Activity Card Sort (ACS)

Evidence Reviewed as of before: 06-04-2011
Author(s)*: Annabel McDermott
Editor(s): Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Professor Carolyn Baum

Purpose

The Activity Card Sort (ACS) is an interview-based tool used to measure an individual’s participation in instrumental, leisure and social activities. The ACS can be used to gain information regarding a client’s activity patterns in order to support development of routines and participation in meaningful activity.

In-Depth Review

Purpose of the measure

The Activity Card Sort (ACS) measures an individual’s occupational performance. The ACS was originally developed in 1995 by Baum in response to the need to measure engagement in activities of older persons with Alzheimer’s disease (Eriksson et al., in press; Schreuer, Rimmerman & Sachs, 2006). The ACS was revised by Baum and Edwards in 2001 to include more activities for a broader population of older adults in a variety of settings. It can be used to monitor change in activity participation over time as a means of comparing premorbid engagement in activities with current activity participation (Baum, Perlmutter & Edwards, 2000; Hartman-Maeir, Soroker, Ring, Avni & Katz, 2007). The ACS is useful for initial assessment, goal setting and intervention planning or to monitor activity following onset of illness (Albert, Bear-Lehman & Burkhardt, 2009; Chan, Chung & Packer, 2006; Packer, Boshoff & DeJonge, 2008).

The ACS also provides information regarding factors such as:

  • Creating an occupational history
  • Recording changes in activity participation due to a chronic health condition, a stroke or aging.

The ACS does not provide information regarding factors such as:

  • Length of time spent engaged in activities
  • Frequency of participation
  • Social interactions during activity participation
  • Difficulty experienced while performing an activity (Baum et al., 2000; Katz, Karpin, Lak, Furman & Hartman-Meier, 2003)

Available versions

The Activity Card Sort, 2nd Edition has three versions:

  • Community Living version for community-dwelling older adults
  • Institutional version for older adults in a hospital, skilled nursing or rehabilitation hospital
  • Recovery version for older adults recovering from an injury or disease.

Each version has the same set of photographs but uses different sorting strategies (Chan et al., 2006; Packer et al., 2008).

The original ACS has been modified to suit populations in Hong Kong, Israel, Puerto Rico, The Netherlands, Korea, Singapore and Australia (Chan et al., 2006; Erickkson et al., in press; Katz et al., 2003; Packer et al., 2008), and a checklist version has also been created (Everard, Lach, Fisher & Baum, 2000).

Alternate versions of the ACS are used for research and clinical purposes (Erickkson et al., in press; Katz et al., 2003). The institutional version is useful for developing intervention goals with a client and the recovering version can be used to monitor change in activity (Law, Baum & Dunn, 2005).

Features of the measure

Items:

The ACS uses a sorting methodology to assess activity participation. The original version of the ACS consisted of photographs of adults performing a variety of social, instrumental and leisure activities. The Activity Card Sort, 2nd Edition (Baum & Edwards, 2001, 2008) consists of 89 activities across instrumental, low-physical-demand leisure, high-physical-demand leisure and social domains of human occupation.

The individual sorts the picture cards according to their engagement in each activity. Sort categories vary according to the version used:

Healthy older adult version:

  1. Never done
  2. Not done as an older adult
  3. Do now
  4. Do less
  5. Given up

Institutional version:

  • Done prior to illness
  • Not done

Recovering version:

  • Not done before illness or injury
  • Continued to due after illness or injury
  • Do less after illness or injury
  • Gave up due to illness or injury
  • Beginning to do again (Baum & Edwards, 2008; Law et al., 2005).

Description of tasks:

The participant views photographs that depict an individual performing an activity and sorts these photographs into piles that represent their own level of engagement in the activity.

Following traditional use of the measure, the clinician can then support the individual to identify the five most important activities from the list and explore factors that are limiting the individual’s engagement in those activities, as a means of facilitating goal setting and intervention planning (Chan et al., 2006).

What to consider before beginning:

The ACS can be used with individual’s caregiver in the event of cognitive difficulties (Baum et al., 2000; Katz et al., 2003).

Scoring and Score Interpretation:

The individual sorts the picture cards into categories, which vary according to the version used (see above). The clinician calculates a Retained Activity Score by dividing the sum total of current activities by the sum total of previous activities:

Current activities / Previous activities = Retained Activity Score

The Retained Activity Score ranges from 0-100 and therefore reflects the percentage of activities the person currently participates in, compared to premorbid involvement (Hartman-Maeir et al, 2003, 2007). A higher score reflects better maintenance of pre-stroke activity (Edwards et al., 2006). A score of 100 indicates that the individual has re-engaged in all premorbid activities, while a score of 0 indicates that the individual has not re-engaged in any premorbid activities, nor introduced any new activities into his/her daily life (Lyons, Li, Tosteson, Meehan & Ahles, 2010).

The amount of activities the individual has abandoned is calculated as an inverse of the Retained Activity Score:

1 – Retained Activity Score x 100 = Activity loss

Time:

The ACS takes approximately 20 – 30 minutes to administer.

Training requirements:

The ACS can be used by occupational therapists. No special training is required.

Subscales:

N/A

Equipment:

In addition to the photographs, the ACS includes:

  • Test description and methodology
  • Test development, validation and reliability
  • Administration and scoring instructions
  • Examples of test utility
  • References
  • Easy-to-use sample forms on CD-ROM.

Alternative forms of the Assessment

Everard et al. (2000) developed a modified checklist version of the ACS. The Activity Checklist contains 55 items in the four domains of instrumental, social, low-demand physical leisure and high-demand physical leisure activities. The Activity Checklist gathers information regarding an individual’s activity maintenance and engagement using the categories: (i) have never done the activity; (ii) have given up the activity; (iii) do the activity less often; or (iv) doing now (Edwards, Hahn & Dromerick, 2005). Frequency of participation and need for assistance are also recorded.

Katz et al. (2003) developed a version of the ACS to suit an Israeli population. This version has 88 picture cards with photographs that represent different ethnic groups. Two activities from the original version were removed and eight culturally-relevant activities were added. The activities are organized within the four domains of IADLS (21 pictures), social-cultural activities (21 pictures), low-physical leisure activities (27 pictures) and high-physical leisure activities (19 pictures).

Packer et al. (2008) developed a version of the ACS to suit an Australian population. The ACS-Australia includes 82 activities, 12 of which are unique to the Australian version. activities are organized according to three domains of household (12 activities), social/educational (24 activities) and leisure (46 activities).

Chan et al. (2006) developed a version of the ACS to suit a Hong Kong population, which resulted in a final list of 65 activities relevant to Hong Kong Chinese elderly people.

Orellano (2008) developed a version of the ACS for a Puerto Rican population that comprised 82 activity cards relevant to the Puerto Rican lifestyle.

Versions of the ACS have also been developed for Korea, Singapore and the Netherlands, which include 79, 85 and 79 activities respectively (Eriksson et al., in press).

Client suitability

Can be used with:

  • Healthy elderly adults (Erickkson et al., in press)
  • Older adults facing disability transitions (Albert et al., 2009)
  • Individuals with Alzheimer’s Disease (Baum et al., 2000)
  • Individuals with Multiple Sclerosis (Katz et al., 2003)
  • Individuals following stem cell transplantation (Lyons et al., 2010)
  • Individuals with cognitive loss or dementia (Baum, 1995; Erickkson et al., in press; Law et al., 2005)
  • Individuals with cancer (Erickkson et al., in press)
  • Individuals with PTSD (Erickkson et al., in press)
  • Individuals who have speech difficulties (Law et al., 2005)
  • Individuals with limited English language (Law et al., 2005)
  • The caregiver or family member of the patient (Law et al., 2005).
  • The ACS can be adapted for use with different cultures by modifying the pictures to be more culturally relevant, while maintaining the methodology of the measure (Katz et al., 2003).

Should not be used with:

  • N/A

In what languages is the measure available?

Languages of the measure

  • English
  • Hebrew
  • Spanish
  • Korean
  • Chinese
  • Dutch

The ACS has been validated for use in the US, Israel, Australia, Hong Kong, Singapore, Puerto Rico and Korea (Erickkson et al., in press).

Summary

What does the tool measure? Activity participation
What types of clients can the tool be used for? Older individuals who have experienced change in their activity participation as a result of onset of illness
Is this a screening or assessment tool? Assessment tool
The ACS can also be used for goal setting and monitoring activity participation as a measure of function/well-being over time.
Time to administer 20 – 30 minutes
Versions ACS Community Version (US)
ACS Institutional Version (US)
ACS Recovery Version (US)
Activity Checklist (US)
ACS (Israeli version)
ACS – Australia
ACS – Hong Kong
ACS – Korean
ACS – Puerto Rican
ACS – Singapore
ACS – The Netherlands
Other Languages Hebrew, Spanish, Korean, Chinese and Dutch
Measurement Properties
Reliability Internal consistency:
– Two studies examined the Pearson’s correlation.
– One study reported excellent Cronbach’s alpha.
– One study reported adequate to excellent Cronbach’s alpha.
Test-retest:
– One study indicated excellent one-week test-retest reliability of the ACS US version.
– One study reported excellent test-retest reliability of the ACS (checklist version).
– One study reported excellent two-week test-retest reliability of the ACS-HK using the ICC.
– One study reported excellent test-retest reliability of the PR-ACS using the ICC.
Intra-rater:
No studies have examined the intra-rater reliability of the ACS.
Inter-rater:
No studies have examined the inter-rater reliability of the ACS.
Validity Content:
– The ACS US version was developed in consultation with two groups of older adults living in the United States.
– Subsequent versions of the ACS were developed based on the ACS US version and/or culturally-relevant activity lists, questionnaires or time-use surveys. All versions were reviewed by expert panels of healthy older adults and some versions were also reviewed by specialist health professionals.
Criterion:
Concurrent:
One study reported excellent concurrent validity between the ACS US version and the ACS (checklist version).
Predictive:
– No studies have reported on the predictive validity of the ACS.
– One study reported adequate concurrent validity between the ACS (Israeli version) and the Occupational Questionnaire.
– One study reported adequate concurrent validity between the ACS-Aus and the Adelaide Activities Profile.
Construct:
One study reported satisfactory Validity of the original ACS to measure previous activity engagement in a sample of individuals with Alzheimer’s disease.
Convergent/Discriminant:
– Two studies investigated convergent validity of the ACS US version. A significant association was reported with the Reintegration to Normal Living Index (RNLI). Significant correlations were reported with SF-12 factors.
– One study reported adequate correlations between the ACS-Aus and the Personal Well-being Index (PWI).
– One study reported excellent correlations between the ACS-HK and the Comprehensive Quality of Life scale (ComQoL).
– One study reported excellent convergent validity between the PR-ACS and the Puerto Rican version of the RAND 36-Short Form Health Survey.
Known Groups:
– Two studies regarding the ACS (Israeli version) have reported satisfactory to excellent Validity to differentiate among groups according to age, illness and carer roles, and satisfactory Validity to identify differences between groups of young and older adults.
– One study reported excellent Validity of the ACS-HK to discriminate between clients presenting with different functional abilities.
– One study reported satisfactory Validity of the PR-ACS to discriminate between clients presenting with different levels of function.
– One study reported satisfactory discriminative Validity of the ACS-Aus.
Floor/Ceiling Effects N/A
Sensitivity / Specificity No studies have explored the Sensitivity/specificity of the ACS.
Does the tool detect change in patients? Yes – the ACS detects change in an individual’s participation in Activities
Acceptability Law et al. (2005) reported that the ACS US version is non-threatening and easy to understand. Katz et al. (2003) reported that the ACS (Israeli version) is user-friendly.
Feasibility Law et al. (2005) reported that the ACS US version can be modified to suit the target audience. Katz et al. (2003) reported that the ACS (Israeli version) is suitable for individuals with language difficulties.
How to obtain the tool? The ACS can be purchased from the AOTA online store: http://www.aota.org.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the assessment. Twelve articles have been reviewed, although studies relate to different versions of the Activity Card Sort.

Reliability

Internal Consistency:
Katz et al. (2003) examined the Internal Consistency of the ACS (Israeli version) in 263 participants across five groups: healthy adults aged 50 – 65 (n=61); healthy older adults aged over 65 (n=61); spouses/caregivers of people with Alzheimer’s disease (n=40); people with Multiple Sclerosis (n=45); and people 1-year post-stroke (n=56). Internal Consistency of the ACS (Israeli version), as calculated using Cronbach’s Coefficient Alpha was excellent for Instrumental Activities of Daily Living (α=0.82) and social-cultural Activities (α=0.80) but poor for low-physical leisure Activities (α=0.66) and high-physical leisure Activities (α=0.61). Internal Consistency of both low and high physical leisure Activities combined was adequate (α=0.77), which the authors considered may have been due to the larger number of items (52 collectively: 35 low-physical-demand Activities and 17 high-physical-demand Activities).

Sachs and Josman (2003) investigated correlations between demographic variables and mean scores of the ACS (Israeli version) in two age groups of young adults (mean age of 23.3 years, n=53) and older adults (mean age of 78.2 years, n=131). Using domains different to those of the original ACS, Pearson’s correlation was calculated for five student group factors of instrumental Activities of daily living (α =0.84), maintenance (α =0.79), leisure (α =0.81), demanding leisure (α=0.83) and social recreation (α =0.73). The social recreation domain showed significant correlations with IADL, leisure and demanding leisure factors domains. Pearson’s correlation was calculated for four elderly group factors of IADL (α =0.75), maintenance (α =0.90), leisure (α=0.70) and demanding leisure (α =0.86).

Chan et al. (2006) examined the Internal Consistency of the ACS-HK in a group of 60 elderly individuals (mean age 74 years) who had experienced a stroke a minimum of 6 months prior. Internal Consistency, calculated using Cronbach’s alpha, was excellent (α= 0.89).

Orellano (2008) examined Internal Consistency of the PR-ACS in a group of healthy older adults (n=106) and a group of adults with Multiple Sclerosis (n=40). Internal Consistency, calculated using Cronbach’s alpha, was excellent for the combined sample and the healthy older adult group (r=0.91), and was adequate for the group of individuals with multiple sclerosis (r=0.77).

Test-retest:
One-week test-retest reliability of the ACS US version in a community dwelling sample (n=20) was excellent (0.897) (Baum & Edwards, 2001). Lyons et al. (2010) noted that similar results have been reported for 14-day and 30-day test-retest reliability.

Everard et al. (2000) examined the test-retest reliability of the ACS (checklist version) on a sample of 20 community-dwelling older adults. Excellent test-retest reliability was found for all categories after 74 days (IADL, 0.95; social, 0.83; low-demand leisure, 0.91; and high demand leisure, 0.88).

Chan et al. (2006) examined test-retest reliability of the ACS-HK in two groups of elderly individuals who had experienced a stroke a minimum of 6 months prior (less active group, n=30; more active group, n=30). Two-week test-retest reliability, as calculated using the intra-class correlation coefficient was excellent for the total group (ICC=0.98). Individual group analysis also revealed excellent test-retest reliability for both groups (less active group ICC=0.91; more active group ICC=0.96).

Orellano (2008) examined test-retest reliability of the PR-ACS in a group of healthy older adults (n=106) and a group of adults with Multiple Sclerosis (n=40). test-retest reliability, as calculated using the intra-class correlation coefficient was excellent (ICC=0.82).

Intra-rater:
Intra-rater reliability has not yet been examined.

Inter-rater:
Inter-rater reliability has not yet been examined.

Validity

Content:
The original version of the ACS was shown to two groups of older adults living in the United States (first sample n=120; second sample n=40). Feedback obtained from the sample groups resulted in the inclusion of another 7 Activities, increasing the number of Activities to 80 (Law et al., 2005).

The ACS (Israeli version) was developed by modifying a translated version of the ACS US in consultation with a convenience sample of healthy adults and older adults (n=50). The final Activities were photographed to depict individuals of different ethnic groups represented within the Israeli population (Katz et al., 2003).

The PR ACS and ACS – Singapore were developed using a translated version of the ACS US, in consultation with a convenience sample of healthy older adults from Puerto Rico and Singapore (respectively). The PR ACS was also reviewed by an expert panel. The resultant selection of culturally-relevant Activities was re-photographed to depict individuals from the respective populations (Erikkson et al., in press).

The ACS – HK was developed from a list of generationally- and culturally-relevant Activities, which was reviewed by two successive expert panels of community-dwelling older adults (first sample n=15; second sample n=15) and a purposive sample of geriatric-specialist healthcare professionals (n=5). The final 65 Activities are represented in photographs of older adults performing the tasks in Hong Kong (Chan et al., 2006).

The ACS – Netherlands was developed from a questionnaire completed by a sample of older adults regarding common Activities and perceived importance of Activities (Erikkson et al., in press). The resultant Activities were depicted using photographs of local individuals. The ACS – Netherlands was pilot-tested with specialist health care professionals and elderly patients (Erikkson et al., in press).

The ACS – Australia was developed by a two-round Delphi Survey method with a sample of older Australian adults (n=54), using Activities from the US and Israeli versions and information from time diaries regarding common daily Activities (Packer et al. 2008).

The ACS – Korea was developed using information from a literature review and a time-use survey. The resultant list of Activities was evaluated and refined by a panel of experts (Erikkson et al., in press).

Criterion:
Concurrent :
Everard et al. (2000) conducted a comparison of the original ACS with the Activity Checklist on a pilot sample of 20 community-dwelling older adults. Excellent concurrent validity was reported between the original and checklist versions of the ACS (instrumental: 0.90; social: 0.78; low-demand leisure: 0.82; high-demand leisure: 0.72).

Katz et al. (2003) assessed the concurrent validity of the ACS (Israeli version) category “doing now” by comparison with the Occupational Questionnaire in 263 adults within five groups including healthy adults aged 50 – 65, healthy older adults aged over 65, spouses/caregivers of people with Alzheimer’s disease, people with Multiple Sclerosis and people 1-year post-stroke. Results indicated adequate concurrent validity (r=0.54), as calculated using Pearson correlation coefficient.

Doney & Packer (2008) assessed the concurrent validity of the ACS-Aus in 93 metropolitan-based adults aged 60 to 95 years. As there is no gold standard for comparison, the authors assessed the direction, strength and significance of the correlation between the Current (retained) Activity Level scores of the ACS-Aus and the Adelaide Activities Profile. A significant, adequate correlation (r=0.434, P=0.000) was found using Pearson-product moment analysis.

Predictive:
No studies have reported on the predictive validity of the ACS.

Construct:
Baum (1995) examined the validity of the original ACS with a sample of individuals with varying stages of Alzheimer’s disease (n=60). Scores of previous activity level did not differ significantly across the stages of the disease (F=0.66, p=0.419), indicating that the ACS was a valid measure of previous activity engagement.

Convergent/Discriminant :
Everard et al. (2000) examined the relationship between engagement and functioning using the ACS and the SF-12 with a sample of 244 community-dwelling adults aged 65 years and older. A significant positive association was seen between physical health and maintenance of instrumental Activities (p=0.006), social Activities (p=0.0001) and high demand leisure Activities (p=0.0001). A significant positive association was seen between mental health and maintenance of low-demand leisure Activities (p=0.0001) only. A significant negative association was found between physical health and maintenance of low-demand leisure Activities (p=0.015).

Edwards et al. (2006) examined the relationship between life satisfaction and participation using the Reintegration to Normal Living Index (RNLI) and ACS (percentage of retained pre-stroke Activities) with a sample of patients with stroke (n=219). An association was seen between life satisfaction and participation in meaningful activity (β=0.14, p=0.001).

Doney & Packer (2008) assessed the convergent validity of the ACS-Aus by comparison with the Personal Well-being Index (PWI) in 93 metropolitan-based adults aged 60 to 95 years. convergent validity between the ACS-Aus current activity level scores and the PWI total score was calculated using Pearson correlation coefficient and was found to be adequate (r=0.354, P=0.01), indicating a positive relationship between participation and well-being. The authors noted that this correlation was likely weakened by a potential ceiling effect from the PWI as many participants rated an extremely high quality of life despite normal distribution of the measure.

Chan et al. (2006) evaluated the convergent validity of the ACS-HK by comparison with the Comprehensive Quality of Life scale (ComQoL) in 60 elderly adults (mean age 74 years) who had experienced a stroke a minimum of 6 months prior. convergent validity as calculated by Pearson’s correlation coefficients, was excellent (r=0.86, p=0.00), indicating a significant positive relationship between retained activity as measured by the ACS-HK and quality of life as measured by the ComQoL.

Orellano (2008) evaluated the convergent validity of the PR-ACS by comparison with the Puerto Rican version of the RAND 36-Short Form Health Survey in healthy older adults (n=106) and adults with Multiple Sclerosis (n=40). convergent validity, as calculated by Pearson’s correlation coefficients, was excellent (r=0.66, p=0.00).

Known Group:
Sachs and Josman (2003) reported satisfactory discriminative validity of the ACS (Israeli version), to identify differences between groups of young and older adults.

