Kallemseyyar 2018
Kallemseyyar 2018
Kallemseyyar 2018
To cite this article: Gulce Kallem Seyyar, Bahar Aras & Ozgen Aras (2018): Trunk control and
functionality in children with spastic cerebral palsy, Developmental Neurorehabilitation, DOI:
10.1080/17518423.2018.1460879
CONTACT Bahar Aras dpuaras@yahoo.com School of Health Sciences, Department of Physical Therapy and Rehabilitation, Dumlupinar University, Evliya
Celebi Campus, Kutahya, Turkey
© 2018 Taylor & Francis
2 G. KALLEM SEYYAR ET AL.
there was a link between postural control and functionality21 functional capabilities and performance of chronically ill or
but studies assessing postural control by means of scales and disabled children. Its reliability and validity were shown in
functional tests or during daily functional activities were children with CP. The PEDI has three domains: functional
lacking.25 In this context, the aim of our study was to investi- skills, caregiver assistance, and social functions. Each domain
gate the relationship between trunk control in sitting and has three subscales: self care, mobility, and social function.
functionality in children with spastic CP. Each domain of the PEDI can be used independently. In our
study, we used the Functional Skills domain of PEDI (PEDI-
FSD). The PEDI-FSD is performed by observing the func-
Methods tional behavior of the child in a controlled manner or asking
Participants to one of the family members. PEDI-FSD includes 197 items.
The items are scored on two-point ordinal scale (0 = cannot
The children with the diagnosis of spastic CP who met the do, 1 = can do). The total PEDI-FSD score can be obtained by
following inclusion criteria were recruited for the study: (1) adding the subscale scores of PEDI-FSD.28
children between the ages of 5 and 18 years, (2) able to sit
without any support at least 30 seconds, (3) between the levels Trunk Control Measurement Scale and Trunk Impairment
of one and four according to the Gross Motor Function Scale
Classification System (GMFCS), and (4) ability to compre- Trunk control in sitting was tested with the Trunk Control
hend commands. The children who had any operation con- Measurement Scale (TCMS) and the Trunk Impairment Scale
cerning musculoskeletal system, intrathecal baclofen pump, (TIS). The TCMS was developed to assess trunk control in
botulinum toxin injection therapy within the last 6 months, children with CP. The TCMS is an expanded version of the
and severe visual, hearing, and cognitive deficits were not TIS, which includes more information about selective control
included in the study. and reaching. The tool is divided into three subscales: static
sitting balance (SSB), dynamic sitting balance, selective move-
Measures ment control (DSB-S), and reaching (DSB-R). It contains 15
items in total. The items are scored on a two-, three-, or four-
Gross Motor Function Classification System point scale. The maximum scores of the subscales are 20, 28,
The GMFCS is a valid and reliable method that is used to and 10, respectively. Total score of the TCMS ranges from 0
classify the patterns of motor disability in children with CP, (low performance) to 58 (high performance). Its reliability
on the basis of self-initiated movement with emphasis on and validity were shown in children and adolescents with
sitting, transfers, and mobility. GMFCS is used between the CP, aged 8 to 15 years.29,30
ages of 1 and 18 years. GMFCS comprises five age intervals and The TIS was originally developed to evaluate the trunk in
levels. The focus is to determine the level that best reflects the patients with stroke. The tool is divided into three subscales:
present abilities and limitations of the child and youth in static sitting balance (TIS-SSB), dynamic sitting balance (TIS-
relation to gross motor functions. Differences between these DSB), and coordination (TIS-C). It has 17 items and each
levels are based on functional limitations, the need for assistive item is scored on 2- to 4-point ordinal scale. The maximum
mobility devices, or wheeled mobility, and to a lesser extent, scores of the subscales are 7, 10, and 6, respectively. The total
quality of movement. Children at GMFCS level I are capable of score of TIS changes in the range of 0–23 (0 = worst perfor-
walking without any limitations, while those at level V have mance, 23 = best performance). Its reliability and validity
severe limitations of body control and need assisted technology were shown in children and adolescents with CP between
and physical assistance for activities of daily living.26 the ages of 5 and 19 years.31
back, and feet support. The child started each item with the III, and 10 as level IV. Demographic characteristics of chil-
trunk in its most upright position and asked to maintain this dren were shown in Table 1.
