Exp Brain Res (2004) 155: 186–195
DOI 10.1007/s00221-003-1716-x
RESEARCH ARTICLES
Dominique van Roon . Bert Steenbergen .
Ruud G. J. Meulenbroek
Trunk recruitment during spoon use in tetraparetic cerebral palsy
Received: 20 August 2002 / Accepted: 5 September 2003 / Published online: 20 December 2003
# Springer-Verlag 2003
Abstract In the present study we investigated the extent
to which individuals suffering from spastic tetraparesis as
a consequence of cerebral palsy tune their trunk involve-
ment to accuracy demands in a spoon-handling task.
Twenty-two participants (ten adolescents with spastic
tetraparesis and 12 control participants) had to transport
a spoon filled with water or sugar to a small or a large
bowl that was placed within reach. Even though trunk
displacement was larger in the tetraparetic participants
than it was in the control participants, the effects of the
imposed accuracy constraints were remarkably similar.
Participants in both groups increased trunk displacement
with increasing precision requirements. Furthermore, in
both groups the largest trunk involvement was found in the
initial and final part of the substance-transporting phase,
when wrist velocity was lowest. We propose several
explanations for these findings and conclude that the large
trunk involvement in individuals with tetraparetic cerebral
palsy should, in any case, not be regarded as a primary
symptom of the disorder, but rather as an adaptive reaction
to increased task demands.
Keywords Spoon use . Spastic tetraparesis . Trunk
involvement . Accuracy constraints . Adaptation
Introduction
Eating with a spoon seems to be an easy task to perform.
This everyday form of tool use, however, is quite complex
when we consider the precise coordination of movements
of the trunk, arm, hand, and fingers that is required to
successfully complete the task. The task becomes
particularly complex when a liquid has to be transported
D. van Roon (*) . B. Steenbergen . R. G. J. Meulenbroek
Nijmegen Institute for Cognition and Information, University
of Nijmegen,
PO Box 9104, 6500 HE Nijmegen, The Netherlands
e-mail: D.vanRoon@nici.kun.nl
Tel.: +31-24-3612148
Fax: +31-24-3616066
(e.g. soup) because of the additional risk of spilling when
bringing the spoon to the mouth. Compared to regular
reaching and grasping tasks, in which accuracy demands
impose themselves mainly at the end of the task (e.g.
dependent on target size), transporting substances with a
spoon requires the continuous monitoring of required
accuracy as the movement unfolds. It is this feature of a
spoon-handling task that makes it particularly interesting
and new to use such a task to study the way in which
people who have to cope with a permanent motor disorder
handle combinations of accuracy demands.
In the present study, we investigated to what extent the
specific accuracy demands of spoon use are reflected in
the recruitment of the trunk in participants suffering from a
spastic tetraparesis as a consequence of cerebral palsy
(CP). CP is a condition caused by chronic, non-progres-
sive brain damage in young children. This damage can be
caused by, for instance, an oxygen shortage at or around
birth, intra-uterine infections, prematurity or (the removal
of) a brain tumour at a very young age. It can cause motor
deficits (e.g. spasticity, dystonia, ataxia, athetosis, hypo-
tonia; Albright 1996) and sensory deficits (e.g. impaired
proprioception and stereognosis; Cooper et al. 1995), but
can also cause seizures and behavioural and cognitive
problems.
Spasticity arises in approximately 60% of the CP cases
(Sugden and Keogh 1990). Sanger et al. (2003) argued
that it is a disorder characterized by hypertonia, in which
one or both of the following signs are present: (1) The
resistance to an externally imposed movement increases
when the velocity of stretch increases and varies with the
direction of joint movement, and/or (2) this resistance rises
fast above a threshold speed or joint angle. In general,
voluntary muscle activation is disturbed. The impairment
may involve muscular weakness, disordered coordination
of synergistic agonist muscles, failure to inhibit antag-
onistic muscles, associated movements, stereotyped move-
ment synergies, and decreased dexterity (Lance 1980;
Barnes et al. 1994; Filloux 1996). As has been shown in
studies of reaching, grasping and eating (Van Thiel and
Steenbergen 2001; Van Roon et al. 2003), a behavioural

