http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2014; 36(19): 1644–1651 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2013.864713
ASSESSMENT PROCEDURES
Development of the Spanish version of the Spinal Cord Independence Measure version III: cross-cultural adaptation and reliability and validity study
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Maria Jose Zarco-Perin˜an, Marı´a J. Barrera-Chaco´n, Inmaculada Garcı´a-Obrero, Juan Bosco Mendez-Ferrer, Luis Eduardo Alarcon, and Carmen Echevarria-Ruiz de Vargas Spinal Cord Unit, Department of Rehabilitation Medicine, Hospital Universitario Virgen del Rocı´o, Seville, Spain
Abstract
Keywords
Purpose: To provide a translation and cross-cultural adaptation of the Spinal Cord Independence Measure (SCIM) version III for Spain and to validate the Spanish version of the SCIM III (eSCIM III). Patients and methods: Development of eSCIM III has involved translation, back-translation and assessment of cultural equivalence procedures. eSCIM version III, was administered to 64 patients with spinal cord injury, admitted to our hospital. Investigation of the psychometric characteristics included: (1) study of the inter-rater reliability, (2) internal consistency (Cronbach’s a), (3) validation and confirmation of the correlation between eSCIM III and Functional Independence Measure (FIM), and (4) sensitivity to change. Results: The reliability of eSCIM III showed an intra-class coefficient value 40.97 in the different subscales assessed. Internal consistency of eSCIM III was shown by a Cronbach’s a value of 0.93. The validity of eSCIM III was confirmed by the close correlation with FIM (r ¼ 0.94, p50.0001). The sensitivity to change of eSCIM III was also confirmed. Conclusions: eSCIM III was found to be culturally equivalent to the original version, as reliability and validity of this tool were demonstrated. It can be used in Spain for functional assessment of patients with spinal cord injury.
Reliability, Spain, Spanish version of the Spinal Cord Independence Measure version III, spinal cord injury, validity History Received 6 May 2013 Revised 28 October 2013 Accepted 7 November 2013 Published online 9 December 2013
ä Implications for Rehabilitation
Development of the Spanish version of the Spinal Cord Independence Measure version III. The importance of the adaptation of Spinal Cord Independence Measure (SCIM) is that it guarantees the possibility of measuring the same concept in different cultures and countries. The eSCIM III is the first, specific assessment tool in patients with spinal cord injury adapted for its use in Spain. The eSCIM III is a tool conceptually equivalent to the original version. It has the reliability and validity of SCIM III in order to be used by clinicians.
Introduction Spinal cord injury represents a significant health problem due to its clinical complexity, prolonged hospitalizations required, clinical follow-up needed throughout life and frequency of complications involved. To describe the real impact derived from the spinal cord injury, it is required not only to assess the degree of deficiency presented by these people, but also to evaluate the level of disability originated. The concept of functionality is not easy to quantify, a circumstance to be resolved by the use of tools of measurement [1]. Hence, the importance of developing scales for functional assessments.
Address for correspondence: Dr Maria Jose Zarco-Perin˜an, PhD, Spinal Cord Unit, Department of Rehabilitation Medicine, Hospital Universitario Virgen del Rocı´o, Seville, Spain. Tel: +34 617557940; +34 955012598. E-mail: [email protected]
The Functional Independence Measure (FIM) was developed and designed to assess the functional level of patients, including those with spinal cord injury [2,3]. Since its creation, this scale has been widely used and diffused, with multiple investigations demonstrating its metric characteristics [3–5]. However, some studies showed certain limitations when this tool is used in subjects with spinal cord injury, as difficulty to the sensitivity to change [6], and in the evaluation of the functional level of patients with tetraplegia, which led to the development of specific instruments [7,8]. Under these premises, the Spinal Cord Independence Measure (SCIM), was designed specifically to quantify the functional assessment of patients with spinal cord injury. Since its establishment, different versions were developed, resulting each version in a more accurate and sensitive tool compared with the previous one. Currently, the version III is used, as reliability, validity and sensitivity to change of this scale have been
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DOI: 10.3109/09638288.2013.864713
evidenced [9,10]. The validity of each version of the SCIM has been determined by comparison with FIM [9,10]. SCIM covers the evaluation of specific areas of function with great relevance in the spinal cord injury, including self-care, respiration and sphincter management, and mobility. Each area is scored according to its proportional weight in the patient’s global activity. The use of SCIM version III is currently recommended to assess the functional recovery of patients with spinal cord injury, both in clinical and research settings, due to the clinical viability and the clinimetric characteristics shown by the tool [9,11]. The English version of the SCIM scale has been developed, but the use of these scales has to be standardized for different countries and cultures. Cross-cultural adaptation of a tool not only requires its translation following a specific methodology, but also evaluates its metric characteristics in the new language and culture [12]. The purpose of this study is to provide the translation and cultural adaptation of the SCIM III to the Spanish language for its use in our country, Spain, and subsequently confirm the reliability and validity of the new tool, the Spanish version of the SCIM III (eSCIM III).
