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Rehab Measures: Medical Outcomes Study Short Form 36

Link to instrument

Available for purchase at SF-36.org (external link) 

Title of Assessment

Medical Outcomes Study Short Form 36 

Acronym

SF-36; SF-36v2

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team; Updated by Wendy Romney, PT, DPT, NCS, Cara Weisbach, PT, DPT, and the SCI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Sue Saliga PT, DHSc, CEEAA and the TBI EDGE task force of the Neurology section og the APTA in 2012. Updated by Erin Hussey, PT, DPT, MS, NCS and Cathy Harro PT, PhD and the PD EDGE task force of the Neurology Section of the APTA in 2013.

Summary Date

1/22/2013 

Purpose

Generic, patient-report measure designed to assess health-related quality of life

Description

  • 36 item measure divided into 8 subscales and 2 composite domains 
  • The 8 subscales are:
    • (1) Physical Functioning
    • (2) Role Limitations due to Physical Problems
    • (3) General Health Perceptions
    • (4) Vitality
    • (5) Social Functioning
    • (6) Role Limitations due to Emotional Problems
    • (7) General Mental Health
    • (8) Health Transition
  • Respondents are asked to answer items referring to the past 4 weeks
  • Recommended scoring system for the SF-36 is a weighted Likert system for each item
  • Items within subscales are totaled to provide a summed score for each subscale or dimension.
  • Each of the 8 summed scores is linearly transformed onto a scale from 0 (negative health) to 100 (positive health) to provide a score for each subscale. Each subscale can be used independently.
  • For each domain (physical and mental composite) mean score = 50 and standard deviation = 10
  • Version 2 norms are based on the 1998 National Survey of Functional Health Status (NSFHS); more information on version 2 can be found on the SF-36 website: http://www.sf-36.org/tools/sf36html 

Area of Assessment

Quality of Life 

Body Part

Not Applicable 

ICF Domain

Body Function; Activity; Participation 

Domain

General Health 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

10 minutes; 41 and 47 minutes, respectively, for individuals with paraplegia & tetraplegia (Anderson, et al 1999)

Number of Items

36 

Equipment Required

Suggests enlarged copy of item response options (Steffen & Seney 2008)

Training Required

Acquire and reading manual needed for item administration and scoring.

Type of training required

No Training 

Cost

Not Free 

Actual Cost

Contact QualityMetric Incorporated for information regarding licensing fees for your institution

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Arthritis; Cardiac Conditions; Geriatrics; Multiple Sclerosis; Pain; Spinal Cord Injury; Stroke; Traumatic Brain Injury 

Populations Tested

The following conditions each have 50 or more publications (Turner-Bowker et al, 2002):
  • Arthritis
  • Back pain
  • Low back pain
  • Multiple sclerosis
  • Musculoskeletal conditions
  • Neuromuscular conditions
  • Osteoarthritis
  • Parkinson Disease
  • Rheumatoid arthritis
  • Spinal injuries
  • Stroke
  • Trauma
  • Traumatic Brain Injury (Nichol et al, 2011)

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes):

(Steffen & Seney, 2008; n = 37 (PD n = 35, Parkinson-Plus n = 2); mean age = 71 (12); mean disease duration = 14 (6) years; Hoehn and Yahr stages median score = 2 (range = 1 to 4); Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; test-retest by same rater at 1-week interval; Administered SF-36 by direct interview.

MDC-95 for each subscale of SF-36 (V1)

SF-36 Subscale

MDC95

Physical Functioning

28

Role limits - Physical

45

Bodily pain

25

General health

28

Vitality

19

Social functioning

29

Role limits - emotional

45

Mental health

19

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Applicable

Normative Data

Parkinson Disease:
(Banks and Martin, 2009; n = 339 with PD (164 male; 179 female); mean age = 54.6 (range 27-75); Version 2 of SF-36; tested multiple configurations to determine recommended model for use and if this scale useful for PD. Identified 8 subscales and 6 models: physical functioning [1], role-physical [2], bodily pain [3], general health [4], vitality [5], social functioning [6], role-emotional [7] and mental health [8]. Compared various models of subscale combinations and assessments and compared against typical recommendation that summary measures of physical health (scales 1–4) and mental health (scales 5–8) can also be calculated and used independently.)
 
SF-36 subscale scores 
Mean
SD
Physical functioning
44.03
26.44
Role–physical
25.41 
34.24

Bodily pain

50.22

34.24

General health

44.08

20.89

Vitality

36.08

20.12

Social functioning

57.05

25.81

Role–emotional

47.81

44.03

Mental health

61.10

19.57 

 
(Leonardi et al, 2012. N = 96 (64 male); mean age = 64.1 (11.3; range 24-90); 74% were married; 79.2% were not employed; Hoehn & Yahr stages: 1 = 13, 2 = 55, 3 = 22, 4 = 6. Compared to normative data from general Italian population.)
 

