18: 326 / 334 Clinical Rehabilitation 2004; 18: 334 ]
The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke G Verheyden, erheyden, A Nieuwboer Nieuwboer Department Department of Rehabilitation Rehabilitation Sciences, Faculty of P hysical Education Education and Physiotherapy Physiotherapy,, Mertin Neurologi Katholieke Universiteit Leuven, Belgium, J Mertin Neurologic c Rehabilitation Rehabilitation Unit of the Kiliani-Klinik, Bad Windsheim, Windsheim, R Preger Neurologi Preger Neurologic C Kiekens Physical Kiekens Physical Medicine and Rehabilitation c Rehabilitation Rehabilitation Unit of the Klinik Kipfenberg, Kipfenberg, Germany, Germany, C Rehabilitation Weerdt Department of Rehabilitation Unit of the University Hospital Pellenberg, Pellenberg, Katholieke Katholieke Universiteit Universiteit Leuven and W De Weerdt Sciences, Sciences, Faculty of Physical Education and Physiotherapy, Physiotherapy, Katholieke Universiteit Universiteit Leuven, Belgium Received Received 17th 17th December December 2002; returned returned for revisions revisions 2nd A pril 2003; revised manuscript manuscript accepted accepted 15th June 2003.
Objective: Objective: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. stroke. The TIS scores, on a range from 0 to 23, st atic and dynamic sitting balance balance as well well as trunk co-ordination. co-ordination. It also aims to score the quality of of trunk movement movement and to be a guide for treatment. physiotherapists sts observed observed each patient patient simultaneously simultaneously,, but scored Design: Design: Two physiotherapi independently. Each patient was re-examined by one of the therapists. Subjects: Twenty-eight patients in a rehabilitation setting. Results: Results: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test / retest retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test / retest retest and interexaminer measurement error were / 2.90, 2.90, 3.68 and / 1.84, 1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r / 0.86) 0.86) and the Trunk Control Test (r / 0.83) 0.83) was used to examine construct and concurrent validity, respectively. Conclusions: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment. ]
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Introduction Most literature literature concerni concerning ng motor rehabil rehabiliitation afte afterr stroke troke focus ocusees on the the uppe upperr and lowe ower 1] 3 extremity. Trunk rehabil rehabilitation itation recei receive vess only only Address Address for correspondence correspondence:: Geert Verheyden, Katholieke Katholieke Unive Universitei rsiteitt Leuve Leuven, n, Faculty Faculty of Physi Physica call Educati Education on and Physiotherapy, Department of Rehabilitation Sciences, Tervuursevest 101, B-3000 Leuven, Belgium. e-mail: geert.verheyden@ flok.kuleuven.ac.be # A r n o ld 200 4
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little ttle attention. attention. Davies Davies4 ass associ ociates ates the loss oss of sel selecti ective ve contr control ol in the trunk with with problem problemss of breathi breathing, ng, speec speech, h, balanc balancee, gait, gait, arm and hand functi unction. on. Sitti tting balance balance is als also report reporteed as a predictor of motor and functional recovery after 5 8 stroke. ] The importance of recov recover ery y of trunk function, although often stated by clinical experts, needs to be confirmed by scientific research. In the literatur teraturee, the use use of a clinical nical tool to measur me asuree trunk function unction is poorly poorly docume documente nted. d. Someti ometime mess a 3-, 4- or 5-poi 5-point nt ordinal ordinal scale ale is 10. 11 91/02692 15504cr 73 3oa
The Trunk Impairment Scale
used without mentioning origin or basic statistical 5,7,9 characteristics. The Sitting Balance Scale developed by Nieuwboer et al .10showed poor reliability, especially for the items evaluating the quality of trunk activity. The Trunk Control Test by Collin and Wade is a quick and reliable measure with predictive validity.11,12 Limitations of the test are that it does not take the quality of movement into account 11 as well as the moderate correlation with 13 trunk strength, measured using a hand dynamometer. The latter was explained by Bohannon because it needs more than trunk muscle strength 13 to complete the tasks of th e Trunk Control Test. In several existing scales, (isolated) trunk activity is scored as one component. Examples are the `leg and trunk’ scale of the Rivermead Motor Assess14 ment, the `balanced sitting’ item of the Motor Assessment Scale,15 the `postural control’ part of 16 the Chedoke-McMa ster Stroke Assessment, th e `lying and sitting’ tests of the Postural Assessment Scale for Stroke Patients17 and the `verticality’ an d `abdominal manual muscle testing’ items of the 18 Stroke Impairment Assessment Set. T he aim o f th is stu dy wa s to d evelop a comprehensive tool to measure motor impairment of the trunk after stroke, the Trunk Impairment Scale (TIS), and to examine reliability, internal consistency and validity of the TIS. The scale should include the o bservation of quality of trunk movement and be a guide for the treatment of the trunk in stroke patients.