Development of the Spanish version SCIM version III
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or C were discussed by the members of the committee, until a consensus was reached. Pilot study: The new Spanish version was assessed by two study investigators, and used initially in five patients with spinal cord injury. Clinicians were asked about: (1) difficulties in the use of the new tool, (2) difficulties with any of the items. Validation of the Spanish version of the eSCIM III: patients and procedure Patients A total of 64 patients with spinal cord injury previously treated in the Spinal Cord Injury Unit were included. Inclusion criteria were: (1) spinal cord injury of traumatic or medical origin; (2) spinal cord injury (ASIA impairment grade A, B, C or D); (3) verbally given consent for inclusion in the study. Exclusion criteria included: (1) concomitant neurological disease which may alter the functional level previously established by the spinal cord injury; (2) presence of cognitive deficit or psychiatric disease, which may prevent collaboration of the patient and influence the functional level. Procedure
Patients and method Study design: cross-sectional study. This study has two welldefined parts, as explained in the following sections. Cross-cultural adaptation: methodology For the development of eSCIM III, we used a procedure with the following steps [12,13]: – Translation into Spanish: Two forward translations from English into Spanish were produced by two independent translators. Both English–Spanish translators have wide experience and were native Spanish speakers. Translators followed specific instructions including: a brief description of the scale, information relative to the measurement concept system and characteristics of the translation, and use of clinical and culturally equivalent sentences. Each translator independently translated the version and then compared and discussed the result with that of the other translator, until a common version was reached. – Back-translation: The Spanish version of the SCIM was again translated into English by other two translators with wide experience. One translator was American, and the other one had lived in the USA. Both translators did not know that there was an original English version. The aim was to identify possible discrepancies in the Spanish translation. Both translations were analyzed, and a final version was established. – Assessment of the cultural equivalence of the Spanish version: A committee consisting of two translators and four clinicians (three experts in spinal cord injury and one in the process of instrument’s adaptation), compared the original English version and the final Spanish version. The aim of the committee was to evaluate the translation of the scale, verify the cultural equivalence of the new version and approve the definitive Spanish version. A previously established comparison criterion was used [13]: an item was classified as Type A if it was conceptually equivalent, i.e. the translation maintained the semantic and conceptual equivalence from the original English version; an item was classified as B when the meaning was similar, but there was some change; while the item was classified as Type C (different), if it was of questionable translation, and did not maintain the meaning of the original item. Items classified as B
Two authors of the study performed all evaluations. In a first phase, demographic variables were collected and, subsequently functional assessments were performed by using eSCIM III and the FIM. Clinicians involved in patient assessment were trained with different scales. (1) Assessment of the reliability of the scale: To show the reproducibility of the tool, 35 subjects were assessed by two independent investigators who were blinded to the results of the other assessment performed. Reliability was assessed in terms of: (1) assessment of agreement between raters, (2) inter-rater reliability between the two evaluations performed, which confirm that the results are independent of the rater, and that correlates with the patient’s situation. (2) Assessment of the internal consistency: This assessment is relevant when the tool, as in our case, has different components or subscales. Analyses performed: (1) assessment of correlation of items with the global score of the scale, and with the score of the corresponding subscale (item–total score correlation); (2) internal consistency, analyzed by Cronbach’s a, in the global SCIM III and also in each of the subscales. This evaluation separately analyzed scores obtained at admission and discharge. (3) Validity analysis: Validity was analyzed by means of the correlation between the eSCIM III and the FIM scales in 64 patients of the study. (4) Sensitivity to change: To determine the sensitivity of the scale to changes produced in the function of the patient, changes during the rehabilitation period were compared. All patients were evaluated at admission and discharge of rehabilitation. The protocol was approved from the Ethics Committees of the hospital. Verbal consent was obtained from the patients to be included in the study. Statistical analysis (1) Reliability: K-coefficient was used for evaluation of agreement between raters, and Pearson’s correlation coefficient for correlation of scale and subscale. Intra-class correlation coefficient was used to determine variability between raters. An intraclass coefficient 40.75 for the scale and different subscales has been used in this study for reliability analysis [14]. (2) Internal consistency: Cronbach’s a coefficient was used as a measure of internal consistency and a value40.70 was considered
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adequate [14]. For homogeneity evaluation the Pearson correlation coefficient between each item and the total score of the scale or corresponding subscale was used. (3) Validity: For correlation between FIM and eSCIM III scales, Rho Spearman’s non-parametric correlation tests were used (4) Sensitivity to change: Wilcoxon’s non-parametric test was used. The statistical program Statistical Package Social Science, version 19 (SPSS Inc, Chicago, IL) was used for the previous analyses.
Results Cross-cultural adaptation
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Assessment of cultural equivalence Once the eSCIM III version was obtained, after translation and back-translation were performed, the expert committee considered that there were no differences in the conceptual and/or semantic equivalence in 16 items (84.21%) of a total of 19 in the scale. The three items classified as B type were two concerning the management of sphincter and one of mobility. The alternative which maintains the equivalence with the original English version was accepted by consensus. With respect to the pilot study, the clinicians did not refer any difficulty in the use of the tool. Population characteristics A total of 64 subjects with spinal cord injury were included in the study, and 35 of them were selected for the reliability study. Socio-demographical characteristics of both populations are shown in Table 1. Out of the 64 patients, 21 (32.8%) were female and 43 (67.2%) male (mean age: 44.79 20.50 years). Thirty-eight subjects (59.4%) had traumatic spinal cord injury, mainly as a consequence of a traffic accident (39.4%). Twenty-six subjects (40.6%) had spinal cord injury of medical origin, most of them of vascular origin. Table 1. Characteristics of the samples.
Number of SCI* patients Traumatic etiology – Traffic – Outrage – Sports accident – Occupational accident – Precipitation – Others Non-traumatic etiology – Vascular – Infections – Tumor etiology – Spinal stenosis – Others De´ficit Neurolo´gico – Complete Tetraplegia – Incomplete Tetraplegia – Complete Paraplegia – Incomplete Paraplegia AIS grade** – A – B – C – D
Reliability study group
Validity study group
35 20 (57.1%) 6 (30%) 1 (5%) 4 (20%) 2 (10%) 5 (25%) 2 (10%) 15 (42.1%) 7 (46.6%) 3 (20%) 2 (13.3%) 3 (20%)
64 38 (59.4%) 15 (39.4%) 1 (2.6%) 6 (15.8%) 4 (10.5%) 10 (26.3%) 2 (5.2%) 26 (40.6%) 8 (30.8%) 3 (11,5%) 7 (26.9%) 6 (23.1%) 2 (7.7%)
9 8 7 11
(25.7%) (22.9%) (20%) (31.5%)
14 13 14 23
(21.9%) (20.3%) (21.9%) (35.9%)
14 10 6 5
(41.2%) (29.4%) (17.6%) (14.7%)
26 11 9 18
(40.6%) (17.1%) (14.06%) (28.1%)
*SCI: Spinal cord injury. **AIS: American Spinal injury Association Impairment scale.
