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Rehab Measures: Spinal Cord Independence Measure

Link to instrument

Find it on the VA's website 

Title of Assessment

Spinal Cord Independence Measure 

Acronym

SCIM

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team; Updated by Eileen Tseng, PT, DPT, NCS, Rachel Tappan, PT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 4/2012.

Summary Date

1/17/2013 

Purpose

Assesses traumatic and non-traumatic, acute and chronic Spinal Cord Injury (SCI)

Description

19 items assesses 3 domains:

  • Self-care (6 items, scores range from 0-20):
    • Feeding
    • Bathing
    • Dressing
    • Grooming
  • Respiration and sphincter management (4 items, scores range from 0-40)
    • Respiration
    • Bladder management
    • Bowel management
    • Use of toilet
  • Mobility (9 items, scores range from 0-40
    • Tasks in the room and toilet
    • Tasks indoors and outdoors
  • The total SCIM scores range from 0 to 100
  • The original SCIM was revised to address substandard reproducibility (< 80%, Kappa = 0.66-0.73) of bathing, dressing, bowel management and mobility in bed, resulting in the SCIM II (Catz, et al. 2001)
  • The SCIM II had been analyzed statistically through Rasch modeling and clinically through expert opinion, the result leading to the SCIM III (Itzkovich, et al. 2007)

Area of Assessment

Activities of Daily Living; Coordination; Eating; Functional Mobility; Incontinence 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

ADL 

Assessment Type

Patient Reported Outcomes 

Length of Test

31 to 60 Minutes 

Time to Administer

30 - 45 minutes by observation, 10 -15 minutes with interview

Number of Items

19 

Equipment Required

None

Training Required

None

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

A copy of the measure can be found in:
Catz, A., Itzkovich, M., et al. (1997). "SCIM-spinal cord independence measure: a new disability scale for patients with spinal cord lesions." Spinal Cord 35(12): 850-856. 

Age Range

Adolescent: 13-17 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Spinal Cord Injury 

Populations Tested

  • Spinal Cord Injury

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

SCI:

(Catz et al, 1997; n = 30; mean age = 45 (18); 9 = tetraplegia and 21 = paraplegia, 9 patients had complete lesions; first assessment was within one week after admission and follow-up range of 1 to 12 months, SCI)

  • Mean total scores = 51 (21); which were lower than FIM total scores = 87 (23)

(Pouw et al., 2010; n = 20 with acute spinal cord ischemia, mean age = 60 (9) years, completeness of injury AIS A and B = 60%, AIS C and D = 40%; n = 73 with traumatic SCI, mean age 34 (15) years, completeness of injury AIS A and B = 93.2%, AIS C and D = 6.8%, all subjects with paraplegia, Chronic SCI)

  • Median SCIM II score ( Note: small sampling, however limited data has been presented in literature regarding acute spinal cord ischemia and SCIM II):

Median (points)

score range of 25-75% subjects (points)

Complete ASCIS

54

38-64.5

Complete tSCI

64

55-68.5

Incomplete ASCIS

63.5

40-73

Incomplete tSCI

73

69.5-81

(Aidinoff et al, 2011; n = 128; mean age = 37.5 (14.7) years; mean time post-SCI = 3.6 (12.0) months; all subjects AIS A injury, SCI)

Injury Level

SCIM III total score

Quartile 1

Median

Quartile 3

C2-3

6.5

8.0

7.0

C4

19.3

21.3

27.3

C5

20.0

23.0

27.5

C6

30.1

43.5

62.9

C7

15.5

21.0

32.8

C8-T1

36.0

42.0

65.5

T2

48.8

60.5

62.8

T3

47.5

60.0

71.0

T4

56.0

62.5

66.5

T5

53.4

63.0

66.9

T6

52.5

57.8

66.0

T7

63.5

66.3

68.9

T8

56.3

69.3

69.9

T9

55.6

64.5

65.6

T10

51.6

63.0

70.9

T11

64.3

69.3

70.3

T12

60.4

67.5

72.8

L1

66.8

72.0

80.0

L2

74.5

76.3

78.0

Test-retest Reliability

Not Established

Interrater/Intrarater Reliability

SCI:

