Journal-based CME article
Spinal Cord Injury-Functional Index: Item Banks to Measure Physical Functioning in Individuals With Spinal Cord Injury

https://doi.org/10.1016/j.apmr.2012.05.007Get rights and content

Abstract

Tulsky DS, Jette AM, Kisala PA, Kalpakjian C, Dijkers MP, Whiteneck G, Ni P, Kirshblum S, Charlifue S, Heinemann AW, Forchheimer M, Slavin MD, Houlihan B, Tate DG, Dyson-Hudson T, Fyffe D, Williams S, Zanca J. Spinal Cord Injury-Functional Index: item banks to measure physical functioning in individuals with spinal cord injury.

Objectives

To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning.

Design

Cross-sectional.

Setting

Inpatient and community.

Participants

Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury.

Interventions

None.

Main Outcome Measure

Spinal Cord Injury-Functional Index (SCI-FI) measurement system.

Results

Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models.

Conclusions

Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Section snippets

Article 1: Spinal Cord Injury-Functional Index: Item Banks to Measure Physical Functioning of Individuals With Spinal Cord Injury

David S. Tulsky, PhD; Alan M. Jette, PT, PhD; Pamela A. Kisala, MA; Claire Kalpakjian, PhD; Marcel P. Dijkers, PhD; Gale Whiteneck, PhD; Pengsheng Ni, MD, MPH; Steven Kirshblum, MD; Susan Charlifue, PhD; Allen W. Heinemann, PhD; Martin Forchheimer, MPP; Mary D. Slavin, PT, PhD; Bethlyn Houlihan, MSW, MPH; Denise G. Tate, PhD; Trevor Dyson-Hudson, MD; Denise Fyffe, PhD; Steve Williams, MD; Jeanne Zanca, MPT, PhD

Article 2: Development and Initial Evaluation of the Spinal Cord Injury-Functional Index

Alan M. Jette, PT, PhD; David S. Tulsky, PhD; Pengsheng Ni, MD, MPH; Pamela A. Kisala, MA; Mary D. Slavin, PT, PhD; Marcel P. Dijkers, PhD; Allen W. Heinemann, PhD; Denise G. Tate, PhD; Gale Whiteneck, PhD; Susan Charlifue, PhD; Bethlyn Houlihan, MSW, MPH; Steve Williams, MD; Steven Kirshblum, MD; Trevor Dyson-Hudson, MD; Jeanne Zanca, MPT, PhD; Denise Fyffe, PhD

Statement of Need

A major treatment goal in the rehabilitation of persons with spinal cord injury (SCI) is to maximize the restoration of physical functioning. Documenting the extent of recovery is imperative for: 1) assessing treatment efficacy; 2) evaluating the cost-effectiveness of treatment interventions; 3) examining the impact of policy changes on patient outcomes; 4) evaluating the quality of care being provided; and 5) providing appropriate, long-term prognostic information to patients and their

Accreditation Statement

This journal-based activity has been planned and developed in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of Professional Education Services Group (PESG).

PESG is accredited by the ACCME to provide continuing medical education (CME) for physicians.

Credit Designation Statement

PESG designates this Journal-based CME activity for a maximum of 2.0 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other health care professionals completing continuing education credit for this activity will be issued a certificate of participation.

Educational Objectives

To support the attainment of knowledge, competence, and performance, the learner should be able to achieve the following objectives:

  • 1

    Describe the current outcomes measurement tools being used with persons with SCI.

  • 2

    Discuss the limitations of the current outcomes measurement tools being used with persons with SCI.

  • 3

    Describe the development of a new outcome measurement tool with the item content and structure being designed specifically for persons with SCI.

