Spinal Cord Injury Outcome Measures Overview

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly  

Introduction

An Outcome Measure is a test used to objectively determine baseline function of an individual at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. With the move towards Evidence Based Practice (EBP), objective measures of outcome are important to provide credible and reliable justification for treatment. The instrument should also be convenient to apply for the therapist and comfortable for the individual.

Measuring the effectiveness of interventions is accepted as being central to good practice. An integral part of evaluating clinical practice is to objectively assess the intervention and measure it against a set of outcomes to determine its efficacy. For results to be meaningful, it is imperative that any measures used to assess outcomes in any health care context cover domains (for example pain, physical function, perceived independence) that are relatively specific and appropriate to both the particular context and population that you are working with and have acceptable measurement properties, including: reliability, validity, responsiveness, acceptability and feasibility specific to that population. [1][2]

There has been an increased focus on outcome measurement in the field of spinal cord injury, with creation of common definitions and data sets to ensure that information being collected is both valid and accurate with consistent recording of both clinical and research information. Despite increased use of validated outcome and more frequent assessment, there is still a broad range of outcome measures being used that limits the ability to compare findings from centre to centre or client to client, which has an impact on identification and implementation of best practice. This page presents the best available information on how outcome measures for spinal cord injury might be classified and selected for use, based upon their measurement qualities incorporating the most recent consensus recommendations. [3][4]

SCI EDGE Task Force Recommended Outcome Measures

The SCI EDGE Task Force reviewed 63 outcome measures covering the range of body structure and function, activities and participation evaluating each for psychometrics and clinical utility for individuals with a Spinal Cord Injury. Through literature review, analysis, and a modified Delphi Procedure, recommendations were formulated for outcome measures that are highly recommended for use in individuals with Spinal Cord Injury during each phase of treatment and for each type of injury, with a summary for each of these outcome measures updated or added to the Shirley Ryan Ability Lab Rehabilitation Measures Database. [4]

  • 20 measures were recommended or highly recommended for both complete and incomplete spinal cord injury
  • 14 measures were recommended or highly recommended for at least 2 levels of acuity
  • 23 measures were recommended for use in physiotherapy education
  • 32 measures were recommended for use in spinal cord injury research

Results also revealed a number of underrepresented areas. In the Body Structure and Function Domain of the International Classification of Functioning, Disability, and Health, none of the measures for tone or cardiovascular function could be recommended secondary to insufficient research specific to the spinal cord injury population to support a stronger recommendation. Similarly in the Activity Domain, balance, upper limb function, and wheelchair skills were also underrepresented with only 1 of 7 balance measures (ie, Berg Balance Scale) and 2 of 9 upper limb function measures (ie, the Capabilities of Upper Extremity Functioning and the Graded and Redefined Assessment of Sensibility, Strength, and Prehension) receiving a “Recommended” rating. Finally in the Participation Domain, all measures that achieved a “Recommended” or “Highly Recommended” rating in at least 3 of the 5 categories were patient- reported outcomes measuring domains of quality of life, community function, health and wellness, and environmental factors, which all displayed extensive psychometric data available in the chronic spinal cord injury population, but only one recommended in the acute spinal cord injury population, (the Needs Assessment Check-list), as such the Participation-level Outcome Measures are most appropriate to be used in the chronic spinal cord injury population. [4]

Phase of Treatment

Overall 14 measures were recommended or highly recommended for at least 2 levels of acuity providing the ability to compare progress over a longer period of time and covering a number of domains of the International Classification of Functioning, Disability, and Health. The acute spinal cord injury category had a total of 6 “Highly Recommended” Outcome Measures and 7 “Recommended” Outcome Measures in comparison with the chronic spinal cord injury category, which had a total of 6 “Highly Recommended” Outcome Measures and 19 “Recommended” Outcome Measures. Limited research in acute spinal cord injury (0 - 3 months) meant fewer measures could be recommended during this phase of injury. In particular in relation to quality of life and upper limb function were areas in which no recommendations could be made, despite the importance of both areas and have been identified as a need for further research and development. [4]

Phase Timeframe Highly Recommended Recommended
Acute 0-3 Months 6 Minute Walk Test (6MWT)

10 Meter Walk Test (10MWT)

Hand Held Myometry

Timed Up and Go (TUG)

Walking Index for Spinal Cord Injury II (WISCI II)

ASIA Impairment Scale

Berg Balance Scale (BBS)

Functional Independence Measure (FIM)

Manual Muscle Test (MMT)

Needs Assessment Checklist

Numeric Pain Rating Scale

Spinal Cord Independence Measure III (SCIM III)

Spinal Cord Injury Functional Ambulation Inventory

Subacute 3-6 Months 6 Minute Walk Test (6MWT)

10 Meter Walk Test (10MWT)

Handheld Myometry

Timed Up and Go (TUG)

ASIA Impairment Scale

Berg Balance Scale (BBS)