Methods The TIS consists of three subscales: static sitting balance, dynamic sitting balance and co-ordination. Each subscale contains between three and ten items. The TIS score ranges from a minimum of 0 to a maximum of 23. In a preliminary study, scoring the symmetry and manual lengthening of the hemiplegic and nonh emiplegic side of th e tru nk were considered a s well. Due to poor reliability, these items were removed from the scoring system. Other parts of the scale were redefined. T he current scale is given in the Appendix. Stroke pa tients were recruited in r ehabilitatio n centres and were included if they were allowed to
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sit upright. Exclusion criteria were a hip p rosthesis at the nonhemiplegic side or a score of 0 on the comprehension or speech item of the European Stroke Scale.19 Further data collection to define the population consisted of patient’s age, sex, hemiplegic side, type of stroke, days since stroke, 20 21 Barthel Index, BrunnstroÈ m-F ugl-M eyer test for upper and lower extremity and Trunk Control 11 Test. Twenty-eight patients (14 female an d 14 male) were included in the study. Eleven had a right hemiplegia, 15 a left hemiplegia and two were bilaterally affected. Eight patients suffered from a haemorrhagic stroke, 20 had an ischaemic accident. Median age was 63 years, median days since stroke 61 (Table 1). The majority of patients had moderate ADL function and limited motor recovery (Table 1). Ethical approval was obtained from the Ethical Commission, M edical Faculty, K.U.Leuven, Belgium. Informed consent was obtained from all patients. For the reliability study, each patient was examined twice. On one occasion, two physiotherapists scored the TIS concurrently but independently. On another occasion, one of the therapists assessed the patient alone. The therapist who examined the patient alone also instructed the patient when both observers were scoring simultaneously. The two observations were always on the same day, separated by 1 or 2 hours of recovery time. During that time no treatment was offered. The observations were planned every half hour, so at least two different patients were evaluated before seeing the same patient again. To further minimize recall bias, the observers filled in the score sheet but did not add up the scores. Allocation of the Table 1
Patient characteristics
Age (years) Days since stroke Barthel Index BrunnstroÈm-Fugl-Meyer Test (arm) BrunnstroÈm-Fugl-Meyer Test (leg) Trunk Control Test a
Median (Q1,Q3)a
Range
63 (47,71) 61 (46,94) 60 (33,80) 9 (4,54)
32 21 5 0
87 / 2341 / 100 / 66 /
] ]
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19 (6,25)
0 / 31
75 (43,94)
0 / 100
Q1 means quartile one; Q3 means quartile three.
