Trunk Impairment Scale
Original Editor - Gayatri Jadav Upadhyay
Top Contributors - Gayatri Jadav Upadhyay, Kristen Holeman, Ajay Upadhyay, Alexandra Stead, Vidya Acharya, 127.0.0.1, WikiSysop and Kim Jackson
Introduction
The Trunk Impairment Scale (TIS) is a 17-item, performance-based assessment of static sitting balance, dynamic sitting balance, and trunk coordination following stroke. Scores range from 0–23, with higher scores indicating better trunk function.[1]
Intended Population
Patients following stroke with trunk motor and postural control impairments as well as patients with brain injury, Cerebral Palsy, Multiple Sclerosis, and Parkinson's Disease.[1][2][3][4]
Available Versions
The TIS was originally developed in English and has since been translated and culturally adapted into several languages, including Norwegian (TIS-modNV)[5], Spanish[6], Polish[7], Korean[8], Italian (TIS-I)[9], and Turkish[10]. The Norwegian version was modified following psychometric analysis, while the Spanish version was developed from the TIS 2.0.
Method of Use
Equipment Required
- Examination table/Plinth
- Stopwatch
- Scoresheet
The Scale
As described by Verheyden,[1] the TIS is a 17-item performance-based assessment performed with the patient in an unsupported sitting position. It assesses three components of trunk function following stroke:
- Static sitting balance
- Dynamic sitting balance
- Trunk coordination
Static sitting balance
This assesses the patient's ability to maintain an unsupported sitting position with the feet supported. The patient is assessed while maintaining the starting position and while the unaffected leg is crossed over the affected leg, both passively by the therapist and actively by the patient. Performance is scored based on the ability to maintain balance without upper extremity support, excessive trunk displacement, or assistance. The maximum score for this subscale is 7 points.
Dynamic sitting balance
This assesses the patient's ability to perform selective lateral trunk movements while maintaining postural control. The patient is asked to shorten and lengthen each side of the trunk by bringing the elbow toward the supporting surface and by lifting each side of the pelvis from the surface. Performance is evaluated based on the ability to complete these movements without loss of balance, upper extremity support, or compensatory movements. The maximum score for this subscale is 10 points.
Trunk coordination
This assesses the patient's ability to selectively rotate the upper and lower trunk. The patient performs repeated rotations of the shoulder girdle while stabilising the lower trunk, followed by repeated rotations of the pelvic girdle while stabilising the upper trunk. Movements are assessed for symmetry and speed, with six alternating rotations performed for each task. The maximum score for this subscale is 6 points.
Scale Items
| Item | Patient Response | Score | |
|---|---|---|---|
| Static Sitting Balance | |||
| 1 | Starting position | Patient falls or cannot maintain starting position for 10 seconds without arm support | 0 |
| Patient can maintain starting position for 10 seconds | 2 | ||
| If score = 0, then TIS total score = 0 | |||
| 2 | Therapist crosses the unaffected leg over the hemiplegic leg | Patient falls or cannot maintain sitting position for 10 seconds without arm support | 0 |
| Patient can maintain sitting position for 10 seconds | 2 | ||
| 3 | Patient crosses the unaffected leg over the hemiplegic leg | Patient falls | 0 |
| Patient cannot cross the legs without arm support on bed or table | 1 | ||
| Patient crosses the legs but displaces the trunk more than 10cm backwards or assists crossing with the hand | 2 | ||
| Patient crosses the legs without trunk displacement or assistance | 3 | ||
| Total Sitting Balance Score | /7 | ||
| Dynamic Sitting Balance | |||
| 1 | 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 | Patient falls, needs support from an upper extremity or the elbow does not touch the bed or table | 0 |
| Patient moves actively without help, elbow touches bed or table | 1 | ||
| If score = 0, then items 2 and 3 score 0 | |||
| 2 | Repeat item 1 | Patient demonstrates no or opposite shortening/lengthening | 0 |
| Patient demonstrates appropriate shortening/lengthening | 1 | ||
| If score = 0, then item 3 scores 0 | |||
| 3 | Repeat 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 than proximal half of femur), (4) knee flexion, (5) sliding of the feet | 0 |
| Patient moves without compensation | 1 | ||
| 4 | Patient is instructed to touch the bed or table with the unaffected elbow (by shortening the unaffected side and lengthening the hemiplegic side) and return to the starting position | Patient falls, needs support from an upper extremity or the elbow does not touch the bed or table | 0 |
| Patient moves actively without help, elbow touches bed or table | 1 | ||
| If score = 0, then items 5 and 6 score 0 | |||
| 5 | Repeat item 4 | Patient demonstrates no or opposite shortening/lengthening | 0 |
| Patient demonstrates appropriate shortening/lengthening | 1 | ||
| If score = 0, then item 6 scores 0 | |||
| 6 | 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 than proximal half of femur), (4) knee flexion, (5) sliding of the feet | 0 |
| Patient moves without compensation | 1 | ||
| 7 | Patient is instructed to lift pelvis from bed or table at the hemiplegic side (by shortening the hemiplegic side and lengthening the unaffected side) and return to starting position | Patient demonstrates no or opposite shortening/lengthening | 0 |