Katz et al. (2003) examined the construct validity of the ACS (Israeli version) in five groups including: healthy adults aged 50 – 65 (n=61); healthy older adults aged over 65 (n=61); spouses/caregivers of people with Alzheimer’s disease (n=40); people with Multiple Sclerosis (n=45); and people 1-year post-stroke (n=56). The mean Retained Activity (RAC) scores and Current Activity Level (CAL) scores were compared by one-way ANOVA. Significant group effects (p<0.0001) were found between groups on all activity areas (IADL, social-cultural Activities, low-physical Activities, high-physical Activities and totals), indicating excellent construct validity to differentiate among groups according to age, illness and carer roles. Post hoc (Scheffe) tests showed significant differences between most groups. Specific to the stroke group, post hoc analysis indicated scores were not significantly different on social-cultural, low-physical or high-physical leisure Activities compared to caregivers, and on high-physical leisure Activities compared to individuals with multiple sclerosis.

Chan et al. (2006) examined the construct validity of the ACS-HK in two groups of elderly individuals who had experienced a stroke a minimum of 6 months prior (less active group, n=30; more active group, n=30). Independent t tests were used to compare mean Retained Activity Scores between the two groups. Significant group differences were found (t=-14.24, p=0.00), with the less active’ group demonstrating significantly lower level of retained activity than the more active’ group. These results indicate that the ACS-HK is able to discriminate between clients presenting with different functional abilities.

Orellano (2008) examined known-group validity of the PR-ACS in a group of healthy older adults (n=106) and a group of adults with Multiple Sclerosis (n=40) and reported that the PR-ACS is able to differentiate between clients with different levels of function (t=0.86; p=0.00).

Doney & Packer (2008) reported strong discriminative validity of the ACS-Aus by comparing current Retained Activity Scores between a younger group of adults aged 60-75 years (n=48) and an older group of adults aged 76-95 years (n=45) living within a metropolitan area. A significant difference was found between the two groups (P=0.000) using independent t-test analysis. Power greater than 90% was revealed by post-hoc power analysis.

Responsiveness

No studies have examined the responsiveness of the ACS.

References

  • Albert, S. M., Bear-Lehman, J., & Burkhardt, A. (2009). Lifestyle-adjusted function: Variation beyond BADL and IADL competencies. The Gerontologist, 49, 767-777.
  • Baum, C. M. (1995). The contribution of occupation to function in persons with Alzheimer’s disease. Journal of Occupational Science, 2, 59-67.
  • Baum, C. & Edwards D. F. (2008). Activity Card Sort (2nd ed.). Bethesda, MD: American Occupational Therapy Association.
  • Baum, C. M., & Edwards, D. F. (2001). The Activity Card Sort. St Louis, MO: Washington University School of Medicine.
  • Baum, C. M., Perlmutter, M. & Edwards, D. (2000). Measuring function in Alzheimer’s disease. Alzheimer’s Care Quarterly, 1, 44-61.
  • Chan, V. W. K., Chung, J. C. C., & Packer, T. L. (2006). Validity and reliability of the Activity Card Sort – Hong Kong version. Occupational Therapy Journal of Research: Occupation, Participation and Health, 26, 152-158.
  • Doney, R. M., & Packer, T.L. (2008). Measuring change in activity participation of older Australians: validation of the Activity Card Sort – Australia. Australasian Journal on Ageing, 27, 33-37.
  • Edwards, D. F., Hahn, M., Baum, C., & Dromerick, A. W. (2006). The impact of mild stroke on meaningful activity and life satisfaction. Journal of Stroke and Cerebrovascular Diseases, 15, 151-157.
  • Edwards, D. F., Hahn, M., & Dromerick, A. (2006). Post stroke urinary loss, incontinence and life satisfaction: When does post-stroke urinary loss become incontinence? Neurourology and Urodynamics, 25, 39-45.
  • Eriksson, G. M., Chung, J. C. C., Beng, L. H., Hartman-Maeir, A., Yoo, E., Orellano, E. M., van Nes, F., de Jonge, D., & Baum, C. (in press). Occupations of older adults: A cross cultural description. Occupational Therapy Journal of Research.
  • Everard, K. M., Lach, H. W., Fisher, E. B., & Baum, M. C. (2000). Relationship of activity and social support to the functional health of older adults. Journal of Gerontology: Social Sciences, 55B, S208-S212.
  • Hartman-Maeir, A., Eliad, Y., Kizoni, R., Nahaloni, I., Kelberman, H., & Katz, N. (2007). Evaluation of a long-term community based rehabilitation program for adult stroke survivors. NeuroRehabilitation, 22, 295-301.
  • Hartman-Maeir, A., Soroker, N., Oman, S. D., & Katz, N. (2003). Awareness of disabilities in stroke rehabilitation – a clinical trial. Disability and Rehabilitation, 25, 35-44.
  • Hartman-Maeir, A., Soroker, N., Ring, H., Avni, N., & Katz, N. (2007). Activities, participation and satisfaction one-year post stroke. Disability and Rehabilitation, 29, 559-566.
  • Katz, N., Karpin, H., Lak, A., Furman, T., & Hartman-Maeir, A. (2003). Participation in occupational performance: reliability and validity of the Activity Card Sort. OTJR: OccupationParticipation and Health, 23, 10-17.
  • Law, M., Baum, C. & Dunn, W. (Eds.). (2005). Measuring Occupational Performance: Supporting Best Practice in Occupational Therapy (2nd edition). Thorofare, NJ: Slack Incorporated.
  • Lyons, K. D., Li, Z., Tosteson, T. D., Meehan, K., & Ahles, T. A. (2010). Consistency and construct validity of the Activity Card Sort (Modified) in measuring activity resumption after stem cell transplantation. American Journal of Occupational Therapy, 64, 562-569.
  • Orellano, E. (2008). Occupational participation of older Puerto Rican adults: reliability and validity of a Spanish version of the Activity Card Sort (PhD dissertation). Retrieved from ProQuest Dissertations database (Publication Number 3330659).
  • Packer, T. L., Boshoff, K., & DeJonge, D. (2008). Development of the Activity Card Sort – Australia. Australian Occupational Therapy Journal, 55, 199-206.
  • Sachs, D., & Josman, N. (2003). The Activity Card Sort: a factor analysis. OTJR: Occupation, Participation and Health, 23, 165-174.
  • Schreuer, N., Rimmerman, A., & Sachs, D. (2006). Adjustment to severe disability: constructing and examining a cognitive and occupational performance model. International Journal of Rehabilitation Research, 29, 201-207.

See the measure

How to obtain the assessment:

The assessment can be purchased online at the American Occupational Therapy Association online store: http://www.aota.org.

A spain version is available in the following article

Table of contents

Assessment of Life Habits (LIFE-H)

Evidence Reviewed as of before: 26-01-2008
Author(s)*: Sabrina Figueiredo, BSc
Editor(s): Johanne Desrosiers, PhD OT; Annie Rochette, PhD OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Assessment of Life Habits (LIFE-H) was developed to assess the quality of social participation of people with disabilities by estimating how a client accomplishes activities of daily living and social roles (Fougeyrollas, Noreau, Bergeron, Cloutier, Dion & St-Michel, 1998).

In-Depth Review

Purpose of the measure

The Assessment of Life Habits (LIFE-H) was developed to assess the quality of social participation of people with disabilities by estimating how a client accomplishes activities of daily living and social roles (Fougeyrollas, Noreau, Bergeron, Cloutier, Dion & St-Michel, 1998).

Available versions

The LIFE-H, with 298 items, was developed by Fougeyrollas, Noreau, Bergeron, Cloutier, Dion and St-Michel, in 1997. In 1998, the number of items was cut down to 240 LIFE-H 3.0 (Fougeyrollas and Noreau, 1998).

The LIFE-H is also available in three shortened versions, the latest one being version 3.1. The LIFE-H 2.1 was developed by Fougeyrollas, Noreau, Bergeron, Cloutier, Dion and St-Michel, in 1997, and contains 58 items. The LIFE-H 3.0, developed by Fougeyrollas and Noreau in 1998 contains 69 items on its short form. The LIFE-H 3.1, developed by Fougeyrollas, Noreau and St-Michel in 2001, contains 77 items.

The International Network of Disability Creation Process (INDCP) encourages use of versions 3.0 and 3.1.

Features of the measure

Items:
The LIFE-H is a self-administered questionnaire. If the client has a low cognitive level the questionnaire can be answered by a proxy respondent (Poulin & Desrosiers, 2008). It evaluates the level of participation in daily activities and social roles by considering the degree of difficulty in carrying out life habits and the type of assistance required (Desrosiers, Noreau, Robichaud, Fougeyrollas, Rochette & Viscogliosi, 2004).

The LIFE-H assesses accomplishment of life habits and satisfaction with how they are accomplished. The accomplishment scale of the LIFE-H covers all 12 domains of life habits proposed by the Disability Creation Process (DCP) model. These 12 domains are similar to 7 of the 9 domains proposed by the International Classification of Functioning and Disabilities (ICF) of the World Health Organization (WHO, 1998). The first 6 domains are related to activities of daily living (ADL) including: nutrition, fitness, personal care, communication, housing, mobility. The remaining are related to social roles: responsibilities, interpersonal relationships, community life, education, employment and leisure (Fougeyrollas et al., 1998).

The versions of the LIFE-H cover all 12 domains with varying number of items under each domain as seen in Table 1.

Domains LIFE-H 3.0 LIFE-H 3.1
Short Version Long Version
Nutrition 3 17 4
Fitness 3 9 4
Personal Care 7 33 8
Communication 7 14 8
Housing 8 40 8
Mobility 5 18 5
Responsibilities 6 25 8
Family relations N/A –
included in
interpersonal
relationship
N/A N/A –
included in
interpersonal
relationship
Interpersonal Relationships 7 14 7
Community Life 7 18 8
Education 3 13 3
Employment 7 12 7
Recreation/Leisure 6 27 7
Number of total items 69 240 77

For each item in the accomplishment scale the client is asked about perceived difficulty in performing a life habit and the type of assistance used to perform it. When a life habit is not realized because it is not part of the person’s daily life, it is considered as a non-applicable item. (Desrosiers et al., 2004; Desrosiers, Boubonnais, Noreau, Rochette, Bravo, & Bourget, 2005; Fougeyrollas et al., 1998; Poulin & Desrosiers, 2008).

The definitions of the difficulty level and the types of assistance are provided within the questionnaire and are as follows (Fougeyrollas et al., 1998):

Level of difficulty Definition
No difficulty The person perceives he/she can easily perform a life habit even if this requires a technical aid, adaptation or human assistance, as needed.
With difficulty The person perceives that he/she performs a life habit with some difficulty even if this requires a technical aid, adaptation or human assistance, as needed.
Performed by substitution The person does not actively participate in the performance of a life habit. It is entirely done by another person (human assistance).
Not performed The person does not perform a life habit because the barriers are too great or lack of assistance.
Not applicable The life habit has no part in the person’s daily life.
Types of aides Definition
Technical aids Any (non-human) support to assist in the accomplishment of a life habit, such as wheelchair, visual aid, hearing aid, medication, other items.
Adaptation Any modification to the person’s environment to facilitate the accomplishment of life habits, such as access ramp, wider door, modification of a life habit or time to carry out (e.g. allow more time to perform it).
Human Assistance Any person assisting in the accomplishment of a life habit such as relatives, friends, orderlies (this covers both physical assistance and supervision)

In the satisfaction scale the client is asked to indicate the degree of satisfaction (on a five point scale from very satisfied to very dissatisfied) in accomplishing each item (Desrosiers et al., 2004; Desrosiers et al, 2005; Fougeyrollas et al., 1998; Poulin & Desrosiers, 2008).

Subscales:
Two sub-scales exist. The ADL sub-scale contains the following categories: nutrition, fitness, personal care, communication, housing, mobility. The Social Role sub-scale is represented by responsibilities, interpersonal relationships, community life, education, employment and leisure (Desrosiers et al., 2004; Desrosiers et al., 2005).

Scoring:
The LIFE-H has a continuous score ranging from 0 to 9. In the original version, a score of 0 implies an optimal level of participation and 9 indicates total handicap or total disruption in participation. However, in the three shortened versions (LIFE-H 2.1, 3.0, and 3.1) the scale was inverted and a score of 0 indicates total handicap or total disruption in participation and a score of 9 means an optimal level of participation (Fougeyrollas et al., 1998).

To calculate a single item score the answers related to the difficulty level and assistance are combined based on the grid below (Desrosiers et al., 2004; Desrosiers et al, 2005; Fougeyrollas et al., 1998; Poulin & Desrosiers, 2008):

Original version Versions 2.1; 3.0; 3.1 Definition
0 9 Performed with no difficulty
1 8 Performed with no difficulty with technical aid (or adaptation)
2 7 Performed with difficulty with no assistance
3 6 Performed with difficulty and technical aid (or adaptation)
4 5 Performed with no difficulty with human assistance
5 4 Performed with no difficulty with technical aid (or adaptation) and human assistance
6 3 Performed with difficulty and human assistance
7 2 Performed with difficulty and technical aid (or adaptation) and human assistance
8 1 Performed by a substitute
9 0 Not performed
N/A N/A Not applicable

The LIFE-H total score is obtained by summing the scores on each item and then dividing by the number of items (means). It is also possible to calculate the categories, ADL and Social Roles sub-scores by calculating the means of the sub-score of interest. (Desrosiers, Rochette, Noreau, Bravo, Hebert & Boutin, 2003; Fougeyrollas et al., 1998).

As the LIFE-H has a different number of items under each category, a normalized score can be calculated. The normalized score takes into account the number of items in each category and the number of non-applicable items, allowing a similar weight to each category sub-score (Noreau, Fougeyrollas & Vincent, 2002).

Normalized score = {SUM (Raw scores) x 10} / (Number of applicable items x 9)

The non-applicable items are not counted into the raw score. The satisfaction level on accomplishing an item is not considered in the scoring process. Rather, the answers related to satisfaction are used to document the quality of social participation (Fougeyrollas et al., 1998).

Time:
The LIFE-H 3.0 (short form) takes approximately 20 to 40 minutes to complete. The administration time for the long form can vary from 20 to 120 minutes, according to the number of categories administered (Noreau et al., 2002). The time required to complete the other versions of the LIFE has not been reported.

Equipment:
Only a pencil and the test are needed.

Training:
None typically reported.

Alternative forms of the LIFE-H

LIFE-H 2.1, LIFE-H 3.0 (short and long version), and LIFE-H 3.1.

Client suitability

Can be used with:

  • Clients with any type of disabilities, including children.
  • Clients with stroke

Should not be used in:

  • When administering the LIFE-H to clients with severe cognitive impairments the answers should be given by a proxy who knows the individual well.

In what languages is the measure available?

French, English, and Dutch (version 3.0).

Summary

What does the tool measure? The LIFE-H assesses the quality of social participation of people with disabilities.
What types of clients can the tool be used for? Clients with any type of disabilities, including children.
Is this a screening or assessment tool? Assessment.
Time to administer The LIFE-H 3.0 (short version) takes approximately 30 to 60 minutes and the long version can takes from 20 to 120 minutes.
Versions LIFE-H 2.0; LIFE-H 2.1., LIFE-H 3.0., and LIFE-H 3.1 (short and long version)
Other Languages French, English and Dutch.
Measurement Properties
Reliability Internal consistency:
Two studies examined the Internal consistency of the LIFE-H. One reported excellent consistency between two repeated measures of the LIFE-H total score and sub-scores and the other reported adequate to excellent consistency between clients and proxies.

Test-retest:
Two studies have examined the test-retest reliability of the LIFE-H and reported excellent test-retest reliability using ICC.

Inter-rater:
One study examined the inter-rater reliability of the LIFE-H and reported adequate to excellent inter-rater reliability using ICC.

Validity Content:
One study examined the content validity of the LIFE-H and reported that after a consultation with 12 rehabilitation experts, few LIFE-H items were either modified or removed from the original version. After this procedure the experts recognized the LIFE-H as being able to measure participation and handicap situations.

Criterion:
Predictive:
Six studies examined the predictive validity of the LIFE-H. Five studies reported that age, environmental barriers, impairments and disability level, lower extremity coordination, leg and arm function, walking endurance and speed, length of stay, the Berg Balance Scale, the Beck Depression Inventory, the Comorbidity Index and the Stress Appraisal Measure measured at 2 weeks after stroke or at discharge from a rehabilitation program were able to predict LIFE-H scores at 6 months, 2 and 4 years post-stroke. One study reported that severity of lower extremity impairments was the best predictor of disagreement on clients and proxies’ responses.

Construct:
Convergent:
Four studies examined convergent validity of the LIFE-H. One study with clients with stroke reported adequate to excellent correlations between the LIFE-H, the SMAF, and the FIM. The three other studies, using different populations, reported poor to excellent correlations between the LIFE-H and the Caregiver Strain Index, the London Handicap Scale and the Impact on participation and Autonomy Questionnaire using Pearson Correlation Coefficient. No correlations were found between the LIFE-H and the Beck Depression Inventory.

Known Groups:
One study examined known groups’ Validity and reported that the LIFE-H is able to discriminate healthy individuals from clients with stroke.

Floor/Ceiling Effects One study verified floor effects in few categories of the LIFE-H, when measuring participation at 2 weeks post-stroke. At 6 months all categories of the LIFE-H showed ceiling effects. The proportion of patients reaching ceiling and floor effects were not reported.
Does the tool detect change in patients? Two studies examined the responsiveness of the LIFE-H and reported greater changes at 2 weeks post stroke (large effects sizes) when compared with changes at 6 months post-stroke (moderate effects sizes). Additionally, changes in participation were more significant on personal relationships, employment and recreation with moderate to large effect sizes.
Acceptability When administered to clients with severe cognitive impairments the scores should be obtained from proxies.
Feasibility The administration of the LIFE-H is simple since it’s a self-administered questionnaire.
How to obtain the tool?

Information on the LIFE-H can be obtained by emailing the International Network of Disability Creation Process (INDCP), at ripph@irdpq.qc.ca

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the LIFE-H. We identified sixteen studies in total, eleven included participants with stroke.

Floor/Ceiling Effects

Rochette, Desrosiers, Bravo, St-Cyr/Tribble & Bourget (2007b) observed, in 35 clients with mild stroke, floor effects in the Nutrition, Mobility, Community Life, Education/Employment and Recreation categories of the LIFE-H when measuring participation at 2 weeks post-stroke. At 6 months post-stroke, ceiling effects could be observed in all categories of the LIFE-H. The proportion of participants scoring the minimum and maximum scores was not reported.

Reliability

Internal consistency:
Lemmens, van Engelen, Post, de Witte, Beurskens, and Wolters (2007) administered the LIFE-H, Dutch version 3.0 (short form), to 35 older adults with functional limitations due to stroke. The consistency of the LIFE-H total score between two repeated measures showed an excellent Intraclass Correlation Coefficient (ICC) of 0.78. Consistency for the two subscales was also excellent (ICC = 0.80).

Poulin and Desrosiers, (2008) evaluated the consistency of the LIFE-H version 3.1, when completed by proxy versus patient respondents by comparing responses from 40 clients and their proxies. Clients and proxies were assessed separately by the same rater. Proxy interviews were conducted one week apart of the client’s assessment. Consistency between clients and proxies was excellent for the total score (ICC = 0.82) and the ADL sub-score (ICC = 0.87). Consistency for the Social Roles sub-score was adequate (ICC = 0.73).

Test-retest:
Noreau, Desrosiers, Robichaud, Fougeyrollas, Rochette, and Viscogliosi (2004) examined the test-retest reliability of the LIFE-H, version 3.0 (short form), in 40 clients with functional limitations caused by many conditions, including stroke. Participants were re-assessed within 5 to 10 days by the same rater and under the same conditions. test-retest reliability assessed using an Intraclass Correlation Coefficient (ICC), was found to be excellent for the LIFE-H total score (ICC = 0.95), for the ADL sub-score (ICC = 0.96) and for the Social Roles sub-score (ICC = 0.76).

Lemmens et al., (2007) assessed the test-retest reliability of the LIFE-H, Dutch version 3.0 (short form), in 35 older adults with functional limitations due to stroke. Participants completed the LIFE-H questionnaire twice, the second time after a 2-week interval. test-retest reliability, as calculated using Intraclass Correlation Coefficient, was excellent for the total score (ICC = 0.80), for the ADL sub-score (ICC = 0.78) and for the Social Roles sub-score (ICC = 0.78).

Inter-rater:
Noreau et al., (2004) evaluated the inter-rater reliability of the LIFE-H, version 3.0 (short form), in 44 older adults with functional limitations caused in part by stroke. The LIFE-H was administered by 2 examiners within 3 to 5 days of each other. inter-rater reliability, as calculated using ICC, was excellent for the total score (ICC = 0.89) and ADL sub-score (ICC = 0.91) and adequate for the Social Roles sub-score (ICC = 0.64).

Validity

Content:
Fougeyrollas, Noreau, Bergeron, Cloutier, Dion and St-Michel (1998) sent the original copy of the LIFE-H to 12 experts including researchers, service providers and consumer representatives having occupational therapy, nursing, social work, psychology as a professional background. Following consultation, modifications related to clearness of items, definitions of the terms, and the rank of the accomplishment level were made and some items were eliminated. After this procedure the experts recognized the LIFE-H as being able to measure participation and handicap situations.

Criterion:
Concurrent:
No gold standard exists against which to compare the LIFE-H.

