Wearable Sensor Use for Assessing Standing Balance and Walking Stability in People with Parkinson’s Disease: A Systematic Review

Background

Postural instability and gait disability threaten the independence and well-being of people with Parkinson’s disease and increase the risk of falls and fall-related injuries. Prospective research has shown that commonly-used clinical assessments of balance and walking lack the sensitivity to accurately and consistently identify those people with Parkinson’s disease who are at a higher risk of falling. Wearable sensors provide a portable and affordable alternative for researchers and clinicians who are seeking to objectively assess movements and falls risk in the clinical setting. However, no consensus currently exists on the optimal placements for sensors and the best outcome measures to use for assessing standing balance and walking stability in Parkinson’s disease patients. Hence, this systematic review aimed to examine the available literature to establish the best sensor types, locations and outcomes to assess standing balance and walking stability in this population.

Methods

Papers listed in three electronic databases were searched by title and abstract to identify articles measuring standing balance or walking stability with any kind of wearable sensor among adults diagnosed with PD. To be eligible for inclusion, papers were required to be full-text articles published in English between January 1994 and December 2014 that assessed measures of standing balance or walking stability with wearable sensors in people with PD. Articles were excluded if they; i) did not use any form of wearable sensor to measure variables associated with standing balance or walking stability; ii) did not include a control group or control condition; iii) were an abstract and/or included in the proceedings of a conference; or iv) were a review article or case study. The targeted search of the three electronic databases identified 340 articles that were potentially eligible for inclusion, but following title, abstract and full-text review only 26 articles were deemed to meet the inclusion criteria. Included articles were assessed for methodological quality and relevant data from the papers were extracted and synthesized.

Results

Quality assessment of these included articles indicated that 31% were of low methodological quality, while 58% were of moderate methodological quality and 11% were of high methodological quality. All studies adopted a cross-sectional design and used a variety of sensor types and outcome measures to assess standing balance or walking stability in people with Parkinson’s disease. Despite the typically low to moderate methodological quality, 81% of the studies reported differences in sensor-based measures of standing balance or walking stability between different groups of Parkinson’s disease patients and/or healthy controls.

Conclusion

These data support the use of wearable sensors for detecting differences in standing balance and walking stability between people with PD and controls. Further high-quality research is needed to better understand the utility of wearable sensors for the early identification of Parkinson’s disease symptoms and for assessing falls risk in this population.

PROSPERO Registration

CRD42014010838     

The effect of attentional focus on local dynamic stability during a repetitive spine flexion task

The association between low back pain and spine movement control suggests that it is important to reliably quantify movement behavior. One method to characterize spine movement behavior is to measure the local dynamic stability (LDS) of spine movement during a repetitive flexion task in which a participant is asked to touch multiple targets repetitively. Within the literature, it has been well established that an individual’s focus of attention (FOA) can modulate their neuromuscular control and affect task performance. The goal of this project was to examine the unknown effect of FOA on LDS measurements and timing error during a repetitive spine flexion task that is commonly used to assess movement control. Fourteen healthy adults (7 male) were instructed to touch two targets (shoulder height and knee height) to the beat of a metronome (4 s/cycle) for 35 consecutive cycles. They completed this task under internal (focus on trunk movement) and external (focus on targets) FOA conditions. Motion capture data of the trunk and sacrum were collected at 120 Hz. The lumbar spine angle was defined as the orientation of the trunk relative to the pelvis. The local divergence exponent (λ_max) was calculated from the sum of squares of the 3-dimensional spine angle. Timing error was calculated as the time difference between target touches and metronome beats. Changing an individual’s FOA had no effect on λ_max calculations or timing error. Although clear task instructions are important, it is not essential to control for FOA during this movement assessment protocol.     