(Catz et al, 1997, SCI)

  • SCIM Interrater Reliability:
    • Adequate for Self-Care items (Kappa = 0.696-0.7333)
    • Adequate to Excellent for Respiration and Sphincter Management items (Kappa = 0.657-0.826)
    • Adequate to Excellent for Mobility in Room and Toilet items (Kappa = 0.656-0.807)
    • Excellent for Mobility Indoors and Outdoors items (Kappa = 0.840-0.983)

(Catz, et al. 2001; n = 28; mean age = 46 (17) years; with tetraplegia = 6 subjects, with paraplegia = 22 subjects; with Frankel A or B = 7 subjects, with Frankel C or D = 21 subjects, SCI)

  • SCIM II Interrater Reliability:
    • Interrater reliability of individual tasks:
      • Adequate to Excellent for Self-care (Kappa = 0.700-0.951)
      • Adequate to Excellent for Respiration and sphincter management (Kappa = 0.524-0.751)
      • Adequate to Excellent for Mobility in room and toilet (Kappa = 0.440-0.742)
      • Adequate to Excellent for Mobility indoors and outdoors (Kappa = 0.690-0.791)
    • Excellent interrater reliability of all 4 subscales:
      • Self-care (r = 0.965)
      • Respiration and Sphincter Management (r = 0.901)
      • Mobility in Room and Toilet (r = 0.919)
      • Mobility Indoors and Outdoors (r = 0.967)

(Itzkovich et al 2003; n = 28; mean age = 46 (17) years; with tetraplegia = 6 subjects, with paraplegia = 22 subjects; with Frankel A or B = 7 subjects, with Frankel C or D = 21 subjects; comparison of interview vs. observation, SCI)

  • SCIM II Interrater Reliability:
    • Interrater reliability of individual tasks by interview (n = 58):
      • Adequate for Self-care (Kappa = 0.429-0.591)
      • Poor to Adequate for Respiration and sphincter management (Kappa = 0.307-0.568)
      • Poor to Adequate for Mobility in room and toilet (Kappa = 0.323-0.588)
      • Poor to Adequate for Mobility indoors and outdoors (Kappa = 0.099-0.701)
    • Excellent interrater reliability of total score and 4 subscales by interview:
      • Total score (r = 0.903)
      • Self-care (n = 61, r = 0.861)
      • Respiration and Sphincter Management (n = 56, r = 0.862)
      • Mobility in Room and Toilet (n = 59, r = 0.797)
      • Mobility Indoors and Outdoors (n = 56, r = 0.800)
    • Adequate to Excellent correlation between scores by interview and observation (r = 0.69- 0.96)

(Itzkovich et al., 2007; n = 425 from six countries; mean age = 46.93 (18.17) years; 188 with tetraplegia, 237 with paraplegia; AIS A = 35.5%, AIS B = 13.9%, AIS C = 21.6%, AIS D = 28%, SCI)

  • SCIM III
    • Adequate to Excellent Interrater reliability for total agreement (Kappa = 0.631 to 0.823)
    • Excellent interrater reliability for SCIM III subscales (r = 0.902-0.944) and SCIM III total score (r = 0.955)
    •  Excellent interrater reliability within SCIM III subscales (ICC = 0.948-0.971) and SCIM III total score (ICC = 0.977)

(Glass, et al., 2009; n = 86; mean age = 43.2 (16.5) years; 46.5% with tetraplegia, 53.5% with paraplegia; completeness of injury AIS A and B = 63%, AIS C and D = 37%, SCI)

  • SCIM III:
    • Adequate to Excellent interrater reliability for individual items (Kappa = 0.491 to 0.835)
    • Excellent interrater reliability for the SCIM III total score (ICC = 0.956) and subscale scores (ICC = 0.844 to 0.956)

(Bluvshtein et al, 2011; n = 261; mean age = 40.1 (17.1) years; 55% tetraplegia, 45% paraplegia; AIS A = 49.2%, AIS B = 13.5%, AIS C = 19.6%, AIS D = 17.7%, Traumatic SCI)