characteristic of individuals with a spastic paresis as a
result of CP is an increased involvement of the trunk. A
similar characteristic was found in hemiparetic stroke
patients (e.g. Cirstea and Levin 2000; Levin et al. 2002).
Here, we wanted to find out whether this larger trunk
involvement reflects a flexible adaptation to the disorder
and the task constraints or, alternatively, whether it should
be regarded as a manifestation of the disorder per se
(Latash and Anson 1996; Steenbergen et al. 2000; Van
Thiel and Steenbergen 2001; Steenbergen and Meulen-
broek 2003). Studying the combined effects of task
constraints and the disorder in everyday perceptuomotor
tasks provides, in our view, a unique way to try to
disentangle indices of flexible and rigid behaviour.
Research in healthy individuals has shown that an
increase in accuracy constraints, both during the move-
ment and at the end of it, gives rise to a larger
displacement of the trunk (Steenbergen et al. 1995; Van
der Kamp and Steenbergen 1999; Mackey et al. 2000).
Steenbergen et al. (1995) and Mackey et al. (2000)
suggested that an increased use of the trunk, with its large
mass and inertia, might help stabilize the arm–hand system
because a damping effect might occur. Alternatively, the
lower velocity of the wrist in tasks demanding higher
accuracy might also underlie the larger trunk displace-
ment. As demonstrated by several researchers, reaching
movements at higher velocities are achieved primarily by
smaller-mass body segments, while during such move-
ments at lower velocities an increased contribution of
greater-mass segments (with a larger inertia) is observed
(Rosenbaum et al. 1991, 1995; Vaughan et al. 1996; Wang
and Stelmach 2001).
In the present study we examined whether individuals
with spastic tetraparesis as a result of CP either flexibly
tune the amount of trunk involvement to the various
precision requirements or rigidly displace the trunk over a
fixed distance during spoon-use, independent of the
imposed accuracy demands. Our participants had to
transport a spoon filled with either a fluid or a solid
substance (manipulation of accuracy during transport) to a
small or a large bowl (manipulation of accuracy at the end
of the transport).
Based on the findings of the studies mentioned above,
we expected a larger trunk involvement in the tetraparetic
group than in the control group. In addition, we expected a
larger trunk involvement if water, rather than sugar, had to
be transported and if the bowl into which the spoon had to
be emptied was small rather than large. An absence of
such accuracy effects would be expected if trunk use
constituted a primary symptom of the disorder.
Methods
Participants
Ten individuals diagnosed as having spastic tetraparesis as a
consequence of CP (mean age 17 years 2 months, SD 1 year 3
months, range 14;7–18;6 years;months) and twelve healthy control
187
participants (mean age 25 years 6 months, SD 3 years 0 months,
range 20;0–30;0 years;months) with no known history of neurolo-
gical disorders took part in the experiment. The study was approved
by the local ethics committee and performed in accordance with the
ethical standards laid down in the 1964 Declaration of Helsinki. At
the time of testing, all participants with tetraparesis were students at
the Werkenrode Institute (Groesbeek, The Netherlands), where they
followed an adapted educational program. They all had sufficient
physical and cognitive abilities to perform the task under study and
normal or corrected-to-normal vision. Four tetraparetic participants
were able to walk independently, while the other six sat unstrappped
in a wheelchair from which they performed their daily activities. We
therefore inferred that all had functional sitting balance. All
participants were naive as to the purpose of the task and gave
their informed consent prior to data collection. Additional
participant information is given in Table 1.
Task and procedure
Participants were seated at a table on an ergonomic chair that could
be adjusted such that the following criteria were met. When the
forearms were on the table, the elbows were flexed at 90°.
Additionally, the feet were flat on the ground (or placed on a foot
rest) and the knees were also flexed at 90°. Prior to the start of the
experiment, the participants of the tetraparetic group performed the
Purdue Pegboard test (Tiffin 1968). As recommended in the
examiner’s manual, they performed the test three times for 30 s
with their preferred hand followed by three times for 30 s with their
non-preferred hand. The total score for each hand is presented in
Table 1.
After the experimenter had given a verbal go-signal, the
participant had to reach for a spoon filled with a particular
substance, and pick it up. Subsequently, they had to transport the
spoon to a cylindrical bowl that was placed further along the sagittal
axis towards the back of the table (hereafter denoted as substance-
transporting phase), and empty the spoon into the bowl (see Fig. 1
for the experimental set-up). The substance-transporting phase was
the focus of our study, and all analyses are performed on this phase.
Participants had to transport red-coloured water in half of the trials,
whereas in the other half they had to transport sugar. The diameter of
the bowl was 5 cm or 11 cm.
To determine a participant-dependent, appropriate position of the
bowl in the workspace, participants were instructed to hold the
spoon in a power grip so that the stem of the spoon was parallel to
the front edge of the table (x-axis, see Fig. 1), and actively stretch
their arm as far as possible without moving their trunk.
Fig. 1 Experimental set-up from the participant’s viewpoint: a
starting block, b spoon holder, c spoon, d letter balance, e bowl
188
Table 1 Participant information (CP cerebral palsy)
Subject Sex Age Active range Hand Purdue Pegboard scorec Diagnosis
ID (years; months) of motion (cm)a preferrenceb
Pref. hand Non-pref. hand

Tetraparetic participants
1 F 18;1 29 Right 25 14 CP, spastic tetraparesis, epileptic
2 M 18;6 34 Left 39 14 CP, spastic tetraparesis
3 F 17;4 43 Right 30 16 CP, spastic tetraparesis
4 M 18;6 42 Right 28 22 CP, spastic tetraparesis
5 M 16;1 42 Left 32 18 CP, spastic tetraparesis
6 F 14;7 32 Left 33 21 CP, spastic tetraparesis
7 M 17;4 47 Right 15 7 CP, spastic tetraparesis
8 F 17;9 39 Left 18 16 CP, spastic tetraparesis
9 M 16;4 50 Right 30 28 CP, spastic tetraparesis
10 F 17;4 32 Right 25 13 CP, spastic tetraparesis, epileptic
Control participants
1–12 8F/4M 25;6 35–42 Right 53 49 –
Norm scores for healthy individuals
a
Distance between the front edge of the table and the midpoint of the bowl. See Task and Procedure section for a detailed description of the
method of determination of this active range of motion
b
As indicated by the participant
c
The total number of pins placed into the holes in three 30-s periods (see Task and Procedure section)

