1276
The Relationship Between Sitting Stability and Functional
Performance in Patients With Paraplegia
Chiung-Ling Chen, MS, OT, Kwok-Tak Yeung, MA, OTR, Liu-Ing Bih, MD, Chun-Hou Wang, BS, PT,
Ming-I Chen, BS, OT, Jung-Chung Chien, BS, OT
ABSTRACT. Chen C-L, Yeung K-T, Bih L-I, Wang C-H,
Chen M-I, Chien J-C. The relationship between sitting stability
and functional performance in patients with paraplegia. Arch
Phys Med Rehabil 2003;84:1276-81.
Objectives: To compare sitting stability between patients
with high and low thoracic spinal cord injury (SCI), to deter-
mine the factors that can predict sitting stability, and to exam-
ine the relationship between sitting stability and functional
performance.
Design: Cross-sectional assessment was performed on sub-
jects with paraplegia.
Setting: Rehabilitation hospital affiliated with a medical
university.
Participants: Convenience sample of 30 adults with com-
plete chronic thoracic SCI.
Interventions: Not applicable.
Main Outcome Measures: (1) Postural sway during quiet
sitting over 30 seconds was recorded as static sitting stability,
and composite maximal weight-shift during leaning tasks over
30 seconds was measured as dynamic sitting stability; (2) age,
body weight, trunk length, trunk strength, postonset duration,
injury level, and presence of spasticity were examined as
predictive variables for sitting stability; and (3) the time for
completion of upper- and lower-body dressing and undressing
and transfer was measured as functional performance.
Results: A significant difference in composite maximal
weight-shift was found between high and low thoracic SCI
subjects (t⫽2.90, P⬍.01). Injury level and trunk length were 2
important predictive factors for dynamic sitting stability, and
they explained 43.5% of the variance. Only the completion
time of upper-body dressing and undressing correlated signif-
icantly with static (r⫽.465, P⫽.01) and dynamic (r⫽⫺.377,
P⬍.05) sitting stability.
Conclusions: The subjects with low thoracic SCI showed
better dynamic sitting stability than those with high thoracic
SCI. Injury level and trunk length, not trunk flexion or exten-
sion strength, predicted the outcome of dynamic sitting stabil-
ity. Measures were not precise enough to predict functional
performance from the viewpoint of injury level and sitting
stability. The underlying premise that a reduction or increase in
trunk strength is indicative of poorer or better sitting stability in
SCI individuals is questioned, and implications for problem
identification and treatment planning are discussed.
From the Rehabilitation Hospital and the Schools of Occupational Therapy (C-L
Chen, Yeung, M-I Chen, Chien), Physical Therapy (Wang), and Rehabilitation
Medicine (Bih), Chung Shan Medical University, Taichung, Taiwan, ROC.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Kwok-Tak Yeung, MA, OTR, Sch of Occupational Therapy,
Chung Shan Medical University, 110, Section 1, Chien-Kuo N Rd, Taichung, Taiwan
402, ROC, e-mail: gordon@csmu.edu.tw.
0003-9993/03/8409-7680$30.00/0
doi:10.1016/S0003-9993(03)00200-4
Arch Phys Med Rehabil Vol 84, September 2003
Key Words: Activities of daily living; Paraplegia; Posture;
Rehabilitation; Spinal cord injuries.
© 2003 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
O MAINTAIN POSTURAL stability is to keep or return
T the center of body mass over the base of support in a
position or during changes in position. It is a complex process
involving the coordinated actions of biomechanical, sensory,
motor, and central nervous system components.1 In patients
with spinal cord injury (SCI), motor performance may be
impaired by muscular weakness and disturbance in somatosen-
sory input, resulting in impairment of postural stability, even in
sitting position. Sitting balance is believed necessary in per-
forming functional activities from a seated position. Several
prognostic studies have shown that sitting balance is a valid
predictor for functional outcome in patients with brain injury2
or stroke.3-6 Sitting balance also can predict the ability to walk
in patients with stroke7 and spina bifida.8 However, Nichols et
al9 found only a poor to moderate relationship between the
functional scores of the FIM™ instrument and sitting balance
measures in patients with hemiparesis.
