Developmental Neurorehabilitation

ISSN: 1751-8423 (Print) 1751-8431 (Online) Journal homepage: https://www.tandfonline.com/loi/ipdr20

Trunk control and functionality in children with

spastic cerebral palsy

Gulce Kallem Seyyar, Bahar Aras & Ozgen Aras

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

To link to this article: https://doi.org/10.1080/17518423.2018.1460879

Published online: 13 Apr 2018.

Submit your article to this journal

Article views: 183

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ipdr20
DEVELOPMENTAL NEUROREHABILITATION
https://doi.org/10.1080/17518423.2018.1460879

Trunk control and functionality in children with spastic cerebral palsy

Gulce Kallem Seyyara, Bahar Arasa, and Ozgen Arasa
a
School of Health Sciences, Department of Physical Therapy and Rehabilitation, Dumlupinar University, Kutahya, Turkey

ABSTRACT ARTICLE HISTORY

Purpose: To investigate the relationship between trunk control in sitting and functionality in children Received 13 December 2017
with spastic cerebral palsy (CP). Revised 15 February 2018
Methods: Fifty-eight children with spastic CP were included in the study. Functional abilities were Accepted 31 March 2018
evaluated with the Gross Motor Function Measurement-88 (GMFM-88) and the Pediatric Evaluation of KEYWORDS
Disability Inventory Functional Skills domain (PEDI-FSD). Trunk control in sitting was tested with the Cerebral palsy; functional
Trunk Control Measurement Scale (TCMS) and the Trunk Impairment Scale (TIS). The scores of the TCMS abilities; trunk control
and TIS were compared with GMFM-88 and PEDI-FSD with Spearman correlation analysis.
Results: The total score of GMFM-88 was significantly correlated with the total score of TCMS (rho = 0.90,
p < 0.01) and TIS (rho = 0.78, p < 0.01). The total score of PEDI-FSD was also significantly correlated with
the total score of TCMS (rho = 0.76, p < 0.01) and TIS (rho = 0.72, p < 0.01).
Conclusions: The evaluation of trunk control can provide valuable information for functional abilities of
children with spastic CP.

Introduction were found to be altered when compared to healthy peers.12,13

In these children, onset latencies of postural muscle activity
Cerebral palsy (CP) is defined as “a group of permanent dis-
are quite delayed despite hyperactive stretch reflexes in spastic
orders of the development of movement and posture, causing
muscles. There is also a poor selective control of muscle
activity limitation, that are attributed to non-progressive dis-
activity and poor regulation of activity in muscle groups in
turbances that occurred in the developing fetal or infant brain.”
anticipation of postural changes and body movements which
The motor disorders present in CP are often accompanied by
result in impaired postural control.14
disturbances of sensation, perception, cognition, communica-
Trunk control, which is an initial frame of reference for
tion, and behavior, by epilepsy, and by secondary musculoske-
postural control, involves stabilization and selective movements
letal problems.1 CP is the most common cause of severe
of the trunk.15 This stabilization is essential for free and selec-
neuromotor disorder in children with worldwide prevalence
tive movements of the head and the extremities.16 Trunk con-
of 2.11 per 1000 live births.2 There are several classification
trol ensures the acquisition of gross motor skills that are basic
systems that exist in order to define the types of CP. According
for the development of goal-directed activities, which are essen-
to the Surveillance of Cerebral Palsy in Europe (SCPE), CP is
tial for independent life at home or in community.17 A stable
classified as spastic, ataxic, and dyskinetic CP based on the
trunk also allows for the development of the child’s social,
predominant neurological findings.3 Spastic CP is the most
cognitive, and communicative skills by increasing orientation
common type of CP. It occurs in 70–80% of all cases.4 It is
of the child to him/herself and environment.18,19
further classified as unilateral (hemiplegic) and bilateral (diple-
Postural control problems, including problems of trunk
gic and quadriplegic) spastic CP.3 The features of spastic CP
control, play a central role in the motor dysfunction of children
include increased muscle tone and pathologic reflexes, resulting
with CP.20 In literature, there are lots of studies concerning
in abnormal pattern of movement, developmental abnormality
postural control, but most of them focused on standing.21,22
in motor functions, and postural control.5
Many of the children with CP cannot obtain standing position
Postural control involves controlling the body’s position in
because of the small support surface that puts high demands on
space for the purposes of stability and orientation.6,7
the postural control system.12 Approximately one-third of these
Maintaining a stable posture demands complex interactions
children spend most of their times in sitting position.23 There is
between central and peripheral nervous systems, and muscu-
a growing interest in the sitting posture of children with CP,
loskeletal system.8–10 These interactions are known to be
especially in studies that aim to increase the functional abilities
affected in children with CP, because of the brain damage
of these children.19,24 Sitting is the best suitable posture to
that causes spasticity, decreased isometric force production,
assess functional level and balance ability, as it is their main
abnormal timing, reduced amplitude of muscle recruitment,
posture for activities of daily living.12 A review of the assess-
sensory loss, and secondary musculoskeletal impairments.11
ment of postural control in children with CP indicated that
In children with spastic CP, postural control mechanisms