Bone mineral density of the spine and radius shaft in children with X-linked hypophosphatemic rickets (XLH)

X-linked hypophosphatemic rickets (XLH) is characterized by inadequate skeletal mineralization. The bone mineral density (BMD) of the radius shaft and the lumbar spine was determined in 13 children with XLH. Ten patients were on treatment, whereas three patients had discontinued treatment 20–32 months prior to this study. Two of them had radiological evidence of rickets.The radius shaft BMD was significantly diminished: Z score was −1.33 ± 0.89 (P < 0.001), while the BMD of lumbar spine was significantly augmented (Z score + 1.95 ± 1.17, P < 0.001). A positive correlation was found between the Z scores for the BMD of the radius shaft and spine. The two patients with overt rickets had lower radius shaft BMD values and a lesser increment of BMD of the spine. The BMD deficit of cortical bone may be related to the lack of efficacy of the treatment and/or to an intrinsic defect of the bone on this disease. On the other hand, the augmented BMD of the lumbar spine might reflect the overabundance of partially mineralized osteoid.The determination of the BMD of the radius shaft by SPA was a sensitive method for detecting abnormalities of the bone mass in XLH patients under treatment without radiological signs of rickets.     

Machine learning in human movement biomechanics: Best practices,common pitfalls,and new opportunities

Traditional laboratory experiments, rehabilitation clinics, and wearable sensors offer biomechanists a wealth of data on healthy and pathological movement. To harness the power of these data and make research more efficient, modern machine learning techniques are starting to complement traditional statistical tools. This survey summarizes the current usage of machine learning methods in human movement biomechanics and highlights best practices that will enable critical evaluation of the literature. We carried out a PubMed/Medline database search for original research articles that used machine learning to study movement biomechanics in patients with musculoskeletal and neuromuscular diseases. Most studies that met our inclusion criteria focused on classifying pathological movement, predicting risk of developing a disease, estimating the effect of an intervention, or automatically recognizing activities to facilitate out-of-clinic patient monitoring. We found that research studies build and evaluate models inconsistently, which motivated our discussion of best practices. We provide recommendations for training and evaluating machine learning models and discuss the potential of several underutilized approaches, such as deep learning, to generate new knowledge about human movement. We believe that cross-training biomechanists in data science and a cultural shift toward sharing of data and tools are essential to maximize the impact of biomechanics research.     

The lumbar and sacrum movement pattern during the back squat exercise

An essential exercise for strength training of the lower limbs is the squat exercise. During this exercise, changes in lumbar lordosis are commonly used to indicate when the descent of the squat should cease, yet the behavior of the lumbar-scarum segments remains unclear. The purpose of this study was to quantify the lumbar-sacrum movements during the back squat, because the movement of the sacrum is influenced by the width of stance, this variable was also investigated. Thirty trained subjects, 18 men with 1 repetition maximum (1RM) squat of 123% (13.9%) of bodyweight and 12 women with 1RM squat of 93% (15.6%), performed a set of narrow and wide stance squats, each carrying an additional 50% of body weight as load. The timing and movement of the lumbar angle (T12/L1), sacrum angle (L5/S1), and lumbar flexion angle (lumbar lordosis) were measured in 3 dimensions for the ascent and decent phases. Men and women achieved similar lumbar angles for both width of stance and phase. Sacrum angles, lumbar flexion angles, and timing differed significantly (p < 0.05) between gender and width of stance. The lumbar flexion range during the descent phase for women in narrow and wide stance was 12.9° and 12.6°, respectively; for men, this range was significantly (p < 0.05) larger at 26.3° and 25.4°, respectively. Men and women developed different movement patterns for the squatting movement, and therefore, this needs to be considered in strength development and screening procedures. The lumbar spine became kyphotic as soon as a load was placed on the shoulders, and any teaching cues to maintain a curved lumbar spine when squatting must be questioned.     

Gene Ontology annotation quality analysis in model eukaryotes

Functional analysis using the Gene Ontology (GO) is crucial for array analysis, but it is often difficult for researchers to assess the amount and quality of GO annotations associated with different sets of gene products. In many cases the source of the GO annotations and the date the GO annotations were last updated is not apparent, further complicating a researchers’ ability to assess the quality of the GO data provided. Moreover, GO biocurators need to ensure that the GO quality is maintained and optimal for the functional processes that are most relevant for their research community. We report the GO Annotation Quality (GAQ) score, a quantitative measure of GO quality that includes breadth of GO annotation, the level of detail of annotation and the type of evidence used to make the annotation. As a case study, we apply the GAQ scoring method to a set of diverse eukaryotes and demonstrate how the GAQ score can be used to track changes in GO annotations over time and to assess the quality of GO annotations available for specific biological processes. The GAQ score also allows researchers to quantitatively assess the functional data available for their experimental systems (arrays or databases).     