For individuals with paraplegia, most functional activities,
such as eating, dressing, and transferring, are performed in a
seated position. The amount of trunk stability and mobility is
directly correlated with the patient’s ability to perform func-
tional tasks. To regain sitting postural control is 1 aim in the
rehabilitation of patients with paraplegia.10,11 Many outcome
studies12-17 of patients with SCI have focused on motor, sen-
sory, and functional recovery rather than postural stability. A
few studies18-20 on the sitting postural control of patients with
paraplegia have focused on compensatory postural muscle ac-
tivities and changes in postural motor programming during
reaching tasks. These studies18,19 showed that patients with
thoracic SCI try to compensate for the loss of postural muscle
function of the erector spine through increased use of different
nonpostural muscles. Seelen et al20 reported that patients with
low thoracic SCI, having more residual sensorimotor functions,
seem to adopt more complex strategies for maintaining and
restoring sitting balance and that these strategies take longer to
specify and to program. Patients with high thoracic SCI seem
to rely on simpler strategies that use more passive postural
support.
Few studies have quantitatively analyzed sitting stability in
terms of postural sway and weight shifting in patients with
paraplegia or addressed sitting stability in relation to functional
performance. The purposes of the present study were (1) to
quantify and compare the sitting stability between patients with
high and low thoracic SCI, so that the magnitude of the
impairment could be defined; (2) to determine factors that
predict sitting stability; and (3) to examine the relation among
injury level, sitting stability, and functional performance. We
hypothesized that patients with low thoracic SCI would have
better sitting stability than patients with high thoracic SCI and
that the injury level and trunk strength would be the factors that
 SITTING STABILITY AND FUNCTIONAL PERFORMANCE, Chen
Fig 1. Setup for sitting stability tests showing the Balance Perfor-
mance Monitor, hard wood stool, subject, and researcher positions.
affected sitting stability. We also hypothesized that patients
with lower injury level and better sitting stability would com-
plete functional activities in less time.
METHODS
Participants
Patients with a diagnosis of complete SCI and 1 year post-
onset were recruited from the Spinal Cord Injury Association
of central Taiwan. Thirty subjects without any obvious con-
tractures were selected for this study. Each subject signed an
informed consent form before participation in the study. De-
mographic data, including age, sex, cause of injury, and years
of postonset, were obtained and recorded.
The study group consisted of 27 men and 3 women. Subjects
ranged in age from 20 to 57 years (mean ⫾ standard deviation
[SD], 33.97⫾10.7y), and the median duration of their disabil-
ities was 7.05 years (range, 1.2–20y). The neurologic injury
levels ranged from T3 to T12. Of the 30 subjects, 15 were
injured in traffic collisions, 7 were injured by falls, and 4 were
injured by penetration. The remaining 4 subjects had an un-
classified cause of injuries.
Instruments
Sitting stability was measured by the Balance Performance
Monitora (fig 1). This monitor is a portable device that assesses
the weight-bearing status of a subject seated on a seat force
plate. Four dynamic force transducers that measure vertical
force are mounted beneath the seat. The monitor’s computer
software gathers data from the forceplate and calculates pos-
tural sway during quiet sitting and the amplitude of weight-
shift during leaning tasks over 30 seconds. The results are
displayed graphically.
A stopwatch was used to record the completion time for a
task in seconds. The 3 selected functional tasks were upper-
body dressing and undressing, lower-body dressing and un-
dressing, and transfer. These tasks were chosen because sitting
stability is considered an important determinant in performing
these skills.
Procedure
After providing informed consent and demographic data,
each subject underwent a physical examination that included
1277
sitting stability, transfer, and dressing and undressing. Subjects
did not perform the tests in a specific sequence and could rest
between tests as needed.
Physical examination. Anthropometric variables, includ-
ing trunk length and body weight, were measured and recorded.