position as much as possible during the performance of the The mean total scores of the TCMS and TIS for all the
items. The TIS was performed while the child was sitting on a children who participated in the study were 32.91 ± 14.67 and
bench with the hands and forearms resting on their thighs 10.68 ± 5.27, respectively. The total scores of the GMFM-88
without a back support. The thighs made full contact with the and PEDI-FSD and, in addition to total scores, subscale scores
bed or table; the feet were hip width apart and placed flat on of the TCMS and TIS are shown and compared in Table 2.
the floor. While performing the items, the head and trunk Comparison of the total scores of the GMFM-88 and PEDI-
were in midline position. For both the tests, three evaluations FSD showed significant differences between topographies
were done for each item, and best of these performances was (p < 0.05). Children with unilateral spastic CP (hemiplegic)
used for statistical analysis. showed significantly higher scores than children with bilateral
spastic CP (diplegic and quadriplegic) in both total and sub-
scale scores of the TCMS and TIS (p < 0.05).
Statistical analysis According to the Kruskal–Wallis Test, children with hemi-
plegia showed significantly higher scores than children with
Distribution analysis using the Shapiro–Wilk test indicated diplegia and quadriplegia in both total and subscale scores of
that variables were not normally distributed. The total scores the TCMS and TIS (p < 0.05). There were no significant
of the TCMS and TIS, and subscale scores of both scales differences between diplegic and quadriplegic children in
were compared between each topography by using Mann– total and subscale scores of the TCMS and TIS (p > 0.05),
Whitney U test, Kruskal–Wallis test, and all pairwise com- except static sitting balance subscale of the TIS (chi
parisons. The total and subscale scores of the TCMS and TIS square = 21.524, p < 0.05). Diplegic children scored higher
were compared with dimension and total scores of the than quadriplegic children in this subscale (p < 0.05).
GMFM-88 and PEDI-FSD by means of Spearman correlation Spearman correlation coefficients between the TCMS, TIS,
analysis. As proposed by Portney and Watkins,32 correlation and GMFM-88 were summarized in Table 3. The total score
coefficients between 0 and 0.25 may be considered to indi- of the GMFM-88 was significantly correlated with the total
cate little or no relationship, between 0.25 and 0.50 low,
between 0.50 and 0.75 moderate to good, and above 0.75
may be considered to indicate a good to excellent relation-
ship. The level of significance was set at 0.05. All of the Table 1. Demographic characteristics of children.
statistical analyses were carried out using SPSS 15.0 Type of CP
(Chicago, IL, USA) statistic package software. Unilateral Spastic CP Bilateral Spastic CP
Hemiplegic Diplegic Quadriplegic
n = 20 n = 31 n=7
Results Age, years (mean ± SD) 7.60 ± 2.64 8.67 ± 3.33 10.71 ± 3.30
(min–max) (5–15) (5–15) (6–15)
Fifty-eight children with spastic CP (39 males, 19 females) Gender Male (n) 15 20 4
Female (n) 5 11 3
with the mean age of 8.55 ± 3.19 years were included in the GMFCS level I 10 3 –
study. Twenty-seven children were under the age of 8 years II 10 15 –
III – 8 2
(5.92 ± 0.91 years). Twenty children had unilateral and 38 IV – 5 5
children had bilateral spastic CP. According to the GMFCS, SD: standard deviation; min: minimum; max: maximum; n: number; CP: cerebral
13 children were classified as level I, 25 as level II, 10 as level palsy; GMFCS: Gross Motor Function Classification System.
Table 2. Comparison of the GMFM-88, PEDI-FSD, TCMS, and TIS according to the SCPE classification.
