Clive Glass

The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study

Purpose. To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. Method. Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. Results. Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P < 0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbachs α was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P < 0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. Conclusions. The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

A multicenter international study on the spinal cord independence measure, version III: Rasch psychometric validation

Background:A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version.Objective:To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis.Design:Multicenter cohort study.Setting:Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East.Subjects:425 patients with spinal cord lesions (SCL).Interventions:SCIM III assessments by professional staff members. Rasch analysis of admission scores.Main outcome measures:SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries.Results:Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79–1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found.Conclusions:The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Abstract Background/Objective: The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop. Method: Evaluation of currently available SCI functional outcome measures by a multinational work group. Results: The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI. Conclusions: The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

A two-part pilot study of sildenafil (VIAGRA) in men with erectile dysfunction caused by spinal cord injury.

Study design: This was a two-part pilot study in men with erectile dysfunction (ED) due to spinal cord injury (SCI: cord level range T6-L5). Part I was a randomised, double-blind, two-way cross-over study comparing a single dose of sildenafil 50 mg or placebo. Part II was a randomised, double-blind, parallel-group evaluation of sildenafil 50 mg or placebo, taken as required (not more than once daily) approximately 1 h prior to sexual activity, over a period of 28 days. Objectives: To assay the efficacy and safety of sildenafil 50 mg and placebo. Setting: Clinic- and home-based assessments in the United Kingdom. Methods: A total of 27 subjects who were able to achieve at least a grade 2 erection (hard, but not hard enough for penetration) in response to penile vibratory stimulation (PVS) were recruited. In Part I, the reflexogenic response of the penis to PVS was evaluated in the clinic while in Part II, the response to treatment was assessed in the home (global efficacy, questionniare, diary). Results: In Part I, 17/26 (65%) subjects had erections of >60% rigidity at the penile base (median duration 3.5 min) after sildenafil compared with 2/26 (8%) (median duration 0 min) after placebo (P=0.0003). In Part II, 9/12 (75%) subjects on sildenafil and 1/14 (7%) subjects on placebo reported that the treatment had improved their erections (P<0.005), and 8/12 (67%) and 2/13 (15%) men, respectively, indicated that they wished to continue treatment (P<0.02). An analysis of diary data showed no difference between the groups with respect to the mean number of erections hard enough for penetration (P=0.08). The mean proportion of attempts at sexual intercourse that were successful was 30 and 15%, respectively (P=0.21). Similarly, responses to the end-of-treatment questionnaire indicated that there were no significant differences between the groups with respect to the frequency of erections hard enough for sexual intercourse (P=0.47) or that lasted as long as the subject would have liked (P=0.11). No subject discontinued sildenafil due to adverse events. Conclusion: Sildenafil is an effective, well-tolerated oral treatment for ED in SCI subjects. Sponsorship: This study was funded by Pfizer Inc.

Aging, spinal cord injury, and quality of life: structural relationships

OBJECTIVE To quantify relationships among 3 sets of factors: demographic factors, health and disability factors, and quality of life (QOL). DESIGN Part of a program of longitudinal research on aging and spinal cord injury (SCI) involving 3 populations: American, British, and Canadian. The present analysis uses data from the 1999 interval. SETTING The Canadian sample was derived from the member database of the Ontario and Manitoba divisions of the Canadian Paraplegic Association. The British sample was recruited from a national and a regional SCI center in England. The American sample was recruited through a hospital in Colorado. PARTICIPANTS A sample of 352 participants was assembled from 4 large, well-established databases. The sample included individuals who had incurred an SCI at least 20 years earlier, were admitted to rehabilitation within 1 year of injury, and were between the ages of 15 and 55 at the time of injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A combination of self-completed questionnaires and interviews. Data included demographics, injury-related variables, health and disability-related factors, QOL, and perceptions about aging. RESULTS Using linear structural relationships modeling, we found that QOL was affected both directly and indirectly by age, health and disability problems, and perceptions of aging. Two surprising findings were as follows: those who experienced fewer disability-related problems were more likely to report a qualitative disadvantage in aging, and the younger members of the sample were more likely to report fatigue. CONCLUSIONS Fatigue is a concern because of the relationship of fatigue with perceived temporal disadvantage in aging, health problems, and disability problems. This finding highlights the need for clinical vigilance among those just beginning to experience the effects of aging.

Utilization, access and satisfaction with primary care among people with spinal cord injuries: a comparison of three countries.

