Spinal Cord Independence Measure

Last Updated

January 17, 2013

Purpose

The SCIM assesses traumatic and non-traumatic, acute and chronic Spinal Cord Injury (SCI).

Link to Instrument

Instrument Details

Acronym SCIM

Area of Assessment

Activities of Daily Living
Coordination
Eating
Functional Mobility
Incontinence

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

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.

Diagnosis/Conditions

Spinal Cord Injury

Spinal Injuries

The SCIM is composed of 19 items that assess 3 domains.
1) Self-care (6 items, scores range from 0-20):
A) Feeding
B) Bathing
C) Dressing
D) Grooming
2) Respiration and sphincter management (4 items, scores range from 0-40)
A) Respiration
B) Bladder management
C) Bowel management
D) Use of toilet
3) Mobility (9 items, scores range from 0-40
A) Tasks in the room and toilet
B) 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).

Number of Items

up to 60 minutes

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

Required Training

Reading an Article/Manual

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living

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

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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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

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)

Construct Validity

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

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.

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.

Berry, C. and Kennedy, P. (2003). "A psychometric analysis of the Needs Assessment Checklist (NAC)." Spinal Cord 41(9): 490-501.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Morganti, B., Scivoletto, G., et al. (2005). "Walking index for spinal cord injury (WISCI): criterion validation." Spinal Cord 43(1): 27-33.

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.

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.

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.

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.

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.

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Last Updated

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Cost Description

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Normative Data

Interrater/Intrarater Reliability

Internal Consistency

Construct Validity

Content Validity

Face Validity

Floor/Ceiling Effects

Responsiveness

Bibliography

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