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patients to the observers as well as the order of the two observations were randomized. Each observer examined a group of 14 patients twice, amounting to 28 patients in total. In this study, every item of the scale was performed three times to avoid a possible scoring bias if a patient reached the maximum score after one or two attempts. Test / r etest reliability was measured by comparing the results of the therapists who examined the patient twice. To determine inter-rater reliability, the results of both therapists who observed the patient simultaneously were compared. Test / r etest and interobserver reliability were determined for all scale items. K appa and weighted kappa values were calculated for dichotomous and ordinal scales, respectively. Percentage of agreement was also determined for all items. Test / retest and interobserver reliability for the subtotals and total score was examined by means of intraclass correlation (ICC). The 95% test / r etest and interexaminer measurement error interval according to 22 Haas was determined. Cronbach’s alpha was calculated to check for internal consistency of the subscales and total scale. Content validity was evaluated. The TIS total score was compared with the Barthel Index by means of Spearman rank correlations for determining construct validity and with the Trunk Control Test for concurrent validity. Item per item reliability was established when the kappa or weighted kappa statistic exceeded 0.6023 or when more then 80% agreement was observed. Test / r etest and interobserver reliability of the subtotals and TIS total was reached when the ICC was 0.80 or higher. Cronbach’s alpha should exceed 0.70, which is suggested as a value of scale reliability and indicates underlying construct.24 ]
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lated for item 3 (test / r etest reliability) and item 4 (test / r etest and inter-rater reliability) of co-ordination because of a skewed distribution of the data. Percentage of agreement for these items ranged from 86% to 100%. ICCs for static and dynamic sitting balance, co-ordination and the total TIS are presented in Table 3 and were between 0.85 and 0.99. The 95% test / r etest and interexaminer measurement error / 2 .90, 3.68 interval on the total TIS score was an d / 1.84, 1.84, respectively. Internal consistency by means of Cronbach’s alpha was calculated for the subscales static sitting balance (0.79), dynamic sitting balance (0.86) and co-ordination (0.65). Cronbach’s alpha for the total Trunk Impairment Scale was 0.89. Content validity of the TIS was achieved through literature review, observing stroke patients, clinical experience of the authors and discussing the content of the scale with specialists within the field of stroke rehabilitation. Spearman rank correlation between the TIS and the Barthel Index (construct validity) was 0.86, between the TIS and the Trunk Control Test (concurrent validity) 0.83. The time needed to complete the TIS ranged from 2 to 18 minutes. All obtained scores ranged between 0 and 21. The median score (quartile 1, quartile 3) was 14 (10, 16). ]
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Discussion
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The aim of this study was to develop a measurement tool to evaluate the impairment of the trunk
Clinical messages The Trunk Impairment Scale (TIS) is a new tool to measure motor impairment of the trunk after stroke. The TIS evaluates static and dynamic sitting . balance as well as co-ordination of trunk movement. . The TIS has sufficient reliability, internal consistency and validity for use in clinical practice and stroke research. .
Results As seen in Table 2, most kappa or weighted kappa values ran ged from 0.62 to 1. Test / r etest agreement of item 2 o f static sitting b alance (0.51) and item 2 of co-ordination (0.46) were insufficient. For these items, a high percentage of agreement, 89% and 93% respectively, was observed. No kappa or weighted kappa values could be calcu]
The Trunk Impairment Scale
329
Table 2 Kappa or weighted kappa, lower value of the 90% con®dence limit of the kappa or weighted kappa and percentage of agreement for test / retest and inter-observer agreement ]
/ w a
Item
Static sitting balance j Item 1 j Item 2 jw Item 3
Co-ordination Item 1 Item 2 Item 3 Item 4
w
j
j
Inter-observer agreement
]
Dynamic sitting balance j Item 1 j Item 2 j Item 3 j Item 4 j Item 5 j Item 6 j Item 7 j Item 8 j Item 9 j Item 10
a
Test / retest agreement
j j
w
j j
Valueb
90%lclc
%d
Valueb
90%lclc
%d
1 0.51 0.87
1 0.11 0.77
100% 89% 86%
1 1 0.97
1 1 0.92
100% 100% 96%
0.70 0.78 0.62 1 1 0.78 0.93 0.73 0.62 0.71
0.47 0.59 0.37 1 1 0.59 0.81 0.49 0.37 0.40
86% 89% 82% 100% 100% 89% 96% 89% 82% 93%
1 0.93 0.84 1 1 0.93 1 0.91 0.84 0.76
1 0.81 0.66 1 1 0.81 1 0.76 0.67 0.49
100% 96% 93% 100% 100% 96% 100% 96% 93% 93%
0.57 0.07
86% 93% 86% 100%
0.71 0.78 0.70 *e
0.48 0.44 0.50
86% 96% 82% 96%
0.76 0.46 *e *e
/
2
/ w indicates the use of a kappa ( j) or weighted kappa ( jw) for statistic analysis. Value of the calculated kappa or weighted kappa. c Lower value of the 90% confidence limit of the kappa or weighted kappa. d Percentage of agreement. e No Kappa or weighted Kappa could be calculated because of the skewed distribution of the data. j j
b
after stroke and to investigate its reliability, internal consistency an d validity. Reliability For item 2 of static sitting balance and coordination, low kappa values of 0.51 and 0.46, Table 3
ICC for test / retest and inter-observer agreement ]
Total
Test / retest agreement
Inter-observer agreement
Static sitting balance Dynamic sitting balance Co-ordination Trunk Impairment Scale
0.91 ( 0.83)
0.99 (0.99)
0.94 ( 0.89)
0.98 (0.96)
0.87 ( 0.76) 0.96 ( 0.93)
0.85 (0.74) 0.99 (0.97)
]
Values are presented as ICC (90% lower confidence limit).
