Brief Symptom Inventory (BSI)

The Brief Symptom Inventory (BSI) is the shortened version of the Symptoms Checklist-90 inquiring about depressive symptoms in nine dimensions: somatization; obsession-compulsion; interpersonal sensitivity; depression; anxiety; hostility; phobic anxiety; paranoid ideation; and psychoticism (Derogatis 1983).

Number of items: 53

Procedure/Administration: Self-report format.  Respondents rank each item on a 5-point scale ranging from 0 (not at all) to 4 (extremely). Rankings represent the intensity of distress over the past week (Derogatis 1975).

How scored: Scoring can is done by hand calculation.

Interpretability: Scores are interpreted by comparison to age-appropriate norms. Normative data are available for both clinical and non-clinical samples (Derogatis 1975). Higher normative scores are recommended for SCI populations because of the somatic items (Heinrich & Tate 1994).

Acceptability: N/a

Languages: The instrument requires only a reading knowledge equivalent to that of a sixth grade education and is available in English, Spanish & French.

Usability: N/a

Time to administer: Less than 8-12 minutes to complete.

Time to score: Time is unknown, but likely minimal.

Training required: Minimal training is required to administer the BSI.A specialized degree in health care with an appropriate license or certificate is required to purchase copyrighted forms and manual from the publisher.

Availability: N/a

Equipment required: N/a

Summary:

• The BSI is a well-known and well-accepted instrument.
• The BSI is best used to screen for global psychological distress.
• The inclusion of somatic items may cause an overestimation of psychiatric symptoms in individuals with SCI.
• Normative data are available for a variety of non-SCI populations. The Zung Self-Rating Depression Scale was found to have higher sensitivity compared to the BSI when identifying individuals with depression (Tate et al. 1993).

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency;Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Derogatis LR, Melisaratos N. The Brief Symptom Inventory: in introductory report. Psychol Med 1983; 13(3): 595-605.
• Derogatis FR. The Brief Symptom Inventory. Clinical Psychometric Research 1975: Baltimore.
• Heinrich RK, Tate DG, Buckelew SP. Brief Symptom Inventory norms for spinal cord injury. Rehabil Psychol 1994; 39(1): 49-56.
• Heinrich RK, Tate DG. Latent variable structure of the Brief Symptom Inventory in a sample of persons with spinal cord injuries. Rehab Psychol 1996; 41:131-147.
• Morlan KK, Tan SY. Comparison of the Brief Psychiatric Rating Scale and the Brief Symptom Inventory. Journal of Clinical Psychology 1998; 54(7): 885-894.
• Schurle Bruce A, Arnett PA. Longitudinal study of the Symptom Checklist 90-Revised in Multiple Sclerosis patients. The Clinical Neuropsychologist 2006; 22:46-59.
• Tate DG, Forcheimer M, Maynard F, Davidoff G, Dijkers M. Comparing Two Measures of Depression in Spinal Cord Injury. Rehabil Psychol 1993;38:53-61.
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The CAGE Questionnaire

The CAGE is a 4 item screening questionnaire used to identify those individuals for whom more extensive evaluation of alcohol use is recommended. It is the oldest and likely most extensively used questionnaire across a variety of clinical and research settings (Ewing 1984). Originally developed for use with adults, it has been used in elderly populations as well. 

Number of items: 4

Procedure/Administration: A self report pen/paper or interview format. Responses of “yes/no” to the following:

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about drinking?
• Have you ever taken a drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover?

How scored: Typically, two or more of the questions answered affirmatively are considered to be “CAGE positive”, though some suggest a positive response to a single item warrants more in-depth investigation of consumption. 

Interpretability:  Score correlates positively with pre-SCI consumption patterns and a greater incidence of medical complications (Tate 2003). In non-SCI populations, the CAGE test (scores >=2) has a sensitivity of 93% and a specificity of 76% for the identification of problem drinkers (Bernadt et al. 1982).

Acceptability: N/a

Languages: N/a

Usability: N/a

Time to administer: Less than 5 minutes to complete.  Easy to administer and score

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• Susceptible to underreporting. Minimum age 16 years, and not recommended for use with adolescents. 
• Questions refer to whole life history rather than a particular period. Thus, the questionnaire does not discriminate between active and inactive drinkers and should be used in combination with information regarding usual consumption patterns (e.g., frequency/quantity/heaviest consumption). In some populations, such inquiry can inhibit responses to CAGE questions, if it precedes them. 

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Bernadt MW, Mumford J, Taylor C, Smith B, Murray RM. Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism. Lancet 1982;1:325–328.
• Ewing JA. Detecting Alcoholism: The CAGE Questionnaire. JAMA 1984; 252:1905-1907.
• Tate D. Alcohol Use Among Spinal Cord Injured Patients. Am J Phys Med Rehabil 1993;72:175-183.

Center for Epidemiological Studies Depression Scale (CES-D)

• A screening measure (NOT a diagnostic tool) developed to identify current depressive symptomatology related to major or clinical depression in adults and adolescents (Radloff 1977).
• Items include depressed mood, feelings of guilt, worthlessness and helplessness, psychomotor retardation, loss of appetite and sleep difficulties. 

Number of items: There are 10 and 20 item versions of the scale.

Procedure/Administration: Self report using pen/paper or interview. Responses are based on the frequency of occurrence during the past week.  Uses a 4-point ordinal scale: Rarely or none of the time (less than 1 day); Some or a little of the time (1-2 days); Occasionally or a moderate amount of the time (3-4 days); Most or all of the time (5-7 days).

How scored: A summary score is calculated. The range of scores on the CES-D-20 is 0-60 (0-30 for the CES-D-10)

Interpretability: A CES-D -20 cutoff score of 16 is indicative of “significant” or “mild” depressive symptomatology, and a cut score of 11 for the shorter version is recommended. It is equivalent to experiencing six symptoms for most of the previous week or a majority of symptoms on one or two days. Higher scores indicating greater symptoms.

Acceptability: N/a

Languages: Translations are available.

Usability: N/a

Time to administer: The measure is easy to complete (grade 4 reading level) and takes 5 – 10 minutes.

Time to score: The measure is easy to score and burden is likely minimal.

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The CES-D- 20 was created for the general population but has been used extensively in SCI (cited in approximately 50 SCI research articles). Shorter versions such as the 10, 8 and 4 item are available but only the CES-D 10 has been assessed in the SCI population.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

 *Data adequate for Thai version of CES-D, not for English version.

References

• Kuptniratsaikul V, Chulakadabba S, Ratanavijitrasil S. An instrument for Assessment of Depression among Spinal Cord Injury Patients: Comparison between the CES-D and the TDI. J Med Assoc Thai 2002; 85:978-982
• Radloff LS. CES-D scale: A self report depression scale for research in the general populations. Applied Psychological Measurement 1977;1:385-401.
• Radloff LS. The Use of the Center for Epidemiological Studies of Depression Scale in Adolescents and Young Adults. J Youth Adoles 1991;20:149-166.

Depression Anxiety Stress Scale-21 (DASS-21)

The DASS-21 is a measure that assesses three negative emotional states: Depression, Anxiety and Stress (Lovibond & Lovibond 1995a).

Number of items: 21 items (7 items for each emotional state).

Procedure/Administration: Self-report format consisting of statements referring to the past week. Each item is scored on a 4-point scale (0 = Did not apply to me at all, to 3 = Applied to me very much or most of the time).

How scored: Scores from each subscale are summed and multiplied by two. Subscale score range from 0 to 42.

Interpretability: Higher scores indicate greater levels of distress. Normative data are available from the DASS manual however these are based on the full DASS (42 items).

Acceptability: Comparison of the DASS-21 to clinical judgment showed that the measure has clinical utility (Mitchell et al. 2007). The scale appears understandable and easy to complete.

Languages: English, Portuguese, and Cantonese.

Usability: N/a

Time to administer: Less than 10 minutes.

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: None

Summary:

• A screening tool for identifying, differentiating and assessing depression, anxiety, and stress in patients with SCI
• Excludes many somatic items that may not be relevant to those with SCI and the instrument has greater sensitivity for identifying SCI patients with possible anxiety disorders (Mitchell et al. 2007). The ability to separately measure the three emotional states may be of considerable use for researchers and clinicians. This is an advantage given that measures of anxiety and depression often do not distinguish between these conditions and anxiety is likely more prevalent than depression.
• Only one study has assessed the psychometric properties of the instrument among patients with SCI. Sensitivity of the tool is better for anxiety than depression.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/A= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995a; 33: 335–342.
• Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales, 2nd edn. Psychology Foundation of Australia: Sydney, 1995b.
• Mitchell MC, Burns NR, Dorstyn DS. Screening for depression and anxiety in spinal cord injury with DASS-21. Spinal Cord 2008; 46: 547-551.
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Fatigue Severity Scale (FSS)

The FSS was originally developed for use among individuals with Multiple Sclerosis (Krupp 1989). It captures the individual’s experience of mental or psychological fatigue and how it interferes with performing certain activities (exercise, work and family life).

Number of items: 9

Procedure/Administration: Self report scale. Participants choose the level of agreement for each question, from 1 = strongly disagree to 7 = strongly agree. Ratings are based on their experience of fatigue over the past seven days.

How scored: A total score is represented by the mean of all the answered items.

Interpretability: Scores range from 1-7 with higher scores indicating higher levels of fatigue. Scores of 4 and over are indicative of significant fatigue in other populations.

Acceptability: Some of the items may not be reflective of the SCI condition. However, the FSS has been extensively validated in other populations and may be the most widely used measure of fatigue in neurologic disorders (Anton et al. 2008).

Languages: N/a

Usability: N/a

Time to administer: 5 minutes

Time to score: Quickly scored

Training required: N/a

Availability: A copy of the tool can be obtained at http://www.mult-sclerosis.org/fatigueseverityscale.html.

Equipment required: None

Summary:

• The FSS might have difficulties distinguishing fatigue from depression (the influence of pain may influence scores on the FSS).
• Can be used as a screen for fatigue in individuals with SCI. However, results should be interpreted with caution as some items may not have meaning for the SCI population.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; AUC= Area under ROC curve; N/a= No information. 

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Anton HA, Miller WC, Townson AF. Measuring fatigue in persons with spinal cord injury. Arch Phys Med Rehabil 2008; 89: 538-542.
• Hammell KW , Miller WC, Forwell SJ, Forman BE, Jacobsen BA. Fatigue and spinal cord injury: a qualitative analysis Spinal Cord 2008; advance online publication 10 June 2008.
• Krupp LB, LaRocca NG, Muir-Nash J, Steinbery AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus Arch Neurol. 1989; 46: 1121-3.

The Scaled General Health Questionnaire-28 (GHQ-28)

• The GHQ is used for the detection of psychiatric distress related to general medical illness (Lykouras et al. 1998).
• Respondents indicate if their current “state” differs from his or her usual state - thereby assessing change in characteristics and not lifelong personality characteristics.

Number of items: 28

Procedure/Administration: A self-administered questionnaire in which the patients base their responses on their health state over the past two weeks.

How scored: Calculation of total scores (1 point per question)

Interpretability: Scores range from 0 to 28. Higher scores indicate a greater probability of a psychiatric distress. Total scores that exceed 4 out of 28 suggest probable distress (Chung et al. 2006).

Acceptability: Only one study has assessed the construct validity of the GHQ-28 among SCI populations (Rush et al. 2008).

Languages: N/a

Usability: The GHQ-28 is appropriate for individuals who are at least 11 years of age

Time to administer: The scale takes less than 15 minutes to administer and score (appears easy to complete).

Time to score: The scale takes less than 15 minutes to administer and score.

Training required: No special training is required.

Availability: N/a

Equipment required: N/a

Summary:

• The GHQ-28’s subscales represent dimensions of symptomatology and not distinct diagnoses.
• As the scales are not independent of each other, the total score has better utility to indicate general psychological disorder than the individual scores do to screen for specific psychological disorders.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Chung MC, Preveza E, Papandreou K, Prevezas N. Spinal cord injury, posttraumatic stress, and locus of control among the elderly: a comparison with young and middle-aged patients. Psychiatry 2006; 69: 69-80.
• Goldberg DP, Hillier VF. A Scaled Version of the General Health Questionnaire. Psychol Med 1979; 9: 139-145.
• Lykouras L, Adrachta D, Kalfakis N, Oulis P, Voulgari A, Christodoulou GN, Papageorgiou C, Stefanis C. GHQ-28 as an aid to detect mental disorders in neurological inpatients 1996; 93: 212-216.
• Rush JA, First MB, Blacker D. Handbook of Psychiatric Measures. American Psychiatric Pub. 2008.

The Hospital Anxiety and Depression Scale (HADS)

The HADS was developed to assess anxiety and depression in a non-psychiatric population. It is meant to differentiate symptoms of depression with those of anxiety. It has also been used with community samples/populations (Snaith 2003).

Number of items: 14

Procedure/Administration: Self-report format. Responses are based on the relative frequency of symptoms over the past week, using a four point scale ranging from 0 (not at all) to 3 (very often indeed).

How scored: Responses are summed to provide separate scores for anxiety and depression symptomology with possible scores ranging from 0 to 21 for each scale.

Interpretability: Higher scores indicate greater likelihood of depression or anxiety. Recommended cutoffs are: 8-10: mild cases, 11-15: moderate cases and 16 or above: severe cases (Zigmond & Snaith 1994).

Acceptability: It is unclear if the few somatic items influence the reliability and validity of this measure with an SCI population.

Languages: English, Arabic, Dutch, French, German, Hebrew, Swedish, Italian, and Spanish.

Usability: The HADS is easy to score and administer. It was originally developed for use with outpatients attending medical clinics. The HADS should only be used as a screening instrument.

Time to administer: 5 minutes. It is easy to administer

Time to score: Time is unknown, but burden is likely quite low.

Training required: N/a

Availability: The HADS and manual is available from http://www.nfer-nelson.co.ukor email: information@nfer-nelson.co.uk. Although an online pdf version is available at: http://www.eardoctor.org/pdf/Hospital%20Anxiety%20and%20Depression%20Scale.pdf.

Equipment required: N/a

Summary:

• Given the co-occurrence of anxiety and depression, a simple scale that captures both is likely of value to the clinician.
• It is one of two instruments with an anxiety specific scale that has had its measurement properties evaluated for the SCI population.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

D = Depression subscale; A = Anxiety subscale.

References

• Snaith RP.The Hospital Anxiety And Depression Scale.Health and Quality of Life Outcomes2003; 1: 29.
• Woolrich RA, Kennedy P, Tasiemski T. A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med 2006; 11: 80–90.
• Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatr Scand 1983; 67: 361–370
• Zigmond AS, Snaith RP. The HADS: Hospital Anxiety and Depression Scale. Windsor 1994: NFER Nelson.

Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a 9 item screening measure to identify probable major depressive disorder (MDD) among adult primary care patients (Bombardier et al. 2004).

Number of items: 9

Procedure/Administration: Self report pen/paper or interview format. Items are rated in terms of how persistent the symptoms have been in the past 2 weeks: 0 (not at all), 1 (several days), 2 (more than half of the days), 3 (nearly every day).

How scored: Sum the scores from each item

Interpretability: Total scores range from 0 to 27. Higher scores indicate increased severity of depression. Scores > 20 are indicative of probably major depressive disorder.

Acceptability: N/a

Languages: English and Spanish versions available

Usability: N/a

Time to administer: Takes 5 minutes to complete and items are easy to understand.

Time to score: N/a

Training required: N/a

Availability: Measure available online in PDF format Copyright © Pfizer Inc. after agreeing to several conditions including use for research, in clinical programs or physician education (http://www.pfizer.com/pfizer/phq-9/index.jsp) or http://www.depression-primarycare.org/clinicians/toolkits/materials/form... (includes scoring guide).

Equipment required: N/a

Summary:

• Can be used as a tool to screen for major depression.
• Corresponds with the DSM-IV criteria.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity; N/a= No information

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Bombardier CH, Richards JS, Krause J, Tulsky D, Tate D. Symptoms of Major Depression in People With Spinal Cord Injury: Implications for Screening. Arch Phys Med Rehabil 2004;85:1749-1756.
• Graves DE and Bombordier CH. Improving the efficiency of screening for major depression in people with spinal cord injury. J Spinal Cord Med. 2008; 31(2): 177-84.
• Williams RT, Heinemann AW, Bode RK, Wilson CS, Fann JR, Tate DG. Improving measurement properties of the Patient Health Questionnaire-9 with Rating Scale analyses. Rehabilitation Psychology 2009; 54(2): 198-203.

The Symptom Checklist -90-Revised (SCL-90-R)

The SCL-90-R is a revised version of the original SCL-90. It is used as a screening measure of general psychiatric symptomatology (Buckelew et al. 1988). It includes dimensions measuring somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, interpersonal sensitivity, paranoid ideation, and psychoticism.

Number of items: 90

Procedure/Administration: Self-report format. Patients are asked to rate the severity of their experiences with each symptom over the past week on a 5-point scale ranging from 0 (not at all) to 4 (extremely).

How scored: Three indices can be obtained. Global Severity Index (GSI) is obtained by averaging the scores over the total number of answered items. The Positive Symptom Total (PST) is the total number of items with non-zero responses and the Positive Symptom Distress Index (PSDI) is the sum of the non-zero scores divided by the PST.

Interpretability: Scores are interpreted by comparison to 4 groups of norms: adult psychiatric outpatients; adult non-patients; adult psychiatric inpatients; and adolescent non-patients.

Acceptability: The SCL-90-R has been found useful in quantifying a variety of emotional reactions in adults following SCI. The inclusion of somatic items may cause an overestimation of psychiatric symptoms.

Languages: English, Spanish and French.

Usability: The SCL-90-R requires a sixth grade reading level. The tool is best used to screen for global psychological distress.

Time to administer: 12-15 minutes to complete.

Time to score: Time is unknown but scoring the questionnaire by hand is relatively simple and computer scoring is also available.

Training required: None

Availability: A specialized degree with an appropriate license or certificate is required to purchase copyrighted forms and the manual from the publisher, www.pearsonassessments.com.

Equipment required: None

Summary:

• The SCL-90-R is best used to screen for global psychological distress and therefore may be uneconomical to use a 90-item questionnaire to obtain a single score for general distress. 
• This questionnaire has received much research attention and as a result normative scores are available for a variety of patient and non-patient populations.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

* was only assessed for the research subscales. To further assess IC, Pearson product-moment correlations were obtained by correlating each item with the total subscale score. Correlations ranged from 0.25 – 0.76 for the somatic depression subscale and from 0.48 – 0.86 for the cognitive/affective subscale.

References

• Buckelew SP, Burk JP, Brownelee-Duffeck M, Frank RG, DeGood D. Cognitive and somatic aspects of depression among a rehabilitation sample: Reliability and Validity of SCL-90-R research subscales. Rehabilitation Psychology 1988; 33: 67-75.
• Derogatis LR, Melisaratos N. The Brief Symptom Inventory: in introductory report. Psychol Med 1983; 13(3): 595-605.
• Frank R, Elliot T. Life stress and psychologic adjustment following spinal cord injury. American Journal of Physical Medicine & Rehabilitation 1987; 68: 344-347.
• Hardt J, Gerbershagen HU, Franke P. the symptom check-list, SCL-(90)-R: its use and characteristics in chronic pain patients. European Journal of Pain 2000; 4: 137-148.
• Overholser JC, Schubert DSP, Foliart R, Frost F. Assessment of emotional distress following a spinal cord injury. Rehabilitation Psychology 1993; 38: 187-198.
• Schurle Bruce A, Arnett PA. Longitudinal study of the Symptom Checklist 90-Revised in Multiple Sclerosis patients. The Clinical Neuropsychologist 2006; 22:46-59.

Zung Self-Rating Depression Scale (SDS)

The SDS is a well-established (Zung 1965) screening measure of adult depression severity that has been used in a variety of mental health areas including primary care, psychiatric, drug trials, and related clinical, institutional, and research settings. 

Number of items: 20

Procedure/Adminstration:  Self-report format. Respondents rate each symptoms “over the past several days” according to a 4-point scale from 1 (little or none of the time) to 4 (most or all of the time). (total possible of 80 points). Half of the items are worded positively and half are worded negatively.

How scored: A total score is obtained by summing the score of each item. Scores range from 20 to 80.

Interpretability: Higher scores indicate increased depressive symptoms. Scores over 50 suggest depression. Scores over 69 indicating severe depression

Acceptability: Sensitivity for correctly identifying when depression is present (using clinician ratings as gold standard) was 86% in SCI population. The SDS has been criticized due to its focus on symptom frequency rather than severity, though its intent is to assess the latter.

Languages: English, Chinese, Russian, Thai, Czech, Farsi, Indonesian, Lithuanian.

Usability: Easy to administer and score. The positive and negative item wording may be confusing for some individuals.

Time to administer: Less than 10 minutes.

Time to score: Time is unknown, but is likely minimal.

Training required: None

Availability: Measure widely available in PDF versions (with scoring key) at: http://healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf. An online version is available at: http://www.afraidtoask.com/depression/depressionzung.htm.

Equipment required: None

Summary:

• Since 1980, the SDS has been cited in approximately 25 investigations of adjustment to SCI.
• In some clinical applications the Beck Depression Inventory or the PHQ-9 may be preferable as they survey a two week period and include an item specific to suicidal ideation (this is consistent with DSM–IV criteria for major depression).

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

*compared to the BSI, MEDS, and Ilfeld-PSI

References

• Tate D. Alcohol Use Among Spinal Cord Injured Patients. Am J Phys Med Rehabil 1993;72:175-183.
• Tate DG, Forcheimer M, Maynard F, Davidoff G, Dijkers M. Comparing Two Measures of Depression in Spinal Cord Injury. Rehabil Psychol 1993;38:53-61.
• Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.