Trunk length was measured with a tape measure from the C7
vertebra to the coccyx.21 Brief neurologic and musculoskeletal
examinations were performed. Each subject’s neurologic injury
level and the presence of spasticity were documented. Neuro-
logic injury level and its completeness were defined according
to the standards of the American Spinal Injury Association.22
Spasticity was assessed through passive limb movement and
recorded as present or absent. The Ashworth Scale or the
Modified Ashworth Scale (MAS) are the measurement tools
most used clinically to rate spasticity. However, previous stud-
ies have shown that more problematic spasticity occurs among
SCI patients with motor-incomplete lesions than in those with
motor-complete lesions,23 particularly in persons with a cervi-
cal level of injury.24 Maynard et al25 found a lower incidence of
spasticity development among subjects with lower thoracic and
lumbosacral levels of injury. Furthermore, Haas et al26 reported
that the Ashworth Scale was slightly more reliable than the
MAS. They also suggested that the Ashworth Scale is of
limited use in the assessment of spasticity in the lower limbs of
patients with SCI. For the purpose of the present study, we
considered that the methods used were sufficient to detect the
state of spasticity. The musculoskeletal examination included
passive joint range of motion (ROM) and trunk strength. The
passive joint ROM was performed to determine the presence of
contractures or deformities in the lower extremities. To test
trunk strength, we used a procedure modified from that used by
Hardcastle et al.27 In their study, the subjects were placed in
their own wheelchairs and asked to sit without using any hand
support. Trunk flexion and extension strength was measured
with a myometer. In the present study, we used a handheld
dynamometer, Nicholas Manual Muscle Tester (model
01160),b to measure maximal isometric strength of trunk flex-
ion and extension in kilograms of force. The subject was seated
on a mat table in a long sitting position without support. The
dynamometer was placed proximal to the midline of the ster-
num, and the subject was then asked to push against the
dynamometer at maximal effort. At the same time, the exam-
iner applied force to break the subject’s effort. The peak force
shown on the dynamometer was recorded as the subject’s trunk
flexion strength. After 3 readings were taken, the mean score
was recorded and normalized to body weight to represent the
strength score of trunk flexion. The same procedure was used
to measure the trunk extension strength, except that the dyna-
mometer was placed in a posterior position at the subject’s
interscapular region and the subject was asked to push back as
hard as possible.
Sitting stability tests. The subject was transferred and
seated on the forceplate, which was placed on the top of a hard
wood stool of appropriate height. The subject was positioned
centrally left and right to accommodate the shape of the seat.
To determine the central position for forward and backward
required the researcher’s judgment because that point varied
among subjects. The subject’s hip, knee, and ankle were kept at
90°, and the height of the foot support was adjusted to each
individual’s anthropometric measurements (see fig 1). To mea-
sure static sitting stability, subjects were asked to maintain a
static sitting position without support for 30 seconds. For
dynamic sitting stability, leaning tasks were performed in 4
directions (forward, backward, left, right). Subjects were asked
to lean forward as far as possible to the point where they could
retain sitting balance without support for 30 seconds. They
Arch Phys Med Rehabil Vol 84, September 2003
1278 SITTING STABILITY AND FUNCTIONAL PERFORMANCE, Chen
Table 1: Characteristics of Subjects With High and Low Thoracic SCI
High Thoracic SCI
Variable (n⫽8)
Age (y) 30.38⫾10.10
Weight (kg) 56.25⫾7.92
Trunk length (cm) 64.69⫾3.08
Trunk flexion strength score* .15⫾.03
Trunk extension strength score* .14⫾.02
Postonset duration (y) 8.18⫾5.85
Presence of spasticity (n)
Yes 6 7
No 2 15
NOTE. Values are mean ⫾ SD.
*Trunk flexion and extension strength were normalized against body weight.
†
Not significant by the independent t test.
were then asked to lean backward, to the right, and to the left
sequentially. Their arms could extend to the opposite side to
help maintain balance. Subjects practiced each movement be-
fore the actual tests to familiarize themselves with the tasks and
to find their own limits of stability. During the testing of sitting
stability, a researcher guarded the subjects for safety (see fig 1).
The test was repeated if the subject regained trunk balance with
arm or hand support.
Transfer. The transfer test was performed between a stan-
dard-height wheelchair without armrests and an adjacent mat
table of the same height. The wheelchair was equipped with a
solid seat and a sling backrest; no cushion was used. The
subjects were instructed to execute transfer from and to the
wheelchair in their normal fashion. They were timed as they
transferred to the mat table. The recording of timing began with
the subject’s first move from the starting position in the wheel-
chair and ended when the subject lay supine on the mat table.
The starting position was with the subject sitting all the way
back in the wheelchair. Subjects were timed again as they
transferred back to the wheelchair. Subjects were asked to rise
from a supine position on the mat table, transfer to the wheel-
chair, and sit in the chair until they sat completely back in the
chair. The time to perform these 2 tasks was added as a single
score. Each subject performed 3 trials, and we calculated the
mean time for the score of transfer.
Dressing and undressing. To perform the upper- and
lower-body dressing and undressing, a pullover shirt and a pair
of elastic waist pants were used. The subject was long-seated
on the mat table with hands placed on both sides. The re-
searcher placed the shirt on the subject’s legs and started
timing. Timing ended when the subject pulled down the shirt
and adjusted it. The subject was again timed while removing
the shirt. The subject was asked to take off the shirt, adjust it,
and place it back on his/her legs. Timing ended when the
subject assumed the original starting position. The time to dress
and undress was totaled as a single score. Each subject per-
formed 3 trials, and we calculated the mean time for the score
of upper-body dressing and undressing. Similar test procedures
were performed for lower-body dressing and undressing, and
its score was obtained accordingly.