Review: Automated techniques for monitoring the behaviour and welfare of broilers and laying hens: towards the goal of precision livestock farming

There is increasing public concern about poultry welfare; the quality of animal welfare is closely related to the quality of livestock products and the health of consumers. Good animal welfare promotes the healthy growth of poultry, which can reduce the disease rate and improve the production quality and capacity. As behaviour responses are an important expression of welfare, the study of behaviour is a simple and non-invasive method to assess animal welfare. The use of modern technology offers the possibility to monitor the behaviour of broilers and laying hens in a continuous and automated way. This paper reviews the latest technologies used for monitoring the behaviour of broilers and laying hens under both experimental conditions and commercial applications and discusses the potential of developing a precision livestock farming (PLF) system. The techniques that are presented and discussed include sound analysis, which can be an online tool to automatically monitor poultry behaviour non-invasively at the group level; wireless, wearable sensors with radio-frequency identification devices, which can automatically identify individual chickens, track the location and movement of individuals in real time and quantify some behavioural traits accordingly and image processing technology, which can be considered a direct tool for measuring behaviours, especially activity behaviours and disease early warning. All of these technologies can monitor and analyse poultry behaviour, at the group level or individual level, on commercial farms. However, the popularity and adoption of these technologies has been hampered by the logistics of applying them to thousands and tens of thousands of birds on commercial farms. This review discusses the advantages and disadvantages of these techniques in commercial applications and presents evidence that they provide potential tools to automatically monitor the behaviours of broilers and laying hens on commercial farms. However, there still has a long way to go to develop a PLF system to detect and predict abnormal situations.     

Intervertebral reaction force prediction using an enhanced assembly of OpenSim models

OpenSim offers a valuable approach to investigating otherwise difficult to assess yet important biomechanical parameters such as joint reaction forces. Although the range of available models in the public repository is continually increasing, there currently exists no OpenSim model for the computation of intervertebral joint reactions during flexion and lifting tasks. The current work combines and improves elements of existing models to develop an enhanced model of the upper body and lumbar spine. Models of the upper body with extremities, neck and head were combined with an improved version of a lumbar spine from the model repository. Translational motion was enabled for each lumbar vertebrae with six controllable degrees of freedom. Motion segment stiffness was implemented at lumbar levels and mass properties were assigned throughout the model. Moreover, body coordinate frames of the spine were modified to allow straightforward variation of sagittal alignment and to simplify interpretation of results. Evaluation of model predictions for level L1–L2, L3–L4 and L4–L5 in various postures of forward flexion and moderate lifting (8 kg) revealed an agreement within 10% to experimental studies and model-based computational analyses. However, in an extended posture or during lifting of heavier loads (20 kg), computed joint reactions differed substantially from reported in vivo measures using instrumented implants. We conclude that agreement between the model and available experimental data was good in view of limitations of both the model and the validation datasets. The presented model is useful in that it permits computation of realistic lumbar spine joint reaction forces during flexion and moderate lifting tasks. The model and corresponding documentation are now available in the online OpenSim repository.     

Estimating the L5S1 flexion/extension moment in symmetrical lifting using a simplified ambulatory measurement system

Mechanical loading of the spine has been shown to be an important risk factor for the development of low-back pain. Inertial motion capture (IMC) systems might allow measuring lumbar moments in realistic working conditions, and thus support evaluation of measures to reduce mechanical loading. As the number of sensors limits applicability, the objective of this study was to investigate the effect of the number of sensors on estimates of L5S1 moments.Hand forces, ground reaction forces (GRF) and full-body kinematics were measured using a gold standard (GS) laboratory setup. In the ambulatory setup, hand forces were estimated based on the force plates measured GRF and body kinematics that were measured using (subsets of) an IMC system. Using top-down inverse dynamics, L5S1 flexion/extension moments were calculated.RMSerrors (Nm) were lowest (16.6) with the full set of 17 sensors and increased to 20.5, 22 and 30.6, for 8, 6 and 4 sensors. Absolute errors in peak moments (Nm) ranged from 17.7 to 16.4, 16.9 and 49.3 Nm, for IMC setup’s with 17, 8, 6 and 4 sensors, respectively. When horizontal GRF were neglected for 6 sensors, RMSerrors and peak moment errors decreased from 22 to 17.3 and from 16.9 to 13 Nm, respectively.In conclusion, while reasonable moment estimates can be obtained with 6 sensors, omitting the forearm sensors led to unacceptable errors. Furthermore, vertical GRF information is sufficient to estimate L5S1 moments in lifting.     