Classification System for Chronic Pain in SCI

This tool proposes a pain classification scheme with 2 major categories: neuropathic and musculoskeletal. This scheme was designed to help with the standardization of pain terminology used in the SCI population (Cardenas et al. 2002).  Pain is categorized by pain location and distribution, as related to level of spinal injury (e.g. above level, at level or below level). This information is combined with a classification of the subject’s SCI pain.

Number of items: 188

Procedure/Administration: This questionnaire is administered by a clinician but could also be completed by the patient. The person identifies the worst pain problem on a body diagram and indicates whether pain worsens with activity, position or change of position or light touch. This procedure is repeated for second worse pain etc.

How scored: Categorization is outlined in the table below

Chronic Pain Categorization Table

Interpretability: This pain classification system provides a nice summary table that makes it easy for clinicians to identify key problem areas expressed by the patient.

Acceptability: The interview format improves utility for those with limited hand function.

Languages: N/a

Usability: There is a high initial patient burden (considerable time is required to complete the assessment); however, follow up sessions require less time. 

Time to administer: Considerable time required to complete (actual time not specified).

Time to score: N/a

Training required: None but expertise understanding pain is an asset.

Availability: See article for a copy of the tool (Cardenas et al. 2002)

Equipment required: None

Summary: This tool has considerable promise but requires additional study.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Cardenas D, Turner J, Warms C, Marshall H. Classification of chronic pain associated with spinal cord injuries. Arch Phys Med Rehabil 2002;83:1708-1714.

Donovan SCI Pain Classification System

The Donovan Pain Classification system proposes 5 pain types. This system combines both mechanistic factors (e.g. slow fibre conduction from skin) and descriptive factors, such as time to onset post-injury, characteristics of pain (e.g. burning, stabbing, dull aching, etc), pain duration, and factors that make it worse or better (Donovan et al. 1982).

Number of Items: N/a

Procedure/Administration: This information is obtained through a semi-structured, pen and paper interview.

How scored: N/a

Interpretability: Presenting the information in a table format (like the one below) facilitates interpretation and clarity.

Donovan SCI Pain Classification System Interpretability Table

Acceptability: N/a

Languages: N/a

Usability: The assessment can be time-consuming for those patients with complex pain issues. However, this type of approach may be more suitable for difficult cases as it allows the patients to explain pain in their own language rather than being forced to pick specific descriptors for their pain.

Time to administer: Up to 40 minutes for those with complex issues.

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Donovan W, Dimitrijevic M, Dahm L, Dimitrijevic M. Neurophysiological approaches to chronic pain following spinal cord injury. Paraplegia 1982;20:135-146.
• Putzke JD, Richards JS, Ness T, Kezar L. Test-retest reliability of the Donovan spinal cord injury pain classification scheme. Spinal Cord 2003;41:239-241.
• Richards JS, Hicken BL, Putzke JD, Ness T, Kezar L. Reliability characteristics of the Donovan spinal cord injury pain classification system. Arch Phys Med Rehabil 2002;83:1290-1294.

The Multidimensional Pain Inventory – SCI version

The West Haven-Yale MPI was developed to gain the subjective experiences of many aspects of chronic pain (Kerns et al. 1985). The MPI is theoretically linked to the cognitive-behavioural conceptualization of chronic pain, where emphasis is placed on the assessment of subjective distress and the impact of pain on patient’s lives (Kerns et al. 1985). A slightly revised version of the MPI was devised for the SCI population.  It consists of 3 sections: Section 1 (life interference, support, life control, pain severity, affective distress); Section 2 (distracting responses, negative responses, solicitous responses); Section 3 (house-hold activities, activities away from home, social activities, outdoor work).

Number of items: 50

Procedure/Administration: The MPI-SCI is a self-report questionnaire that may be administered by a trained assessor.

How scored: Each item is rated on a 7-point scale (0-6). Scale scores are computed by summing over all items and then the mean is composed based on the number of scale items. A total score is not possible.

Interpretability: Higher ratings may indicate a greater or lesser impact of pain. No information is given regarding norms or meaningful cutoff scores.

Acceptability: The MPI-SCI was developed specifically for use in SCI populations. The questionnaire can be self-completed or done via interview/proxy and is not considered to be a burden to patients.

Languages: The MPI-SCI is only available in English (The MPI is available in Swedish, Dutch, German, Italian, Spanish, Portuguese, French and Japanese)

Usability: N/a

Time to administer:  At least 20 minutes.

Time to score: N/a

Training required: Minimal

Availability: The MPI-SCI questionnaire is available in Widerstrom-Noga et al. (2002).

Equipment required: None

Summary: The emphasis of the MPI-SCI is on the assessment of the subjective distress experienced by patients in terms of pain and suffering and how pain impacts the individual’s life. Although evidence supports the use of the MPI-SCI to assess the impact of chronic pain with SCI populations, more psychometric evidence is needed to warrant its sustained use.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985; 23: 345-356.
• Widerstrom-Noga EG, Cruz-Almeida Y, Martinez-Arizala A, Turk DC. Internal consistency, stability, and validity of the spinal cord injury version of the multidimensional pain inventory. Arch Phys Med Rehabil 2006;87:516-523.
• Widerstrom-Noga EG, Duncan R, Felipe-Cuervo E, Turk DC. Assessment of the impact of pain and impairments associated with spinal cord injuries. Arch Phys Med Rehabil 2002;83:395-404.

Multidimensional Pain Readiness to Change Questionnaire: MPRCQ2

The MPRCQ2 is a measure of readiness to adopt various pain management and coping strategies. It is made up of two sections and nine subscales.  The first section concerns the use  of adaptive coping behaviours while the second addresses stopping maladaptive coping behaviours. The nine sub-scales include exercise, task persistence, relaxation, cognitive control, pacing, avoiding pain contingent rest, avoiding asking for assistance, assertive communication and use of proper body mechanics (Nielson et al. 2008).

Number of items: 69

Procedure/Administration: Participants rate each of the 69 statements on a scale of 1-7.

How scored: Scores are calculated for each of the 9 subscales by summing the responses for each statement and dividing by the number of items. Subscale scores range from 1 to 7, and a total score can be calculated by summing scores from each of the 9 primary scales.

Interpretability: Higher scores indicate a greater use of adaptive coping behaviours (or less use of maladaptive ones). Total scores from each of the 9 primary scales are grand-totaled, with a range of total scores from 9-63.  No information is given regarding cut-off or normative scores, however it has been tested in other populations (fibromyalgia and arthritis) so meaningful comparisons can be made.

Acceptability: N/a

Languages: N/a

Usability: Answering the questions do not represent a significant burden to SCI patients. A self-administered format is recommended but an interviewer or proxy could be used in the case of severe physical disability.

Time to administer: No specifics are given in terms of time to administer and score, however it seems fairly simple

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: No special equipment is required.

Summary: The MPRCQ2 is more practical to use than the original MPRCQ as the statements have been simplified and the number of response items expanded from 6 to 7 options, which provides a more accurate assessment along the readiness to change continuum. It is easily administered and easy to score. The multidimensional subscales allow specific aspects of readiness to change to be examined.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Nielson WR, Jensen MP, Ehde DM, Kerns RD, Molton IR. Further Development of the Multidimensional Pain Readiness to Change Questionnaire: The MPRCQ2. Journal of Pain 2008;9(6): 552-565.

Quantitative Sensory Testing (QST)

Quantitative sensory testing (QST) is used to assess neurological function in chronic pain patients (Felix & Widerstrom-Noga, 2009). QST measures thresholds for mechanical detection, vibration detection, cool and warm detection and cold and hot pain sensations. Assessment of thresholds can be used to evaluate the involvement of different nervous system functions (Nathan et al,1986). The test is used to quantify the neurological dysfunction associated with neuropathic pain.

Procedure: The QST is performed by administrating six different threshold tests including, the mechanical detection threshold, the vibration detection threshold, the cool and warm threshold detection and the cold and hot pain threshold at eight standard test sites on the various dermatomes (Felix & Widerstrom-Noga, 2009). Threshold values are recorded at either the first or last detectible level of intensity. If the maximum stimulus is reached without the patient indicating sensation, the maximum value is recorded as threshold.

Advantages: QST has been used extensively to asses the functional integrity of the somatosensory system among various populations (Felix & Widerstrom-Noga, 2009). Preliminary evidence indicates high reliability among SCI participants. A significant correlation was found between average thermal pain thresholds (ATPT) and the severity of self reported pain. The scale was not developed specifically for the SCI population, although preliminary research shows it can be used within this group without any adaptations.

Limitations: For SCI, at test sites where stimuli cannot be distinguished, either maximum or minimum threshold levels are recorded which may lead to floor or ceiling effects. Only the ATPT is significantly correlated with self-reported measures of pain, indicating potentially low validity of the other QST thresholds. In addition, SCI patients have reported sensations that are not due to the stimulus (Felix & Widerstrom-Noga, 2009). Only one study has assessed the QST’s psychometric properties.

Interpretability: For each location, the high and low threshold detection values for each of the six stimuli are recorded. The high and low scores are averaged and can be compared to data from ‘un-injured’ populations. Threshold measurements for pressure and vibration can evaluate large-fiber and dorsal column function, while thresholds for thermal detection and pain can be used to assess small-fibre and spinothalamic tract function (Nathan et al, 1986).

Acceptability: For each QST threshold, several measurements need to be taken in different dermatomes. Thresholds are to be measured both for increasing and decreasing intensity. Patient burden is extensive; testing must be in person at a clinic or hospital. Although time to complete the entire QST is not mentioned, it may be substantial.

Feasibility: QST requires several pieces of equipment to ensure accurate threshold detection. Clinicians need to be trained in the use of each piece of equipment. Though there are instructions that are to be read to the patient prior to each test, these were not found in the original publication ((Felix & Widerstrom-Noga, 2009).

Clinical Summary: Thermal pain thresholds may be particularly useful when used in combination with self-report measures of neuropathic pain for the development of pain management strategies. QST may not feasible as a general test used across clinical sites due to the necessary equipment, but may be feasible for specific clinics that focus on pain and pain management.

Psychometric Summary:

Note: +++ = Excellent; ++ = Adequate; + = Poor; TR=Test retest

References

• Felix ER and Widerstrom-Noga EG. Reliability and validity of quantitative sensory testing in persons with spinal cord injury and neuropathic pain. JRRD. 2009;46:69-83.
• Nathan PW, Smith MC, Cook AW. Sensory effects in man of lesions of the posterior columns and some other afferent pathways. Brain. 1986;109(5):1003-41.

Tunk's Classification Scheme

Tunk’s Classification Scheme

The Tunks model identifies 11 types of pain for those with spinal cord injury according to the lesion level (Tunks 1986). 

Number of items: N/a

Procedure/Administration: Information is obtained through a semi-structured interview. This pain classification allows the clinician to describe the general location and whether the pain differentiates between several types of pain.

How scored: N/a

Interpretability: This system requires considerable knowledge from the clinician classifying the pain as well as from other health care professionals who may be using the information to help with pain management.

Acceptability: The tool should be augmented using a batter of other tools that would address pain duration, location and intensity in order to provide a complete picture of pain.  

Languages: N/a

Usability: Although this system has merit for giving more categories for which to describe the various types of pain an individual may have, it most likely would be useful for more complex pain cases where more time is allocated towards understanding the origins of the individual’s pain.

Time to administer: 15-20 minutes (longer for complex cases)

Time to score: N/a

Training required: No formal training is required but knowledge about neuroanatomy, physiology (specifically sensation) and theories of pain is an asset.

Availability: N/a

Equipment required: N/a

Summary: The classification system does not follow a systematic method for acquiring the data from the patients, thus obtaining consistent information from one time to another or between individuals very difficult. This system is very clinician dependent as it requires considerable knowledge about the various origins of pain to be able to interpret the patient’s comments into the defined classification scheme.

 Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= AInter O: Red light single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Putzke JD, Richards JS, Ness T, Kezar L. Interrater reliability of the International Association for the Study of Pain and Tunks' spinal cord injury pain classification schemes. Am J Phys Med Rehabil 2003;82:437-440.
• Tunks E. Pain in spinal cord injured patients. In: Bloch R, Basbaum M (ed). Management of Spinal Cord Injuries. Williams and Wilkins, Baltimore, MD, 1986: p 180-211.

Wheelchair Users Shoulder Pain Index (WUSPI)

The WUSPI measures the functional cost of shoulder pain in wheelchair users (Curtis et al. 1995). The scale targets activity limitation resulting from shoulder pain on a 10 cm visual analogue scale, covering 4 subsections which include transfers, wheelchair mobility, self-care, and general activities.

Number of items: 15

Procedure/Administration: Self report format. Respondents indicate how much pain they experience performing each activity on visual analog scale. The anchors for the items range from 0 “no interference due to pain” to 10 “completely interferes due to shoulder pain”. 

How scored: The total score is derived by adding the individual item scores. Total scores range from 0 (no pain) to 150 (extreme pain).

Interpretability: Higher scores indicate more limitation due to pain. No information is available regarding norms or meaningful cut scores. 

Acceptability: No psychometric evidence is available for responsiveness and the majority of research for reliability and validity has been conducted using a mixed sample (not just SCI).

Languages: English

Usability: N/a

Time to administer: 5 minutes

Time to score: 10 minutes

Training required: None

Availability: N/a

Equipment required: ruler to measure each visual analog scale.

Summary:

• The WUSPI is a simple and effective joint specific method of quickly determining the degree of interference due to pain when doing typical tasks of daily living.
• This tool is specific to shoulder pain. It does not obtain information about the type or frequency of pain experienced during the activities. No strategies are suggested to assist with scoring if a person indicates they do not do certain activities (e.g. load their chair into a car).

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Curtis KA, Roach KE, Applegate EB, Amar T, Benbow CS, Genecco TD, Gualano J. Development of the Wheelchair User's Shoulder Pain Index (WUSPI). Paraplegia 1995;33:290-293.
• Curtis KA, Roach KE, Applegate EB, Amar T, Benbow CS, Genecco TD, Gualano J. Reliability and validity of the Wheelchair User's Shoulder Pain Index (WUSPI). Paraplegia 1995;33:595-601.
• Sawatzky BJ, Slobogean GP, Reilly CW, Chambers CT, Hol AT. Prevalence of shoulder pain in adult- versus childhood-onset wheelchair users: a pilot study. J Rehabil Res Dev 2005;42:1-8.

Six-Minute Arm Test (6-MAT)

The 6-MAT assesses cardiovascular fitness in people with SCI (Hol et al. 2007).

Number of items:  N/A

Procedure/Administration: It involves 6 minutes of sub-maximal arm ergometry at a constant power output (PO). Through the use of published guidelines, clinicians can determine the appropriate PO. Baseline outcome variables of heart rate and ratings of perceived exertion (RPE) are determined by recording the client’s exercising heart rate during the final 30 seconds of the test, and recording their RPE at the end of the test (Hol et al. 2007). The 6-MAT should be re-administered at the same PO for follow up tests, including those to assess changes resulting from cardiovascular fitness interventions.

How scored: N/a

Interpretability: Used after a fitness intervention or as a follow up measure, 6-MAT results can determine changes in fitness level. Decrease in heart rate and/or RPE may indicate an increase in cardiovascular fitness, whereas an increase in heart rate and/or RPE may indicate a decrease in cardiovascular fitness (Hol et al. 2007).

Acceptability: The test was designed specifically for individuals with SCI.

Languages: N/a

Usability: The test is easy to complete and can be administered to people of all fitness levels.

Time to administer: 6 minutes

Time to score: N/a

Training required: None

Availability: A complete set of guidelines and instructions can be found in Hol et al (2007).

Equipment required: An arm ergometer, heart rate monitor, and an RPE scale.

Summary:

• The 6-MAT is single stage test that is simple and quick to administer clinically, and is a practical test that can be administered to all fitness levels. Its reliability and concurrent validity for assessing cardiovascular fitness in people with SCI is excellent.
• The 6-MAT can be quickly conducted in most settings and the results provide immediate feedback about the fitness of the individual.

 Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Hol AT, Eng JJ, Miller WC, Sproule S, Krassioukov AV. Reliability and Validity of the Six-Minute Arm Test for the Evaluation of Cardiovascular Fitness in People With Spinal Cord Injury. Arch Phys Med Rehabil 2007; 88:489-95.

Wingate Anaerobic Testing (WAnT)

The WAnT assesses muscle power. It involves a 30 second maximal effort trial on a leg or arm ergometer.

Number of items: N/a

Procedure/Administration: The WAnT requires the use of an arm ergometer to apply consistent resistance. The ergometer is linked to a computer with specific software to calculate peak power based on resistance and speed (the highest average power output at any given 5 sec period) and mean power (average power output over a 30 sec trial). The individual “free wheels” with no resistance for 3-5 minutes, after which they increase the cadence to 100 rev/min. The resistance load is then applied (3.5% body weight) and the subject pedals as fast as they can for 30 seconds, followed by a 1-2 minute cool down without resistance.

How scored: N/a

Interpretability: The higher the outcome measures (peak and mean power), the greater strength the individual exhibits. 

Acceptability: N/a

Languages: N/a

Usability: The test is relatively easy and inexpensive to administer with the appropriate equipment; however, the initial expenditure is significant.

Time to administer: 8 minutes

Time to score: N/a

Training required: Minimal

Availability: N/a

Equipment required: Arm ergometer, computer and software.

Summary:

• The WAnT is the only standardized test to monitor upper extremity strength and power. Most assessments look at aerobic function rather than anaerobic tasks. This test has been shown to be valid and reliable across a wide range of able bodied and disabled individuals, including those with paraplegia. It is also a well established protocol that has been used in many populations so comparisons are possible.
• Arm WAnT has been used in persons with paraplegia to compare to performance of upper limb anaerobic tasks such as transferring in and out of the car and 26m wheelchair sprints.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Ayalon A, Inbar O, Bar-Or O. Relationships among measurements of explosive strength and anaerobic power. In: Nelson RC, Morehouse CA. (ed). International Series on Sport Science 1: Biomechanics IV. University park press, Baltimore, MD, 1974, p 527-532.
• Bar-Or O, Inbar O, Dotan R. Proficiency, speed and endurance test for the wheelchair-bound. In: Simri U. (ed). Motor Learning in Physical Education and Sports. Wingate Institute, Natanya, Israel,1976: p 310-318.
• Bar-Or O, Dotan R, Inbar O. A 30 second all out ergometric test – its reliability and validity for anaerobic capacity. Israeli J Med Sci 1977;13:326.
• Bar-Or, Inbar O. Relationships among anaerobic capacity, sprint and middle distance running of school children. In: Shephard RJ, Lavelle H. (ed). Physical Fitness Assessment. Charles C Thomas, Springfield, IL,1978: p 142-147.
• Hawley JA, Williams MM, Vickovic MM, Handcock PJ. Muscle power predicts freestyle swimming performance. Br J Sports Med 1992;26:151-155.
• Jacobs P, Mahoney E, Johnson B. Reliability of wingate anaerobic testing in persons with complete paraplegia. J Spinal Cord Med 2003;26:141-144.
• Jacobs PL, Johnson B, Somarriba GA, Carter AB. Reliability of upper extremity anaerobic power assessment in persons with tetraplegia. J Spinal Cord Med 2005;28:109-113.
•  
•  
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The American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury

 The ASIA Impairment Scale (AIS) is a multi-dimensional approach to categorize motor and sensory impairment in individuals with SCI (ASIA 2002). Currently in its 6^th edition, it identifies sensory and motor levels indicative of the most rostral spinal levels demonstrating “unimpaired” function. Twenty-eight dermatomes are assessed bilaterally using pinprick and light touch sensation and 10 key muscles are assessed bilaterally with manual muscle testing. The results are summed to produce overall sensory and motor scores and are used in combination with evaluation of anal sensory and motor function as a basis for the determination of AIS classification.

Procedure/Administration: A clinical examination is conducted to test whether sensation is 0-absent; 1-impaired; 2-normal. Muscle function is rated from 0-total paralysis to 5-normal (active movement, full ROM against significant resistance).  The presence of anal sensation and voluntary anal contraction are assessed as a yes/no.

How scored: Bilateral motor and sensory levels and the AIS are based on the results of these examinations.

Interpretability: The AIS (5 point ordinal scale), based on the Frankel scale (Frankel et al. 1969), classifies individuals from “A” (complete SCI) to “E” (normal sensory and motor function). Preservation of function in the sacral segments (S4-S5) is key for determining the AIS. The AIS scores are clearly defined and understood by most clinicians. 

Acceptability: The exam is generally well tolerated although sensory testing for those with severe hypersensitivity may be uncomfortable and testing for anal sensation/voluntary contraction can result in the stimulation of a bowel movement.

Languages: N/a

Usability: N/a

Time to administer: 20 minutes to conduct/score

Time to score: N/a

Training required: Training is mandatory

Availability: www.asiaspinalinjury.org

Equipment required: No specialized equipment is required.

