A multi-center international study on the spinal cord independence measure, version IV: Rasch psychometric validation.

CONTEXT: The Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL). OBJECTIVE: To validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods. STUDY DESIGN: Multi-center cohort study. SETTING: Nineteen SCL units in 11 countries. METHODS: SCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis. RESULTS: The study included inpatients aged 16-87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6-6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable. CONCLUSIONS: Rasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Reliability Validity and Responsiveness of the Spinal Cord Independence Measure 4th Version in a Multicultural Setup.

OBJECTIVE: To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity. DESIGN: Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations. SETTING: A multicultural cohort from 19 spinal cord injury units in 11 countries. PARTICIPANTS: A total of 648 patients with spinal cord injury. INTERVENTION: Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge. MAIN OUTCOME MEASURES: SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness. RESULTS: Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (P<.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (P<.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons. CONCLUSIONS: The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

Performance of Everyday Occupations and Perceived Health of Spouses of Men With Spinal Cord Injury at Discharge and 6 Months Later.

STUDY DESIGN: An exploratory longitudinal study. OBJECTIVES: (a) Compare the occupational performance, and life satisfaction of spouses of men with SCI with those of spouses of healthy men, (b) compare the occupational performance, perceived health, and life satisfaction of spouses of men with SCI at discharge from inpatient rehabilitation and 6 months postdischarge; and (c) assess whether the functioning levels of men with SCI and the perceived mental health of the spouse, correlate with her occupational performance. SUMMARY OF BACKGROUND DATA: Spouses of men with spinal cord injury (SCI) report having symptoms of depression and anxiety. However, their ability to choose everyday occupations and perform them satisfactorily (occupational performance) was less studied. METHODS: Fifteen women spouses of men with SCI and 15 women spouses of healthy men participated. Study measures included four self-report questionnaires and the Occupational Performance History Interview that was analyzed quantitatively and measured occupational performance by three components: occupational identity, competence, and settings. RESULTS: Occupational performance and life satisfaction of caregivers were lower than those of spouses of healthy men and did not significantly change over 6 months. However, they had higher scores on physical, mental, and general health 6 months postdischarge than at discharge. Mental health of the spouse correlated with her occupational identity. CONCLUSION: It is recommended that rehabilitation intervention focus not only on patients with SCI, but also on their healthy spouses to promote their occupational performance, health, and well-being. LEVEL OF EVIDENCE: 3.

An international age- and gender-controlled model for the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI).

Background. A quadratic formula of the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) has previously been published. This formula was based on a model of Spinal Cord Independence Measure (SCIM95), the 95th percentile of the SCIM III values, which correspond with the American Spinal Injury Association Motor Scores (AMS) of SCI patients. Objective. To further develop the original formula. Setting. Spinal cord injury centers from 6 countries and the Statistical Laboratory, Tel-Aviv University, Israel. Methods. SCIM95 of 661 SCI patients was modeled, using a quantile regression with or without adjustment for age and gender, to calculate SCI-ARMI values. SCI-ARMI gain during rehabilitation and its correlations were examined. Results. A new quadratic SCIM95 model was created. This resembled the previously published model, which yielded similar SCIM95 values in all the countries, after adjustment for age and gender. Without this adjustment, however, only 86% of the non-Israeli SCIM III observations were lower than those SCIM95 values (P < .0001). Adding the variables age and gender to the new model affected the SCIM95 value significantly (P < .04). Adding country information did not add a significant effect (P > .1). SCI-ARMI gain was positive (38.8 ± 22 points, P < .0001) and correlated weakly with admission age and AMS. Conclusions. The original quadratic SCI-ARMI formula is valid for an international population after adjustment for age and gender. The new formula considers more factors that affect functional ability following SCI.

Spinal Cord Independence Measure, version III: applicability to the UK spinal cord injured population.