  • SCIM III
    • Adequate to Excellent interrater reliability on individual items of SCIM III (Kappa = 0.649-0.858)
    • Excellent interrater reliability for SCIM III subscales (r = 0.917-0.959) and SCIM III total score (r = 0.960)

Internal Consistency

SCI:

(Berry and Kennedy, 2003; n = 43; mean age = 42.19 (14.6) years; mean time between injury and assessment for = 17.5 (13.2) weeks; 13.9% = complete tetraplegia, 37.2% = incomplete tetraplegia, 23.3%= complete paraplegia, and 25.6% = incomplete paraplegia, Subacute SCI)

  • SCIM
    • Excellent internal consistency (Cronbach's alpha = 0.9227)

(Itzkovich et al., 2007, SCI)

  • SCIM III
    • Excellent internal consistency (Cronbach’s alpha = 0.847-0.849)
    • Adequate to Excellent internal consistency (Cronbach’s alpha = 0.770-0.849)

(Glass et al, 2009, SCI)

  • SCIM III
    • Adequate internal consistency (Cronbach’s alpha = 0.770 to 0.780)

(Bluvshtein et al., 2011, Traumatic SCI)

  • SCIM III
    • Excellent internal consistency (Cronbach’s alpha = 0.833-0.835)

Criterion Validity (Predictive/Concurrent)

Not Established

Construct Validity (Convergent/Discriminant)

SCI:

(Catz et al, 1997, Acute SCI)

  • SCIM
    • Excellent correlation between the SCIM and FIM (r = 0.85)

(Catz, et al, 2007; n = 425; 46.93 (18.17) years; 188 tetraplegia, and 237 = paraplegia; sample drawn from an international sample, Acute SCI)

  • Rasch modeling confirms unidimensionality

(Morganti et al, 2005; n = 184, mean age = 50.4 (19.3) years; mean time from injury to rehab 56.9 (43.9) days; lesion levels 81 with cervical, 148 with thoracic, and 55 with lumbar-sacral; completeness of injury AIS A and B = 103 subjects, AIS C and D = 181 subjects, Subacute SCI)

  • Excellent correlation between the SCIM and Walking Index for Spinal Cord Injury (WISCI) (n = 76, r = 0.97)
  • Excellent correlation between the SCIM and Rivermead Mobility Index (RMI) (n = 76, r = 0.75)
  • Excellent correlation between the SCIM and Barthel Index (BI; n = 0.76, r = 0.70)

(Catz, et al., 2001, SCI)

  • SCIM II
    • Excellent correlation of SCIM II scores and FIM scores (r = 0.84)

(Van Hedel, 2009; n = 1182 from 18 European centers; subjects with AIS A = 413, mean age 39 (18) years, 65% with paraplegia; subjects with AIS B = 113, mean age 42 (18) years, 44% with paraplegia, subject with AIS C = 137, mean age 48 (20) years, 47% with paraplegia; subjects with AIS D = 223, mean age 47 (17) years, 37% with paraplegia, Subacute SCI)

  • SCIM II
    • Excellent correlation of walking speed and 5 ambulation categories as defined by the SCIM II mobility items (r = 0.84-0.97)

(Wirz, et al. 2010; n = 42; median age = 51.1 (range 24-65) years, median time since injury = 62.7 (12-426) months; AIS A and B = 9.6%, AIS C and D = 90.4%, Chronic SCI)

  • SCIM II
    • Excellent correlation of SCIM II mobility score and Berg Balance Scale (Spearman’s r = 0.89), Walking Index for Spinal Cord Injury (Spearman’s r = 0.81), 10 Meter Walk Test (Spearman’s r = 0.89) and inverse relationship with Falls Efficacy Scale-I (Spearman’s r = -0.78)

(Itzkovich et al., 2007, SCI)

  • SCIM III
    • Excellent correlation of SCIM III and FIM (r = 0.779-0.790

(Glass, et al., 2009, SCI)

  • SCIM III
    • Excellent correlation of SCIM III and FIM (r = 0.782-0.798)