Summary:

• ASIA scores are considered essential when classifying persons with SCI as to their neurological status. ASIA scores are routinely collected in administrative data bases such the Model Systems and CIHI National Rehabilitation Reporting System.
• This is an internationally recognized standard which is widely used for research and clinical purposes. Its development and continued evolution are well grounded in expert clinical consensus thereby ensuring high content validity. However, inter-rater reliability for assignment of motor and sensory levels and AIS classifications is less than optimal. Enhanced training methods and materials have been recommended to improve this.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002. 2002. Chicago, IL, American Spinal Injury Association.
• Blaustein DM, Zafonte R, Thomas D, Herbison GJ, Ditunno JF. Predicting recovery of motor complete quadriplegic patients. 24 hour v 72 hour motor index scores. Am J Phys Med Rehabil 1993;72:306-311.
• Cohen ME, Ditunno JF, Jr., Donovan WH, Maynard FM, Jr. A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord 1998;36:554-560.
• Cohen ME, Sheehan TP, Herbison GJ. Content validity and reliability of the International Standards for Neurological Classification of Spinal Cord Injury. Top Spinal Cord Inj Rehabil 1996;1:15-31.
• Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD, Walsh JJ. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969;7:179-192.
• Graves DE, Frankiewicz RG, Donovan WH. Construct validity and dimensional structure of the ASIA motor scale. J Spinal Cord Med 2006;29:39-45.
• Jonsson M, Tollback A, Gonzales H, Borg J. Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury. Spinal Cord 2000;38:675-679.
• Lazar RB, Yarkony GM, Ortolano D, Heinemann AW, Perlow E, Lovell L, Meyer PR. Prediction of functional outcome by motor capability after spinal cord injury. Arch Phys Med Rehabil 1989;70:819-822.
• Marino RJ, Graves DE. Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil 2004;85:1804-1810.
• Priebe MM, Waring WP. The interobserver reliability of the revised American Spinal Injury Association standards for neurological classification of spinal injury patients. Am J Phys Med Rehabil 1991;70:268-270.
• van Middendorp JJ, Hosman AJF, Pouw MH, EM-SCI Study Group, and Van de Meent H. ASIS impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 2009; 47: 555-560.

Ashworth and Modified Ashworth

The Ashworth measure of spasticity was developed as a simple clinical classification to assess the anti-spastic effects of carisoprodol in multiple sclerosis (Ashworth 1964).  It is a 5-point nominal scale using subjective clinical assessments of tone ranging from 0 – ‘no increases in tone’ to 4 – ‘limb rigid in flexion or extension [abduction/adduction]’. An additional grade was added (1+) for the Modified Ashworth (MAS) to enhance sensitivity and accommodate hemiplegic patients who typically graded at the lower end of the scale (Bohannon & Smith 1986). These measures have been adopted for measuring spasticity in a variety of other diagnoses, including SCI (Haas et al. 1996).

Number of items: N/a

Procedure/Administration: Both tests (Ashworth and MAS) are clinical examination performed on a relaxed patient in the supine position. The muscle is assessed by rating the resistance to passive range of motion (ROM) about a single joint.

How scored: N/a

Interpretability: The Ashworth scale is easily interpretable with discrete categories that reflect clinical experience. The MAS adds an additional grade at the lower end of spasticity.

Acceptability: N/a    

Languages: N/a

Usability: These measures are easily administered during routine clinic visits and don’t require specialized equipment. The assessments are well accepted and tolerated by patients.

Time to administer: N/a

Time to score: N/a

Training required: None specifically indicated, however the observation of resistance is subjective and requires experienced clinical judgment.

Availability: N/a

Equipment required: None

Summary:

• These measures are the clinical gold standard for assessing spasticity in people with SCI. However, it should be noted that spasticity is a multi-faceted construct with individual components of spasticity weakly related to each other suggesting that different clinical scales measure unique aspects of spasticity (Priebe et al. 1996).
• These measures assess single-joint resistance to passive ROM or a velocity dependent stretch reflex. They do not address spasm frequency or severity, nor do they differentiate between phasic and tonic components of spasticity. Therefore, the overall construct of spasticity is best measured with an appropriate battery of tests including the Ashworth or MAS.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964;192:540-542.
• Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil 2005;86:52-59.
• Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206-207.
• Craven BC, Morris AR. Modified Ashworth scale reliability for measurement of lower extremity spasticity among patients with SCI. Spinal Cord advance online publication, 29 Spetember 2009; doi:10.1038/sc.2009.107.
• Haas BM, Bergstrom 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;34:560-564.
• Lechner HE, Frotzler A, Eser P. Relationship between self- and clinically rated spasticity in spinal cord injury. Arch Phys Med Rehabil 2006;87:15-19.
• Noth J. Trends in the pathophysiology and pharmacotherapy of spasticity. J Neurol 1991;238:131-139.
• Priebe MM, Sherwood AM, Thornby JI, Kharas NF, Markowski J. Clinical assessment of spasticity in spinal cord injury: a multidimensional problem. Arch Phys Med Rehabil 1996; 77:713-716.
• Skold C. Spasticity in spinal cord injury: self- and clinically rated intrinsic fluctuations and intervention-induced changes. Arch Phys Med Rehabil 2000;81:144-149.

Penn Spasm Frequency Scale (PSFS)

The PSFS is a self report measure of the frequency of reported muscle spasms which is commonly used to quantify spasticity (Penn et al. 1989; Priebe et al. 1996). The PSFS is a 2 component self-report scale developed to augment clinical ratings of spasticity (Benz et al. 2006) and provide a more comprehensive understanding of an individual’s spasticity status. The first component is a 5 point scale assessing the frequency with which spasms occur ranging from “0 = No spasms” to “4 = Spontaneous spasms occurring more than ten times per hour”. The second component is a 3 point scale assessing the severity of spasms ranging from “1 = Mild” to “3 = Severe”. The second component is not answered if the person indicates they have no spasms in part 1.

Number of items: N/a

Procedure/Administration: Patients report their perceptions of spasticity with regards to frequency and severity.

How scored: N/a

Interpretability: The specific grades simple to interpret although no standardization of time frame is specified for test administration (i.e. within the last hour, day, week, etc.) and specific grades for spasm severity may mean different things to different people.

Acceptability: N/a

Languages: N/a

Usability: The PSFS is easy to understand presents minimal patient burden (easy to administer during routine clinical visits).

Time to administer: Quick (though no time is specified)

Time to score: N/a

Training required: No training is required, however understanding spasticity likely improves the scale’s utility.

Availability: N/a

Equipment required: None

Summary:

• The scale is subject to concomitant subclinical conditions such as fullness of the bladder, development of a symptomatic urinary tract infection, anxiety level, room temperature, subject comfort, and many other conditions.
• In general, self-report measures of spasticity correlate only moderately with clinical examination suggesting that the elements of spasticity evaluated in the physical examination do not represent what is important to persons with SCI spasticity. To more fully understand spasticity as experienced by the client, self-report spasticity measures are an important adjunct to other clinical measures of spasticity.

 Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Aydin G, Tomruk S, Keles I, Demir SO, Orkun S. Transcutaneous electrical nerve stimulation versus baclofen in spasticity: clinical and electrophysiologic comparison. Am J Phys Med Rehabil 2005;84:584-592.
• Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil 2005;86:52-59.
• Boviatsis EJ, Kouyialis AT, Korfias S, Sakas DE. Functional outcome of intrathecal baclofen administration for severe spasticity. Clin Neurol Neurosurg 2005;107:289-295.
• Gianino JM, York MM, Paice JA, Shott S. Quality of life: effect of reduced spasticity from intrathecal baclofen. J Neurosci Nurs 1998;30:47-54.
• Penn RD. Intrathecal baclofen for severe spasticity. Ann N Y Acad Sci 1988;531:157-166.
• Priebe MM, Sherwood AM, Thornby JI, Kharas NF, Markowski J. Clinical assessment of spasticity in spinal cord injury: a multidimensional problem. Arch Phys Med Rehabil 1996; 77:713-716.
•  

Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

The SCATS is a physiologically based measure for spastic reflexes for use in individuals with SCI.  It was developed in response to the demand for a standardized, simple clinical measure that encompasses the primary spastic reaction in the SCI population. The SCATS is split into 3 subscales, each addressing a separate spasm: clonus; flexor spasms; and extensor spasms. For each subscale, the spasm is triggered and then rated with a score ranging from 0 – 3.

Number of items: N/a

Procedure/Administration: The SCATS is administrated by a trained clinician.  SCATS clonus is measured by rapid passive dorsiflexion.  The degree of spasm is rated between 0 (no spasm) – 3 (severe spasm lasting longer than 10 seconds).  SCATS flexor spasm is measured by applying a pinprick stimulus to the medial arch with the knee and hip extended straight. The degree of spasm is rated between 0 (no spasm) and 3 (severe spasm, 30 knee and hip flexion). SCATS extensor spasm is measured by extending the hip and knee joints from with the knee and hip extended at 90 and 110 degrees. The degree of spasm is rated between 0 (no spasm) and 3 (severe spasm, longer than 10 seconds).

How scored: N/a

Interpretability: Scores in each subscale range from 0 - 3, with scores above zero indicating the presence of spasm. Scores of three indicate severe spasms. The results of the SCATS will indicate to the clinician the type(s) of spasticity present in an individual, as well as the degree of severity of each type of spasticity.

Acceptability: As spasms are often uncomfortable for individuals with SCI, and the SCATS is recommended to be done in tandem with self reporting measures of spasm, there is the possibility of high respondent burden in terms of both length and comfort.  The measure could be conducted during a home visit or at a clinic/hospital.  

Languages: N/a

Usability: N/a

Time to administer: Each subscale is quick (<5 sec) to administer; however, if a spasm is elicited, spasm duration is patient specific and could be enduring.

Time to score: N/a

Training required: Administration should be done by a trained clinician

Availability: N/a

Equipment required: Equipment to quantitatively measure joint angle changes

Summary:

• The SCATS does not gather information on patient perspective, an important aspect of spasms, as some spasms are perceived as beneficial to the patient.
• Spasticity literature in the SCI population reveals three different forms of spasticity, each with a different reflex pathway - the SCATS appears to be comprehensive in differentiating each of these spastic responses (Little et al. 1989).

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Adams M, Martin Ginis K, Hicks A. “The Spinal Cord Injury Spasticity Evaluation Tool: Development and Evaluation.” Arch Phys Med Rehabil. 2007;88:1185-1192.
• Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil 2005;86:52-59.
• Little JW, Micklesen P, Umlauf R, Britell C. Lower extremity manifestations of spasticity in chronic spinal cord injury. Am J Phys Med Rehabil. 1989;68:32-36

The Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET)

The SCI-SET assesses the impact of spasticity on daily life in people with SCI (Adams et al. 2007).  It requires participants to recall their past 7 days when rating spasticity on a scale ranging from -3 (extremely problematic) to +3 (extremely helpful).  

Number of items: 35

Procedure/Administration: The SCI-SET is a self-report questionnaire. It can be administrated in person or over the phone.

How scored: N/a

Interpretability: The SCI-SET is scored by summing all the responses from the applicable items then dividing the sum by the number of applicable items, generating a total score between -3 and +3.

Acceptability: The SCI-SET was developed specifically for the SCI population.

Languages: N/a

Usability: The scale is easy to administer and score. Definitions of ‘spasm’ and the scale responses are clearly outlined in the instructions.

Time to administer: 7 minutes

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The SCI-SET can be used as a tool for medical management decisions as well as a measurement of current treatment effects. Preliminary results provide evidence in support of face validity, internal consistency, and test-retest reliability.
• Spasticity is known to be highly variable, fluctuating on a daily and even hourly basis. A seven day recall of the impact of spasticity may be overshadowed by current levels of spasticity. Repeated administration may therefore be necessary to provide a more accurate picture of the impacts spasticity has on daily life.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Adams M, Martin Ginis K, Hicks A. “The Spinal Cord Injury Spasticity Evaluation Tool: Development and Evaluation.” Arch Phys Med Rehabil. 2007;88:1185-1192.

Surface Electromyography (sEMG)

Surface electromyography (sEMG) is a noninvasive technique used to measure muscle activity (both voluntary and involuntary) in individuals with neuromuscular conditions (Pullman et al. 2000).

Number of items: N/a

Procedure/Administration: Surface electrodes are placed on the skin overlying the muscles of interest.  Patients are instructed to voluntarily activate lower limb muscles to provide either maximal muscle strength or to perform simple movements (e.g. ankle flexion/extension).  

How scored: N/a

Interpretability: No normative values exist and interpretation of the data is not standardized.

Acceptability: N/a

Languages: N/a

Usability:  The technique is well tolerated and is much less intrusive than the gold standard (needle EMG), so there is minimal burden for patients. However, an EMG can range in cost from several hundred to over a thousand dollars depending on features

Time to administer: 15-20 minutes

Time to score: N/a

Training required: Special training is mandatory to conduct and interpret the results.

Availability: N/a

Equipment required: N/a

Summary:

• sEMG recordings can complement the clinical examination specifically by providing objective and quantifiable measures of muscle activity. They have been shown to be valid in comparison to the clinical testing of motor strength and might be of highest value to monitor motor recovery in incomplete SCI.
• As these measures need special training and equipment they will be most suitable in the frame of clinical studies rather than for clinical day to day routine.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Calancie B, Molano MR, Broton JG, Bean JA, Alexeeva N. Relationship between EMG and muscle force after spinal cord injury. J Spinal Cord Med 2001;24:19-25.
• Lim HK, Lee DC, McKay WB, Priebe MM, Holmes SA, Sherwood AM. Neurophysiological assessment of lower-limb voluntary control in incomplete spinal cord injury. Spinal Cord 2005;43:283-290.
• Lim HK, Sherwood AM. Reliability of surface electromyographic measurements from subjects with spinal cord injury during voluntary motor tasks. Journal of Rehabilitation Research & Development 2005;42:413-421.
• Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:171-177.

Abruzzese Scale

The Abruzzese scale, based on the Norton and Gosnell scales, is designed to assess the risk of pressure sore development in acute and long-term care settings (Abruzzese 1985). Domains include: general health, mental status, activity, mobility, continence, nutrition, and predisposing disease.

Number of items: 9

Procedure/Administration: Raters indicate the client status based on personal observation or chart review. The items are scored on a 4-point scale, either 0 – 3, or 0,1,4,6 depending on the item, with higher scores indicating increased risk of developing a pressure ulcer. Scores are summed to produce an overall score between 0 (best prognosis) and 30 (worst prognosis).

How scored: N/a

Interpretability: A cutoff score ≥12 is suggested as the cut score to identify individuals at risk for developing pressure ulcers.

Acceptability: The measure is well accepted by persons with disabilities.

Languages: English

Usability: N/a

Time to administer: 5 – 10 minutes

Time to score: N/a

Training required: None

Availability: N/a

Equipment required: N/a

Summary: N/a

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Abruzzese RS. Early assessment and prevention of pressure sores. In: Lee BY (ed). Chronic Ulcers of the Skin. McGraw Hill: New York, 1985, pp 1 -19
• Abruzzese RS. Early assessment and prevention of pressure sores. In: Lee BY (ed). Chronic Ulcers of the Skin. McGraw Hill: New York, 1985, pp 1 -19

Braden Scale

The Braden Scale is an assessment tool for determining a patient’s risk level for incurring skin breakdown. It has been tested in both acute care and long-term-care settings (Bergstrom et al. 1987). Items were developed based on expert consensus. The scale evaluates skin breakdown in six domains: (1) sensory perception, (2) moisture, (3) activity, (4) mobility, (5) nutrition, and (6) friction and shear.

Number of items: 6

Procedure/Administration: Raters indicate client status in the five domains (which could be based on personal experience or chart review).

How scored: Each domain is given a rating of 1-4 based on descriptive criteria provided on the scoring sheet, which are summed for a total of 6-23. Scoring instructions are relatively detailed.

Interpretability: Higher scores are equivalent to better prognosis. Alternative cut-off scores are suggested depending on the population. Although a cut off score of 16 was originally suggested as indicative of those who develop a pressure sore (100% sensitivity and 64% sensitivity) (Bergstrom et al. 1987), 11 or less has been suggested for an ICU trauma population and less than or equal to 10 has been suggested for individuals with SCI

Acceptability: The scale omits items previously found to be important predictors of pressure ulcer development for people with SCI and includes three factors (sensory perception, mobility and nutritional variables) that were not significantly related to pressure ulcer development for individuals with SCI. Though the reliability of the scale has been demonstrated in a variety of settings, it has not specifically been tested with individuals with SCI.

Languages: Many languages

Usability: There is minimal examiner and no respondent burden (the patient is not asked to perform any special activities).

Time to administer: 5-10 minutes

Time to score: N/a

Training required: None

Availability: The scale, scoring information (free) and a video tape manual ($150 US) are available: www.Bradenscale.com

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Agency for Health Care Policy and Research (AHCPR). Panel on the prediction and prevention of pressure ulcers in adults. Pressure Ulcers in Adults: Prediction and Prevention. In Clinical Practice Guideline No. 3. AHCPR Publication No. 92-0047. Rockville MD: AHCPR; 1992.
• Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res 1987;36:205-210.
• Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.
• Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.

Gosnell Measure

The Gosnell scale was developed to identify individuals living in extended care and over the age of 65 who were at risk for developing a pressure ulcer (Gosnell 1973). Patients are evaluated on five domains: 1) mental status, 2) continence, 3) mobility (the amount and control of movement of one's body), 4) activity (ability to ambulate) and 5) nutrition (the process of food intake). The evaluation also includes recording of: vital signs (which includes temperature pulse respirations and blood pressure), skin condition (which includes appearance, skin tone and sensation) and medications, but these are not scored. 

Number of items:N/a

Procedure/Administration: Raters indicate client status on each of the items (which could be based on personal experience or chart review). Scales are scored based on descriptive criteria provided on the scoring sheet. This produces a summary score from between 5 (worst prognosis) to 20 (best prognosis).

How scored: N/a

Interpretability: N/a

Acceptability: The scale omits items found to be important predictors of pressure ulcer development for people with SCI such as pulmonary disease, serum creatinine, extent of paralysis, severe spasticity, age, tobacco use/smoking, disease, cardiac disease, renal disease, and living in a nursing home or hospital.

Languages: N/a

Usability: If the data required is normally collected as part of patient care, items on the scale would not represent a burden to either the client or the assessor. If not, the scale would place considerable rater burden and some respondent burden.

Time to administer: N/a

Time to score: 5-10 minutes. The score is easy for a health care provider to calculate, but additional items such as the assessment of skin condition may require additional patient assessment. 

Training required: N/a

Availability: N/a

Equipment required: None

Summary: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Gosnell DJ. An assessment tool to identify pressure sores. Nurs Res 1973;22:55-59.
• Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.
• Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.

Norton Measure

The 5 item Norton scale was the first pressure ulcer risk assessment that was developed and was intended for use with a geriatric hospital population (Norton et al. 1962).  The measure, based on the researcher’s clinical expertise, considers five domains relevant to skin condition: (1) physical condition, (2) mental condition, (3) activity, (4) mobility and (5) incontinence.  They are measured on an ordinal scale from 1 to 4.

Number of items: N/a

Procedure/Administration: Raters indicate client status based on personal observation or chart review.  Scales are scored on a domain specific ordinal scale from 1 to 4.

How scored: Though each item comes with standardized descriptive criteria on the score sheet, descriptors for item scoring are very brief.  A summary score ranging from 5 – 20 is calculated.

Interpretability: Higher scores equal better prognosis. A cut-off score of 14 has been suggested to identify individuals at risk for developing pressure sores. However, there is currently no research evidence to support the use of this value (Norton et al. 1962).

Acceptability: The Norton is a commonly used scale with a variety of populations. However, it omits items previously found to be important predictors of pressure ulcer development for people with SCI such as pulmonary disease, serum creatinine, extent of paralysis, severe spasticity, age, tobacco use/smoking, disease, cardiac disease, renal disease, and living in a nursing home or hospital. The reliability of the scale has not been demonstrated with the SCI population.  The Norton was the worst measure for predicting stage and number of pressure ulcers in individuals with SCI during the first 30 days of admission compared to the SCIPUS, SCUIPUS-A, Braden, Gosnell and Abruzzese. 

Languages: N/a

Usability: The Norton scale is quick to administer and easy to score. There is no patient burden.

Time to administer: 5-10 minutes

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Agency for Health Care Policy and Research (AHCPR). Panel on the prediction and prevention of pressure ulcers in adults. Pressure Ulcers in Adults: Prediction and Prevention. In Clinical Practice Guideline No. 3. AHCPR Publication No. 92-0047. Rockville MD: AHCPR; 1992.
• Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. J Clin Nurs 2002;11:470-478.
• Norton D, McLaren R, Exton-Smith AN. An Investigation of Geriatric Nursing Problems in Hospitals. London: National Corporation for the Care of Old People;1962.
• Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.
• Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.
• Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.

Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) Measure

The SCIPUS scale was developed as a measure of the risk for pressure ulcer development for individuals with SCI who are in a rehabilitation centre(Salzeber et al. 1996). Items for the scale were identified based on statistical analysis of data from 176 individuals with SCI, which compared development of pressure ulcers with demographic variables and potential pressure ulcer risk factors. Every patient is evaluated in fifteen domains: 1) level of activity, 2) mobility, 3) complete SCI, 4) urine incontinence or constantly moist, 5) autonomic dysreflexia or sever spasticity, 6) age, 7) tobacco use/smoking, 8) pulmonary disease, 9) cardiac disease or glucose > 110 mg/dl, 11) renal disease, 12) impaired cognitive function, 13) in a nursing home or hospital, 14)  albumin < 3.4 or T, protein < 6.4 and 15) hematorcrit <36.0%. Most items are scored dichotomously as either present or absent, but 4 items have three response options.

Number of items: 15

Procedure/Administration: Raters indicate client status based on personal knowledge of the of the client or chart review.

How scored: Dichotomous items are given a weighted score of 0 when absent and 1 or 2 when present and non dichotomous items are given a weighted score based on the descriptive criteria provided on the scoring sheet. For example, the presence of pulmonary disease (ICD codes 450, 460-519 & 796.0) = a score of 2. By adding domain scores together a summary score is calculated. 

Interpretability:  Scores range from 0 (best prognosis) to 25 (worst prognosis). A cut off score of 6 has been suggested to indicate clients at risk for pressure ulcer development. 

Acceptability: Although the SCIPUS is reported to be the best measure for individuals with SCI, the reliability of the scale has not been demonstrated with this population. The scale was developed specifically for use in rehabilitation centers and has not been tested in community dwelling populations..