Subsequently, the bowl was positioned so that its midpoint
corresponded to the midpoint of the spoon. We made the position
of the bowl dependent on the distance that could be covered by
moving only the arm, because we wanted to study the involvement
of the trunk during task performance when this involvement was not
strictly necessary to perform the task. On average, the distance
between the front edge of the table and the midpoint of the bowl
(active range of motion; see Table 1) in the tetraparetic group (mean
39 cm, SD 7.0 cm) was the same as this distance in the control group
(mean 39 cm, SD 2.4 cm; t=0.085, P=0.933). Note that the distance
that needed to be covered with the spoon in the substance-
transporting phase (hereafter denoted as transport distance), was
less than half the active range of motion (or more precisely, this
distance minus 7 cm—the distance between the front edge of the
table and the midpoint of the starting block—divided by two). The
spoon had a stem that measured 12 cm in length and an aluminium
round bowl (diameter of 4.5 cm and depth of 1.2 cm). It weighed
approximately 80 g.
The manipulations resulted in four unique conditions, defined by
Substance (water, sugar), and Bowl (small, large). For each
condition, 45 trials were performed resulting in a grand total of
180 trials per participant. The two substances were presented in two
blocks of 90 trials, counterbalanced across the participants of each
group. Within each block, the factor Bowl was randomized.
The tetraparetic participants performed the task with their least
affected hand, as indicated by the participant and confirmed by the
Purdue-Pegboard scores. The control participants used the hand that
they had indicated as being used for everyday unimanual tasks. At
the start of each trial, the experimenter placed the spoon on top of a
plastic cube of approximately 10 cm in height (located half-way
between the midpoint of the starting block and the midpoint of
bowl), just underneath a plastic slat and on top of a little metal
detector, thereby leaving the stem ‘free in the air’ (see Fig. 1).
Presenting the spoon like this allowed the participants to grasp the
spoon in their preferred way. The spoon was filled with
approximately 6 g of either sugar or water. Participants were
asked to sit upright, with their back against the back of the chair. The
palm of their preferred hand rested on the starting block to
standardize the starting position of the hand. This block measured
10.0 cm in length, 14.3 cm in width, and 6.5 cm in height. It was
positioned 2 cm from the front edge of the table and approximately
8 cm to the ipsilateral side of the midsagittal plane of the body, so
that the midpoint of the block corresponded with the midpoint of the
stem of the spoon. The other hand rested on the tabletop.
Participants were not restrained by any means, nor were any
speed demands imposed. In addition, no instructions were given
concerning the type of grip that had to be used. However, they were
instructed to try not to spill any of the substance. At the end of each
trial, the substance that was successfully transported to the bowl was
weighed by means of a letter-balance (precision 0.5 g). Before the
experiment started, each participant performed six practice trials in
which three spoons filled with water and three spoons filled with
sugar had to be transported to the small bowl. After half of the
experimental trials, there was always a short break, but participants
could always indicate when they needed extra rest. The total
experiment took approximately 1.5 to 2 h of which 30 to 45 min
were spent on preparations and 60 to 75 min on the performance of
the 180 trials.
A 3-D motion-tracking device (Optotrak 3020) was used for
movement recording. Four infrared light-emitting diodes (IREDs)
were placed on the wrist, elbow and both shoulders and their
positions were sampled at a rate of 200 Hz with a spatial accuracy of
0.2 mm in the x-, y-, and z-dimension. The actual testing was also
videotaped.
Data analysis
The positional data were filtered using a zero-phase lag, second-
order Butterworth filter with a cutoff frequency of 10 Hz and then
differentiated to calculate movement velocity and acceleration.
Semi-automatic segmentation routines were used to define the start
and end of the substance-transporting phase, on which all
subsequent analyses were performed. The start of the movement
was determined by the moment at which the wrist velocity in the y-
direction (see Fig. 1) reached 20 mm/s after the spoon had lost
 189
Fig. 2 Typical examples of
task performance. Y-position
profiles of the wrist, the ipsilat-
eral and the contralateral shoul-
der (upper graphs) and the
tangential wrist velocity profile
(lower graphs) as a function of
movement duration for one trial
of a control participant (left
graphs) and for one trial of a
tetraparetic participant (right
graphs). In both depicted trials
water had to be transported to
the small bowl

