the form of some ergonomic adjustments to provide better movement pattern training. Upper body pressure sensor can provide feedback to the participant, encouraging them to use less upper body support during training. Future study can incorporate more elderly centers having control group to independently assess the effect of elderly lifter training. 4.1 Conclusion Despite the advance age of the participants and their health conditions, most participants were able to improve their lower limb functional capacity and some balance aspects, indicating training benefits on this often-overlooked demographics. Declarations Ethics approval and consent to participate This study complied with the Declaration of Helsinki and International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use Good Clinical Practice. Ethical approval given by the Human Subjects Ethics Subcommittee of the Hong Kong Polytechnic University no HSEARS20250203016. All participants provided written informed consent for the study and were aware that the anonymized study results will be used for academic publication prior to the start of data collection. Clinical trial number: not applicable Author contributions Everyone that significantly contributed to this work has been listed. Author contributions are: Dhananjaya Sutanto : methodology, project coordination, data collection, data analysis, data curation, formal analysis, investigation, software, supervision, validation, visualization, writing-original draft, writing-review and editing. Ka-Lun Fan: Resources, methodology, writing-review. Billy C.L. So: conceptualization, funding acquisition, resources, methodology, project administration, writing-review. Competing interest Ka-Lun Fan was formerly employed by Hong Kong Logistics and Supply Chain MultiTech (LSCM) R&D Centre and led the developed the elderly lifter prototype used in this study. LSCM management was not involved in the data collection and analysis of the results reported in this study. Funding sources Innovation and Technology Commission provided the Innovation and Technology Fund no ITT/007/24LP received by Ka-Lun Fan partially used to develop the lifter prototype and provide financial support for Dhananjaya Sutanto. The Fund and financial support were not contingent on the results reported in this study, Dhananjaya Sutanto no longer received financial support from ITF and Ka-Lun Fan no longer employed by LSCM at the time of this paper submission. Sponsor’s Role Innovation and Technology Commission aims to develop research and development in Hong Kong, and provided no editorial input for this paper. Conflict of Interest All others declare there is no other conflict of interest beyond what is disclosed in prior section. Acknowledgements Siu Lai Har and Chong Kai Chun, senior physiotherapist and resident physiotherapist at Sik Sik Yuen supervised the participant training and assisted in the outcome measures, with Alex Chong, senior R&D engineer from LSCM provided elderly lifter prototype product support. References Tu, W.-J., X. Zeng, and Q. Liu, Aging tsunami coming: the main finding from China’s seventh national population census. Aging clinical and experimental research, 2022. 34 (5): p. 1159-1163. Population by Sex and Age Group. 2024 15 August 2024 2 January 2025]; Available from: https://www.censtatd.gov.hk/en/web_table.html?id=110-01001. Di Girolamo, F.G., et al., The aging muscle in experimental bed rest: a systematic review and meta-analysis. Frontiers in nutrition, 2021. 8 : p. 633987. Cruz-Jentoft, A.J. and A.A. Sayer, Sarcopenia. 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Ng, S., Balance ability, not muscle strength and exercise endurance, determines the performance of hemiparetic subjects on the timed-sit-to-stand test. American Journal of Physical Medicine & Rehabilitation, 2010. 89 (6): p. 497-504. Whitney, S.L., et al., Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test. Physical therapy, 2005. 85 (10): p. 1034-1045. Stojanović, M.D.M., et al., Effects of Chair-Based, Low-Load Elastic Band Resistance Training on Functional Fitness and Metabolic Biomarkers in Older Women. J Sports Sci Med, 2021. 20 (1): p. 133-141. Cordes, T., et al., Chair-Based Exercise Interventions for Nursing Home Residents: A Systematic Review. Journal of the American Medical Directors Association, 2021. 22 (4): p. 733-740. Latham, N.K., et al., A Randomized, Controlled Trial of Quadriceps Resistance Exercise and Vitamin D in Frail Older People: The Frailty Interventions Trial in Elderly Subjects (FITNESS). Journal of the American Geriatrics Society, 2003. 51 (3): p. 291-299. Vogler, C.M., et al., Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits. Archives of Physical Medicine and Rehabilitation, 2009. 90 (8): p. 1317-1324. Krebs, D.E., D.M. Scarborough, and C.A. McGibbon, Functional vs. Strength Training in Disabled Elderly Outpatients. American Journal of Physical Medicine & Rehabilitation, 2007. 86 (2): p. 93-103. Li, C., et al. Review on development of stand assist lifts for the elderly. in 2016 International Conference on Advanced Robotics and Mechatronics (ICARM). 