Mean score (SD)

Normative data

t-test

P-value

SF-36 (v2)

Physical Functioning

72.0 (22.6)

84.46

−5.04

P < 0.001

Role Physical

46.9 (38.9)

78.21

−7.88

P < 0.001

Bodily Pain

58.9 (29.9)

73.67

−4.83

P < 0.001

General Health

41.2 (20.5)

65.22

−11.44

P < 0.001

Vitality

56.7 (20.1)

61.89

−2.52

P = 0.013

Social Functioning

69.2 (27.6)

77.43

−2.93

P = 0.004

Role Emotional

68.4 (40.3)

76.16

−1.88

P = 0.063

Mental Health

64.6 (19.6)

66.50

−0.94

P = 0.350

PCS

40.0 (8.8)

50

−11.09

P < 0.001

MCS

46.7 (11.0)

50

−2.90

P = 0.005

 
Chronic Stroke:
(Anderson et al, 1996; n = 90; mean age = 72 (12) years; assessed 1 year post stroke; Australian version)
 
SF-36 Domain 
  Mean  
SD 
Physical functioning 
48
33
Role limits–physical  
 76 
 34 

Bodily pain

76

28

General health 

64

22

Vitality

56

20

Social functioning

86

23

Role limits–emotional

83

31

Mental health

77

22

Chronic Spinal Cord Injury:

(Forchheimer et al, 2004; n = 215, mean age = 38.8 years; assessed > 1 year post traumatic SCI)

SF-36 Domain

Mean

SD

Physical functioning

26.6

11.5

Role Physical

40.7

10.9

Bodily pain

42.2

12.4

General Health

44.4

11.8

Vitalitiy

46.8

9.6

Social Functioning

43.0

13.3

Role Emotional

49.0

10.6

Mental Health

48.3

11.0

Physical Component Summary

33.5

10.1

Mental Component Summary

53.5

11.6

TBI:

(Colantonio et al., 1998; n = 51; mean age = 18.28 (2.04) years; assessed 5 years post TBI )

Mild (n = 24)

Moderate / Severe (n = 27)

Mean

SD

Mean

SD

Physical Functioning

84.91

22.02

75.43

35.43

Role Limits–physical

79.17

36.94

75.32

37.01

Bodily Pain

77.40

19.29

81.44

17.89

General Health

63.98

26.74

68.33

22.74

Vitality

53.54

9.83

52.90

13.79

Social Functioning

72.92

27.25

73.15

27.23

Mental Health

46.50

16.42

46.67

17.40

Role Limits–mental health

81.94

32.57

75.64

38.36

Mild Traumatic Brain Injury:

(Emanuelson et al, 2003; n = 117, patients assessed at 3 months post injury and n = 101, patients assessed 1 year post injury; age = 16-60)

Domain in SF-36

Patients 3 Months (n = 117) Mean, SEM, median

Patients 1 Year (n = 101) Mean, SEM, median

Mean

SD

Median

Minimum

Maximum

PF

85.4 (1.9), 95

87.5 (2.1), 95

0.85

12.93

0.00

−35.00

60.00

RF

72.5 (3.5), 100

74.7 (3.8), 100

−0.42

30.07

0.00

−100.00

100.00

BP

66.7 (3.0), 72

72.2 (3.1), 74

1.31

25.52

0.00

−69.00

69.00

GH

68.3 (2.4), 72

70.9 (2.5), 72

0.78

17.67

0.00

−52.00

48.00

VT

59.3 (2.4), 60

62.3 (2.6), 65

1.86

19.97

0.00

−70.00

60.00

SF

81.6 (2.5), 100

83.2 (2.4), 100

−0.12

20.35

0.00

−62.50

50.00

RE

72.7 (2.4), 80

77.2 (3.7), 100

3.00

33.87

0.00

−100.00

100.00

MH

71.2 (2.4), 80

74.9 (2.2), 84

1.74

17.87

0.00

−48.00

56.00

PCS

48.4 (1.2), 52

49.1 (1.1), 52

−0.02

6.80

−0.06

−23.16

18.94

MCS

44.8 (1.2), 48

46.5 (1.3), 51

1.09

10.43

0.47

−36.97

36.67

 

 

 

 

 

 

 

 

 

PF =physical functioning, RF =role physical, BP =bodily pain, GH =general health, VT =vitality, SF = social functioning, RE =role emotional, MH =mental health, PCS =physical composite score, MCS =mental composite score.