OBJECTIVE: To examine the validity, reliability and usefulness of the Spinal Cord Independence Measure for the UK spinal cord injury population. DESIGN: Multi-centre cohort study. SETTING: Four UK regional spinal cord injury centres. SUBJECTS: Eighty-six people with spinal cord injury. INTERVENTIONS: Spinal Cord Independence Measure and Functional Independence Measure on admission analysed using inferential statistics, and Rasch analysis of Spinal Cord Independence Measure. MAIN OUTCOME MEASURES: Internal consistency, inter-rater reliability, discriminant validity; Spinal Cord Independence Measure subscale match between distribution of item difficulty and patient ability measurements; reliability of patient ability measures; fit of data to Rasch model; unidimensionality of subscales; hierarchical ordering of categories within items; differential item functioning across patient groups. RESULTS: Scale reliability (kappa coefficients range 0.491-0.835; (p < 0.001)), internal consistency (Cronbach's alpha 0.770 and 0.780 for raters), and validity (Pearson correlation; p < 0.01) were all significant. Spinal Cord Independence Measure subscales compatible with stringent Rasch requirements; mean infit indices high; distinct strata of abilities identified; most thresholds ordered; item hierarchy stable across clinical groups and centres. Misfit and differences in item hierarchy identified. Difficulties assessing central cord injuries highlighted. CONCLUSION: Conventional statistical and Rasch analyses justify the use of the Spinal Cord Independence Measure in clinical practice and research in the UK. Cross-cultural validity may be further improved.

Spinal Cord Independence Measure: comprehensive ability rating scale for the spinal cord lesion patient.

The Spinal Cord Independence Measure (SCIM) is, at present, the only comprehensive rating scale that measures the ability of patients with spinal cord lesions (SCL) to perform everyday tasks according to their value for the patient. This article describes the scale and its scoring techniques, presents the purposes for which SCIM is used, and details its advantages for patients with SCL. Findings of an international multicenter study supported the validity and reliability of its third version, despite intercultural differences, and demonstrated its superior sensitivity to changes in function compared with the Functional Independence Measure. SCIM can be used in patients with SCL for ability assessment, as a compact guide for determining certain treatment goals, and for outcome assessment following interventions designed to promote recovery.

Survey on the use of function assessment and outcome measures in rehabilitation facilities in Israel (SUFA 2004).

BACKGROUND: Measurement of function is an essential component of routine rehabilitation work (mainly for quantifying function at different phases in the rehabilitation process), rehabilitation policy (admission and discharge criteria, length of stay in rehabilitation), goal setting, and outcome measurement. OBJECTIVE: To explore the scope of the scales used for function assessment by the various disciplines of rehabilitation medicine in rehabilitation facilities. METHOD: A structured questionnaire was sent to 36 rehabilitation facilities. Respondents were asked to specify the scales they use for functional assessment for each of 15 selected pathologies. Also examined were satisfaction with the scales, as well as the existence of a computerized database of routine function assessment in the facility and the willingness to create a national agreed "common data set" of the assessments. RESULTS: The general response rate was 86.1% (31 of 36 questionnaires were returned). For the sake of data presentation, rehabilitation facilities were classified into four categories: general, geriatric, pediatric, and community. Most facilities performed function assessment using a total of 125 scales. Heterogeneity was found between facilities and between pathologies. The highest number of scales was found in the area of neurologic pathologies. For most pathologies, assessment of impairment was used more than assessment of disability. Most facilities in the survey did not have a computerized database of function assessments. CONCLUSIONS: A common data set of function assessments in everyday clinical work would ensure standardization without necessarily limiting the use of additional scales and at the same time significantly minimize the current heterogeneity.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis.

PURPOSE: To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel. METHOD: This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA. RESULTS: Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay. CONCLUSIONS: Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis.

PURPOSE: To evaluate outcome measures and the factors affecting them in patients treated between 1,962 and 2,000 at Loewenstein Rehabilitation Hospital, Israel. METHOD: This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA. RESULTS: Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay. CONCLUSIONS: Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index.