respectively, were found in combination with a high percentage of agreement. Haas22 points out that if there is a large percentage of agreement but most of that agreement is limited to one of the possible scores, the kappa value is not an appropriate index of reliability. In this study this would suggest that these items are too easy. This conclusion would not be sound because a number of patients scored 0 on the tests. Secondly, we expect that the evaluation of the static sitting balance will be particularly relevant when examining an acute stroke population. Limited variance was also found for items 3 and 4 of co-ordination as well. These items evaluate the symmetry of the (timed) co-ordination of the lower part of the trunk. Symmetric trunk movements are apparently difficult for stroke p atients. Because the TIS should also be a guide for treatment, inclusion of these items seems appropriate. Besides if fast, alternating trunk movements are difficult to achieve, there will
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be no ceiling effect of the scale. The level of difficulty for the various items could be determined by means of a Rasch analysis. However a very large number of patients is needed for this analysis. Although the percentage of observer agreement is high and exceeds the proposed limit, several a ut h or s p oin t o ut t ha t t he a gr eem en t d ue t o chance alone is not taken into account when percentage agreement is presented.22,25To establish the reliability of items 1 and 2 of static sitting balance (easy items) and items 2, 3 and 4 of coordination (difficult items), a new study should be set up examining the TIS on an acute ward with severely impaired stroke patients and on a nearly fully recovered stroke population, respectively. Measurement error In this study, values for inter-rater reliability exceeded those for test / r etest agreement. This could be explained by the fact that in the case of the inter-rater reliability, both observers were scoring the patient at the same time, so all possible areas of bias and variability were minimized. Variation within the patient’s performance can also be a possible reason for lower test / retest reliability. This is confirmed by the higher test / retest examiner measurement error, 3.68 (16% of TIS total) in comparison with the 1.84 (8% of TIS total) for the interexaminer measurement error. The latter is comparab le with the repo rted limits of agreement of the Action Research Arm test (between 10 and 10.88%) and the BrunnstroÈ mFugl-M eyer assessment scale (between 7.58 and 10%).26 For the Sickness Impact Profile, Beckerma n et al .27 also found a minimum decrease of 9.26% before an unbiased improvement can be considered. T he test / r etest examiner measurement error of the TIS (3.68) was based on a method 22 suggested by Haas, an alternative to the method of Altman and Bland.28 An increase of 4 points on the TIS can be seen as an improvement without reproducibility bias. ]
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Internal consistency Cronbach’s alpha for the subscale co-ordination was under the suggested value of 0.70. This reflects only moderate reliability according to Nunnally.24 Still the ICC values for the subscale co-ordination are well above the critical value. Further, 0.70 is only a rule of thumb. Hatcher and Stepanski29
describe literatu re where useful alpha coefficients are reported under 0.70 or 0.60. In this study Cronbach’s alpha was mainly used to examine the underlying construct of the subscales and total TIS, which seems confirm ed by th e presented data. Comparison with other scales Kappa and weighted kappa values for the test / retest and inter-rater agreement of the individual items of the TIS ranged from 0.46 to 1 and from 0.70 to 1, respectively. Kappa values reported for the lying and sitting items of the Postural 17 Assessment Scale for Stroke Patients are similar. They ranged between 0.45 and 1 for intra- and between 0.64 and 1 for inter-rater reliability. 10 Nieuwboer et al . reported lower values from 0.20 to 1. Items regarding quality of movement ranged from 0.20 to 0.64. The previous two stud ies do not mention percentage of agreement if there was a low kappa value. Total scale score o f the TIS is highly reliable. Reported Spearman rho correlation coefficients for the inter-rater agreement of the Trunk Control Test 11 was 0.76, for the sitting balance item of the Motor Assessment Scale30 0.99. Product moment and rank order correlation coefficients only have a limited value as indices of reliability. Systematic errors are not taken into 22,25,31,32 account. Adding up dichotomous and ordinal items is a widely used method in scale development. The total score can thus be seen as a continuous variable. Therefore ICC can be used as an approp riate statistic for examining reliability. Franchignoni et al. 12 reported for the Trunk Control Test Cronbach’s alpha coefficients of 0.83 and 0.86. Benaim et al . 