2016. IEEE. Wu, J. and M. Shino, Hip lift transfer assistive system for reducing burden on caregiver’s waist. Sensors, 2021. 21 (22): p. 7548. Applebaum, E.V., et al., Modified 30-second Sit to Stand test predicts falls in a cohort of institutionalized older veterans. PloS one, 2017. 12 (5): p. e0176946. Kouzaki, M. and K. Masani, Postural sway during quiet standing is related to physiological tremor and muscle volume in young and elderly adults. Gait & posture, 2012. 35 (1): p. 11-17. Foulger, L.H., et al., Estimating whole-body centre of mass sway during quiet standing with inertial measurement units. PloS one, 2025. 20 (1): p. e0315851. Orimo, H., et al., Reviewing the definition of “elderly”. Geriatrics & gerontology international, 2006. 6 (3): p. 149-158. Hasselgren, L., L.L. Olsson, and L. Nyberg, Is leg muscle strength correlated with functional balance and mobility among inpatients in geriatric rehabilitation? Archives of gerontology and geriatrics, 2011. 52 (3): p. e220-e225. Additional Declarations Competing interest reported. Ka-Lun Fan was employed by Hong Kong Logistics and Supply Chain MultiTech (LSCM) R&D Centre and led the developed the elderly lifter prototype used in this study. LSCM management was not involved in the data collection and analysis of the results reported in this study. Innovation and Technology Commission provided the Innovation and Technology Fund (ITF) no ITT/007/24LP received by Ka-Lun Fan partially used to develop the lifter prototype and provide financial support for Dhananjaya Sutanto. The Fund and financial support were not contingent on the results reported in this study, Dhananjaya Sutanto no longer received financial support from ITF and Ka-Lun Fan no longer employed by LSCM at the time of this paper submission. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:03:53","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81140,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7787674/v1/752abd7e3e7e09f17911b179.html"},{"id":94760479,"identity":"499e8fad-ed1f-4c0e-9cfb-a5c774cf2800","added_by":"auto","created_at":"2025-10-30 12:03:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":725935,"visible":true,"origin":"","legend":"\u003cp\u003eLSCM Elderly Lifter prototype\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7787674/v1/361e47a2ec0a1fb5a8121276.png"},{"id":94823997,"identity":"32ed595a-deee-4aaa-bdd6-2d5a7d8cb9f6","added_by":"auto","created_at":"2025-10-31 06:48:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":137533,"visible":true,"origin":"","legend":"\u003cp\u003eCenter-of-mass displacement of participant 16 post intervention\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7787674/v1/4b49b12d1c08c18e2bbfbedb.png"},{"id":94760469,"identity":"af4f52c0-2fac-4781-9f30-c83b4ef7dbe2","added_by":"auto","created_at":"2025-10-30 12:03:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33368,"visible":true,"origin":"","legend":"\u003cp\u003eCenter-of-mass displacement of participant 20 post intervention\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7787674/v1/524e85f78db4b8736d691f9c.png"},{"id":96279325,"identity":"b717a2e5-d512-4c0c-ac2a-a341e451aaa3","added_by":"auto","created_at":"2025-11-19 10:53:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1737599,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7787674/v1/dbd0547b-4044-4f05-8615-8b7026cfb4e9.pdf"}],"financialInterests":"Competing interest reported. Ka-Lun Fan was employed by Hong Kong Logistics and Supply Chain MultiTech (LSCM) R\u0026D Centre and led the developed the elderly lifter prototype used in this study. LSCM management was not involved in the data collection and analysis of the results reported in this study.\nInnovation and Technology Commission provided the Innovation and Technology Fund (ITF) no ITT/007/24LP received by Ka-Lun Fan partially used to develop the lifter prototype and provide financial support for Dhananjaya Sutanto. The Fund and financial support were not contingent on the results reported in this study, Dhananjaya Sutanto no longer received financial support from ITF and Ka-Lun Fan no longer employed by LSCM at the time of this paper submission.","formattedTitle":"Balance and Strength Improvement on Elderlies with Limited Mobility Following Elderly Lifter Training Program: A Cohort Study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eApproximately one fifth of Chinese population are elderly over retirement age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with greater percentage in Hong Kong [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Elderly on prolonged bed rest would experience significant decrease in leg strength and muscle mass [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Sarcopenia is a progressive loss in skeletal muscle that affects a person\u0026rsquo;s strength and functional performance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Elderlies diagnosed with sarcopenia have higher risk of incident falls [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], bone fracture [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and all-cause mortality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Approximately 17% of Chinese elderly are diagnosed with sarcopenia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs sarcopenia affects leg strength, it would also affect elderly\u0026rsquo;s ability to do stand up from seated position [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and decrease in mobility is associated with decrease in mortality and dependence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. More than half of nursing home elderlies have significant decrease in physiological reserve [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and unable to complete five repetitions of sit-to stand movement [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Strength training has been shown to be effective in improving functional ability of e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], with functional training such as repetitive sit-to-stand shown to improve lower limb strength [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSit-to-stand is an essential functional movement, with the average sedentary adult performing approximately 60 repetitions per day [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sit-to-stand test is highly related to functional independence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The movement itself is requires sufficient lower limb muscle strength [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and balance control [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo compensate for the decreased ability of some elderlies to maintain weight bearing positions, seated exercise has been developed to assist mobility constrained elderlies in participating in exercise intervention [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite the benefits of seated exercise on the participants\u0026rsquo; physical and cognitive functions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], seated exercise is not as effective as weight bearing exercise in improving lower limb functional capacity and balance [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. With functional exercise resulting in greater muscular control and coordination relative to seated exercise [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eExisting elderly lifting devices have been developed with the focus on decreasing the load of caretakers during weight transfer tasks of moving elderly home residents. The device would execute the main weight bearing task, with no movement contribution requirement from the elderlies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The LSCM Elderly Lifter prototype (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) is a programmable 3-axis movement allowing custom movement for different users, allowing the user to be trained in natural sit-to-stand movement with varying degree of movement speed and support level from the device. The Elderly Lifter prototype was used both by the caretaker to assist in weight transfer tasks, and as weight bearing exercise tool for the elderlies themselves.\u003c/p\u003e\u003cp\u003eThe aim of this study is to assess the effect of progressive sit-to-stand training with the elderly lifter prototype combined with standard physiotherapy intervention on functional capacity, movement quality and balance of elderlies with lower limb mobility limitations. The hypothesis is that the combined training intervention will allow the participants to improve their functional capacity, movement kinematics and balance relative to baseline measurement.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eThis is a cohort study where all participants received progressive sit-to-stand training assisted with LCSM Elderly Lifter. The training intervention involves twice per week over six-week period. For the first four weeks of intervention, participants executed 15 to 20 repetitions of assisted sit-to-stand. On the fifth and sixth week, they executed 20 to 25 repetitions. Training duration is 20 to 30 minutes, the participants controlling the number of repetitions done per session, including pauses at standing and seated positions to ensure that they trained within their capacity. Registered physiotherapist customized the elderly lifter motion over the 3 axis of movements to ensure suitability with the participant\u0026rsquo;s trunk and lower limb proportions. Participants are also engaged in regular physiotherapy in the form of leg cycling with THERA-Trainer mobi (medica Medizintechnik GmbH, Hochdorf, Germany) and parallel bar assisted walking five times per week.\u003c/p\u003e\u003cp\u003eParticipants may experience muscular fatigue or soreness during the training, or within 1\u0026ndash;2 days following the training. Residence caregivers at Sik Sik Yuen monitored all participants and regularly update the same registered physiotherapist that first assessed the participants to ensure the training would not cause undue discomfort on the participants.