Reproductive hormones and bone mineral density in women runners.

We examined the relationships among reproductive hormone concentrations and bone mineral density (BMD) in 43 women runners classified as eumenorrheic (n = 24), oligomenorrheic (n = 8), or amenorrheic (n = 11). Results were compared with a eumenorrheic nonrunner control group (n = 11). Serum 17 beta-estradiol, progesterone, and dehydroepiandrosterone sulfate concentrations were determined in daily blood samples for 21 days, and integrated concentrations (areas under the curve) were calculated. BMD was assessed at the lumbar spine and proximal femur by dual-photon absorptiometry. As expected, 17 beta-estradiol, progesterone, and lumbar spine BMD were higher in the control and eumenorrheic runner groups than in the oligomenorrheic and amenorrheic runner groups (P less than 0.05). Progesterone concentration was significantly correlated with lumbar spine BMD in the eumenorrheic runners (r = 0.61). None of the steroid hormones was significantly related to BMD in the oligomenorrheic/amenorrheic group. The present data suggest that circulating levels of gonadal steroid hormones affect axial BMD in eumenorrheic runners.     

The use of surface strain data and a neural networks solution method to determine lumbar facet joint loads during in vitro spine testing

A new method for determining facet loads during in vitro spine loading using strain gauges and a neural networks solution method was investigated. A test showed that the new solution method was more robust than and as accurate as a previously presented graphical solution method for computing facet loads using surface strain. The technique was subsequently utilized to assess facet loads at L1-L2 during flexibility testing [7.5Nm pure moments in flexion (FL), extension (EX), right and left axial rotation (AR), and right and left lateral bending (LB)], and stiffness testing (FL-EX with 400N compressive follower load) of six human lumbar spine segments (T12-L2). In contrast to other techniques, such as thin film sensors or pressure-sensitive film, the strain-gauge method leaves the facet joint capsule intact during data collection, presumably allowing more natural load transmission. During flexibility tests, the mean (+/-standard deviation) calculated facet loads (in N) were 46.1+/-41.3 (FL), 51.5+/-39.0 (EX), 70.3+/-43.2 (AR-contralateral side), 31.3+/-33.4 (AR-ipsilateral side), 30.6+/-29.1 (LB-contralateral side), and 32.0+/-44.4 (LB-ipsilateral side). During stiffness tests, the calculated facet loads were 45.5+/-40.4 (upright), 46.6+/-41.9 (full FL), and 75.4+/-39.0 (full EX), corresponding to an equivalent of 11.4%, 11.6%, and 18.8% of the compressive follower load (upright, full FL and EX, respectively). The error associated with this technique, which was below 11N for loads up to 125N, is comparable to that reported with other techniques. The new method shows promise for assessing facet load during in vitro spine testing, an important parameter when evaluating new implant systems and surgical techniques.     

The value of protein structure classification information—Surveying the scientific literature

The Structural Classification of Proteins (SCOP) and Class, Architecture, Topology, Homology (CATH) databases have been valuable resources for protein structure classification for over 20 years. Development of SCOP (version 1) concluded in June 2009 with SCOP 1.75. The SCOPe (SCOP–extended) database offers continued development of the classic SCOP hierarchy, adding over 33,000 structures. We have attempted to assess the impact of these two decade old resources and guide future development. To this end, we surveyed recent articles to learn how structure classification data are used. Of 571 articles published in 2012–2013 that cite SCOP, 439 actually use data from the resource. We found that the type of use was fairly evenly distributed among four top categories: A) study protein structure or evolution (27% of articles), B) train and/or benchmark algorithms (28% of articles), C) augment non‐SCOP datasets with SCOP classification (21% of articles), and D) examine the classification of one protein/a small set of proteins (22% of articles). Most articles described computational research, although 11% described purely experimental research, and a further 9% included both. We examined how CATH and SCOP were used in 158 articles that cited both databases: while some studies used only one dataset, the majority used data from both resources. Protein structure classification remains highly relevant for a diverse range of problems and settings. Proteins 2015; 83:2025–2038. © 2015 The Authors. Proteins: Structure, Function, and Bioinformatics Published by Wiley Periodicals, Inc.     