Predictive:
Rochette, Desrosiers, and Noreau (2001) examined the ability of age, gender, impairments and disabilities level (comprised of cognition, perception, depression, communication, sensorimotor and comorbidity) and environmental factors (comprised of perceived environmental barriers and facilitators), measured at discharge from a rehabilitation program, to predict handicap situations at 6 months post-stroke in 51 clients. Handicap situations were measured with the LIFE-H, version 2.1. Logistic regression revealed the best predictor of handicap situations at 6 months to be impairment and disabilities level (R2 = 38.3%) followed by age (R2 = 14.4%) and environmental barriers (R2 = 6.2%), respectively.

Desrosiers, Noreau, Rochette, Bravo and Boutin (2002) assessed, in 102 clients, whether age, length of stay in a rehabilitation program, motivation, communication problems, urinary and fecal incontinence, upper and lower extremity coordination, motor function impairment, lower and upper extremity disabilities, affect, visual perceptual performance, cognition, comorbidity and perceived social support, measured at discharge from a rehabilitation program, were able to predict handicap situations at 6 months after a stroke. Handicap situations were measured with the LIFE-H, version 2.1., motor function impairment with the Fugl-Meyer Assessment (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975); lower extremity disabilities with walking speed, the Berg Balance Scale (Berg, Wood-Dauphinee, Williams & Maki, 1989) and the 2-Minute Walk Test (Kosak & Smith, 2005); upper extremity disabilities with the Upper Extremity Performance Evaluation Test for the Elderly (Test d’evaluation des membres superieurs des personnes agees – TEMPA) (Desrosiers, Hébert, Dutil, & Bravo, 1994); affect with the (Beck, Ward, Mendelson, Mock, & Erbraugh, 1961); visual perceptual performance with the Motor-Free Visual Perceptual test (Colarusso & Hammill, 1972); cognition with the Modified Mini-Mental State (Teng & Chui, 1987); comorbidity with the Comorbidity Index (Charlson, Pompei, Ales, Mock, & Erbraugh, 1987) and perceived social support with the Social Provisions Scale (Cutrona, 1986). Multiple regression analysis indicated that the Beck depression Inventory (R2 = 23.0%), lower extremity coordination (R2 = 31.0%), length of stay (R2 = 3.0%), the Berg Balance Scale (R2 = 9.0%), age (R2 = 1.0 %) and the Comorbidity Index (R2 = 1.0%) were the best predictors of handicap situations 6 months post-stroke.

Desrosiers, Malouin, Bourbonnais, Richards, Rochette & Bravo (2003) analyzed, in 102 clients with stroke, the ability of arm and leg impairments and disabilities, measured at discharge of a rehabilitation program, to predict participation 6 months later. participation was measured with the LIFE-H, version 2.1., motor function and sensation with the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975), arm coordination with the Finger to Nose test and leg coordination with a specific test developed by the same researcher team (Desrosiers, Hébert, Bravo, Dutil, 1995), arm disabilities with the Upper Extremity Performance Evaluation Test for the Elderly (Test d’evaluation des membres superieurs des personnes agees – TEMPA) (Desrosiers et al., 1994) and leg disabilities with the Berg Balance Scale (Berg et al., 1989), the 2-Minute Walk Test (Kosak & Smith, 2005) and walking speed. Balance (r = 0.67), walking endurance (r = 0.63), walking speed (r = 0.62), and leg coordination (r = 0.62) were found to be excellent predictors of the LIFE-H. Leg function (r = 0.58), arm disabilities (r = 0.48), arm coordination (r = 0.47), arm function (r = 0.43), and leg sensation (r = 0.31) were considered adequate predictors of the LIFE-H. Finally, arm sensation and the LIFE-H were poorly correlated, suggesting this variable is not able to predict the LIFE-H.

Desrosiers, Noreau, Rochette, Bourbonnais, Bravo and Bourget (2006) verified, in 66 clients, whether age, length of stay in a rehabilitation program, motivation, communication problems, urinary and fecal incontinence, upper and lower extremity coordination, motor function impairment, lower extremity disabilities, upper extremity disabilities, affect, visual perceptual performance, cognition, comorbidity, and perceived social support, measured at discharge from a rehabilitation program, were able to predict participation at 2 and 4 years after a stroke. participation was measured by the LIFE-H, version 2.1., motor function impairment with the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975); lower extremity disabilities with walking speed, the Berg Balance Scale (Berg et al., 1989) and the 2-Minute Walk Test (Kosak & Smith, 2005); upper extremity disabilities with the Upper Extremity Performance Evaluation Test for the Elderly (Test d’evaluation des membres superieurs des personnes agees – TEMPA) (Desrosiers et al., 1994); affect with the Beck depression Inventory (Beck et al., 1961); visual perceptual performance with the Motor-Free Visual Perceptual test (Colarusso & Hammill, 1972); cognition with the Modified Mini-Mental State (Teng & Chui, 1987); comorbidity with the Comorbidity Index (Charlson et al., 1961) and perceived social support with the Social Provisions Scale (Cutrona, 1986). From a multiple regression analysis the best predictors for participation at 2 and 4 years post-stroke are age (R2 = 11.0%), comorbidity (R2 = 18.0%), motor coordination (R2 = 15.0%), upper extremity disability (R2 = 6.0%) and affect (R2 = 3.0%).

Rochette, Bravo, Desrosiers, St-Cyr/Tribble and Bourget (2007a) estimated, in 88 clients with stroke the ability of the Stress Appraisal Measure (Peacock & Wong, 1990) and the Revised Ways of Coping Questionnaire (Folkman & Lazarus, 1988) measured in the first 2 weeks post-stroke to predict the LIFE-H, version 3.0 (short form) 6 months post-stroke. Multiple linear regression analysis suggested that the Threat, Challenge, Centrality and Stressfulness’ subscales of the Stress Appraisal Measure were more likely to predict the LIFE-H scores. These four variables together were able to explain 25 % of variance on the LIFE-H scores provided by clients with stroke.

Poulin and Desrosiers (2008) examined, in 40 clients with stroke and 40 proxies, whether age, gender, schooling, living environment, relationship of proxy, stroke type, side of motor impairment, previous stroke, number of months since stroke, self-perceived health, the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975), the Chedoke McMaster stroke Assessment (Gowland, Van Hullenar, Moreland, Vanspall, Barreca, Ward et al., 1995) and the Geriatric depression Scale (Jongenelis, Pot, Eisses, Gerritsen, Derksen, Beekman et al., 2005) were able to predict disagreement on responses provided by clients and their proxies on the LIFE-H, version 3.1. All the variables were measured at one point in time among community-dwelling individuals who had been hospitalized due to stroke and their proxies. Severe lower extremity impairment and poorer cognitive performance were found to be the best predictors of disagreement on the LIFE-H total score (R2 = 40%). For the ADL sub-score, the variables able to predict disagreement on the LIFE-H were severity of lower extremity impairment, living environment and gender (R2 = 44%). For the Social Role sub-scores the best predictors of disagreement were severity of lower extremity impairment, cognitive functions and number of months since stroke, explaining 32% of the variance.
Note: Although disagreement levels between clients’ responses and their proxies do not appear to be clinically significant, the predictors of disagreement should be considered when interpreting proxy responses.

Construct:
Desrosiers, Rochette, Noreau, Bravo, Hébert and Boutin (2003) evaluated the construct validity of the LIFE-H, version 2.1, by comparing it to the Functional Autonomy Measurement System (Systeme de mésure de l’autonomie fonctionelle – SMAF) (Hébert, Carries, & Bilodeau, 1988) and the Functional Independence Measure (FIM) (Keith, Granger, Hamilton, & Sherwin, 1987) at 2 weeks and at 6 months after discharge from a stroke rehabilitation program. At the first point in time, 118 participants were available and at the second point in time 102. Correlations, as calculated using Pearson Correlation coefficients, were found to be excellent between the SMAF and the LIFE-H total score (r1 = 0.85; r2 = 0.89), the LIFE-H ADL sub-score (r1 = 0.89; r2 = 0.91), and the LIFE-H Social Roles sub-score (r1 = 0.66; r2 = 0.77) and between the FIM and the LIFE-H total score (r1 = 0.79; r2 = 0.85), the LIFE-H ADL sub-score (r1 = 0.85; r2 = 0.88), and the LIFE-H Social Roles sub-score (r2 = 0.71). Correlations between the LIFE-H and the FIM at 2 weeks after discharge were adequate (r1 = 0.57).

Convergent:
Three studies have investigated the convergent validity of the LIFE-H in older individuals with functional limitations but not necessarily individuals with stroke.

Desrosiers, Noreau, Robichaud, Fougeyrollas, Rochette and Viscogliosi (2004) measured the convergent validity of the LIFE-H, version 3.0 (short form), by comparing it to the Functional Autonomy Measurement System (Système de mesure de l’autonomie fonctionelle – SMAF) (Hébert et al., 1988) in 87 elderly adults with functional limitations. Correlations were excellent between the SMAF and LIFE-H total score (r = 0.70) and the ADL sub-score (r = 0.76) and adequate between the SMAF and the LIFE-H Social Roles sub-score (r = 0.43).

Rochette, Desrosiers, Bravo, St-Cyr/Tribble and Bourget (2007c) analyzed the convergent validity by comparing changes of participation’s level on the LIFE-H version 3.0 (short form) to the Caregiver Strain Index (Robinson, 1983) and the Beck depression Inventory (Beck et al., 1961) in 54 spouses of individuals with a first ever stroke. Correlations between the Caregiver Strain Index and the LIFE-H total score (r = 0.32) and the Social Roles sub-score (r = 0.39) were adequate. The Caregiver Strain Index and the LIFE-H ADL sub-score were poorly correlated (0.02). No correlations were found between the LIFE-H and the Beck depression Inventory.

Lemmens et al., (2007) examined the convergent validity of the LIFE-H, Dutch version 3.0 (short form), with the Impact on participation and Autonomy Questionnaire (IPA) (Cardol, Haan, Van den Bos, De Jong, & De Groot, 1999) and the London Handicap Scale (LHS) (Hardwood, Roger, Dickinson, & Ebrahim, 1994) in 63 older adults with functional limitations. Excellent correlations were found between the total score and the IPA (rho = 0.82) and the LHS (rho = 0.90).

Known groups:
Desrosiers, Bourbonnais, Noreau, Rochette, Bravo, and Bourget (2005) verified the ability of the LIFE-H, version 2.1, to discriminate between older individuals who had experienced a stroke (n = 46) and healthy older individuals (n = 46). Known group validity, as calculated using Student’s t-test, showed that scores of healthy subjects were significantly higher than the scores of the participants with stroke.

Responsiveness

Rochette et al., (2007b) examined the responsiveness of the LIFE-H, version 3.0 (short form) in 35 clients with mild stroke. participation level was measured before stroke (T0), in a retrospective way, at 2 weeks (T1), 3 months (T2) and 6 months post (T3). At T1, effects sizes were large for the LIFE-H total score (1.21) as well as for the ADL and Social Roles sub-scores (1.15; 1.24). For the timeline T3-T1 and T3-T0, effects sizes were all moderate : LIFE-H total score (0.60; 0.62), ADL sub-score (0.64; 0.58), and the Social Roles sub-score (0.56; 0.70).

Rochette et al., (2007c) analyzed the responsiveness of the LIFE-H, version 3.0 (short form) in 54 spouses of individuals with a first ever stroke. participation level was measured before stroke (T0), in a retrospective way, and at 2 weeks (T1) and 6 months (T2) post-stroke. At T1, effects sizes were moderate for the LIFE-H total score (0.53), small for the ADL sub-scores (0.0), and large for the Social Roles sub-score (0.90). At T2, the LIFE-H total score (0.38) and the ADL sub-score (0.13) demonstrated a small effect size and the Social Roles sub-scores a moderate one (0.76). Changes in participation were larger for personal relationships (T1 = 0.67; T2 = 0.83), employment (T1 = 0.68; T2 = 0.63) and recreation (T1 = 1.16; T2 = 0.93) showing moderate to large effect sizes.

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  • Fougeyrollas, P., Noreau,L., & St-Michel,G. (1997). Life Habits Measure – Shortened Version (LIFE-H 2.1) Lac St Lac St-Charles, Québec, Canada.
  • Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
  • Gowland, C., Van Hullenaar, S., Torresin, W., et al. (1995). Chedoke-McMaster Stroke Assessment: development, validation, and administration manual. Hamilton, ON, Canada: School of Rehabilitation Science, McMaster University.
  • Hardwood, R.H., Roger, A., Dickinson, E., & Ebrahim, S. (1994). Measuring handicap: the London Handicap Scale, a new measure for chronic disease. Qual Health Care, 3, 11-16.
  • Hébert, C., Carrier, R., & Bilodeau, A. (1988). The Functional Autonomy Measurement System (SMAF): description and validation of an instrument for the measurement of handicaps. Age Ageing, 17, 293-302.
  • Jongenelis, K., Pot, A.M., Eisses, A.M., Gerritsen, D.L., Derksen, M., Beekman, A.T. et al. (2005). Diagnostic accuracy of the original 30-item and shortened version of the Geriatic Depression Scale in nursing home patients. Int J Geriatrics Psychiatry, 20, 1067-1074.
  • Keith, R. A., Granger, C. V., Hamilton, B. B., & Sherwin, F. S. (1987). The functional independence measure: A new tool for rehabilitation. Adv Clin Rehabil, 1, 6-18.
  • Kosak, M., & Smith, T. (2005). Comparison of the 2-, 6-, and 12-minute walk tests in patients with stroke. J Rehabil Res Dev, 42(1), 103-107.
  • Lemmens, J., van Engelen, E., Post, M.W., Beurskens, A.J., de Witte, L.P., & Wolters, P.M. (2007). Reproducibility and validity of the Dutch life habits questionnaire (life-h 3.0) in older adults. Clin Rehabil, 21, 853-862.
  • Noreau, L., Desrosiers, J., Robichaud, L., Fougeyrollas, P., Rochette, A., & Viscogliosi, C. (2004). Measuring social participation: reliability of the life-h in older adults with disabilities. Disability & Rehabilitation, 26(6), 346-52.
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  • Rochette, A., Desrosiers, J., Bravo, G., Tribble, D.S., Bourget, A. (2007c). Changes in participation level after spouse’s first stroke and relationship to burden and depressive symptoms. Cerebrovascular Diseases, 24(2-3), 255-260.
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See the measure

How to obtain the LIFE-H

A copy of the LIFE-H can be ordered from the International Network on the Disability Creation Process (INDCP). The initial user’s rights fee is CAN$ 288.00 and enhances using the LIFE-H for a 3-year period. One assessment tool can be obtained for CAN$ 23.00 and additional information records forms for CAN$ 3.00 each. INDCP detains all rights on the reproduction and distribution on all the versions of the LIFE-H.

Students are not charged the initial user’s rights fee (CAN$ 288.00) and are allowed to reproduce the LIFE-H for their ongoing research project. However, to do so, students have to buy one copy of the assessment tool (CAN$ 23.00) and commit in not using it for purposes other than their current research project. At the end of the project, a copy of their master’s or doctorate thesis should be sent to the INDCP.

Further information on the LIFE-H can be obtained by emailing the International Network of Disability Creation Process (INDCP), at ripph@irdpq.qc.ca.

The following links allow you to download sample versions of both the General Short Form (LIFE- H 3.1), and General Long Form (LIFE- H 3.0). They are for viewing purposes only and may not be reproduced.

Table of contents

Reintegration to Normal Living Index (RNLI)

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Elissa Sitcoff, BA BSc
Editor(s): Nicol Korner-Bitensky, PhD OT; Lisa Zeltzer, MSc OT

Purpose

The Reintegration to Normal Living Index (RNLI) was developed to assess, quantitatively, the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities (e.g. recreation, movement in the community, and interaction in family or other relationships). Reintegration to normal living was defined by the scale authors as the “reorganization of physical, psychological, and social characteristics of an individual into a harmonious whole so that one can resume well-adjusted living after incapacitating illness or trauma” (Wood-Dauphinee & Williams, 1987).

The RNLI has been tested for use with individuals with stroke, malignant tumors, degenerative heart disease, central nervous system disorders, arthritis, fractures and amputations; spinal cord injury; traumatic brain injury; rheumatoid arthritis; subarachnoid hemorrhage; hip fracture; physical disability; and community-dwelling elderly.

In-Depth Review

Purpose of the measure

The Reintegration to Normal Living Index (RNLI) was developed to assess, quantitatively, the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities (e.g. recreation, movement in the community, and interaction in family or other relationships). Reintegration to normal living was defined by the scale authors as the “reorganization of physical, psychological, and social characteristics of an individual into a harmonious whole so that one can resume well-adjusted living after incapacitating illness or trauma” (Wood-Dauphinee & Williams, 1987).

The RNLI has been tested for use with individuals with stroke, malignant tumors, degenerative heart disease, central nervous system disorders, arthritis, fractures and amputations; spinal cord injury; traumatic brain injury; rheumatoid arthritis; subarachnoid hemorrhage; hip fracture; physical disability; and community-dwelling elderly.

Available versions

The RNLI was developed by Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer in 1988.

Features of the measure

Items:

The RNLI index is made up of 11 declarative statements (e.g. I move around my living quarters as I feel necessary), including the following domains: indoor, community, and distance mobility; self-care; daily activity (work and school); recreational and social activities;; family role(s); personal relationships; presentation of self to others and general coping skills. The first 8 items represent ‘daily functioning’ and the remaining 3 items represent ‘perception of self’.

Scoring:

Each domain is accompanied by a visual analogue scale (VAS) (0 to 10 cm). The VAS is anchored by the statements “does not describe my situation” (1 or minimal integration) and “fully describes my situation” (10 or complete integration). Individual item scores are summed to provide a total score out of 110 points that is proportionally converted to create a score out of 100.

Three- and 4-point categorical scoring systems were also developed (Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer, 1988), and the 3-point categorical system has been used in the evaluation of stroke patients (Mayo et al., 2000; Mayo et al., 2002). In the 3-point system, an additional category is inserted between the two anchor points (“partially describes my situation”) and the respondent selects the most applicable of the three categories. This option yields total scale scores from 22-0, with higher scores indicating poorer reintegration (Mayo et al., 2000, Mayo et al., 2002).

Time:

The time to administer depends on the mode of administration (e.g. self-administration, interviewer-administration, proxy, postal, etc.) and the participant’s abilities, but typically takes less than 10 minutes to complete.

Subscales:

There are two subscales to the RNLI: Daily Functioning (indoor, community, and distance mobility; self-care; daily activity (work and school); recreational and social activities; general coping skills) and Perception of Self (family role(s); personal relationships; and presentation of self to others.).

Equipment:

Only the test and a pencil are required to complete the RNLI.

Training:

The RNLI requires no training to administer.

Alternative forms of the Reintegration to Normal Living Index

  • Reintegration to Normal Living Index – Postal Version (RNLI-P) was developed by Daneski, Coshall, Tilling, and Wolfe in 2003.
    This measure modified the original RNLI in phrasing and scoring for use by post with stroke patients. The RNLI – P uses an agree/disagree format (0=disagree, 1= agree).
  • There are also versions created with minor modifications in wording to the original RNLI for: individuals who use adaptive devices motor aids or human assistance where the use of equipment and resources are clarified; use by health care professionals; and use by significant others (Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer,1988).

Client suitability

Can be used with:

  • Patients with stroke.

Should not be used with:

  • The use of a visual analogue scale may not be appropriate for the assessment of some stroke patients (i.e. those with attentional deficits or visual impairments or difficulty comprehending the meaning of a VAS). Instead, the use of the 3- or 4-point categorical scoring system is recommended.

In what languages is the measure available?

The RNLI is available in Canadian English and Canadian French (Wood-Dauphinee & Williams, 1987; Wood-Dauphinee, Opzoomer, Williams, Marchand, & Spitzer, 1988).

Please click here to access the french language version. A research version is also available.

Summary

What does the tool measure? The degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities.
What types of clients can the tool be used for? The RNLI has been tested for use with individuals with stroke, malignant tumors, degenerative heart disease, central nervous system disorders, arthritis, fractures and amputations; spinal cord injury; traumatic brain injury; rheumatoid arthritis; subarachnoid hemorrhage; hip fracture; physical disability; and community-dwelling elderly.
Is this a screening or assessment tool? Assessment
Time to administer The amount of time it takes to administer the RNLI is dependent upon mode of administration and participant’s abilities but should take approximately 10 minutes.
Versions
  • Reintegration to Normal Living Index ( RNLI)
  • Reintegration to Normal Living Index- Postal Version (RNLI-P).
  • There are also versions created with minor modifications in wording to the original RNLI for: individuals who use adaptive devices motor aids or human assistance where the use of equipment and resources are clarified; use by health care professionals; and use by significant others.
  • The original RNLI index is made up of 11 declarative statements Three- and 4-point categorical scoring systems are also available.
Other Languages Canadian French (Please click here to access the french language version. A research version is also available.)
Measurement Properties
Reliability Internal consistency:
Six studies have examined the Internal consistency of the RNLI. Four reported excellent Cronbach’s alphas. One reported excellent Cronbach alphas for the total RNLI patient and significant other score as well as for the patient score on the Perception of Self subscale, adequate Cronbach alphas for the Daily Functioning subscale for both patient and significant other score, as well as on the significant other score on the Perception of Self subscale. One study reported adequate to excellent Cronbach alphas.