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
but studies assessing postural control by means of scales and
functional tests or during daily functional activities were
lacking.25 In this context, the aim of our study was to investi-
gate the relationship between trunk control in sitting and
functionality in children with spastic CP.
Methods
Participants
The children with the diagnosis of spastic CP who met the
following inclusion criteria were recruited for the study: (1)
children between the ages of 5 and 18 years, (2) able to sit
without any support at least 30 seconds, (3) between the levels
of one and four according to the Gross Motor Function
Classification System (GMFCS), and (4) ability to compre-
hend commands. The children who had any operation con-
cerning musculoskeletal system, intrathecal baclofen pump,
botulinum toxin injection therapy within the last 6 months,
and severe visual, hearing, and cognitive deficits were not
included in the study.
Measures
Gross Motor Function Classification System
The GMFCS is a valid and reliable method that is used to
classify the patterns of motor disability in children with CP,
on the basis of self-initiated movement with emphasis on
sitting, transfers, and mobility. GMFCS is used between the
ages of 1 and 18 years. GMFCS comprises five age intervals and
levels. The focus is to determine the level that best reflects the
present abilities and limitations of the child and youth in
relation to gross motor functions. Differences between these
levels are based on functional limitations, the need for assistive
mobility devices, or wheeled mobility, and to a lesser extent,
quality of movement. Children at GMFCS level I are capable of
walking without any limitations, while those at level V have
severe limitations of body control and need assisted technology
and physical assistance for activities of daily living.26
Gross Motor Function Measurement-88
The Gross Motor Function Measurement-88 (GMFM-88) is a
reliable and valid tool for the assessment of gross motor
function in children with CP. It consists of 88 items, and
these items were organized into five dimensions as lying and
rolling (A), sitting (B), crawling and kneeling (C), standing
(D), and walking, running, and jumping (E). Items are scored
on a four-point ordinal scale by observation of a child’s
performance on each item (0 = does not initiate, 1 = initiates
<10% of activity, 2 = partially completes 10–100% of activity,
3 = completes activity). Scores of each dimension are
expressed as a percentage of the maximum score for that
dimension, finally total score of the GMFM-88 is obtained
by dividing the percentage scores into five.27
Pediatric Evaluation of Disability Inventory
The Pediatric Evaluation of Disability Inventory (PEDI) is a
comprehensive clinical assessment for determining the key
functional capabilities and performance of chronically ill or
disabled children. Its reliability and validity were shown in
children with CP. The PEDI has three domains: functional
skills, caregiver assistance, and social functions. Each domain
has three subscales: self care, mobility, and social function.
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-
tional behavior of the child in a controlled manner or asking
to one of the family members. PEDI-FSD includes 197 items.
The items are scored on two-point ordinal scale (0 = cannot
do, 1 = can do). The total PEDI-FSD score can be obtained by
adding the subscale scores of PEDI-FSD.28
Trunk Control Measurement Scale and Trunk Impairment
Scale
Trunk control in sitting was tested with the Trunk Control
Measurement Scale (TCMS) and the Trunk Impairment Scale
(TIS). The TCMS was developed to assess trunk control in
children with CP. The TCMS is an expanded version of the
TIS, which includes more information about selective control
and reaching. The tool is divided into three subscales: static
sitting balance (SSB), dynamic sitting balance, selective move-
ment control (DSB-S), and reaching (DSB-R). It contains 15
items in total. The items are scored on a two-, three-, or four-
point scale. The maximum scores of the subscales are 20, 28,
and 10, respectively. Total score of the TCMS ranges from 0
(low performance) to 58 (high performance). Its reliability
and validity were shown in children and adolescents with
CP, aged 8 to 15 years.29,30
The TIS was originally developed to evaluate the trunk in
patients with stroke. The tool is divided into three subscales:
static sitting balance (TIS-SSB), dynamic sitting balance (TIS-
DSB), and coordination (TIS-C). It has 17 items and each
item is scored on 2- to 4-point ordinal scale. The maximum
scores of the subscales are 7, 10, and 6, respectively. The total
score of TIS changes in the range of 0–23 (0 = worst perfor-
mance, 23 = best performance). Its reliability and validity
were shown in children and adolescents with CP between
the ages of 5 and 19 years.31
Procedure
The data were collected in five different special education and
rehabilitation centers in Kutahya, Afyon, and Sakarya cities in
Turkey between September 2014 and April 2015. All partici-
pants were informed about the aim and the methods of the
study, and the written informed consents were signed by the
caregivers or family members of the children with CP. The
study was approved by the Medical Ethics Committee of
Eskisehir Osmangazi University on 17 June 2014. All research
activity was performed in accordance with the ethical stan-
dards laid down in the Declaration of Helsinki.
Demographical data were collected from all participants
before the evaluation process. Children were assessed in
their private practice sessions in a quiet setting. All of the
evaluations were done by the same physical therapist with a
clinical experience in children with CP. The TCMS was per-
formed while the child was seated on a bench without arm,
 DEVELOPMENTAL NEUROREHABILITATION 3