 

Mild Traumatic Brain Injury:

(Emanuelson et al, 2003; n = 117, patients assessed at 3 months post injury and n = 101, patients assessed 1 year post-injury; age = 16-60)

Domain in SF-36

Patients 3 Months (n = 117) Mean, SEM, median

Patients 1 Year (n = 101) Mean, SEM, median

Physical Function

85.4 (1.9), 95

87.5 (2.1), 95

Role Functioning:Physical

72.5 (3.5), 100

74.7 (3.8), 100

Bodily Pain

66.7 (3.0), 72

72.2 (3.1), 74

General Health

68.3 (2.4), 72

70.9 (2.5), 72

Vitality

59.3 (2.4), 60

62.3 (2.6), 65

Social Functioning

81.6 (2.5), 100

83.2 (2.4), 100

Role Functioning: Emotional

72.7 (2.4), 80

77.2 (3.7), 100

Mental Health

71.2 (2.4), 80

74.9 (2.2), 84

Physical Composite

48.4 (1.2), 52

49.1 (1.1), 52

Mental Composite

44.8 (1.2), 48

46.5 (1.3), 51

Test-retest Reliability

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes)
(Steffen & Seney, 2008; n = 37 (PD n = 35, Parkinson-Plus n = 2); mean age = 71 (12); mean disease duration = 14 (6) years; Hoehn and Yahr stages median score = 2 (range = 1 to 4); Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; test-retest by same rater at 1-week interval; mean number of falls in the past 6 months = 7; Administered SF-36 (v1) by direct interview.)
 

SF-36 Domain

Test-Retest reliability
(ICC)

Physical Functioning

0.80 Adequate

Role Physical

0.85 Excellent

Bodily Pain

0.89 Excellent

General Health

0.85 Excellent

Vitality

0.89 Excellent

Social Functioning

0.71 Adequate

Role Emotional

0.84 Excellent

Mental Health

0.83 Excellent

 
Chronic Stroke:
(Dorman et al, 1998; n = 209; 3 weeks between assessments; mean time since stroke onset 64(30) weeks)
 
Domain
Patient ICC's
Proxy ICC's
Combined ICC's
Physical Functioning
0.80
0.59
0.74
Role Limits–physical
0.77
0.45
0.67
Bodily Pain
0.81
0.65
0.75
General Health
0.81
0.71
0.79
Vitality
0.77
0.55
0.70
Social Functioning
0.79

0.76

0.80
Role Limits–emotional
0.60
0.50
0.57
Mental Health 
0.30
0.24
0.28
 

Chronic Traumatic Spinal Cord Injury:

(Lin et al, 2007; n = 187; 4 weeks between assessments; mean time since injury was 7.8 years)

20 random participants were selected to assess their original responses within 2 weeks; n = 10 by same interviewer (intra interviewer), n = 10 with a second interviewer (inter interviewer)

SF-36 Domain

Intra interviewer
(ICC)

Inter interviewer
(ICC)

Physical Functioning

0.71

0.67

Role Physical

0.89

0.90

Bodily Pain

0.87

0.70

General Health

0.85

0.41

Vitality

0.93

0.86

Social Functioning

0.93

0.52

Role Emotional

0.99

0.98

Mental Health

0.77

0.57

Excellent Intra ICC > 0.9 in BOLD; Excellent Inter ICC > 0.7 in BOLD

Interrater/Intrarater Reliability

Not applicable

Internal Consistency

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes):
(Steffen & Seney, 2008; n = 37; mean age = 71; mean disease duration = 14 (6) years); Hoehn and Yahr Stages range from 1-to-4. ; Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; Test-retest by same rater at 1-week interval; mean number of falls in the past 6 months = 7)
 
Internal Consistency for SF-36 v1 (Cronbach’s alpha):  [No source for this linked to SF-36v2]

SF-36 Domain

Internal Consistency
Cronbach’s alpha Strength

Physical Functioning

0.87 Excellent

Role Physical

0.74 Adequate

Bodily Pain

0.91 Excellent

General Health

0.80 Adequate

Vitality

0.91 Excellent

Social Functioning

0.84 Excellent

Role Emotional

0.89 Excellent

Mental Health

0.93 Excellent

 
(Brown et al, n = 96 total (n = 58 with follow-up data and 38 without); mean age = 72 (88% white, 84% male); years of school = 15.7 (2.4); via standardized telephone interview at baseline and ~18 months (mean = 17.9 (4.2) months In PD subjects, Hoehn & Yahr stages not reported.)
 