Test-retest:
Three studies have examined the test-retest reliability of the RNLI and reported adequate test-retest agreement between items using kappa statistics, and excellent test-retest on the global score using correlation coefficients.

Intra-rater:
No studies have examined the intra-rater reliability of the RNLI.

Inter-rater:
No studies have examined the inter-rater reliability of the RNLI.

Validity Construct:
Convergent/Discriminant:
– Excellent correlations between the total score of the RNLI-P and the Frenchay activities Index (FAI), the Short Form 36 Health Survey (SF-36) and with the Hospital Anxiety and Depression Scale-Depression subscale (HADS). Excellent correlations between the Daily Function subscale of the RNLI-P and the FAI and the SF-36. Poor correlations between the RNLI-P Daily Functioning subscale and the HADS-Anxiety subscale as well as between the Perceptions of Self subscale and both the FAI and the Barthel Index.
– Excellent correlation between the RNLI and the Quality of Life Index (QL) and with a measure of psychological wellbeing. Excellent correlation between Daily Functioning subscale and with Quality of Life Index items Activity and Daily Living. Adequate correlations between Perceptions of Self subscale and Support and Outlook items from the Quality of Life Index. Strong correlation between the RNLI and the Participation Survey/Mobility (PARTS/M). A positive relationship between the Health Options Scale and the RNLI for stroke survivors well as a positive relationship between the Herth Hope Index and the RNLI for both stroke survivors and their spouses.
– Adequate correlation between the RNLI and items on the subscale related to physical performance of the Prosthetic Profile of the Amputee (PPA) with the exception of the item “active use of the prosthesis indoors” which was poor. No correlation between items of the Perception of Self subscale of the RNLI with items on the subscale related to physical performance of the PPA with the exception of prosthetic wear which was adequate. Adequate to excellent correlations between items of the total RNLI with items in the subscale related to Physical performance of the PPA with the exception of items “Active use indoors” and “Active use outdoors” which had non-significant correlations.
– Poor to adequate correlations between items of the total RNLI, and its two subscales with items on the PPA subscale related to acceptance of amputation and prosthesis.
– Significant correlations between the RNLI and the Functional Independence Measure (FIM).
– Adequate to excellent correlations between scores the total RNLI and the Daily Functioning subscale with patient (with Rheumatoid arthritis) age, number of affected joints, the Functional Independence Measure (FIM), the Lee Index (pain, fatigue, and stiffness), and the American Rheumatism Association Classification. The total RNLI was also adequately correlated to disease duration.
Acceptability The use of the 3 or 4 point categorical scoring system may be more appropriate for the assessment of some stroke patients than the visual analogue scale
Feasibility The administration of the RNLI is quick and simple and requires no training to administer. The RNLI index is made up of 11 declarative statements representing the domains ‘daily functioning’ (indoor, community, and distance mobility; self-care; daily activity (work and school); recreational and social activities;; family role(s); personal relationships; and ‘perception of self'(presentation of self to others, general coping skills. Each domain is accompanied by a visual analogue scale (VAS) (0 to 10 cm). The VAS is anchored by the statements “does not describe my situation” (1 or minimal integration) and “fully describes my situation” (10 or complete integration). Individual item scores are summed to provide a total score out of 110 points that is proportionally converted to create a score out of 100.
How to obtain the tool? The RNLI is available by clicking here.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Reintegration to Normal Living Index (RNLI).

Floor/Ceiling Effects

Not yet examined.

Reliability

Internal consistency:
Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer (1988) administered the RNLI to three samples of patients with varied diagnoses to determine Internal consistency. The RNLI was completed by patients, significant others, and healthcare professionals. The Cronbach’s alphas were excellent for patients, significant others, and health care professionals (alpha = 0.90, 0.92, and 0.95, respectively). Corrected item to total correlations ranged from 0.39 (patient assessment of “comfort with self-care needs”) to 0.75 for patients, 0.61 to 0.87 for significant others, and 0.70 to 0.90 for health professionals.

Tooth, McKenna, Smith, and O’Rourke (2003) administered the RNLI to 57 pairs of patients and significant others six months after stroke rehabilitation. Cronbach’s alphas were excellent for the total RNLI patient and significant other scores (alpha = 0.80 and 0.81, respectively). For the Daily Functioning subscale, adequate Cronbach’s alphas were found for both patient and significant other scores (alpha = 0.71 and 0.73, respectively). For the Perception of Self subscale, Cronbach’s alpha was excellent for patient scores (alpha = 0.84) and adequate for significant other scores (alpha = 0.76).

Steiner et al. (1996) examined the Internal consistency of the RNLI in two samples of community-dwelling persons aged 75 and over (n=414, n=50). Cronbach’s alphas were adequate (0.76) to excellent (0.83).

Daneski, Coshall, Tilling, and Wolfe (2002) examined the Internal consistency of a postal version of the RNLI (the RNLI-P) administered to 76 patients with stroke (at one-year). The Cronbach’s alpha was excellent (0.84).

Stark, Edwards, Hollingsworth, and Gray (2005) administered the RNLI to 604 people between the ages of 18 and 80 years who had a mobility limitation (including patients with spinal cord injury, Multiple Sclerosis, stroke, cerebral palsy, and polio), lived in the community, and had been discharged from rehabilitation for at least 1 year. The Cronbach’s alpha for this sample was excellent (0.91).

Bluvol and Ford-Gilboe (2004) administered the RNLI to both spouses in 40 families in which one of the partners had experienced a stroke with moderate to severe functional impairments (6 months to 5 years post-stroke). The Internal consistency of the measure was excellent for both the partners with stroke (alpha = 0.92) and their spouses (alpha = 0.85).

Test-retest:
Steiner et al. (1996) examined the test-retest reliability of the RNLI in 50 community-dwelling persons aged 75 and over interviewed twice, by the same interviewer, with 7 to 14 days between interviews. Test-retest for the total sample of community-dwelling elderly was excellent (r = 0.83). When examined by age group, correlations were excellent for the 75 to 79 age group (r = 0.82), 80 to 84 age group (r = 0.93), and for the 85+ age group (r = 0.76).

Daneski, Coshall, Tilling and Wolfe (2002) examined the test-retest reliability of a postal version of the RNLI (the RNLI-P) in 26 patients with stroke (3-12 months post-stroke) who completed the test twice within a 2-week interval. All 11 items demonstrated agreement between the two occasions above that expected by chance. Kappa values ranged from poor to excellent agreement (kappa = 0.38 for the item “embarrassed when with others”, to 0.92 for the item “getting around outside”).

Korner-Bitensky, Wood-Dauphinee, Siemiatycki, Shapiro, and Becker (1994) examined the test-retest reliability of the RNLI in 366 patients with a diagnosis of stroke or orthopedic condition discharged from a rehabilitation hospital. The test was administered twice – once by face-to-face interview and once by a structured telephone interview to either a self or proxy respondent. The interclass coefficient (ICC) for the RNL Index was 0.80 indicating excellent agreement between the two modes of interview. However, for the self-respondents, poor community reintegration was reported more often during the home interview than the interview conducted over the telephone.

Type of rater:
Korner – Bitensky, Wood Dauphinee, Shapiro, and Becker (1994) analyzed the reliability of RNLI scores of 366 participants (with stroke or an orthopedic condition post discharge from a rehabilitation hospital) who completed both a home interview (conducted by a health professional only) and a telephone interview (conducted by either a lay person or health professional). Results revealed that there were no significant differences on the comparison of kappa scores when patients were interviewed by lay interviewers or health professionals. When a dichotomized score of 40 was used (0-40 = no disability, scores of >40 equals disability), the group interviewed by phone by a layperson was significantly more likely to report difficulties in community reintegration compared to when interviewed face-to-face.

Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer (1988) analyzed the reliability of RNLI scores between patients and relatives and between patients and health professionals. Using Pearson’s correlation coefficient to measure reliability they reported adequate significant other to patient correlations of r = 0.62 and r = 0.65 in two different patient/significant other samples. They also reported poor to adequate health professional to patient correlations of r = 0.39 and r = 0.43. Based on these results, the authors stated that patients or significant others could complete the RNLI but that the use of health professionals as proxies should be avoided.

Trombly, Radomski, and Davis (1998) administered the RNLI to 16 adults with traumatic brain injury and their significant others. At admission to a treatment program, patients’ and proxies’ scores did not differ significantly, however at discharge and follow-up, they differed significantly

Tooth, McKenna, Smith, and O’Rourke (2003) examined patient proxy reliability of RNLI scores in 57 subacute patients paired with a significant other 6 months post stroke rehabilitation. Intra-class correlation Coefficients were poor for the total RNLI score (0.36) and the Daily Functioning subscale (0.24). Adequate reliability was found for the Perception of Self subscale (0.55.).

Validity

Content:

The RNLI was developed based on literature reviews, incorporation of experiences of investigators, and open- and closed-ended questionnaires given to patients with myocardial infarction, cancer, and other chronic diseases, health professionals (physicians, social workers, physical and occupational therapists, psychologists), significant others of patients; and clergy and other lay people.

Construct:

Convergent/Discriminant:
Daneski, Coshall, Tilling and Wolfe (2003) examined the construct validity of a postal version of the RNLI (RNLI-P) with other similar measures in 76 patients with stroke. Excellent correlations were found between the total score on the RNLI-P and the Frenchay Activities Index (FAI – Holbrook & Skilbeck, 1983) (r = 0.69), the Short Form 36 Health Survey (SF-36 – Ware, Snow, Kosinski & Gandek, 1993) (r = 0.74), and with the Hospital Anxiety and Depression Scale-Depression subscale (HADS – Zigmond & Snaith, 1983) (r = -0.61). Excellent correlations were reported between the Daily Function subscale of the RNLI-P and the FAI (r = 0.74) and the SF-36 (r = 0.73). The RNLI-P Daily Function subscale correlated poorly with the HADS-Anxiety subscale(r=-0.30). The Perceptions of Self subscale correlated poorly with the FAI (r = 0.26) and with the Barthel Index (Mahoney & Barthel, 1965), (r = 0.06).

Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer (1988) administered the RNLI to 70 patients with myocardial infarct or cancer and reported excellent correlation with scores on the Quality of Life (QL) Index (Spitzer, Dobson, Hall, Chesterman, Levi, Shepherd, Battista & Catchlove, 1981) (r = 0.68) and with a measure of psychological well-being (r = 0.32 for positive wellbeing, -0.41 for negative wellbeing, and 0.41 for overall). Daily Functioning subscale scores showed excellent correlation with QL Index items Activity and Daily Living (r = 0.67) while Perceptions of Self scores correlated adequately with Support and Outlook from the QL Index (r = 0.36).Items on the QL Index that reflected dimensions not included on the RNLI, correlated less strongly (r < 0.20).

In a study describing the development and psychometric properties of the Participation Survey/Mobility (PARTS/M), Gray, Hollingsworth, Stark and Morgan (2006) administered the RNLI to 604 people with mobility limitations due to a diagnosis of spinal cord injury, Multiple Sclerosis, cerebral palsy, stroke or post poliomyelitis and reported a strong correlation between the two indices (canonical correlation =0.71).

Bluvol and Ford-Gilboe (2004) administered the Herth Hope Index (measure of hope – Herth, 1992), the Health Options Scale (measure of health work – Ford-Gilboe, 1997, 2002b) and the RNLI to both spouses in 40 families in which one of the partners had experienced a stroke with moderate to severe functional impairments (6 months to 5 years post-stroke). They found a positive relationship between the Health Options Scale (health work) and the RNLI for stroke survivors (r = 0.50) but not for their spouses(r = 0.06) as well as a positive relationship between the Herth Hope Index (hope) and the RNLI (quality of life) for both stroke survivors (r = 0.59) and spouses (r = 0.32).
Note: Health work is defined as “an active process through which families learn ways of coping and developing that are conducive to healthy living over time” Ford-Gilboa 2002a.

Gauthier-Gagnon, and Grise (1994) administered the RNLI and the Prosthetic Profile of the Amputee (PPA) questionnaire (Grise, Gauthier-Gagnon, 1993) to 89 people with a lower limb amputation. Items on the Daily Activities subscale of the RNLI correlated adequately (r = 0.36 to 0.56) with items on the subscale related to physical performance of the PPA with the exception of the item “active use of the prosthesis indoors” which was poor ( r = 0.28).

In this same study, items of the Perception of Self subscale of the RNLI failed to correlate with items on the subscale related to physical performance of the PPA with the exception of prosthetic wear which was adequate (r = 0.32).

Items of the total RNLI had adequate to excellent correlations (r = 0.36 to 0.53) with items in the subscale related to Physical performance of the PPA with the exception of items “Active use indoors” and “Active use outdoors” which had non-significant correlations.

Items of the total RNLI, and its two subscales revealed poor to adequate correlations (r = 0.53 to 0.30) with items on the subscale related to acceptance of amputation and prosthesis.

Daverat, Petit, Kemoun, Dartigues, and Barat (1995) conducted a longitudinal study of 149 individuals with long-standing spinal cord injury. The univariate analysis showed that the RNLI significantly correlated with the Functional Independence Measure (FIM) (Hamilton, Granger, & Sherwin, 1987) FIM. The multivariate analysis determined that the following significant seven independent variables contributed to 72% of the RNLI variance. They included the FIM, the Yale Scale Score (Chehrazi, Wagner, Collins, Freedman, 1981) the Centre for Epidemiological Studies Depression Scale (CES-D – Radloff, 1977), living conditions, relationship, sexual life and age.

Calmels, Pereira, Domenach, Pallot-Prades, Alexandre, and Minaire (1994) administered the RNLI to 57 individuals with rheumatoid arthritis, with a mean disease duration of 15 years. In this study, scores on the total RNLI and the Daily Function subscale had adequate to excellent correlations with patient age, number of affected joints, the Functional Independence Measure (FIM), the Lee Index (pain, fatigue, and stiffness), and the American Rheumatism Association Classification (r = 0.38 to 0.84). The total RNLI was also adequately correlated to disease duration (r = 0.31).

McColl, Paterson, Davies, Doubt, and Law (2000) administered the RNLI to 61 community-dwelling individuals with a disability and found that RNLI scores were adequately correlated with the satisfaction subscale of the Canadian Occupational Performance Measure (COPM – Law et al., 1991, 1994, 1998) (r = 0.38) but only poorly correlated with the Performance subscale (r = 0.22). The RNLI had excellent correlations with the Life Satisfaction Scale (Michalos, 1980) (r = 0.71) and with the Satisfaction with Performance Scaled Questionnaire (Yerxa, Burnett-Beaulieu, Stocking & Azen, 1988) (r = 0.72).

Steiner et al. (1996) evaluated the performance of the RNLI in an elderly community-based population (n = 414). The RNLI demonstrated adequate positive correlations with instrumental Activities of daily living scale (Lawton, Moss, Fulcomer & Klegan, 1982) (r = 0.47) and perceived health (r = 0.45). Poor to adequate negative correlations were reported for living alone (r = -0.14) and number of both bed days (r = -0.16) and chronic conditions(r = -0.32). There was an unpredicted negative correlation between age and RNLI (r = -0.11).

May and Warren (2002) examined the external and structural components of validity of the spinal cord injury version of the Ferrans and Powers Quality of Life Index (Ferrans & Powers, 1992) in a sample of 98 individuals with spinal cord injury living in the community and reported an excellent correlation with the RNLI (r = -0.65).

Patrick, Perugini, and Leclerc (2002) reported that in a study of 48 consecutive referrals for neuropsychological evaluation following admission to a geriatric rehabilitation inpatient service (for various diagnosis including: orthopedic injury, stroke, functional deconditioning, Parkinson’s disease and other various medical conditions) that the RNLI was significantly correlated to the number of falls sustained and functional status at 6 months. Results of the partial correlations coefficients revealed significant relationships between the RNL and the California Verbal Learning Test (CVLT) (measures memory functioning) and Hooper Visual Organization Test (HVOT – measures spatial skills).
Note: The authors did not report the actual r scores.

Known groups:
Clarke, Black, Badley, Lawrence & Williams, (1999) divided subjects at 3 months and 1 year post-stroke by level of impairment (mild-moderate-severe according to Adam’s Hemispheric stroke Scale), by the presence or absence of Depression (Zung Self-Rating Depression scale), by levels of physical disability (independent-moderately dependent-dependent according to the Functional Independence Measure), RNLI scores for these known groups demonstrated expected gradients and were significantly different as analyzed by analysis of variance. The difference in mean RLNI scores between categories in these analyses ranged from 12% to 62%.

Responsiveness

Wood-Dauphinee, Opzoomer, Williams, Marchand, and Spitzer (1988) administered the RNLI to a sample 70 patients to determine the responsiveness of the RNLI. They concluded that the scale is sensitive to change but the use of subscales provides a more accurate reflection as change (improvement or worsening) in specific domains could be hidden within the total score.

References

  • Bluvol, A., Ford-Gilboe, M. (2004). Hope, health work and quality of life in families of stroke survivors. Journal of Advanced Nursing, 48(4) 322-332.
  • Calmels, P., Pereira, A., Domenach, M., Pallot-Prades, B., Alexandre, C., Minaire, P. (1994). Functional ability and quality of life in rheumatoid arthritis: Evaluation using the Functional Independence Measure and the Reintegration to Normal Living Index. Revue Du Rhumatisme, 61(11), 723-731.
  • Clarke, P. A., Black, S. E., Badley, E. M., Lawrence, J. M., Williams, J. L. (1999). Handicap in stroke survivors. Disability and Rehabilitation, 21(3), 116-123.
  • Daneski, K., Coshall, C., Tilling, K., Wolfe, C.D.A. (2003). Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients. Clinical Rehabilitation, 17, 835-839.
  • Daverat, P., Petit, H., Kemoun, G., Dartigues, J. F., Barat, M. (1995). The long term outcome in 149 patients with spinal cord injury. Paraplegia, 33, 665-668.
  • Dawson, D. R., Levine, B., Schwartz, M., Stuss, D. T. (2000). Quality of life following traumatic brain injury: A prospective study. Brain and Cognition, 44, 35-39.
  • Friedland, J. F., Dawson, D. R. (2001). Function after motor vehicle accidents: A prospective study of mild head injury and posttraumatic stress. The Journal of Nervous and Mental Disease, 189(7), 426-434.
  • Gauthier-Gagnon, C., Grise, M-C. (1994). Prosthetic Profile of the Amputee Questionnaire: Validity and reliability. Archives of Physical Medicine and Rehabilitation, 75, 1309-1314.
  • Gray, D. B., Hollingsworth, H. H., Stark, S. L., Morgan, K. A. (2006). Participation Survey/Mobility: Psychometric properties of a measure of participation for people with mobility impairments and limitations. Archives of Physical Medicine and Rehabilitation, 87(2), 189-197
  • Korner – Bitensky, N., Wood Dauphinee, S., Shapiro, S., Becker, R. (1994). Eliciting health status information by telephone after discharge from hospital: Health professionals versus trained lay persons. Canadian Journal of Rehabilitation, 8(1) 23-34.
  • Korner-Bitensky, N., Wood-Dauphinee, S., Siemiatycki, J., Shapiro, S., Becker, R. (1994). Health related information postdischarge: Telephone versus face-to-face interviewing. Archives of Physical Medicine and Rehabilitation, 75, 1287-1296.
  • May, L. A, Warren, S. (2002). Measuring quality of life of persons with spinal cord injury: external and structural validity. Spinal Cord, 40, 341-350.
  • Mayo, N. E., Wood-Dauphinee S., Cote, R., Gayton, D., Carlton, J., Buttery, J., Tamblyn, R. (2000). There is no place like home: An evaluation of early supported discharge for stroke. Stroke, 31, 1016-1023.
  • Mayo N., Wood-Dauphinee S., Cote R., Durcan L., Carlton J. (2002). Activity, participation & quality of life 6 months post-stroke. Archives of Physical Medicine & Rehabilitation, 83, 1035-1042.
  • McColl, M. A., Paterson, M., Davies, D., Doubt, L., Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67(1), 22-33.
  • Patrick, L., Perugini, M. Leclerc, C. ( 2002). Neuropsychological assessment and competency for independent living among geriatric patients. Topics in Geriatric Rehabilitation, 14(4) 65-77.
  • Stark, D. L., Edwards, D. F., Hollingsworth, H., Grey, D. B. (2005).Validation of the Reintegration to Normal Living Index in a population of community-dwelling people with mobility limitations. Archives of Physical Medicine & Rehabilitation, 86(2), 344-345.
  • Steiner, A., Raube, K., Stuck, A. E., Aronow, H. U., Draper, D., Rubenstein, L. Z., Beck, J. C. (1996). Measuring psychosocial aspects of well-being in older community residents: Performance of four short scales. The Gerontologist, 36(1), 54-62.
  • Tooth, L.R., McKenna, KT., Smith, M., O’Rourke, P.K. (2003). Reliability of scores between stroke patients and significant others on the Reintegration to Normal Living (RNL) Index. Disability and Rehabilitation, 25(9), 433-440.
  • Trombly, C. A., Radomski, M. V., Davis, E. S. (1998). Achievement of self identified goals by adults with traumatic brain injury: Phase 1. The American Journal of Occupational Therapy, 52(10), 810-818.
  • Wood-Dauphinee, S. L., Opzoomer, M. A., Williams, J. I., Marchand, B., Spitzer, W. O. (1988). Assessment of global function: The Reintegration to Normal Living Index. Archives of Physical Medicine and Rehabilitation, 69, 583-590.
  • Wood-Dauphinee, S., Williams, J. I. (1987). Reintegration to normal living as a proxy to quality of life. Journal of Chronic Diseases, 40(6), 491-499.