Physical activity assessment with accelerometers: an evaluation against doubly labeled water

This review focuses on the ability of different accelerometers to assess daily physical activity as compared with the doubly labeled water (DLW) technique, which is considered the gold standard for measuring energy expenditure under free-living conditions. The PubMed Central database (U.S. NIH free digital archive of biomedical and life sciences journal literature) was searched using the following key words: doubly or double labeled or labeled water in combination with accelerometer, accelerometry, motion sensor, or activity monitor. In total, 41 articles were identified, and screening the articles' references resulted in one extra article. Of these, 28 contained sufficient and new data. Eight different accelerometers were identified: 3 uniaxial (the Lifecorder, the Caltrac, and the CSA/MTI/Actigraph), one biaxial (the Actiwatch AW16), 2 triaxial (the Tritrac-R3D and the Tracmor), one device based on two position sensors and two motion sensors (ActiReg), and the foot-ground contact pedometer. Many studies showed poor results. Only a few mentioned partial correlations for accelerometer counts or the increase in R(2) caused by the accelerometer. The correlation between the two methods was often driven by subject characteristics such as body weight. In addition, standard errors or limits of agreement were often large or not presented. The CSA/MTI/Actigraph and the Tracmor were the two most extensively validated accelerometers. The best results were found for the Tracmor; however, this accelerometer is not yet commercially available. Of those commercially available, only the CSA/MTI/Actigraph has been proven to correlate reasonably with DLW-derived energy expenditure.     

Biomechanical implications of lumbar spinal ligament transection

Many lumbar spine surgeries either intentionally or inadvertently damage or transect spinal ligaments. The purpose of this work was to quantify the previously unknown biomechanical consequences of isolated spinal ligament transection on the remaining spinal ligaments (stress transfer), vertebrae (bone remodelling stimulus) and intervertebral discs (disc pressure) of the lumbar spine. A finite element model of the full lumbar spine was developed and validated against experimental data and tested in the primary modes of spinal motion in the intact condition. Once a ligament was removed, stress increased in the remaining spinal ligaments and changes occurred in vertebral strain energy, but disc pressure remained similar. All major biomechanical changes occurred at the same spinal level as the transected ligament, with minor changes at adjacent levels. This work demonstrates that iatrogenic damage to spinal ligaments disturbs the load sharing within the spinal ligament network and may induce significant clinically relevant changes in the spinal motion segment.     

Trunk and lower limb coordination during lifting in people with and without chronic low back pain

Differences in synchronous movement between the trunk and lower limb during lifting have been reported in chronic low back pain (CLBP) patients compared to healthy people. However, the relationship between movement coordination and disability in CLBP patients has not been investigated. A cross-sectional study was conducted to compare regional lumbar and lower limb coordination between CLBP (n = 43) and control (n = 29) groups. The CLBP group was divided into high- and low-disability groups based on their Oswestry Disability Index (ODI) score. The mean absolute relative phase (MARP) angles and mean deviation phase (DP) between the (1) lumbar spine and hip, and (2) hip and knee were measured. The relationship between MARP angle and DP and ODI were investigated using linear regression. The higher-disability CLBP group demonstrated significantly greater lumbar-hip MARP angles than the lower-disability CLBP group (mean difference = 12.97, % difference = 36, p = 0.041, 95% CI [2.97, 22.98]). The higher-disability CLBP group demonstrated significantly smaller hip-knee DP than controls (mean difference = 0.11, % difference = 76, p = 0.011, 95% CI [0.03, 0.19]). There were no significant differences in lumbar-hip and hip-knee MARP and DP between the lower-disability CLBP and control groups. Lumbar-hip MARP was positively associated with ODI (R² = 0.092, β = 0.30, p = 0.048). High-disability CLBP patients demonstrated decreased lumbar-hip movement coordination and stiffer hip-knee movement during lifting than low-disability CLBP patients and healthy controls.     