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.

before 2 years of age can predict walking in children with all forms
of CP.23,37 The GMFM-88 and PEDI are frequently used instru-
ments for measuring baseline functional outcomes and the
changes of intervention results in children with CP.38,39 We used
both scales together because they evaluate different aspects of
functional abilities. While the GMFM-88 is based on normal
motor development and basically evaluates gross motor functions,
PEDI measures the ability to perform activities which are used in
daily life. The relationship between functional abilities and sitting
postural control was significant in previous studies. Curtis et al.40
investigated the relation between trunk control evaluated with the
Segmental Assessment of Trunk Control (SATCo) and PEDI by
using linear modeling and found positive relation between the
SATCo and PEDI. Pham et al.41 found significant relation between
the TIS, TCMS, and GMFM-66, correlation coefficients ranged
from 0.64 to 0.75 for TIS and 0.57 to 0.72 for TCMS according to
Spearman correlation analysis. In the study of Saether et al.,31 the
total and subscale scores of the TIS were significantly correlated
with dimension scores of the GMFM (dimensions B, D, and E),
with correlation coefficients varying between 0.62 and 0.87.
According to Jeon et al.,42 the Spearman rank correlation coeffi-
cient between the TCMS and GMFM-B dimension was 0.86. In
our study, close parallel to those of previous studies, trunk control
evaluated with the TCMS and TIS, both correlated strongly with
the GMFM-88 and PEDI-FSD, but the correlation coefficients of
the TCMS were higher than TIS. The TIS was originally developed
for patients with stroke who have unilateral involvement, and
assesses selective movements of the trunk in frontal and transvers
planes. On the other hand, the TCMS was developed specifically
for individuals with CP who have both unilateral and bilateral
involvements. In addition to frontal and transverse planes in the
TIS, TCMS evaluates trunk movements in sagittal plane. When
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
were higher than the TIS.
In a previous study which was performed by Heyrman et al.,29
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
correlation between the GMFM-88 dimension A and the TCMS
with a correlation coefficient of 0.63. This result is not surprising
because dimension A evaluates the child’s ability to perform
functional activities in supine or prone position. Preparation for
sitting begins in the prone and supine positions, as the child
grows, early components which are prerequisites for upright sit-
ting position, such as cephalo-caudally progressing antigravity
extension of the spine, pelvic mobility, intra-axial rotation, scap-
ular mobility, and weight bearing on the upper extremities, are
acquired in supine and prone positions. The difference between
Heyrman’s and our work can be due to the difference in age
ranges of children which can affect the correlations.
Early recognition of problems associated with CP helps clin-
icians to design appropriate interventions to enhance the func-
tional independence and the quality of life of the children with CP.
Many problems respond well to interventions in early childhood,
when brain plasticity is at its greatest.43 Clinical measures of sitting
balance whose reliability and validity are supported by research
evidence increase the likelihood that clinicians can accurately
DEVELOPMENTAL NEUROREHABILITATION 5
identify sitting balance problems, describe change in sitting bal-
ance over time, and estimate the impact of sitting balance
