RehabMeasures Instrument
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  2. Reintegration to Normal Living Index

Reintegration to Normal Living Index

Last Updated

Purpose

Assesses quantitatively the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities.

Link to Instrument

Instrument Details

Acronym RNLI

Area of Assessment

Activities of Daily Living
Social Relationships

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Brain Injury Recovery
  • Cardiac Dysfunction
  • Spinal Cord Injury
  • Stroke Recovery

Populations

Stroke
Spinal Injuries
Mixed Populations
Cancer
Brain Injury

Key Descriptions

  • The RNLI includes 11 declarative statements.
  • The first 8 items represent 'daily functioning' and the remaining 3 items represent 'perception of self.
  • 8 domains that include:
    1) Indoor
    2) Community and distance mobility
    3) Self-care
    4) Daily activities (work and school)
    5) Recreational and social activities
    6) Family role(s)
    7) Personal relationships
    8) Presentation of self to others and general coping skills
  • Each domain is accompanied by a visual analogue scale (VAS, 0 to 10 cm), and the VAS is anchored by the statements:
    1) "Does not describe my situation" (1 or minimal integration)
    2) "Fully describes my situation" (10 or complete integration)
  • Scoring:
    Adjusted Score = (Total Score/110) x 100
    Total Score = sum of all 11 items
    Minimum Score = 0
    Maximum Score = 100

Number of Items

11

Time to Administer

10 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team; Updated by Rachel Tappan, PT, NCS, Eileen Tseng, PT, DPT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 4/2012; Updated by Anna de Joya PT, MS, NCS, Coby Nirider PT, DPT, and the TBI EDGE task force of the Neurology section of the APTA in 2012

ICF Domain

Participation

Measurement Domain

Activities of Daily Living
Cognition
Emotion

Professional Association Recommendation

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 (Vestibular EDGE) 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:  

 

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

LS

LS

R

 

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

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

NR

NR

NR

UR

UR

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

 

 

 

 

 

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

StrokEDGE

No

No

No

Not reported

TBI EDGE

No

No

No

Not reported

Considerations

  • This measure has been translated into French (Egan et al, 2015) and Chinese (Pang et al, 2011).

  • A 10-point Likert scale was substituted for the visual analogue scale (Egan et al., 2015).

  • Based on results of Tooth et al (2003), this measure should not be completed by proxy by a caregiver of someone with chronic stroke.

  • The Reintegration to Normal Living Index – Postal (RNLI-P) was developed from the RNLI for use by mail in people with chronic stroke. The phrasing of each item was modified and a rating scale of “Agree” or “Disagree” was used rather than a VAS. This modified scale has the following properties in: 

  • Chronic Stroke: (Daneski et al, 2003; n = 26; mean age = 70.5 (11.92) years; 3–12 months post stroke).

    • Test-retest reliability: Poor to Excellent (item level kappa = 0.38 to 0.92)

    • Internal Consistency: Excellent (Cronbach’s alpha = 0.84)

    • Convergent Validity: (n = 76; mean age = 67.1 (12.72) years; assessed by RNLI-Postal 1 year post stroke)

      • Excellent correlation with Frenchay Actvities Index (r  = 0.69), SF-36 (r = 0.74), and HADS Depression Score (r = -0.61)

      • Adequate correlation with Barthel Index (r = 0.42) and HADS Anxiety Score (r = -0.38)

Mixed Populations

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Standard Error of Measurement (SEM)

Patients Receiving Outpatient Occupational Therapy: (Miller, Clemson, & Lannin, 2011; n = 46; mean age = 55.2 (20.3) years; mean length of stay = 64.1 (79) days; mean time since injury/illness = 10.4 (15.7) months; brain injury, n = 15; stroke, n = 12; fractured neck of femurs, n = 4; multiple sclerosis, n = 3; spinal injuries, n = 3; heart disease, n = 2; other, n = 7; Australian sample)

  • SEM for Daily Functioning subscale = 1.90

  • SEM for Personal Integration subscale = 1.26

  • SEM for total score = 4.57

Minimally Clinically Important Difference (MCID)

  • For the distribution methods, 10% of the range of 90% of the sample (excluding the two tails or 95%) was used, and the clinically meaningful difference for RNL Index is 7% (Mayo et al., 2015).