Languages: N/a

Usability: There is minimal burden related to administering or scoring the scale if tests for diabetes, albumin and hemocrit are already part of the patient’s medical record.  Otherwise the blood tests required would be invasive and create respondent burden.

Time to administer: 10-15 minutes to administer (as long as laboratory data is already available).

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.

Spinal Cord Injury Pressure Ulcer Scale – Acute (SCIPUS-A)

Spinal Cord Injury Pressure Ulcer Scale – Acute (SCIPUS-A)

The SCIPUS-A scale was developed as a measure of the risk for pressure ulcer development for individuals with SCI during the acute phase of injury (within 30 days of admission) (Salzber et al. 1999). It evaluates eight domains: 1) extent of paralysis, 2) moisture, 3) serum creatinine, 4) incontinence, 5) albumin, 6) mobility, 7) pulmonary disease, and 8) level of activity. 

Number of items: 8

Procedure/Administration: Raters indicate client function status based on personal experience or chart review. Response categories are either dichotomous (present/ absent (score = 1 to 2 or 0, respectively) or have 3 to 5 options. For example, for ‘extent of paralysis’ - absent (i.e. no paralysis) is awarded a score of 0, paraparesis:1, tetraparesis:4, paraplegia:8 and tetraplegia:10.

How scored: Scales are scored based on descriptive criteria provided on the scoring sheet. Responses to each item are awarded a value between 0 to 1-10 and these are added together to create a summary score ranging from 0-25. 

Interpretability: Lower scores equal better prognosis. Sensitivity and specificity percentages are provided at a variety of cut-off scores.

Acceptability: Items for the scale were identified based on statistical analysis of data from 226 individuals with SCI, which compared development of pressure ulcers with demographic variables and 50 potential pressure ulcer risk factors. The content validity for the tool is high as it was designed for individuals with SCI.

Languages: English

Usability: There is minimal burden related to administering or scoring the scale if tests for albumin and serum creatinine are already part of the patient’s medical record.  Otherwise the blood tests required would be invasive and create respondent burden.

Time to administer: 5-10 minutes (as long as laboratory data is already available).

Time to score: N/a

Training required: N/a

Availability: The scale and its operational scoring definitions is available in the article that describes its development and testing (Salzberg et al. 1999).

Equipment required: N/a

Summary: The SCIPUS-A scale is a quick and easy to use measure that provides predictive information about risk of pressure sore development. Despite the good content validity, other validity evidence is only adequate, and there has been no reliability or responsiveness testing with these individuals with SCI

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. J Clin Nurs 2002;11:470-478.
• Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.

Stirling's Pressure Ulcer Severity Scale

The Stirling’s Pressure Ulcer Severity Scale is used to describe the severity of pressure ulcers (Pedley 2004). The scale has several variations, with the most common being the 1 and 2-digit scales, where the nature and severity of the ulcer are graded.

Number of items: N/a

Procedure/Administration: Using the 1-digit scale, raters indicate the severity of the ulcer from 0 to 4, according to the stage definitions. Using the 2-digit scale, raters indicate the severity of the ulcer according to the stage definitions and specific descriptors. For example, for stage 0 there are three descriptors, 0.1 - normal appearance, intact skin; 0.2 - healed with scarring, and 0.3 - tissue damage, but not assessed as a pressure sore.

How scored: The scale has 5 stages (0 = no clinical evidence of a pressure sore; 1 = discoloration of the intact skin, 2 = partial-thickness skin loss or damage involving epidermis and/or dermis; 3 = full-thickness skin loss involving damage or necrosis of subcutaneous tissue but not extending to underlying bone, tendon or joint capsule; and 4 = full-thickness skin loss with extensive destruction and tissue necrosis extending to bone, tendon or capsule). The two digit version includes more detailed ulcer descriptors.

Interpretability: Differentiation between the grade descriptors depends on clinical identification of the tissues. Differentiation requires not only observing the wound bed, but also having sufficient knowledge to distinguish the different tissue layers. The higher the grade of the ulcer, the greater the severity of the ulcer.

Acceptability: The measure was derived from previously published UK scales developed by a consensus panel of national tissue viability experts.

Languages: English

Usability:  The Stirling scale is easy to use, has good ulcer description, and good choice of descriptors. The descriptors in the 2-digit version enable a more accurate grading in comparison to other pressure ulcer severity scales. However, because the stage 1 descriptor of the scale focuses on skin discoloration, the validity of the Stirling scale is questionable when used with dark-skinned patients as this criterion may be masked by the skin pigment.  And, as with all pressure ulcer grading scales, this scale is open to bias and subjectivity.

Time to administer: No information was found on how long it takes to use the scale.

Time to score: N/a

Training required: To ensure basic understanding of skin and soft tissue anatomy and relevant physiological concepts, practitioners should undergo training prior to using the scale. 

Availability: The2-digit and 1-digit scales can be found in Pedley 2004

Equipment required: N/a

Summary: Observational pressure ulcer grading scales are open to bias and subjectivity resulting from individual interpretations. These interpretations reflect clinician knowledge and ability to identify anatomical structures and changes. The 2-digit version has greater range of descriptors than the 1-digit version, which makes grading easier and provides a more accurate and clinically meaningful description of the damage (Pedley 2004).

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Pedley GE. Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability. International Journal of Nursing Studies 2004;41:129-140.
• Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.

Waterlow Scale

The Waterlow scale (Waterlow 1985) is a tool used to assess the risk for pressure ulcer development. It was created to provide better sensitivity and specificity than the Norton by increasing the number of items used (Wellard & Lo 2000). Every patient is evaluated on: 1 ) age, 2) sex, 3) body build, 4)appetite, 5) continence of urine and feces, 6) mobility, 7) skin appearance in risk areas and (8) special risks (disorders associated with tissue malnutrition, neurological deficits, medication, recent surgery or trauma).

Number of items: 8

Procedure/Administrator: Raters indicate client status based on personal knowledge of the client or chart review. Items are scored as either dichotomous (yes/no) or on domain specific scales that range from 0-1 to 3-5. Domains are scored based on descriptive criteria provided on the scoring sheet (for example, ‘body build’: average – 0; above average – 1; obese – 2; below average - 3). 

How scored: Scores are totaled to produce a summary score from 3 (best prognosis) to 45 (worst prognosis).

Interpretability: Interpreting scores is difficult given lack of detail in item descriptions. Scores of 10+ denote risk of developing a pressure ulcer, 15+ high risk and 20+ very high risk. No rationale is provided for how these numbers were determined. 

Acceptability: The scale omits items previously found to be important predictors of pressure ulcer development for people with SCI in acute and rehabilitation settings. The reliability of the scale has not been demonstrated with a SCI population, but poor inter-rater reliability has been reported in other populations.

Languages: N/a

Usability: The scale is easy to score and administrate with no patient burden.

Time to administer: 5-10 minutes

Time to score: N/a

Training required: None

Availability: N/a

Equipment required: N/a

Clinical Summary: The Waterlow scale is quick and easy to use screen that provides predictive information about the risk of developing a pressure sore. 

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; AUC=area under curve

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. J Clin Nurs 2002;11:470-478.
• Kelly J. Inter-rater reliability and Waterlow’s pressure ulcer risk assessment tool. Nursing Standard 2005;19:86-87,90-92.
• Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.
• Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.
• Waterlow JJ. Pressure sores: a risk assessment card. Nurs Times1985;81:49-55.
• Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.

Emotional Quality of the Relationship Scale (EQR)

The EQR scale measures:

•  feelings of affection and intimacy
• ability to solve problems within the relationship
• ability to communicate about sex with the partner
• satisfaction with these areas and the relationship as a whole (Kreuter et al. 1994a).

Number of items: 7

Procedure/Administration: Self-report instrument.

How scored: Scores are summed resulting in a composite score that ranges from a maximum value of 28 to a minimum of 7. Items scored on a four-point scale ranging from 4 (very great) to 1 (very poor) (Kreuter et al. 1996).

Interpretability: Higher scores indicate that the emotional quality of the relationship is stronger. Mean values for SCI patients range from approximately 22 to 24 (Kreuter et al. 1994a; 1994b; 1996). There are no definitions and classifications of the results provided.

Acceptability: The tool could feasibly be used for individuals with either tetraplegia or paraplegia.

Languages: English

Usability: Staff burden is limited given the self-report nature of the scale

Time to administer: 2-5 minutes.

Time to score: N/a

Training required: Though no special equipment or training is required, items can illicit an emotional response that may require professional attention.

Availability: N/a

Equipment required: N/a

Summary:

• The EQR is useful in looking at aspects of relationships experienced by individuals with SCI. No other similar measures of these characteristics exist.
• 30% - 40% of the subjects thought the questions regarding sex were difficult to answer.
• Due to the lack of current literature using this tool, other more mainstream methods such as client interview should be used in conjunction with this scale.

 Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment and quality of relationships in spinal paraplegia: A controlled study. Arch Phys Med Rehabil 1996;77:541-548.
• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment after spinal cord injury (SCI) focusing on partner experiences. Paraplegia 1994; 32:225-235.
• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment after spinal cord injury (SCI) -comparison of partner experiences in pre- and postinjury relationships. Paraplegia 1994;32:759-770.

Knowledge, Comfort, Approach and Attitude towards Sexuality Scale (KCAASS)

• The KCAASS was developed to assess the training needs and professional skills of staff working in sexuality rehabilitation with SCI patients (Kendall et al. 2003)
• Four subscales are found within the questionnaire: knowledge (14 items), comfort (21 items), approach (5 items), and attitudes (5 items).

Number of items: 45

Procedure/Administration: The KCAASS is administered by interview, but can be self-administered.  A four-point Likert scale is used for all subscales, where 1=no knowledge/no discomfort/strongly disagree and 4=excellent knowledge/high discomfort/strongly agree.

How scored: Summary scores for each of the four aspects of sexuality are calculated. Higher scores represent greater knowledge and skills. The subscales comfort, approach and attitude are reverse scored. A maximum composite score of 200 is obtained by summing up the subscales.

Interpretability: Scores for each scale provide an assessment of where education time should be allocated when creating a sexual education program. Mean values for comparison are available in the Kendall et al. (2003) and Fronek et al. (2005) articles in case comparisons with other users need to be made.

Acceptability: The KCAASS was developed specifically for use within the SCI population.

Languages: N/a

Usability: N/a

Time to administer: Approximately 10-15 minutes is required to complete the scale

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment Required: N/a

Summary:

• The KCAASS addresses a broad range of potential topics which helps identify specific areas that should be focused on when developing sexual education programs for staff working within the spinal cord population.
• Information elicited from this tool could enhance the quality and comfort of sexual education for both the staff and client.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Fronek P, Booth S, Kendall M, Miller D, Geraght T. The effectiveness of a sexuality training program for the interdisciplinary spinal cord injury rehabilitation team. Sex Disabil 2005;23:51-63.
• Kendall M, Booth S, Fronek P, Miller D, Geraghty T. The development of a scale to assess the training needs of professionals in providing sexuality rehabilitation following spinal cord injury. Sex Disabil 2003;21:49-64.

Sexual Attitude and Information Questionnaire

• The SAIQ was developed to evaluate the impact of counseling programs and sexual education for persons with SCI and their partners (Brockway et al. 1978).
• The SAIQ consists of 4 scales: I) sexual information; II) sexual behavior acceptability; III) sexual concerns; and IV) non-sexual concerns.

Number of items: 39

Procedure/Administration: The SAIQ is a self-report questionnaire.

How scored: The SAIQ is scored using a 6-point Likert-scale (from ‘totally disagree/extremely concerned’ to ‘totally agree/not concerned’). The subscales are scored independently of one another. Scale I is scored according to the number of items answered correctly and Scales II - IV by summing ratings across items. 

Interpretability: N/a

Acceptability: The questionnaire may require up-dating, as there has been a considerable increase in public awareness and understanding of issues such as erectile dysfunction since its publication in 1980.

Languages: N/a

Usability: The SAIQ is easy to complete and the phrasing is clear; however, the content may be culturally sensitive.

Time to administer: Administration and scoring of the tool takes 10-15 minutes

Time to score: Administration and scoring of the tool takes 10-15 minutes

Training required: If the SAIQ is used as part of a counseling or training program then staff training is required. 

Availability: N/a

Equipment Required: N/a

Summary:

• The SAIQ considers both sexual behavior and sexual/non-sexual concerns, illustrating a client-centered questionnaire.
• Each subscale presents separate information: higher scores for scale I suggest individuals are knowledgeable about physiological aspects of sexual functioning, higher scores on scale II represents acceptance of sexual behaviors, higher scores on scale III indicates little concern about sexual functioning, and higher scores on scale IV suggests considerable concern about non-sexual functioning
• The SAIQ may prove to be a useful tool to evaluate the effectiveness of sexual counseling and education programs designed for individuals SCI. It may also be useful for identifying individuals who would benefit from such a program.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

Please contact the author at brockja@u.washington.edu for more information about this tool.

References

• Brockway JA, Steger JC. Sexual attitude and information questionnaire: Reliability and validity in a spinal cord injured population. Sex Disabil 1981;4:49-60.
• Brockway JA, Steger JC, Berni R, Ost V, Williamson-Kirkland TE, Peck CL. Effectiveness of a sex education and counseling program for spinal cord injured patients. Sex Disabil 1978;1:127-136.

Sexual Behaviour Scale (SB)

The SB scale measures the sexual expressions used by couples. There are seven items that cover touching, kissing, manual and oral stimulation of genital and other erogenous zones, and sexual intercourse (Kreuter et al. 1996).

Procedure: The SB is a self-report instrument. Items are summed resulting in a composite score that ranges from a maximum value of 49 to a minimum value of 7.

Advantages: There is high internal consistency (alpha=.96) suggesting the stability of the items is good and the high factor loadings of the items using principle components suggest the scale is measuring a single dimension (behaviour). 

Limitations: There is no description of the response categories used with this scale. The scale has only been used as part of a larger battery of questionnaires and not on its own. Additional study of the psychometrics such as test-retest reliability is required.

Interpretability: There are no definitions or classifications, important cut point or norms provided to assist with interpreting the scores. No descriptions of scores are given, other than the higher the score the better.

Acceptability: The time taken to complete the SB is less than 5 minutes.

Feasibility: Staff burden is minimal. No special equipment or training is required.  Contact the author at margareta.kreuter@fhs.gu.se to obtain a copy of the scale.

Clinical Summary: The SB allows a couple to gain insight into the type and degree of sexual expression they experience together. The information obtained from this tool might be useful in assisting couples with issues related to sexual intimacy. There is limited information found on the SB and further study is required before recommending this tool for clinical use.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; FA= Factor Analysis; N/a= No information

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

Contact the author at margareta.kreuter@fhs.gu.se for more information about this tool.

References

• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment and quality of relationships in spinal paraplegia: A controlled study. Arch Phys Med Rehabil 1996;77:541-548.

Sexual Interest, Activity and Satisfaction (SIAS) / Sexual Activity and Satisfaction (SAS) Scales

These 2 tools investigate the sexual activity and satisfaction of individuals with SCI. SIAS covers sexual desire, sexual activity, and sexual satisfaction (Kreuter et al. 1994a; 1994b). The SAS covers sexual activity and sexual satisfaction (Kreuter et al. 1996).

Number of items: SIAS - 6 items; SAS – 3 items

Procedure/Administration: Both scales are self-report but may be administered in interview format if required. 

How scored: The response items can be summed without weights or standardization. Higher scores indicate greater sexual activity and satisfaction. For mean values for normative comparisons consult Kreuter et al. (1994a; 1994b) for the SAIS and Kreuter et al. (1996) for the SAS.

Interpretability: There are no consistent definitions or classifications for the results detailed within the paper that developed SAS (Kreuter et al. 1996). For mean values for normative comparisons consult Kreuter et al. (1994a; 1994b) for the SAIS and Kreuter et al. (1996) for the SAS.

Acceptability: These tools are two of the better researched measures within the area of sexual interest and satisfaction: There is strong psychometric support for the scales.

Languages: English

Usability: Some items may contain content that is culturally sensitive. There is relatively no staff burden due to the short length of this measure

Time to administer: The scales take between 1-2 minutes to complete

Time to score: N/a

Training required: No special training is required to score or administer the scales.

Availability: The tools may be found in Kreuter et al. (1994,1996)

Equipment required: N/a

Summary:

• Detailed explanation of the purpose of the scale modification is not provided in the literature.
• Both of these tools may be clinically useful to assist in understanding, describing and quantifying the sexual activity and satisfaction of individuals with SCI (both tetra and paraplegia).
• Ultimately, these tools may also be effective in evaluating the effectiveness of sex specific interventions.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment and quality of relationships in spinal paraplegia: A controlled study. Arch Phys Med Rehabil 1996;77:541-548.
• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment after spinal cord injury (SCI) focusing on partner experiences. Paraplegia 1994; 32:225-235.
• Kreuter M, Sullivan M, Siosteen A. Sexual adjustment after spinal cord injury (SCI) -comparison of partner experiences in pre- and postinjury relationships. Paraplegia 1994;32:759-770.

Sexual Interest and Satisfaction Scale (SIS)

• The SIS scale measures sexual adjustment after SCI. It was designed to assess different aspects of sexuality before and after injury (Siosteen et al. 1990). 

Number of items: 7

Procedure/Administration: The SIS is self-administered then checked by personal interview. Four items determine the impact SCI had on sexuality and sexual function using a 4-point response scale (increased=3, unchanged=2, decreased=1, and absent=0). The remaining 3 questions assess general satisfaction before and after injury, using a modified 7-point visual analogue scale (ranging from very dissatisfied (1) to very satisfied (7)).

How scored: The scores for the 3 satisfaction items are rescaled to a range of 0 to 3 in order to enable calculation of a composite score. The composite score is a sum of 6 items and has a maximum value of 18 and a minimum value of 0.  

Interpretability: Achieving a high score on the SIS illustrates greater sexual adjustment while a lower scorer demonstrates poor sexual adjustments after SCI. There are no known cut points or norms to assist with interpretation.

Acceptability: The SIS was developed for use in the SCI population. It provides a quick review of the individual’s sexual experiences, while factoring in their pre-injury state.

Languages: N/a

Usability: The type of SCI needs to be taken into consideration when interpreting the results. Sexual adjustment for those with incomplete injuries may differ considerably when compared to complete injuries. Items should be acceptable to both males and females though items may seem personal and embarrassing to some.

Time to administer: Administration and scoring requires approximately 5 minutes.

Time to score: Administration and scoring requires approximately 5 minutes.

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The SIS provides a reasonably well defined spinal cord specific measure that may be useful in eliciting information regarding a sensitive area.
• Although it has not been widely used and psychometric properties have been reported by only one study, it is one of few sexuality scales that have been used within the SCI population.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Siosteen A, Lundqvist C, Blomstrand C, Sullivan L, Sullivan M. Sexual ability, activity, attitudes and satisfaction as part of adjustment in spinal cord-injured subjects. Paraplegia 1990;8:285-295.

Spinal Cord Injury Secondary Conditions Scale (SCI-SCS)

The SCI-SCS specifically targets secondary conditions associated with SCI that directly and indirectly impact health and physical functioning. Items represent problems in the areas of skin, musculoskeletal, pain, bowel/bladder, and cardio-vascular.

Number of items: 16  

Procedure/Administration: The instrument is a self-report questionnaire. The rating scale uses a 4-point ordinal scale ranging from 0 (not experienced/insignificant problem never limiting activity) to 3 (significant/chronic problem).

How scored: Scores are derived from the sum of the problem ratings.

Interpretability: Total scores range from 0 to 48. Higher scores indicate greater overall problems with secondary conditions. No meaningful cut points or responsiveness data exists at this time.

Acceptability: Only one study has assessed the psychometric properties of the SCI-SCS among the SCI population.

Languages: N/a

Usability: N/a

Time to administer: N/a

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• Item selection for the SCI-SCS was based on 3 criteria: that they represent conditions that are physiologic in nature (vs. psychological or environmental); that they are measurable by patient history and physical examination, reported episodes, validated scales, or medical tests or interventions; and those that can be either prevented or managed with medical intervention and/or health behaviors (Kalpakjian et al. 2007).

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Kalpakjian CZ, Scelza WM, Forchheimer MB, Toussaint LL. Preliminary Reliability and Validity of a Spinal Cord Injury Secondary Conditions Scale. The Journal of Spinal Cord Medicine 2007; 30: 131-39.

The Appraisals of DisAbility: Primary and Secondary Scale (ADAPSS)

References

The ADAPSS primary scale assesses ‘an individual’s initial evaluation of an event or situation’. Its secondary scale assesses ‘an individual’s evaluation of their own coping resources, the possibility of these resources being adequate, and the likelihood that these resources can be employed effectively’ (Dean & Kennedy, 2009).  The scale consists of 6 subscales: Fearful Despondency; Overwhelming Disbelief; Determined Resolve; Growth and Resilience; Negative Perceptions of Disability; and Personal Agency.

Number of items: 33

Procedure/Administration: The ADAPSS is a self-administered questionnaire.  Participants are asked to rate their agreement/disagreement with the statements on a Likert Scale.

How scored: N/a

Interpretability: High scores on the Fearful Despondency, Overwhelming Disbelief, and Negative Perceptions of Disability subscales represent greater agreement with the appraisals whereas low scores on the Determined Resolve, Growth and Resilience, and Personal Agency subscales represent greater agreement with the appraisals (though the range of scores is not provided). No information is given regarding norms or meaningful cut-off scores, although the ADAPSS is still in early stages of development. 