interventions.33 The TCMS was found to be reliable and valid in
children between the ages of 8 and 15 years. However, the relia-
bility and the validity of the TCMS have not been assessed in
children under the age of 8 years. In their studies, Heyrman et al.29
only included children from the age of 8 to 15 years because before
this age, developmental adjustments during voluntary activity are
still in a transitional phase. Saether et al.31 showed that measure-
ment of trunk activity using the TIS was possible in children aged
5 years. For that reason, we decided to include children from the
age of 5 years as long as they were able to understand the instruc-
tions. In the study of Heyrman et al.,29 the construct validity of
TCMS was evaluated by comparing the TCMS subtotals and total
score with dimension scores and total score of the GMFM by
means of Spearman correlation analysis. In our study, strong
correlation between the GMFM-88 and TCMS supports good
construct validity of the TCMS between the ages of 5 and 15
years, but further studies should be performed in order to inves-
tigate the use of the TCMS in children younger than 8 years of age.
The definition of CP underscores the notion that there is large
variation among children diagnosed with CP. The limitation of
our study is to include only children with spastic CP and exclude
the other types as ataxic and dyskinetic. Further research is
needed in order to evaluate clinical characteristics of trunk con-
trol in these children. In conclusion, this study supports earlier
studies related to trunk control and functionality, with a further
evidence that trunk control in sitting is strongly related with
functions in children with spastic CP. Evaluation of trunk control
by using the TCMS can provide valuable information for trunk
control impairments when compared to the TIS with higher
correlation coefficients with functional measures.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
References
1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M,
Damiano D, Dan B, Jacobsson B. A report: the definition and
classification of cerebral palsy. Dev Med Child Neurol. 2007;49:8–
14. doi:10.1111/j.1469-8749.2007.tb12610.x.
2. Oskouı M, Coutinho F, Dykeman J, Jette N, Pringsheim T. An
update on the prevalence of cerebral palsy: a systematic review
and meta-analysis. Dev Med Child Neurol. 2013;55:509–19.
doi:10.1111/dmcn.12080.
3. Gainsborough M, Surman G, Maestri G, Colver A, Cans C. Validity
and reliability of the guidelines of the surveillance of cerebral palsy in
Europe for the classification of cerebral palsy. Dev Med Child
Neurol. 2008;50:828–31. doi:10.1111/j.1469-8749.2008.03141.x.
4. Rajab A, Abdulgalil A, Kathiri S, Ahmed R, Mochida GH, Bodell A,
Barkovich AJ, Walsh CA. An autosomal recessive form of spastic
cerebral (CP) palsy with microcephaly and mental retardation. Am J
Med Genet Part A. 2006;140:1504–10. doi:10.1002/ajmg.a.31288.
5. Rassafiani M, Sahaf R. Hypertonicity in children with cerebral palsy:
a new perspective. Iranian Rehabilitation Journal. 2011;9:66–74.
6. Massion J. Postural control systems in developmental perspective.
Neurosci Biobehav Rev. 1998;22:465–72. doi:10.1016/S0149-7634(97)
00031-6.
6 G. KALLEM SEYYAR ET AL.
7. Duarte M, Freitas SM. Revision of posturography based on force
plate for balance evaluation. Braz J Phys Ther. 2010;14:183–92.
doi:10.1590/S1413-35552010000300003.
8. Newell KM, Slobounov SM, Slobounova BS, Molenaar PCM. Short-
term non-stationary and the development of postural control. Gait
Posture. 1997;6:56–62. doi:10.1016/S0966-6362(96)01103-4.
9. Woollacott MH, Jenssen PB, Jasiewicz J, Roncesvalles N, Sveistrup
H. Development of postural responses during standing in health