Test/Retest Reliability

Patients Receiving Outpatient Occupational Therapy: (Miller et al, 2011)

  • Acceptable test-retest reliability: (ICC = 0.83 (95% CI 0.67-0.92))

Internal Consistency

Mixed Sample: (Wood-Dauphinee et al, 1988; n = 109; varied diagnoses including: malignant tumors, degenerative heart disease. Central nervous system disorders, cerebral vascular disorders, arthritis, fracture and amputation; for each subject, a significant other and health professional were tested as well) 

  • Excellent internal consistency when administered to: 

    • Patients (Cronbach’s alpha = 0.90) 

    • Significant others (Cronbach’s alpha = 0.92) 

    • Health professionals (Cronbach’s alpha = 0.95) 

 

Mixed Sample: (Miller et al., 2011; n = 46; mean age = 55.2 years; different reasons for rehabilitation including: brain injury, stroke, fractured neck of femurs, Multiple Sclerosis, spinal injuries, heart disease, Parkinson’s disease, Guillain-Barré syndrome) 

  • Excellent internal consistency: (Cronbach's Αlpha = 0.80)

Criterion Validity (Predictive/Concurrent)

Concurrent validity

Mixed Sample: (Miller et al., 2011) 

  • Moderate correlation between MRNL Index total score and Daily Functioning sub-score (0.62, p = 0.001)

  • Moderate correlation between MRNL Index total score and Personal Integration sub-score (0.52, p = 0.001).

Content Validity

The RNLI was developed based on literature reviews, incorporation of experiences of investigators, and open- and closed-ended questionnaires given to patients with myocardial infarction, cancer, and other chronic diseases, health professionals (physicians, social workers, physical and occupational therapists, psychologists), significant others of patients; and clergy and other lay people (Wood-Dauphinee et al, 1988).

Responsiveness

Responsiveness: (Wood-Dauphinee et al, 1988; n = 70)

  • Subscales may be more responsive to changes than RNLI total scores (difference between subscales might obscure real changes in specific domains).

Spinal Injuries

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Normative Data

Chronic SCI: (May and Warren, 2002; n = 98; mean age = 45.2 (range = 21 to 81) years; mean time since injury = 15.5 (range = 1.1 to 77.7) years; 56.1% had a cervical injury)

Normative Data for QOL Measures:

Instrument

mean (SD)

Range

RNL

23.05 (13.54)

3-78.36

QLI Overall

21.01 (4.27)

11-30

QLI Health & Functioning

19.92 (4.83)

6.38-30

QLI Social & Economic

21.56 (4.26)

11.75-30

QLI Psychological & Spiritual

21.74 (5.49)

5.64-30

QLI Family

22.94 (5.58)

8-30

ASIA

43.38 (26.09)

0-98

FIM

62.58 (25.57)

18-91

RSES

31.29 (5.42)

19-40

LOC

9.1 (3.75)

0-17

RNL = Reintegration to Normal Living (Index)
QLI = Quality of Life Index
ASIA = American Spinal Injury Association (motor score)
FIM = Functional Independence Measure
RSES = Rosenberg Self-esteem Scale
LOC = Locus of Control

Internal Consistency

Chronic SCI: (Hitzig et al, 2012; n = 618; mean age = 49.2 years; mean time since SCI = 16.3 years; 32.8% incomplete tetraplegia, 16.5% complete tetraplegia, 25.2% incomplete paraplegia, 25.4% complete paraplegia; used 3 point scale version of RNLI) 

  • Excellent internal consistency (Cronbach’s alpha = 0.87)

Construct Validity

Chronic SCI: (May and Warren, 2002; n = 98; mean age = 45.2 (range = 21 to 81) years; mean time since injury = 15.5 (range = 1.1 to 77.7)  years; 56.1% had a cervical injury)) 

  • Excellent correlations between the RNL and Quality of Life Index (QLI) (r = -0.654) 

  • Adequate correlation between the RNL and Functional Independence Measure (r = -0.348) 

 

Chronic SCI: (Fox Harker et al, 2002; n = 440; mean age = 39.69 (11.76) years; mean time since SCI = 12.30 (9.86) years; 41.6% with incomplete paraplegia, 48.1% with incomplete tetraplegia, 4.9% with complete paraplegia, 5.5% with complete tetraplegia) 

  • Adequate correlation with DeJong and Hughes’ classification system of productivity status (r = -0.4013) 

Stroke

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Standard Error of Measurement (SEM)

Chronic Stroke: (Pang, Lau, Yeung, Liao, & Chung, 2011; n = 75; mean age = 64.4 (12.3) years; hemorrhagic stroke, n = 21; ischemic stroke, n = 51; other, n = 3; left-sided hemiparesis, n = 30; right-sided hemiparesis, n = 41; bilateral paresis, n = 4; Chinese sample)

  • SEM for “daily functioning” subscale = 5.7

  • SEM for “perception of self” subscale = 9.9

  • SEM for total scores = 5.4

Minimal Detectable Change (MDC)