contact with the metal detector.1 The end of this phase was
determined by the moment at which the wrist velocity in the y-
direction fell below 10% of its peak velocity.
On the basis of the displacement data of the wrist several standard
kinematic variables (mean tangential velocity, maximum tangential
velocity, percentage of the movement time to peak velocity,
dysfluency of the movement, and wrist displacement [in the y-
direction] relative to the transport distance) were determined.
Dysfluency was determined by the number of zero-crossings per
second in the acceleration profile of the wrist. The forward wrist
displacement relative to the transport distance was taken as a
measure of the way in which the bowl was approached (which was
also dependent on the type of grip used) in combination with the
location at which the spoon was emptied (e.g. in front of or behind
the midpoint of the large bowl). When the bowl of the spoon was
held out further to empty the spoon, or when the spoon was emptied
earlier (closer to the front edge of the bowl), the distance that was
covered by the wrist was shorter.
To examine the trunk involvement in the substance-transporting
phase we determined the absolute displacement in the y-direction of
both the ipsilateral shoulder (i.e. the shoulder of the same body-side
as the arm that performed the task) and the contralateral shoulder
between the start and the end of that phase. The displacement of the
contralateral shoulder in the y-direction was taken as a measure of
sagittal trunk displacement. When the sagittal displacement of the
ipsilateral shoulder was larger than the sagittal displacement of the
contralateral shoulder, the trunk was rotated. Trunk rotation between
the start and the end of the substance-transporting phase was
calculated as the difference in the angle between the x-axis and the
line connecting the IREDs on the ipsilateral and contralateral
1We checked in two control participants and two tetraparetic
participants (the slowest and the fastest one of each group) whether
different results were obtained if we determined the start by the
moment at which the wrist velocity in the y-direction rose above
10% of peak wrist velocity in the y-direction after the spoon had lost
contact with the metal detector. It appeared that the results were
qualitatively similar to the results reported below.
shoulder. To determine the distribution of sagittal trunk displace-
ment across the initial, middle and final part of the substance-
transporting phase, we divided this phase into three equal parts on
the basis of the distance covered by the wrist in the y-direction.
Subsequently, we determined the displacement of the contralateral
shoulder in the y-direction in each of the three parts of the substance-
transporting phase.
Statistical analysis
Means of the dependent variables across the replications of each
condition were analysed using repeated measures analysis of
variance (ANOVA). The design consisted of one between-subjects
factor, Group (tetraparetic versus control), and two within-subjects
factors, namely, Substance (water versus sugar) and Bowl (small
versus large). To analyse the distribution of the displacement of the
trunk across the three successive parts of the substance-transporting
phase, and the mean wrist velocity in these three parts, we added an
extra within-subjects factor Part (initial, middle and final part).
When requirements for homogeneity of variances (Levene’s test)
were not met, which was only the case for the displacement of the
trunk in the final part of the substance-transporting phase, we used a
parametric modification of the F-test (Welch’s test; see Maxwell and
Delaney 1990) to study the differences between groups. Step-down
analyses of statistically significant interactions were performed by
means of contrasts. To determine the relationship between the
sagittal trunk displacement and the mean wrist velocity, Pearson’s
correlation coefficients were calculated for each participant
separately, across all 180 trials. The level for significance was set
to P≤0.05. As a measure of effect size η2-values are reported.
190

subject SD and CV for each condition (combination of factors Substance and Bowl) and
Results

General task performance

Tetraparetic
Coefficient of variation (%)

17***
17***
25***
47***
12
then averaging across the participants of each group (control and tetraparetic)
Both the control participants and the participants with
spastic tetraparesis were able to perform the task. Hardly
any of the substance was spilled. In each condition a total
of 90 g of the substance (6 g in each of the 15 trials) had to
be transported to the bowl. The control participants

Control
transported on average 89.5 g per condition (SD 1.1 g,
range 85–90 g) and the tetraparetic participants 89 g (SD

11
10

12
59
15
1.1 g, range 84.5–90 g). It must be noted that the spilling
almost always took place at the end of the task when the
spoon was emptied. In Fig. 2, two examples of the

Tetraparetic

2.3*
recorded movements and corresponding movement kine-

23*
34
11***

8
matics are displayed (one trial for each group).

Within-subject SD
Upon careful checking of the video recordings, it was
established that the employed grip types were comparable
across groups. In each group, two participants used

Control
predominantly power grips, while the other participants

1.7
19
31
6

9
used precision grips.

5.2 (1.5)***
Kinematic data of the end-effector

Table 2 shows the kinematic characteristics of the wrist

movement in the substance-transporting phase for the

48 (4)*

70 (11)
143 (32)***
212 (53)***
tetraparetic group and the control group separately.
Tetraparetic
Mean (between-subject SD)
Table 2 Kinematic characteristics of the wrist for the substance-transporting phase (across
both bowls and substances). The average within-subject standard deviations (SDs) and the
average coefficients of variation (CVs) were determined by first calculating the within-

Mean tangential wrist velocity

To check whether our manipulations of accuracy had been

2.8 (1.0)

effective, we examined their effects on the mean tangential

wrist velocity. We expected that the task was performed at
192 (19)
278 (29)
52 (4)

64 (11)

a lower speed if accuracy constraints were higher, as is

Control

normally the case in regular reaching tasks (e.g. Marteniuk

et al 1987).
The participants with spastic tetraparesis made slower
movements than the control participants in the substance-
Movement time to peak velocity (% total movement time)

transporting phase (143 mm/s and 192 mm/s, respectively;

F(1,20)=20.20, P<0.001, η2=0.502). Across both groups,
the movements were performed slower when water had to
be transported than for sugar transportation (147 mm/s
versus 193 mm/s; F(1,20)=117.89, P<0.001, η2=0.855), and
when the bowl was small rather than large (157 mm/s
Wrist displacement (% transport distance)

versus 183 mm/s; F(1,20)=55.87, P<0.001, η2=0.736).