Acceptability: The ADAPSS is a SCI-specific appraisal scale. The questions are straightforward and the scale covers a range of appraisal themes. However, the ADAPSS is still in the early stages of development: its psychometric properties have been evaluated in only one study and it has only been tested in the community-dwelling SCI population

Languages: N/a

Usability: A self-administered format is recommended but an interviewer or proxy could be used in the case of severe physical disability. The assessment seems easy to administer and score

Time to administer: N/a

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: None

Summary: Appraisals are important psychosocial variables in SCI populations as they have been found to be good predictors of emotional adjustment. The ADAPSS is useful in the clinical setting to better understand the appraisals which are significant for adjustment to SCI and thus to tailor treatment programs for patients.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.
* the Determined Resolve, Growth and Resilience, and Personal Agency subscales had adequate internal consistency. The other subscales had excellent internal consistency.

References

• Dean RE, Kennedy P. Measuring Appraisals Following Acquired Spinal Cord Injury: A Preliminary Psychometric Analysis of the Appraisals of Disability. Rehabilitation Psychology 2009;54(2): 222-231.

SCI Exercise Self-Efficacy Scale (ESES)

The SCI ESES was developed to measure perceived exercise self-efficacy in individuals with SCI. The scale requires individuals to indicate their confidence in performing physical activities and exercise.  One dichotomous item asks whether the individual has exercised at home and/or in a gym in the past 12 months. The scale is SCI-specific and measures perceived self-efficacy for various types of physical exercise.

Number of items: 10

Procedure/Administration: Self-report, pen and paper format. It requires individuals to respond to items on a 4-point Likert scale (1-not at all true, 4-always true). Exercise activity is based on the response to a dichotomous item that specifies whether respondents have exercised ‘at home and/or gym’ vs. ‘no exercise’. 

How scored: The total score is derived by summing the scores for the individual items; possible scores range from 10 to 40.

Interpretability: Higher scores indicate greater perceived self-efficacy. The dichotomous item is used to estimate the subject’s average exercise activity. No cut points or norms have been established.

Acceptability: The ESES was developed specifically for the SCI population based on expert comments and interviews with individuals with SCI. Therefore, it should represent the physical activity and exercise self-efficacy issues of this unique population.

Languages: English

Usability: The scale is easy to administer and score.

Time to administer: 5 minutes

Time to score: N/a

Training required: None

Availability: The scale is available from the initial publication (Kroll et al., 2007). 

Equipment required: None

Summary:  Self-efficacy is the belief individuals have in their ability to perform certain behaviours to achieve desired outcomes. The ESES measures the subject’s perceived exercise self-efficacy beliefs. Evidence suggests that the adoption of and adherence to regular exercise is influenced by self-efficacy to perform physical activity. Consequently, this scale was developed to address the lack of an exercise self-efficacy tool for people with SCI.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Kroll T, Kehn M, Ho PS, Groah S. The SCI exercise self-efficacy scale (ESES): development and psychometric properties. International Journal of Behavioral Nutrition and Physical Activity 2007, 4:34.

Moorong Self-Efficacy Scale (MSES)

The Moorong Self-Efficacy Scale was developed to measure self-efficacy in performing functional activities of daily living in individuals with SCI.

Number of items: 16

Procedure/Administration: The scale is a pen and paper format self-report questionnaire. Participants rate their confidence in their ability to complete the 16 tasks on a seven-point Likert scale (1-very uncertain, 7-very certain).

How scored: The total scale score is obtained by summing the individual item responses and range from 16 to 112.

Interpretability: Higher scores indicate higher perceived self-efficacy. The scale was able to show a mean change of 8 points (84 – 92) over 6 months in a sample of individuals under-going sub-acute rehabilitation post-SCI. However, no normative data or cut points for the scale have been provided yet. 

Acceptability: The scale is specific to individuals with SCI.

Languages: English

Usability: Little respondent burden.

Time to administer: 5 minutes

Time to score: N/a

Training required: None.

Availability: The scale items are available from the original publications (Middleton et al; 2003).

Equipment required:

Interpretability: N/a

Feasibility: The scale is easy and quick to administer. No administrator training is required.

Clinical Summary:  Individuals with a strong sense of self-efficacy will set challenging goals and have greater expectations resulting from their efforts. Such an efficacious outlook may positively influence rehabilitation efforts.The measurement of self-efficacy in rehabilitation may thus help to identify areas in which individuals with SCI have low self-efficacy of which may be modified via self-efficacy enhancing sources of information.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Middleton JW, Tate RL, Geraghty TJ. Self-efficacy and spinal cord injury: psychometric properties of a new scale. Rehabilitation Psychology 2003, 48(4): 281-288.
• Miller WC, Anton HA, Townson AF. Measurement properties of the CESD scale among individuals with spinal cord injury. Spinal Cord 2008; 46: 287-292.

Spinal Cord Lesion Coping Strategies Questionnaire (SCL CSQ)

The SCL CSQ was developed to measure coping after a sudden onset SCI. It is made up of three domains: 1) acceptance of injury; 2) social reliance; 3) and fighting spirit. The acceptance domain measures the extent of reevaluation of life values, fighting spirit domain measures efforts to behave independently, and the social reliance domain measures the tendency towards depended behavior.

Number of items: 12

Procedure/Administration:  This self report scale can be completed in hard copy, online or over the telephone. Participants are asked to answer each question on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree).

How scored: N/a

Interpretability: Scores are averaged in each domain and range from 1 to 4. Higher scores indicate greater affirmation of the domain to coping. No cut scores or norms are given.

Acceptability: The scale was originally developed for the SCI population.

Languages: Swedish, English

Usability: The SCL CSQ can be completed online, over the telephone or in person. It is short and simple to complete, and represents no significant burden to the respondent. The scale is simple to administer and score.

Time to administer: N/a

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: None

Summary: The results of the SCL CSQ are to be used to advise clinicians about specific coping mechanisms of acceptance, fighting spirit and social reliance. Coping strategies have been shown to be associated with emotional well-being. The SCL CSQ is a measure to assess coping efforts, rather than the outcomes of coping which is more typically measured, and may be a more pertinent tool to assess emotional well-being.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Migliorini CE, Elfstom ML, Tonge BJ. “Translation and Australian validation of the spinal cord lesion-related coping strategies and emotional wellbeing questionnaires.” Spinal Cord 2008:46;690-695.

Spinal Cord Lesion Emotional Wellbeing Questionnaire (SCL EWQ)

The SCL EWQ was developed to measure emotional consequences after SCI. It consists of three domains: 1) the positive emotional outcome of person growth, which determines current positive changes; 2) negative outcomes of helplessness, which determines the level of perplexity, out of control and low self-esteem; and 3) intrusion, which determines the level of bitterness and brooding.

Number of items: 12

Procedure/Administration: The scale can be self-completed in hard copy, online or by telephone interview.  Participants are asked to answer each question on a 4-point Likert Scale (1 = strongly disagree, 2=disagree, 3=agree, 4=strongly agree).

How scored: Domain scores are summed and then averaged. Scores range between 1 and 4 for each domain.

Interpretability: Higher scores indicate greater affirmation of the domain. So, higher scores on the personal growth scale indicate more positive emotional consequences of the SCI and higher scores on the helplessness or intrusion scale indicate more negative emotional consequences.  No cut scores or norms are given.

Acceptability: The scale was originally developed for the SCI population.

Languages: Swedish, English

Usability: The SCL EWQ is short and simple to complete. There is no significant respondent burden. The scale is simple to administer and score.

Time to administer: N/a

Time to score: N/a

Training required: None

Availability: N/a

Equipment required: N/a

Summary: The results of the SCL EWQ are used to advise clinicians about specific emotional consequences of a traumatic SCI.

Psychometric Summary: 

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Migliorini CE, Elfstom ML, Tonge BJ. “Translation and Australian validation of the spinal cord lesion-related coping strategies and emotional wellbeing questionnaires.” Spinal Cord 2008:46;690-695.

Functional Tests for Persons who Self-Propel a Manual Wheelchair (4FTPSMW)

This test was developed to assist clinicians in assessing the effect of different postural supports (e.g. back support and seat cushions). The 4FTPSMW was developed by an experienced group of physiotherapists using a literature review and input from both individuals with SCI and researchers (May et al. 2003).

Number of items: 4

Procedure/Administration: The test includes 4 tasks: 1) timed forward wheeling (23m); 2) ramp ascent (forward wheeling); 3) forward vertical reach distance; and 4) one-stroke push. Five minute rest breaks were provided between tasks to limit fatigue. 

How scored: The wheeling tasks are scored in seconds and the reaching and one-stroke push tasks in centimeters.  

Interpretability: The scoring system is objective and has ratio level properties. No normative data is available.

Acceptability: Is only relevant to individual who use a manual wheelchair (i.e. not suited to individuals who use an electric wheelchair). 

Languages: N/a

Usability: The tasks were tolerated well by participants. Only the ramp ascent task was difficult for an individual with C6 SCI at 4 months post injury. 

Time to administer: It takes between 30 - 45 minutes to complete 2 trials of the 4 functional tasks including rest breaks (note: 2 trials were required for test re-test reliability rather than to eliminate the practice effect).

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: 23 m corridor, 1 m measuring stick, ramp (10.3 m and 1:13 grade), carpeted surface (1.5 cm pile), and a stop watch.

Summary:

• The 4FTPSMW is a functional test suited for the clinical setting (eg. the timed forward wheeling task is based on a distance of 23 meters (plus length of the wheelbase) - the average length of a crosswalk in a 4 lane intersection). 

 Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• May LA, Butt C, Minor L, Kolbinson K, Tulloch K. Measurement reliability of functional tasks for person who self-propel a manual wheelchair. Arch Phys Med Rehabil 2003;84:578-83.

6-Minute Walk Test (6MWT)

• A self-paced test. It measures the distance that a patient can walk on a flat, hard surface in 6 minutes and assesses the sub-maximal level of functional capacity (American Thoracic Society 2000).
• The test in its entirety evaluates the integrated response of pulmonary, cardiovascular, and circulatory systems, in addition to level of motor control, functional neuromuscular units, and muscle (Ditunno et al. 2007).

Number of items: N/a

Procedure/Administration: The 6MWT may be performed either indoors or outdoors, along a long, flat, straight, and hard surface. The American Thoracic Society (ATS) recommends that the walking course should be 30 meters in length, marked at every 3 meters, and a turnaround point marked with a cone.

How scored: The distance (total distance walked rounding to the nearest meter) is reported. Fatigue level is also reported. Pulse oximetry (baseline heart rate and oxygen saturation) is optional.

Interpretability: For single measurements, reference equations from healthy samples using the 6MWT are not available for comparison.

Acceptability: It is suitable for patients who can walk with moderate or less assistance for 6 minutes. It is a self paced test and subjects may take stop to rest.

Languages: N/a

Usability: N/a

Time to administer: N/a

Time to score: N/a

Training required: People who administer the test should be trained using the standard protocol and then supervised for several tests before performing them alone. The test administrator should also have CPR training.

Availability: N/a

Equipment required: A countdown timer, mechanical lap counter, cones to mark the turnaround, a chair that can be easily moved along the walking course, worksheets, a source of oxygen, sphygmomanometer, telephone, and an automated electronic defibrillator.

Summary:

• According to the American Thoracic Society, the 6MWT is easier to administer, better tolerated, and more reflective of activities of daily living than other walking tests.
• There are many sources of variability including height, age, body weight, sex, and motivation (ATS 2002).

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• American Thoracic Society. ATS Statement: Guideline for the Six-Minute Walk Test. Am J Respir Crit Care Med 2002; 166: 111-117.
• Ditunno JF Jr, Barbeau H, Dobkin BH, Elashoff R, Harkema S, Marino RJ, Hauck WW, Apple D, Basso DM, Behrman A, Deforge D, Fugate L, Saulino M, Scott M, Chung J, Spinal Cord Injury Locomotor Trial Group. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair 2007; 21: 539-550.
• van Hedel HJA, Wirz M, Curt A. Improving walking assessment in subjects with incomplete spinal cord injury: responsiveness. Spinal Cord 2006;44:352-356.

10 Meter Walking Test (10MWT)

• Assesses short duration walking speed (m/sec).  It has been used in various patient populations including stroke, Parkinson’s disease, general neurologic movement disorders and SCI (van Hedel et al. 2005; 2006).

Number of items: N/a

Procedure/Administration: The 10 MWT measures the time required to walk 10 meters. It is performed using a “flying start”: the patient walks 14 meters and the time is measured for the intermediate 10 meters. The individual walks at their preferred walking speed. Individuals can use an assistive device and must wear shoes. 

How scored: The time (seconds) is reported and can also calculate a walking speed m/sec.

Interpretability: Results of the 10 MWT have been reported in the literature for individuals with incomplete SCI.  An average time of 30 seconds with a walking speed of 4.5 km h^-1 (1.25 m s^-1) has been reported.  Normative values are approximately 4.7 km h^-1 [1.31 m s^-1]). 

Acceptability: Is suitable for individuals who can, at a minimum, ambulate in household settings (i.e. > 14 m).

Languages: N/a

Usability: N/a

Time to administer: Approx 30 seconds.

Time to score: N/a

Training required: Does not require advanced training.

Availability: N/a

Equipment required: Can be administered in the clinical setting or in the community. A 14m corridor and a stopwatch are required.

Summary:

• The 10 MWT only assesses walking ability and does not consider the amount of physical assistance required, devices or endurance. 
• The test is conducted in a controlled environment (i.e. lab or hospital setting), so results can not be directly translated to the environment (i.e. crossing a busy street).  The 10 MWT also requires an individual to ambulate a minimum of 14 m.  There have been reports in the literature that the distance is not always standardized (i.e. 10 m versus 14 m).
• It appears to be a useful measure in the SCI population for both research and clinical practice.  The scale properties (time in sec or m/sec) of the 10 MWT make it a responsive test well suited to evaluating clinical interventions.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; varied (re. floor/ceiling effects; mixed results); SS= Sensitivity/Specificity; N/a= No information

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

*Responsiveness assessed using the Freidman’s test.

** For construct validity, the results with other walking tests (i.e. TUG & 6 MWT) were considered stronger evidence to support validity compared to LEMS based on ASIA.

References 

• van Hedel HJA, Dietz V, and the EM-SCI Study Group. Walking during daily life can be validly and responsively assessed in subjects with a spinal cord injury. Neurorehabil Neural Repair 2009; 23: 117-124.
• van Hedel HJA for the EMSCI Study Group. Gait speed in relation to categories of functional ambulation after spinal cord injury. Neural Repair 2009; 23(4): 343-350.
• van Hedel HJA, Wirz M, Dietz V. Standardized assessment of walking capacity after spinal cord injury: the European network approach. Neurological Research 2008; 30: 61-73.
• van Hedel HJA, Wirz M, Curt A. Improving walking assessment in subjects with incomplete spinal cord injury: responsiveness. Spinal Cord 2006;44:352-356.
• van Hedel HJA  Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury:validity and reliability of 3 walking tests. Arch Phys Med Rehabil 2005;86:190-196.

Berg Balance Scale (BBS)

The BBS is a performance based measure of balance. Tasks are of progressing difficulty and include functional activities related to balance while reaching, bending, transferring, and standing. Originally developed for use with the elderly, the scale has been used in a variety of populations including stroke, Parkinson’s, multiple sclerosis, and recently SCI. Some researchers have used the BBS as the gold standard for balance in criterion validity studies (Liston & Brouwer, 1996; Tyson & DeSouza, 2004).

Number of items: 14

Procedure/Administration: The BBS is an observer rated measure. The rater observes the patient perform each of the tasks while ensuring the individual does not fall.

How scored: Each of the 14 tasks are rated on a 5-point scale from 0 (cannot perform) to 4 (normal performance). Total scores range from 0 (severely impaired balance) to 56 (excellent balance). Some tasks are rated according to the quality of the performance of the task, while others are evaluated by the time required to complete the task.

Interpretability: Results from studies of older adults suggest the follow cut points: 0-20 = wheelchair bound; 21-40 = walking with assistance; and 41-56 = independent. Scores below 41 are suggested to indicate increased risk of falling. Change scores >7 are said to be clinically relevant in studies of older adults. This interpretation has not been validated with SCI populations.

Acceptability: The BBS is generally well received among clinicians who specialize in the area of gait and balance training. The tool is only applicable to individuals with incomplete SCI who retain some ability to stand and walk. It has been found to be an appropriate assessment of standing balance for these individuals as shown by its strong associations with various clinical walking evaluations

Languages: English, Italian, Turkish, Brazilian-Portuguese, German, Korean, and Dutch.

Usability: The BBS is limited to those patients with SCI who have some form of standing and/or ambulatory capacity.

Time to administer: Approximately 20 minutes (in relative well functioning older adults). In general the time required is inversely related to the lower extremity ability of the individual.

Time to score: N/a

Training required: Raters are typically health professional with knowledge of balance and trained to assign ratings.

Availability: www.aahf.info/pdf/Berg_Balance_Scale.pdf.

Equipment required: 2 standard chairs (1 with arms and 1 without), a stop watch, step or stepstool, and a ruler

Summary: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada 1989; 41(6): 304-311.
• Lemay JF, Nadeau S. Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale. Spinal Cord advance online publication, 22 September 2009; doi: 10.1038/sc.2009.119.
• Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil 1996; 77: 425-430.
• Tyson SF, DeSouza LH. Development of the Brunel Balance assessment: a new measure of balance disability post stroke. Clin Rehabil 2004; 18: 801-810.
• Wirz M, Muller R, Bastiaenen C. Falls in persons with spinal cord injury: Validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair 2010;24: 70-77.

Clinical Outcome Variables Scale (COVS)

The COVS is a measure of mobility that has been applied to specific diagnostic groups such as stroke, traumatic brain injury, amputations, and musculoskeletal injuries (Berker et al. 2007). It has been applied in acute, inpatient/outpatient rehabilitation, and community settings. Its items include rolling, lying to sitting, sitting balance, transfers, ambulation, wheelchair mobility, and arm function (Campbell & Kendall 2003).

Number of Items: 13

Procedure/Administration: The COVS can be conducted via in-person interviews or over the telephone (TCOVS).

How scored: Each item is scored on a 7-point scale ranging from 1(fully dependent mobility) to 7 (normal independent mobility).

Interpretability: Scores are generally reported as a single score ranging from 13 to 91. The general mobility subscale has scores that range from 7-49, while the ambulation subscale has scores ranging from 5-35. Lower scores reflect poorer levels of mobility. In an SCI population, 2 subscales have been reported: 1) general mobility with scores ranging from 7-49; and 2) ambulation with scores ranging from 5-35.

Acceptability: N/a

Languages: English

Usability: N/a

Time to administer: Telephone interview takes 5 minutes (subjects are given the questions ahead of time). In-person assessment takes 35 minutes.

Time to score: N/a

Training required: Raters should be trained in the administration of both the COVS and TCOVS.

Availability: N/a

Equipment required: Bed sticks, bed ladders, lifting blocks, transfer boards, leg straps, exercise mat, ramp (1inch to 12inch rise), and a 6 inch platform

Summary: The tool offers a more relevant and complete profile of mobility after SCI when compared with other mobility tools.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity; ER=Equivalence reliability between COVS and TCOVS.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Barker RN, Amsters DI, Kendall MD, Pershouse KJ, Haines TP. Reliability of the Clinical Outcome Variables Scale when administered via telephone to assess mobility in people with spinal cord injury. Arch Phys Med Rehabil 2007; 88: 632-7.
• Campbell J, Kendall M. Investigating the suitability of the Clinical Outcome Variables Scale (COVS) as a mobility outcome measure in spinal cord in jury rehabilitation. Physiother. Can 2003; 55: 135-144.

Capabilities of Upper Extremity Instrument (CUE)

The CUE measures functional limitation and assesses the amount of difficulty experienced in performing specific actions with one or both arms and hands in individuals with tetraplegia (Marino et al. 1998).

Number of items: 32: fifteen items inquire about unilaterally (left and right) hand and arm function and 2 items assess bilateral hand and arm use.

Procedure/Administration: Interview format. Questions focus on the individuals’ ability to reach or lift; pull and push with their arms; move and position their arm and wrist; use their hand and fingers; and press with the tip of the index finger.

How scored: Responses are given on a 7-point scale representing self-perceived difficulty in performing the action, with scores ranging from 1 (unable to perform) to 7 (can perform without difficulty).

Interpretability: Item by item results of the test are straight forward to interpret. Total scores range from 32 to 224 with higher scores reflecting better function. Left and right arm/hand function can be derived separately. A percent of normal function score is also possible using the following algorithm ((total score – 32) / 192 * 100%.

Acceptability: The method of item generation would suggest the CUE is likely to be widely accepted with therapists and individuals with an SCI.

Languages: English

Usability: N/a

Time to administer: 30 minutes.

Time to score: N/a

Training required: None.

Availability: N/a

Equipment required: None.

Summary:

• The CUE has considerable potential clinical appeal because it reflects hand and/or arm function and scores can be derived for either limb which is appealing given the number of individuals with incomplete injuries.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information

References:  

• Marino RJ, Shea JA, Stineman MG. The Capabilities of Upper Extremity Instrument: Reliability and Validity of a Measure of Functional Limitation in Tetraplegia. Arch Phys Med Rehabil 1998;79:1512-21.
• Mulcahey MJ, Smith BT, Betz RR. Psychometric rigor of the Grasp and REslease Test for measuring functional limitation of persons with tetraplegia: a preliminary analysis. J Spinal Cord Med 2004; 27:41-6.

Functional Standing Test (FST)

• Assesses an individual’s ability to perform one handed reaching tasks while standing (Triolo et al. 1994).
• The FST consists of 21 tasks (6 are the same as in the Jebson Test of Hand Function). 
• Tasks involve performing both gross and fine motor skills; crossing midline; and lifting and lowering light and heavy objects. Examples of tasks include: lifting light objects down from the lowest shelf; stacking checkers on the counter top at the midline; lifting heavy objects up to the top shelf.