\u003c/p\u003e\u003cp\u003eAdverse events were recorded according to Treatment Emergent Symptom Scale (TESS): Adverse Events were collected during every visit at each time point by TESS and using the grading according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Participant demographics\u003c/h2\u003e\u003cp\u003eParticipants were recruited in collaboration with Sik Sik Yuen for the following recruitment criteria: 1) 60 years or older, 2) Proficiency in Chinese and/or English, 3) Requires walking aid and caregiver assistance to walk and stand up from seated position, 4) Currently living at Sik Sik Yuen elderly care center. Exclusion criteria include: 1) Inability to attend all intervention session due to schedule conflict, 2) Lack of capacity to provide informed consent due to cognitive impairment, 2) Absolute contraindication to physical activities, 3) Inability to follow training instructions (due to complete loss of hearing or vision), 4) Inability to complete a single repetition of sit-to-stand with walker support within 30 seconds.\u003c/p\u003e\u003cp\u003eA registered physiotherapist with more than 10 years\u0026rsquo; experience assessed potential participants to ensure they meet the inclusion and exclusion criteria. This study complied with the Declaration of Helsinki and all the procedures was approved by Subjects Ethics Subcommittee of the Hong Kong Polytechnic University no HSEARS2025020301. Information sheet were provided and all the participants provided written informed consent for this study participation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Outcome Measures\u003c/h2\u003e\u003cp\u003eNoraxon Portable Lab (Noraxon U.S.A. Inc., Scottsdale, Az, United States) Inertial Measurement Units (IMU) were attached on the participant\u0026rsquo;s upper thoracic, lower thoracic, pelvic, left and right thigh, shank and foot based on the Noraxon myoMOTION Quick Start Guide (Version 30 July, 2024), with Noraxon MyoMOTION version 3.16 was used to process the IMU data and assess participant\u0026rsquo;s trunk and lower limb kinematic position data. Prior to each data collection, static calibration was done in seated position due to participant\u0026rsquo;s functional limitations.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1. Functional Performance and Movement Quality\u003c/h2\u003e\u003cp\u003eParticipants were tasked to execute 30-seconds Sit-To-Stand (30s-STS) where participants were tasked to stand up from seated position as many times as possible within 30 seconds using hand walker as support [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Number of repetitions was considered as the primary functional outcome, with thoracic and lumbar lean needed standing up quantified as the secondary movement quality outcome. Thoracic and lumbar lean Active Range of Motion (AROM) were quantified by the average maximal thoracic and lumbar position prior to standing up subtracted by the thoracic and lumbar position when participants were standing up.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2. Postural Sway\u003c/h2\u003e\u003cp\u003eParticipants were task to execute bipedal quiet standing with their eyes open for postural sway assessment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. 15 seconds duration was used to ensure that all participants can complete the task at pre-intervention. Center-of-mass (COM) as calculated from the IMU sensors was used to calculate the Total Excursion (TOTEX) and Mean Velocity (MVEL) variables that quantify the participant\u0026rsquo;s balance during unassisted standing [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistic of the recruited participant age, sex, weight and height were calculated along with two-tailed paired samples t-test to assess the change in outcome measured pre and post intervention. The level of significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all analysis to balance the type I and II errors.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e26 participants were recruited with 6 drop out due to prolonged hospitalization not related to musculoskeletal issues. Out of the 20 participants completed the study, most (18) have hypertension, 12 participants have diabetes mellitus, 9 have cerebrovascular incident (stroke), and 6 have liver disease either hyperlipidemia or fatty liver. Other conditions where less than 5 participants experience includes hypercholesterolemia, osteoporosis, ischemic heart disease, Parkinson\u0026rsquo;s, gout and other conditions. Demographics of participants that completed the study are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Years) Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.6 (5.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (male n (%): female n (%))\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60%): 8 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm) Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161.6 (6.