Unilateral Bilateral
Spastic CP Spastic CP
(mean ± SD) (mean ± SD) Z p
GMFM-88 total 94.25 ± 4.44 68.47 ± 22.40 −5.338 0.000
PEDI-FSD total 164.80 ± 27.66 137.50 ± 36.63 −2.790 0.005
TCMS total (max: 58) 44.15 ± 8.44 27.00 ± 13.81 −4.395 0.000
Static sitting balance 18.80 ± 1.67 12.92 ± 5.53 −4.416 0.000
(SSB) (max:20)
Selective movement control 16.35 ± 6.44 9.05 ± 5.72 −3.605 0.000
(DSB-S) (max: 28)
Dynamic reaching 9.00 ± 1.74 5.02 ± 3.22 −4.535 0.000
(DSB-R) (max: 10)
TIS total (max: 23) 14.45 ± 5.05 8.71 ± 4.26 −3.693 0.000
Static sitting balance 6.80 ± 0.41 5.26 ± 1.82 −3.912 0.000
(SSB) (max: 7)
Dynamic sitting balance 4.55 ± 3.05 2.02 ± 1.95 −3.155 0.002
(DSB) (max: 10)
Coordination 3.10 ± 2.07 1.42 ± 1.08 −3.167 0.002
(TIS-C) (max: 6)
SD: standard deviation; max: maximum; GMFM-88: Gross Motor Function Measurement-88; PEDI-FSD: Pediatric Evaluation of Disability Inventory, Functional Skills
Domain; TCMS: Trunk Control Measurement Scale; TIS: Trunk Impairment Scale, Z: Mann–Whitney U test.
4 G. KALLEM SEYYAR ET AL.
Table 3. Spearman correlation coefficients (rho) between the TCMS, TIS, and Table 5. Spearman correlation coefficients (rho) between the TCMS, TIS, and the
GMFM-88. PEDI-FSD.
GMFM-88 PEDI-FSD
N = 58 A B C D E Total N = 58 Self care Mobility Social function Total
TCMS total score 0.630** 0.729** 0.778** 0.889** 0.898** 0.903** TCMS total score 0.628** 0.875** 0.346* 0.767**
Static sitting balance 0.664** 0.790** 0.827** 0.913** 0.895** 0.930** Static sitting balance (SSB) 0.541** 0.895** ns 0.704**
(SSB) Selective movement control 0.648** 0.785** 0.428** 0.755**
Selective movement 0.518** 0.598** 0.642** 0.786** 0.821** 0.785** (DSB-S)
control (DSB-S) Dynamic reaching (DSB-R) 0.551** 0.782** 0.283* 0.673**
Dynamic reaching 0.627** 0.695** 0.758** 0.810** 0.808** 0.844** TIS total score 0.618** 0.784** 0.374* 0.727**
(DSB-R) Static sitting balance (SSB) 0.535* 0.856** ns 0.671**
TIS total score 0.508** 0.608** 0.640** 0.789** 0.824** 0.787** Dynamic sitting balance 0.561** 0.662** 0.412* 0.658**
Static sitting balance 0.683** 0.809** 0.822** 0.860** 0.832** 0.897** (DSB)
(SSB) Coordination (TIS-C) 0.526** 0.569** 0.344* 0.580**
Dynamic sitting 0.339* 0.429* 0.468** 0.639** 0.712** 0.625** PEDI-FSD: Pediatric Evaluation of Disability Inventory, Functional Skills Domain;
balance (DSB) TCMS: Trunk Control Measurement Scale; TIS: Trunk Impairment Scale;
Coordination (TIS-C) 0.383* 0.432* 0.458* 0.617** 0.640** 0.598** N: number;, ns: nonsignificant.
GMFM-88: Gross Motor Function Measurement-88; TCMS: Trunk Control *p < 0.05, **p < 0.01.
Measurement Scale; TIS: Trunk Impairment Scale; N: number.
