RehabMeasures Instrument
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  2. Trunk Impairment Scale

Trunk Impairment Scale

Last Updated

Purpose

The TIS measures the motor impairment of the trunk after a stroke through the evaluation of static and dynamic sitting balance as well as co-ordination of trunk movement (Verheyden et al., 2004).

Link to Instrument

Acronym TIS

Assessment Type

Performance Measure

Cost

Not Free

Cost Description

Cost of equipment

Diagnosis/Conditions

  • Brain Injury Recovery
  • Cerebral Palsy
  • Multiple Sclerosis
  • Parkinson's Disease & Movement Disorders
  • Stroke Recovery

Populations

Stroke
Parkinson's Disease
Non-Specific Patient Population

Key Descriptions

  • Scores range from a minimum of 0 to a maximum of 23.
  • If patient scores 0 on the first item, the total score on the TIS is 0.
  • Each item can be performed three times.
  • The highest score counts; otherwise, no practice sessions are allowed.
  • The patient can be corrected between attempts.
  • The tests are verbally explained to the patient and can be demonstrated if needed.
  • Three subscales: static sitting, balance, dynamic sitting balance and coordination. Each subscale has between three and 10 items.
  • Starting position:
    1) Patient is sitting at the edge of a bed or treatment table without back and arm support.
    2) Thighs are supported, knees at 90*, feet flat on the floor, arms resting on the legs, head and trunk in midline position.
    3) If hypertonia is present, the position of the arm is taken as the starting position.
  • The TIS can be found in the Appendix of Verheyden & Nieuwboer, 2004.

Number of Items

17

Equipment Required

  • Treatment table or bed without back and arm support
  • Score sheet
  • Stop watch

Time to Administer

20 minutes

Less than 20 minutes.

Required Training

No Training

Instrument Reviewers

Initially reviewed by Irene Ward, PT, DPT, NCS and the TBI task force of the Neurology Section of the APTA in 6/2012; Updated by Onkar J. Rajadhyaksha, PT in 10/2012; Updated with references from the PD population by Rosemary Gallagher, PT, DPT, GCS and the PDEdge Taskforce of the Neurology Section of the APTA in 2/2013; Updated by Michele Sulwer, PT, DPT, NCS and Genevieve Pinto-Zipp, PT, of the StrokEdge II, Neurology Section, APTA in 3/2016.

ICF Domain

Body Structure
Body Function
Activity

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

R

R

R

Recommendations Based on Parkinson Disease Hoehn and Yahr stage: 

 

I

II

III

IV

V

PD EDGE

LS/UR

LS/UR

LS/UR

LS/UR

NR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

R

R

R

NR

R

StrokEDGE

R

R

R

R

R

TBI EDGE

LS

LS

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

NR

R

R

R

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

Yes

Yes

Yes

Yes

PD EDGE

No

No

No

Not reported

StrokEDGE

No

Yes

Yes

Not reported

TBI EDGE

No

Yes

No

Not reported

Considerations

  • There are two different scales both named the Trunk Impairment Scale and both intended for the stroke population. One scale was originally published in 2004 by Verheyden et al. and is the focus of this review. The other scale was published by Fujiwara in 2004 and is not the focus of this review.

  • The patient will need to be permitted to sit-up for the test and be able to follow basic commands. 

  • The TIS has sufficient reliability, internal consistency and validity for use in clinical practice and stroke research (Verheyden et al., 2004). 

  • Younger individuals, females and individuals who are more active in their daily life are found to score higher on TIS. Older individuals, males and less physically active individuals score lower on TIS. (Verheyden et al, 2005)

  • TIS 2.0 consists of a dynamic balance subscale and a coordination subscale. The sitting balance subscale was not included due to ceiling effects (Verheyden and Kersten, 2010).

  • The TIS has been found to have large ceiling effects in two out of the three subscales of the test in this population. Further research is needed regarding: reliability, measurement error, predictive validity, and responsiveness before this measure can be recommended for clinical or use in research.

Stroke

back to Populations

Normative Data

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Time needed to complete the TIS ranged between 2 to 18 minutes

  • Scores ranged between 0 and 21, median score was 14 

Chronic Stroke (Verheyden et al. 2006, n = 51 (16 females, 35 males), mean age = 65 (11) years (range 39-84), median days post stroke= 129, 29 patients walked without assistance, 22 patients could not walk without assistance or were non-ambulatory)

  • Median total score = 11 points (48%)

  • Median score for the static sitting balance subscale = 6 (86%)

  • Median score for the dynamic sitting balance subscale = 3 (30%) 

  • Median score for the coordination subscale = 2 (23%) 

  • Non-ambulatory patients had a median TIS score of 8 (3-9)

  • Ambulatory patients had a median TIS score of 14 (11-18)

Test/Retest Reliability

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke = 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Excellent reliability for clinical care and research in the static sitting balance subscale, 0.91 (0.83)