(Rudhe et al, 2009; n = 29; mean age = 50 (18) years; mean time since injury 4.5 (3) months; German and Swiss sample, SCI)

  • SCIM III scores correlated well with UEMS, MMT and hand capacity tests total scores (see table below)

SCIM III and Strength and Capacity Correlations (Spearman’s correlation coefficients):

SCIM III

Rating

UEMS

MMT

Hand Capacity Tests

Feeding

Excellent

0.73

0.75

0.67

Bathing upper body

Excellent

0.80

0.77

0.77

Bathing lower body

Excellent

0.72

0.76

0.71

Dressing upper body

Excellent

0.73

0.76

0.76

Dressing lower body

Excellent

0.64

0.70

0.60

Grooming

Excellent

0.88

0.89

0.80

UEMS = upper extremity muscle score
MMT = manual muscle testing

(Van Hedel, 2009, Subacute SCI)

  • Adequate to Excellent Spearman’s correlation coefficient of SCIM II/SCIM III scores and subjective independence

Group

Time after SCI (Months)

SCIM total score

Self-Care

Respiration/Bladder Bowel

Mobility

Tetraplegic motor complete

1

0.36

0.58

0.12

0.27

3

0.84

0.77

0.76

0.16

6

0.32

0.06

0.42

0.43

Tetraplegic motor incomplete

1

0.37

0.53

0.30

0.30

3

0.67

0.67

0.71

0.57

6

0.41

0.35

0.47

0.28

Paraplegic motor complete

1

0.00

0.19

-0.08

-0.11

3

0.11

0.18

-0.03

-0.10

6

0.30

0.39

0.02

0.31

Paraplegic motor incomplete

1

0.59

0.72

0.54

0.57

3

0.11

0.05

0.17

0.13

6

0.22

0.01

0.39

0.15

BOLD = Adequate to Excellent Correlations

(Bluvshtein, et al., 2011, Traumatic SCI)

  • SCIM III
    • Excellent correlation of SCIM III scores to FIM scores (r = 0.835-0.839)

Content Validity

The SCIM was developed with input provided by health care providers (Catz et al, 2001)

Face Validity

SCI:

(Ackerman et al, 2010, Subacute SCI)

  • Staff in an outpatient day program who used the SCIM III reported feeling that the SCIM III reflects functional change overall, but that it does not reflect changes in the ability of people with SCI (especially high level cervical injuries) to direct their care.

Floor/Ceiling Effects

(Catz, et al, 2007, Acute SCI)

  • Floor effect have been observed for the mobility sub scale

(Ackerman et al, 2010, Subacute SCI)

  • SCIM III
    • A floor effect was observed in 13 of 19 skills for the C1-C4 subgroup as well as for the C5 subgroup for skills that require greater upper extremity musculature
    • A ceiling effect was observed for the T1-T6 and T7-T12 subgroups for self care, respiration, and sphincter management.

Responsiveness

SCI:

(Catz et al, 1997, SCI) SCIM

  • Both the FIM and the SCIM detected functional changes but FIM missed 26% of the changes detected by the SCIM. Consecutive scores on the SCIM had a higher mean difference than on the FIM (10.6 pts vs 7.5 pts, p < 0.01)

(Ackerman, et al. 2010; n = 114; median age = 25 years; median time post injury = 98.5 days; level of injury cervical = 52%, thoracic = 48%, lumbar = 0%; completeness of injury AIS A = 80%, AIS B = 20%; data taken status post outpatient day program rehabilitation, Subacute SCI)

Median changes in SCIM III subscales and total score

C1-4 (NS)

C5

C6

C7-8

T1-6

T7-12

Self Care

0

1.0

2.0

1.5

1.0

0

Respiration/Sphincter Mangement

0

0

0

0

2.0

2.0

Mobility

0

0.5

4.0

3.0

3.0

2.0

Total SCIM III score

0

3.0

9.0

7.0

5.5

6.0

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

R

R

R

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

R

R

 

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)