*p < 0.05, **p < 0.01.
with other subtypes according to the classification of SCPE.
scores of TCMS (rho = 0.90, p < 0.01) and TIS (rho = 0.78, Mendoza et al.35 also found similar results. In our study, children
p < 0.01). Correlation coefficients between other dimensions with unilateral spastic CP (hemiplegic) showed better perfor-
were significant and varied between rho = 0.33 (p < 0.05) and mance in trunk control scores than children with bilateral spastic
rho = 0.91 (p < 0.01). Spearman correlation coefficients CP (diplegic and quadriplegic) in accordance with the previous
between the TCMS, TIS, and GMFM-88 of children under studies.
the age of 8 years are shown in Table 4. Mendoza et al.35 mentioned that within bilateral spastic CP,
Spearman correlation coefficients between the TCMS, TIS, children could have very different sitting abilities. In their study,
and PEDI-FSD are summarized in Table 5. There were mod- diplegic children had higher trunk scores than quadriplegic chil-
erate to good and good to excellent correlations between the dren. For this reason, we also compared the trunk scores of
total scores of the TCMS and TIS with PEDI-FSD (p < 0.01). hemiplegic, diplegic, and quadriplegic children with each other.
In a study performed by Heyrman et al.30 hemiplegic children
obtained significantly higher scores than children with diplegia
Discussion except for the SSB subscale of TCMS. On this subscale, children
Clinical measures provide a more practical means for clinicians with hemiplegia and diplegia showed only minor problems with
and clinical researchers of assessing sitting balance and quantify- no differences found between these two topographies. In his study,
ing intervention outcomes. In a systematic review of sitting bal- children with quadriplegia obtained the lowest scores in total and
ance measures, Banas et al.33 identified seven measures which subscale scores of the TCMS. In our study, children with hemi-
included the TCMS and TIS. Both the tests assess static and plegia achieved higher scores than children with diplegia and
dynamic aspects of trunk control in a short time without using quadriplegia in total and subscale scores of the TCMS and TIS.
any equipment or materials. In our study, we used the TCMS and In addition, we found no significant differences between diplegic
TIS together in order to see whether the shorter and less time- and quadriplegic children in total and subscale scores of the TCMS
consuming TIS would show equally good correlation with func- and TIS except TIS-SSB subscale, in which diplegic children scored
tional abilities as more detailed and time-consuming TCMS. higher than quadriplegic children. According to our findings,
In our study, trunk control was found to be impaired in when evaluating activities that require static control of the trunk,
children with spastic CP. The median total scores of the TCMS using TIS-SSB subscale may be more appropriate as it had better
and TIS were 56% and 46% of the maximal scores of the scales, ability to differentiate trunk impairment according to
respectively. Previous studies indicated that degree of trunk topographies.
impairment depended on the severity and topography of motor The acquisition of sitting postural control has proven to be a
impairment in CP. Bousquet et al.34 found that children with predictor of function in both children and adults with neurological
spastic unilateral CP predicted better sitting ability than children damage.16,36 Studies have shown that achieving sitting balance
Table 4. Spearman correlation coefficients between the TCMS, TIS, and GMFM-88 in children under the age of 8 years.
GMFM-88
n = 27 A B C D E Total
TCMS total score 0.477* 0.690** 0.765** 0.872** 0.877** 0.889**
Static sitting balance (SSB) 0.480* 0.694** 0.778** 0.806** 0.834** 0.837**
Selective movement control (DSB-S) 0.475* 0.640** 0.673** 0.832** 0.798** 0.823**
Dynamic reaching (DSB-R) 0.416* 0.647** 0.817** 0.848** 0.882** 0.868**
TIS total score 0.453* 0.675** 0.656** 0.777** 0.814** 0.828**
Static sitting balance (SSB) 0.516** 0.758** 0.840** 0.839** 0.889** 0.898**
Dynamic sitting balance (DSB) 0.394* 0.556** 0.590** 0.654** 0.714** 0.717**
Coordination (TIS-C) 0.459* 0.569** 0.509** 0.712** 0.695** 0.715**
GMFM-88: Gross Motor Function Measurement-88; TCMS: Trunk Control Measurement Scale; TIS: Trunk Impairment Scale; n: number.