Subscale (item #)

Cronbach’s alpha (strength)

Physical Functioning (10)

0.94 (Excellent)

Role Limitations–Physical (4)

0.81 (Excellent)

Role Limitations–Emotional (3)

0.98 (Excellent)

Pain (2)

0.85 (Excellent)

Emotional Well-Being (5)

0.86 (Excellent)

Energy (4)

0.92 (Excellent)

General Health (5)

0.76 (Adequate)

Social Function (2)

0.98 (Excellent)

Physical Health (PCS)

0.93 (Excellent)

Mental Health (MCS)

0.97 (Excellent)

 
Acute Stroke:
(Hagen et al, 2003; n  = 136; mean age = 70 (11) years; assessed 1, 3 and 6 months post-stroke)
  • Adequate to Excellent internal consistency across domains (alpha > 0.70) over multiple administrations (1, 3 and 6 months) except Vitality at 1 month post stroke (a = 0.6824) and General Health at 3 months post-stroke (a = 0.6650) 
Chronic Stroke:
(Anderson et al, 1996)
  • Excellent internal consistency (Cronbach's alpha > 0.7, except Vitality section):
SF-36 Domain
Strength
alpha
Physical Functioning
Excellent
0.9
Role Limits–physical
Adequate
0.8
Bodily Pain
Excellent
0.9
General Health
Adequate
0.7
Vitality
Adequate
0.6
Social Functioning 
Adequate
0.7
Role Limits–emotional
Excellent
0.9
Mental Health Adequate
0.7

Spinal Cord Injury:

(Forchheimer,et al 2004)

  • Adequate to Excellent internal consistency across all domains (Chronbach’s α = 0.76 to 0.90, mean = 0.82)

SF-36 Domain

Internal Consistency
(Cronbach’s alpha)

Physical Functioning

0.98

Role Physical

0.94

Bodily Pain

0.79

General Health

0.82

Vitality

0.76

Social Functioning

0.72

Role Emotional

0.89

Mental Health

0.78

Excellent internal consistency > 0.80 in BOLD; Adequate internal consistency 0.70-0.80

Chronic SCI:

(van Leeuwen et al 2012, n = 145, AIS A-D, 5 years post injury)

  • Adequate internal consistency of the Mental Health subscale of SF-36 (MHI-5), Cronbach’s α = 0.79

 

Traumatic Brain Injury: (Mackenzie, et al 2002, n =1230 (1197 without proxy, 33 by proxy), age range 18-54 years, gender=male 66%)

The α coefficient for the SF-36 health survey with the cognitive function scale

SF-36 Domain

α coefficient

Strength

Physical Functioning

0.93

Excellent

Role Limits–physical

0.88

Excellent

Bodily Pain

0.89

Excellent

General Health

0.77

Adequate

Vitality

0.84

Excellent

Social Functioning

0.82

Excellent

Role Limits–emotional

0.87

Excellent

Mental Health

0.88

Excellent

Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8)

  • Cronbach’s alpha ranged from 0.68-0.87 (adequate to excellent) for the comparison group , from 0.83-0.91 (excellent) for the mild TBI group, and from 0.79-0.92 (adequate to excellent) for the moderate-severe TBI group

Traumatic Brain Injury: (Guilfoyle et al, 2011; n=514; mean age=36.6 (16.1) years; gender=male 76.3%)

SF-36 domain

Alpha coefficient

Strength

Physical Function

0.95

Excellent

Role Physical

0.89

Excellent

Bodily Pain

0.90

Excellent

General Health

0.83

Excellent

Vitality

0.83

Excellent

Social function

0.82

Excellent

Role Emotional

0.90

Excellent

Mental Health

0.86

Excellent

Criterion Validity (Predictive/Concurrent)

Parkinson Disease:
(Leonardi et al, 2012; n = 86 all scales)

Pearson correlations all significant at p < 0.0001

N=86 all scales

SF-36 PCS / Correlation Strength

SF-36 MCS / Correlation Strength

NMS Questionnaire /

Correlation Strength

WHO-DAS II summary score

-0.70 / Excellent

-0.52 / Adequate

0.65 / Excellent

NMS questionnaire

-0.54 / Adequate

-0.40 / Adequate

--

NMS = non motor symptoms questionnaire
WHO-DAS II = World Health Organization Disability Assessment Schedule

(Nilsson et al, 2010; n = 79 with diagnosis of idiopathic PD, 37 outpatient and 42 via survey; mean age 64 years (7.2) correlation study; 8.8 (2.3) days between testing sessions; duration of diagnosis = 15.9 (7.3) years; Hoehn & Yahr ratings not specified. Focus of study on FES (Swedish-13) & SAFFE (modified Survey of Activities and Fear of Falling in the Elderly))
  • Adequate correlation SF-36v1 PF subscale and FES(s): rs = 0.66; p < 0.001
  • Excellent SF-36v1 PF subscale and SAFFE:  rs = -0.76; p < 0.001
Chronic Stroke:
(Dorman et al, 1999; n = 688)
  • Adequate concurrent validity between the EuroQol health-related quality of life and the SF-36's general health domain r = 0.66
  • Poor concurrent validity between SF-36 mental health domain and the EuroQol psychological functioning subtest
  • Excellent to Poor correlations between individual Barthel Index scores at five years and dimensions of the SF36. (Wilkinson et al, 1997; UK sample, n = 97, mean age at stroke = 61, mean follow-up 4.9 years)
SF36
r =
Physical functioning
0.810
Social functioning
0.481
Role: physical
0.415
Role: emotional
0.217
Mental health
0.332
Vitality
0.500
Bodily pain
0.356
General health
0.438