| Patient demonstrates appropriate shortening/lengthening | 1 | ||
| If score=0, then item 8 scores 0 | |||
| 8 | Repeat item 7 | Patient compensates. Possible compensations are: (1) use of upper extremity, (2) pushing off the ipsilateral foot (heel loses contact with the floor) | 0 |
| Patient moves without compensation | 1 | ||
| 9 | Patient is instructed to lift pelvis from bed or table at the unaffected side (by shortening the unaffected side and lengthening the hemiplegic side) and return to starting position | Patient demonstrates no or opposite shortening/lengthening | 0 |
| Patient demonstrates appropriate shortening/lengthening | 1 | ||
| If score = 0, then item 10 scores 0 | |||
| 10 | Repeat item 9 | Patient compensates. Possible compensations are: (1) use of upper extremity, (2) pushing off the ipsilateral foot (heel loses contact with the floor) | 0 |
| Patient moves without compensation | 1 | ||
| Total Dynamic Sitting Balance Score | /10 | ||
| Coordination | |||
| 1 | Patient is instructed to rotate upper trunk 6 times (every shoulder should be moved forward 3 times), first side that moves must be hemiplegic side, head should be fixated in starting position | Hemiplegic side is not moved three times | 0 |
| Rotation is asymmetrical | 1 | ||
| Rotation is symmetrical | 2 | ||
| If score = 0, then item 2 scores 0 | |||
| 2 | Repeat item 1 within 6 seconds | Rotation is asymmetrical | 0 |
| Rotation is symmetrical | 1 | ||
| 3 | Patient is instructed to rotate lower trunk 6 times (every knee should be moved forward 3 times), first side that moves must be hemiplegic side, head should be fixated in starting position | Hemiplegic side is not moved three times | 0 |
| Rotation is asymmetrical | 1 | ||
| Rotation is symmetrical | 2 | ||
| If score = 0, then item 4 scores 0 | |||
| 4 | Repeat item 3 within 6 seconds | Rotation is asymmetrical | 0 |
| Rotation is symmetrical | 1 | ||
| Total Coordination Score | /6 | ||
| Total Trunk Impairment Scale Score | /23 | ||
Interpretation
The total TIS score ranges from 0 to 23 points, with higher scores indicating better trunk function.[1][2] [12] Due to a ceiling effect within the static sitting balance subscale, Verheyden and Kersten developed the TIS 2.0, which excludes the static sitting balance items. The TIS 2.0 therefore has a total score ranging from 0 to 16 points.[2]
Evidence
The TIS has been widely used to assess trunk control following stroke and has been evaluated across acute, subacute, and chronic stroke populations.[1] Studies have investigated its reliability, validity, measurement error, and responsiveness. A recent systematic review evaluated 13 studies examining the psychometric properties of the Verheyden TIS following stroke.[12]
Reliability
The TIS has demonstrated acceptable to excellent internal consistency, with Cronbach's α values ranging from 0.726 to 0.931 across individual studies.[12] A recent meta-analysis of six studies reported a pooled Cronbach's α of 0.88 (95% CI 0.83–0.91).[12]
Intra- and inter-rater reliability have also been demonstrated to be high. Across five studies, intra-rater reliability ranged from intraclass correlation coefficient (ICC) 0.911 to 0.99, while inter-rater reliability ranged from ICC 0.933 to 0.992. Pooled estimates demonstrated a mean ICC of 0.98 for both intra-rater and inter-rater reliability.[12]
Studies examining measurement error reported standard error of measurement (SEM) values ranging from 0.24 to 3.68 and a minimal detectable change at the 95% confidence level (MDC95) values ranging from 0.67 to 4.55 points, indicating variability across study populations and settings.[12]
Validity
The TIS has demonstrated associations with established measures of balance and trunk function following stroke. Strong correlations have been reported with the Berg Balance Scale (r = 0.81) and Trunk Control Test (r = 0.81–0.83). One study reported an area under the curve (AUC) of 0.94 for identifying levels of independent sitting balance.[12]
Construct validity has also been investigated, with generally moderate to strong associations reported between the TIS and related measures of balance, mobility, and functional performance. However, available studies did not establish predefined hypotheses regarding expected relationships between measures, limiting conclusions regarding construct validity.[12]
Cross-cultural adaptations of the TIS have also been investigated. However, methodological limitations, including small sample sizes and insufficient reporting, currently limit conclusions regarding measurement equivalence across languages and cultural settings.[12]
Responsiveness
The TIS has demonstrated the ability to detect changes in trunk function over time following stroke. Studies examining responsiveness reported effect sizes ranging from 0.633 to 0.997, standardised response means (SRM) ranging from 0.985 to 1.634, and AUC values ranging from 0.709 to 0.94, suggesting good to excellent responsiveness.[12]
Estimates of minimal important change (MIC) vary according to the stage of stroke recovery. One study reported an MIC of 3.5 points in individuals with acute stroke and 2.5 points in individuals with chronic stroke as measured with the original Verheyden TIS, distinct from Fujiwara-version estimates.[12] These values should be interpreted within the population and methodology in which they were established rather than applied as universal thresholds.
