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; 1 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; 1 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 reliability:

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, Lawton Instrumental 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 validity:

  • 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 validity

Known groups validity:

  • 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.

Convergent/Discriminant validity:

  • 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.
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; 1 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).
  • SIS 3.0: One study reported medium responsiveness for Hand function, Stroke recovery and SIS total score; other domains showed small responsiveness.
  • SIS 3.0: 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.

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.

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).

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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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

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