All subjects were asked to perform the functional tasks as
quickly as possible but safely to retain balance.
Statistical Analysis
The postural sway of static sitting for 30 seconds was de-
rived from the Balance Performance Monitor’s sway coeffi-
cient as an indicator of static sitting stability. The sway coef-
Arch Phys Med Rehabil Vol 84, September 2003
Low Thoracic SCI
(n⫽22) P Value
35.27⫾10.84 .275†
64.37⫾11.11 .069†
64.80⫾3.55 .940†
.20⫾.07 .108†
.17⫾.08 .430†
6.73⫾4.96 .507†
ficient was calculated as the SD of the mean weight-shift over
the 30 seconds. The higher the value, the higher the deviation
and the greater the impairment of sitting balance. Two sway
coefficients represent the anteroposterior and lateral compo-
nents of sway,28 and we totaled them for a score. Maximal
amplitude of weight-shift in leaning tasks during 30 seconds
was calculated and expressed as a percentage change in body-
weight distribution derived from the graph presentation. Each
measurement was obtained by measuring the distance between
the initial position and maximal displacement in 4 directions
with a ruler. The measurement was expressed as a percentage
derived from the measuring distance in millimeters, and each
16-mm block represented 10% of body-weight distribution. A
composite score summing the 4 maximal weight-shift measures
was calculated as an indicator of dynamic sitting stability.
We used the independent t test to analyze the difference in
sitting stability between high and low thoracic SCI groups.
Subjects with T1 to T6 paraplegia were in the high thoracic SCI
group, and subjects with T7 to T12 paraplegia were in the low
thoracic SCI group. Pearson product-moment correlations were
calculated to determine the relation between independent vari-
ables and sitting stability. Stepwise multiple regression deter-
mined which set of independent variables could best predict
sitting stability. Age, weight, trunk length, trunk flexion and
extension strength, years of postonset, injury level, and pres-
ence of spasticity were counted as independent variables. The
injury level was recorded as an ordinal variable. Each injury
level was assigned a number from 1 to 12; for example, T1
equals 1 and T10 equals 10. Spasticity was recorded as a
dichotomous variable (ie, present or absent). To examine the
relation among injury level, sitting stability, and functional
performance, Pearson product-moment analysis was used to
determine the correlation between sitting stability and the time
to complete the functional activities. Spearman rank-order cor-
relation coefficient analysis was also used to determine the
correlation between injury level and the completion time of
functional activities. An ␣ value of .05 was considered signif-
icant for all statistical analyses.
RESULTS
Eight subjects were included in the high thoracic SCI group,
and 22 subjects were in the low thoracic SCI group. None of
the subjects had obvious contractures or deformities that would
prevent them from assuming the sitting position. The clinical
characteristics of the 2 groups are in table 1. No significant
differences were found between the 2 groups for age, weight,
trunk length, trunk strength, or years of postonset.
 SITTING STABILITY AND FUNCTIONAL PERFORMANCE, Chen
Table 2: Comparison of Sitting Stability in Subjects With High and Low Thoracic SCI
Outcome Measurement
Static sitting stability
Postural sway (%)
Dynamic sitting stability
Composite maximal weight-shift (%)
NOTE. Values are mean ⫾ SD.
*Not significant by the independent t test.
†
Significant at P⬍.01 by the independent t test.
Sitting Stability of High and Low Thoracic SCI Subjects
The means and SDs of the sitting stability scores for both
SCI groups are in table 2. Comparing the sitting stability for the
2 groups, we found no significant difference in static postural
sway (t⫽.26, P⬎.05), whereas a significant difference in com-
posite maximal weight-shift was found (t⫽2.90, P⬍.01). It
seems that low thoracic SCI subjects had better dynamic sitting
stability than high thoracic SCI subjects did.
Predictive Factors for Sitting Stability
The correlation analysis showed that no single independent
variable correlated significantly with static sitting stability. The
correlation coefficients ranged from .065 to .303. In contrast,
the injury level correlated significantly with dynamic sitting
stability (r⫽.554, P⬍.01) and trunk flexion strength (r⫽.489,
P⬍.01). The stepwise multiple regression analysis showed that
dynamic sitting stability could be predicted (P⬍.05) by the
independent variables. Regression analysis showed that injury
level and trunk length were significant predictors of dynamic
sitting stability. These 2 factors explained 43.3% of the vari-
ance in dynamic sitting stability (table 3).