Functional Independence Measure (FIM)

Manual Muscle Test (MMT)

Needs Assessment Checklist

Numeric Pain Rating Scale

Sickness Impact Profile 68

Spinal Cord Injury Functional Ambulation Inventory

Spinal Cord Independence Measure III (SCIM III)

Walking Index for Spinal Cord Injury II (WISCI II)

Chronic > 6 Months 6 Minute Walk Test (6MWT)

10 Meter Walk Test (10MWT)

Handheld Myometry

Numeric Pain Rating Scale (NRS)

World Health Organization Quality of Life - BREF (WHOQOL - BREF)

ASIA Impairment Scale

Berg Balance Scale (BBS)

Capabilities of Upper Extremity Instrument (CUE)

Craig Handicap Assessment & Reporting Technique (CHART)

Craig Hospital Inventory of Environmental Factors

Functional Independence Measure (FIM)

Graded and Redefined Assessment of Sensibility, Strength and Prehension (GRASSP)

Life Satisfaction Questionnaire 9

Manual Muscle Test (MMT)

Multidimensional Pain Inventory, SCI Version

Reintegration to Normal Living Index

Satisfaction With Life Scale

Short Form 36 (SF-36)

Sickness Impact Profile 68

Spinal Cord Injury Functional Ambulation Inventory

Spinal Cord Injury Functional Ambulation Profile

Spinal Cord Injury Independence Measure III (SCIM III)

Timed Up and Go (TUG)

Walking Index for Spinal Cord Injury II (WISCI II)

Wheelchair Skills Test (WST)

Wheelchair Users Shoulder Pain Index

ASIA Impairment Scale Level

Overall 20 measures were given a rating of “Recommended” or “Highly Recommended” in both incomplete and complete spinal cord injury categories including measures covering the Body Structure and Function, Activity, Participation and Environment Domains of the International Classification of Functioning, Disability, and Health. [4]

Type of Injury AIS Level Highly Recommended Recommended
Motor Complete AIS A

AIS B

Handheld Myometry

World Health Organization Quality of Life - BREF (WHOQOL - BREF)

ASIA Impairment Scale

Capabilities of Upper Extremity Instrument (CUE)

Craig Handicap Assessment and Reporting Technique

Craig Hospital Inventory of Environmental Factors

Functional Independence Measure

Graded and Redefined Assessment of Sensibility Strength and Prehension

Life Satisfaction Questionnaire 9

Manual Muscle Test (MMT)

Multidimensional Pain Inventory, SCI Version

Needs Assessment Checklist

Numeric Pain Rating Scale

Reintegration to Normal Living Index

Satisfaction With Life Scale

Short Form 36 (SF-36)

Sickness Impact Profile 68

Spinal Cord Injury Independence Measure III (SCIM III)

Walking Index for Spinal Cord Injury II (WISCI II)

Wheelchair Users Shoulder Pain Index

Motor Incomplete AIS C

AIS D

6 Minute Walk Test (6MWT)

10 Meter Walk Test (10MWT)

Handheld Myometry

Timed Up and Go (TUG)

Walking Index for Spinal Cord Injury II (WISCI II)

World Health Organization Quality of Life - BREF (WHOQOL - BREF)

ASIA Impairment Scale

Berg Balance Scale (BBS)

Capabilities of Upper Extremity Instrument (CUE)

Craig Handicap Assessment & Reporting Technique (CHART)

Craig Hospital Inventory of Environmental Factors

Functional Independence Measure (FIM)

Graded and Redefined Assessment of Sensibility Strength and Prehension (GRASSP)

Life Satisfaction Questionnaire 9

Manual Muscle Test (MMT)

Multidimensional Pain Inventory, SCI Version

Needs Assessment Checklist

Numeric Pain Rating Scale

Reintegration to Normal Living Index

Spinal Cord Injury Functional Ambulation Inventory

Spinal Cord Injury Functional Ambulation Profile

Satisfaction With Life Scale

Short Form 36 (SF-36)

Sickness Impact Profile 68

Spinal Cord Injury Independence Measure III (SCIM III)

Wheelchair Users Shoulder Pain Index

SCIRE Spinal Cord Injury Outcome Measures Toolkit

Specific and validated outcome measures data is central to understanding the needs of clients, their level of care, and the services that will enhance their rehabilitation. Developed in 2017 specifically for clinicians working in spinal cord injury rehabilitation, the Spinal Cord Injury Research Evidence (SCIRE) Outcome Measures Toolkit aims to further address the need for common measures in spinal cord injury clinical practice, to support practical and clinically applicable research, and ensures up-to-date educational material. [3]