17 found for the Postural Assessment Scale for Stroke Patients 0.95 as coefficient of internal consistency. These are in line with t he results for the TIS in this study (0.89). Content, construct (r / 0 .86 with Barthel Index) and concurrent validity (r / 0 .83 with Trunk Control Test) of the TIS were established. Construct validity of the Trunk Control Test was examined by comparison with the Functional Independence Measure (F IM ). Correlation coefficients ranged from 0.71 to 0.79 and from 0.82 to 0.86 for the t ota l F I M a n d fo r th e m o to r p ar t o f t h e F I M , respectively.12 Benaim et al .17 found a correlation of 0.73 between the Postural Assessment Scale for Stroke Patients a nd the F IM . A correlation o f 0.28 was found between the sitting balance item of the ]
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The Trunk Impairment Scale
Motor Assessment Scale and the BrunnstroÈ m30 Fu gl-Meyer assessment. An additional aim of the TIS was to score the quality of trunk movement and to be a guide for treatment. The four tasks of the subscale dynamic sitting balance evaluate an appropriate shortening or lengthening of both sides of the trunk as well as the use of compensation strategies. In the present study, th is method was foun d more reliable than scoring a symmetrical or asymmetrical per10 form ance as index of qua lity of movement. Static and dynamic sitting balance as well as the coordination of the trunk are considered. Although not all aspects of trunk function are covered by the TIS, it can be used as a guideline for treatment. Proprioception of the trunk and muscle strength for instance are no t evaluated in th e TIS. Therefore furth er validat ion of the TIS is required to evaluate its value as a measure of total trunk function.
References 1
Moreland J, Thomson M A. Ef®cacy of electromyographic biofeedback compared with conventional physical therapy for upper-extremity function in patients following stroke: a research overview and meta-ana lysis. Phys T her 1994; 74: 534 / 47. Moreland JD, Thomson MA, Fuoco AR. Electromyographic biofeedback to improve lower extremity function after stroke: a meta-analysis. A rch Phy s M ed R ehabil 1998; 79 : 134 / 40. van der Lee JH, Snels IAK, Beckerman H , Lankhorst GJ, Wagenaar RC, Bouter LM. Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials. Clin Rehabil 2001; 15 : 20 / 31. Davies PM . Problems associated with the loss of selective trunk activity in hemiplegia. In: Right in the middle. Berlin, H eidelberg: Springer-Verlag, 1990: 31 / 65. Wade DT, Skilbeck CE, Langton Hewer R . Predicting Barthel ADL score at 6 months after an acute stroke. A rch Phys M ed Rehabil 1983; 64 : 24 / 28. Loewen SC, Anderson BA. Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21 : 78 / 81. Sandin KJ, Smith BS. The measure of balance in sitting in stroke rehabilitation prognosis. S troke 1990; 21 : 82 / 86. Kwakkel G, Wagenaar RC, Kollen BJ, Lankhorst GJ. Predicting disability in stroke / a critical review of the literature. Age Ageing 1996; 25 : 479 / 89. Bohannon RW. Lateral trunk ¯exion strength: impairment, measurement reliability and implications following unilateral brain lesion. Int J R ehabil R es 1992; 15 : 249 / 51. Nieuwboer A, Feys H, De Weerdt W, Nuyens G, De Corte E. Developing a clinical tool to measure sitting balance after stroke: a reliability study. Physiotherapy 1995; 81 : 439 / 45. Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg P sy chiatry 1990; 53 : 576 / 79. Franchignoni F P, Tesio L, R icupero C, Mart ino MT. Trunk control test as an early predictor of stroke rehabilitation outcome. Stroke 1997; 28 : 1382 / 85. Bohannon RW. Recovery and correlates of trunk muscle strength after stroke. Int J R ehabil R es 1995; 18: 162 / 67. Lincoln N, Leadbitter D. Assessment of motor function in stroke patients. Physiotherapy 1979; 65 : 48 / 51. ]
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Conclusion 6
This study reports the development of the Trunk Impairment Scale, a clinical test to measure motor impairment of the trunk after stroke. The TIS measures static and dynamic sitting balance and co-ordination of the trunk. Item per item reliability, subtotal and scale total agreement were established as well as the internal consistency of the subscales a nd the total scale. Content, construct and concurrent validity were evaluated. Statistical analysis of the different clinimetric parameters of the TIS endorse its further use in clinical practice as well as in research. The assessment can be used as a guideline for treatment and takes the quality of tru nk movement into a ccount. To the best of our knowledge, the TIS is a unique measurement of its kind in stroke literature.