OBJECTIVES: To introduce a new measure of disability weighted for the neurologic deficit in patients with spinal cord lesions and to examine the effect on the instrument of being in rehabilitation. DESIGN: Development of instrument and preliminary comparative before-after study. SETTING: Spinal department in a rehabilitation hospital in Israel. PARTICIPANTS: Seventy-nine patients with spinal cord lesions. INTERVENTIONS: Patients were repeatedly assessed during rehabilitation with the American Spinal Injury Association Impairment Scale (AIS) to measure neurologic motor impairment and with the Spinal Cord Independence Measure (SCIM-II) to measure disability. Scores of the 2 assessments were combined to create the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI). MAIN OUTCOME MEASURES: A preliminary formula for the calculation of SCI-ARMI using the individual patients' SCIM-II and AIS motor scores and changes in SCI-ARMI values through rehabilitation. RESULTS: The highest observed SCIM-II scores at patients' AIS level correlated highly with the AIS motor scores (r=.96, P<.01). A regression performed for this linear relationship resulted in a preliminary SCI-ARMI formula. The calculated SCI-ARMI values improved during rehabilitation irrespective of patient age, gender, lesion level, or lesion severity (P<.001). CONCLUSIONS: The preliminary version of the SCI-ARMI can be used to assess quantitatively changes in functional ability, isolating them from the effect of neurologic changes.

Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation.

OBJECTIVE: To examine the reliability of assessment with the Catz-Itzkovich Spinal Cord Independence Measure II (SCIM II) by interview and compare the findings with assessment by observation. DESIGN: In a cohort, comparative study, 28 inpatients with spinal cord lesions were assessed by two nurses using the Catz-Itzkovich SCIM II (interview) and by a multidisciplinary team (observation). RESULTS: Total agreement between interviewers ranged from 50% to 80% (Kappa coefficients 0.40-0.60). Pearson's coefficients of the correlation between scores obtained for the various SCIM subscales by interview or observation were 0.765-0.940 (P < 0.0001). The differences in mean scores obtained between the interview and observation methods were small and not statistically significant for most of the subscales. CONCLUSIONS: The results support the reliability of the Catz-Itzkovich SCIM assessment by interview and show it to be comparable with assessment by observation. The SCIM II interview may serve as an accurate measure of daily function in patients with spinal cord injury. However, with the sample of the study being relatively small, a larger scale examination is needed to generalize the results.

Disability assessment by a single rater or a team: a comparative study with the Catz-Itzkovich spinal cord independence measure.

The Catz-Itzkovich Spinal Cord Independence Measure was found to be reliable and more sensitive than the FIM to functional changes, when used by a multidisciplinary team. This study was performed to find out whether assessment may be similar when done by a single rater. Twenty-eight patients with spinal cord lesions participated in the study, in which examinations performed within a week by a single nurse or a team were compared for correlation, differences and agreement. The team members scored their relevant fields. A significant correlation was found between the nurse's scoring and that of physiotherapists and occupational therapists (r = 0.82-0.94; p < 0.0001), and the differences between the mean scores were small. The agreement between raters was modest, however (total agreement 38-90%, Kappa 0.17-0.73). It was concluded that although disability assessment performed by a single nurse may not be as accurate as by a multidisciplinary team, it could be reliable and valid.

[SCIM--spinal cord independence measure (version II): sensitivity to functional changes].

Until recently, the functional ability of patients with spinal cord lesions (SCL) was assessed by standardized scales designed for various disabilities. However, these scales have either a relatively low sensitivity to changes in the functions that are most important for SCL patients or a limited suitability for a specific SCL subgroup. To counter this problem the team of the Spinal Department of Loewenstein Rehabilitation Hospital developed the Spinal Cord Independence Measure (SCIM), which is specific for SCL patients, adjusts for disadvantages of earlier scales, and is user-friendly. It was found to be reliable and more sensitive to functional changes in SCL patients than the Functional Independence Measure (FIM), the most often used disability scale today. A second version (SCIM II) was constructed with improved phrasing of some of the components. It too, was found reliable, even more than the original version for certain functions. The present study examined the sensitivity of the SCIM II to changes in function in SCL patients compared to the FIM. Twenty-six patients with SCL underwent sequential SCIM II and FIM examinations during hospitalization for rehabilitation. A high correlation was found between the total scores of the two scales (r = 0.915; p < 0.0001). The mean change in function score from the first to the last examination was significantly larger with the SCIM II than with the FIM (p < 0.04), and the rate of detection of functional change was usually higher with the SCIM II. The advantage of the SCIM II over the FIM in detecting functional changes was evident in areas in which the two scales differ substantially. These results support the validity of the SCIM II. Studies with larger groups in different countries and cultures are still needed before the scale can be applied on an international basis.