Chronic SCI:

(Van Leeuwen et al, 2012)

Concurrent Validity

Spearman Correlation

LiSat 9

0.531ᵃ

Neuroticism

-0.546ᵃ

SF- Vitality

0.528ᵃ

SF- general health

0.367ᵃ

Divergent Validity

FIM

0.094

SIP-mobility range

-0.283

Type of injury

-0.009

Completeness of injury

-0.008

Cause of injury

0.192

Demographics

Age

-0.020

Gender

-0.067

Education

0.028

ᵃ=Adequate validity 0.31-0.59; Poor validity ≤ 0.30; VanLeeuwen anticipated poor correlations with Demographics and injury

Construct Validity (Convergent/Discriminant)

Parkinson Disease: (Leonardi et al, 2012)

  • Distinguish severity: SF-36v2 composite scores were significantly different between patients rated Hoehn & Yahr < 3 (n = 68) and those rated HY ≥ 3 (n = 28), with the more advanced group reporting lower composite scores on PCS (reduced by 16.8%) and MCS (reduced by 18.1%)

Chronic Spinal Cord Injury:

(Forchheimer, et al 2004)

  • Excellent discriminant validity established between Physical capacity score (PCS) and Mental capacity score (MCS) constructs (-0.075)
  • Excellent convergent validity between impairment severity and PCS (F = 5.62, df = 3, P = 0.001)
  • Excellent Divergent validity between impairment severity and MCS scores (F = 0.175, df = 3, P = NS)

Chronic Spinal Cord Injury:

(Lin et al, 2007)

WHOQOL-BREF

SF-36

Rating Scale

Overall

Physical Capacity

Psych

Social

Environ

Rating Scale

---

0.68

0.73

0.64

0.54

0.57

Physical Functioning

0.71

0.57

0.78

0.57

0.50

0.54

Role physical

0.47

0.35

0.51

0.40

0.33

0.48

Bodily pain

0.64

0.52

0.68

0.56

0.48

0.55

General Health

0.72

0.65

0.69

0.62

0.45

0.59

Vitality

0.59

0.59

0.67

0.65

0.48

0.62

Social Functioning

0.50

0.52

0.62

0.63

0.43

0.58

Role Emotional

0.32

0.30

0.41

0.37

0.24

0.39

Mental Health

0.36

0.51

0.52

0.59

0.40

0.56

Excellent correlation > 0.60 in BOLD; Adequate correlation 0.31-0.59; Excellent to Adequate convergent validity between SF-36 and WHOQOL-BREF subscales

Chronic Spinal Cord Injury:

(Anderson et al, 1999 n = 181 veterans with SCI who were hospitalized within 6 months of assessment)

  • Excellent to adequate correlations between SF-36 and Behavioral Risk Factor Surveillance System (BRFSS) subscales
  • Mental Capacity Summary to all BRFSS subscales (r = -0.427-0.761 )
  • Mental Health subscale to all BRFSS subscales (r= -0.446 - -0.795)
  • Vitality subscale to all BRFSS subscales (r = -0.450 - -0.789)
  • Social Functioning subscale to all BRFSS (r = -0.293 - -0.622)
  • Role Emotional subscale to all BRFSS (r = -0.290- -0.610)
  • Poor to adequate correlations between SF-36 subscales Physical Functioning, Role Physical, Bodily Pain, General Health and Physical Summary and all BRFSS subscales (r = 0.065- 0.597)
  • Poor to adequate correlations between SF-36 and Quality of Well Being (r = 0.044 to 0.417) (poor ≤ 0.03; adequate 0.31-0.59)
  • Adequate to Poor correlation between SF-36 and IADLs (r = -0.159- to -0.454)

Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8)

Mild TBI:

  • Adequate to excellent correlations (-0.50 to -0.63) were found between SF-36 scales pertaining directly to physical functioning (General Health, Physical Functioning, Physical Role, Bodily Pain, Vitality) and the Physical symptoms scale of the Symptoms Checklist (SCL)
  • Excellent correlations between SF-36 scales and participants’ Health Problems List (HPL) responses (-0.60 to -0.75)
  • Emotional Role and Mental Health scores were more strongly related to psychological factors (Cognitive and Affective/Behavioral) than to physical factors on the Symptom Checklist (SCL)

Adequate to excellent correlations (-0.52 to -0.77) were found between Beck Depression Inventory second edition (BDI-II) scores and the SF-36 subscales

Moderate to Severe TBI:

  • Correlations were lower and more uniform, strongest correlations found between the SF-36 Emotional Role scale and the SCL Affective/Behavioral scale (-0.53).
  • Correlations between the Physical Functioning scale of the SF-36 and the Cognitive and Affective/Behavioural scales of the SCL were lower than other correlations between scales within this group (-0.11 and -0.19, respectively).