Mean tangential wrist velocity (mm/s)
Peak tangential wrist velocity (mm/s)

Number of zero-crossings per second

A step-down analysis of the interaction between

Substance, Bowl and Group (F(1,20)=4.84, P=0.04,
*P<0.05, **P<0.01, ***P<0.001

η2=0.195) showed that the interaction between Substance

and Bowl was only significant for the control group
(F(1,11)=32.35, P<0.001, η2=0.746). In that group the
difference in mean wrist velocity between the water
condition and the sugar condition was larger when the
substance was transported to the large bowl (difference
53 mm/s; F(1,11)=74.03, P<0.001, η2=0.871) rather than
the small bowl (difference 38 mm/s; F(1,11)=66.52,
P<0.001, η2=0.858).

Fig. 3 Mean tangential wrist velocity for each group separately in
three successive parts of the substance-transporting phase. Error bars
represent between-subjects variability (SDs)
Mean tangential wrist velocity in the initial, middle,
and final part of the substance-transporting phase
To further examine the course of wrist velocity during the
substance-transporting phase, we divided this phase into
three equal parts on the basis of the distance covered by
the wrist. It appeared that the mean tangential velocity of
the wrist was highest in the middle part of the substance-
transporting phase and lower in the initial and final part
(F(2,40)=153.50, P<0.001, η2=0.885), as is usually the case
in regular reaching tasks (see Fig. 3). In both groups the
difference in wrist velocity between the initial part and
middle part, and between the middle and final part were
statistically significant (statistics respectively
F(1,11)=324.58, P<0.001, η2=0.967 and F(1,11)=178.68,
P<0.001, η2=0.942 for the control group, and F(1,9)=86.68,
P<0.001, η2=0.906 and F(1,9)=33.47, P<0.001, η2=0.788
for the tetraparetic group). No significant difference was
found between the wrist velocity in the initial part and that
in the final part. Furthermore, it was shown that a
difference in wrist velocity between the two groups existed
in all three parts (part 1: F(1,20)=9.99, P=0.005, η2=0.333;
part 2: F(1,20)=17.54, P<0.001, η2=0.467; part 3:
F(1,20)=23.20, P<0.001, η2=0.537).
Wrist displacement as a percentage of the transport
distance of the spoon
Participants were left completely free with respect to the
way in which the spoon was emptied in to the bowl. Here,
we examined the effects of Group, Substance and Bowl on
Table 3 Means and between-subject standard deviations (in
parentheses) of mean tangential wrist velocity and wrist displace-
ment as percentage of the distance between spoonholder and
Control participants
Sugar
Large Small
Mean tangential wrist velocity (mm/s) 230 (32) 199 (20)
Wrist displacement (% transport distance) 57 (15) 63 (10)
191
the adopted emptying strategy (see Table 3). The distance
that was covered by the wrist relative to the transport
distance of the spoon was taken as a measure of this
strategy. In two cases, the distance that was covered by the
wrist was shorter than the transport distance of the spoon:
when the bowl of the spoon was extended further to empty
the spoon (which was easier when the spoon was held in a
precision grip), and when the spoon was emptied closer to
the front edge of the bowl. It appeared that the relative
distance that was covered by the wrist was smaller when
sugar was transported than for water transportation
(F(1,20)=40.67, P<0.001, η2=0.670), and when the bowl
was large rather than small (F(1,20)=18.69, P<0.001,
η2=0.483). However, no difference was found between
the control group and the tetraparetic group.
Trunk recruitment
Total trunk displacement and trunk rotation
It was verified that the participants with spastic tetraparesis
displaced their trunk more than the control participants
during the substance-transporting phase (F(1,20)=6.49,
P=0.019, η2=0.245; see Fig. 4), as we expected on the
basis of previous research. The tetraparetic group
displaced the trunk on average 11.8 mm, which equates
with an average of 11.2% of the displacement of the wrist.
The control group showed an average trunk displacement
of 4.7 mm, which equates with an average of 5.5% of the
displacement of the wrist. As a control measure, we
examined trunk displacement prior to the substance-
transporting phase (reaching towards and picking up the
spoon), which also was larger in the tetraparetic group
than in the control group (21.3 mm and 7.3 mm,
respectively; F(1,20)=4.83, P=0.040, η2=0.194).
The within-subjects standard deviation of the trunk
displacement in the substance-transporting phase was
larger for the tetraparetic group than for the control
group, but this was probably a consequence of the larger
mean displacement. This was substantiated by the absence
of any difference between groups for the within-subjects
coefficient of variation for trunk displacement.
An important finding was that the participants were able
to tune the amount of trunk displacement to the various
precision requirements. Averaged across groups, the trunk
displacement was larger when the substance had to be
transported to the small bowl rather than to the large bowl
midpoint of the bowl in the substance-transporting phase: effects of
factors Substance (sugar, water) and Bowl (large, small)
Tetraparetic participants
Water Sugar Water
Large Small Large Small Large Small