Number of items: 21 tasks (6 of which are the same as in the Jebson Test of Hand Function

Procedure/Administration: Tasks are done as quickly as possible and the individual is allowed to use assistive devices such as knee-ankle-foot-orthoses (KAFO) or functional neuromuscular stimulation

How scored: The time in minutes/seconds to complete each of the 21 tasks is recorded.

Interpretability: N/a

Acceptability: Was originally developed using able-bodied individuals and has been modified for individuals with SCI. However, the only testing of the FST for SCI has been done in individuals with T3-6 injuries

Languages: N/a

Usability: N/a

Time to administer: The time to complete the entire test (i.e. total standing time) was 15.58 + 2.99 minutes. Time required for each task ranged from 1.86 to 13.70 seconds for individuals with SCI.

Time to score: N/a

Training required: Training is required to administer the test.

Availability: N/a

Equipment required: A standard Jebson Test board and a set of shelves mounted on a counter top 36 inches high (to simulate a kitchen cabinet). 

Summary:

• The tasks simulate skills required to work in a kitchen environment but theses skills are easily transferred to other environments (e.g. shopping). The tasks cover a broad range of difficulty.
• The specialized equipment may limit its usefulness in some clinical/research settings.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

* the ICC values for the IO reliability ranged from 0.13 – 0.98. If the tasks that were identified as being unreliable in the SCI group were eliminated, then the results for reliability would be assessed as yellow.

 This test was not readily available and has not been included in this summary.

References

• Triolo RJ, Bevelheimer T, Eisenhower G, Wormser D. Inter-rater reliability of a clinical test of standing function. J Spinal Cord Med. 1994;18:14-22.

The Grasp and Release Test (GRT)

The GRT was designed to assess hand neuro-prosthesis in individuals with C5-C6 SCIs, but has also been used to assess hand function prior to and following tendon transfers in people with C6-7 level injuries (Harvey et al. 2001). The GRT assesses the ability to pick up, move, and release six objects of varying sizes, weights and textures using a palmar or lateral grasp (Stroh Wuolle et al. 1994, Harvey et al. 2001). Each object was chosen to represent one or more objects routinely manipulated for activities of daily living (ADL) that represented a range of difficulties.

Number of items: 6 tasks

Procedure/Administration: Clinician administered standardized performance test. Specific instructions are provided for establishing the start position and for recording a successful completion of the task.

How scored: Subjects are scored on their ability to successfully move each of the objects as many times as possible in 30 seconds. Each hand is tested and scored separately. A pretrial practice test for each object is permitted and practice continues until a successful completion is achieved

Interpretability: A summed score is calculated by adding the item scores. If a subject fails to move an item, they score zero for that particular item. Single items may be used.

Acceptability: N/a

Languages: N/a

Usability: Completion of the tool may vary depending on the individual’s abilities. For example, subjects with paralysis of the finger and/or thumb flexor muscles are generally unable to hold the fork or paperweight between the thumb and index finger so floor effects are possible.

Time to administer: Approximately 20 minutes, including the pretest.

Time to score: Minimal

Training required: N/a

Availability: N/a

Equipment required: The objects used in the GRT include a peg, paperweight, fork, block, can and videotape.

Summary: This is a well standardized quick test of hand function that would be appropriate for a limited sub-sample of individuals with SCI.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

This test was not readily available and has not been included in this summary.

References

• Harvey LA, Batty J, Jones R, Crosbie J. Hand function of C6 and C7 tetraplegics 1-16 years following injury. Spinal Cord 2001;39:37-43.
• Mulcahey MJ, Smith BT, Betz RR. Psychometric rigor of the Grasp and REslease Test for measuring functional limitation of persons with tetraplegia: a preliminary analysis. J Spinal Cord Med 2004; 27:41-6.
• Stroh Wuolle K, Van Doren CL, Thorpe GB, Keith MW, Peckham PH. Development of Quantitative Hand Grasp and Release Test for Patients with Tetraplegia using a Hand Neuroprosthesis. The Journal of Hand Surgery: 1994;19:209-18.
• Taylor P, Esnouf J, Hobby J. The functional impact of the Freehand System on tetraplegic hand function. Clinical results. Spinal Cord 2002;11:550-6.

Hand-Held Myometer

The Hand-Held Myometer is a portable device used as a quantitative and objective method of muscle assessment (Schwartz et al. 1992). Testing is performed using one of two techniques, 1) make or 2) break. The ‘make’ technique requires the examiner to resist a maximal voluntary contraction by the patient, thereby producing an isometric contraction. In the ‘break’ technique, the examiner applies adequate force to overcome the patient, thereby producing an eccentric contraction.

Number of items: N/a

Procedure/Administration: Clinician administered. The mean force of three administrations for each muscle group tested is preferred (Noreau et al. 1998) and some investigators suggest a practice trial (Andrews et al. 1996). A break of 5 to 10 seconds between trials is suggested. The starting position of the individual and the myometer is critical and encouragement to maximize muscle contraction is suggested (Noreau et al. 1998).

How scored: The recommended unit of measurement is Kg in order avoid interpretation issues. Measurements are generally rounded to the nearest Kg. 

Interpretability: Normative values for various adult age groups are available. A predicted muscle force can be calculated by taking into consideration the individual’s gender, weight, and age. By comparing the predicted force to the observed force, an estimate of percentage of deficit may be determined. However, no meaningful cut-points have been reported.  Computer software is available to assist with data analyses.

Acceptability: N/a

Languages: N/a

Usability: N/a

Time to administer: 30 minutes for a bilateral assessment of the upper extremities. And, multiple position changes are required to capture maximal muscle contractions

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: A myometer. Initial cost of this device may be seen as a limitation to its general use.

Summary:

• Myometer testing presents an objective, quantifiable method of measuring muscle strength. However this does not necessarily reflect function.
• It is superior to MMT for detection of mild to moderate weakness and changes in muscle strength. It also eliminates potential bias from the evaluator for various age groups and gender.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Andrews AW, Thomas MW, Bohannon RW. Normative Values for Isometric Muscle Force Measurements Obtained With Hand-held Dynamometers. Physical Therapy 1996; 76:248-259.
• Burns SP, Breuninger A, Kaplan C, Marin H. Hand-Held Dynamometry in Persons with Tetraplegia. Am. J. Phys. Med. Rehabil. 2005;84:22-29.
• Cohen ME, Herbison GJ, Shah A. Relationship Between Two Measure of Upper Extremity Strength: Manual Muscle Test Compared to Hand-Held Myometry. Arch Phys Med Rehabil 1992;73:1063-1068.
• Noreau L & Vachon J. Comparison of three methods to assess muscular strength in individuals with spinal cord injury. Spinal Cord 1998;36:716-723.
• Schwartz S, Cohen ME, Herbison GJ, Shah A. Relationship Between Two Measure of Upper Extremity Strength: Manual Muscle Test Compared to Hand-Held Myometry. Arch Phys Med Rehabil 1992;73:1063-1068.

Jebsen Hand Function Test

The JHFT was developed to provide a standardized and objective evaluation of several major aspects of hand function using simulated activities of daily living.

Number of items: 7

Procedure/Administration: Fine motor, weighted and non-weighted hand function is assessed through writing; turning over 3 by 5 inch cards; picking up small common objects; simulated feeding; stacking checkers; picking up large objects; and picking up large heavy objects. Patients are required to perform all of the subtests with both the right and left hands, with the non-dominant hand tested first (Jebsen et al. 1969). 

How scored: The scoring method is the time necessary to complete each subtest (rounded the nearest second). The results are measured by using a stop watch.

Interpretability: Test results appear easy to interpret. Norms are available with the instruction manual. Slow times reflect a less desirable performance.

Acceptability: The JHFT represents one of the oldest standardized tests of hand function and used individuals with SCI during its initial development.

Languages: English

Usability: N/a

Time to administer: 30-45 minutes

Time to score: ~15 minutes.

Training required: Training is not required – however, given the standardized nature of the JHFT assessors should refer to the Jebsen paper for details on how to administer the test (Jebsen et al.1969).

Availability: N/a

Equipment required: N/a

Summary: The JHFT only assesses the speed and not the quality of performance

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency;Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Bovend Eerdt TJH, Dawes H, Johansen-Berg H, Wade DT. Evaluation of the Modified Jebsen Test of Hand Function and the University of Maryland Arm Questionnaire for Stroke. Clinical Rehabilitation 2004; 18: 195-202.
• Jebsen RH, Taylor N, Trieschmann RB, Trotter MH, Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehabil 1969;50:311-19.
• Spaulding SJ, McPherson HH, Strachota E, Kuphal M, Ramponi M. Jebsen Hand Function Test: Performance of the Uninvolved Hand in Hemiplegia and of Right-handed, Right and Left Hemiplegic Persons. Arch Phys Rehabil 1988;69:419-22.
• Stern EB. Stability of the Jebsen-Taylor Hand Function Test Across Three Test Sessions. The American Journal of Occupational Therapy 1992;46:647-49.

Modified Functional Reach Test (mFRT)

The FRT was originally designed as a simple reach test designed to assess standing balance. It was then modified by Lynch et al. (1998) to assess sitting balance in individuals with SCI (i.e. modified FRT). Balance is defined as the ability to maintain control over upright posture during forward reach without stabilization.

Number of items: N/a

Procedure/Administration: The individual is seated on a bench and the maximum distance forward they could reach is measured with the upper extremity flexed to 90 degrees. The anatomical landmark is the ulnar styloid process. No weight bearing is allowed through the non reaching arm. The individual is allowed two practice trials and then the following three trials are recorded. 

How scored: The average of the three trials is reported in either cm or inches. 

Interpretability: No normative data exists for the mFRT for any health care condition at this time. 

Acceptability: The mFRT has been developed specifically for individuals with SCI. As long as an individual has 90 degrees of shoulder flexion, he/she can complete the test.

Languages: N/a

Usability: The mFRT requires an individual to have 90 degrees of shoulder flexion and it is therefore not suitable for individuals with limited range of motion or musculoskeletal deformity. 

Time to administer: N/a

Time to score: N/a

Training required: A meter stick/yardstick (attached horizontally to the wall); seat (mat or bench approximately 61 cm in width); and a backboard (at an angle of 80 degrees).

Summary:

• The mFRT mimics a very functional activity that is required in daily living. It can distinguish between individuals who have abdominal and back extensors (i.e. high tetraplegia/high paraplegia versus low paraplegia) but not between individuals with high lesions. 

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Lynch SM, Leahy P, Barker SP. Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury. Phys Ther 1998;78:128-133.

Rivermead Mobility Index (RMI)

The RMI was originally developed to measure mobility for patients with acquired brain injury (Hseih et al. 2000). It evaluates patients’ bed mobility, postural transfers, and walking ability. The RMI covers a range of activities, from turning over in bed to running (Hseih et al. 2000).

Number of items: 15-item scale: 14 questions and one direct observation

Procedure/Administration: The RMI uses a combined interview and observation format.

How scored: Question 5 requires the patient to stand for 10 seconds without any aid. The other questions require the patient to respond either yes (scored 1) or no (scored 0). For question 5, if the subject can stand for 10 seconds, a response of ‘yes’ is indicated.

Interpretability: Scores for the 15 items are summed. The range of scores is between 0 (poor mobility) and 15 (good mobility). No information is available regarding norms or meaningful cut scores.

Acceptability: N/a

Languages: N/a

Usability: Several questions refer to either walking or running which may not be appropriate for all SCI patients.

Time to administer: 3-5 minutes

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The RMI is simple and quick to complete making it easy to perform in the home, institutional or office settings. There is minimal patient or clinician burden.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

* correlated with WISCI, SCIM, FIM and BI.

References

• Forlander DA, Bohannon RW. Rivermead Mobility Index: a brief review of research to date. Clinical Rehabilitation 1999; 13: 97-100.
• Hsieh CL, Hsueh IP, Mao HF. Validity and responsiveness of the Rivermead Mobility Index in stroke patients. Scand J Rehab Med 2000; 32: 140-142.
• Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking Index for spinal cord injury (WISCI): criterion validation. Spinal Cord 2005;43:27-33.

The Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI)

The SCI-FAI is a mobility measure focusing on gait abnormalities (Field-Fote et al. 2001). It was developed to assess ambulation in SCI patients. The gait parameters were developed by a panel of experts in SCI rehabilitation and consist of three components:

• Gait parameter (weight shift, step width, step rhythm, step height, foot contact, step length)
• Assistive devices use (degree of assistance provided by each of device - eg. cane, walker, parallel bars
• Walking mobility (walking distance, speed, and walking frequency)

Number of items: N/a

Procedure/Administration: Raters provide scores for each of the gait parameter and assistive device use components. The gait parameter component is scored out of 20, 10 points for each of the right and left sides. The assistive device component is scored out of 14 (7 points for each side), and assesses upper and lower extremities in addition to the left and right limbs. In the walking mobility component, subjects are asked about their walking frequency on a scale of 0 to 5 (0 = does not walk; 5 = regularly walks in community). The distance walked in two minutes is also measured.  Walking can be videotaped for later evaluation.

How scored: N/a

Interpretability: Scores within each component are summed. Component scores range from 0 to 20 in the gait parameter component, 0 to 14 in the assistive device component, and 0 to 5 in the walking mobility component. Higher score indicate higher levels of function. It is not meaningful to combine component scores into an overall total score.  No cut scores or norms are given.

Acceptability: The SCI-FAI can only be used among SCI patients who can ambulate independently, with or without the use of assistive devices.  

Languages: N/a

Usability: The SCI-FAI can be completed during regular check ups or during home visits. Patients are to walk for a maximum of 2 minutes and can use what ever walking devices they require. The SCI-FAI is short in duration and scoring is straight forward for all items on the scale.

Time to administer: 2 minutes

Time to score: N/a

Training required: Training is required for proper recognition of separate criterion; though the test can be scored reliably from video recording, which allows the rater to rewind, pause and slow down the tape.

Availability: N/a

Equipment required: N/a

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Field- Fote E, Fluet G, Schafer S, Scheider E, Smith R, Downey P, Huhl C. The Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI). J Rehabil Med. 2001;33:177-181

Sollerman Hand Function Test

 This test was developed to provide an overall measure of hand and grip function when engaging in ADLs (Sollermen & Ejeskar 1985).  It was designed to measure grips that are needed for certain ADLs such as eating, driving, personal hygiene, and writing. The test includes subtests that represent common handgrips (volar, transverse volar, spherical volar and pinch positions - pulp, lateral, tripod, and the five finger) and activities (using a key; picking up coins from a flat surface; writing with a pen; using a phone; and pouring water from a jug).

Number of items: 20

Procedure/Administration: Clinician administered standardized performance test.  A test box is place in front of the patients who are required to start each subtask in a seated position but they may stand to complete a task if necessary. Three subtasks are completed using the hands bilaterally while the rest are completed with each hand separately. The subtests are timed and the performance is observed.

How scored: Scoring takes into account the time taken, level of difficulty displayed, and the quality of performance using the correct pinch or grip position. Patients are then scored on a 5-point scale from 0 (task cannot be performed at all) to 4 (task is completed without any difficulty within the time frame (20 seconds) and with the prescribed hand-grip of normal quality). Scoring the test can be challenging as the assessor must be aware of multiple factors occurring simultaneously (passage of time, difficulty, correct positioning and quality of performance). Definitions for interpreting the scoring scheme are not inherently obvious.

Interpretability: A total sum score is created by adding up the scores from the different subtests.  Scores range from 0 to 80 with higher scores reflecting a better performance. Subjects with no hand function impairment typically score 80 with the dominant hand and 77-79 for the non-dominant hand.

Acceptability: The test was designed with tetraplegic patients in mind and therefore reflects the needs of this group.

Languages: English

Usability: N/a

Time to administer: 20-25 minutes (one minute for each subsection plus introduction of the test)

Time to score: N/a

Training required: It can be used by clinicians who have little experience - though knowledge of hand function is an asset when scoring.

Availability: N/a

Equipment required: Special equipment is required.

Summary: N/a

Clinical Summary:

• The Sollerman (unlike the Jebsen Hand Function Test) considers the quality and level of difficulty with the performance which are important components with respect to hand function.

Psychometric Summary :

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Dellhag B & Burckhardt CS. Predictors of Hand Function in Patients with Rheumatoid Arthritis. Arthritis Care and Research 1995;8:16-20.
• Sollerman C & Ejeskär A. Sollerman Hand Function Test. A Standardised Method and its Use in Tetraplegic Patients. Scand J Plast Reconstr Hand Surg 1995;29:167-176.

Tool for assessing mobility in wheelchair-dependent paraplegics

The tool is used to quantify the mobility of individuals with SCI who use a wheelchair through the assessment of motor tasks such as moving from lying to sitting; completing a horizontal transfer; completing a vertical transfer; pushing a wheelchair on flat ground; pushing a wheelchair up/down ramps; and negotiating curbs in a wheelchair (Harvey et al. 1998).

Number of items: 6

Procedure/Administration: This is a performance based assessment. For each task, subjects are scored on a six-point scale with 6 representing complete independence, and 1 representing total assistance.  Patients must perform the tasks in the following order: Task 1) supine to long sitting; Task 2) horizontal transfer; Task 3) vertical transfer; Task 4) push on flat; Task 5) push on ramp; Task 6) negotiate curbs. For tasks 2 through 6, the patients are allowed three attempts with the best score recorded.  If a task is not attempted, ‘not applicable’ is recorded.

How scored: Higher scores indicate greater independence. The scores for each task are not meant to be added together to give an overall score. Rather, each task is given a score and interpretation is in relation to that specific task. No norms or cut scores are available at this time.

Interpretability: N/a

Acceptability: The tool was designed specifically for individuals with paraplegia who use a manual wheelchair.

Languages: N/a

Usability: N/a

Time to administer: Less than 15 minutes

Time to score: N/a

Training required: Trained physiotherapist

Availability: N/a

Equipment required: A 25 meter hallway, cones, a 15 meter ramp, and curbs 2.5 cm and 15 cm high are required for the test.

Summary:

• The results of the assessment tool summarize the basic level of wheelchair mobility of patients in a manner that is readily understood by other professionals

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Harvey LA, Batty J, Fahey A. Reliability of a tool for assessing mobility in wheelchair-dependent paraplegics. Spinal Cord 1998;36:427-431.

Tetraplegia Hand Activity Questionnaire (THAQ)

The THAQ is a measure of arm and hand function in individuals with tetraplegia (Land et al. 2004). It consists of 9 subclasses: self-care, dressing, continence, mobility, eating and drinking, work/admin/telecom, leisure, household, and miscellaneous.

Number of items: 153

Procedure/Administration: Information is collected using an interview format.

How scored: Items are scored based on 3 dimensions: 1) Performance or Doing (0= without difficulty to 3=help from others); 2) Use of an aid (0=never and 3=always); 3) Importance of performing activity independently (0=not important to 2 very important).

Interpretability: There is no information regarding interpretability of the scores (e.g. norms).

Acceptability: It is specific to the tetraplegic population. The items were identified by client population.

Languages: N/a

Usability: The test may not be useful when the individual is an in-patient as exposure to out of facility activities (i.e. community living, work, leisure) is required.

Time to administer: 30-45 minutes

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary: The THAQ is a SCI specific questionnaire used to assess performance, use of an aid and importance in completing actual activities. It has relevant application for individuals with tetraplegia who have completed in-patient rehabilitation. The test may not be useful when the individual is an in-patient as exposure to out of facility activities related to community living, work, leisure, which are not typically addressed in early phases of in patient rehabilitation.The THAQ could potentially be used as a method of goal identification for intervention and/or as a test to measure change after intervention. However, while the THAQ is promising considerable additional development and psychometric assessment is required before recommendations can be made to use the scale clinically.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Land NE, Odding E, Duivenvoorden HJ, Bergen MP, Stam HJ. Tetraplegia Hand Activity Questionnaire (THAQ): the development, assessment of arm-hand function-related activities in tetraplegic patients with a spinal cord injury. Spinal Cord 2004;42:294-301.

Timed Motor Test (TMT)

• Assesses the capacity to perform ADL in children with SCI (who use a manual wheelchair).
• Tasks include: donning a shirt; donning sweat pants; performance of even transfers; performance of uneven transfers (4 inch height difference); wheelchair propulsion on even surfaces; and wheelchair performance up a ramp (Chafetz et al. 2004).

Number of items: 6

Procedure/Administration: The individual completes each task 5 times, except for wheelchair skills which is only done 3 times. They are instructed to complete the task quickly but safely. If they are unsuccessful in completing the task, they can re-try it and if they are not able to complete all 5 trials then no time is reported. If the individual requires more than 20 seconds to complete the task then it is considered “incomplete”. 

How scored: A clinician records the time (seconds) to complete each task. Based on the results of the reliability data it was decided to use the fastest 3 trials for scoring each task.

Interpretability: No norms are available and the results for the 3 fastest trials for each task were not reported.

Acceptability: N/a

Languages: N/a

Usability: N/a

Time to administer: The scale takes between 60–90 minutes to complete.

Time to score: N/a

Training required: No special training is required.

Availability: N/a

Equipment required: Anadjustable mat; an 80 foot (24.3 m) corridor; and a 45 foot (13.72 m) ramp with an 8 degree angle.  

Summary:

• The TMT includes common ADL tasks for children with SCI.
• The objective scale such as time (seconds) is useful to detect change.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

* TR values for each of the 6 tasks were >0.75 for 4 tasks, 0.67 for one task and 0.30 for one task. An overall value of adequate (++) was selected to best represent the range of values.
** There is support for construct validity by using the data comparing known groups (TLSO versus no brace). F values were reported and 5 out of 6 tasks demonstrated that the TLSO times were significantly (p<0.05) compared to no brace.

 A copy of this tool could not be found.