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg) Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.5 (10.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody Mass Index (kg/m\u003csup\u003e2\u003c/sup\u003e) Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.1 (3.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eSD\u003c/b\u003e: Standard Deviation\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on the 30sSTS outcomes, the participants increased the number of repetitions done within 30 seconds (t\u0026thinsp;=\u0026thinsp;2.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), decreases thoracic (t\u0026thinsp;=\u0026thinsp;2.306, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020) and lumbar (t\u0026thinsp;=\u0026thinsp;2.306, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) lean before standing up, and decreased postural sway as quantified by TOTEX (t\u0026thinsp;=\u0026thinsp;2.306, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007) and MVEL (t\u0026thinsp;=\u0026thinsp;2.306, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) during 15 seconds bipedal quiet standing. Detailed results are available on Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTraining Effect on Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-Intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSignificance (t, \u003cem\u003ep\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30s-STS (repetitions)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.09, 0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLumbar Lean AROM (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;78.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;34.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.09, 0.016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThoracic Lean AROM (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e28.6\u0026thinsp;\u0026plusmn;\u0026thinsp;562.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;30.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.09, 0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTOTEX (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1120.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e46.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7257.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.09, 0.868\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMVEL (mm/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;135.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;28.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.09, \u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003e30s-STS\u003c/b\u003e: thirty seconds sit-to-stand; \u003cb\u003eSD\u003c/b\u003e: Standard Deviation; \u003cb\u003eAROM\u003c/b\u003e: Active Range of Motion; \u003cb\u003eTOTEX\u003c/b\u003e: Total Excursion; \u003cb\u003eMVEL\u003c/b\u003e: Mean Velocity\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLarge variation in the TOTEX was observed as some participants. Participant 16 has hypertension, diabetes mellitus, suffered acute right ischemic stroke and swayed his COM up to the edge of his base of support as seen on Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e during 15 seconds bilateral standing at post intervention. At pre-intervention participant 16 has TOTEX of 19.9 mm and MVEL of 8.4 mm/s while at post-intervention has TOTEX of 398.7 mm and MVEL of 2.9 mm/s. Participant 20 has hypercholesterolemia, thyroid disease, hypertension, diabetes mellitus, suffered cerebrovascular incident and swayed his COM significantly closer to the starting point as seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Participant 20 had TOTEX of 38.1 mm and MVEL of 14.5 mm/s at pre-intervention and TOTEX of 16.8 and MVEL of 12.0 mm/s.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eSeated based exercise are compromise for people unable to either maintain prolonged weight bearing position or stand up from seated position unassisted such as those classified as late elderly [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] recruited in this study, recovering from injury or having specific disability. Late elderly unable to stand up from seated position without arm supports may experience functional mobility and balance improvements following assisted sit-to-stand exercise using the elderly lifter on their functional capacity, movement quality and balance.\u003c/p\u003e\u003cp\u003eWithin the recruited demographics of this study, participants require significant thoracic and lumbar flexion prior to standing up possibly as they need to first shift their center of mass forward closer to the walker support prior to extension to stand up position at pre-intervention. The large value of standard deviation when compared to post intervention may indicate that at pre-intervention, there was a varying degree of reliance on arm support for standing up movement that became more uniform during the training period. Over the 6 weeks of training, there was a decrease in both the average lumbar and thoracic lean AROM and related standard deviation, indicating the participant\u0026rsquo;s decreased reliance on the arm support that could be due to improved leg strength. Increasing movement pattern uniformity based on trunk leaning angle at post-intervention may indicate a ceiling on the improvement over prolonged period using the current training module.