177 (17) 161 (19) 182 (39) 152 (37) 133 (32) 105 (31)
64 (13) 71 (10) 66 (12) 69 (10) 70 (14) 75 (9)
192
Fig. 4 Sagittal displacement of the ipsilateral and the contralateral
shoulder (in millimetres) during the substance-transporting phase,
for each group separately. Error bars represent between-subjects
variability (SDs)
Fig. 5 Sagittal trunk displacement (in millimetres) during the
substance-transporting phase as a function of Substance (sugar,
water), Bowl (large, small) and Group (control, tetraparetic
subjects). Error bars above the mean bars represent between-
subjects variability (SDs) and error bars within the bars represent the
mean within-subject variability
Fig. 6 Sagittal displacement of the trunk (in millimetres) for each
group separately in three successive parts of the substance-
transporting phase. Error bars represent between-subjects variability
(SDs)
(10.5 mm and 5.3 mm, respectively; F(1,20)=32.93,
P<0.001, η2=0.622) and when water had to be transported
rather than sugar (9.6 mm and 6.2 mm, respectively;
F(1,20)=25.04, P<0.001, η2=0.556; see Fig. 5). However,
an interaction between Substance and Group was found
(F(1,20)=8.22, P=0.010, η2=0.291). It appeared that the
effect of Substance was only present in the tetraparetic
group (F(1,9)=20.69, P=0.001, η2=0.697).
Besides a larger trunk displacement, the participants
with spastic tetraparesis also showed a larger trunk
rotation than the control participants during the sub-
stance-transporting phase (4.5° and 3.3°, respectively;
F(1,20)=5.13, P=0.035, η2=0.204). As can be observed in
Fig. 4, the difference between the ipsilateral and the
contralateral shoulder displacement was larger in the
tetraparetic group.
The distribution of trunk displacement across the
initial, middle and final part of the substance-
transporting phase
To examine the time-course of trunk involvement during
the transporting phase, we examined the trunk displace-
ment in each of the three parts of the substance-
transporting phase (initial, middle and final part). As
shown in Fig. 6, the involvement of the trunk decreased
from the initial to the middle part of the substance-
transporting phase and then increased from the middle to
the final part for both groups. A main effect of Part
(F(2,40)=9.72, P<0.001, η2=0.327) was found, as well as an
interaction between Part and Group (F(2,40)=5.04,
P=0.011, η2=0.201). In the control group the displacement
was 2.7 mm in the initial part, 0.5 mm in the middle part
and 1.4 mm in the final part of the movement (note that
these values are not cumulative but represent distances
covered in each part separately). Since especially the last
two displacements are very short, it must be kept in mind
that they could have been a result of skin displacement
during task performance. Nevertheless, step-down ana-
lyses showed that in this group the difference between the
initial part and middle part, and between the middle and
final part were statistically significant (statistics respec-
tively F(1,11)=19.18, P=0.001, η2=0.635 and F(1,11)=13.89,
P=0.003, η2=0.558). In the tetraparetic group the distances
covered by the trunk were 3.8 mm, 2.3 mm and 5.6 mm, in
the initial, middle, and final part, respectively. The trunk
displacement did not differ between the initial and middle
part, while this displacement increased during the final
part (F(1,9)=9.33, P=0.014, η2=0.509). Furthermore, the
difference between the two groups only existed in the
middle and final part of the substance-transporting phase
(F(1,20)=4.49, P=0.047, η2=0.183 and Welch’s
W(1,11.2)=10.91, P<0.01, respectively), whereas the differ-
ence between the groups was not statistically significant in
the initial part.
Relationship between trunk displacement and mean
tangential wrist velocity
To determine the relationship between the sagittal trunk
displacement and the mean tangential wrist velocity,
Pearson’s correlation coefficients were calculated for
 193
Table 4 Correlations between Subject ID Correlation coefficient Trunk displacement (mm) Mean tangential wrist velocity (mm/s)
sagittal trunk displacement and
mean tangential wrist velocity in Mean (SD) Range Mean (SD) Range
the substance-transporting phase
(across all 180 trials) for each Control participants
control and tetraparetic partici- 1 −0.18* 1 (5) −12 to 27 164 (27) 105 to 272
pant
2 −0.53*** 5 (7) −8 to 38 211 (36) 136 to 307
3 −0.28*** 5 (4) −4 to 16 204 (38) 144 to 308
4 −0.32*** 5 (3) −3 to 13 169 (31) 123 to 284
5 −0.63*** 2 (5) −11 to 18 166 (32) 97 to 262
6 −0.19** −1 (2) −6 to 4 213 (27) 138 to 281
7 −0.63*** 4 (4) −5 to 16 196 (34) 130 to 278
8 −0.19* 0 (2) −8 to 6 180 (26) 125 to 242
9 −0.22** 4 (5) −5 to 20 184 (35) 103 to 286
10 +0.17* 0 (2) −5 to 7 198 (21) 140 to 260
11 −0.31*** 15 (10) −1 to 50 217 (61) 118 to 337
12 −0.07 16 (12) −4 to 52 203 (30) 140 to 289
Tetraparetic participants
1 −0.28*** 10 (7) −1 to 36 108 (27) 59 to 199
2 −0.26*** 2 (3) −13 to 15 152 (18) 114 to 201
3 −0.63*** 16 (9) −5 to 40 142 (42) 63 to 267
4 −0.53*** 20 (13) −3 to 66 125 (50) 43 to 228
5 −0.47*** 22 (15) −1 to 93 141 (38) 63 to 230
6 −0.40*** 17 (13) −11 to 75 162 (45) 79 to 309
7 +0.31*** −2 (7) −20 to 20 168 (55) 78 to 302
8 −0.46*** 12 (9) −1 to 59 115 (37) 51 to 197
9 −0.07 14 (15) −20 to 65 210 (42) 102 to 301
*P<0.05, **P<0.01, 10 −0.26*** 7 (5) −7 to 29 107 (31) 42 to 194
***P<0.001