See the measure

You can obtain the RNLI here.

Please click here to access the french language version. A research version is also available.

Table of contents

SATIS-Stroke

Evidence Reviewed as of before: 15-02-2012
Author(s)*: Katie Marvin, MSc. PT
Editor(s): Nicol Korner-Bitensky, PhD OT; Annabel McDermott, OT

Purpose

The SATIS-Stroke is a questionnaire that can be used to measure satisfaction with activities and participation among patients with stroke. The questions are tailored to assess the individual’s satisfaction with participation in their everyday activities.

In-Depth Review

Purpose of the measure

The SATIS-Stroke is a questionnaire that can be used to measure satisfaction with activities and participation among patients with stroke. The questions are tailored to assess the individual’s satisfaction with participation in their everyday activities. The SATIS-Stroke can be used with patients with chronic stroke regardless of their age, gender, social status, place of residence, delay since stroke and type of stroke.

The SATIS-Stroke includes 36 items, covering the 9 ICF domains: learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, and community, social and civic life. The 36 items are sorted and numbered in order of decreasing satisfactory level, meaning that the first item (moving outside your home in any circumstance) requires the highest satisfactory level in order to be performed, whereas the last item (listening to and watching television according to your needs) requires the lowest satisfactory level.

Available versions

There are no alternative versions.

Features of the measure

Items:
There are no actual items to the MTS.

Description of tasks:
The patient is asked to rate their perceived satisfaction in performing each of the following daily activities and life situations using a 4-point scale.

  1. Moving outside your home in any circumstances
  2. Climbing and going downstairs all stages in your home according to your needs
  3. Using knife, fork and spoon in all circumstances
  4. Having a sexual relationship with somebody
  5. Using coins and banknotes in all circumstances
  6. Participating in spoken exchange of information with your entourage
  7. To supplement administrative documents in all circumstances
  8. Washing your hair according to your needs
  9. Taking a bath or your shower according to your needs
  10. Undresssing to use the toilet and redressing in your home or outside of it
  11. Entering and exiting home your home according to your needs
  12. Participating in arts and culture (cinema, theatre, etc.)
  13. Reaching objects in your near space
  14. Dressing and undressing in all circumstances and according to your needs
  15. Managing your income in all circumstances
  16. Getting clothes out of the closet
  17. Using storage spaces in your house
  18. Participating in spousal relationships
  19. Ensuring that your rights are respected
  20. Carrying out your personal hygiene according to your needs
  21. Asking for help in an emergency situation
  22. Reading and understanding a document in all circumstances
  23. Moving inside your home
  24. Managing your pain in all circumstances
  25. Using the telephone at home according to your needs
  26. Maintaining emotional relationships
  27. Expressing oneself to someone
  28. Having urinary continence in your home and outside of it
  29. Participating in food and drink preparation in all circumstances
  30. Opening and closing doors in your home
  31. Co-operating with your entourage
  32. Being aware of what surrounds you
  33. Participating in ceremonies (marriage, gathering family, etc)
  34. Choosing appropriate clothes
  35. Getting feelings across
  36. Listening to and watching television according to your needs

Scoring and Score Interpretation:
The 36 items are sorted and numbered in order of decreasing satisfactory level, meaning that the first item requires the most amount of satisfaction in order to perform the task, whereas the last item requires the least amount of satisfaction in order to perform the task.

Perceived satisfaction is rated on a 4-point scale.

  1. Very dissatisfied
  2. Dissatisfied
  3. Satisfied
  4. Very Satisfied

Scores range from 0 to 105 with a higher score indicating greater perceived satisfaction with tasks.

Information on score interpretation is not yet available.

Time:
Not reported.

Training requirements:
No training requirements have been reported.

Subscales:
None reported.

Equipment:
None required.

Alternative forms of the SATIS-Stroke

There are no alternative forms of the SATIS-Stroke.

Client suitability

Can be used with:

  • Patients with chronic stroke regardless of their age, gender, social status, place of residence, delay since stroke and type of stroke (Bouffioulx et al., 2008).

Should not be used with:

  • Patients with cognitive deficits, as these patients were excluded from the original validation study (Bouffioulx et al., 2008).

In what languages is the measure available?

English, french.

Summary

What does the tool measure? Patients’ perceived satisfaction with activities and participation.
What types of clients can the tool be used for? Clients with stroke.
Is this a screening or assessment tool? Assessment tool.
Time to administer Not reported.
Versions None reported.
Other Languages English and French.
Measurement Properties
Reliability Test-retest:
One study examined the test-retest reliability of the SATIS-Stroke and found excellent test-retest reliability.
Validity Criterion:
Concurrent:
One study examined the concurrent validity between the SATIS-Stroke and the Barthel Index and found excellent correlation between the two measures.
Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the SATIS-Stroke.
Does the tool detect change in patients? One study examined the ability of the SATIS-Stroke to detect change and reported that the SATIS-Stroke had a large ability to detect change from the acute to chronic phase of stroke.
Acceptability Results support preliminary validation of the psychometric properties, however further research is needed before the tool is ready for use clinically.
Feasibility The administration of the SATIS-Stroke is easy and simple to administer.
How to obtain the tool? Information on the SATIS-Stroke can be obtained from the article by Bouffioulx, Arnould and Thonnard (2008).

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the SATIS-Stroke and revealed only the initial validation study. Results support preliminary validation of the psychometric properties, however further research is needed before the tool is ready for clinical use.

Floor/Ceiling Effects

Floor or ceiling effects of the SATIS-Stroke have not been examined.

Reliability

Internal consistency:
Internal consistency of the SATIS-Stroke has not been examined.

Test-retest:
Bouffioulx, Arnould and Thonnard (2008) examined the test-retest reliability of the SATIS-Stroke in 101 patients with stroke. The SATIS-Stroke was administered two times, with an interval of 32 days between each administration. Excellent test-retest reliability was found, as calculated using Intraclass Correlation Coefficient (ICC=0.98, p<0.001).

Intra-rater:
Intra-rater reliability of the SATIS-Stroke has not been examined.

Inter-rater:
Inter-rater reliability of the SATIS-Stroke has not been examined.

Validity

Content:
Content validity of the SATIS-Stroke has not been examined.

Criterion:
Concurrent:
Bouffioulx, Arnould and Thonnard (2008) investigated the concurrent validity between the SATIS-Stroke and the Barthel Index. An excellent (r=0.74, p<0.05) Correlation was found between the two measures. Results from this study suggest that independence in activity and life situations is related to patient ratings of perceived satisfaction.

Predictive:
Predictive validity of the SATIS-Stroke has not been examined.

Construct:
Convergent/Discriminant:
The convergent or discriminant of the SATIS-Stroke validity has not been examined.

Known groups:
The known groups validity of the SATIS-Stroke has not been examined.

Sensitivity/ Specificity:
The Sensitivity or Specificity of the SATIS-Stroke has not been examined.

Responsiveness

Bouffioulx, Arnould, Vandervelde and Thonnard (2010) examined the responsiveness of the SATIS-Stroke in 45 patients with acute, subacute or chronic stroke. The SATIS-Stroke was administered at 1 week (acute), 3 months (subacute) and six months (chronic) following onset of stroke. The patients were also asked to subjectively rate their perceptions of change in overall functional status at the three time points, which was then used to classify their status as ‘deteriorating’, ‘stable’ or ‘improved’. The SATIS-Stroke was found to have the greatest responsiveness for detecting change in patients’s function from the acute to chronic phase, demonstrating a large effect size (effect size=1.12, standardized response mean=0.62). The SATIS-Stroke was found to be less responsive from the acute to subacute phase (effect size=0.76, standardized response mean 0.59) and from the sub-acute to chronic phase (effect size=0.42, standardized response mean=0.27); however, it may be that less drastic changes in satisfaction may be occurring during these time periods. This study also reviewed the minimal clinically important difference but concluded that further investigate is necessary.

References

  • Bouffioulx, E., Arnould, C. & Thonnard, J-L. (2008). SATIS-Stroke: A satisfaction measure of activities and participation in the actual environment experienced by patients with chronic stroke. Journal of Rehabilitation Medicine, 40, 836-843.
  • Bouffioulx, E., Arnould, C. Vandervelde, L. & Thonnard, J-L. (2010). Changes in satisfaction with activities and participation between acute, post-acute and chronic stroke phases: A responsiveness study of the SATIS-Stroke questionnaire. Journal of Rehabilitation Medicine, 42, 944-948.

See the measure

How to obtain the SATIS-Stroke?

Information on the SATIS-Stroke can be obtained from the Bouffioulx, Arnould and Thonnard (2008) article.

Table of contents

Stroke Impact Scale (SIS)

Evidence Reviewed as of before: 29-06-2018
Author(s)*: Lisa Zeltzer, MSc OT; Katherine Salter, BA; Annabel McDermott
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Stroke Impact Scale (SIS) is a stroke-specific, self-report, health status measure. It was designed to assess multidimensional Stroke outcomes, including strength, hand function Activities of Daily Living / Instrumental Activities of Daily Living (ADL/IADL), mobility, communication, emotion, memory and thinking, and participation. The SIS can be used both in clinical and in research settings.

In-Depth Review

Purpose of the measure

The Stroke Impact Scale (SIS) is a stroke-specific, self-report, health status measure. It was designed to assess multidimensional Stroke outcomes, including strength, hand function, Activities of Daily Living / Instrumental Activities of Daily Living (ADL/IADL), mobility, communication, emotion, memory and thinking, and participation. The SIS can be used both in clinical and research settings.

Available versions

The Stroke Impact Scale was developed at the Landon Center on Aging, University of Kansas Medical Center. The scale was first published as version 2.0 by Duncan, Wallace, Lai, Johnson, Embretson, and Laster in 1999. Version 2.0 of the SIS is comprised of 64 items in 8 domains (Strength, Hand function, Activities of Daily Living (ADL) / Instrumental ADL, Mobility, Communication, Emotion, Memory and thinking, participation). Based on the results of a Rasch analysis process, 5 items were removed from version 2.0 to create the current version 3.0 (Duncan, Bode, Lai, & Perera, 2003b).

Features of the measure

Items:

The SIS version 3.0 includes 59 items and assesses 8 domains:

  • Strength – 4 items
  • Hand function – 5 items
  • ADL/IADL – 10 items
  • Mobility – 9 items
  • Communication – 7 items
  • Emotion – 9 items
  • Memory and thinking – 7 items
  • participation/Role function – 8 items

An extra question on Stroke recovery asks that the client rate on a scale from 0 – 100 how much the client feels that he/she has recovered from his/her Stroke.

To see the items of the SIS, please click here.

Instructions on item administration:

Prior to administering the SIS, the purpose statement must be read as written below. It is important to tell the respondent that the information is based on his/her point of view.

Purpose statement:
“The purpose of this questionnaire is to evaluate how Stroke has impacted your health and life. We want to know from your point of view how Stroke has affected you. We will ask you questions about impairments and disabilities caused by your Stroke, as well as how Stroke has affected your quality of life. Finally, we will ask you to rate how much you think you have recovered from your Stroke”.

Response sheets in large print should be provided with the instrument, so that the respondent may see, as well as hear, the choice of responses for each question. The respondent may either answer with the number or the text associated with the number (eg. “5” or “Not difficult at all”) for an individual question. If the respondent uses the number, it is important for the interviewer to verify the answer by stating the corresponding text response. The interviewer should display the sheet appropriate for that particular set of questions, and after each question must read all five choices.

Questions are listed in sections, or domains, with a general description of the type of questions that will follow (eg. “These questions are about the physical problems which may have occurred as a result of your Stroke”). Each group of questions is then given a statement with a reference to a specific time period (eg. “In the past week how would you rate the strength of your…”). The statement must be repeated before each individual question. Within the measure the time period changes from one week, to two weeks, to four weeks. It is therefore important to emphasize the change in the time period being assessed for the specific group of questions.

Scoring:

The SIS is a patient-based, self-report questionnaire. Each item is rated using a 5-point Likert scale. The patient rates his/her difficulty completing each item, where:

  • 1 = an inability to complete the item
  • 5 = no difficulty experienced at all.

Note: Scores for three items in the Emotion domain (3f, 3h, 3i) must be reversed before calculating the Emotion domain score (i.e. 1 » 5, 2 » 4, 3 = 3, 4 » 2, 5 » 1). The SIS scoring database (see link below) takes this change of direction into account when scoring. When scoring manually, use the following equation to compute the item score for 3f, 3h and 3i: Item score = 6 – individual’s rating.

A final single-item Recovery domain assesses the individual’s perception of his/her recovery from Stroke, measured in the form of a visual analogue scale from 0-100, where:

  • 0 = no recovery
  • 100 = full recovery.

Domain scores range from 0-100 and are calculated using the following equation:

  • Domain score = [(Mean item score – 1) / 5-1 ] x 100

Scores are interpreted by generating a summative score for each domain using an algorithm equivalent to that used in the SF-36 (Ware & Sherbourne, 1992).

See http://www.kumc.edu/school-of-medicine/preventive-medicine-and-public-health/research-and-community-engagement/stroke-impact-scale/instructions.html to download the scoring database.

Time:

The SIS is reported to take approximately 15-20 minutes to administer (Finch, Brooks, Stratford, & Mayo, 2002).

Subscales:

The SIS 3.0 is comprised of 8 subscales or ‘Domains’:

  1. Strength
  2. Hand function
  3. ADL/IADL
  4. Mobility
  5. Communication
  6. Emotion
  7. Memory and thinking
  8. participation

A final single-item domain measures perceived recovery since Stroke onset.

Equipment:

Only the scale and a pencil are needed.

Training:

The SIS 3.0 requires no formal training for administration (Mulder & Nijland, 2016). Instructions for administration of the SIS 3.0 are available online through the University of Kansas Medical Center SIS information page.

Alternative forms of the SIS

SIS-16 (Duncan et al., 2003a).

Duncan et al. (2003) developed the SIS-16 to address the lack of sensitivity to differences in physical functioning in functional measures of Stroke outcome. Factor analysis of the SIS 2.0 revealed that the four physical domains (Strength, Hand function, ADL/IADL, Mobility) are highly correlated and can be summed together to create a single physical dimension score (Duncan et al., 1999; Mulder & Nijland, 2016). Accordingly, the SIS-16 consists of 16 items from the SIS 2.0:

  1. ADL/IADL – 7 items
  2. Mobility – 8 items
  3. Hand Function – 1 item.

All other domains should remain separate (Duncan et al., 1999).

SF-SIS (Jenkinson et al., 2013).

Jenkinson et al. (2013) developed a modified short form of the SIS (SF-SIS) comprised of eight items. The developers selected the one item from each domain that correlated most highly with the total domain score, through three methods: initial pilot research, validation analysis and a focus group. The final choice of questions for the SF-SIS comprised those items that were chosen by methods on 2 or more occasions. The SF-SIS was evaluated for face validity and acceptability within a focus group of patients from acute and rehabilitation Stroke settings and with multidisciplinary Stroke healthcare staff. The SF-SIS has also been evaluated for content, convergent and discriminant validity (MacIsaac et al., 2016).

Client suitability

Can be used with:

  • The SIS can only be administered to patients with Stroke.
  • The SIS 3.0 and SIS-16 can be completed by telephone, mail administration, by proxy, and by proxy mail administration (Duncan et al., 2002a; Duncan et al., 2002b; Kwon et al., 2006). Studies have shown potential proxy bias for physical domains (Mulder & Nijland, 2016). It is recommended that possible responder bias and the inherent difficulties of proxy use be weighed against the economic advantages of a mailed survey when considering these methods of administration.

Should not be used with:

  • The SIS version 2.0 should be used with caution in individuals with mild impairment as items in the Communication, Memory and Emotion domains are considered easy and only capture limitations in the most impaired individuals (Duncan et al., 2003).
  • Respondents must be able to follow a 3-step command (Sullivan, 2014).
  • Time taken to administer the SIS is a limitation for individuals with difficulties with concentration, attention or fatigue following Stroke (MacIsaac et al., 2016).

In what languages is the measure available?

The SIS was originally developed in English.

Cultural adaptations, translations and psychometric testing have also been conducted in the following languages:

  • Brazilian (Carod-Artal et al., 2008)
  • French (Cael et al., 2015)
  • German (Geyh, Cieza & Stucki, 2009)
  • Italian (Vellone et al., 2010; Vellone et al., 2015)
  • Japanese (Ochi et al., 2017)
  • Korean (Choi et al., 2017; Lee & Song, 2015)
  • Nigerian (Hausa) (Hamza et al., 2012; Hamza et al., 2014)
  • Portuguese (Goncalves et al., 2012; Brandao et al., 2018)
  • Ugandan (Kamwesiga et al., 2016)
  • United Kingdom (Jenkinson et al., 2013)

The MAPI Research Institute has translated the SIS and/or SIS-16 into numerous languages including Afrikaans, Arabic, Bulgarian, Cantonese, Czech, Danish, Dutch, Farsi, Finnish, French, German, Greek, Hebrew, Hungarian, Icelandic, Italian, Japanese, Korean, Malay, Mandarin, Norwegian, Portuguese, Russian, Slovak, Spanish, Swedish, Tagalog, Thai and Turkish. Translations may not be validated.

Summary

What does the tool measure? Multidimentional stroke outcomes, including strength, hand function, Activities of daily living/Instrumental Activities of daily living, mobility, communication, emotion, memory, thinking and participation.
What types of clients can the tool be used for? Patients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer The SIS takes 15-20 minutes to administer.
Versions SIS 2.0, SIS 3.0, SIS-16, SF-SIS.
Other Languages The SIS has been translated into several languages. Please click here to see a list of translations.
Measurement Properties
Reliability Internal consistency:
SIS 2.0:
Two studies reported excellent Internal consistency; one study reported excellent Internal consistency for 5/8 domains and adequate Internal consistency for 3/8 domains.

SIS 3.0:
Two studies reported excellent Internal consistency; one study reported excellent Internal consistency for 6/8 domains and adequate Internal consistency for 2/8 domains.

SIS-16:
One study reported good spread of item difficulty.

SF-SIS:
One study reported excellent Internal consistency.

Test-retest:
SIS 2.0:
One study reported adequate to excellent test-rest Reliability in all domains except for the Emotion domain.

Validity Criterion :
Concurrent:
SIS 2.0:
Excellent correlations with the Barthel Index, FMA, nstrumental Activities of Daily Living (IADL) Scale, Duke Mobility Scale and Geriatric Depression Scale; adequate to excellent correlations with the FIM; adequate correlations with the NIHSS and MMSE; and poor to excellent correlations with the SF-36.

SIS 3.0:
Excellent correlation between SIS Hand Function and MAL-QOM; excellent correlation between SIS ADL/IADL and FIM, Barthel Index, Lawton IADL Scale; excellent correlation between SIS Strength and Motricity Index; excellent correlation between SIS Mobility and Barthel Index; adequate to excellent correlation between SIS ADL/IADL and NEADL; adequate correlation between SIS Social participation and SF-36 Social Functioning, Lawton IADL scale; adequate correlation between SIS Memory domain and MMSE; poor to adequate correlations between remaining SIS domains and FIM, NEADL, FMA, MAL-AOU, MAL-QOM, FAI.

SIS-16:
Excellent correlation with the Barthel Index; adequate to excellent correlations with the STREAM total and subscale scores; adequate correlation with SF-36 Physical Functioning.

Predictive:
SIS 2.0:
Physical function, Emotion and participation domains were statistically significant predictors of the patient’s own assessment of recovery; SIS scores were poor predictors of mean steps per day.

SIS 3.0:
Pre-treatment SIS scores were compared with outcome measures after 3 weeks of upper extremity rehabilitation: Hand function and ADL/IADL domains showed adequate to excellent correlations with FIM, FMA, MAL-AOU, MAL-QOM, FAI, and NEADL; other domains demonstrated poor to adequate correlations with outcome measures.

SIS-16:
– Admission scores show an excellent correlation with actual length of stay and an adequate correlation with predicted length of stay; there was a significant correlation with discharge destination (home/rehabilitation).
– The combination of early outcomes of MAL-QOM and SIS show high accuracy in predicting final QOL among patients with stroke.

Construct:
Convergent/Discriminant:
SIS 2.0:
Domains demonstrate adequate to excellent correlations with corresponding WHOQOL-BREF subscales and Zung’s Self-Rating Depression Scale; poor correlations between the SIS Communication domain and both WHOQOL-BREF and Zung’s Self-Rating Depression Scale; and a poor correlation between the SIS Physical domain and the WHOQOL Environment scores.

SIS 3.0:
Excellent correlation with the SF-SIS, EQ-5D, mRS, BI, NIHSS, EQ-5D; moderate to excellent correlations with the EQ-VAS; and a moderate correlation with the SIS-VAS.