When the neurological impairment was considered (Table 1), 28 subjects (43.8%) had a complete injury, with incomplete injury in 36 (56.3%). Twenty-seven subjects (42.2%) had tetraplegia and 37 (48.4%) showed paraplegia. According to the ASIA impairment scale, 26 subjects (40.6%) were classified as grade A, and 18 (28.1%) were grade D. Validation of the Spanish version of the SCIM version III Reliability analysis All items showed a high level of agreement, with a K-value40.90, as shown in Table 2. Inter-rater reliability: the intra-class coefficient for the eSCIM III was 0.97 and a value 40.90 was obtained for different subscales of the tool at admission and discharge (Tables 3 and 4). The Pearson correlation coefficient for all subscales and the total score was higher than 0.90 in all cases, with values ranging from 0.90 in the self-care subscale to 0.95 in the mobility scale (Table 3). Homogeneity of the scale: internal consistency Correlation of the item with the scale total score: Correlation of each item of the eSCIM III with the total score was higher than 0.2 in all cases, with the exception of the respiration item with values in the range 0.17–0.85. The higher values were obtained in the mobility subscale (Table 5). Internal consistency: Cronbach’s a coefficient for the eSCIM III was 0.93, with no substantial deviation of this a coefficient when Table 2. Agreement between raters: K coefficients eSCIM III. Items
K Correlations
p Value
0.99 0.96 0.93 0.92 0.91 0.95 1 1 0.96 0.91 1 0.97 0.94 1 0.95 1 1 0.98 0.91
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Feeding Bathing upper body Bathing lower body Dressing upper body Dressing lower body Grooming Respiration Bladder management Bowel management Use of toilet Mobility in bed Transfers bed/wheelchair Transfers wheelchair/toilet/tub Mobility indoors Mobility moderate distances Mobility outdoors Stair management Transfers wheechair/card Transfers ground/wheelchair
eSCIM: Spanish Spinal Cord Independence Measure.
Table 3. Reliability: inter-observer reliability. Intra-class correlation coefficient: admission.
eSCIM
1 evaluator Mean (sd)
2 evaluator Mean (sd)
ICC
Self-care Respiration/sphincter Mobility in the room Mobility indoors/outdoors eSCIM total
11.08 24.77 4.9 6.9 47.77
10.74 24.77 5.4 7.4 46.57
0.97 0.99 0.97 0.7 0.97
(7.01) (8.42) (3.4) (5.3) (23.64)
eSCIM: Spanish Spinal Cord Independence Measure. sd: standard deviation. ICC: Intra-class correlation coefficient.
(6.84) (8.42) (3.4) (5.4) (24.13)
Development of the Spanish version SCIM version III
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scale homogeneity was intended to be improved after systematic elimination of the items. Cronbach’s a coefficient at discharge for the eSCIM III was 0.93. Cronbach’s a for different subscales was higher than 0.80 (Table 5), except in the ‘‘Respiration – sphincter management’’ subscale with an a value of 0.63. In this subscale, a-value increased when ‘‘Respiration’’ item was eliminated, and decreased when any of the other items of the scale were eliminated. In the mobility scale, Cronbach’s a also improved after elimination of the ‘‘Transfer bed – chair’’ item. Validity study
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eSCIM III showed a significant correlation with FIM, as described in Table 5. The correlation between the eSCIM III and FIM was lower at admission in rehabilitation (r ¼ 0.87, Table 4. Reliability: inter-observer reliability. Intraclass correlation coefficient: discharge.
eSCIM
2 evaluator Mean (sd)
ICC
Self-care Respiration/sphincter Mobility in the room Mobility indoors/outdoors eSCIM total
13.95 28.89 6.85 9.43 59.07
13.59 29.07 6.89 9.5 58.65
0.95 0.94 0.96 0.96 0.96
(6.87) (8.72) (3.75) (7.52) (23.57)
eSCIM: Spanish Spinal Cord Independence Measure. sd: standard deviation. ICC: Intra-class correlation coefficient.
p50.0001) than at discharge (r ¼ 0.94, p50.0001). A significant correlation (p50.0001) was also obtained between the eSCIM III subscales and FIM (Table 6), with a higher correlation at discharge of rehabilitation (0.85–0.91). Sensitivity to change eSCIM III showed sensitivity to functional changes of the patients with spinal cord injury (p50.0001). Comparison of the differences between eSCIM III scale at admission and discharge of the rehabilitation period, and FIM showed that values obtained were higher for eSCIM III than for FIM (p50.0001).
Discussion Functional assessment with specific tools is fundamental in patients with spinal cord injury. The SCIM III scale, designed specifically for these patients, assessed the most relevant areas, including self-care, sphincter management and mobility [9,10]. Table 6. Validity: correlation between FIM and eSCIM III at admission and discharge.
1 evaluator Mean (sd) (6.81) (8.59) (3.71) (7.63) (23.63)
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eSCIM III Self-care Respiration-sphincter management Mobility in the rooms Mobility indoors/outdoors eSCIM total
Admission Rho Spearman
Discharge Rho Spearman
0.89 (p50.0001) 0.86 (p50.0001)
0.90 (p50.0001) 0.87 (p50.0001)
0.87 (p50.0001) 0.81 (p50.0001) 0.87 (p50.0001)
0.90 (p50.0001) 0.85 (p50.0001) 0.94 (p50.0001)
Table 5. Internal consistency: Cronbach’s coefficient a and scale homogeneity.