Chronic Stroke: (Pang et al, 2011)

  • MDC for Daily Functioning subscale = 15.8

  • MDC for Perception of Self subscale = 27.4

  • MDC for total scores = 14.8

Normative Data

Chronic Stroke: (Tooth et al, 2003; n = 57 dyads composed of stroke patients and their significant others; patient mean age = 70 (12) years; assessed 6 months post-stroke) 

 

Patient mean scores (SD)

Significant other mean scores (SD)

Total RNLI score/100

84.3 (14.4) 

74.1 (15.0) 

Perception of self subscale /30

26.7 (5.6) 

23.9 (6.3)

Test/Retest Reliability

Chronic Stroke: (Pang et al, 2011)

  • Moderate reliability for all of the items (κ = 0.41–0.60), except for items 7 and 11, which exhibited fair reliability (κ = 0.21–0.40).

Interrater/Intrarater Reliability

Chronic Stroke: (Tooth et al, 2003; n = 57 dyads composed of stroke patients and their significant others; patient mean age = 70 (12) years; assessed 6 months post-stroke) 

  • Poor agreement between patients’ ratings and caregivers’ ratings on RNLI total scores (ICC = 0.36) 

  • Poor agreement between patients’ ratings and caregivers’ ratings on RNLI daily functioning subscale (ICC = 0.24)

  • Adequate agreement between patients’ ratings and caregivers’ ratings on RNLI perception of self subscale (ICC = 0.55) 

Internal Consistency

Chronic Stroke: (Bluvol and Ford-Gilboe, 2004; n = 40 stroke survivors and 40 significant others; mean age = 69.5 (9.45) years; mean time since stroke onset = 2.5 (1.66) years) 

  • Excellent internal consistency for stroke survivors: (Cronbach’s alpha = 0.92

  • Excellent internal consistency for stroke survivors' significant others: (Cronbach's Αlpha = 0.85) 

Construct Validity

Chronic Stroke: (Pang et al, 2007; n = 63; mean age = 65.4 (87) years; mean time since stroke = 5.5 (4.9) years) 

  • Adequate correlation between the RNLI and Activies Specific Balance Confidence Scale (r = 0.527), Geriatric Depression Scale (r = -0.490), Berg Balance Scale (r = 0.455), and 6 Minute Walk Test (r = 0.347) 

 

Chronic Stroke: (Bluvol & Ford-Gilboe, 2004) 

  • Adequate correlation between Health Options Scale for family health work and RNLI of stroke survivors (r = 0.50, p ≤ 0.001) 

  • Adequate correlation between Herth Hope Index for individual measure of hope and RNLI of stroke survivors (r = 0.59, p ≤ 0.001) as well as significant others (r = 0.32, p = 0.02) 

Brain Injury

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Test/Retest Reliability

Traumatic Brain Injury: Test-Retest (Trombly et al 1998; n = 16; mean age = 43 (12.6); gender = 7 females and 9 males; mean time post injury = 22 months (5.4))

  • Participants: Poor (r = 0.12 ; p < .005; mean lapse time between administration = 5.3 days (5.99))

  • Proxy: Excellent (r = 0.79; p < .005; mean lapse time between administration = 8.58 days (7.0))

Construct Validity

Chronic TBI: (Fox Harker et al, 2002; n = 47; 31.78 (9.69) years; mean time since TBI = 4.36 (0.90) years; severity in 6-hour Glasgow Coma Scale: 51.1% = mild, 17.0% = moderate, 31.9% = severe)

  • Adequate correlation with DeJong and Hughes’ classification system of productivity status (r = -0.4920) 

 

Known-Groups

Traumatic Brain Injury: (Dawson et al, 2000) 

  • When grouped by baseline severity of TBI (mild, moderate, severe), no significant differences in RNLI scores (mean of 4.4 years post-injury) 

  • Healthy controls had significantly higher RNL scores than subjects with TBI (p < .02) 

 

Traumatic Brain Injury: (Friedland et al, 2001; status post MVA: mild TBI, n = 64; no mild TBI, n = 35; mean age = 33 (10.67); 64% male) 

  • Individuals with mild TBI, grouped by definite, possible or no post-traumatic stress (PTS), demonstrated significant between group differences on RNLI scores (p < .0001) 

  • Definite PTS mean score = 54.0 (22.04); n = 24 

  • Possible PTS mean score = 66.6 (19.20); n = 36 

  • No PTS mean score = 85.2 (14.30); n = 39 

 

Traumatic Brain Injury: (Dawson et al, 2000) 

  • Excellent correlation between RNL and Flanagan’s QOL scale (r = 0.80, p = 0.0004) 