Three-dimensional static modeling of the lumbar spine

This paper presents three-dimensional static modeling of the human lumbar spine to be used in the formation of anatomically-correct movement patterns for a fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The mathematical model incorporates five lumbar vertebrae between the first lumbar vertebra and the sacrum, with dimensions of an average adult human spine. The vertebrae are connected to each other by elastic elements, torsional springs and a spherical joint located at the inferoposterior corner in the mid-sagittal plane of the vertebral body. Elastic elements represent the ligaments that surround the facet joints and the torsional springs represent the collective effect of intervertebral disc which plays a major role in balancing torsional load during upper body motion and the remaining ligaments that support the spinal column. The elastic elements and torsional springs are considered to be nonlinear. The nonlinear stiffness constants for six motion types were solved using a multiobjective optimization technique. The quantitative comparison between the angles of rotations predicted by the proposed model and in the experimental data confirmed that the model yields angles of rotation close to the experimental data. The main contribution is that the new model can be used for all motions while the experimental data was only obtained at discrete measurement points.     

Postural control of trunk during unstable sitting

A method for quantifying postural control of the lumbar spine during unstable sitting was developed. The unstable seat apparatus was equipped with leg and foot supports to isolate the control of the lumbar spine and trunk from the adjustments in the lower body joints. Polyester resin hemispheres with decreasing diameters were attached to the bottom of the seat to achieve increasing levels of task difficulty. The seat was placed on a force plate at the edge of a table and the participating subjects were instructed to maintain their balance while sitting on the seat. Coordinates of center of pressure (CoP) were recorded and quantified with summary statistics and random walk analysis. The CoP movement increased significantly with increased seat instability (task difficulty) (p<0.01). Stabilogram plots of the CoP movement revealed short and long-term regions consistent with the hypothesis that the two regions reflect open and closed-loop postural control mechanisms. Repeatability of the CoP parameters was excellent for the summary statistics and the short-term random walk coefficients (0.77<R<0.96). It was fair for the long-term diffusion coefficients (0.56<R<0.57) and poor for the long-term scaling exponents (0.14<R<0.40). Summary statistics of the CoP movement were positively correlated with body weight (0.69<R<0.73) and the T9 to L4/L5 distance (0.43<R<0.54) of the subjects. This method can be applied to study the deficits in postural control of the lumbar spine in low-back pain population.     

Kinematic perturbation in the flexion-extension axis for two lumbar rigs during a high impact jump task

The measurement of lumbar spine motion is an important step for injury prevention research during complex and high impact activities, such as cricket fast bowling or javelin throwing. This study examined the performance of two designs of a lumbar rig, previously used in gait research, during a controlled high impact bench jump task. An 8-camera retro-reflective motion analysis system was used to track the lumbar rig. Eleven athletes completed the task wearing the two different lumbar rig designs. Flexion extension data were analyzed using a fast Fourier transformation to assess the signal power of these data during the impact phase of the jump. The lumbar rig featuring an increased and pliable base of support recorded moderately less signal power through the 0-60 Hz spectrum, with statistically less magnitudes at the 0-5 Hz (p = .039), 5-10 Hz (p = .005) and 10-20 Hz (p = .006) frequency bins. A lumbar rig of this design would seem likely to provide less noisy lumbar motion data during high impact tasks.     

Lower limb postures resembling sitting and standing alter lumbar angles along the passive stiffness curve

In vivo lumbar passive stiffness is often used to assess time-dependent changes in lumbar tissues and to define the neutral zone. We tested the hypothesis that flexing the hips would alter tension in hip and spine musculature, leading to a more extended passive stiffness curve (i.e., right-shifted), without changes in lumbar stiffness. Twenty participants underwent side-lying passive testing with the lower limbs positioned in Stand, Kneel, and Sit representative postures. Moment-angle curves were constructed from the lumbar angles and the moment at L4/5 and partitioned into three zones. Partially supporting our hypothesis, lumbar stiffness within the low and transition stiffness zones was similar between the Stand and Sit. Contrary to our hypothesis, lumbar angles were significantly larger in the Sit compared to the Stand and Kneel postures at the first and second breakpoints, with average differences of 9.3° or 27.2% of passive range of motion (%PassRoM) in flexion and 5.6° or 16.6 %PassRoM in extension. Increased flexion in the Sit may be linked to increased posterior pelvic tilt and associated lower lumbar vertebrae flexion. Investigators must ensure consistent pelvis and hip positioning when measuring lumbar stiffness. Additionally, the adaptability of the neutral zone to pelvis posture, particularly between standing and sitting, should be considered in ergonomic applications.