  • 4

    Explain how the Spinal Cord

Planning Committee

Susan Charlifue, PhD; Marcel P. Dijkers, PhD; Trevor Dyson-Hudson, MD; Martin Forchheimer, MPP; Denise Fyffe, PhD; Allen W. Heinemann, PhD; Bethlyn Houlihan, MSW, MPH; Alan M. Jette, PT, PhD; Claire Kalpakjian, PhD; Steven Kirshblum, MD; Pamela A. Kisala, MA; Pengsheng Ni, MD, MPH; Mary D. Slavin, PT, PhD; Denise G. Tate, PhD; David S. Tulsky, PhD; Gale Whiteneck, PhD; Steve Williams, MD, Jeanne Zanca, MPT, PhD; PESG staff.

Faculty Profiles & Disclosure Information

As a sponsor accredited by the ACCME, it is the policy of PESG to require the disclosure of anyone who is in a position to control the content of an educational activity. All relevant financial relationships with any commercial interests and/or manufacturers must be disclosed to participants at the beginning of each activity. The faculty of this educational activity disclose the following:

Susan Charlifue, PhD

Craig Hospital, Englewood, CO

No financial conflicts to disclose.

Marcel P. Dijkers, PhD

Mt. Sinai School of Medicine, New York, NY

No financial conflicts to disclose.

Trevor Dyson-Hudson, MD

University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ

No financial conflicts to disclose.

Martin Forchheimer, MPP

University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI

No financial conflicts to disclose.

Denise Fyffe, PhD

University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ

No financial conflicts to disclose.

Allen W. Heinemann, PhD

Northwestern University and Rehabilitation Institute of Chicago, Department of Physical Medicine and Rehabilitation, Chicago, IL

No financial conflicts to disclose.

Bethlyn Houlihan, MSW, MPH

Boston University School of Public Health, Health and Disability Research Institute, Boston, MA

No financial conflicts to disclose.

Alan M. Jette, PT, PhD

Boston University School of Public Health, Health and Disability Research Institute, Boston, MA

No financial conflicts to disclose.

Claire Kalpakjian, PhD

University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI

No financial conflicts to disclose.

Steven Kirshblum, MD

Kessler Institute for Rehabilitation, West Orange, NJ

No financial conflicts to disclose.

Pamela A. Kisala, MA

University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI

No financial conflicts to disclose.

Pengsheng Ni, MD, MPH

Boston University School of Public Health, Health and Disability Research Institute, Boston, MA

No financial conflicts to disclose.

Mary D. Slavin, PT, PhD

Boston University School of Public Health, Health and Disability Research Institute, Boston, MA

No financial conflicts to disclose.

Denise G. Tate, PhD

University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI

No financial conflicts to disclose.

David S. Tulsky, PhD

University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI

No financial conflicts to disclose.

Gale Whiteneck, PhD

Craig Hospital, Englewood, CO

No financial conflicts to disclose.

Steve Williams, MD

Boston Medical Center, New England Regional Spinal Cord Injury Center, Boston, MA

No financial conflicts to disclose.

Jeanne Zanca, MPT, PhD

Mt. Sinai School of Medicine, New York, NY

No financial conflicts to disclose.

PESG Staff

No financial conflicts to disclose.

Resolution of Conflict of Interest

PESG has implemented a process to resolve conflict of interest for each CME activity. In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, PESG has resolved the conflict by external content review.

Unapproved/Off-Label Use Disclosure

PESG requires CME faculty to disclose to the participants:

  • 1

    When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and

  • 2

    Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Faculty may discuss information about pharmaceutical agents that is outside of FDA-approved labeling. This

Intended Audience

This program is intended for physicians and healthcare professionals responsible for the comprehensive care for individuals with chronic illness and disabilities.

Method of Participation

In order to claim credit, participants must complete the following:

  • 1

    Pre-activity self-assessment questions

  • 2

    Read the 2 articles included in this activity.

  • 3

    Complete the CME Test and Evaluation. Participants must achieve a score of 70% on the CME Test.