Multiple Neurologic Diagnosis (polio, acute stroke, and TBI): McNaughton et al., 2005; n=308, Polio n=38, Stroke n=181, TBI n=89; mean age=polio 62.5 (11.3), stroke=74.4 (12.0), TBI=34.0 (17.8); gender, female=polio 27%, stroke 96%, TBI 32%)

  • examined validity of the mental component score (MCS) and physical component score (PCS)
  • Principal component analysis (PCA) on the 12-month measures for subjects with stroke and TBI: 2 dimensions might account for a large proportion of the variability in the data set
  • Varimax rotation shows that the 2-factor model has 85% of the variance of the underlying variables with 1 factor loading mainly onto the Barthel Index, Functional Independence Meausre (FIM), PCS,Community Integration Questionnaire (CIQ), and London Handicap Scale (LHS) and the other factor mainly onto the MCS

Traumatic Brain Injury: (Guilfoyle et al; n=514; mean age=36.6 (16.1) years; gender=male 76.3%)

  • Principal component analysis (PCA) of the correlation matrix of the eight SF-36 domains extracted a single PC with an eigenvalue exceeding unity, which explained 59.2% of the variance in the data
  • The second PC extracted had an associated eigenvalue of 0.75, and accounted for only 9.4% of the variance

Known Groups

Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8)

  • mild TBI and moderate to severe TBI groups reported significantly lower health status across all scales compared to the comparison group
  • mild TBI group reported significantly lower scores (poorer health)on all scales compared to the moderate± severe TBI group, with the exception of Physical Function, where there were no differences between the two groups

Traumatic Brain Injury: (Jacobsson et al., 2010 n=67, mild TBI n=32, moderate to severe TBI n=35; mean age at time of injury=mild TBI:13 (13) years, moderate to severe TBI: 30 (12) years); gender=mild TBI: male75%, moderate to severe TBI: male 77%; Swedish version of the SF-36)

SF-36PCS

MCS

SWLS

Sex

Age at Injury

Injury Severity

Time since injury

Marital status

Vocational situation

SF-36: MCS

-0.00

SWLS

0.41**

0.48**

Sex

-0.19

0.01

-0.02

Age at injury

-0.14

0.29*

0.05

0.23

Injury severity

0.20

-0.10

-0.06

-0.03

0.32**

Time since injury

0.13

0.06

0.30*

-0.05

-0.15

0.10

Marital status

0.11

0.06

0.36**

-0.01

-.18

-0.11

0.08

Vocational situation

0.48**

-0.02

0.32**

-0.11

-0.37**

0.13

0.11

0.21

Self appraisal of the TBI

-0.54**

-0.12

-0.46**

0.09

-0.05

-0.31**

-0.04

-0.27*

-0.35**

Correlation (Spearman’s rho) is significant (two-tailed) on *0.05, and **0.01 levels

SWLS-Satisfaction With Life Scale

Content Validity

Items that compose the SF-36 were drawn from a number of prior measures including:
  • The General Psychological Well-Being Inventory (GPWBI) (Dupuy, 1984)
  • Physical and role functioning measures (Patrick, Bush, & Chen, 1973; Hulka & Cassel, 1973; Reynolds, Rushing, & Miles, 1974; Stewart, Ware, & Brook, 1981)
  • The Health Perceptions Questionnaire (HPQ) (Ware, 1976)
  • The Functioning and Well-Being Profile (FWBP) (Stewart & Ware, 1992)

Face Validity

Not statistically assessed

Floor/Ceiling Effects

Parkinson Disease:
(Brown et al, 2009) regarding SF-36v1 {not located for SF-36v2}
  • Floor effects:SF-36v1 subscales: Role limitations – physical (51% scored min possible); Role limits – emotional (21.9% scored min possible).
  • Ceiling effects: SF-36v1 subscale: Role limitations – Emotional (75% scored max possible); Pain (15.6% scored max possible); Social function (29.2% scored max possible).
Subscale
% score min (0)
max (100)
Physical Functioning
4.2
3.1
Role LimitationsPhysical
51.0

10.4

Role LimitationsEmotional
21.9
75.0
Pain
0.0
15.6
Emotional Well-Being
1.0
0.0
Energy
3.1
0.0
General Health
2.1
1.0
Social Function
6.3
29.2
 
Acute Stroke:
(Hagen et al, 2003; n = 153; 1 month post stroke)
 
SF-36 Domain
% Floor
% Ceiling
Physical Functioning
23
1
Role Physical
70

4

(Lack of) Bodily Pain
6
35
General Health
0
3
Vitality
4
0
Social Functioning
27
16
Role Emotional
37
26
Mental Health
0
2
 