Relations Among Injury Level, Sitting Stability, and
Functional Performance
The mean scores of completion times for the functional
activities were 19.18⫾6.25 seconds for upper-body dressing
and undressing, 53.69⫾18.56 seconds for lower-body dressing
and undressing, and 28.75⫾21.78 seconds for transfer. The
correlation matrix describing the association among the mea-
sures is shown in table 4. Only the completion time of upper-
body dressing and undressing correlated significantly with in-
jury level (r⫽⫺.408, P⬍.05), static sitting stability (r⫽.465,
P⫽.01), and dynamic sitting stability (r⫽⫺.377, P⬍.05). In-
jury level, static sitting stability, and dynamic sitting stability
did not correlate significantly with the completion time of
transfer or lower-body dressing and undressing.
DISCUSSION
Impaired sitting stability in people with SCI seems to be
related to defective motor performance. Function of abdominal
and paraspinal extensor muscles from partial to full innerva-
tions varies with the neurologic level. It has been hypothesized
Table 3: Stepwise Multiple Regression for Predicting Dynamic
Sitting Stability
Variable R2 Adjusted R2 F B ␤ t
Neurologic level .344 .320 14.66* 3.168 .584 4.03*
Trunk length .433 .391 10.31* ⫺1.558 ⫺.299 ⫺2.06*
*Significant at P⬍.05.
1279
High Thoracic Low Thoracic
SCI (n⫽8) SCI (n⫽22) P Value
4.06⫾2.72 3.80⫾1.30 .786*
42.70⫾13.99 61.51⫾16.24 .007†
that the subjects with low thoracic SCI will have better sitting
stability because they have more residual muscles innervated
than the subjects with high thoracic SCI do. However, the
present study’s results showed no significant difference in
static sitting stability between the 2 groups. Moreover, no
significant correlation was found between injury level and
static sitting stability. This finding may be attributed to the
ceiling effect in measuring static sitting stability. Dynamic
sitting stability presents a more challenging activity for persons
with paraplegia and is more sensitive in detecting sitting insta-
bility between the high and low thoracic SCI groups. The
magnitude of impairment of sitting balance among patients
with different levels of lesions might need further investiga-
tion.
Our second hypothesis, that trunk strength and injury level
are important predictors of sitting stability, was not fully sup-
ported. The results of the regression analysis indicated that
trunk flexion or extension strength did not significantly influ-
ence sitting stability in SCI subjects. In a study of elderly men,
Iverson et al29 reported a significant correlation between iso-
metric hip muscle strength and the ability to maintain balance.
However, researchers who have studied the relations between
muscle strength and postural control among elderly adults have
reported that to be a low correlation.30-32 They suggested that
postural muscle control, rather than muscle force development,
may be a critical variable in determining postural control.
Coordination of central and peripheral afferent and efferent
signals, as well as muscle fiber function, is needed to maintain
postural stability. Patla et al33 believed that substantial muscle
activation or strength was not required to maintain double-
stance stability. Our inability to find a significant correlation
between trunk strength and sitting stability indicated that max-
imal isometric contraction of trunk muscles was not critical to
maintaining sitting stability. Therefore, therapists should not
assume that treating deficits in trunk strength would necessarily
improve sitting stability. Instead, therapists should treat trunk
muscle weakness and sitting instability as independent prob-
lems amenable to muscle strengthening and postural control
training.
It is interesting to observe that the trunk length was a major
factor for predicting dynamic sitting stability. Trunk length
negatively correlated with dynamic sitting stability; that is, the
longer the trunk, the smaller the composite maximal weight-
shift. In the present study, the measure of maximal weight-shift
in 4 directions by the leaning tasks performed while sitting was
similar to the measure of center of pressure (COP) excursion
while standing. COP excursion is measured with the subject
standing on a force platform and is recorded as the subject
leans forward, backward, and sideways.34 Functional reach, a
measurement of the margin of stability, is biomechanically
analogous to the COP excursion. Duncan et al,21 who designed
the test, reported that age and height are the most significant
Arch Phys Med Rehabil Vol 84, September 2003
1280 SITTING STABILITY AND FUNCTIONAL PERFORMANCE, Chen
Table 4: Correlation Matrix Among Injury Level, Sitting Stability, and Functional Performance
Sitting Stability
Variable Injury Level Postural Sway
Injury level ⫺.155
Sitting stability
Postural sway
Maximal weight-shift
Functional performance
UBD/U
LBD/U
Transfer
Abbreviations: UBD/U, upper-body dressing and undressing; LBD/U, lower-body dressing and undressing.