eSCIM Self-care – Feeding – Bathing upper body – Bathing lower body – Dressing upper body – Dressing lower body – Grooming Respiration-sphincter management – Respiration – Bladder management – Bowel management – Use of toilet Mobility in the rooms – Mobility bed – Transfers bed/wheelchair – Transfer wheelchair/toilet Mobility indoors/outdoors – Mobility indoors – Mobility moderate distance – Mobility outdoors – Stair management – Transfer wheelchair/card – Transfer ground/wheelchair SCIM total –Self-care – Respiration-sphincter – Mobility in rooms – Mobility indoors/outdoors
Cronbach‘s coefficient a Admission
Item-total correlation Admission
Cronbach‘s coefficient a Discharge
Item-total correlation Discharge
0.87 a if item is deleted 0.86 0.83 0.87 0.87 0.86 0.83 0.63 a if item is deleted 0.42 0.9 0.99 0.42 0.93 a if item is deleted 0.93 0.52 0.59 0.93 a if item is deleted 0.68 0.66 0.85 0.85 0.84 0.92 0.93 a if item is deleted 0.81 0.82 0.8 0.81
0.58–0.83
0.92 a if item is deleted 0.91 0.9 0.9 0.89 0.91 0.9 0.79 a if item is deleted 0.44 0.81 0.72 0.65 0.79 a if item is deleted 0.91 0.63 0.62 0.91 a if item is deleted 0.87 0.86 0.87 0.89 0.91 0.92 0.93 a if item is deleted 0.82 0.81 0.8 0.82
0.75–0.84
eSCIM: Spanish Spinal Cord Independence Measure.
0.07–0.75
0.79–0.87
0.75–0.94
0.175–0.85
0.6–0.78
0.78–0.84
0.70–0.93
0.64–0.93
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Besides, this scale has shown greater sensitivity to change compared to FIM, particularly in areas like sphincter management [15]. This has led us to perform the adaptation of this tool to the Spanish language for its use in Spain. The use of an instrument in a different language and country requires performing the processes of translation and cultural adaptation, i.e. to create a tool equivalent to the original scale. This guarantees the assessment of the same concept in different cultures, allowing the comparison of the results [13,16,17]. The methodology used in this study assures the quality of the process, considering eSCIM III as a tool conceptually equivalent to the original version [13,18]. Moreover, eSCIM III is the first, specific assessment tool in patients with spinal cord injury adapted for its use in Spain. This study evaluated the clinimetric characteristics and demonstrated that eSCIM III is a valid and reliable scale to be used in spinal cord injury. Reliability has been shown by the high rate of agreement among raters. Moreover, our data support the inter-rater reliability, with values higher than those obtained in the original version [10], for the global scale and also for the subscales, although similar to those obtained during the cultural adaptation performed with this tool [19,20]. By analysis of the homogeneity of the scale, we verified that this instrument is designed to assess the same characteristic or functional area [10], and that elimination of the items of the scale is not required, with the exception of the item ‘‘Respiration’’. We confirmed that, similar to the original version, the subscale respiration-sphincter showed the lowest correlation values. The internal consistency of eSCIM III, as measured by Cronbach’s a coefficient, was shown to be higher than the usually accepted limit of 0.7 for the global eSCIM III (0.93 in our study) and also for the subscales, and is in agreement with values reported in previous studies [21]. However, the subscale ‘‘Respiration-Sphincter’’ showed Cronbach’s a value of 0.63, which is similar to that found in the original validation and also in the validity studies of the tool [20,22,23]. Despite the relevance of the assessment of the item ‘‘Respiration’’ in patients with spinal cord injury, the results show that this item is not clearly related to the ‘‘Sphincter Management’’ item, and does not contribute to the internal consistency of this subscale [10,23]. This was also confirmed by the increased Cronbach’s a value observed after elimination of the ‘‘Respiration’’ item. This exception had no influence on the internal consistency of SCIM III [22,24]. With regard to the validity study, it is important to notice that an attempt has been made to keep the idiomatic, semantic and conceptual equivalence with the original version during the translation and cross-cultural adaptation processes, in order to maintain the appearance and content of the new version of the tool. The validity of the eSCIM III is supported by the close correlation observed between this scale and FIM, a correlation previously reported [19,20]. However, higher values to those reported for the original version were found [10]. In our study, values probably could be affected by the small sample size used; however, it must be said that the adaptation and validation of SCIM to other countries have been performed using similar samples [19]. Other factor to take into account is the uniformity of the population in our study, with a large proportion of neurologically complete injuries. The neurological deficit of the patients, nearly 43.8% of the population presented a complete injury, while 56.2% had incomplete injury. In addition, a more proportional distribution was evidenced in comparison with previous studies [19,25], which might reasonably explain the same distribution as breathing–sphincter subscale. Despite the good correlation observed between FIM and SCIM III scales, differences between both tools should be considered.
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However, analysis of the validity of a tool should be regarded as a successive verification, as one measurement is only considered valid after accumulation of the evidences was obtained, and needs to be fulfilled. New studies demonstrating the validity of the Spanish version of the SCIIM III are required, which has been already assessed in the original tool [26]. Our work has some limitations. The first is the small sample used, although a similar sample size was used for the adaptation of this tool to other cultures [19]. Lack of variability within the sample is another possible limitation, which may determine data generation. It could increase the reliability values. However, other published studies have also used samples with a similar distribution to ours [21]. In addition, in our work, the rater’s bias has been controlled because in the reliability study each patient was evaluated by two evaluators belonging to the same profession (physicians) and who knew the tool. The agreement between raters was confirmed in our results.
Conclusion The Spanish version of SCIM III is a tool culturally equivalent to the original version. The validity and reliability of the eSCIM III version have been demonstrated. The Spanish version of the SCIM III can be used as a tool for functional assessment of patients with spinal cord injury in our country (see Appendix).
Declaration of interest The authors report no conflicts of interest.
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20. Invernizzi M, Carda S, Milani P, et al. Development and validation of the Italian versio´n of the spinal cord Independence measure III. Disabil Rehabil 2010;32:1194–203. 21. Anderson KD, Acuff ME, Arp BG, et al. United States (US) multicenter study to assess the validity and reliability of the spinal cord independence measure (SCIM III). Spinal Cord 2011;49:880–5. 22. Bluvshtein V, Front L, Itzkovich M, et al. SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions. Spinal Cord 2011;49:292–6. 23. Glass CQ, Tesio L, Itzkovich M, et al. Spinal cord Independence measure versio´n III: applicability to the UK spinal cord injured population. J Rehabil Med 2009;41:723–8. 24. Catz A, Itzkovich M, Tesio L, et al. A multicenter international study on the spinal cord Independence Measure Version III: Rasch psychometric validation. Spinal Cord 2007;45:275–91. 25. Aidonoff E, Front L, Itzkpvich M, et al. Expected spinal cord independence measure, third version, scored for various neurological levels after complete spinal cord lesions. Spinal Cord 2011; 49:893–6. 26. Ackerman P, Morrison SA, McDowell S, Vazquez L. Using the spinal cord independence measure III to measure functional recovery in a post-acute spinal cord injury program. Spinal Cord 2010;48:380–7.