SCI EDGE

No

Yes

Yes

Not reported

Considerations

An Italian version of the SCIM III has been validated with excellent internal consistency (Cronbach’s alpha = 0.91), excellent interrater reliability (r = 0.99), and excellent correlation with the FIM (r = 0.80-0.82) (Invernizzi, et al., 2010)
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Bibliography

Ackerman, P., Morrison, S. A., et al. (2010). "Using the Spinal Cord Independence Measure III to measure functional recovery in a post-acute spinal cord injury program." Spinal Cord 48(5): 380-387. Find it on PubMed
 
Aidinoff, E., Front, L., et al. (2011). "Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions." Spinal Cord 49(8): 893-896. Find it on PubMed
 
Berry, C. and Kennedy, P. (2003). "A psychometric analysis of the Needs Assessment Checklist (NAC)." Spinal Cord 41(9): 490-501. Find it on PubMed
 
Bluvshtein, V., Front, L., et al. (2011). "SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions." Spinal Cord 49(2): 292-296. Find it on PubMed
 
Catz, A., Itzkovich, M., et al. (1997). "SCIM--spinal cord independence measure: a new disability scale for patients with spinal cord lesions." Spinal Cord 35(12): 850-856. Find it on PubMed
 
Catz, A., Itzkovich, M., et al. (2001). "The spinal cord independence measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients." Spinal Cord 39(2): 97-100. Find it on PubMed
 
Catz, A., Itzkovich, M., et al. (2001). "The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure." Disabil Rehabil 23(6): 263-268. Find it on PubMed
 
Catz, A., Itzkovich, M., et al. (2007). "A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation." Spinal Cord 45(4): 275-291. Find it on PubMed
 
Dawson, J., Shamley, D., et al. (2008). "A structured review of outcome measures used for the assessment of rehabilitation interventions for spinal cord injury." Spinal Cord 46(12): 768-780. Find it on PubMed
 
Glass, C. A., Tesio, L., et al. (2009). "Spinal Cord Independence Measure, version III: applicability to the UK spinal cord injured population." J Rehabil Med 41(9): 723-728. Find it on PubMed
 
Invernizzi, M., Carda, S., et al. (2010). "Development and validation of the Italian version of the Spinal Cord Independence Measure III." Disabil Rehabil 32(14): 1194-1203. Find it on PubMed
 
Itzkovich, M., Gelernter, I., et al. (2007). "The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study." Disabil Rehabil 29(24): 1926-1933. Find it on PubMed
 
Itzkovich, M., Tamir, A., et al. (2003). "Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation." Am J Phys Med Rehabil 82(4): 267-272. Find it on PubMed
 
Morganti, B., Scivoletto, G., et al. (2005). "Walking index for spinal cord injury (WISCI): criterion validation." Spinal Cord 43(1): 27-33. Find it on PubMed
 
Pouw, M. H., Hosman, A. J., et al. (2011). "Is the outcome in acute spinal cord ischaemia different from that in traumatic spinal cord injury? A cross-sectional analysis of the neurological and functional outcome in a cohort of 93 paraplegics." Spinal Cord 49(2): 307-312. Find it on PubMed
 
Rudhe, C. and van Hedel, H. J. (2009). "Upper extremity function in persons with tetraplegia: relationships between strength, capacity, and the spinal cord independence measure." Neurorehabil Neural Repair 23(5): 413-421. Find it on PubMed
 
van Hedel, H. J., Dokladal, P., et al. (2011). "Mismatch between investigator-determined and patient-reported independence after spinal cord injury: consequences for rehabilitation and trials." Neurorehabil Neural Repair 25(9): 855-864. Find it on PubMed
 
van Hedel, H. J. and Group, E. S. (2009). "Gait speed in relation to categories of functional ambulation after spinal cord injury." Neurorehabil Neural Repair 23(4): 343-350. Find it on PubMed
 
Wirz, M., Muller, R., et al. (2010). "Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale." Neurorehabil Neural Repair 24(1): 70-77. Find it on PubMed

Year published

1997 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
SCIM.pdf    
Created at 3/15/2011 1:41 PM  by Jason Raad 
Last modified at 8/28/2014 4:27 PM  by Jason Raad