Participants can complete the pre-activity self-assessment and CME Test and Evaluation online by logging on to http://acrm.cds.pesgce.com. Upon successful completion of the online tests and evaluation form, you can instantly download and print your

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For all CME certificate inquiries, please contact us at [email protected].

This continuing education activity is active starting October 1, 2012 and will expire September 30, 2013.

Estimated Time to Complete This Activity: 2.0 hours

Development of the SCI-FI Item Pools

SCI-FI development (fig 1) began with a thorough literature review, input from focus groups conducted with individuals with SCI and SCI clinicians, and feedback from experts in SCI rehabilitation. As reported by Slavin et al,15 12 focus groups with individuals who had SCI and 6 focus groups with SCI clinicians were held at 6 Spinal Cord Injury Model System (SCIMS) centers, and a rigorous qualitative analysis was conducted to extract potential activities, skills, and tasks to be included in the

Results

As shown in table 2, the SCI-FI item pool for field testing comprised 328 items, including 204 new, SCI-specific physical functioning items, 37 Neuro-QOL physical health items, 25 AM-PAC items, 33 PROMIS physical functioning items, 57 Shriners Pediatric SCI-CAT items, and 6 PROMIS assistive technology items.

Demographic data for the calibration study participants are shown in table 3. Approximately 46% of the individuals were diagnosed with paraplegia and 54% with tetraplegia; 46% of the sample

Discussion

The SCI-FI marks a significant advance in measuring physical functioning in individuals with SCI. Its content is based on direct feedback from individuals with SCI as well as SCI clinicians, and psychometric analyses24 provide evidence of the content validity of the SCI-FI. We followed the PROMIS standards for scale development throughout the qualitative and quantitative phases of this study. No other measure of physical functioning is as comprehensive and uniquely tailored to the needs of

Conclusions

The SCI-FI represents an ambitious attempt to develop a patient-reported measure of physical functioning in the SCI population. A rigorous item development process occurred that involved literature reviews, integration with previously existing items and scales, expert opinion, and feedback from consumers. After these procedures, a large multisite field test was conducted in which 855 individuals with traumatic SCI participated. The results of this study support a 5-factor solution breaking down

References (41)

  • Clinical Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM™ instrument)

    (1997)
  • R.A. Keith et al.

    The Functional Independence Measure: a new tool for rehabilitation

    Adv Clin Rehabil

    (1987)
  • A. Catz et al.

    The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure

    Disabil Rehabil

    (2001)
  • M.S. Alexander et al.

    Outcome measures in spinal cord injury: recent assessments and recommendations for future directions

    Spinal Cord

    (2009)
  • A. Catz et al.

    A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation

    Spinal Cord

    (2007)
  • P.L. Ditunno et al.

    Walking Index for Spinal Cord injury (WISCI II): scale revision

    Spinal Cord

    (2001)
  • A.S. Burns et al.

    The reproducibility and convergent validity of the Walking Index for Spinal Cord Injury (WISCI) in chronic spinal cord injury

    Neurorehabil Neural Repair

    (2011)
  • F. Mahoney et al.

    Functional evaluation: the Barthel Index

    Md Med State J

    (1965)
  • C.V. Granger et al.

    Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index

    Arch Phys Med Rehabil

    (1979)
  • G.E. Gresham et al.

    The Quadriplegia Index of Function (QIF)–sensivitiy and reliability demonstrated in a study of 30 quadriplegic patients

    Paraplegia

    (1986)
  • Cited by (0)

    Supported by the U.S. Department of Education, National Institute of Disability and Rehabilitation Research (grant nos. H133N060022, H133N060024, H133N060014, H133N060005, H133N060027, and H133N060032) and by the National Institutes of Health, National Institute of Child Health & Human Development, National Center for Medical Rehabilitation Research, and National Institute of Neurological Disorders and Stroke (grant no. 5R01HD054659).

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

    In-press corrected proof published online on Jul 30, 2012, at www.archives-pmr.org.

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