Appendix SPANISH VERSION OF THE SPINAL CORD INDEPENDENCE MEASURE VERSION III (eSCIM III) Unidad de Lesionados Medulares. Hospital Universitario Virgen del Rocı´o, Sevilla CUIDADO PERSONAL ´N 1. ALIMENTACIO œœœœœœ (Cortar, abrir envases, servirse, llevarse la comida a la boca, sostener una taza con lı´quido) 0. Requiere nutricio´n parenteral, gastrostomı´a o asistencia total para la alimentacio´n oral. 1. Requiere ayuda parcial para comer y/o beber, o para utilizar ayudas te´cnicas. 2. Come independientemente; necesita ayudas te´cnicas o asistencia so´lo para cortar los alimentos y/o servir y/o abrir recipientes. 3. Come y bebe independientemente; no requiere asistencia o ayudas te´cnicas. ˜O 2. BAN (Enjabonarse, lavarse, secarse cuerpo y cabeza, manejar el grifo) A. Parte superior del cuerpo 0. Requiere asistencia total. 1. Requiere asistencia parcial. 2. Se lava de forma independiente con ayudas te´cnicas o accesorios especı´ficos (por ej. silla, barras. . .). 3. Se lava de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos (no habituales para personas sanas). B. 0. 1. 2. 3.
Parte inferior del cuerpo Requiere asistencia total. Requiere asistencia parcial. Se lava de forma independiente con ayudas te´cnicas o accesorios especı´ficos. Se lava de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos.
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3. VESTIDO (Ropa, zapatos, ortesis permanentes: pone´rselos, llevarlos puesto y quita´rselos) A. Parte superior del cuerpo œœœœœœ 0. Requiere asistencia total. 1. Requiere asistencia parcial con prendas de ropa sin botones, cremalleras o cordones. 2. Independiente con prendas de ropa sin botones, cremalleras o cordones; requiere ayudas te´cnicas y/o accesorios especı´ficos. 3. Independiente con prendas de ropa sin botones, cremalleras o botones; no requiere ayudas te´cnicas ni accesorios especı´ficos; requiere asistencia o ayudas te´cnicas o accesorios especı´ficos so´lo para botones, cremalleras o cordones. 4. Se pone (cualquier prenda) independientemente; no requiere ayudas te´cnicas o accesorios especı´ficos. Parte inferior del cuerpo œœœœœœ Requiere asistencia total Requiere asistencia parcial con prendas de ropa sin botones, cremalleras o cordones. Independiente con prendas de ropa sin botones, cremalleras o cordones; requiere ayudas te´cnicas y/o accesorios especı´ficos. Independiente con prendas de ropa sin botones, cremalleras o botones sin ayudas te´cnicas ni accesorios especı´ficos; requiere asistencia o ayudas te´cnicas o accesorios especifico so´lo para botones, cremalleras o cordones. 4. Se pone (cualquier prenda) independientemente; no requiere ayudas te´cnicas o accesorios especı´ficos. B. 0. 1. 2. 3.
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œœœœœœ
4. CUIDADOS Y APARIENCIA (Lavarse las manos y la cara, cepillarse los dientes, peinarse, afeitarse, maquillarse) 0. Requiere asistencia total. 1. Requiere asistencia parcial. 2. Se arregla independientemente con ayudas te´cnicas. 3. Se arregla independientemente sin ayudas te´cnicas.
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SUBTOTAL (0–20) œœœœœœ ´ N Y MANEJO ESFINTERIANO RESPIRACIO ´N 5. RESPIRACIO œœœœœœ 0. Requiere ca´nula de traqueostomı´a y ventilacio´n asistida permanente o intermitente. 2. Respiracio´n esponta´nea con ca´nula de traqueostomı´a; requiere oxı´geno, gran asistencia para toser o para el manejo de la ca´nula de traqueostomı´a. 4. Respiracio´n esponta´nea con ca´nula de traqueostomı´a; requiere pequen˜a asistencia para toser o para el manejo de la ca´nula de traqueostomı´a. 6. Respiracio´n esponta´nea sin ca´nula de traqueostomı´a; requiere oxı´geno, gran asistencia para toser, mascarilla (p.e. ma´scara de presio´n positiva espiratoria (PPE) o ventilacio´n asistida intermitente (BiPAP). 8. Respiracio´n esponta´nea sin ca´nula de traqueostomı´a; requiere pequen˜a asistencia o estimulacio´n para toser. 10. Respiracio´n esponta´nea sin asistencia ni dispositivos. 6. MANEJO ESFINTERIANO - VEJIGA œœœœœœ 0. Sonda permanente. 3. Volumen de orina residual 4100 cc; no cateterismo regular o cateterismo intermitente asistido. 6. Volumen de orina residual 5100 cc o autocateterismos intermitentes; necesita asistencia para utilizar los instrumentos de drenaje. 9. Autocateterismos intermitentes; usa instrumentos de drenaje externo; no necesita asistencia para coloca´rselos. 11. Autocateterismos intermitentes; continente entre sondajes; no utiliza instrumentos de drenaje externos. 13. Volumen de orina residual 5100 cc; necesita u´nicamente instrumento de drenaje externo de orina; no requiere asistencia para el drenaje. 15. Volumen urinario residual 5100 cc; continente; no utiliza instrumento de drenaje externo. 7. MANEJO ESFINTERIANO - INTESTINO œœœœœœ 0. Cadencia irregular o frecuencia muy baja (menos de una vez cada 3 dı´as) de deposiciones. 5. Cadencia regular pero requiere asistencia (por ej. para aplicarse un supositorio); accidentes espora´dicos (menos de dos al mes). 8. Evacuacio´n regular, sin asistencia; accidentes espora´dicos (menos de dos al mes). 10. Evacuacio´n regular, sin asistencia; no accidentes. 8. WC - INODORO (Higiene perineal, ajuste de prendas antes/despue´s, uso de compresas o pan˜ales) 0. Requiere asistencia total. 1. Requiere asistencia parcial: no se limpia solo. 2. Requiere asistencia parcial: se limpia independientemente. 4. Usa el WC de forma independiente en todas las tareas pero necesita ayudas te´cnicas o accesorios especı´ficos (por ej. barras). 5. Usa el WC de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos. SUBTOTAL (0–40)