children and in children with spastic diplegia. Neurosci Biobehav
Rev. 1998;22:583–89. doi:10.1016/S0149-7634(97)00048-1.
10. Corrêa JC, Corrêa FI, Franco RC, Bigongiari A. Corporal oscilla-
tion during static biped posture in children with cerebral palsy.
Electromyogr Clin Neurophysiol. 2007;46:131–36.
11. Love SR, Johnston LM. Exercise interventions improve postural
control in children with cerebral palsy: a systematic review. Dev
Med Child Neurol. 2015;57:504–20. doi:10.1111/dmcn.12660.
12. Brogren E, Hadders-Algra M, Forssberg H. Postural control in
sitting children with cerebral palsy. Neurosci Biobehav Rev.
1998;22:591–96. doi:10.1016/S0149-7634(97)00049-3.
13. Liu WY, Zaino CA, McCoy SW. Anticipatory postural adjust-
ments in children with cerebral palsy and children with typical
development. Pediatr Phys Ther. 2007;19:188–95. doi:10.1097/
PEP.0b013e31812574a9.
14. Shumway-Cook A, Woollacott MH. Abnormal postural control.
Motor control theory and practical applications. 2nd. Baltimore:
Lippincott Williams & Wilkins. 2001. p. 248–70.
15. Assaiante C, Malllau S, Viel S, Jover M, Schmitz C. Development
of postural control in healthy children: a functional approach.
Neural Plast. 2005;12:109–17. doi:10.1155/NP.2005.109.
16. Verheyden G, Vereeck L, Tuijen S, Troch M, Herregodts I, Lafosse
C, Nieuwboer A, De Weerdt W. Trunk performance after stroke and
the relationship with balance, gait and functional ability. Clin
Rehabil. 2006;20:451–58. doi:10.1191/0269215505cr955oa.
17. Saxena S, Rao BK, Kumaran S. Analysis of postural stability in
children with cerebral palsy and children with typical develop-
ment: an observational study. Pediatr Phys Ther. 2014;26:325–30.
doi:10.1097/PEP.0000000000000060.
18. Reid DT. The effects of the saddle seat on seated postural control
and upper-extremity movement in children with cerebral palsy.
Dev Med Child Neurol. 1996;38:805–15. doi:10.1111/j.1469-
8749.1996.tb15115.x.
19. Harbourne RT, Willett S, Kyvelidou A, Deffeyes J, Stergiou N. A
comparison of interventions for children with cerebral palsy to
improve sitting postural control: a clinical trial. Phys Ther.
2010;90:1881–98. doi:10.2522/ptj.2010132.
20. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N. Proposed
definition and classification of cerebral palsy, April 2005. Dev Med
Child Neurol. 2005;47:571–76. doi:10.1017/S001216220500112X.
21. Chen J, Woollacott MH. Lower extremity kinetics for balance
control in children with cerebral palsy. J Mot Behav.
2007;39:306–16. doi:10.3200/JMBR.39.4.306-316.
22. Rojas VG, Rebolledo GM, Munoz EG, Cortes NI, Gaete CB,
Delgado CM. Differences in standing balance between patients
with diplegic and hemiplegic cerebral palsy. Neural Regen Res.
2013;8:2478–83.
23. Rodby-Bousquet E, Hägglund G. Use of manual and powered wheel-
chair in children with cerebral palsy: a cross-sectional study. BMC
Pediatr. 2010 Aug 16;10:59. doi:10.1186/1471-2431-10-59.
24. Chung J, Evans J, Lee C, Lee J, Rabbani Y, Roxborough L,
Harris SR. Effectiveness of adaptive seating on sitting posture
and postural control in children with cerebral palsy. Phys
Ther. 2008;20:303–17.
25. Pavão SL, Dos Santos AN, Woollacott MH, Rocha NACF. Assessment
of postural control in children with cerebral palsy: a review. Res Dev
Disabil. 2013;34:1367–75. doi:10.1016/j.ridd.2013.01.034.
26. Palisano RJ, Hanna SE, Rosenbaum PL, Russell DJ, Walter SD,
Wood EP, Raina PS, Galuppi BE. Validation of a model of gross
motor function for children with cerebral palsy. Phys Ther.
2000;80:974–85.
27. Russell DJ, Avery LM, Rosenbaum PL, Raina PS, Walter SD,
Palisano RJ. Improved scaling of the gross motor function mea-