\u003c/p\u003e\u003cp\u003eParticipants balance also significantly improved as indicated by decrease in postural sway during 15 seconds bipedal quiet standing as measured by MVEL which is supported by prior study showing leg strength training improved balance[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] among geriatric patients. Our study did not result in balance improvement based on TOTEX measurement possibly as the elderly lifter training and the existing physiotherapy program given to the participants did not include specific balance or trunk muscle training component. The elderly lifter training program also involve the participants using arm support the whole time, that could limit the benefit on lower limb proprioception. MVEL and TOTEX may be measuring different aspects of balance and advance elderly (mean age\u0026thinsp;\u0026gt;\u0026thinsp;85 years) recruited in our study, all with various forms of chronic disease or past surgeries, may experience significant decrease in trunk and lower limb proprioception not affected by leg strengthening protocol.\u003c/p\u003e\u003cp\u003eFuture study should include a control group, with both training and control group receiving a standard physiotherapy intervention, or both training and control group not receiving any training other than the intervention receiving the elderly lifter training. Such research design can verify the independent effect of the training. Larger sample size would also allow more detailed analysis on potential confounding factors that can affect training effectiveness. More outcome measures such as knee and hip extensor and flexor strength measurement can provide more insight on the improvement mechanism from the training program. The modified sit-to-stand protocol used in this study, and the elderly lifter prototype itself assumed that arm support would always be needed for the participants to stand up from seated position, while an ideal training progression and related outcome measure should be one that aims to have participants stand up only using their legs.\u003c/p\u003e\u003cp\u003eImprovements on the elderly lifter prototype can be in the form of some ergonomic adjustments to provide better movement pattern training. Upper body pressure sensor can provide feedback to the participant, encouraging them to use less upper body support during training. Future study can incorporate more elderly centers having control group to independently assess the effect of elderly lifter training.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Conclusion\u003c/h2\u003e\u003cp\u003eDespite the advance age of the participants and their health conditions, most participants were able to improve their lower limb functional capacity and some balance aspects, indicating training benefits on this often-overlooked demographics.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complied with the Declaration of Helsinki and International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use Good Clinical Practice. Ethical approval given by the Human Subjects Ethics Subcommittee of the Hong Kong Polytechnic University no HSEARS20250203016.\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent for the study and were aware that the anonymized study results will be used for academic publication prior to the start of data collection.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEveryone that significantly contributed to this work has been listed. Author contributions are: \u003cstrong\u003e\u0026nbsp;Dhananjaya Sutanto\u003c/strong\u003e: methodology, project coordination, data collection, data analysis, data curation, formal analysis, investigation, software, supervision, validation, visualization, writing-original draft, writing-review and editing. \u003cstrong\u003eKa-Lun Fan:\u003c/strong\u003e Resources, methodology, writing-review. \u003cstrong\u003eBilly C.L. So:\u003c/strong\u003e conceptualization, funding acquisition, resources, methodology, project administration, writing-review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKa-Lun Fan was formerly employed by\u0026nbsp;Hong Kong Logistics and Supply Chain MultiTech (LSCM) R\u0026amp;D Centre and led the developed the elderly lifter prototype used in this study. LSCM management was not involved in the data collection and analysis of the results reported in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInnovation and Technology Commission provided the Innovation and Technology Fund no ITT/007/24LP received by Ka-Lun Fan partially used to develop the lifter prototype and provide financial support for Dhananjaya Sutanto. The Fund and financial support were not contingent on the results reported in this