each participant separately across all 180 trials. Significant
negative correlations between trunk displacement and
mean wrist velocity were found for 10 of 12 control
participants (one-tailed sign-test, P=0.019) and for 8 of 10
tetraparetic participants (one-tailed sign-test, P=0.055),
indicating that a decrease in the speed of moving
coincided with an increase in trunk displacement. On
average this correlation was approximately −0.30 in both
groups (see Table 4).
Discussion
In this study, we examined how the damaged nervous
system of individuals with tetraparesis as a result of CP
deals with increased accuracy constraints. For this
purpose, we studied spoon use because this task allowed
us to manipulate accuracy demands both during transport
(by variations in the substance to be transported) and at the
end of the task (by variations in the size of the bowl in
which the spoon needed to be emptied). The effect of the
latter accuracy constraint on the mean wrist velocity is in
line with reaching and grasping studies that also examined
the effects of accuracy constraints at the end of the
movement (Marteniuk et al. 1990; Bootsma et al. 1994;
Berthier et al. 1996; Weir et al. 1998). In addition, the
effects of manipulation of accuracy during the task
corroborated previous findings in a healthy subject
population (cf. Van der Kamp and Steenbergen 1999).
Our main question was whether the larger trunk
recruitment commonly found in individuals with a paresis
as a result of CP represents a fixed movement pattern or,
alternatively, might be regarded as a flexible adaptation to
deal with the combination of disorder and task constraints.
Overall, participants with tetraparesis showed an increase
in trunk involvement compared to control participants.
Although absolute values of trunk displacement (and
rotation) were small, when taken relative to wrist
displacement trunk displacement in the tetraparetic group
was more than double that of the control group (11.2%
versus 5.5%). This finding extends previous findings on
trunk involvement in individuals with unilateral brain
damage, either from CP (cf. Steenbergen et al. 2000; Van
Thiel and Steenbergen 2001) or from stroke (cf. Cirstea
and Levin 2000; Levin et al. 2002), to individuals with
more diffuse damage of the brain (tetraparetic patients).
Hence, a general reorganization may involve an increased
involvement of the trunk.
Two additional remarks must be made to put this
finding into perspective. First, we showed that prior to the
substance-transporting phase, the tetraparetic participants
already displayed a larger trunk involvement than the
control participants did. This means that a larger
anticipatory trunk displacement which might have been
present in the control group can be ruled out as an
194
explanation for the larger trunk displacement in the
tetraparetic group in the substance-transporting phase.
Second, as explained in the Methods section, the bowl was
placed within the active range of motion for each
participant and trunk recruitment was therefore not
necessary for the performance of the task.
The effects of the requirement for accuracy on trunk
involvement were straightforward. Increasing the accuracy
constraint at the end of the task caused an increased trunk
displacement for both the control and the tetraparetic
participants. Consequently, rather than displacing the trunk
a fixed, standardized distance, tetraparetic participants
flexibly tuned the degree of trunk involvement to the
accuracy demands imposed, as has previously been shown
in control participants (cf. Steenbergen et al. 1995;
Mackey et al. 2000). Whereas the accuracy constraint
during the movement had no effect on trunk involvement
for the control participants, participants with tetraparesis
increased trunk involvement when transporting water. In
sum, tetraparetic participants dealt with increased accuracy
constraints by an increased use of the trunk. This leads us
to conclude that trunk involvement in this group may be
regarded as a flexible adaptation to the imposed task
demands. Note that the preferred hand of all tetraparetic
participants was relatively mildly impaired, although they
made slower movements, needed more time decelerating,
and moved less fluently than the control participants. They
were all able to perform the task without spilling. It
therefore remains to be seen whether this pattern of results
will hold true when more severely affected people are
tested.
To further examine the nature of trunk involvement, we
also analysed its time-course. In both groups, the
displacement was largest during the initial and the final
part and smallest during the middle part, although in the
tetraparetic group the decrease in trunk displacement from
the initial to the middle part was not significant. One
reason for this distribution of trunk displacement might be
the speed of the movement in the three parts of the task.
When mean wrist velocity was highest (in the middle part
of the substance-transporting phase), the trunk displace-
ment was smallest. In line with this, correlations between
mean wrist velocity and trunk displacement were mainly
negative in both groups (10 of 12 control participants, and
8 of 10 tetraparetic participants), indicating there was a
clear tendency for increased trunk use with lower move-
ment speed. A combination of these findings might, at
least partly, explain why individuals with spastic tetrapa-