SIS 3.0 telephone survey:
Adequate to excellent correlations with the FIM and SF-36V.

SIS-16:
Adequate to excellent correlations with the WHOQOL-BREF Physical domain; poor correlation with the WHOQOL Social relationships domain.

SF-SIS:
Excellent correlations with the EQ-5D, mRS, BI, NIHSS, EQ-5D; moderate to excellent correlations with the EQ-VAS; and moderate correlation with the SIS-VAS.

Known groups:
SIS 2.0: Most domains can differentiate between patients with varying degrees of stroke severity.

SIS 3.0:
Physical and ADL/IADL domains showed score discrimination and distribution for different degrees of stroke severity.

SIS-16:
Can discriminate between patients of varying degrees of stroke severity.

Floor/Ceiling Effects Three studies have examined floor/ceiling effects of the SIS.

SIS 2.0:
Two studies reported the potential for floor effects in the domain of Hand function among patients with moderate stroke severity, and a potential for ceiling effects in the Communication, Memory and Emotion domains.

SIS 3.0:
One study reported minimal floor and ceiling effects for the Social participation domain; one study reported ceiling effects for the Hand function, Memory and thinking, Communication, Mobility and ADL/IADL domains over time.

SIS-16:
One study reported no floor effects and minimal ceiling effects.

Does the tool detect change in patients? Five studies have investigated responsiveness of the SIS.

SIS 2.0:
One study reported significant change in patients’ recovery in the expected direction between assessments at 1 and 3 months, and at 1 and 6 months post-stroke, however sensitivity to change was affected by stroke severity and time of post-stroke assessment.

SIS 3.0:
– One study determined change scores for a clinically important difference (CID) within four subscales of the Strength, ADL/IADL, Mobility, Hand function. The MDC was 24.0, 17.3, 15.1 and 25.9 (respectively); minimal CID was 9.2, 5.9, 4.5 and 17.8 (respectively).
– One study reported medium responsiveness for Hand function, stroke recovery and SIS total score; other domains showed small responsiveness.
– One study found participation and Recovery from stroke were the most responsive domains over the first year post-stroke; Strength and Hand function domains also showed high clinically meaningful positive/negative change.

SIS-16:
One study reported change scores of 23.1 indicated statistically significant improvement from admission to discharge, and sensitivity to change was large.

Acceptability – SIS 3.0 and SIS-16 are available in proxy version. The patient-centred nature of the scale’s development may enhance its relevance to patients and assessment across multiple levels may reduce patient burden.
– Time taken to administer the SIS has been identified as a limitation.
– The SIS 2.0 should be used with caution in individuals with mild impairment as some domains only capture limitations in the most impaired individuals.
Feasibility – The SIS is a patient-based self-report scale that takes 15-20 minutes to administer.
– The SIS can be administered in person or by proxy, by mail or telephone.
– The SIS does not require any formal training.
– Instructions for administration of the SIS 3.0 are available online.
How to obtain the tool?

Please click here to see a copy of the SIS.

Psychometric Properties

Overview

We conducted a literature search to identify relevant publications on the psychometric properties of the SIS. Seventeen studies were included. Studies included in this review are specific to the original English versions of the SIS version 2.0, SIS 3.0 or SIS-16.

Floor/Ceiling Effects

Duncan et al. (1999) found that SIS version 2.0 showed the potential for floor effects in the Hand function domain in the moderate stroke group (40.2%) and a possible ceiling effect in the Communication domain for both the mild (35.4%) and moderate (25.7%) stroke groups. The highest percentage of ceiling effects for the SIS was for the Communication domain (35%) compared with a 64.6% ceiling rate for the Barthel Index (Mahoney & Barthel, 1965).

Duncan et al. (2003b) conducted a Rasch analysis which confirmed these two effects observed in Duncan et al. (1999) – a floor effect in the SIS Hand function domain and a ceiling effect in the Communication domain. A ceiling effect in the Memory and Emotion domains was also reported.

Lai et al. (2003) examined floor/ceiling effects of the SIS-16 and SIS Social Participation domain in a sample of 278 patients at 3 months post-stroke. The authors reported floor/ceiling effects of 0% and 4% (respectively) for the SIS-16, and 1% and 5% (respectively) for the SIS Social Participation domain.

Richardson et al. (2016) examined floor/ceiling effects of the SIS 3.0 in a sample of 164 patients with subacute stroke. Measures were taken at three timepoints: on admission to the study and at 6-month and 12-month follow-up (n=164, 108, 37 respectively). Poor ceiling effects (>20%) were seen for the Hand function domain at baseline, 6 months and 12 months (25.0%, 36.4%, 37.8%, respectively); the Memory and thinking domain at 6 months and 12 months (22.2%, 21.6%, respectively); the Communication domain at 6 months and 12 months (30.6%, 27%, respectively); the Mobility domain at 6 months (20.4%); and the ADL/IADL domain at 12 months (21.6%). There were no significant floor effects at any timepoint.

Reliability

Internal consistency:
Duncan et al (1999) examined Internal consistency of the SIS version 2.0 using Cronbach’s alpha coefficients and reported excellent Internal consistency for each of the 8 domains (ranging from a=0.83 to 0.90).

Duncan et al. (2003b) examined reliability of the SIS version 2.0 by Rasch analysis. Item separation reliability is the ratio of the “true” (observed minus error) variance to the obtained variation. The smaller the error, the higher the ratio will be. It ranges from 0.00 to 1.00 and is interpreted the same as the Cronbach’s alpha. Item separation reliability of the SIS version 2.0 ranged from 0.93-1.00. A separation index > 2.00 is equivalent to a Cronbach’s alpha of 0.80 or greater (excellent). In this study, 5 out of 8 domains had a separation index that exceeded 2.00 (in addition to the composite physical domain). The values for the Emotion and Communication domains were only in the adequate range because of the ceiling effect in those domains and those for the Hand function domain were only adequate because of the floor effect in that domain.

Edwards and O’Connell (2003) administered the SIS version 2.0 to 74 patients with stroke and reported excellent Internal consistency (ranging from a=0.87 for Participation to a=0.95 for hand function). The percentage of item-domain correlations >0.40 was 100% for all domains except emotion and ADL/IADL. In the ADL/IADL scale, one item (cutting food) was more closely associated with hand function than ADL/IADL.

Lai et al. (2003) examined reliability of the SIS-16 and SIS Social Participation domain in a sample of 278 patients at 3 months post-stroke. Both the SIS-16 and SIS Social Participation domain showed good spread of item difficulty, with easier items that are able to measure lower levels of physical functioning in patients with severe stroke.

Jenkinson et al. (2013) examined Internal consistency of the SIS 3.0 and the SF-SIS among individuals with stroke (n=73, 151 respectively), using Cronbach’s alpha. Internal consistency of the SIS 3.0 was excellent for all domains (a=0.86 to 0.96). Higher order factor analysis of the SIS 3.0 showed one factor with an eigenvalue > 1 that accounted for 68.76% of the variance. Each dimension of the SIS 3.0 loaded on this factor (eigen value = 5.5). Internal consistency of the SF-SIS was high (a=0.89). Factor analysis of the SF-SIS similarly showed one factor that accounted for 57.25% of the variance.

Richardson et al. (2016) examined Internal consistency of the SIS 3.0 in a sample of 164 patients with subacute stroke, using Cronbach’s alpha. Internal consistency was measured at three timepoints: on admission to the study and at 6-month and 12-month follow-up. Internal consistency of all domains was excellent at all timepoints (a=0.81 to 0.97). The composite Physical Functioning score was excellent at all timepoints (a=0.95 to 0.97).

MacIsaac et al. (2016) examined Internal consistency of the SIS 3.0 in a sample of 5549 individuals in an acute stroke setting and 332 individuals in a stroke rehabilitation setting, using Cronbach’s alpha. Internal consistency was excellent within both acute and rehabilitation data sets (a=0.98, 0.93 respectively). Internal consistency of individual domains was excellent for both acute and rehabilitation data sets, except for the Emotion domain (a=0.60, 0.63 respectively) and the Strength domain (a=0.77, rehabilitation data set only).

Test-retest:
Duncan et al. (1999) examined test-retest reliability of the SIS version 2.0 in 25 patients who were administered the SIS at 3 or 6 months post stroke and again one week later. Test-retest was calculated using intraclass correlation coefficients (ICC), which ranged from adequate to excellent (ICC=0.7 to 0.92) with the exception of the Emotion domain, which had only a poor correlation (ICC=0.57).

Validity

Content:

Development of the SIS was based on a study at the Landon Center on Aging, University of Kansas Medical Center (Duncan, Wallace, Studenski, Lai, & Johnson, 2001) using feedback from individual interviews with patients and focus group interviews with patients, caregivers, and health care professionals. Participants included 30 individuals with mild and moderate stroke, 23 caregivers, and 9 stroke experts. Qualitative analysis of the individual and focus group interviews generated a list of potential items. Consensus panels reviewed the potential items, established domains for the measure, developed item scales, and decided on mechanisms for administration and scoring.

Criterion:

Concurrent:
Duncan et al. (1999) examined concurrent validity of the SIS by comparison with the Barthel Index, Functional Independence Measure (FIM), Fugl-Meyer Assessment (FMA), Mini-Mental State Examination (MMSE), National Institute of Health stroke Scale (NIHSS), Medical Outcomes Study Short Form 36 (SF-36), Lawton Instrumental Activities of Daily Living (IADL) Scale, Duke Mobility Scale and Geriatric Depression Scale. The following results were found for each domain of the SIS:

SIS Domain Comparative Measure correlation Rating
Hand function FMA – Upper Extremity Motor r = 0.81 Excellent
Mobility FIM Motor r = 0.83 Excellent
Barthel Index r = 0.82 Excellent
Duke Mobility Scale r = 0.83 Excellent
SF-36 Physical Functioning r = 0.84 Excellent
Strength NIHSS Motor r = -0.59 Adequate
FMA Total r = 0.72 Excellent
ADL/IADL Barthel Index r = 0.84 Excellent
FIM Motor r = 0.84 Excellent
Lawton IADL Scale r = 0.82 Excellent
Memory MMSE r = 0.58 Adequate
Communication FIM Social/Cognition r = 0.53 Adequate
NIHSS Language r = -0.44 Adequate
Emotion Geriatric Depression Scale r = -0.77 Excellent
SF-36 Mental Health r = 0.74 Excellent
Participation SF-36 Emotional Role r = 0.28 Poor
SF-36 Physical Role r = 0.45 Adequate
SF-36 Social Functioning r = 0.70 Excellent
Physical Barthel Index r = 0.76 Excellent
FIM Motor r = 0.79 Excellent
SF-36 Physical Functioning r = 0.75 Excellent
Lawton IADL Scale r = 0.73 Excellent

Duncan et al. (2002a) examined concurrent validity of the SIS version 3.0 and SIS-16 using Pearson correlations. The SIS was correlated with the Mini-Mental State Examination (MMSE), Barthel Index, Lawton IADL Scale and the Motricity Index. The SIS ADL/IADL domain showed an excellent correlation with the Barthel Index (r=0.72) and with the Lawton IADL Scale (r=0.77). The SIS Mobility domain showed an excellent correlation with the Barthel Index (r=0.69). The SIS Strength domain showed an excellent correlation with the Motricity Index (r=0.67). The SIS Memory domain showed an adequate correlation with the MMSE (r=0.42).

Lai et al. (2003) examined concurrent validity of the SIS-16 and SIS Social Participation domain by comparison with the SF-36 Physical Functioning and Social Functioning subscales, Barthel Index and Lawson IADL Scale, using Pearson correlation coefficients. Measures were administered to 278 patients with stroke at 3 months post-stroke. There was an adequate correlation between SIS-16 and SF-36 Physical Functioning (r=0.79), and an adequate correlation between SIS Social Participation and SF-36 Social Functioning (r=0.65). There was an excellent correlation between SIS-16 and the Barthel Index at 3 months post-stroke (r=0.75), and an adequate correlation between SIS Social Participation and Lawton IADL Scale at 3 months post-stroke (r=0.47).

Lin et al. (2010a) examined concurrent validity of the SIS version 3.0 by comparison with the Fugl-Meyer Assessment (FMA), Motor Activity Log – Amount of Use and – Quality of Movement (MAL-AOU, MAL-QOM), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Nottingham Extended Activities of Daily Living Scale (NEADL). concurrent validity was measured using Spearman correlation coefficients prior to and on completion of a 3-week intervention period. SIS Hand Function showed an excellent correlation with MAL-QOM at pre-treatment and post-treatment (r=0.65, 0.68, respectively, p<0.01), and adequate correlations with all other measures (FMA, MAL-AOU, FIM, FAI, NEADL). SIS ADL/IADL showed an excellent correlation with the FIM at pre-treatment and post-treatment (r=0.69, 0.75, respectively, p<0.01). Correlations between SIS ADL/IADL and the NEADL were adequate at pre-treatment (r=0.54, p<0.01) and excellent at post-treatment (r=0.62, p<0.01). Correlations between the SIS ADL-IADL and all other measures (FMA, MAL-AOU, MAL-QOM, FAI) were adequate at pre-treatment and post-treatment. Other SIS domains demonstrated poor to adequate correlations with comparison measures.

Ward et al. (2011) examined concurrent validity of the SIS-16 by comparison with the stroke Rehabilitation Assessment of Movement (STREAM), using Spearman correlations. Measures were administered to 30 patients with acute stroke on admission to and discharge from an acute rehabilitation setting. Correlations between the SIS-16 and STREAM total and subscale scores were adequate to excellent on admission (STREAM total r=0.7073; STREAM subtests r=0.5992 to 0.6451, p<0.0005) and discharge (STREAM total r=0.7153; STREAM subtests r=0.5499 to 0.7985, p<0.0002).

Richardson et al. (2016) examined concurrent validity of the SIS 3.0 by comparison with the 5-level EuroQol 5D (EQ-5D-5L), using Pearson correlation coefficients. Measures were administered to patients with subacute stroke on admission to the study and at 6-month and 12-month follow-up (n=164, 108, 37, respectively). At admission correlations with the EQ-5D-5L were excellent for the ADL (r=0.663) and Hand function (r=0.618) domains and Physical composite score (r=0.71); correlations with other domains were adequate (r=0.318 to 0.588), except for the Communication domain (r=0.228). At 6-month follow-up correlations with the EQ-5D-5L were excellent for the Strength (r=0.628), ADL (r=0.684), Mobility (r=0.765), Hand function (r=0.668), Participation (r=0.740) and Recovery domains (r=0.601) and Physical composite score (r=0.772); correlations with other domains were adequate (r=0.402 to 0.562). At 12-month follow-up correlations with the EQ-5D-5L were excellent for the Strength (r=0.604), ADL (r=0.760), Mobility (r=0.683) and Participation (r=0.738) domains and the Physical composite score (r=756); correlations with other domains were adequate (r=0.364 to 0.592).

Predictive:
Duncan et al. (1999) examined which domain scores of the SIS version 2.0 could most accurately predict a patient’s own assessment of stroke recovery, using multiple regression analysis. The SIS domains of Physical function, Emotion, and Participation were found to be statistically significant predictors of the patient’s assessment of recovery. Forty-five percent of the variance in the patient’s assessment of percentage of recovery was explained by these factors.

Fulk, Reynolds, Mondal & Deutsch (2010) examined the predictive validity of the 6MWT and other widely used clinical measures (FMA-LE, self-selected gait-speed, SIS and BBS) in 19 patients with stroke. The SIS was found to be a poor predictor of mean steps per day (r=0.18, p=0.471). Although gait speed and balance were related to walking activity, only the 6MWT was found to be a predictor of community ambulation in patients with stroke.

Huang et al. (2010) examined change in quality of life after distributed constraint-induced movement therapy (CIMT) in a sample of 58 patients with chronic stroke, using CHAID analysis. Predictors of change included age, gender, side of lesion, time since stroke, cognitive status (measured by the MMSE), upper extremity motor impairment (measured by the FMA-UE) and independence in Activities of daily living (measured by the FIM). Initial FIM scores were the strongest predictor of overall SIS score (p=0.006) and ADL/IADL domain score (p=0.004) at post-treatment. Participants with FIM scores ≤ 109 showed significantly greater improvement in overall SIS scores than participants with FIM scores > 109. There were no significant associations between other SIS domains and other predictors.

Lin et al. (2010a) examined predictive validity of the SIS version 3.0 by comparing pre-treatment SIS scores with post-treatment scores of the Fugl-Meyer Assessment (FMA), Motor Activity Log – Amount of Use and – Quality of Movement (MAL-AOU, MAL-QOM), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Nottingham Extended Activities of Daily Living Scale (NEADL). predictive validity was measured using Spearman correlation coefficients prior to and on completion of a 3-week intervention period. The SIS Hand Function showed excellent correlations with MAL-AOU (r=0.61, p<0.01) and MAL-QOM (r=0.66, p<0.01), and adequate correlations with all other measures (FMA, FIM, FAI, NEADL). The SIS ADL/IADL showed an excellent correlation with the FIM (r=0.70, p<0.01), and adequate correlations with all other measures (FMA, MAL-AOU, MAL-QOM, FAI, NEADL). Other SIS domains demonstrated poor to adequate correlations with comparison measures.

Ward et al. (2011) examined predictive validity of the SIS-16 and other clinical measures (STREAM, FIM) in a sample of 30 patients in an acute rehabilitation setting, using Spearman rho coefficients and Wilcoxon rank-sum tests. Results indicated an adequate correlation between SIS-16 admission scores and predicted length of stay (rho=-0.6743, p<0.001) and an excellent correlation between SIS-16 admission scores and actual length of stay (rho=-0.7953, p<0.001). There was an significant correlation with discharge destination (p<0.05).

Lee et al. (2016) developed a computational method to predict quality of life after stroke rehabilitation, using Particle Swarm-Optimized Support Vector Machine (PSO-SVM) classifier. A sample of 130 patients with subacute/chronic stroke received occupational therapy for 1.5-2 hours/day, 5 days/week for 3-4 weeks. Predictors of outcome included 5 personal parameters (age, gender, time since stroke onset, education, MMSE score) and 9 early functional outcomes (Fugl-Meyer Assessment, Wolf Motor Function Test, Action Research Arm Test, Functional Independence Measure, Motor Activity Log – Amount of Use (MAL-AOU) and – Quality of Movement (MAL-QOM), ABILHAND, physical function, SIS). The combination of early outcomes of MAL-QOM and SIS showed highest accuracy (70%) and highest cross-validated accuracy (81.43%) in predicting final QOL among patients with stroke. SIS alone showed high accuracy (60%) and cross-validated accuracy (81.43%).

Construct:

Duncan et al. (2003b) performed a Rasch analysis on version 2.0 of the SIS. For measures that have been developed using a conceptual hierarchy of items, the theoretical ordering can be compared with the empirical ordering produced by the Rasch analysis as evidence of the construct validity of the measure. In this study, the expectation regarding the theoretical ordering of task difficulty was consistent with the empirical ordering of the items by difficulty for each domain, providing evidence for the construct validity of the SIS.

Convergent/Discriminant:
Edwards and O’Connell (2003) examined discriminant validity of the SIS version 2.0 and SIS-16 in a sample of 74 patients with stroke, by comparison with the World Health Organization Quality of Life Bref-Scale (WHOQOL-BREF) and Zung’s Self-Rating Depression Scale (ZSRDS). There were adequate to excellent correlations between the SIS-16 and the WHOQOL-BREF Physical domain (r=0.40 to 0.63); correlations with the WHOQOL-BREF Social relationships domain were poor (r=0.13 to 0.18). There were adequate to excellent correlations between the SIS Participation domain and all WHOQOL-BREF domains (r=0.45 to 0.69). The correlation between the SIS Participation domain and the WHOQOL-BREF Physical domain was excellent (r=0.69). The SIS Participation domain demonstrated an adequate correlation with the ZSRDS (r=-0.56). There were adequate correlations between the SIS Memory and Emotion domains and the WHOQOL-BREF Psychological domain (r=0.49, 0.70, respectively) and between the SIS Memory and Emotion domains and the ZSRDS (r=-0.38, -0.62, respectively). There was a poor correlation between the SIS Physical domain and the WHOQOL-BREF Environment scores (r=0.15). Neither the ZSRDS nor the WHOQOL-BREF assess communication, accordingly both measures demonstrated poor correlations with the SIS Communication domain (ZSRDS: r=-0.28; WHOQOL-BREF: r=0.11 to 0.28).
Note: Some correlations are negative because a high score on the SIS indicates normal performance whereas a high score on other measures indicates impairment.