References

• Chafetz R, McDonald C, Mulcahey MJ, Betz R, Anderson C, Vogel L, Gaughan JP, Martin S, O'Dell MA, Flanagan A. Timed motor test for wheelchair users: initial development and application in children with spinal cord injury. J SCI Med 2004;27:S38-43.

Timed Up and Go Test (TUG)

• A test of basic functional mobility for frail elderly persons (Mathias et al. 1986).
• Is a timed walking test designed to measure gait performance and balance.  

Number of items: N/a

Procedure/Administration: The individual is instructed to stand up from an arm chair, walk 3 meters, return to the chair and sit down at their preferred walking speed.

How scored:

Time for ‘Up and Go’ test:  _________sec.

Unstable on turning?  Y/N

Walking aid used?  Y/N  Type of aid: ______________

Interpretability: N/a

Acceptability: The test is not suitable for many individuals with SCI.

Languages: N/a

Usability: N/a

Time to administer: N/a

Time to score: N/a

Training required: Does not require any special training.

Availability: N/a

Equipment required: N/a

Summary:

• Discriminates balance and ambulatory function between patients and evaluate change over time in a single patient.
• The TUG is a quick and easy test to administer and can be done in any setting (i.e. clinical setting or community). The task is very functional and incorporates mobility, balance and lower extremity leg strength. 
• TUG appears to be a very useful measure for individuals with incomplete SCI who have lower extremity function and provides some information on a basic mobility task.  

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67:387-389.
• van Hedel HJA Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch Phys Med Rehabil 2005;86:190-196.

The Van Lieshout Test Short Version (VLT-SV)

This test was originally developed to assess basic functional modalities of the arm and hand in individuals cervical SCIs. It assesses positioning and stabilization of the arms, opening and closing of the functional hand, grasping and releasing of the hands, and manipulation of the thumbs and fingers (Post et al. 2006). The VLT-SV assesses forward reaching, arm extension against gravity, thumb closure, finger strength, pen grip, lighting a match and opening a bottle (Spooren et al. 2006).

Number of items: 10

Procedure/Administration: Clinician administered standardized performance test. All tasks are performed while the patient is seated in their wheelchair for the “best hand” only.  The VLT-SV is scored on a 6-point scale, where 0 = task was not possible, and 5 = highest level of accomplishment. Individual item scores take into acount the 1) ability to complete the task; 2) behavioural quality of performance (e.g./accuracy of task completion); and 3) independence in performing the task without using external support (e.g./assistance of the contra-lateral arm).

How scored: A total score may be calculated by summing the scores of all 10 items.

Interpretability: Scores range from 0 to 50 with higher scores indicating greater functional ability.

Acceptability: It was developed with the cervical SCI population in mind, implying appropriate item selection / challenge. During administration of the test, the patient and clinician together identify for the best way to complete the task.

Languages: The test’s measurement properties have only been assessed for the Dutch version. English and German versions are available but the measurement properties have yet to be tested.

Usability: N/a

Time to administer: 25 – 35

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: Current published literature does not provide details about standardization of the test (e.g./ table heights, distance of reaching tasks, etc.)

Summary:The VLT-SV presents as a promising new measure that should be able to capture evidence of change in hand function.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Post MWM, van Lieshout F, Seelen HAM, Snoek GJ, IJzerman MJ, Pons C. Measurement properties of the short version of the Van Lieshout test for arm/hand function of persons with tetraplegia after spinal cord injury. Spinal Cord 2006; 44: 763-771
• Spooren AI, Janssen-Potten YJ, Post MW, Kerckhofs E, Nene A, Seelen HA. Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test. Spinal Cord 2006; 44: 772-779.

Walking Index for Spinal Cord Injury (WISCI) and WISCI II

The WISCI is a measure of ambulation designed specifically for SCI clinical trials (Ditunno et al. 2000). The WISCI evaluates the amount of physical assistance, braces or devices required to walk 10 metres. 

Number of items: N/a

Procedure/Administration: The client walks 10 meters – this distance represents household ambulation.

How scored: The clinician observes walking and rates the level which the person is considered safe. A score from 0 to 20 is assigned. Level 0: “patient is unable to stand and/or participate in walking” to level 20: “ambulates with no devices, with brace and no assistance”.

Interpretability: No normative data or cut scores are available but the WISCI is gaining popularity and comparisons can be made with existing studies. Scores are self evident.

Acceptability: The WISCI is an SCI specific test. It covers the entire range of walking ability.

Languages: English

Usability: A score is possible even if the individual cannot walk 10m. However, because the furthest walk distance is 10m, it would not be suitable for individuals with minor impairments

Time to administer: Varies between subjects.

Time to score: Minimal.

Training required: Training beyond knowledge of ambulation is not required. Scoring definitions provided are clear.

Availability: N/a

Equipment required: Equipment is typically available in the clinical setting: 5 meter parallel bars and walking devices (e.g. braces, cane, walker).

Summary:

• The WISCI levels are relevant to individuals with SCI. There is no additional burden is as the test falls into typical clinical practice parameters.  Administration time is.
• It would be a useful to incorporate the WISCI into clinical practice and to evaluate new SCI therapies.  Additional tests may be necessary to assess endurance (e.g. 6MWT) and/or walking speed (eg.10MWT), especially for individuals with greater walking capacity.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

References

• Ditunno JF, Ditunno PL, Graziani V, Scivoletto G, Bernardi M, Castellano V, Marchetti M, Barbeau H Frankel HL D'Andrea Greve JM, Ko HY, Marshall R, Nance P. Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal Cord 2000;38:234-243.
• Dittuno PL Dittuno JF. Walking index for spinal cord injury (WISCI II): scale revision. Spinal Cord 2001;39:654-656.
• Ditunno JF, Burns AS, Marino RJ. 2005. Neurological and functional capacity outcome measures: essential to spinal cord injury clinical trials. J Rehab Res Dev 2005;42(Suppl 1): 35-41.
• Ditunno JF, Scivoletto G, Patrick M, Biering-Sorensen F, Abel R, Marino R. Validation of the walking index for spinal cord injury in a US and European clinical population. Spinal Cord 2008; 46: 181-188.
• Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking Index for spinal cord injury (WISCI): criterion validation. Spinal Cord 2005;43:27-33.
• van Hedel HJA Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch Phys Med Rehabil 2005;86:190-196.

Wheelchair Circuit (WC)

The WC assesses manual wheelchair mobility (i.e. skill and performance). Tasks cover 3 aspects of mobility: 1) tempo (tasks = figure-of-8 shape and sprint); 2) technical skill (tasks = crossing a doorstep, mounting a platform, and transferring); and 3) physical capacity (tasks = wheelchair propulsion and ascending slopes).

Number of items: N/a

Procedure/Administration:

How scored: No normative data is available, but results can be compared to published data. Separate scores for ability (ordinal scale); performance time (seconds); and physical strain (formula using HR data) are calculated.

Interpretability: N/a

Acceptability: The WC includes functional tasks developed specifically for the SCI population. However, the tasks are only relevant to manual wheelchair users. Some tasks may be too difficult / not suitable if individuals have medical complications or are older.

Languages: N/a

Usability: N/a

Time to administer: N/a

Time to score: N/a

Training required: Clinicians require specialized training to perform exercise testing and a practice test is recommended.   

Availability: N/a

Equipment required:  An adjustable mat; treadmill (with 3% and 6% grade); HR monitor; stop watch; 0.10 m platform on floor; wood doorstep height 0.4 m; open space; and 15 m corridor. are required for the WC. 

Summary:

• The performance time and physical strain are useful to monitor progress once the individual achieves a maximal score on the ability score or if they have not demonstrated any change over repeated administrations.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

** Varied (re: floor/ceiling effects; mixed results)

References

• Dallmeijer AJ, van der Woude LH, Hollander AP, van As HH. Physical performance during rehabilitation in persons with spinal cord injuries. Med Sci Sports Exerc 1999;31:1330-1335.
• Harvey LA, Batty J, Fahey A. Reliability of a tool for assessing mobility in wheelchair-dependent paraplegics. Spinal Cord 1998;36:427-431.
• Janssen TW, van Oers CA, van der Woude LH, Hollander AP. Reliability of heart rate response to non-steady-state activities of daily living in men with spinal cord injuries. Scand J Rehabil Med 1994;26:71-78.
• Kilkens OJ, Dallmeijer AJ, De Witte LP, Van Der Woude LH, Post MW. The Wheelchair Circuit: Construct validity and responsiveness of a test to assess manual wheelchair mobility in persons with spinal cord injury. Arch Phys Med Rehabil 2004;85:424-431.
• Kilkens OJ, Post MW, van der Woude LH, Dallmeijer AJ, van den Heuvel WJ. The Wheelchair Circuit: reliability of a test to assess mobility in persons with spinal cord injuries. Arch Phys Med Rehabil 2002;83:1783-1788.

Wheelchair Skills Test

The WST is a comprehensive measure used to objectively evaluate manual wheelchair skills (Kirby et al. 2002). Existing wheelchair tests (Harvey et al. 1998) do not include the level of wheelchair skills required for daily functioning.

Number of items: 50

Procedure/Administration: The revised WST 2.4 includes 50 skills in 10 areas (brakes, armrests, footrests, rolling, turning, reaching, transfers, fold/open, obstacles, and wheelie). The individual is required to use a manual wheelchair and two attempts, with a rest, are permitted to complete the task.

How scored: Scoring is on a pass-fail basis (pass=1, fail=0, N/A=not applicable) with an additional goal attainment score (GAS), for which the clinician indicates whether or not the skill is a reasonable goal for the individual case (N/G=not a goal). The total WST score for individuals with SCI was 68.4+15.1%, indicating that these individuals were able to complete approximately 70% of the tasks deemed suitable.

Interpretability: N/a

Acceptability: N/a

Languages: N/a

Usability: N/a

Time to administer: On average, it takes 27.0+9.3mins (range 12–70mins) to complete

Time to score: N/a

Training required: The clinician requires test familiarization and a spotter is mandatory.

Availability: N/a

Equipment required: A specialized wheelchair circuit or access to a variety of environmental obstacles.

Summary:

• The tasks cover a wide range of difficulty while remaining functional. It is a generic tool that can be used for several populations (e.g. SCI, amputees, stroke, musculoskeletal disorders, able-bodied) and it was developed using both inpatient and community dwelling samples.

. Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; varied (re. floor/ceiling effects; mixed results).

SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References:

• Kirby RL, Swuste J, Dupuis DJ, MacLeod DA, Monroe R. The Wheelchair Skills Test: a pilot study of a new outcome measure. Arch Phys Med Rehabil 2002;83:10-18. 
• Harvey LA, Batty J, Fahey A. Reliability of a tool for assessing mobility in wheelchair-dependent paraplegics. Spinal Cord 1998;36:427-431.

The Barthel Index

The Barthel Index is one of the oldest developed measures of ADLs. It was originally developed to assess the severity of disability in personal care and mobility in stroke patients (Mahoney & Barthel 1965).

Number of items: 10

Procedure/Administration: Scores are obtained using direct observation, self-report, or responses from family/friends. Scores based on the past 48 hours are preferred.

How scored: Total scores are calculated by summing the individual item scores. Scores are weighted and range from 0 (dependence) to 100 (independence).

Interpretability: Scores reflect the nursing burden and social acceptability of the activity. Cut scores have been established on the stroke population and are not necessarily representative for the SCI population. Scores of 0-20 indicate total dependence; 21-60: severe dependence; 61-90: moderate dependence and 91-99: slight dependence. 

Acceptability: Though the test items are deemed important to society, they not reflect activities that are of importance to individuals with SCI.

Languages: The 10 item English version has been assessed for the SCI population.

Usability: There is minimum patient burden unless the entire test is scored by observation. Only the modified BI has published properties for the SCI population. Floor and ceiling effects makes the scale less useful for the SCI population.

Time to administer: 2-10 minutes to complete (more if assessed by observation).

Time to score: N/a

Training required: No training is required though clinical experience/practice is beneficial.

Availability: N/a

Equipment required: None

Summary:

• The BI is one of the best researched ADL tools and has been used with a number of patient populations. Use of adaptive aids is permitted with a score of ‘independent’.
• The BI covers very basic functional abilities and while a score of 100 suggests independence, assistance may still be required with other higher order tasks such as cooking/cleaning and therefore other measures are needed to assess these areas.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Granger CV, Albrecht GL, Hamilton BB. Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index. Arch Phys Med Rehabil 1979;60:145-154.
• Kucukdeveci AA, Yavuzer G, Tennant A, Suldur N, Sonel B, Arasil T. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med 2000;32:87-92.
• Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J 1965;14:61-65.

Frenchay Activities Index (FAI)

The FAI assesses frequency of doing Instrumental Activities of Daily Living (IADL); the index includes items which reflect the patient’s behavior in the areas of domestic chores, leisure/work, and outdoor activities (Holbrook & Skilbeck 1983). A revised 13-item FAI* has recently been assessed among SCI patients. The following summary therefore focuses on the revised FAI.

Number of items: 13

Procedure/Administration: Self administered or interview format. Items include washing up; preparing main meals; washing clothes; driving car/bus travel; light housework; heavy housework; local shopping; social occasions; actively pursuing hobby; gainful work; travel outings/car rides; gardening; and household/car maintenance. 

How scored: Responses measure the frequency of engaging in an activity on a 2 and 3 point ordinal scale. Four items (washing up, washing clothes, driving a car/bus travel, and gainful work) are scored on a 2-point scale. The 9 other items are scored on a 3-point scale. Total score are derived by summing the score from each item and range from 0 (no activity) to 22 (most frequently doing the activities).

Interpretability: Higher scores indicate greater frequency of doing IADL. The raw scores of the 13-item FAI can be transformed to interval scores thereby enabling clinicians and researchers to quantify and monitor IADL function in SCI patients (Hsieh et al. 2007).

Acceptability: The 13 item revised FAI was developed specifically for use with SCI patients.

Languages: English

Usability: The revised 13-item scale is brief, quick to complete, and reflects the everyday activities of normal living

Time to administer: Between 5 and 15 minutes

Time to score: N/a

Training required: Minimal

Availability: N/a

Equipment required: N/a

Summary: The FAI does not assess whether patients can perform IADL.

Psychometric Summary

TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.

* Based on Rasch analysis and the authors’ findings that the results assess a single, unidimensional IADL for SCI patients living in the community.

References

• Holbrook M, Skilbeck CE. An Activities Index for use with stroke patients. Age and Ageing 1983; 12: 166-170.
• Hsieh CL, Jang Y, Yu TY, Wang WC, Sheu CF, Wang YH. A Rasch analysis of the Frenchay Activities Index in patients with spinal cord injury. Spine 2007; 32: 437-442.

Functional Independence Measure (FIM)

The FIM assesses physical and cognitive disability. It consists of two subscales, motor and socio-cognitive.

Number of items: 18

Procedure/Administration: The tool is completed by observation of performance.  The motor subscale includes 13 items: eating, grooming bathing, dressing upper extremity, dressing lower extremity, bowel management, bladder management, transfers to bed, chair or wheelchair, transfer to tub, toilet and shower, walking or wheelchair propulsion and stair climbing. The socio-cognitive subscale includes 5 items: comprehension, expression, social interaction, problem solving and memory.

How scored: Each item is scored on a 7 point ordinal scale ranging from 1 (total dependence) to a score of 7 (total independence). The scoring considers the use of adaptive equipment and/or the extent of personal assistance or supervision required to complete the task.  FIM motor, cognitive and/or total scores can be derived by summing items.

Interpretability: Total FIM scores range from 18 (totally dependent) to 126 (totally independent); motor scores range from 13 (total dependence) to 91 (total independence); and cognitive scores range from 5 (total dependence) to 35 (total independence).  Higher scores reflect fewer care hours required upon discharge (Heinemann et al. 1997; Hamilton et al. 1999).

Acceptability: The FIM is not SCI specific. It has limitations in sensitivity to component abilities within tasks for people with SCI. There is a ceiling effect with the socio-cognitive subscale for individuals with and it does not measure the social, psychological, or vocational impact of disability experienced by those living with SCI.

Languages: The FIM has been translated into 10 languages.

Usability: The FIM is used widely for research, clinical and administrative purposes. 

Time to administer: 45 minutes.

Time to score: N/a

Training required: Certification for FIM administration is required

Availability: Information on training can be obtained from http://www.udsmr.org/. See McDowell & Newell (1996) for a copy of the FIM.

Equipment required: None

Summary:

• The FIM is often considered the gold standard for assessing ADLs.
• Though it is the best researched measure of function, it may not be sensitive to the subtle important changes in function for SCI individuals.
• As a result of the limitations of the FIM for use with individuals with SCI, the SCIM was developed and may perhaps be a better tool to use with SCI patients.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Davidoff GN, Roth EJ, Haughton JS, Ardner MS. Cognitive dysfunction in spinal cord injury patients: sensitivity of the Functional Independence Measure subscales vs. neuropsychologic assessment. Arch Phys Med Rehabil 1990;71:326-329.
• Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients Arch Phys Med Rehabil, 1993; 74: 531-536.
• Granger CV, Hamilton BB, Keith RA et al. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1:59-74.
• Graves D. The construct validity and explanatory power of the AISA Motor Score and the FIM: implications for theoretical models of spinal cord injury Top Spinal Cord Inj Rehabil 2005;10:65-74.
• Hall KM, Cohen ME, Wright J, Call M, Werner P. Characteristics of the Functional Independence Measure in traumatic spinal cord injury. Arch Phys Med Rehabil 1999;80:1471-1476.
• Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehab Med 1994;26:115-119.
• Hamilton BB, Deutsch A, Russell C, Fiedler RC, Granger CV. Relation of disability costs to function: spinal cord injury. Arch Phys Med Rehabil 1999;80:385-391.
• Heinemann AW, Kirk P, Hastie BA Semik,P, Hamilton BB, Linacre JM, Wright BD, Granger C. Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury. Arch Phys Med Rehabil 1997;78:143-149.
• McCabe MA, Granger CV. Content validity of a pediatric Functional Independence Measure. Appl Nurs Res 1990;3:120-122.
• McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires. Oxford University Press, New York NY, 1996.
• Middleton JW, Harvey LA, Batty J, Cameron I, Quirk R, Winstanley J. Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury. Spinal Cord 2006; 44: 495-504.
• Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil 1996;77:1226-1232.

Functional Independence Measure Self-Report (FIM-SR)

This FIM-SR, similar to the FIM, assesses burden of care and functional impairment. The original FIM is completed by trained clinicians whereas the FIM-SR is completed by the patient. The FIM-SR, contains 6 scales: self-care, sphincter control, mobility, locomotion, communication, and social cognition (Masedo et al. 2005).

Number of items: N/a

Procedure/Administration: The FIM Self Report was developed for administration by telephone interview. The scores can be reported as FIM Motor scores, FIM Cognitive scores or FIM Total summed scores.

How scored: The 18 items are rated on a 1 – 7 scale where 1 = total assistance is needed and 7 = complete independence.

Interpretability: Total FIM-SR scores range from 18 (total dependence) to 126 (total independence). The higher the FIM score, the fewer care hours required upon discharge (Hamilton et al. 1999; Heinemann et al. 1997).

Acceptability: Most items on the FIM-SR generalize to all populations, however modified versions of the FIM exist to accommodate the needs of individuals with SCI. The motor scale adequately discriminated subjects with different injury levels

Languages: N/a

Usability: N/a

Time to administer: Requires minimal time to complete (is very short).

Time to score: N/a

Training required: Health care professionals scoring the FIM–SR are required to complete training and testing protocol.

Availability: N/a

Equipment required: N/a

Summary:

• The instrument reports the patient perspective on their level of independence and in general, is well known as the internationally accepted, global tool to measure functional independence.  
• The FIM-SR has less clinician and client burden than the original FIM which requires observation of tasks.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Graves D. The construct validity and explanatory power of the AISA Motor Score and the FIM: implications for theoretical models of spinal cord injury Top Spinal Cord Inj Rehabil 2005;10:65-74.
• Hall KM, Cohen ME, Wright J, Call M, Werner P. Characteristics of the Functional Independence Measure in traumatic spinal cord injury. Arch Phys Med Rehabil 1999;80:1471-1476.
• Hamilton BB, Deutsch A, Russell C, Fiedler RC, Granger CV. Relation of disability costs to function: spinal cord injury. Arch Phys Med Rehabil 1999;80:385-391.
• Heinemann AW, Kirk P, Hastie BA Semik,P, Hamilton BB, Linacre JM, Wright BD, Granger C. Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury. Arch Phys Med Rehabil 1997;78:143-149.
• Masedo AI, Hanley M, Jensen MP, Ehde D, Cardenas DD. Reliability and validity of a self-report FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain. Am J Phys Med Rehabil 2005;84:167-176.

Klein-Bell Activities of Daily Living Scale (K-B Scale)

The K-B Scale is a generic instrument that can be used with persons with or without disability. It was developed to measure ADL independence in both adults and children.  Items are divided into six sub-dimensions: Mobility, Emergency Communication, Dressing, Elimination, Bathing/Hygiene, and Eating. The majority of items measure ADLs and others measure body function (bladder/bowel emptying and incontinence, chewing/swallowing food and liquids, verbalizing telephone messages).

Number of items: 170

Procedure/Administration: Each subtask on this performance oriented measure is scored as able to perform, unable to perform, or not applicable.

How scored: Subtask weights of 1, 2, or 3 are assigned to each subtask. In developing the weights, four factors were considers, including: importance to health, difficulty for non-disabled persons, time required to perform the task, and the burden of care-giving. Overall independence scores range from 0 to 313 (0%-100%).

Interpretability: Higher scores indicate greater independence.

Acceptability: The scale was not designed specifically for SCI subjects; therefore, items included in the scale may not be important for SCI populations.