Certainty of Evidence
Despite generally favourable findings for several psychometric properties, the overall certainty of evidence supporting the TIS remains limited. Using a modified GRADE approach, a 2026 COSMIN systematic review rated the certainty of evidence as low for internal consistency and very low for the remaining nine measurement properties, including reliability, validity, measurement error, and responsiveness.[12]
These ratings largely reflect limitations in the quality and reporting of the available research, rather than poor performance of the TIS itself. Limitations included inconsistent study methods, lack of clearly defined hypotheses, limited reporting of cross-cultural adaptations, and differences in rater training and retest procedures.[12]
Limitations
Several limitations should be considered when using the TIS. Multiple versions and culturally adapted translations are available, with differences in item structure and scoring that may limit direct comparison across versions and studies. Ceiling effects have been reported within the static sitting balance subscale of the original TIS, contributing to its removal in TIS 2.0, while floor effects have also been identified in some stroke populations.[12] As a performance-based measure, scores may be influenced by factors such as fatigue, attention, ability to follow instructions, and other impairments that affect task performance. Differences in administration, scoring, and rater training may also affect consistency across clinicians and settings.[12] Additionally, because the TIS primarily evaluates trunk control in sitting, it may not fully represent trunk performance during standing, walking, or more complex functional activities.
Summary
The TIS is a performance-based outcome measure used to assess trunk function used in individuals with stroke or other neurological conditions, including acquired brain injury, cerebral palsy, multiple sclerosis, and Parkinson’s disease.[4] It evaluates static sitting balance, dynamic sitting balance, and trunk coordination.[1] The original 17-item scale has a maximum score of 23 points, with higher scores indicating better trunk function, while the TIS 2.0 excludes the static sitting balance subscale.[1] [2] Overall, the TIS is a practical clinical measure with generally favourable reliability, validity, and responsiveness, although the certainty of available evidence remains limited.[12]
Resources
Trunk Impairment Scale - Shirley Ryan
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Verheyden G, Mertin J, Preger R, Kiekens C, De Weerdt W. The Trunk Impairment Scale: A new tool to measure motor impairment of the trunk after stroke. Clin Rehabil. 2004;18(3):326-34
- ↑ 2.0 2.1 2.2 2.3 Verheyden G, Kersten P. Investigating the internal validity of the Trunk Impairment Scale (TIS) using Rasch analysis: the TIS 2.0. Disabil Rehabil. 2010;32(25):2127-37.
- ↑ Fujiwara T, Liu M, Tsuji T, Sonoda S, Mizuno K, Akaboshi K, et al. Development of a new measure to assess trunk impairment after stroke (Trunk Impairment Scale): its psychometric properties. Am J Phys Med Rehabil. 2004;83(9):681-8.
- ↑ 4.0 4.1 Academy of Neurologic Physical Therapy. ANPT Outcome Measures Recommendations (EDGE) [Internet]. Roseville (MN): Academy of Neurologic Physical Therapy; [cited 2026 Sep 11]. Available from: ANPT Outcome Measures Recommendations (EDGE)
- ↑ Gjelsvik B, Breivik K, Verheyden G, Smedal T, Hofstad H, Strand LI. The Trunk Impairment Scale—modified to ordinal scales in the Norwegian version. Disabil Rehabil. 2012;34(16):1385-95.
- ↑ Cabanas-Valdés R, Urrútia G, Bagur-Calafat C, Caballero-Gómez FM, Germán-Romero A, Girabent-Farrés M. Validation of the Spanish version of the Trunk Impairment Scale Version 2.0 (TIS 2.0) to assess dynamic sitting balance and coordination in post-stroke adult patients. Top Stroke Rehabil. 2016;23(4):225-32.
- ↑ Małecka J, Goliwąs M, Adamczewska K, Lewandowski J, Verheyden G, Łochyński D. Translation, reliability, and validity of the Trunk Impairment Scale in a Polish population after stroke. J Rehabil Med. 2026;58:jrm44789.
- ↑ Seo HD, Kim NJ, Chung YJ. Reliability of the Korean Version of the Trunk Impairment Scale in patients with stroke. Phys Ther Korea 2008; 15: 87–96.
- ↑ Lombardi B, Orioli A, Casavola D, Paci M. The Italian version of the Trunk Impairment Scale: development and psychometric properties. Eur J Phys Rehabil Med. 2017;53(4):516-20.
- ↑ Sag S, Buyukavci R, Sahin F, Sag MS, Dogu B, Kuran B. Assessing the validity and reliability of the Turkish version of the Trunk Impairment Scale in stroke patients. North Clin Istanb. 2019;6(2):156-65.
- ↑ Verheyden G. Trunk Impairment Scale: instruction video. Available from: www.youtube.com/watch?v=-9tiR-V2UTM&t=1s [last accessed 11/9/2026].
- ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 12.13 12.14 12.15 Eguchi M, Jimbo K, Nomoto M, Koja T, Komatsu M, Miyata K. The psychometric properties of the Trunk Impairment Scale used after stroke: a systematic review using COSMIN methodology. Phys Ther. 2026 Jul 02 [Online ahead of print].