*Significant at P⬍.05; †significant at P⬍.01.
factors that influence functional reach. The taller the subject,
the greater the distance of functional reach. It was presumed
that the longer the trunk length, the greater the composite
maximal weight-shift would be.
The disparate results correlate with decreased pelvic and
trunk stability secondary to trunk and hip musculature paralysis
in patients with paraplegia. Duval-Beaupere and Robain35 re-
ported that the center of gravity (COG) was higher by 5% of
the body length in their patients with paraplegia than in the
normal subjects. This upward displacement of the COG reflects
a disproportional loss of lower-body weight. Such a change in
COG must lead to a loss of sitting stability and may contribute
to the change in a person’s limit of stability. Therefore, we
assumed that a subject with a longer trunk length may have a
higher COG and may come to have a lesser extent of stability
limits, as shown by the smaller amplitude of the weight-shift.
In the present study, a continuous scale measurement of
functional performance was more sensitive than the ordinal
scoring of functional scale (eg, FIM).36 Also, because the
continuous scale measurement is applicable to a wide range of
functional levels with minimal ceiling effect, it may be able to
distinguish precisely the levels of “functional disabilities.” The
poor sitting stability found in subjects with paraplegia may
result from limited upper-extremity function.37 These functions
include upper-body dressing, reaching for lower-body dressing,
and, possibly, the ability to transfer. However if the trunk
muscles are strong enough to maintain sitting stability, one
might expect that the completion time of dressing and undress-
ing and transfer would be shorter. The results of the present
study indicate that only the completion time of upper-body
dressing and undressing correlated significantly with injury
level and the 2 measures of sitting stability. Static sitting
stability correlated more than dynamic sitting stability with the
completion time of upper-body dressing and undressing. The
specific functional pattern of upper-body dressing and undress-
ing may explain this finding. When performing upper-body
dressing and undressing in a long sitting position on the mat
table without support, it is crucial to maintain the COG within
a small zone of limited weight-shift for optimal upper-extrem-
ity function. The act of keeping the trunk as stable as possible
while dressing and undressing the upper body is similar to the
test for static sitting stability. The low correlation between
sitting stability and the other 2 functional activities may be
explained by factors other than sitting stability. The skills of
lower-body dressing and undressing and transfer are more
complex than those of upper-body dressing and undressing. We
observed that lower-body dressing and undressing requires
more steps. While performing lower-body dressing and un-
dressing, subjects must lie supine, begin a series of rolls to pull
Arch Phys Med Rehabil Vol 84, September 2003
Functional Performance
Maximal Weight-Shift UBD/U LBD/U Transfer
.554 †
⫺.408* ⫺.086 ⫺.247
⫺.055 .465† .230 .264
⫺.377* ⫺.288 ⫺.249
.552† .772†
.615†
over or push down a pair of pants across the buttocks, and then
sit up to the original starting position.38 For the transfer activ-
ity, many biomechanical factors—such as body build, ROM,
muscle strength, hand placement, and the degree and force of
head and trunk motion—have been associated with the ability
to transfer.39 In addition to these factors, Allison et al40 re-
ported that at least 2 movement strategies adopted by individ-
uals with SCI when transferring account for the variability in
the factors associated with the ability to transfer. It was hy-
pothesized that more steps are needed in lower-body dressing
or that the contributing factors of transfer may diminish the
importance of sitting stability for lower-body dressing and
undressing and transfer.
In this study, the timing of a series of functional tasks was
used to assess subjects’ functional performance. We believe
that the ability to complete a particular activity in a specified
period of time provides important information on a patient’s
overall ability. However, time scores alone do not always yield
the complete functional picture. Because speed does not equate
with function, various behaviors that are characteristic of func-
tion, such as dependence level, difficulty, coordination, effi-
ciency, and endurance, must be considered in the overall anal-
ysis.41
In general, it is difficult to predict the degree of disability
exclusively from knowledge of neurologic levels and a pa-
tient’s sitting stability. It is also inappropriate to determine
levels of function or rehabilitation goals entirely according to a
patient’s neurologic level of injury and sitting stability.
CONCLUSIONS
The results of the present study suggest a significant differ-
ence in dynamic sitting stability between subjects with high
and low thoracic SCI. Low thoracic SCI subjects show better
maximal weight-shift in leaning tasks. The injury level and
trunk length are 2 important factors affecting a person’s dy-
namic sitting stability. Sitting stability and injury level both
correlated significantly with the completion time of upper-body
dressing and undressing, but not with the completion time for
lower-body dressing and undressing and transfer.