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˜ O) MOVILIDAD (DORMITORIO Y BAN ´ N DE U ´N ´ LCERAS POR PRESIO 9. MOVILIDAD EN CAMA Y ACTIVIDADES DE PREVENCIO œœœœœœ 0. Necesita asistencia en todas las actividades: voltear la parte superior del cuerpo en la cama, voltear la parte inferior del cuerpo en la cama, sentarse en la cama, pulsarse de la silla de ruedas, con o sin ayudas te´cnicas, pero no con adaptaciones ele´ctricas. 2. Realiza una de las actividades sin asistencia. 4. Realiza dos o tres de las actividades sin asistencia. 6. Realiza todas las movilizaciones en la cama y las actividades de liberacio´n de presio´n de forma independiente. 10. TRANSFERENCIAS CAMA - SILLA DE RUEDAS (Frenar silla de ruedas, subir reposapie´s, retirar y ajustar reposabrazos, transferirse, subir los pies) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n, y/o ayudas te´cnicas (por ej. tabla de transferencias). 2. Independiente (o no requiere silla de ruedas).
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˜ ERA 11. TRANSFERENCIAS SILLA DE RUEDAS - WC - BAN œœœœœœ (Si utiliza silla con inodoro: realizar transferencias a y desde ella; si usa silla de ruedas convencional: frenar la silla de ruedas, subir reposapie´s, retirar y ajustar reposabrazos, transferirse, subir los pies) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n, y/o ayudas te´cnicas (por ej. barras de ban˜o). 2. Independiente (o no requiere silla de ruedas). MOVILIDAD (INTERIORES Y EXTERIORES, EN CUALQUIER SUPERFICIE) 12. MOVILIDAD EN INTERIORES 0. Requiere asistencia total. 1. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. 2. Se desplaza de forma independiente con silla de ruedas manual. 3. Requiere supervisio´n mientras camina (con o sin ayudas).
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4. 5. 6. 7. 8.
Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
13. 0. 1. 2. 3. 4. 5. 6. 7. 8.
MOVILIDAD EN DISTANCIAS MODERADAS (10–100 METROS) Requiere asistencia total. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. Se desplaza de forma independiente con silla de ruedas manual. Requiere supervisio´n mientras deambula (con o sin ayudas). Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
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14. 0. 1. 2. 3. 4. 5. 6. 7. 8.
´ S DE 100 METROS) MOVILIDAD EN EXTERIORES (MA Requiere asistencia total. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. Se desplaza de forma independiente con silla de ruedas manual. Requiere supervisio´n mientras deambula (con o sin ayudas). Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
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15. 0. 1. 2. 3.
MANEJO EN ESCALERAS Incapacidad para subir o bajar escaleras. Sube y baja al menos 3 escalones con soporte o supervisio´n de otra persona. Sube y baja al menos 3 escalones con soporte de barandilla y/o muleta o basto´n. Sube y baja al menos 3 escalones sin ningu´n soporte ni supervisio´n.
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16. TRANSFERENCIAS SILLA DE RUEDAS - COCHE œœœœœœ (Acercarse al coche, frenar la silla de ruedas, retirar reposabrazos y reposapie´s, realizar transferencias a y desde el coche, introducir la silla de ruedas dentro y fuera del coche) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n y/o ayudas te´cnicas. 2. Se transfiere de forma independiente; no requiere ayudas te´cnicas (o no requiere silla de ruedas). œœœœœœ
17. TRANSFERENCIAS SUELO - SILLA DE RUEDAS 0. Requiere asistencia total. 1. Se transfiere de forma independiente con o sin ayudas te´cnicas (o no requiere silla de ruedas).
´ N SCIM (0–100) TOTAL PUNTUACIO
SUBTOTAL 0–40
œœœœœœ œœœœœœ
ASSESSMENT PROCEDURES
Development of the Spanish version of the Spinal Cord Independence Measure version III: cross-cultural adaptation and reliability and validity study
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Maria Jose Zarco-Perin˜an, Marı´a J. Barrera-Chaco´n, Inmaculada Garcı´a-Obrero, Juan Bosco Mendez-Ferrer, Luis Eduardo Alarcon, and Carmen Echevarria-Ruiz de Vargas Spinal Cord Unit, Department of Rehabilitation Medicine, Hospital Universitario Virgen del Rocı´o, Seville, Spain
Abstract
Keywords
Purpose: To provide a translation and cross-cultural adaptation of the Spinal Cord Independence Measure (SCIM) version III for Spain and to validate the Spanish version of the SCIM III (eSCIM III). Patients and methods: Development of eSCIM III has involved translation, back-translation and assessment of cultural equivalence procedures. eSCIM version III, was administered to 64 patients with spinal cord injury, admitted to our hospital. Investigation of the psychometric characteristics included: (1) study of the inter-rater reliability, (2) internal consistency (Cronbach’s a), (3) validation and confirmation of the correlation between eSCIM III and Functional Independence Measure (FIM), and (4) sensitivity to change. Results: The reliability of eSCIM III showed an intra-class coefficient value 40.97 in the different subscales assessed. Internal consistency of eSCIM III was shown by a Cronbach’s a value of 0.93. The validity of eSCIM III was confirmed by the close correlation with FIM (r ¼ 0.94, p50.0001). The sensitivity to change of eSCIM III was also confirmed. Conclusions: eSCIM III was found to be culturally equivalent to the original version, as reliability and validity of this tool were demonstrated. It can be used in Spain for functional assessment of patients with spinal cord injury.