Languages: N/a

Usability: N/a

Time to administer: 1-3 hours

Time to score: 15 minutes

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The K-B Scale divides each activity into its essential components to get a measure of basic ADL. This is advantageous over other known ADL scales as it makes it possible to detect problematic items within activities and thus helps to better identify rehabilitation treatment.
• The authors suggest using the scale as a method to generate discussion about goals they wish to achieve.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Dahlgren A, Karlsson A-K, Lundgren Nilsson Ã…, Fridén J, Claesson L. Activity performance and upper extremity function in cervical spinal cord injury patients according to the Klein-Bell ADL Scale. Spinal Cord 2007; 45: 475-484.
• Lynch KB, Bridle MJ. Validity of the Jebsen-Taylor Hand Function Test in Predicting Activities of Daily Living. The Occupational Therapy Journal of Research 1989; Volume 9, Number 5: 316-18.

Lawton Instrumental Activities of Daily Living scale (IADL)

This IADL scale was developed to assess the complex ADLs for older adults living in the community (Lawton & Brody 1969). It assesses a person’s ability to perform tasks such as using a telephone, doing laundry, and handling finances. Each item relies on either cognitive or physical function, though all require some degree of both.

Number of items: 8

Procedure/Administration: The scale can be administered with a written questionnaire or by interview. The patient or a family member or caregiver may provide answers. Responses to each of the eight items in the scale will vary ranging from independence in performing the activity to not performing the activity at all.

How scored: Responses range from 0 (unable or partially able) to 1 (able).  Alternatively, the level of independence can be reflected using a three point scale; 0=unable, 1=needs assistance or 2=independent.

Interpretability: Item responses are summed to derive a scale score with higher scores indicating great independence. 

Acceptability:  Only one study, with findings of weak construct validity has been performed to test the IADL psychometric properties among an SCI population

Languages: English

Usability: It is easy to administer and provides various response options for each item, thereby, enabling flexibility when scoring.

Time to administer: 1 minute

Time to score: N/a

Training required: N/a

Availability: www.abramsoncenter.org/pri/documents/iadl.pdf

Equipment required: N/a

Summary:

• The IADL measures more complex (instrumental) levels of functioning than other ADL instruments. The IADL scale is therefore likely to be more sensitive in detecting earlier, less severe dysfunction.
• The content of IADL measures often reflects specific cultural concerns. For example, British measures frequently include the ability to make a cup of tea. There is also potential for gender bias as the scale may overemphasize tasks customarily performed by women and thus overestimate dependency in men.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Lawton G, Lundgren-Nilsson A, Biering-Sorensen F, Tesio L, Slade A, Penta M, Grimby G, Ring H, Tennant A. Cross-cultural validity of FIM in spinal cord injury. Spinal Cord 2006; 44: 746-752.

Physical Activity Scale for Individuals with Physical Disabilities (PASIPD)

The PASIPD is a modified version of the 10 item Physical Activity Scale for the Elderly (PASE) (Washburn et al. 1993). It captures information about leisure, household, and work related physical activity over the preceding 7 days (Washburn et al. 2002). The PASIPD was developed targeting individuals with visual/auditory and locomotor/SCI disabilities. It solicits information about the frequency (number of days a week) and duration (daily hours) of current participation. The specific activity performed in each of these areas is also captured. The PASIPD assesses 5 distinct dimensions of physical activity: home repair, lawn and garden work, housework, vigorous sport and recreation, moderate sport and recreation, and occupation and transportation.

Number of items: 13

Procedure/Administration: Survey administered by mail, telephone, or in person. Individuals respond to 2 ordinally ranked responses. Frequency responses range from 1 (never) to 4 (often) while duration responses range from 1 (less than 1) hour to 4 (greater than 4 hours). 

How scored: The average hours per day for each item is multiplied by a MET value associated with the intensity of the activity and summing over items 2 through 13. Scores range from 0 (no activity) to >100 METS hr/day (very high).

Interpretability: N/a

Acceptability: Items were developed with disabled population in mind.

Languages: N/a

Usability: N/a

Time to administer: Approximately 15 minutes.

Time to score: Not mentioned, but can be complicated.

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The PASIPD has the potential to provide in-depth information about the degree of activity in the form of Metabolic Equivalents (METS hr/day) and or descriptive information about various activities individuals are performing as well as the frequency and duration of this activity.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol.1993 Feb;46:153-62.
• Washburn RA, Zhu W, McAuley E, Frogley M, Figoni SF. The Physical Activity Scale for Individuals With Physical Disabilities: Development and Evaluation. Arch Phys Med Rehabil 2002; 83: 193-200.

Quadriplegia Index of Function (QIF)

The QIF was developed in 1980 to provide a functional assessment that would be useful in documenting the small but clinically significant gains made by quadriplegics throughout in-patient rehabilitation (Gresham et al. 1986). This index assess transfers, grooming, bathing, feeding, dressing, wheelchair mobility, bed activities, bowel program, bladder program and understanding of personal care. The first 9 areas represent functional performance activities and the final area is a questionnaire - designed to assess the client’s understanding of skin care, nutrition, equipment medications and infections.

Number of items: 37

Procedure/Administration: Information is collected in an interview format. Scores are provided to give credit for being able to complete a portion of the task rather than the entire task.

How scored: Each category of functional performance is calculated according to weighted scores - Functional performance categories:  /180; Understanding of personal care: /20; Total:  200 /2 =  /100.  The functional performance categories are scored on a 5 point scale from 0 (dependent) to 4 (independent).

Interpretability: No information regarding interpretability of the scores (e.g.: norms or cut points) is provided.

Acceptability: The QIF was designed for the SCI population and specifically for individuals with tetraplegia. It has been tested on a total of 59 SCI subjects in two separate studies.

Languages: N/a

Usability: N/a

Time to administer:  Less than 30 minutes when the assessor is familiar with the measure.

Time to score: N/a

Training required: None

Availability: N/a

Equipment required: None

Summary: N/a

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Gresham GE, Labi ML, Dittmar SS, Hicks JT, Joyce SZ, Stehlik MA. The Quadriplegia Index of Function (QIF): sensitivity and reliability demonstrated in a study of thirty quadriplegic patients. Paraplegia 1986;24:38-44
• Yavuz N, Tezyurek M, Akyuz M. A comparison of two functional tests in quadriplegia: the quadriplegia index of function and the functional independence measure. Spinal Cord 1998;36:832-837.

Quadriplegia Index of Function (QIF) – Short Form

The QIF – SF was developed to provide a sensitive global functional scale for measuring gains in individuals with tetraplegia during rehabilitation. Items include: wash/dry hair, turn supine to side in bed, lower extremity dressing, open carton/jar, transfer from bed to wheelchair and lock wheelchair. These items were selected from five of the functional performance categories of self-care and mobility on the QIF in order to reduce item redundancies of the original 37-item version. 

Number of items: 6

Procedure/Administration: Information is collected in interview format. It is scored on a 5 point scale from 0 (dependent) to 4 (independent). 

How scored: Scores from the 6 items are summed and scores range from 0 to 24.

Interpretability: Higher scores indicate greater independence in key ADLs. Ceiling effects may be plausible for individuals with lower level injuries.

Acceptability: The QIF – Short Form is designed specifically for SCI population.

Languages: N/a

Usability: N/a

Time to administer: N/a

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary:

• The QIF – Short Form is more practical to use than the original QIF as the number of items have been reduced.

Psychometric Summary

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Marino RJ, Goin JE. Development of a short-form Quadriplegia Index of Function scale. Spinal Cord 1999;37:289-296.

Self Care Assessment Tool (SCAT)

The SCAT was developed by experienced clinicians to assess cognitive and functional skills required by individuals with an SCI below C7 to perform self-care (McFarland et al. 1992). Cognitive and functional skills are measured in eight self-care areas: bathing/grooming; nutritional management; medications; mobility/transfers/safety; skin management; bladder management; and bowel management.  For each area the clinician assesses the cognitive and functional skills. The items in the SCAT consider the use of physical assistance as well as assistive devices. The scale for each item is yes/no/not applicable.

Number of items: 81 (41 cognitive and 40 functional)

Procedure/Administration: The SCAT is an interviewer administered test. A cognitive and a functional subscale score can be calculated as well as an overall score, although no details are provided on how to calculate the scores. 

How scored: N/a

Interpretability: No standardized norms are available and no results were reported so it is difficult to make any comparisons. 

Acceptability: The SCAT was developed specifically for the SCI patient population whereas many other self-care measures have been developed for a broad range of health conditions. However, the SCAT does not appear to be widely used in either the clinical setting or in research.

Languages: N/a

Usability: The tool has been used in both the rehabilitation and community setting.

Time to administer: No information available.

Time to score: No information available.

Training required: None

Availability: For a copy, contact the authors of the original article (McFarland et al; 1992).

Equipment required: N/a

Summary: N/a

Psychometric Summary:      

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

* TR was assessed using Pearson correlation coefficients
** Validity was predictive validity (construct as no gold standard exists) and it was assessed by comparing pre-discharge score with 6 months post discharge score.

References

• McFarland SM, Sasser L, Boss BJ, Dickerson JL, Stelling JD. Self-care assessment tool for spinal cord injured persons. SCI Nursing 1992;9:111-116.

Self Reported Functional Measure (SRFM)

The 13 item Self Reported Functional Measure (SRFM) was developed to provide clinically useful information pertinent to the different levels of the disablement process.  It is suitable for people with SCI and was designed to correspond closely in wording, format, and scoring to the Functional Independence Measure (FIM). While the FIM provides seven levels of measurement of 13 motor functions (basic activities of daily living (ADL)) and measurements of cognitive and communication functions, the SRFM has four-level response categories to 13 items of basic ADL and 5 items of instrumental ADL.  (The cognitive and communications domains were excluded to difficulties with accurate self-report of these items.) 

Procedure: The SRFM is a self report tool that may be administered either in person or by mail. The 4-point scale is as follows: 4 = no extra time or help, 3 = extra time or special tool, 2 = some help, and 1 = total help or never do. Total scores are derived by summing the scores from each question.  

Advantages: The SRFM is a self-report tool that can be mailed to respondents. The SRFM has high test-retest reliability and excellent internal consistency. The SRFM total score was significantly correlated to the hours of daily assistance the responder required.  This scale has been adapted specifically for the SCI population from the FIM.

Limitations: Only one study has assessed the SRFM’s psychometric properties. The SRFM does not distinguish between needing maximum help to do an activity and never doing the activity. This may limit the usefulness of the responses in individuals who require maximum levels of assistance. No cut scores or norms are established.

Interpretability: Scores range from 13 to 52, with lower scores indicating greater need for assistance. No cut scores or normative values are available for this tool.

Acceptability:  The SRFM is comprehensible to persons with a fourth grade reading level. It can be completed in less than10 minutes. 

Feasibility: The SRFM is easily administered and scored. No specialized administration learning is required. A complete copy of the scale can be obtained in the paper by Hoenig et al., 1998.

Clinical Summary: The SRFM covers personal functioning such as moving around indoors and personal hygiene. The scores of the SRFM can indicate the amount of assistance (burden of care) an individual requires. This may be useful when monitoring treatment efficacy after rehabilitation or when the individual has returned to the community. With the development of the Spinal Cord Independence Measures, the use of the SRFM among SCI populations may be limited, however, there is no evidence to suggest the SRFM performs less adequately.

Psychometric Summary:

Note: +++ = Excellent; ++ = Adequate; + = Poor; IC=internal consistency; TR=test-retest

Skin Management Needs Assessment Checklist (SMNAC)

The SMNA (Berry et al. 2004), extracted from the Needs Assessment Checklist (Kenny & Hamilton 1999), was developed as a post discharge measure to assess client knowledge and ability to perform skin checks, pressure relief and prevention of skin breakdown.  It is based on the individual’s perception his/her ability to independently perform skin management activities.

Number of items: N/a

Procedure/Administration: The self-report measure requires individuals to demonstrate or, for an individual with a high lesion, instruct their personal care attendant to perform the activities. Each item on the SMNAC receives a score ranging from 0-3 (0-complete dependence; 1-mostly dependent; 2-moderately dependent; 3-complete independence) or N/A (not applicable, representing no rehabilitation need or goal to be identified).

How scored: The items are summed to generate a total score out of 36. The value reported is a proportion (client score/36).

Interpretability: Higher scores reflect greater independence. No risk specific scores or normative data is available at this time.

Acceptability: N/a

Languages: N/a

Usability: There is minimal patient burden however some embarrassment may be evident.

Time to administer: 20 minutes to administer and score

Time to score: None

Training required: None, however, experience with wound care may enhance tool use

Availability:  A copy can be obtained from the author.

Equipment required: None

Summary: The SMNAC provides SCI specific information related to skin management needs. Its score may be used to identify the problems for individuals living in the community to establish priorities and goal setting or to inform community health care professionals about a clients’ ability to manage skin management activities.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Berry C, Kennedy P, Hindson L. Internal consistency and responsiveness of the skin management needs assessment checklist post spinal cord injury. J Spinal Cord Med 2004;27:63-71.
• Keith RA, Lipsey MW. The role of theory in rehabilitation assessment, treatment and outcomes. In: Glueckauf RL, Sechrest LB, Bond GR, McDonel EC. (ed). Improving Assessment in Rehabilitation and Health. Sage Publications, Newbury Park, CA, 1993, p 33-60.
• Kennedy P, Hamilton LR. The needs assessment checklist: a clinical approach to measuring outcome.  Spinal Cord 1999;37:136-139.

Spinal Cord Injury Lifestyle Scale (SCILS)

The SCILS is a self-report measure of the frequency of health-related behaviour performance in individuals with SCI. The tool was designed to enable examination of the effectiveness of clinical and educational efforts for health maintenance and prevention of secondary impairments (Pruitt et al. 1998). The items were developed from a review of the literature on secondary impairments related to SCI.  In addition, expert clinicians (physician assistants, nurses and physiotherapists) generated items describing health related behaviours. Each item describes different health behaviours. The 5 subscales include: cardiovascular, genitourinary, neuromuscular, skin, and psychosocial.  Its’ purpose is to evaluate the effectiveness of clinical and educational efforts for health maintenance and the prevention of secondary impairments following SCI..

Number of items: 25

Procedure/Administration:  Data can be collected by pen and paper or through interview if the individual is unable to write. The frequency with which each behaviour has been performed over the past 3 months is rated using an ordinal scale where 4-‘almost always’, 3-‘frequently’, 2-‘sometimes’, 1-‘rarely’ and 0-‘never’. One item (genitourinary) is reverse scored.

How scored: A score is generated for each scale by totaling scores of each item using a 0-4 point scale. A total score is calculated by summing the 5 scale scores. Sub-scale scores may be used to identify/address specific areas of concern.

Interpretability: Higher total scores are intended to indicate better performance of behaviours which in turn promote health in individuals with SCI. The scores could be used for each sub-scale or as a tool for general overall health. There are no norms or reported cut scores.

Acceptability: Individuals with SCI participated in item elimination during tool development therefore the included items should resonate with the population.

Languages: English

Usability: N/a

Time to administer: 10-15 minutes

Time to score: 10-15 minutes

Training required: N/a

Availability: A copy is available from the authors.

Equipment required: N/a

Summary:

• Although the authors identified a comprehensive list of secondary impairments, only some of these impairments have been included in the tool. For example, some of the missed items include autonomic dysreflexia, deep vein thrombosis, pressure relief in bed, and adjustment to disability.

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Pruitt SD, Wahlgren DR, Epping-Jordan JE, Rossi AL. Health behavior in persons with spinal cord injury: development and initial validation of an outcome measure. Spinal Cord 1998;36:724-731

The Spinal Cord Independence Measure (SCIM)

The SCIM, now in its third iteration, is a new disability scale developed to specifically address the ability of SCI patients to accomplish ADLs (Catz et al. 1997). The SCIM assesses three areas:1) self-care (feeding, grooming, bathing, and dressing); 2) respiration and sphincter management and 3) mobility (bed and transfers and indoor/outdoor).

Number of items: 19

Procedure/Administration: Clinical staff scores the items based on the activities the patient is performing during the regular daily activities or as the patient reports in an interview.

How scored: Item scores are weighted related to the assumed clinical relevance. Scores are derived by adding up the items producing a total score (0 to 100) and/or subscale scores (self care: 0-20; respiration and sphincter management: 0-40; mobility 0-40).

Interpretability: Higher scores reflect higher levels of independence.

Acceptability: This is an SCI specific measure of basic functional independence.

Languages: English

Usability: Minimal staff/patient burden is required as the variables collected are important to patient care and reflect basic areas of patient concern.

Time to administer: 30-45 minutes to conduct and score.

Time to score: 30-45 minutes to conduct and score.

Training required: N/a

Availability: A copy of the SCIM III can be obtained from the article by Catz et al. (2007).

Equipment required: None

Summary:

• The SCIM is quickly becoming one of the best research tools within the SCI population and has high clinical relevance for the rehabilitation for individuals with either traumatic/non-traumatic and complete/incomplete SCI.
• Ceiling and floor effects (especially floor) may be an issue for individuals at either who have very high or low level lesions. 

Psychometric Summary:

Note: TR= Test re-test; IC= Internal Consistency; Inter-O=Inter-observer; Intra-O=Intra-observer; SS=Sensitivity/Specificity; N/a= No information.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

References

• Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM--spinal cord independence measure: a new disability scale for patients with spinal cord lesions. Spinal Cord 1997;35:850-856.
• Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. The spinal cord independence measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients. Spinal Cord 2001a;39:97-100.
• Catz A, Itzkovich M, Steinberg F, Philo O, Ring H, Ronen J, Spasser R, Gepstein R, Tamir A. The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure. Disabil Rehabil 2001b;23:263-268.
• Catz A, Itzkovich M, Steinberg F, Philo O, Ring H, Ronen J, Spasser R, Gepstein R, Tamir A. Disability assessment by a single rater or a team: a comparative study with the Catz-Itzkovich spinal cord independence measure. J Rehabil Med 2002;34:226-230.
• Catz A, Goldin D, Fishel B, Ronen J, Bluvshtein V, Gelernter I. Recovery of neurologic function following nontraumatic spinal cord lesions in Israel. Spine 2004;29:2278-2282.
• Catz A, Greenberg E, Itzkovich M, Bluvshtein V, Ronen J, Gelernter I. A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index. Arch Phys Med Rehabil 2004;85:399-404.
• Catz A, Itzkovich M, Tesio L, Biering-Sørensen F, Weeks C, Laramee M, Craven BC, Tonack M, Hitzig SL, Glazer E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, El Masry WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergstrom EM, Bluvshtein V, Ronen J. A multi-center International Study on the Spinal Cord Independence Measure, Version III: Rasch psychometric validation. Spinal Cord Resubmission requested 2006.
• Catz A, Itzkovich M, Tesio L, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, Tonack M, Hitzig SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, El Masry WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergstrom EM, Bluvshtein V, Ronen J. A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation. Spinal Cord 2007; 45: 275-291.
• Glass CA, Tesio L, Itzkovich M, Soni BM, Silva P, Mecci M, Chadwick R, et al. Spinal Cord Independence Measure, Version III: Applicability to the UK spinal cord injured population. J Rehabil Med 2009; 41: 723-728.
• Grijalva I, Guizar-Sahagun G, Castaneda-Hernandez G, Mino D, Maldonado-Julian H, Vidal-Cantu G, Ibarra A, Serra O, Salgado-Ceballos H, Arenas-Hernandez R. Efficacy and safety of 4-aminopyridine in patients with long-term spinal cord injury: a randomized, double-blind, placebo-controlled trial. Pharmacotherapy 2003;23:823-834.
• Itzkovich M, Tripolski M, Zeilig G, Ring H, Rosentul N, Ronen J, Spasser R, Gepstein R, Catz A. Rasch analysis of the Catz-Itzkovich spinal cord independence measure. Spinal Cord 2002;40:396-407.
• Itzkovich M, Tamir A, Philo O, Steinberg F, Ronen J, Spasser R, Gepstein R, Ring H, Catz A. Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation. Am J Phys Med Rehabil 2003;82:267-272.
• Itzkovich M, Catz A, Biering-Sørensen F. SCIM III Reliability And Validity: A Multi-Center International Study. ISCoS Meeting Oct 2005 Munich, Germany Abs 34/8 http://www.iscos.org.uk/index.html Accessed May 2, 2006
• Jackson AB, Dijkers M, DeVivo MJ, Poczatek RB. A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years. Arch Phys Med Rehabil 2004;85:1740-1748.
• McKinley WO, Seel RT, Gadi RK, Tewksbury MA. Nontraumatic vs. traumatic spinal cord injury: a rehabilitation outcome comparison. Am J Phys Med Rehabil 2001;80:693-699.
• Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking Index for spinal cord injury (WISCI): criterion validation. Spinal Cord 2005;43:27-33.
• Popovic MR, Thrasher TA, Adams ME, Takes V, Zivanovic V, Tonack MI. Functional electrical therapy: retraining grasping in spinal cord injury. Spinal Cord 2006;44:143-151.
• Ronen J, Itzkovich M, Bluvshtein V, Thaleisnik M, Goldin D, Gelernter I, David R, Gepstein R, Catz A. Length of stay in hospital following spinal cord lesions in Israel. Spinal Cord 2004;42:353-358.
• Scivoletto G, Morganti B, Ditunno P, Ditunno JF, Molinari M. Effects on age on spinal cord lesion patients' rehabilitation. Spinal Cord 2003;41:457-464.
• van Hedel HJA, Dietz V, and the EM-SCI Study Group. Walking during daily life can be validly and responsively assessed in subjects with a spinal cord injury. Neurorehabil Neural Repair 2009; 23: 117-124.
• van Hedel HJA for the EMSCI Study Group. Gait speed in relation to categories of functional ambulation after spinal cord injury. Neural Repair 2009; 23(4): 343-350.