These results imply that various factors must be examined
when functional skills assessments of patients with SCI are
interpreted. Each functional task requires adequate strength,
joint ROM, and postural control to perform the motion in-
volved. However, a program limited to strengthening, ROM
exercises, and postural control training will not result in the
development of functional skills. Besides these physical pre-
requisites, each functional task involves the factors of body
build and the performance of a set of skills. Functional inde-
 SITTING STABILITY AND FUNCTIONAL PERFORMANCE, Chen
pendence requires all of these physical and skill prerequisites to
be developed.39,42
Acknowledgments: We thank Jiun-Nan Tsai, BS, OT, and Ming-
Shun Wu, BS, OT, Department of Occupational Therapy, Taichung
Rehabilitation Hospital, for their assistance with data collection. We
also thank Edward Yang, MD, PhD, and Guey Fang Jih, PhD, OTR,
for their assistance in the preparation of the manuscript.
References
1. Horak FB, Shumway-Cook A. Clinical implications of postural
control research. In: Duncan PW, editor. Balance. Alexandria:
American Physical Therapy Association; 1990. p 105-11.
2. Black K, Zafonte R, Millis S, et al. Sitting balance following brain
injury: does it predict outcome? Brain Inj 2000;14:141-52.
3. Kwakkel G, Wagenaar RC, Kollen BJ, Lankhorst GJ. Predicting
disability in stroke—a critical review of the literature. Age Ageing
1996;25:479-89.
4. Sandin KJ, Smith BS. The measure of balance in sitting in stroke
rehabilitation prognosis. Stroke 1990;21:82-6.
5. Wade DT, Hewer RL. Functional abilities after stroke: measure-
ment, natural history and prognosis. J Neurol Neurosurg Psychi-
atry 1987;50:177-82.
6. Wade DT, Skilbeck CE, Hewer RL. Predicting Barthel ADL score
at 6 months after an acute stroke. Arch Phys Med Rehabil 1983;
64:24-8.
7. Feigin L, Sharon B, Czaczkes B, Rosin AJ. Sitting equilibrium 2
weeks after a stroke can predict the walking ability after 6 months.
Gerontology 1996;42:348-53.
8. Swank M, Dias LS. Walking ability in spina bifida patients: a
model for predicting future ambulatory status based on sitting
balance and motor level. J Pediatr Orthop 1994;14:715-8.
9. Nichols DS, Miller L, Colby LA, Pease WS. Sitting balance: its
relation to function in individuals with hemiparesis. Arch Phys
Med Rehabil 1996;77:865-9.
10. Nixon V. Spinal cord injury: a guide to functional outcomes in
physical therapy management. Rockville: Aspen; 1985. p 23-36.
11. Farmer AR. Setting goals. In: Hill JP, Intagliata S, editors. Spinal
cord injury: a guide to functional outcomes in occupational ther-
apy. Rockville: Aspen; 1986. p 19-23.
12. Yarkony GM, Roth EJ, Heinemann AW, Lovell L, Wu YC.
Functional skills after spinal cord injury rehabilitation: three-year
longitudinal follow-up. Arch Phys Med Rehabil 1988;69:111-4.
13. Yarkony GM, Roth EJ, Meyer PR, Lovell LL, Heinemann AW.
Rehabilitation outcomes in patients with complete thoracic spinal
cord injury. Am J Phys Med Rehabil 1990;69:23-7.
14. Waters RL, Yakura JS, Adkins RH, Sie I. Recovery following
complete paraplegia. Arch Phys Med Rehabil 1992;73:784-9.
15. Daverat P, Petit H, Kemoun G, Dartigues JF, Barat M. The long
term outcome in 149 patients with spinal cord injury. Paraplegia
1995;33:665-8.
16. Müslümanoğlu L, Aki S, Öztürk Y, et al. Motor, sensory and
functional recovery in patients with spinal cord lesions. Spinal
Cord 1997;35:386-9.
17. Dzidic I, Moslavac S. Functional skills after the rehabilitation of
spinal cord injury patients: observation period of 3 years. Spinal
Cord 1997;35:620-3.
18. Seelen HA, Vuurman EF. Compensatory muscle activity for sit-
ting posture during upper extremity task performance in paraple-
gic persons. Scand J Rehabil Med 1991;23:89-96.
19. Seelen HA, Potten YJ, Huson A, Spaans F, Reulen JP. Impaired
balance control in paraplegic subjects. J Electromyogr Kinesiol
1997;7:149-60.