*p < 0.05, **p < 0.01.
DEVELOPMENTAL NEUROREHABILITATION 5
before 2 years of age can predict walking in children with all forms identify sitting balance problems, describe change in sitting bal-
of CP.23,37 The GMFM-88 and PEDI are frequently used instru- ance over time, and estimate the impact of sitting balance
ments for measuring baseline functional outcomes and the interventions.33 The TCMS was found to be reliable and valid in
changes of intervention results in children with CP.38,39 We used children between the ages of 8 and 15 years. However, the relia-
both scales together because they evaluate different aspects of bility and the validity of the TCMS have not been assessed in
functional abilities. While the GMFM-88 is based on normal children under the age of 8 years. In their studies, Heyrman et al.29
motor development and basically evaluates gross motor functions, only included children from the age of 8 to 15 years because before
PEDI measures the ability to perform activities which are used in this age, developmental adjustments during voluntary activity are
daily life. The relationship between functional abilities and sitting still in a transitional phase. Saether et al.31 showed that measure-
postural control was significant in previous studies. Curtis et al.40 ment of trunk activity using the TIS was possible in children aged
investigated the relation between trunk control evaluated with the 5 years. For that reason, we decided to include children from the
Segmental Assessment of Trunk Control (SATCo) and PEDI by age of 5 years as long as they were able to understand the instruc-
using linear modeling and found positive relation between the tions. In the study of Heyrman et al.,29 the construct validity of
SATCo and PEDI. Pham et al.41 found significant relation between TCMS was evaluated by comparing the TCMS subtotals and total
the TIS, TCMS, and GMFM-66, correlation coefficients ranged score with dimension scores and total score of the GMFM by
from 0.64 to 0.75 for TIS and 0.57 to 0.72 for TCMS according to means of Spearman correlation analysis. In our study, strong
Spearman correlation analysis. In the study of Saether et al.,31 the correlation between the GMFM-88 and TCMS supports good
total and subscale scores of the TIS were significantly correlated construct validity of the TCMS between the ages of 5 and 15
with dimension scores of the GMFM (dimensions B, D, and E), years, but further studies should be performed in order to inves-
with correlation coefficients varying between 0.62 and 0.87. tigate the use of the TCMS in children younger than 8 years of age.
According to Jeon et al.,42 the Spearman rank correlation coeffi- The definition of CP underscores the notion that there is large
cient between the TCMS and GMFM-B dimension was 0.86. In variation among children diagnosed with CP. The limitation of
our study, close parallel to those of previous studies, trunk control our study is to include only children with spastic CP and exclude
evaluated with the TCMS and TIS, both correlated strongly with the other types as ataxic and dyskinetic. Further research is
the GMFM-88 and PEDI-FSD, but the correlation coefficients of needed in order to evaluate clinical characteristics of trunk con-
the TCMS were higher than TIS. The TIS was originally developed trol in these children. In conclusion, this study supports earlier
for patients with stroke who have unilateral involvement, and studies related to trunk control and functionality, with a further
assesses selective movements of the trunk in frontal and transvers evidence that trunk control in sitting is strongly related with
planes. On the other hand, the TCMS was developed specifically functions in children with spastic CP. Evaluation of trunk control
for individuals with CP who have both unilateral and bilateral by using the TCMS can provide valuable information for trunk
involvements. In addition to frontal and transverse planes in the control impairments when compared to the TIS with higher
TIS, TCMS evaluates trunk movements in sagittal plane. When correlation coefficients with functional measures.
compared to the TIS, TCMS is a more time-consuming assessment
of trunk control, but in our opinion, it may have a higher potential
to determine trunk control deficits as its correlation coefficients Declaration of interest
were higher than the TIS.
In a previous study which was performed by Heyrman et al.,29 The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
all dimension scores of the GMFM-88 correlated significantly
with the total and subscale scores of TCMS, except dimension
A. In contrast to Heyrman’s study, we found moderate-to-good
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