  • Excellent reliability for clinical care and research in the dynamic sitting balance subscale, 0.94 (0.89)

  • Good reliability for research in the coordination subscale, 0.87 (0.76)

  • Overall, Excellent reliability for clinical care and research in the TIS, 0.96 (0.93) 

Sub-Acute to Chronic Stroke: (Verheyden et al, 2003; n = 28; Median age = 63 (range = 32-87); days since stroke = 21-2341) 

  • Excellent test-retest reliability (ICC = 0.96)

Interrater/Intrarater Reliability

Interrater Reliability:

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Excellent reliability in the static sitting balance subscale, 0.99 (0.99)

  • Excellent reliability in the dynamic sitting balance subscale, 0.98 (0.96)

  • Excellent reliability in the coordination subscale, 0.85 (0.74)

  • Overall, excellent reliability for in the TIS, 0.99 (0.97) 

Sub-Acute to Chronic Stroke: (Verheyden et al., 2003) 

  • Excellent inter-observer reliability when the patients were observed on the same day separated by 1 or 2 hours of recovery time (ICC = 0.99)

Internal Consistency

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Adequate for static sitting balance subscale(Cronbach’s alpha = 0.79)

  • Excellent for dynamic sitting balance subscale (Cronbach’s alpha = 0.86)

  • Not adequate for the coordination subscale (Cronbach’s alpha = 0.65)

  • Excellent for the total TIS (Cronbach’s alpha =  0.89)

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Excellent concurrent validity between TIS and Trunk Control Test, 0.83 

 

Acute Stroke: (Di Monaco et al, 2010; n = 60, mean age = 68.0(12.2), interval between stroke and admission to rehab = 21.4(13.3) days)

  • Excellent concurrent validity between TIS and Postural Assessment Scale, (0.849, P < 0.001) 

 

Sub-Acute to Chronic Stroke: (Verheyden et al, 2003)

  • Excellent correlation between the TIS and Trunk Control Test (ρ = 0.83) in patients with acute to sub-acute stroke 

 

Predictive validity: 

Acute Stroke: (Verheyden et al, 2007, n = 102, mean age = 70(10) years, 47 female and 55 men, tested upon admission to acute rehab and again 6 months after stroke)

  • Total TIS (partial R2 = 0.52, p < 0.0001) and static sitting balance subscale score (partial R2 = 0.50, p < 0.0001) were the most important factors when predicting Barthel Index score at 6 months after stroke. 

 

Acute Stroke:

(Di Monaco et al, 2010; n = 60, mean age = 68.0(12.2), interval between stroke and admission to rehab = 21.4(13.3) days)

  • Excellent validity between TIS at admission and FIM scores at discharge (0.695, p < 0.001)

  • TIS scores assessed at admission to rehabilitation were significantly lower in the patients who were transferred to an institution than those discharged home at the end of inpatient rehabilitation (P = 0.002)

  • Odds ratio analysis of TIS and discharge destination (0.620, 95% CI = 0.393 to 0.979, p = 0.040)

Sub-Acute to Chronic Stroke: (Kim et al, 2015) n = 135, mean age = 62.14 (12.9), tested at 4 weeks post stroke and again at 6 months after stroke.

  • Initial total TIS scores (and subscales including Sitting, Dynamic TIS) in non-ambulatory patients were positively correlated with all sub-items in the Korean version of Modified Barthel Index (K-MBI) at 4 weeks after stroke (p < 0.05). Particularly the TIS – Dynamic subscale was shown to be the only significant factor for K-MBI 6 months after stroke (R2 = 0.653, p < 0.001)

  • Initial total TIS scores (and subscales including Sitting, Dynamic TIS) in non-ambulatory patients were significantly correlated with Functional Ambulation Categories at 4 weeks and 6 months after stroke

Construct Validity

Convergent:

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Adequate construct validity between the TIS and Barthel Index, 0.86 

 

Sub-Acute to Chronic Stroke:

(Verheyden et al., 2003)

  • Excellent spearman rank correlation between the TIS and the Barthel Index (ρ = 0.86) 

 

Acute to Sub-acute Stroke: (Verheyden & Kersten, 2008; n = 162; Mean age = 67(11) years; all stages of stroke) 

  • Construct validity of dynamic sitting balance and coordination subscale confirmed using Rasch analysis. (chi-square = 42.65;p-value = 0.0052 for dynamic sitting balance, chi-square = 7.87, p-value = 0.446 for coordination subscale) 

 

Discriminant: 

 

Stroke: (Verheyden et al., 2005; n = 40 stroke patients and n = 40 age and sex-matched healthy individuals, mean age = 65) 

  • Significant differences between stroke patients and healthy individuals (P < 0.0001)

Content Validity

Sub-Acute Stroke: (Verheyden & Nieuwboer, 2004; n = 28, median age = 63 years, median days since stroke 61 days, majority of patients had moderate ADL function and limited motor recovery)

  • Content validity of the TIS was achieved through literature review, observation of stroke patients, clinical experience of the authors and discussing the content of the scale with stroke rehabilitation specialists.