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Acknowledgements The authors would like to thank Inge Taillieu and Ilse Baert for helping to collect the data. We are also grateful for th e logistic support of L Lutter (Kiliani-Klinik Bad Windsheim, Germany), F Roelandt (Klinik Kipfenberg, Germany) and P Popelier (U niversitair Ziekenhuis Pellenberg, Belgium).
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G Verheyden et al. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys T her 1985; 2 : 175 / 80. Gowland CA. Staging motor impairment after stroke. Stroke 1990; 21 : II-19 / II-21. Benaim C, PeÂrennou DA, Villy J, Rousseaux M , Pelissier JY. Validation of a standardized assessment of postural control in stroke patients. The postural assessment scale for stroke patients (PASS). Stroke 1999; 30 : 1862 / 68. Tsuji T, Liu M , Sonoda S, Domen K, Chino N. The stroke impairment assessment set: its internal consistency and predictive validity. A rch Phys M ed R ehabil 2000; 81: 863 / 68. Hantson L, D e Weerdt W, De Keyser J et al . The European stroke scale. Stroke 1994; 25 : 2215 / 19. Mahon ey F, Barthel D. F unctional evaluation: the Barthel index. M d M e d J 1965; 14 : 61 / 65. Fugl-Meyer AR, JaÈ aÈ skoÈ L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. Scand J Rehabil Med 1975; 7 : 13 / 31. H aas M. Statistical methodo logy for reliability studies. J M anip Physiol Ther 1991; 14 : 119 / 32. Landis RJ, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159 / 74. Nunnally J. Psychometric theory. New York: McGraw-Hill, 1978.
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The Trunk Impairment Scale
Appendix
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333
Trunk Impairment Scale (TIS)
The starting position for each item is th e same. The patient is sittin g on the edge of a bed or treatment table without back a nd arm support. T he thighs make full contact with th e bed or table, the feet are hip width apart and placed flat on the floor. The knee angle is 90 8. The arms rest on the legs. If hypertonia is present the position of the h emiplegic arm is taken as the starting position . The h ead an d tru nk are in a midline position . If the patient scores 0 on the first item, the total score for the TIS is 0. Each item of the test can be performed three times. The highest score counts. No practice session is allowed. The patient can be corrected between the attempts. The tests are verbally explained to the patient and can be demonstrated if needed.