Reliability, Spain, Spanish version of the Spinal Cord Independence Measure version III, spinal cord injury, validity History Received 6 May 2013 Revised 28 October 2013 Accepted 7 November 2013 Published online 9 December 2013
ä Implications for Rehabilitation
Development of the Spanish version of the Spinal Cord Independence Measure version III. The importance of the adaptation of Spinal Cord Independence Measure (SCIM) is that it guarantees the possibility of measuring the same concept in different cultures and countries. The eSCIM III is the first, specific assessment tool in patients with spinal cord injury adapted for its use in Spain. The eSCIM III is a tool conceptually equivalent to the original version. It has the reliability and validity of SCIM III in order to be used by clinicians.
Introduction Spinal cord injury represents a significant health problem due to its clinical complexity, prolonged hospitalizations required, clinical follow-up needed throughout life and frequency of complications involved. To describe the real impact derived from the spinal cord injury, it is required not only to assess the degree of deficiency presented by these people, but also to evaluate the level of disability originated. The concept of functionality is not easy to quantify, a circumstance to be resolved by the use of tools of measurement [1]. Hence, the importance of developing scales for functional assessments.
Address for correspondence: Dr Maria Jose Zarco-Perin˜an, PhD, Spinal Cord Unit, Department of Rehabilitation Medicine, Hospital Universitario Virgen del Rocı´o, Seville, Spain. Tel: +34 617557940; +34 955012598. E-mail: [email protected]
The Functional Independence Measure (FIM) was developed and designed to assess the functional level of patients, including those with spinal cord injury [2,3]. Since its creation, this scale has been widely used and diffused, with multiple investigations demonstrating its metric characteristics [3–5]. However, some studies showed certain limitations when this tool is used in subjects with spinal cord injury, as difficulty to the sensitivity to change [6], and in the evaluation of the functional level of patients with tetraplegia, which led to the development of specific instruments [7,8]. Under these premises, the Spinal Cord Independence Measure (SCIM), was designed specifically to quantify the functional assessment of patients with spinal cord injury. Since its establishment, different versions were developed, resulting each version in a more accurate and sensitive tool compared with the previous one. Currently, the version III is used, as reliability, validity and sensitivity to change of this scale have been
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DOI: 10.3109/09638288.2013.864713
evidenced [9,10]. The validity of each version of the SCIM has been determined by comparison with FIM [9,10]. SCIM covers the evaluation of specific areas of function with great relevance in the spinal cord injury, including self-care, respiration and sphincter management, and mobility. Each area is scored according to its proportional weight in the patient’s global activity. The use of SCIM version III is currently recommended to assess the functional recovery of patients with spinal cord injury, both in clinical and research settings, due to the clinical viability and the clinimetric characteristics shown by the tool [9,11]. The English version of the SCIM scale has been developed, but the use of these scales has to be standardized for different countries and cultures. Cross-cultural adaptation of a tool not only requires its translation following a specific methodology, but also evaluates its metric characteristics in the new language and culture [12]. The purpose of this study is to provide the translation and cultural adaptation of the SCIM III to the Spanish language for its use in our country, Spain, and subsequently confirm the reliability and validity of the new tool, the Spanish version of the SCIM III (eSCIM III).
Development of the Spanish version SCIM version III
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or C were discussed by the members of the committee, until a consensus was reached. Pilot study: The new Spanish version was assessed by two study investigators, and used initially in five patients with spinal cord injury. Clinicians were asked about: (1) difficulties in the use of the new tool, (2) difficulties with any of the items. Validation of the Spanish version of the eSCIM III: patients and procedure Patients A total of 64 patients with spinal cord injury previously treated in the Spinal Cord Injury Unit were included. Inclusion criteria were: (1) spinal cord injury of traumatic or medical origin; (2) spinal cord injury (ASIA impairment grade A, B, C or D); (3) verbally given consent for inclusion in the study. Exclusion criteria included: (1) concomitant neurological disease which may alter the functional level previously established by the spinal cord injury; (2) presence of cognitive deficit or psychiatric disease, which may prevent collaboration of the patient and influence the functional level. Procedure
Patients and method Study design: cross-sectional study. This study has two welldefined parts, as explained in the following sections. Cross-cultural adaptation: methodology For the development of eSCIM III, we used a procedure with the following steps [12,13]: – Translation into Spanish: Two forward translations from English into Spanish were produced by two independent translators. Both English–Spanish translators have wide experience and were native Spanish speakers. Translators followed specific instructions including: a brief description of the scale, information relative to the measurement concept system and characteristics of the translation, and use of clinical and culturally equivalent sentences. Each translator independently translated the version and then compared and discussed the result with that of the other translator, until a common version was reached. – Back-translation: The Spanish version of the SCIM was again translated into English by other two translators with wide experience. One translator was American, and the other one had lived in the USA. Both translators did not know that there was an original English version. The aim was to identify possible discrepancies in the Spanish translation. Both translations were analyzed, and a final version was established. – Assessment of the cultural equivalence of the Spanish version: A committee consisting of two translators and four clinicians (three experts in spinal cord injury and one in the process of instrument’s adaptation), compared the original English version and the final Spanish version. The aim of the committee was to evaluate the translation of the scale, verify the cultural equivalence of the new version and approve the definitive Spanish version. A previously established comparison criterion was used [13]: an item was classified as Type A if it was conceptually equivalent, i.e. the translation maintained the semantic and conceptual equivalence from the original English version; an item was classified as B when the meaning was similar, but there was some change; while the item was classified as Type C (different), if it was of questionable translation, and did not maintain the meaning of the original item. Items classified as B