Jenkinson et al. (2013) examined convergent validity of the SIS version 3.0 and the SF-SIS in a sample of individuals with stroke (n=73, 151, respectively) by comparison with the EuroQoL EQ-5D, using Spearmans correlation coefficient. The SIS and SF-SIS demonstrated identical excellent correlations with the EQ-5D (r=0.83)

MacIsaac et al. (2016) examined convergent validity of the SIS 3.0 and the SF-SIS in a sample of 5549 patients in an acute stroke setting and 332 patients in a stroke rehabilitation setting, using Spearman’s correlation coefficient. convergent validity was measured by comparison with the SIS-VAS, patient-reported outcome measures the EuroQoL EQ-5D and EQ-5D-VAS, and functional measures the Barthel Index (BI), modified Rankin Score (mRS), and the National Institutes of Health stroke Scale (NIHSS). Within acute data, the SIS and SF-SIS demonstrated significant excellent correlations with the mRS (p=-0.87, -0.80, respectively), the BI (p=0.89, 0.80), the NIHSS (p=-0.77, -0.73), the EQ-5D (p=0.88, 0.82) and the EQ-VAS (p=0.73, 0.72). Within rehabilitation data, the SIS and SF-SIS demonstrated excellent correlations with the BI (p=0.72, 0.65, respectively) and the EQ5D (p=0.69, 0.69), and moderate correlations with the SIS-VAS (p=0.56, 0.57) and the EQ-VAS (p=0.46, 0.40). Correlations between the SIS and SF-SIS were excellent in the acute data (p=0.94) and rehabilitation data (p=0.96).

Kwon et al. (2006) examined convergent validity of the SIS 3.0 by telephone administration in a sample of 95 patients with stroke, using Pearson coefficients. convergent validity was measured by comparison with the Functional Independence Measure (FIM) – Motor component (FIM-M) and – Cognitive component (FIM-C), with the Medical Outcomes Study Short Form 36 for veterans (SF-36V). Patients were administered the SIS at 12 weeks post-stroke and the FIM and SF-36 at 16 weeks post-stroke. The SIS 3.0 telephone survey showed adequate to excellent correlations with the FIM (r=0.404 to 0.858, p<0.001) and SF-36V (r=0.362 to 0.768, p<0.001).

Known groups:
Duncan et al. (1999) found that all domains of the SIS version 2.0, with the exception of the Memory/thinking and Emotion domains, were able to discriminate between patients across 4 Rankin levels of stroke severity (p<0.0001, except for the Communication domain, p=0.02). These results suggest that scores from most domains of the SIS can differentiate between patients based on stroke severity.

Lai et al. (2003) administered the SIS and SF-36 to 278 patients with stroke 90 days after stroke. The SIS-16 was able to discriminate among the Modified Rankin Scale (MRS) levels of 0 to 1, 2, 3, and 4. The SIS Participation domain was also able to discriminate across the MRS levels of 0 to 1, 2, and 3 to 4. These results suggest that the SIS can discriminate between patients of varying degrees of stroke severity.

Kwon et al. (2006) administered the SIS 3.0 by telephone administration to a sample of 95 patients at 12 weeks post-stroke. The MRS was administered to patients at hospital discharge. SIS 3.0 scores were reported by domains: SIS-16, SIS-Physical and SIS-ADL; all domains showed score discrimination and distribution for different degrees of stroke severity: MRS 0/1 vs. MRS 4/5; MRS 2 vs. MRS 4/5; and MRS 3 vs. MRS 4/5.

Sensitivity and Specificity:

Beninato, Portney & Sullivan (2009) examined sensitivity and specificity of the SIS-16 relative to a history of multiple falls in a sample of 27 patients with chronic stroke. Participants reported a history of no falls or one fall (n=18) vs. multiple falls (n=9), according to Tinetti’s definition of falls. SIS-16 cut-off scores of 61.7 yielded 78% sensitivity and 89% specificity. Area under the ROC curve was adequate (0.86). Likelihood ratios were used to calculate post-test probability of a history of falls, and results showed high positive (LR+ = 7.0) and low negative (LR- = 0.25) likelihood ratios. Results indicate that the SIS-16 demonstrated good overall accuracy in detecting individuals with a history of multiple falls.

Responsiveness

Duncan et al. (1999) examined responsiveness of the SIS version 2.0. Significant change was observed in patients’ recovery in the expected direction between assessments at 1 and 3 months, and at 1 and 6 months post-stroke, however sensitivity to change was affected by stroke severity and time of post-stroke assessment. All domains of the SIS showed statistically significant change from 1 to 3 months and 1 to 6 months post-stroke, but this was not observed between 3 and 6 months post-stroke for the domains of Hand function, Mobility, ADL/IADL, combined physical, and Participation among patients recovering from minor stroke. For patients with moderate stroke, statistically significant change was observed at both 1 to 3 months and 1 to 6 months post-stroke in all domains, and from 3 to 6 months for the domains of Mobility, ADL/IADL, combined physical, and Participation.

Lin et al. (2010a) examined responsiveness of the SIS version 3.0 in a sample of 74 patients with chronic stroke. Participants were randomly assigned to receive constraint-induced movement therapy (CIMT), bilateral arm training (BAT) or conventional rehabilitation over a 3-week intervention period. responsiveness was measured according to change from pre- to post-treatment, using Wilcoxon signed rank test and Standardised Response Mean (SRM). Most SIS domains showed small responsiveness (SRM = 0.22-0.33, Wilcoxon Z = 1.78-2.72). Medium responsiveness was seen for Hand Function (SRM = 0.52, Wilcoxon Z = 4.24, P<0.05), stroke Recovery (SRM = 0.57, Wilcoxon Z = 4.56, P<0.05) and SIS total score (SRM=0.50, Wilcoxon Z = 3.89, P<0.05).

Lin et al. (2010b) evaluated the clinically important difference (CID) within four physical domains of the SIS 3.0 (strength, ADL/IADL, mobility, hand function) in a sample of 74 patients with chronic stroke. Participants were randomly assigned to receive CIMT, BAT or conventional rehabilitation over a 3-week intervention period. The following change scores were found to indicate a true and reliable improvement (MDC): Strength subscale = 24.0; ADL/IADL subscale = 17.3; Mobility subscale = 15.1; and Hand Function subscale = 25.9. The following mean change scores were considered to represent a CID: Strength subscale = 9.2; ADL/IADL subscale = 5.9; Mobility subscale = 4.5; and Hand Function subscale = 17.8. CID values were determined by the effect-size index and from comparison with a global rating of change (defined by a score of 10-15% in patients’ perceived overall recovery from pre- to post-treatment).
Note: Lin et al. (2010b) note that CID estimates may have been influenced by the age of participants and baseline degree of severity. Younger patients needed greater change scores from pre- to post-treatment to have a clinically important improvement compared to older patients. Those with higher baseline severity of symptoms showed greater MDC values therefore must show more change from pre- to post-treatment in order to demonstrate significant improvements. Also, the results may be limited to stroke patients who demonstrate improvement after rehabilitation therapies, Brunnstromm stage III and sufficient cognitive ability. Therefore, a larger sample size is recommended for future validation of these findings.

Ward et al. (2011) examined responsiveness of the SIS-16 and other clinical measures (STREAM, FIM) in a sample of 30 patients with acute stroke. Change scores were evaluated using Wilcoxon signed rank test and responsiveness to change was assessed using standardized response means (SRM). Measures were taken on admission to and discharge from an acute rehabilitation setting (average length of stay 23.3 days, range 7-53 days). SIS-16 change scores indicated statistically significant improvement from admission to discharge (23.1, p<0.0001) and sensitivity to change was large (SRM=1.65).

Guidetti et al. (2014) examined responsiveness of the SIS 3.0 in a sample of 204 patients with stroke who were assessed at 3 and 12 months post-stroke, using Wilcoxon’s matched pairs test. Clinically meaningful change within a domain was defined as a change of 10-15 points between timepoints. The Participation and Recovery domains were the most responsive domains over the first year post-stroke, with 27.5% and 29.4% of participants (respectively) reporting a clinically meaningful positive change, and 20% and 10.3% of participants (respectively) reporting a clinically meaningful negative change, from 3 to 12 months post-stroke. The Strength and Hand function domains also showed high clinically meaningful positive change (23%, 18.0% respectively) and negative change (14.7%, 14.2% respectively) from 3 to 12 months post-stroke. There were significant changes in scores on the Strength (p=0.045), Emotion (p=0.001) and Recovery (p<0.001) domains from 3 to 12 months post-stroke. The Strength, Hand function and Participation domains had the highest perceived impact (i.e. lowest mean scores) at 3 months and 12 months.

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  • Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-98.
  • Fugl-Meyer, A.R., Jaasko, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient: a method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
  • Fulk, G.D., Reynolds, C., Mondal, S., & Deutsch, J.E. (2010). Predicting home and community walking activity in people with stroke. Archives of Physical Medicine and Rehabilitation, 91, 1582-6.
  • Geyh, S., Cieza, A., & Stucki, G. (2009). Evaluation of the German translation of the Stroke Impact Scale using Rasch analysis. The Clinical Neuropsychologist, 23(6), 978-95.
  • Goncalves, R.S., Gil, J.N., Cavalheiro, L.M., Costa, R.D., & Ferreira, P.L. (2012). Reliability and validity of the Portuguese version of the Stroke Impact Scale 2.0 (SIS 2.0). Quality of Life Research, 21(4), 691-6.
  • Guidetti, S., Ytterberg, C., Ekstam, L., Johansson, U., & Eriksson, G. (2014). Changes in the impact of stroke between 3 and 12 months post-stroke, assessed with the Stroke Impact Scale. Journal of Rehabilitative Medicine, 46, 963-8.
  • Hamilton, B.B., Granger, C.V., & Sherwin, F.S. (1987). A uniform national data system for medical rehabilitation. In: Fuhrer, M. J., ed. Rehabilitation Outcome: Analysis and Measurement. Baltimore, Md: Paul Brookes, 137-47.
  • Hamza, A.M., Nabilla, A.S., & Loh, S.Y. (2012). Evaluation of quality of life among stroke survivors: linguistic validation of the Stroke Impact Scale (SIS) 3.0 in Hausa language. Journal of Nigeria Soc Physiotherapy, 20, 52-9.
  • Hamza, A.M., Nabilla, A.-S., Yim, L.S., & Chinna, K. (2014). Reliability and validity of the Nigerian (Hausa) version of the Stroke Impact Scale (SIS) 3.0 index. BioMed Research International, 14, Article ID 302097, 7 pages. doi: 10.1155/2014/302097
  • Hogue, C., Studenski, S., Duncan, P.W. (1990). Assessing mobility: The first steps in preventing fall. In: Funk, SG., Tornquist, EM., Champagne, M.T., Copp, L.A., & Wiese, R.A., eds. Key Aspects of Recovery. New York, NY: Springer, 275-81.
  • Hsieh, F.-H., Lee, J.-D., Chang, T.-C., Yang, S.-T., Huang, C.-H., & Wu, C.-Y. (2016). Prediction of quality of life after stroke rehabilitation. Neuropsychiatry, 6(6), 369-75.
  • Huang, Y-h., Wu, C-y., Hsieh, Y-w., & Lin, K-c. (2010). Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke. Neurorehabilitation and Neural Repair, 24(6), 559-66. doi: 10.1177/1545968309358074
  • Jenkinson, C., Fitzpatrick, R., Crocker, H., & Peters, M. (2013). The Stroke Impact Scale: validation in a UK setting and development of a SIS short form and SIS index. Stroke, 44, 2532-5.
  • Kamwesiga, J.T., von Koch, L., Kottorp, A., & Guidetti, S. (2009). Cultural adaptation and validation of Stroke Impact Scale 3.0 version in Uganda: a small-scale study. SAGE Open Medicine, 4: 2050312116671859. doi: 10.1177/2050312116671859
  • Kwon, S., Duncan, P., Studenski, S., Perera, S., Lai, S.M., & Reker, D. (2006). Measuring stroke impact with SIS: Construct validity of SIS telephone administration. Quality of Life Research, 15, 367-76.
  • Lai, S.M., Perera, S., Duncan, P.W., & Bode, R. (2003). Physical and Social Functioning After Stroke: Comparison of the Stroke Impact Scale and Short Form-36. Stroke, 34, 488-93.
  • Lawton, M. & Brody, E. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179 -86.
  • Lee, H.-J. & Song, J.-M. (2015). The Korean language version of Stroke Impact Scale 3.0: cross-cultural adaptation and translation. Journal of the Korean Society of Physical Medicine, 10(3), 47-55.
  • Lin, K.C., Fu, T., Wu, C.Y., Hsieh, Y.W., Chen, C.L., & Lee, P.C. (2010a). Psychometric comparisons of the Stroke Impact Scale 3.0 and Stroke-Specific Quality of Life Scale. Quality of Life Research, 19(3), 435-43. doi: 10.1007/s11136-010-9597-5.
  • Lin K.-C., Fu T., Wu C.Y., Wang Y.-H., Wang Y-.H., Liu J.-S., Hsieh C.-J., & Lin S.-F. (2010b). Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients. Neurorehabilitation and Neural Repair, 24, 486-92.
  • MacIsaac, R., Ali, M., Peters, M., English, C., Rodgers, H., Jenkinson, C., Lees, K.R., Quinn, T.J., VISTA Collaboration. (2016). Derivation and validation of a modified short form of the Stroke Impact Scale. Journal of the American Heart Association, 5:e003108. doi: 10/1161/JAHA.115003108.
  • Mahoney, F.I. & Barthel, D.W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61-5.
  • Mulder, M. & Nijland, R. (2016). Stroke Impact Scale. Journal of Physiotherapy, 62, 117.
  • Ochi, M., Ohashi, H., Hachisuka, K., & Saeki, S. (2017). The reliability and validity of the Japanese version of the Stroke Impact Scale version 3.0. Journal of UOEH, 39(3), 215-21. doi: 10.7888/juoeh.39.215
  • Richardson, M., Campbell, N., Allen, L., Meyer, M., & Teasell, R. (2016). The stroke impact scale: performance as a quality of life measure in a community-based stroke rehabilitation setting. Disability and Rehabilitation, 38(14), 1425-30. doi: 10.310/09638288.2015.1102337
  • Sullivan, J. (2014). Measurement characteristics and clinical utility of the Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation, 95, 1799-1800.
  • Vellone, E., Savini, S., Barbato, N., Carovillano, G., Caramia, M., & Alvaro, R. (2010). Quality of life in stroke survivors: first results from the reliability and validity of the Italian version of the Stroke Impact Scale 3.0. Annali di Igiene, 22, 469-79.
  • Vellone, E., Savini, S., Fida, R., Dickson, V.V., Melkus, G.D., Carod-Artal, F.J., Rocco, G., & Alvaro, R. (2015). Psychometric evaluation of the Stroke Impact Scale 3.0. Journal of Cardiovascular Nursing, 30(3), 229-41. doi: 10.1097/JCN.0000000000000145
  • Ward, I., Pivko, S., Brooks, G., & Parkin, K. (2011). Validity of the Stroke Rehabilitation Assessment of Movement Scale in acute rehabilitation: a comparison with the Functional Independence Measure and Stroke Impact Scale-16. Physical Medicine and Rehabilitation, 3(11), 1013-21. doi: 10.1016/j.pmrj.2011.08.537
  • Ware, J.E. Jr., & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30, 473-83.
  • Yesavage, J.A., Brink, T., Rose, T.L., Lum, O., Huang, V., Adey, M., & Leirer, V.O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.

See the measure

How to obtain the SIS?

Please click here to see a copy of the SIS.

This instrument was developed by:

  • Pamela Duncan, PhD, PT
  • Dennis Wallace, PhD
  • Sue Min Lai, PhD, MS, MBA
  • Stephanie Studenski, MD, MPH
  • DallasJohnson, PhD, and
  • Susan Embretson, PhD.

In order to gain permission to use the SIS and its translations, please contact MAPI Research Trust: contact@mapi-trust.org

Table of contents

Stroke Specific Quality of Life Scale (SS-QOL)

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Stroke Specific Quality Of Life scale (SS-QOL) is a patient-centered outcome measure intended to provide an assessment of health-related quality of life (HRQOL) specific to patients with Stroke.

In-Depth Review

Purpose of the measure

The Stroke Specific Quality Of Life scale (SS-QOL) is a patient-centered outcome measure intended to provide an assessment of health-related quality of life specific to patients with Stroke.

Available versions

The SS-QOL was published and validated in 1999 by Williams, Weinberger, Harris, and Clark.

Features of the measure

Items:
Scale domains and items were derived from a series of interviews with post-stroke patients (Williams et al. 1999a).

Patients must respond to each question of the SS-QOL with reference to the past week. It is a self-report scale containing 49 items in 12 domains:

  • Mobility (6 items)
  • Energy (3 items)
  • Upper extremity function (5 items)
  • Work/productivity (3 items)
  • Mood (5 items)
  • Self-care (5 items)
  • Social roles (5 items)
  • Family roles (3 items)
  • Vision (3 items)
  • Language (5 items)
  • Thinking (3 items)
  • Personality (3 items)

Subscales:
Energy, Upper extremity function, Work/productivity, Mood, Self-care, Social roles, Family roles, Vision, Language, Thinking, and Personality.

Equipment:
Only a pencil and the test are needed.

Training:
No training is required, as the SS-QOL is intended to be self-administered. One study suggests that the scale can be administered to patients with Stroke reliably over the telephone (Williams, Redmon, Saul & Weinberger, 2000).

Time:
It takes approximately 10-15 minutes to complete the SS-QOL scale.

Scoring:
Items are rated on a 5-point Likert scale. There are 3 different response sets (see table below). Patients must respond to each item using the corresponding response set as indicated on the scale (Williams et al. 1999a). For example, the item “did you have any trouble doing daily work around the house?” requires response set 2, which ranges from “couldn’t do it at all” to “no trouble at all”.

Response Sets:

1. Total help 2. A lot of help 3. Some help 4. A little help 5. No help needed
1. Couldn’t do it at all 2. A lot of trouble 3. Some trouble 4. A little trouble 5. No trouble at all
1. Strongly agree 2. Moderately agree 3. Neither agree nor disagree 4. Moderately disagree 5. Strongly disagree

Higher scores indicate better functioning. The SS-QOL yields both domain scores and an overall SS-QOL summary score. The domain scores are unweighted averages of the associated items while the summary score is an unweighted average of all twelve domain scores (Williams et al. 1999b).

Alternative forms of SS-QOL

  • The Stroke and Aphasia Quality Of Life Scale (SAQOL-39 – Hilari, Byng, Lamping, & Smith, 2003). Developed from the SS-QOL for use in patients with long-term Aphasia, the SAQOL-39 has four subdomains (Physical, Psychosocial, Communication, and Energy). It is an interview-administered self-report scale. It is comprised of items from the SS-QOL that have been modified to ensure they are appropriate for use in individuals with Aphasia. The SAQOL-39 has four additional items that were added to increase the content validity of the scale with this population. These four items focus on the difficulties with understanding speech, issues with decision-making, and the impact of language difficulties on family and social life.

Hilari et al. (2003) reported that the SAQOL-39 has good acceptability, adequate to excellent internal consistency (Cronbach’s alphas ranging from 0.74 to 0.94), excellent test-retest reliability (intraclass correlation coefficient = 0.89 to 0.98), and poor to excellent construct validity (corrected domain-total correlations, r = 0.38 to 0.58; convergent, r = 0.55 to 0.67; discriminant, r = 0.02 to 0.27 validity). Further research is needed to confirm its psychometric properties and to determine its appropriateness as a clinical outcome measure.

Client suitability

Can be used with:

  • Individuals with mild or moderate Stroke.

Should not be used in:

  • Patients without Stroke. The SS-QOL was developed and validated specifically for individuals with Stroke and has been examined for use in this population only.
  • Severe Stroke populations. The SS-QOL has not yet been tested among patients with severe Stroke.
  • Should be used with caution in patients with Aphasia. Although the modified version of the scale, the SAQOL-39, has been validated for use in patients with long-term Aphasia, it is a relatively new measure that requires further psychometric testing.
  • Patients who require a proxy to complete. A study by Williams et al. (2006) compared proxy ratings of the SS-QOL to patient self administration in 225 patient-proxy pairs. Proxies rated all domains of SS-QOL lower than the patients. The intraclass correlation coefficient (ICC) for each domain ranged from poor (r = 30 for role function) to adequate (r = 0.59 for physical function). Proxy overall SS-QOL score was also rated lower than the patient score (3.7 versus 3.4) with an ICC of r = 0.41. It is recommended that information obtained from proxy respondents be treated as supplementary rather than substantive and that use of proxy be restricted to individuals either living with or in daily contact with the patient (Snow, Cook, Lin, Morgan & Magaziner, 2005; Muus, Petzold & Ringsberg, 2009).
  • For patients who require a proxy, the Stroke Impact Scale is a more reliable and valid measure of HRQOL (Duncan, Lai, Tyler, Perera, Reker, & Studenski, 2002).

In what languages is the measure available?

  • Danish (SS-QOL-DK): translated Muus & Ringsberg, 2005 and validated Muus, Williams & Ringesberg, 2007.
  • German: translated Ewart & Stucki, 2007 and initial validation study completed Ewart & Stucki, 2007. The initial validation study revealed validity of the total SS-QOL German score, however, some subscales (Energy, Mood and Thinking) were not validated. Further research is required.

Summary

What does the tool measure? Health related quality of life
What types of clients can the tool be used for? The SS-QOL was developed for use in patients with stroke.
Is this a screening or assessment tool? Assessment.
Time to administer Approximately 10-15 minutes to complete.
Versions The stroke and Aphasia Quality Of Life Scale (SAQOL-39)
Other Languages Translated and validated in Danish. Translated in German.
Measurement Properties
Reliability Internal consistency:
One study examined the Internal consistency of the SS-QOL and found that the Internal consistency ranged from adequate (for work/productivity subscale) to excellent (for self-care).

