After a stroke, the two questions family members ask most often are: "When will he be able to walk alone?" and "Why does the physiotherapist keep asking him to sit at the bedside and practise turning and reaching, and not practise walking straight away?" The answers to both point to one key that is easy to overlook: trunk control, and the standardised tool used to measure it, the Trunk Impairment Scale (TIS).
From the point of view of physiotherapy assessment, this article explains the scoring structure of the TIS, what the key cutoff of 12 points means for outlook, and how family members can follow progress in rehabilitation through the trend in scores. For the general idea of trunk control, why it matters and an overview of how it is trained, see the wider picture of stroke rehabilitation. This page concentrates on the TIS as an assessment tool.
Sitting steadily is a precondition for walking independently
The conclusion first: trunk control is more than the end point of rehabilitation. It is the upstream foundation of walking and self-care. The patient must first be able to sit steadily and reach out to both sides without losing balance, and only then will standing and walking later have a firm base. The role of the TIS is to turn the impression of whether the patient sits steadily into an objective tracking measure scored from 0 to 23, so that therapists, patients and family members can follow progress by the same standard (Verheyden et al. 2004).
How should a TIS score be understood? The TIS is not an examination mark. It shows how many daily movements the trunk can support. The patient has to sit steadily first before reaching for things and turning, and then moving on to standing and walking. A high score is not an aim in itself, and the trend of the score rising step by step over time is the sign that rehabilitation is working.
The three parts of the TIS
The TIS was developed by Verheyden and colleagues in 2004. It is a scale designed specifically to assess motor impairment of the trunk after stroke, has good reliability, internal consistency and validity, and is widely used in clinical practice and research (Verheyden et al. 2004). The scale has three subscales, which progress from whether the patient can sit steadily to whether the trunk can rotate actively:
The three subscales add up to 0–23 points. It is worth noting that the TIS assesses purely the trunk itself, and not overall balance or walking performance. For this reason, even when the patient still cannot stand or step in early rehabilitation, the TIS can show the trunk foundation first.
What a TIS of 12 means for predicting independent walking
For the question of when the patient will be able to walk alone, the medical literature offers a concrete threshold. Ishiwatari and colleagues (2022) followed 102 patients in the acute phase of stroke and found that a TIS of 12 or more in the acute phase predicts walking independently at discharge, and the predictive accuracy of this indicator was rated excellent:
The same study also found that the TIS score and age are the two key factors in predicting whether the patient can walk independently at discharge (Ishiwatari et al. 2022). It must be stressed, however, that a score below 12 does not mean the patient will never walk. It only suggests that before starting high-intensity walking training, strengthening the trunk first is the more realistic and more efficient approach.
The 12-point figure is a reference number from overall statistics. It is not the final verdict on an individual.Each patient's progress in rehabilitation is affected by many factors, such as the location of the brain damage, other illnesses and how fully the patient takes part in rehabilitation. It is advisable to use the TIS score as a way of discussing progress with the therapist, and not as a conclusion that replaces professional clinical judgement.
Why practise turning and reaching while seated before practising walking?
Many family members are anxious and ask why walking is not practised directly. This follows a training order that has evidence behind it and is no way of killing time. Several studies reach the same conclusion: early trunk control is an important predictor of later self-care in daily life and walking performance:
Effect of trunk control on self-care in daily life
- Early trunk control (PASS-TC) performance alone explains about 45% of the variance in overall ADL function at discharge (Hsieh 2002)
- Its predictive power is higher than that of basic ADL and motor scores, which shows that trunk control is the basis of other movements
Effect of trunk control on overall recovery
- Combining age, the TIS and early ADL within 48 hours of onset explains about 79% of the variance in ADL at discharge (Ishiwatari 2021)
- The TIS is a reliable early indicator, in the acute phase, of later ADL performance
In other words, when the therapist has the patient practise turning while seated and reaching to both sides first, the aim is to lay the foundation for every later function. With a firm foundation, the patient is less likely to fall repeatedly, or to build up poor compensatory movements, when later practising standing and walking. This page does not go into the overall stages of recovery after stroke and the golden period; see the stroke recovery timeline. This page only focuses on using the TIS to measure progress in the single area of the trunk.
Family members should watch the trend in scores
The value of the TIS lies in more than the score the patient has now. It lies in whether the score is still rising. Yamamoto and colleagues (2025) studied inpatients in the subacute phase who needed help to walk and estimated the minimal important change (MIC) of the TIS at about 2.5 points. This means that when the patient is reassessed every one to two weeks, a rise of about 2–3 points counts as clinically meaningful progress.
Advice for family members: do not worry over a single score. Look at the trend in the scores from each assessment joined together. A rise from 8 to 11 points within a month means more than noting that the patient has only 11 today and has not yet reached 12, because it clearly shows that trunk function is steadily recovering.
Besides the score, family members can also see for themselves, day to day, indicators of trunk progress that correspond to the items assessed in the TIS. Each of the stages below means one more step forward in trunk control:
- Progress from needing someone to hold the patient to sit steadily, to sitting steadily alone after the hands are let go (static sitting balance)
- Reaching to the left and right for things while seated without losing balance and falling (dynamic sitting balance)
- Being able to turn the trunk actively while seated, for example turning to help with putting on clothes (coordination)
- Deciding from the height of one score alone whether the patient can walk, and ignoring the overall trend in scores
- Thinking that training is not working because the score has not yet reached 12, and becoming discouraged and giving up
How the TIS and other assessment tools divide the work
No single tool can cover rehabilitation assessment completely. Different scales look at different levels, and they complement each other:
- Measures static and dynamic sitting balance and coordination of the trunk itself
- 0–23 points, with 12 as the outlook threshold for independent walking
- Can show the trunk foundation even while the patient cannot yet stand or walk
- PASS-TC / Berg: measure overall sitting and standing balance and the risk of falls
- FAC (Functional Ambulation Categories): measures the level of independence in walking
- These complement fall risk assessment; general community fall prevention is covered on a separate page
For the care of sitting and standing balance and fall prevention, there are related pages on balance and falls after stroke, and on balance and fall prevention training for older adults and people in the community in general, which belongs to a different field. This page concentrates on trunk assessment after stroke and does not cover them here.
Note on professional roles: this page covers only the trunk assessment and outlook for recovery in physiotherapy. Retraining self-care skills such as dressing and bathing, and dealing with problems such as spatial neglect, belong to the professional field of occupational therapy. For details see occupational therapy after stroke, which is best combined with physiotherapy.