 

Traumatic Brain Injury: (Harker et al, 2002; TBI participants n = 47; SCI participants n = 440; mean age TBI participants = 31.78 (9.69); mean age SCI participants=39.69 (11.76))

  • Adequate correlation between RNL and participation in productive activity (r = -0.4920, p < 0.0007)

Responsiveness

Traumatic Brain Injury: (Trombly et al, 1998; n = 16; mean age = 43 (12.6); gender = 7 females and 9 males; mean time post injury = 22 months (5.4)) 

  • Significant change (p < 0.05) over time in RNLI ratings provided by patients with TBI and their significant others from admission to discharge from outpatient occupational therapy services. Effect Size for proxy ratings = 0.71.

Cancer

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Interrater/Intrarater Reliability

Post-Op Patients With Primary Malignant Bone Tumor Of the Lower Extremity: (Liu et al., 2014; n = 94; mean age = 22.84 years; diagnosis: primary bone tumor of the lower extremities)

  • Excellent internal consistency: Cronbach’s alpha = 0.885

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Cancer patients: (Spitzer et al, 1981; n = 150 physicians who rated 879 patients)

  • Excellent correlation between RNLI and Spitzer’s Quality of Life Index (r = 0.72)

Bibliography

Bluvol, A. and Ford-Gilboe, M. (2004). "Hope, health work and quality of life in families of stroke survivors." J Adv Nurs 48: 322-332. 

Bruno, M. A., et al. (2011). A survey on self-assessed well-being in a cohort of chronic locked-in syndrome patients: happy majority, miserable minority. BMJ Open, 1(1).

Daneski, K., Coshall, C., et al. (2003). "Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients." Clin Rehabil 17: 835-839. 

Egan, M., et al. (2014). Participation and Well-Being Poststroke: Evidence of Reciprocal Effects. Arch Phys Med Rehabil, 95(2), 262-268. 

Egan, M., et al. (2015). Very low neighbourhood income limits participation post stroke: preliminary evidence from a cohort study. BMC Public Health, 15, 528. 

Harker, W. F., Dawson, D. R., et al. (2002). "A comparison of independent living outcomes following traumatic brain injury and spinal cord injury." Int J Rehabil Res 25(2): 93-102. 

Hitzig, S. L., Romero Escobar, E. M., et al. (2012). "Validation of the Reintegration to Normal Living Index for community-dwelling persons with chronic spinal cord injury." Arch Phys Med Rehabil 93(1): 108-114. 

Jones, M. L., et al, (2014). Activity-Based Therapy for Recovery of Walking in Individuals With Chronic Spinal Cord Injury: Results From a Randomized Clinical Trial. Arch Phys Med Rehabil, 95(12), 2239-2246.e2232. 

Liu, Y., et al, (2014). Correlation between functional status and quality of life after surgery in patients with primary malignant bone tumor of the lower extremities. Orthop Nurs, 33(3), 163-170. 

May, L. A. and Warren, S. (2002). "Measuring quality of life of persons with spinal cord injury: external and structural validity." Spinal Cord 40(7): 341-350. 

Mayo, N. E., et al, (2015). Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke. Clin Rehabil, 29(12), 1198-1211. 

Miller, A., Clemson, L., & Lannin, N. (2011). Measurement properties of a modified Reintegration to Normal Living Index in a community-dwelling adult rehabilitation population. Disabil Rehabil, 33(21-22), 1968-1978. 

Pang, M. Y., Eng, J. J., et al. (2007). "Determinants of satisfaction with community reintegration in older adults with chronic stroke: role of balance self-efficacy." Phys Ther 87(3): 282-291. 

Pang, M. Y., et al, (2011). Development and validation of the Chinese version of the Reintegration to Normal Living Index for use with stroke patients. J Rehabil Med, 43(3), 243-250. 

Spitzer, W. O., Dobson, A. J., et al. (1981). "Measuring the quality of life of cancer patients: a concise QL-index for use by physicians." J Chronic Dis 34(12): 585-597. 

Tooth, L. R., McKenna, K. T., et al. (2003). "Reliability of scores between stroke patients and significant others on the Reintegration to Normal Living (RNL) Index." Disabil Rehabil 25: 433-440. 

Trombly, C. A., Radomski, M. V., et al. (1998). "Achievement of self-identified goals by adults with traumatic brain injury: Phase I." The American Journal of Occupational Therapy 52(10): 810-818. 

Wood-Dauphinee, S. L., Opzoomer, M. A., et al. (1988). "Assessment of global function: The Reintegration to Normal Living Index." Arch Phys Med Rehabil 69: 583-590. 

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