Chronic Stroke:
(Anderson et al, 1996)
  • The SF-36 avoids the "ceiling effect" of most disability scales:
SF-36 Domain
% floor
% ceiling
Physical Functioning
4
6
Role Physical
7

53

(Lack of) Bodily Pain
2
43
General Health
2
2
Vitality
1
1
Social Functioning
3
67
Role Emotional
7
72
Mental Health
1
4
 
 

Traumatic Brain Injury:

(Guilfoyle et al, 2011; n = 514; mean age = 36.6 (16.1) years; gender = male 76.3%)

  • Floor effects were observed in two domains—Role Physical and Role Emotional—and ceiling effects were observed in four domains—Physical Function, Role Physical, Bodily Pain, and Role Emotional

SF-36 domain

Floor %

Ceiling %

Physical Function

4.7%

16.7

Role Physical

56.8

19.1

Bodily Pain

2.0

21.4

General Health

0.2

5.1

Vitality

2.2

2.8

Social function

7.3

0.0

Role Emotional

43.9

37.5

Mental Health

0.6

4.0

Responsiveness

Chronic spinal cord injury:

(Lin et al, 2007)

  • Highly sensitive (ES = 0.60 & 0.92) with respect to employment status with Physical Functioning and Role Physical domains.
  • Moderately sensitive (ES = 0.21-0.44) with respect to employment status with Social Functioning, Role Emotional and Mental Health domains
  • Small responsiveness (ES = 0.00-0.16) with respect to employment status in Bodily Pain, General Health, and Vitality domains.

 

Mild Traumatic Brain Injury (mTBI): (Paniak et al.,1999; n=120 with mild TBI, 120 control group; mean age=mTBI 32.7 (11.9), control 30.4 (11.6))

SF 36 variable

Effect Size

Physical Functioning

3.5

Moderate change

Social

1.98

Small change

Role Functioning Physical

2.72

Moderate change

Bodily Pain

2.04

Moderate change

Mental Health

0.90

Small change

Role Functioning Emotional

0.96

Small change

Vitality

1.78

Small change

General Health

0.18

Small change

Mental

0.93

Small chage

Physical 2.48 Moderate change

Traumatic Brain Injury: (Hawthorne et al, 2009; n=66; mean age at time of injury=36 (15); mean time since injury=32 months; utilized SF-36 version 2)

SF 36 variable

Effect Size

Physical Functioning

-0.56

Role Functioning Physical

-0.77

Bodily Pain

-0.38

General Health

-0.44

Vitality

-0.43

Social Function

-0.81

Role Functioning Emotional

-0.86

Mental Health

-0.70

Physical

-0.47

Mental -0.76

  • The largest effect sizes were for sub-scales assessing social, emotional, and mental health, but there were moderate to large effects across all of the eight sub-scales, suggesting that TBI may have very broad effects across many different life parts.

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

NR

LS

R

StrokEDGE

NR

R

R

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

LS/UR

LS/UR

LS/UR

LS/UR

LS/UR

 

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

NR

NR

NR

R

R

StrokEDGE

NR

R

R

R

R

TBI EDGE

NR

NR

NR

LS

LS

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

R

R

 

 

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

R

R

R

NR

 

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

Yes

Yes

No

PD EDGE

No

No

Yes

Not reported

SCI EDGE

No

Yes

Yes

Not reported

StrokEDGE

No

Yes

Yes

Not reported

TBI EDGE

No

Yes

Yes

Not reported

Considerations

Physical function domain: significant floor effects for patients with SCI and other disabilities due to inability to perform some of the physical tasks described. Recommend the SF-36 state “walkwheel” to improve responsiveness for patients with spinal cord injury. (Lee et al., 2009)

Not recommended for:

  • Patients who cannot understand written or spoken language
  • Severely affected stroke survivors who require a proxy to complete the assessment
  • To document patient change (Dorman et al., 1999)
  • Some disadvantaged populations, slight declines in reliability may result (Turner-Bowker et al., 2002)
  • Postal administration of the SF-36 is not recommended (O'Mahony et al, 1998)
  • The Mental Health Subscale of SF-36 (MHI-5) VanLeeuwen, 2012 may be used in the future to determine mental health and severe mental health problems in persons with SCI. Cut off score ≤ 72 and ≤ 60 respectively.
  • The SF-12 is a shorter version of the SF-36 containing 12 items;  covers the summary physical health and mental health scales, but no information about each of the eight dimensions of the SF-36
  • The SF-12 is beginning to be  more commonly used in the TBI population however its psychometric properties in this population have not been specifically assessed (Nichol et al, 2011)
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Anderson, C., Laubscher, S., et al. (1996). "Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients." Stroke 27: 1812-1816. Find it on PubMed

Andresen, E. M., Fouts, B. S., et al. (1999). "Performance of health-related quality-of-life instruments in a spinal cord injured population." Archives of physical medicine and rehabilitation 80(8): 877.