Item
1
Static sitting balance Starting position
e
0
e
2
e
0
e
2
Patient falls Patient cannot cross the legs without arm support on bed or table Patient crosses th e legs but displaces the trun k more than 10 cm backwards or assists crossing with the h and Patient crosses the legs without trunk displacement or assistance Total static sitting balance
e e
0 1 2
e
3 /7
Patient falls, needs suppo rt from an upper extremity or the elbow does not touch the bed or table Patient moves actively without help, elbow touches bed or table If score / 0 , then items 2 and 3 score 0
e
0
e
1
e
0
e
1
e
0
e
1
e
0
e
1
e
0
e
1
Patient falls or cannot maintain starting position for 10 seconds without arm support Patient can maintain starting position for 10 seconds If score / 0 , then TIS total score / 0 5
2
3
1
2
St ar tin g p o sit io n Therapist crosses the unaffected leg over the hemiplegic leg
St ar tin g p o sit io n Patient crosses the unaffected leg over the hemiplegic leg
Dynamic sitting balance St ar tin g p o sit io n Patient is instructed to touch the bed or table with the hemiplegic elbow (by shortening the hemiplegic side and lengthening the unaffected side) and return to the starting position R epeat item 1
5
Patient falls or cannot maintain sitting position for 10 seconds without arm support Patient can maintain sitting position for 10 seconds
e
5
Patient demonstrates no or opposite shortening/lengthening Patient demonstrates appropriate shortening/lengthening If score / 0 , then item 3 scores 0 5
3
4
5
R epeat item 1
Patient compensates. Possible compensations are: (1) use of upper extremity, (2) contralateral hip abduction, (3) hip flexion (if elbow touches bed or table further then proximal half of femur), (4) knee flexion, (5) sliding of the feet Patient moves without compensation
St ar tin g p o sit io n Patient is instructed to touch the bed or table with the unaffected elbow (by shortening the unaffected side a nd lengthening the hemiplegic side) and return to the starting p osition
Patient falls, needs suppo rt from an upper extremity or the elbow does not touch the bed or table Patient moves actively without help, elbow touches bed or table If score / 0 , then items 5 and 6 score 0
R epeat item 4
Patient demonstrates no or opposite shortening/lengthening Patient demonstrates appropriate shortening/lengthening If score / 0 , then item 6 scores 0
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Item 6
7
8
9
e
0
e
1
e
0
e
1
e
0
e
1
St ar t in g p o sit io n Patient demonstrates n o or opposite shortening/lengthening Patient is instructed to lift pelvis from b ed or table at the Patient demonstrates appropriate shortening/lengthening una ffected side (by shor tening the un affected side an d lengthening If score / 0 , then item 10 scores 0 the hemiplegic side) and return to the starting p osition
e e
0 1
Repeat item 9
e
0
Repeat item 4
Patient compensates. Possible compensations are: (1) use of upper extremity, (2) contralateral hip abduction, (3) hip flexion (if elbow touches bed or table further then proximal half of femur), (4) knee flexion, (5) sliding of the feet Patient moves without compensation
St ar t in g p o sit io n Patient is instructed to lift pelvis from b ed or table at the hemiplegic side (by shortening th e hemiplegic side and lengthen ing the un affected side) and return to the starting po sition
Patient demonstrates no or opposite shortening/lengthening Patient demonstrates appropriate shortening/lengthening If score / 0 , then item 8 scores 0
Repeat item 7
Patient compensates. Possible compensations are: (1) use of upper extremity, (2) pushing o ff with the ip silateral foot (heel loses cont act with the floor) Patient moves without compensation
5
5
10
1
2
3
4
Co-ordination St ar t in g p o sit io n Patient is instructed to rotate upper trunk 6 times (every shoulder should be moved forward 3 times), first side that moves must b e hemiplegic side, head should be fixated in starting position
Patient compensates. Possible compensations are: (1) use of upper extremities, (2) pushing off with the ipsilateral foot (heel loses contact with the floor) Patient moves without compensation Total dynamic sitting balance
e
1 /10
Hemiplegic side is not moved three times Rotation is asymmetrical Rotation is symmetrical If score / 0 , then item 2 scores 0
e
Rotation is asymmetrical Rotation is symmetrical
e
St ar t in g p o sit io n Patient is instructed to rotate lower trunk 6 times (every knee should be moved forward 3 times), first side that moves must b e hemiplegic side, upper trunk should be fixated in starting position
Hemiplegic side is not moved three times Rotation is asymmetrical Rotation is symmetrical If score / 0 , then item 4 scores 0
e
Repeat item 3 within 6 seconds
Rotation is asymmetrical Rotation is symmetrical Total co-ordination
e
Repeat item 1 within 6 seconds
e e
0 1 2
5
e
e e
0 1 0 1 2
5
Total Trunk Impairment Scale
e
0 1 /6
/23
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