Test-retest:
One study examined the test-retest reliability of the SS-QOL and found excellent test-retest.

Inter-rater:
One study examined the inter-rater reliability of the SS-QOL and found excellent inter-rater.

Validity Criterion:
Predictive:
The SS-QOL summary score significantly predicted overall post-stroke health-related quality of life.

Construct:
Convergent:
Most domains of the SS-QOL correlate with the Barthel Index, the Beck Depression Inventory, and subscales of the SF-36.

Floor/Ceiling Effects One study reported ceiling effects exceeding 20% in 10 out of 12 domains of the SS-QOL, and a floor effect of 24% in the Energy domain. Floor or ceiling effect exceeding 20% are typically considered poor.
Does the tool detect change in patients? One study found that the SS-QOL had only a moderate ability to detect change in patients between 1 and 3 months post-stroke. A subsequent study involving an alternative language version of the SS-QOL, found a small to moderate ability to detect change in patients between 3 and 12 month post-stroke. In a later study, the minimal clinically detectable difference for the mobility, self-care and upper extremity function subscales was defined as a mean change in score of at least 1.5, 1.2 and 1.2 respectively.
Acceptability Further investigation on the Reliability, Validity, and sensitivity of the SS-QOL is required with larger numbers of subjects. This measure has not been tested in severely affected patients with stroke. For patients with Aphasia, the SAQOL-39 is a more suitable version of the measure, however, it is a relatively new measure, which requires further psychometric testing. The scale is not suitable for use by proxy.
Feasibility No training is required for the SS-QOL as the measure is intended to be completed by self-report. The measure is simple to score and is based on a 5-point Likert scale.
How to obtain the tool?

Click here to find a copy of the SS-QOL.

Psychometric Properties

Overview

The Stroke Specific Quality of Life Scale (SS-QOL) is a new scale and has not been well studied. It has not been tested among severe Stroke populations. To our knowledge, the creators of the SS-QOL have personally gathered the majority of psychometric data that are currently published on the scale. Further investigation on the reliability, validity, and sensitivity of the SS-QOL is required with larger numbers of subjects.

Floor and Ceiling Effects

Czechowsky and Hill (2002) examined the SS-QOL and reported ceiling effects exceeding 20% in 10 out of 12 domains of the SS-QOL, and a ceiling effects exceeding 20% are typically considered poor.

Reliability

Internal consistency:
Williams et al. (1999a) examined the Internal consistency of the SS-QOL in 34 individuals with Stroke and found that Cronbach’s alpha ranged from adequate (alpha = 0.75 for work/productivity subscale) to excellent (alpha = 0.89 for self-care), suggesting that the SS-QOL has a strong Internal consistency.

Test-retest:
In a study by Williams et al. (2000), the SS-QOL was administered by a trained interviewer to 47 Stroke survivors at baseline and again within 2 hours of the initial interview. SS-QOL scores were highly correlated (r = 0.92), showing excellent test-retest reliability.

Inter-rater:
The SS-QOL was also administered by a trained interviewer to 24 Stroke survivors and then a second trained interviewer re-administered the SS-QOL within 2 hours of the first interview. SS-QOL scores were highly correlated (r = 0.92), demonstrating excellent inter-rater reliability of the SS-QOL.

Validity

Criterion:
Predictive:
Williams et al. (1999b) administered the SS-QOL to a total of 71 patients 1-month post-ischemic Stroke. Multivariate analysis showed that the SS-QOL summary score significantly predicted overall post-stroke health-related quality of life (HRQOL) (OR = 2.97). When scores were examined on the domain level, however, only one domain, Family Roles, was significantly different between groups, with higher scores in those patients with better overall HRQOL.

Construct:
Convergent:
Williams et al. (1999a) examined the validity of the SS-QOL in 34 survivors of Stroke and reported that most domains of the SS-QOL correlated with the Barthel Index, Beck Depression Inventory, and subscales of the SF-36. The Energy, Family Roles, Mobility and Work/Productivity domains were significantly associated with corresponding subscales on the SF-36. Total SS-QOL score correlated excellently with the overall SF-36 health status rating (r = 0.65). The self-care domain was adequately correlated with the Barthel Index (r = 0.45). Upper Extremity Function showed a positive but poor relationship with the Barthel Index and the National Institutes of Health Stroke Scale Upper Extremity score (r = 0.18).

However, in this study, a few domains did not show a significant relationship with their corresponding measures. Scores in the Language and Thinking domains were not associated with selected items from the National Institutes of Health Stroke Scale (r = 0.00 and r = 0.10 respectively). This most likely occurred because patients with language and cognitive deficits were excluded, i.e., there were no patients with a score > 1 on these items. Furthermore, the SS-QOL Social Roles domain was not associated with the SF-36 Social Functioning subscale score (r = 0.01). Finally, the Vision domain of the SS-QOL did not correlate with the National Institutes of Health Stroke Scale Visual Field and Ocular Movement scores (r = 0.11).

Responsiveness

Williams et al. (1999a) examined the standardized effect size scores for the interval between 1 and 3 months post-stroke in 34 individuals with Stroke. Effect sizes ranged from small (ES = 0.20 for the personality domain) to large (ES = 0.83 for the social roles domain). One half of the SS-QOL domains demonstrated less than moderate effect sizes. The ‘amount of help’ response set appeared to lack responsiveness. The results of this study demonstrate that the SS-QOL has only adequate responsiveness.

Muus et al. (2011) investigated the responsiveness of the Danish language version of the SS-QOL (SSQOL-DK). Patients were assessed at 3 and 12 months following Stroke. Small standardized effect sizes were found for all domains (-0.03-0.40), except the social roles domain which demonstrated moderate standardized effect size (-0.53).

Lin, Fu, Wu & Hsieh (2011) examined the minimal clinically important difference (CID), of the mobility, self-care and upper extremity function subscales of the SS-QOL. The study included 74 patients with Stroke receiving rehabilitation and the SS-QOL was administered at baseline and at 3 weeks. The MCID ranges for the mobility, self-care and upper extremity function subscales were 1.5 – 2.4, 1.2 – 1.9, and 1.2 – 1.8 respectively. The results of the study indicate that mean change of score on the mobility, self-care and upper extremity function subscale should reach 1.5, 1.2 and 1.2, respectively, in order for change to be interpreted as clinically meaningful.

References

  • Czechowsky, D., Hill, M. D. (2002). Neurological Outcome and Quality of Life after Stroke due to Vertebral Artery Dissection. Cerebrovascular Diseases, 13, 192-197.
  • Duncan, P. W., Lai, S. M., Tyler, D., Perera, S., Reker, D. M., Studenski, S. (2002). Evaluation of proxy responses to the Stroke Impact Scale. Stroke, 33, 2593-2599.
  • Ewart, T. & Stucki, G, (2007). Validity of the SS-QOL in Germany and in survivors of hemorrhagic or ischemic stroke. Neurorehabilitation and Neuro Repair, 21, 161-168.
  • Hilari, K., Byng, S., Lamping, D. L., Smith, S. C. (2003). Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39): Evaluation of acceptability, reliability, and validity. Stroke, 34, 1944-1950.
  • Lin, K-C., Fu, T., Wu, C-Y. & Hsieh, C-J. (2011). Assessing the stroke-specific quality of life for outcomes measurement in stroke rehabilitation: Minimal detectable change and clinically important difference. Health and Quality of Life Outcomes, 9, 5. Retrieved April 25, 2012 from Sage Journals database.
  • Muus, I., Christensen, D., Petzold, M., Harder, I., Johnsen, S.P., Kirkevold, M., Ringsberg, K.C. (2011). Responsiveness and sensitivity of the Stroke Specific Quality of Life Danish version. Disability and Rehabilitation, 33(25-26), 2425-2433.
  • Muus, I., Petzold, M. & Ringsberg, K.C. (2009). Health-related quality of life after stroke: Reliability of proxy responses. Clinical Nursing Research, 18(2), 103-118.
  • Muus, I., Ringsberg, K. C. (2005). Stroke Specific Quality of Life Scale: Danish adaptation and a pilot study for testing psychometric properties. Scand J Caring Sci, 19, 140-147.
  • Muus, I., Williams, L.S. & Ringsberg, K.C. (2007). Validation of the Stroke Specific Quality of Life Scale (SS-QOL): Test of reliability and validity of the Danish version (SS-QOL-DK). Clinical Rehabilitation, 21, 620-627.
  • Snow, A.L., Cook, K.F., Lin, P.S., Morgan, R.O. & Magaziner, J. (2005). Proxies and other external raters: Methodological considerations. Health Services Research, 40(5), 1976-1693.
  • Williams, L. S., Weinberger, M., Harris, L. E., Clark, D. O., Biller, J. (1999a). Development of a stroke-specific quality of life scale. Stroke, 30(7), 1362-1369.
  • Williams, L. S., Weinberger, M., Harris, L. E., Biller, J. (1999b). Measuring quality of life in a way that is meaningful to stroke patients. Neurology, 53, 1839-1843.
  • Williams, L. S., Redmon, G., Saul, D. C., Weinberger, M. (2000). Reliability and telephone validity of the Stroke-specific Quality of Life (SS-QOL) scale. Stroke, 32, 339-b.
  • Williams, L. S., Bakas, T., Brizendine, E., Plue, L., Tu, W., Hendrie, H., Kroenke, K. (2006). How valid are family proxy assessments of stroke patients’ health-related quality of life? Stroke, 37, 2081-2085.

See the measure

Please click here for a copy of the Stroke-Specific-Quality-of-Life-Scale (SS-QOL).

Table of contents

Toronto Bedside Swallowing Screening Test (TOR-BSST©)

Evidence Reviewed as of before: 18-02-2019
Author(s)*: Annabel McDermott, OT
Expert Reviewer: Trixie Reichardt, MHSc, RD, Rosemary Martino, PhD
Content consistency: Gabriel Plumier

Purpose

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a Screening tool which identifies patients at risk for dysphagia following stroke.

In-Depth Review

Purpose of the measure

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a Screening tool administered at the bedside by trained screeners which identifies patients at risk for dysphagia following stroke.

Available versions

There is one version of the TOR-BSST©. See https://swallowinglab.com/tor-bsst/.

Features of the measure

Items:

The TOR-BSST© is comprised of 5 items:

  1. Baseline vocal quality
  2. Tongue movement
  3. 50mL water test
  4. Cup sip
  5. Final judgment of vocal quality

Scoring:

The TOR-BSST© uses binary scoring (i.e. abnormal/normal) for each item. Failure on any item discontinues the screen and prompts referral to a Speech-Language Pathologist dysphagia expert.

What to consider before beginning:

The TOR-BSST© should only be used with patients who are alert, able to sit upright at 90 degrees, and are able to follow simple instructions. Patients who do not meet these guidelines should not be screened but, instead, be referred to a Speech-Language Pathologist for assessment.

International best practice guidelines advise that, following stroke, patients should undergo Screening for swallowing difficulties before oral intake of food, fluids or oral medication. Screening should be performed by specially trained personnel, using a validated Screening tool. Swallowing should be screened as soon as possible after admission provided that the patient is able to participate. Patients who fail the swallowing Screening should be referred to a Speech-Language Pathologist for comprehensive swallowing assessment. For patients who are confirmed at high risk of aspiration and/or dysphagia should undergo an instrumental assessment such as videofluoroscopy swallowing study (VFS) and/or fibreoptic evaluation of swallowing (FEES).

Time:

The TOR-BSST© takes less than 10 minutes to administer and score. Administration ceases immediately on failure of an item.

Training requirements:

The TOR-BSST© can be administered by health professionals who have undergone the requisite 4-hour didactic standardized training program. Didactic training is followed by individual training/competency observations. Training is provided by Speech-Language Pathologists who have completed the “TOR-BSST© Training for the SLP dysphagia Expert” trainers course.

See The Swallowing Lab (https://swallowinglab.com/tor-bsst/) for details.

Equipment:

The TOR-BSST© is a one-page double-sided form that includes standardized instructions for administration

Client suitability

Can be used with:

  • The TOR-BSST© is suitable for use with individuals with stroke across the recovery continuum (Martino et al., 2009).
  • The TOR-BSST© is being validated for use with critically ill patients who have undergone prolonged intubation and may be at risk of swallowing problems.

Should not be used in:

  • Following stroke, patients should be assessed and managed according to best practice guidelines for dysphagia. The TOR-BSST© should not be used with individuals with decreased alertness or cognition, or those who are being tube-fed. Patients who are being tube-fed have already been identified to have dysphagia and therefore should be referred to a Speech-Language Pathologist for a comprehensive assessment and management.

In what languages is the screening tool available?

  • English
  • French
  • Chinese
  • German
  • Italian
  • Portuguese (Brazil)

Summary

What does the tool measure? Risk for dysphagia following stroke.
What types of clients can the tool be used for? The TOR-BSST© was developed for patients with stroke across the recovery continuum.
Is this a screening or assessment tool? screening tool
Time to administer Ten minutes.
Versions There is one version of the TOR-BSST©.
Languages Chinese, English, French, German, Italian, Portuguese (Brazil)
Measurement Properties
Reliability Internal consistency:
No studies have reported on the Internal consistency of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:
Two studies have reported excellent inter-rater reliability of the TOR-BSST©.

Validity Content:
Development of the TOR-BSST© involved item generation from systematic review and subsequent item reduction, in combination with consultation with expert Speech-Language Pathologists.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the TOR-BSST©.

Predictive:
One study has conducted a randomized controlled diagnostic study of the TOR-BSST© by comparison with videofluoroscopy.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent or discriminant validity of the TOR-BSST©.

Known Groups:
No studies have reported on the known group Validity of the TOR-BSST©.

Floor/Ceiling Effects Not applicable
Does the tool detect change in patients? The TOR-BSST© is designed as a screening test and scored using binary responses, so is not intended to detect change.
Acceptability – The TOR-BSST© is quick to administer.
– The TOR-BSST© requires specialised training.
Feasibility The TOR-BSST© is suitable for administration across acute and rehabilitation settings. The screening is easily portable and is quick to administer, score and interpret.
How to obtain the tool? Click here for information regarding the TOR-BSST©.

Psychometric Properties

Overview

The TOR-BSST© was developed and validated by Dr. Martino of The Swallowing Lab, University Health Network, University of Toronto.

A literature search was conducted to identify all relevant publications on the psychometric properties of the TOR-BSST©. Four studies were identified.

Floor/Ceiling Effects

The TOR-BSST© is a 5-item screening test to determine risk of dysphagia. The screening should be discontinued as soon as an individual fails an item.

Reliability

Internal consistency:
No studies have reported on Internal consistency of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:
Martino et al. (2009) established inter-rater reliability of the TOR-BSST© in the first 50 patients with stroke enrolled, using intraclass correlation coefficient (ICC) and 95% confidence intervals (CI). Results indicated excellent test-retest reliability (ICC=0.92; CI, 0.85 to 0.96).

Martino et al. (2006) examined 24-hour inter-rater reliability of the TOR-BSST© item and total screen scores in a sample of 286 patients with stroke (acute, n=78; subacute/chronic, n=208), using kappa statistics. Results indicated moderate reliability for the total score, with a higher reliability early after training (k = 0.90). Item reliability ranged from poor to adequate; the item ‘water swallowing’ including both the 50-ml and sip achieved the highest item reliability (k=0.82; CI, 0.66-0.98).

Validity

Content:

Initial item generation for the TOR-BSST© resulted from systematic review of the accuracy and benefit of non-invasive bedside dysphagia screening tests with patients with stroke (see Martino, Pron & Diamant, 2000). Two measures were shown to be accurate predictors of dysphagia by videofluroscopic assessment (VFS) of aspiration, and a further two were considered to show promising (although inconsistent) predictive ability:

  1. Dysphonia/coughing during the 50mL Kidd water swallow test
  2. Impaired pharyngeal sensation
  3. Impaired tongue movement
  4. General dysphonia – voice before or voice after water intake

The final measure, general dysphonia, was defined as two sub-items (voice before, voice after).

Item reduction was then performed, whereby positive results across the 5 items were compared with the total score. The item ‘water swallow’ contributed 25% to the total positive score, indicating that this item was the most frequent single item to identify dysphagia. The item ‘tongue movements’ contributed 8% to the total positive score. The remaining items contributed less than 5% each to the total positive score, and so were considered for elimination on review of practical application as determined by expert Speech-Language Pathologists. These expert clinicians considered the item ‘pharyngeal sensation’ to be impractical due to difficulty differentiating from a gag reflex in the clinical setting.

Martino et al. (2014) conducted item descriptive analysis in the original sample of 311 patients with stroke from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses. Items were eliminated individually to evaluate the impact of each item on the total score. Results showed that the ‘water swallow’ item contributed most significantly to identification of dysphagia, identifying 42.7% of patients in the acute setting and 29.0% of patients in the rehabilitation setting.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the TOR-BSST©.

Predictive:
Martino et al. (2009) examined predictive validity of the TOR-BSST© by comparison with gold standard VFS assessment identifying any abnormal swallow physiology including all severity. The randomized controlled diagnostic study design included four blinded Speech-Language Pathologists and 68 patients with stroke in acute and rehabilitation settings. Nine participants with stroke were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart as per a priori criteria for patient flow. VFS assessment was used to confirm findings obtained by TOR-BSST© screening; clinicians rated the VFS images using three standardized scales: (1) Penetration Aspiration Scale; (2) Mann Assessment of Swallowing Ability (MASA) dysphagia subscore; and (3) MASA aspiration subscore. Across the entire sample of acute and rehab patients, results showed that 61% (n=36) of patients were confirmed by experts to have no dysphagia vs. 39% (n=23) with dysphagia. These results indicate high accuracy to predict dysphagia using the TOR-BSST©, where dysphagia is defined by aspiration and/or physiological abnormality on VFS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the TOR-SST©.

Known Group:
No studies have reported on the known-group validity of the TOR-BSST(c).

Sensitivity & Specificity:

Martino et al. (2009) examined sensitivity of the TOR-BSST© by comparison with VFS assessment, in a sample of 68 patients with stroke in acute and rehabilitation settings. Nine patients were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart. The TOR-BSST showed 91.3% sensitivity (CI, 71.9 – 98.7) and 66.7% specificity (CI, 49.0 – 81.4) among all patients. sensitivity and specificity was 96.3% and 63.6% (respectively) among patients in an acute setting, and 80.0% and 68.0% (respectively) among patients in rehabilitation settings. The TOR-BSST© showed high negative predictive value of 93.3% and 89.5% in participants in acute and rehabilitation stroke settings, respectively.

Martino et al. (2014) conducted sensitivity analysis of the TOR-BSST© in the original sample of 311 patients with stroke from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses using the standard 10 teaspoons plus a sip of water. Positive screening occurred in 59.2% of patients in the acute setting (n=103) and 38.5% of patients in the rehabilitation setting (n=208).

Martino et al. (2014) further examined sensitivity of the TOR-BSST© when modifying administration according to water volume intake. Using the original sample from Martino et al. (2009), sensitivity was examined on administration of 1 to 10 teaspoons of water to determine the acceptable cut-point to identify dysphagia. Among all participants (n=311), sensitivity ranged from moderate to excellent for 5, 8 and 10 teaspoons of water (79%, 92%, 96% respectively). Among patients in the acute setting and rehabilitation settings, sensitivities were 84% and 75% (respectively) for 5 teaspoons of water, 93% and 92% (respectively) for 8 teaspoons, and 95% and 97% (respectively) for 10 teaspoons. Results indicate greater accuracy on administration of 10x 5mL teaspoons of water, as per the original assessment guidelines

References

  • Martino, R., Maki, E., & Diamant, N. (2014). Identification of dysphagia using the Toronto Bedside Swallowing Screening Test (TOR-BSST©): are 10 teaspoons of water necessary? International Journal of Speech-Language Pathology, 16(3), 193-8. https://www.ncbi.nlm.nih.gov/pubmed/24833425
  • Martino, R., Nicholson, G., Bayley, M., Teasell, R., Silver, F., & Diamant, N. (2006). Interrater reliability of the Toronto Bedside Swallowing Screening Test (TOR-BSST©) [Abstract]. Dysphagia, 21(4), 287-334. https://doi.org/10.1007/s00455-006-9044-5
  • Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15, 19-30. https://www.ncbi.nlm.nih.gov/pubmed/10594255
  • Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D.L., & Diamant, N.E. (2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40, 555-61. https://www.ncbi.nlm.nih.gov/pubmed/19074483

See the measure

How to obtain the TOR-BSST©:

Click here for information regarding the TOR-BSST©.

Other measures of dysphagia:

Instrumental Assessments:

  • Videofluoroscopy swallowing study (gold standard)
  • Fiberoptic endoscopic examination of swallowing
  • Rosenbeck’s Penetration Aspiration Scale

Clinical Bedside Assessments:

  • The Modified Mann Assessment of Swallowing Ability (Modified MASA)

Screening Tools:

  • Massey Bedside Swallowing Screen Volume-Viscosity Swallowing Test (Clave et al., 2008)
  • The Gugging Swallowing Screen (GUSS) (Trapl et al., 2007)
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