Banks, P. and Martin, C. R. (2009). "The factor structure of the SF-36 in Parkinson's disease." J Eval Clin Pract 15(3): 460-463. Find it on PubMed

Brown, C. A., Cheng, E. M., et al. (2009). "SF-36 includes less Parkinson Disease (PD)-targeted content but is more responsive to change than two PD-targeted health-related quality of life measures." Quality of Life Research 18(9): 1219-1237.

Dorman, P., Slattery, J., et al. (1998). "Qualitative comparison of the reliability of health status assessments with the EuroQol and SF-36 questionnaires after stroke. United Kingdom Collaborators in the International Stroke Trial." Stroke 29: 63-68. Find it on PubMed

Dorman, P. J., Dennis, M., et al. (1999). "How do scores on the EuroQol relate to scores on the SF-36 after stroke?" Stroke 30: 2146-2151. Find it on PubMed

Emanuelson, I., Andersson Holmkvist, E., et al. (2003). "Quality of life and post-concussion symptoms in adults after mild traumatic brain injury: a population-based study in western Sweden." Acta Neurol Scand 108(5): 332-338. Find it on PubMed

Findler, M., Cantor, J., et al. (2001). "The reliability and validity of the SF-36 health survey questionnaire for use with individuals with traumatic brain injury." Brain Inj 15(8): 715-723. Find it on PubMed

Forchheimer, M., McAweeney, M., et al. (2004). "Use of the SF-36 among persons with spinal cord injury." Am J Phys Med Rehabil 83(5): 390-395. Find it on PubMed

Guilfoyle, M. R., Seeley, H. M., et al. (2010). "Assessing quality of life after traumatic brain injury: examination of the short form 36 health survey." J Neurotrauma 27(12): 2173-2181. Find it on PubMed

Hagen, S., Bugge, C., et al. (2003). "Psychometric properties of the SF-36 in the early post-stroke phase." Journal of Advanced Nursing 44(5): 461-468. Find it on PubMed

Jacobsson, L. J., Westerberg, M., et al. (2010). "Health-related quality-of-life and life satisfaction 6-15 years after traumatic brain injuries in northern Sweden." Brain Inj 24(9): 1075-1086. Find it on PubMed

Lee, B. B., Simpson, J. M., et al. (2009). "The SF-36 walk-wheel: a simple modification of the SF-36 physical domain improves its responsiveness for measuring health status change in spinal cord injury." Spinal Cord 47(1): 50-55. Find it on PubMed

Leonardi, M., Raggi, A., et al. (2012). "Relationships between disability, quality of life and prevalence of nonmotor symptoms in Parkinson’s disease." Parkinsonism & related disorders 18(1): 35-39.

Lin, M. R., Hwang, H. F., et al. (2007). "Comparisons of the brief form of the World Health Organization Quality of Life and Short Form-36 for persons with spinal cord injuries." American journal of physical medicine & rehabilitation 86(2): 104-113.

MacKenzie, E. J., McCarthy, M. L., et al. (2002). "Using the SF-36 for characterizing outcome after multiple trauma involving head injury." The Journal of Trauma and Acute Care Surgery 52(3): 527-534.

Martinez-Martin, P., Jeukens-Visser, M., et al. (2011). "Health-related quality-of-life scales in Parkinson's disease: critique and recommendations." Mov Disord 26(13): 2371-2380. Find it on PubMed 

McNaughton, H. K., Weatherall, M., et al. (2005). "Functional measures across neurologic disease states: analysis of factors in common." Arch Phys Med Rehabil 86(11): 2184-2188. Find it on PubMed

Nilsson, M. H., Drake, A. M., et al. (2010). "Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson's disease." BMC Geriatr 10(1): 78. Find it on PubMed

O'Mahony, P. G., Rodgers, H., et al. (1998). "Is the SF-36 suitable for assessing health status of older stroke patients?" Age Ageing 27: 19-22. Find it on PubMed

Paniak, C., Phillips, K., et al. (1999). "Sensitivity of three recent questionnaires to mild traumatic brain injury-related effects." J Head Trauma Rehabil 14(3): 211-219. Find it on PubMed

Steffen, T. and Seney, M. (2008). "Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism." Phys Ther 88(6): 733-746. Find it on PubMed

Turner-Bowker, D., Bartley, P., et al. (2002). "SF-36® Health Survey & “SF” Bibliography:(1988–2000)." Lincoln, RI: Quality Metric Incorporated.

van Leeuwen, C. M., van der Woude, L. H., et al. (2012). "Validity of the mental health subscale of the SF-36 in persons with spinal cord injury." Spinal Cord 50(9): 707-710. Find it on PubMed

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Year published

1992 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 9/24/2014 2:43 PM  by Jason Raad