resis displace their trunk more than healthy individuals,
and also why trunk displacement increases when accuracy
demands increase. If a task becomes more complex (e.g. as
a result of motor and somatosensory problems or higher
accuracy demands or both), the movement is performed
more slowly. As a consequence of that, the trunk is
recruited more (see also Rosenbaum et al. 1991, 1995;
Vaughan et al. 1996; Wang and Stelmach 2001). A note of
caution must be made here. The correlation coefficients
that we found were not very large and we even found a
positive correlation for one participant in each group.
Therefore, variations in movement speed did not exclu-
sively account for variations in trunk involvement. How-
ever, it has to be pointed out that this experiment was not
designed to test this specific hypothesis, as we did not
explicitly manipulate movement speed. To be able to draw
more definite conclusions on this matter, a wider range of
velocities should be investigated. Are there alternative
explanations for the increased trunk involvement?
One factor that might have influenced trunk involve-
ment is the emptying strategy that participants adopted.
The emptying strategy entails both the way in which the
spoon is oriented before emptying (cf. Roby-Brami 1997)
and, especially relevant for the large bowl, the location at
which the spoon is emptied (e.g. close to the front edge of
the bowl). The different emptying strategies were reflected
by the distance that was covered by the wrist relative to the
transport distance of the spoon. Most participants used
precision grips, which make it easier to extend the bowl of
the spoon further. The distance that was covered by the
wrist relative to the transport distance was on average
67%, indicating that the participants used the length of the
stem of the spoon to shorten the distance that had to be
covered by the wrist. Importantly, no difference in
emptying strategy was found between the two groups,
although, in general, the relative wrist displacement was
larger when water was transported and when the bowl was
small. Nevertheless, these findings can only partly account
for the larger trunk displacement in these conditions,
because the trunk displacement was not necessary to
empty the spoon into the bowl, as was assessed prior to the
start of the experiment. Combining this finding with the
observed relationship between speed and trunk displace-
ment leads us to the following explanation: when larger
distances are covered by the wrist in the more complex
conditions (small bowl, water), participants move their
hand for a longer time at a lower velocity, leading to a
larger trunk displacement.
Another factor that may have influenced trunk involve-
ment is the increased cocontraction of agonist/antagonist
muscle pairs, which is a typical symptom accompanying
spasticity in individuals with CP (O’Sullivan et al. 1998).
As a result of the increased limb stiffness, the functional
range of motion during task performance in the elbow and
shoulder joints might be reduced. Increasing the displace-
ment of the trunk might compensate for this decreased
functional range of motion. Indeed, it was recently shown
in a healthy subject population that cocontraction at the
elbow and shoulder increases when pointing movements
have to be made towards small targets rather than large
ones (Gribble et al. 2003). Gribble and colleagues
suggested that cocontraction might be a strategy employed
by the motor system to increase arm movement accuracy.
An electromyographic study is currently underway in our
lab to examine whether the same strategy is used by
individuals with spasticity.
A final factor for the increased trunk use may be sought
in the need to reduce variability of the end-effector
trajectory, which is most prominent for high accuracy
tasks (cf. Cirstea and Levin 2000). Our finding that the

displacement of the trunk was largest in the tetraparetic
participants in the final part of the movement might
provide evidence for this since the instability of the end-
effector is assumed to be largest near the end of the
movement. In this final part, the elbow is most extended
and, due to the muscular weakness in these individuals,
movements of the end effector may then become more
variable. However, with the present set-up we could not
draw any definite conclusion with respect to this point and
further research is needed to examine whether fixating the
trunk will increase the end-effector dysfluency in this
group.
Summing up, similar to healthy people, tetraparetic
individuals flexibly tune the amount of trunk involvement
to variations in accuracy demands, despite the somatosen-
sory and motor problems that these individuals have to
cope with. An increased trunk displacement was found
when accuracy constraints of the task were higher. We
therefore conclude that the increased trunk involvement in
individuals with mild tetraparesis as a consequence of CP
should not be regarded as a primary symptom of the
disorder.
Acknowledgements We thank all volunteers who participated in
this study, Marcel Mutsaarts for his assistance in carrying out the
experiment, and Chris Bouwhuisen for his technical support. This
research was supported by a grant awarded by The Netherlands
Organization for Scientific Research (NWO) to the second author
for the research project ‘Adaptation in movement disorder’.
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