Floor/Ceiling Effects

Chronic Stroke: (Verheyden et al., 2006; n = 51 (16 females, 35 males), mean age = 65 (11) years (range 39-84), median days post stroke = 129, 29 patients walked without assistance, 22 patients could not walk without assistance or were non-ambulatory)

  • No patient was able to score the maximum of 23 points on the TIS as opposed to 12 (24%) participants reached the maximum score of 100 points on the Trunk Control Test. 

 

Acute to Sub-Acute Stroke: (Verheyden & Kersten, 2010; n = 162 from acute unit, in-patient and out-patient rehabilitation setting ; Mean age = 67(11) years; days since stroke = 6-94 days)

  • Poor ceiling effects (90%)(ceiling effect for static sitting balance subscale was large and hence, it was excluded from the TIS version 2.0)

Parkinson's Disease

back to Populations

Criterion Validity (Predictive/Concurrent)

Concurrent validity: 

Parkinson's Disease: (Verheyden et al., 2007; n = 52; n = 26 PD patients (17M), mean age 65 (9) years, mean disease duration 9 (4)years; n = 26 controls)

  • Significant Spearman's Rank correlation with a combination of part III score of the UPDRS (partial R2 = 0.54, P < 0.000) and age (partial R2 = 0.09, P = 0.030)

Construct Validity

Convergent: 

Parkinson's Disease: (Verheyden et al., 2007)

  • The authors state that results of the study demonstrate Construct validity of the TIS in people with PD because they had significantly lower scores than controls on the total TIS and static sitting balance and coordination subscale of the TIS. Scores on the dynamic sitting balance subscale were lower for people with PD but were not significant.

Floor/Ceiling Effects

Parkinson’s Disease: (Verheyden et al., 2007)

  • Poor ceiling effects: 73% reached max score on static sitting balance subscale; 38% reached max score on dynamic sitting balance subscale; (8%) reached max score on coordination subscale; and (4%) reached max score of total TIS

Non-Specific Patient Population

back to Populations

Normative Data

Healthy individuals: (Verheyden et al., 2005; n = 80, 40 patients with stroke and 40 age- and sex-matched healthy individuals; mean age of patients with stroke = 64(14) years and that of healthy individuals = 65(14) years; median number of days since stroke onset = 46 (range = 9- 2341)) 

TIS (Subscale) 

Median 

IQR 

Range 

Static Sitting Balance 

(range 0-7) 

7 

7 

7 

Dynamic Sitting Balance 

(range 0-10) 

10 

9-10 

6-10 

Coordination 

(range 0-6) 

6 

5-6 

4-6 

Total TIS

(range 0-23) 

23 

22-23 

17-23

Bibliography

Di Monaco, M., Trucco, M., et al. (2010). "The relationship between initial trunk control or postural balance and inpatient rehabilitation outcome after stroke: a prospective comparative study." Clinical Rehabilitation 24(6): 543-554.

Fujiwara, T., Liu, M., et al. (2004). "Development of a new measure to assess trunk impairment after stroke (trunk impairment scale): its psychometric properties." American Journal of Physical Medicine and Rehabilitation 83(9): 681-688.

Verheyden, G. and Kersten, P. (2008). "Evaluating the construct validity of the Trunk Impairment Scale: a Rasch analysis of its subscales... Proceedings of SRR: abstracts from the Society for Research in Rehabilitation summer meeting held at Weetwood Hall, Leeds, 3 and 4 July 2007." Clinical Rehabilitation 22(7): 664-664.

Verheyden, G. and Kersten, P. (2010). "Investigating the internal validity of the Trunk Impairment Scale (TIS) using Rasch analysis: the TIS 2.0." Disability and Rehabilitation 32(25): 2127-2137.

Verheyden, G., Nieuwboer, A., et al. (2007). "Trunk performance after stroke: an eye catching predictor of functional outcome." Journal of Neurology, Neurosurgery and Psychiatry 78(7): 694-698.

Verheyden, G., Nieuwboer, A., et al. (2005). "Discriminant ability of the Trunk Impairment Scale: a comparison between stroke patients and healthy individuals." Disability and Rehabilitation 27(17): 1023-1028.

Verheyden, G., Nieuwboer, A., et al. (2004). "The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke." Clinical Rehabilitation 18(3): 326-334.

Verheyden, G., Vereeck, L., et al. (2006). "Trunk performance after stroke and the relationship with balance, gait and functional ability." Clinical Rehabilitation 20(5): 451-458.

Verheyden, G., Willems, A. M., et al. (2007). "Validity of the trunk impairment scale as a measure of trunk performance in people with Parkinson's disease." Archives of Physical Medicine and Rehabilitation 88(10): 1304-1308.

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