Study design:Cross-sectional; survey.Objectives:To describe the utilization, accessibility and satisfaction of primary and preventive health-care services to individuals with long-term spinal cord injuries, and compare results among three countries: the United States, Canada and the United Kingdom.Setting:The Canadian sample was obtained from the Canadian Paraplegic Association – Ontario and Manitoba Divisions. The British sample was recruited from the Northwest Regional Spinal Injuries Centre in Southport and National Spinal Injuries Centre at Stoke Mandeville Hospital in Aylesbury. The American sample was recruited through Craig Hospital in Englewood, CO, USA.Method:A total sample of 373 individuals aging with a spinal cord injury participated in a mailed survey. The Health Care Questionnaire was used to measure utilization, access and satisfaction with primary care and preventive services.Results:In total, 93% of individuals reported having a family doctor, 63% had a spinal injuries specialist and 56% had both a family doctor and spinal injuries specialist. Considerable duplication of services occurred for general medical and preventive services, although lifestyle and emotional issues were not addressed for over 75% of the participants. Significant differences were found in utilization among Canada, US and UK, with Canadians most likely to receive health care from family physicians and Americans most likely to receive care from specialists. Access to and satisfaction with health services was not significantly different among countries.Conclusion:People with long-standing spinal cord injuries develop complex maps by which they seek out appropriate primary health-care and preventive services. Given the differences among countries, it is clear that the health delivery model plays an important role in how and where individuals receive health services.

Correlates of stress in long-term spinal cord injury.

Study Design: Longitudinal. Objectives: To characterize long-injured SCI persons with high reported stress; to assess the relationship between severity of disability and perceived stress; to identify correlates of future stress and outcomes of previous stress. Setting: Two SCI centres in England: Stoke Mandeville Hospital in Aylesbury, and the District General Hospital in Southport. Methods: In 1990, 1993 and 1996 187 persons who sustained spinal cord injuries prior to 1971 underwent comprehensive physical evaluations and health status interviews and completed a battery of tests to measure psychosocial functioning. Using mean scores on the Perceived Stress Scale (PSS) as the reference, a range of outcomes were analyzed to identify concurrent, previous, and future variables that were significantly correlated with perceived stress. Results: No associations were found between stress and any of the proxy variables that represented injury severity. Such common SCI-related medical conditions as pressure sores and upper extremity pain were not related to stress; not even fatigue was significantly associated with stress in both time periods studied. However, depressive symptoms, poorer life satisfaction, and poorer perceived well being were associated with future stress and were outcomes that appeared to be related to earlier stress. Conclusion: Perceived stress in long-term SCI is not closely related to the severity of the disability or physical independence. It is, however, related to scores on several measures of adjustment and coping. Though mean stress scores in this sample did not appear to differ substantially from scores in the general nondisabled population, further controlled study is needed to definitively answer the question: Do SCI survivors report more stress than their nondisabled counterparts? Sponsorship: This research was supported by a Rehabilitation Research and Training Center on Aging with Spinal Cord Injury (1993–1997), which was funded by the National Institute on Disability and Rehabilitation Research of the US Department of Education under grant number H133B30040. The opinions contained in this publication are those of the authors and no not necessarily represent those of the US Department of Education.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions

Study design:A multi-center international cohort study.Objective:To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs).Setting:A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East.Methods:SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity.Results:In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearsons coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ⩾0.95. Cronbachs α values for the entire SCIM III scale were 0.833–0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02).Conclusion:The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

International differences in ageing and spinal cord injury

Design: The present study is part of a programme of longitudinal research on ageing and spinal cord injury involving three populations – American, British and Canadian. The design was multivariate.Objective: To identify international differences in outcomes associated with ageing and spinal cord injury.Setting: A sample of 352 participants was assembled from five large, well-established databases. The Canadian sample was derived from the member database of the Canadian Paraplegic Association (Ontario and Manitoba divisions). The British sample was recruited from Southport Hospitals Northwest Regional Spinal Injuries Centre and Stoke-Mandeville Hospitals National Spinal Injuries Centre. The American sample has been recruited through Craig Hospital in Denver, Colorado.Methods: The sample included individuals who had incurred a spinal cord injury at least 20 years previously; were admitted to rehabilitation within 1 year of injury; were between age 15 and 55 at the time of injury. Data were collected using a combination of self-completed questionnaires and interviews. Data included medical information, general health, hospitalisations, and changes in bladder and bowel management, equipment, pain, spasticity, the need for assistance, and other health issues.Results: Clear international differences existed between the three samples in the three different countries. After controlling for sampling differences (ie, differences in age, level of lesion, duration of disability, etc.), the following differences were seen: (1) American participants had a better psychological profile and fewer health and disability-related problems; (2) British participants had less joint pain and less likelihood of perceiving they were ageing more quickly; (3) Canadians had more health and disability-related complications (particularly bowel, pain and fatigue problems).Conclusion: These differences are discussed in terms of socio-political, health care system and cultural factors that might be used to explain them, and to generate hypotheses for future research.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

Study design:Multicenter international cohort study.Objective:The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels.Setting:In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken.Methods:Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation.Results:Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001).Conclusions:Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.