study, Dhananjaya Sutanto no longer received financial support from ITF and Ka-Lun Fan no longer employed by LSCM at the time of this paper submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSponsor\u0026rsquo;s Role\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInnovation and Technology Commission aims to develop research and development in Hong Kong, and provided no editorial input for this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll others declare there is no other conflict of interest beyond what is disclosed in prior section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSiu Lai Har and Chong Kai Chun, senior physiotherapist and resident physiotherapist at Sik Sik Yuen supervised the participant training and assisted in the outcome measures, with Alex Chong, senior R\u0026amp;D engineer from LSCM provided elderly lifter prototype product support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTu, W.-J., X. Zeng, and Q. Liu, Aging tsunami coming: the main finding from China\u0026rsquo;s seventh national population census. Aging clinical and experimental research, 2022. \u003cstrong\u003e34\u003c/strong\u003e(5): p. 1159-1163.\u003c/li\u003e\n\u003cli\u003ePopulation by Sex and Age Group. 2024 15 August 2024 2 January 2025]; Available from: https://www.censtatd.gov.hk/en/web_table.html?id=110-01001.\u003c/li\u003e\n\u003cli\u003eDi Girolamo, F.G., et al., The aging muscle in experimental bed rest: a systematic review and meta-analysis. Frontiers in nutrition, 2021. \u003cstrong\u003e8\u003c/strong\u003e: p. 633987.\u003c/li\u003e\n\u003cli\u003eCruz-Jentoft, A.J. and A.A. Sayer, Sarcopenia. The Lancet, 2019. \u003cstrong\u003e393\u003c/strong\u003e(10191): p. 2636-2646.\u003c/li\u003e\n\u003cli\u003eLandi, F., et al., Sarcopenia as a risk factor for falls in elderly individuals: Results from the ilSIRENTE study. 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Maturitas, 2017. \u003cstrong\u003e103\u003c/strong\u003e: p. 16-22.\u003c/li\u003e\n\u003cli\u003eRen, X., et al., Prevalence of sarcopenia in Chinese community-dwelling elderly: a systematic review. BMC Public Health, 2022. \u003cstrong\u003e22\u003c/strong\u003e(1): p. 1702.\u003c/li\u003e\n\u003cli\u003eMilanović, Z., et al., Age-related decrease in physical activity and functional fitness among elderly men and women. Clin Interv Aging, 2013. \u003cstrong\u003e8\u003c/strong\u003e: p. 549-56.\u003c/li\u003e\n\u003cli\u003eHirvensalo, M., T. Rantanen, and E. Heikkinen, Mobility difficulties and physical activity as predictors of mortality and loss of independence in the community‐living older population. Journal of the American Geriatrics Society, 2000. \u003cstrong\u003e48\u003c/strong\u003e(5): p. 493-498.\u003c/li\u003e\n\u003cli\u003eKojima, G., Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. Journal of the American Medical Directors Association, 2015. \u003cstrong\u003e16\u003c/strong\u003e(11): p. 940-945.\u003c/li\u003e\n\u003cli\u003eTiihonen, M., S. Hartikainen, and I. Nyk\u0026auml;nen, Chair rise capacity and associated factors in older home-care clients. Scandinavian Journal of Public Health, 2018. \u003cstrong\u003e46\u003c/strong\u003e(7): p. 699-703.\u003c/li\u003e\n\u003cli\u003eFahlman, M.M., et al., Effects of Resistance Training on Functional Ability in Elderly Individuals. American Journal of Health Promotion, 2011. \u003cstrong\u003e25\u003c/strong\u003e(4): p. 237-243.\u003c/li\u003e\n\u003cli\u003eFujita, E., et al., Repeated sit-to-stand exercise enhances muscle strength and reduces lower body muscular demands in physically frail elders. Experimental Gerontology, 2019. \u003cstrong\u003e116\u003c/strong\u003e: p. 86-92.\u003c/li\u003e\n\u003cli\u003eDall, P.M. and A. Kerr, Frequency of the sit to stand task: An observational study of free-living adults. Applied Ergonomics, 2010. \u003cstrong\u003e41\u003c/strong\u003e(1): p. 58-61.\u003c/li\u003e\n\u003cli\u003eGill, T.M., C.S. Williams, and M.E. Tinetti, Assessing Risk for the Onset of Functional Dependence Among Older Adults: The Role of Physical Performance. Journal of the American Geriatrics Society, 1995. \u003cstrong\u003e43\u003c/strong\u003e(6): p. 603-609.\u003c/li\u003e\n\u003cli\u003eLord, S.R., et al., Sit-to-Stand Performance Depends on Sensation, Speed, Balance, and Psychological Status in Addition to Strength in Older People. The Journals of Gerontology: Series A, 2002. \u003cstrong\u003e57\u003c/strong\u003e(8): p. M539-M543.\u003c/li\u003e\n\u003cli\u003eMcCarthy, E.K., et al., Repeated chair stands as a measure of lower limb strength in sexagenarian women. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2004. \u003cstrong\u003e59\u003c/strong\u003e(11): p. 1207-1212.\u003c/li\u003e\n\u003cli\u003eNg, S., Balance ability, not muscle strength and exercise endurance, determines the performance of hemiparetic subjects on the timed-sit-to-stand test. American Journal of Physical Medicine \u0026amp; Rehabilitation, 2010. \u003cstrong\u003e89\u003c/strong\u003e(6): p. 497-504.