sure for children with cerebral palsy: evidence of reliability and
validity. Phys Ther. 2000;80:873–85.
28. Berg M, Jahnsen R, Frøslie KF, Hussain A. Reliability of the
Pediatric Evaluation of Disability Inventory (PEDI). Phys Occup
Ther Pediatr. 2004;24:61–77. doi:10.1300/J006v24n03_05.
29. Heyrman L, Molenaers G, Desloovere K, Verheyden G, De Cat
J, Monbaliu E, Feys H. A clinical tool to measure trunk
control in children with cerebral palsy: the Trunk Control
Measurement Scale. Res Dev Disabil. 2011;32:2624–35.
doi:10.1016/j.ridd.2011.06.012.
30. Heyrman L, Desloovere K, Molenaers G, Verheyden G, Klingels
K, Monbaliu E, Feys H. Clinical characteristics of impaired trunk
control in children with spastic cerebral palsy. Res Dev Disabil.
2013;34:327–34. doi:10.1016/j.ridd.2012.08.015.
31. Saether R, Helbostad JL, Adde L, Jørgensen L, Vik T. Reliability
and validity of the Trunk Impairment Scale in children and
adolescents with cerebral palsy. Res Dev Disabil. 2013;34:2075–
84. doi:10.1016/j.ridd.2013.03.029.
32. Portney LG, Watkins MP. Correlations. Foundations of clinical
research: applications to practice. 3rd. Philadelphia: Davis
Company. 2015. p. 523–37.
33. Bañas BB, Gorgon EJR. Clinimetric properties of sitting balance
measures for children with cerebral palsy: a systematic review.
Phys Occup Ther Pediatr. 2014;34(3):313–34. doi:10.3109/
01942638.2014.881952.
34. Bousquet E, Hägglund G. Sitting and standing performance in a
total population of children with cerebral palsy: across-sectional
study. BMCMusculoskelet Disord. 2010;11:131. doi:10.1186/1471-
2474-11-131.
35. Mendoza SM, Gómez-Conesa A, Hidalgo Montesinos MD.
Association between gross motor function and postural control
in sitting in children with cerebral palsy: a correlational study
in Spain. BMC Pediatr. 2015;15:124. doi:10.1186/s12887-015-
0442-4.
36. Wu YW, Day SM, Strauss DJ, Shavelle RM. Prognosis for ambu-
lation in cerebral palsy: a population-based study. Pediatrics.
2004;114:1264–71. doi:10.1542/peds.2004-0114.
37. Boyce WF, Gowland C, Hardy S, Rosenbaum PL, Lane M, Plews
N, Goldsmith C, Russel DJ. Development of a quality of move-
ment measure for children with cerebral palsy. Phys Ther.
1991;71:820–28. doi:10.1093/ptj/71.11.820.
38. Harvey A, Robin J, Morris ME, Graham HK, Baker R. A systema-
tic review of measures of activity limitation for children with
cerebral palsy. Dev Med Child Neurol. 2008;50:190–98.
doi:10.1111/j.1469-8749.2008.02027.x.
39. Han T, Gray N, Vasquez MM, Zou LP, Shen K, Duncan B.
Comparison of the GMFM-66 and the PEDI functional skills
mobility domain in a group of Chinese children with cerebral
palsy. Child Care Health Dev. 2011;37:398–403. doi:10.1111/
j.1365-2214.2010.01149.x.
40. Curtis DJ, Butler P, Saavedra S, Bencke J, Kallemose T, Sonne-
Holm S, Woollacott M. The central role of trunk control in the
gross motor function of children with cerebral palsy: a retrospec-
tive cross-sectional study. Dev Med Child Neurol. 2015;57:351–57.
doi:10.1111/dmcn.12641.
41. Pham HP, Eidem A, Hansen G, Nyquist A, Torstein V, Saether R.
Validity and responsiveness of the Trunk Impairment Scale and
Trunk Control Measurement Scale in young individuals with
cerebral palsy. Phys Occup Ther Pediatr. 2016;36:440–52.
doi:10.3109/01942638.2015.1127867.
42. Jeon YJ, Shin WS. Reliability and validity of the Korean version of the
Trunk Control Measurement Scale (TCMS-K) for children with
cerebral palsy. Res Dev Disabil. 2014;35:581–90. doi:10.1016/j.
ridd.2014.01.009.
43. Johnston MV, Ishida A, Ishida WN, Matsushita HB, Nishimura A,
Tsuji M. Plasticity and injury in the developing brain. Brain Dev.
2009;31(1):1–10. doi:10.1016/j.braindev.2008.03.014.