20. Seelen HA, Potten YJ, Adam JJ, Drukker J, Spaans F, Huson A.
Postural motor programming in paraplegic patients during reha-
bilitation. Ergonomics 1998;41:302-16.
1281
21. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional
reach: a new clinical measure of balance. J Gerontol 1990;45:
M192-7.
22. Ditunno JF Jr, Young W, Donovan WH, Creasey G. The interna-
tional standards booklet for neurological and functional classifi-
cation of spinal cord injury. Paraplegia 1994;32:70-80.
23. Little JW, Micklesen P, Umlauf R, Britell C. Lower extremity
manifestations of spasticity in chronic spinal cord injury. Am J
Phys Med Rehabil 1989;68:32-6.
24. Sköld C, Levi R, Seiger Å. Spasticity after traumatic spinal cord
injury: nature, severity, and location. Arch Phys Med Rehabil
1999;80:1548-57.
25. Maynard FM, Karunas RS, Waring WP. Epidemiology of spas-
ticity following traumatic spinal cord injury. Arch Phys Med
Rehabil 1990;71:566-9.
26. Haas BM, Bergström E, Jamous A, Bennie A. The inter rater
reliability of the original and of the modified Ashworth scale for
the assessment of spasticity in patients with spinal cord injury.
Spinal Cord 1996;34:560-4.
27. Hardcastle P, Bedbrook G, Curtis K. Long-term results of con-
servative and operative management in complete paraplegics with
spinal cord injuries between T10 and L2 with respect to function.
Clin Orthop 1987;Nov(224):88-96.
28. Hinman MR. Validity and reliability of measures obtained from
the Balance Performance Monitor during quiet standing. Physio-
therapy 1997;83:579-81.
29. Iverson BD, Gossman MR, Shaddeau SA, Turner ME. Balance
performance, force production, and activity levels in noninstitu-
tionalized men 60 to 90 years of age. Phys Ther 1990;70:348-55.
30. Topp R, Mikesky A, Thompson K. Determinants of 4 functional
tasks among older adults: an exploratory regression analysis.
J Orthop Sports Phys Ther 1998;27:144-53.
31. Judge JO, Lindsey C, Underwood M, Winsemius D. Balance
improvements in older women: effects of exercise training. Phys
Ther 1993;73:254-65.
32. Topp R, Estes PK, Dayhoff N, Surheinrich J. Postural control and
strength and mood among older adults. Appl Nurs Res 1997;10:
11-8.
33. Patla A, Frank J, Winter D. Assessment of balance control in the
elderly: major issues. Physiother Can 1990;42:89-97.
34. Murray MP, Seireg AA, Sepic SB. Normal postural stability and
steadiness: quantitative assessment. J Bone Joint Surg Am 1975;
57:510-6.
35. Duval-Beaupere G, Robain G. Upward displacement of the center
of gravity in paraplegic patients. Paraplegia 1991;29:309-17.
36. Granger CV, Cotter AC, Hamilton BB, Fiedler RC, Hens MM.
Functional assessment scales: a study of persons with multiple
sclerosis. Arch Phys Med Rehabil 1990;71:870-5.
37. Farmer AR. Evaluation. In: Hill JP, Intagliata S, editors. Spinal
cord injury: a guide to functional outcomes in occupational ther-
apy. Rockville: Aspen; 1986. p 7-18.
38. Farmer AR. Dressing. In: Hill JP, Intagliata S, editors. Spinal cord
injury: a guide to functional outcomes in occupational therapy.
Rockville: Aspen; 1986. p 125-44.
39. Somers MF. Spinal cord injury: functional rehabilitation. 2nd ed.
Upper Saddle River: Prentice Hall; 2001. p 228-68.
40. Allison GT, Singer KP, Marshall RN. Transfer movement strate-
gies of individuals with spinal cord injuries. Disabil Rehabil
1996;18:35-41.
41. Guccione AA. Functional assessment. In: O’Sullivan SB, Schmitz
TJ, editors. Physical rehabilitation: assessment and treatment. 3rd
ed. Philadelphia: FA Davis; 1994. p 193-207.
42. Somers MF. Spinal cord injury: functional rehabilitation. 2nd ed.
Upper Saddle River: Prentice Hall; 2001. p 164-82.
Suppliers
a. SMS Healthcare, Elizabeth Way, Harlow, Essex, CM 19 5TL, UK.
b. Lafayette Inc, PO Box 5729, Sagamore Pkwy, North Lafayette, IN
47903.
Arch Phys Med Rehabil Vol 84, September 2003