\u003c/li\u003e\n\u003cli\u003eWhitney, S.L., et al., Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test. Physical therapy, 2005. \u003cstrong\u003e85\u003c/strong\u003e(10): p. 1034-1045.\u003c/li\u003e\n\u003cli\u003eStojanović, M.D.M., et al., Effects of Chair-Based, Low-Load Elastic Band Resistance Training on Functional Fitness and Metabolic Biomarkers in Older Women. 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Archives of Physical Medicine and Rehabilitation, 2009. \u003cstrong\u003e90\u003c/strong\u003e(8): p. 1317-1324.\u003c/li\u003e\n\u003cli\u003eKrebs, D.E., D.M. Scarborough, and C.A. McGibbon, Functional vs. Strength Training in Disabled Elderly Outpatients. American Journal of Physical Medicine \u0026amp; Rehabilitation, 2007. \u003cstrong\u003e86\u003c/strong\u003e(2): p. 93-103.\u003c/li\u003e\n\u003cli\u003eLi, C., et al. Review on development of stand assist lifts for the elderly. in 2016 International Conference on Advanced Robotics and Mechatronics (ICARM). 2016. IEEE.\u003c/li\u003e\n\u003cli\u003eWu, J. and M. Shino, Hip lift transfer assistive system for reducing burden on caregiver\u0026rsquo;s waist. Sensors, 2021. \u003cstrong\u003e21\u003c/strong\u003e(22): p. 7548.\u003c/li\u003e\n\u003cli\u003eApplebaum, E.V., et al., Modified 30-second Sit to Stand test predicts falls in a cohort of institutionalized older veterans. PloS one, 2017. \u003cstrong\u003e12\u003c/strong\u003e(5): p. e0176946.\u003c/li\u003e\n\u003cli\u003eKouzaki, M. and K. Masani, Postural sway during quiet standing is related to physiological tremor and muscle volume in young and elderly adults. Gait \u0026amp; posture, 2012. \u003cstrong\u003e35\u003c/strong\u003e(1): p. 11-17.\u003c/li\u003e\n\u003cli\u003eFoulger, L.H., et al., Estimating whole-body centre of mass sway during quiet standing with inertial measurement units. PloS one, 2025. \u003cstrong\u003e20\u003c/strong\u003e(1): p. e0315851.\u003c/li\u003e\n\u003cli\u003eOrimo, H., et al., Reviewing the definition of \u0026ldquo;elderly\u0026rdquo;. Geriatrics \u0026amp; gerontology international, 2006. \u003cstrong\u003e6\u003c/strong\u003e(3): p. 149-158.\u003c/li\u003e\n\u003cli\u003eHasselgren, L., L.L. Olsson, and L. Nyberg, Is leg muscle strength correlated with functional balance and mobility among inpatients in geriatric rehabilitation? Archives of gerontology and geriatrics, 2011. \u003cstrong\u003e52\u003c/strong\u003e(3): p. e220-e225.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aging, elderly, balance performance, postural control, strength training","lastPublishedDoi":"10.21203/rs.3.rs-7787674/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7787674/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLate elderlies with mobility restrictions commonly received chair-bound training interventions that are less effective than weight bearing exercises. We developed the elderly lifter prototype with three-axis movement that allows personalized sit-to-stand movement program for participants requiring variety of upper body support to engage in squat exercise. 26 late elderlies with mean age \u0026gt; 84 years with multiple comorbidities were recruited in elderly care home.\u003cstrong\u003e \u003c/strong\u003eThe participants received six weeks of training using the prototype in a cohort study. Outcome measures were functional performance as measured by number of modified sit-to-stand they can do within thirty seconds, movement quality based on average peak trunk lean before standing up, and postural stability during bilateral standing based on using center-of-mass (COM) total excursion and mean velocity measured pre- and post-intervention. Most participants improved their functional mobility, movement quality and balance based on COM mean velocity. 6 participants dropped out due to unrelated health reasons.\u003cstrong\u003e \u003c/strong\u003eMost participants were able to improve on most of the measured outcomes. Further study is needed on the characteristics of the non-responders and how to improve their outcomes. A separate training intervention may be needed to improve COM total excursion during bilateral standing for late elderlies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics Subcommittee of the Hong Kong Polytechnic University No HSEARS2025020301\u003c/p\u003e","manuscriptTitle":"Balance and Strength Improvement on Elderlies with Limited Mobility Following Elderly Lifter Training Program: A Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 12:03:48","doi":"10.21203/rs.3.rs-7787674/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7cf78f25-12be-45f1-96ac-997c4e948d7d","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57087593,"name":"Health sciences/Health care"},{"id":57087594,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-11-19T10:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 12:03:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7787674","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7787674","identity":"rs-7787674","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}