One hundred and forty-eight outcome measures were initially considered for inclusion with consensus reached for 23 out of 30 clinical areas. In the remaining seven clinical areas, more than one outcome measure was recommended. The final toolkit comprises 33 Outcome Measures across 30 Clinical Areas with sufficient measurement properties for use with a spinal cord injury population. It was highlighted that many of the other measures not selected were missing clinically important measurement properties, such as responsiveness, that assist the most in documenting a client’s progress in rehabilitation. As such further research is recommended to establish the clinical suitability of the other measures for later inclusion in the toolkit. [3]

International Classification of Functioning, Disability, and Health Component

ICF Area Clinical Area Outcome Measure
Body Structure and Function Neurological and Autonomic International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

Surface Electromyography

Strength Hand-Held Myometer
Spasticity Ashworth and Modified Ashworth

Penn Spasm Frequency Scale

Pendulum Test

Sensory - Pain Brief Pain Inventory

Classification System for Chronic Pain in Spinal Cord Injury

Skin Health Braden Scale

Spinal Cord Injury Pressure Ulcer Scale (SCIPUS)

Mental Health CAGE Questionnaire

Depression Anxiety Stress Scale - 21

Patient Health Questionnaire - 9

Activities Lower Limb and Walking 6 Minute Walk Test (6MWT)

10 Meter Walk Test (10MWT)

Berg Balance Scale (BBS)

Timed Up and Go Test (TUG)

Walking Index for Spinal Cord Injury (WISCI)

Standing and Walking Toolkit

Wheeled Mobility Wheelchair Skills Test (WST)
Upper Limb Capabilities of Upper Extremity Instrument (CUE)

Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)

Jebsen Hand Function Test

Sollerman Hand Function Test

Box and Block Test

Self Care Frenchay Activities Index (FAI)

Lawton Instrumental Activities of Daily Living Scale (IADL)

Spinal Cord Independence Measure (SCIM)

Participation Community Reintegration Craig Handicap Assessment & Reporting Technique (CHART)

Reintegration to Normal Living Index

Quality of Life Short Form-36 (SF-36)

World Health Organization Quality of Life - BREF (WHOQOL-BREF)

Environment Assistive Technology Assistive Technology Device Predisposition Assessment (ATD-PA)

Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST)

Conclusion

Spinal cord injury is a medically complex and life-disrupting condition with a high likelihood that secondary health complications, such as pressure ulcers, fractures, or circulatory dysfunction, will develop. Clinicians who work with individuals with a spinal cord injury share a commitment toward providing the best interventions to produce successful out- comes for those that they work with. [3]

The most meaningful determinant of treatment efficacy from the perspective of the individual with a spinal cord injury generally relates to improvements in their ability to function in everyday activities and must be forefront in our minds as health care professionals throughout all stages of treatment and rehabilitation. While there will never be a perfect questionnaire or measure of outcome, choosing the right measure to use involves identifying the most appropriate measure for the chosen population group, context and purpose, where evidence exists to show that the questionnaire has exhibited adequate measurement properties pertaining to that group and/or context. [1][3]

Prior to determining any intervention, careful choice of treatment goals and aims is essential in individuals with a spinal cord injury in order to identify and determine the most appropriate outcome measures to use. This means the therapist can ensure they are providing the most appropriate intervention that meets the treatment goals and expectations of the individual with a spinal cord injury. Use of an outcome measures toolkit, specifically validated for spinal cord injury, should lead to improved identification of best practice and enable clinicians to more effectively monitor client progress. [2][3]

Resources

Spinal Cord Injury Research Evidence Project Outcome Measures Database

Participation and Quality of Life (PAR-QoL) Tool-Kit

Shirley Ryan Ability Lab Rehabilitation Measures Database

References

  1. 1.0 1.1 Dawson J, Shamley D, Jamous MA. A Structured Review of Outcome Measures used for the Assessment of Rehabilitation Interventions for Spinal Cord Injury. Spinal Cord. 2008 Dec;46(12):768.
  2. 2.0 2.1 Lam T, Noonan VK, Eng JJ. A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury. Spinal Cord. 2008 Apr;46(4):246.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Chan CW, Miller WC, Querée M, Noonan VK, Wolfe DL, SCIRE Research Team. The Development of an Outcome Measures Toolkit for Spinal Cord Injury Rehabilitation: Création d’une Trousse de Mesures des Résultats pour la Réadaptation des Personnes ayant subi une lésion de la Moelle épinière. Canadian Journal of Occupational Therapy. 2017 Apr;84(2):119-29.
  4. 4.0 4.1 4.2 4.3 4.4 Kahn JH, Tappan R, Newman CP, Palma P, Romney W, Tseng Stultz E, Tefertiller C, Weisbach CL. Outcome Measure Recommendations From the Spinal Cord Injury EDGE Task Force. Physical Therapy. 2016 Nov 1;96(11):1832-42.
  5. RickHansenInstitute. Outcome Measures in SCI Interventions - Dr. Sukhvinder Kalsi-Ryan. Available from: https://youtu.be/2C2Owo7y23Q[last accessed 30/10/18]