Two authors of the study performed all evaluations. In a first phase, demographic variables were collected and, subsequently functional assessments were performed by using eSCIM III and the FIM. Clinicians involved in patient assessment were trained with different scales. (1) Assessment of the reliability of the scale: To show the reproducibility of the tool, 35 subjects were assessed by two independent investigators who were blinded to the results of the other assessment performed. Reliability was assessed in terms of: (1) assessment of agreement between raters, (2) inter-rater reliability between the two evaluations performed, which confirm that the results are independent of the rater, and that correlates with the patient’s situation. (2) Assessment of the internal consistency: This assessment is relevant when the tool, as in our case, has different components or subscales. Analyses performed: (1) assessment of correlation of items with the global score of the scale, and with the score of the corresponding subscale (item–total score correlation); (2) internal consistency, analyzed by Cronbach’s a, in the global SCIM III and also in each of the subscales. This evaluation separately analyzed scores obtained at admission and discharge. (3) Validity analysis: Validity was analyzed by means of the correlation between the eSCIM III and the FIM scales in 64 patients of the study. (4) Sensitivity to change: To determine the sensitivity of the scale to changes produced in the function of the patient, changes during the rehabilitation period were compared. All patients were evaluated at admission and discharge of rehabilitation. The protocol was approved from the Ethics Committees of the hospital. Verbal consent was obtained from the patients to be included in the study. Statistical analysis (1) Reliability: K-coefficient was used for evaluation of agreement between raters, and Pearson’s correlation coefficient for correlation of scale and subscale. Intra-class correlation coefficient was used to determine variability between raters. An intraclass coefficient 40.75 for the scale and different subscales has been used in this study for reliability analysis [14]. (2) Internal consistency: Cronbach’s a coefficient was used as a measure of internal consistency and a value40.70 was considered
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adequate [14]. For homogeneity evaluation the Pearson correlation coefficient between each item and the total score of the scale or corresponding subscale was used. (3) Validity: For correlation between FIM and eSCIM III scales, Rho Spearman’s non-parametric correlation tests were used (4) Sensitivity to change: Wilcoxon’s non-parametric test was used. The statistical program Statistical Package Social Science, version 19 (SPSS Inc, Chicago, IL) was used for the previous analyses.
Results Cross-cultural adaptation
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Assessment of cultural equivalence Once the eSCIM III version was obtained, after translation and back-translation were performed, the expert committee considered that there were no differences in the conceptual and/or semantic equivalence in 16 items (84.21%) of a total of 19 in the scale. The three items classified as B type were two concerning the management of sphincter and one of mobility. The alternative which maintains the equivalence with the original English version was accepted by consensus. With respect to the pilot study, the clinicians did not refer any difficulty in the use of the tool. Population characteristics A total of 64 subjects with spinal cord injury were included in the study, and 35 of them were selected for the reliability study. Socio-demographical characteristics of both populations are shown in Table 1. Out of the 64 patients, 21 (32.8%) were female and 43 (67.2%) male (mean age: 44.79 20.50 years). Thirty-eight subjects (59.4%) had traumatic spinal cord injury, mainly as a consequence of a traffic accident (39.4%). Twenty-six subjects (40.6%) had spinal cord injury of medical origin, most of them of vascular origin. Table 1. Characteristics of the samples.
Number of SCI* patients Traumatic etiology – Traffic – Outrage – Sports accident – Occupational accident – Precipitation – Others Non-traumatic etiology – Vascular – Infections – Tumor etiology – Spinal stenosis – Others De´ficit Neurolo´gico – Complete Tetraplegia – Incomplete Tetraplegia – Complete Paraplegia – Incomplete Paraplegia AIS grade** – A – B – C – D
Reliability study group
Validity study group
35 20 (57.1%) 6 (30%) 1 (5%) 4 (20%) 2 (10%) 5 (25%) 2 (10%) 15 (42.1%) 7 (46.6%) 3 (20%) 2 (13.3%) 3 (20%)
64 38 (59.4%) 15 (39.4%) 1 (2.6%) 6 (15.8%) 4 (10.5%) 10 (26.3%) 2 (5.2%) 26 (40.6%) 8 (30.8%) 3 (11,5%) 7 (26.9%) 6 (23.1%) 2 (7.7%)
9 8 7 11
(25.7%) (22.9%) (20%) (31.5%)
14 13 14 23
(21.9%) (20.3%) (21.9%) (35.9%)
14 10 6 5
(41.2%) (29.4%) (17.6%) (14.7%)
26 11 9 18
(40.6%) (17.1%) (14.06%) (28.1%)
*SCI: Spinal cord injury. **AIS: American Spinal injury Association Impairment scale.
When the neurological impairment was considered (Table 1), 28 subjects (43.8%) had a complete injury, with incomplete injury in 36 (56.3%). Twenty-seven subjects (42.2%) had tetraplegia and 37 (48.4%) showed paraplegia. According to the ASIA impairment scale, 26 subjects (40.6%) were classified as grade A, and 18 (28.1%) were grade D. Validation of the Spanish version of the SCIM version III Reliability analysis All items showed a high level of agreement, with a K-value40.90, as shown in Table 2. Inter-rater reliability: the intra-class coefficient for the eSCIM III was 0.97 and a value 40.90 was obtained for different subscales of the tool at admission and discharge (Tables 3 and 4). The Pearson correlation coefficient for all subscales and the total score was higher than 0.90 in all cases, with values ranging from 0.90 in the self-care subscale to 0.95 in the mobility scale (Table 3). Homogeneity of the scale: internal consistency Correlation of the item with the scale total score: Correlation of each item of the eSCIM III with the total score was higher than 0.2 in all cases, with the exception of the respiration item with values in the range 0.17–0.85. The higher values were obtained in the mobility subscale (Table 5). Internal consistency: Cronbach’s a coefficient for the eSCIM III was 0.93, with no substantial deviation of this a coefficient when Table 2. Agreement between raters: K coefficients eSCIM III. Items
K Correlations
p Value
0.99 0.96 0.93 0.92 0.91 0.95 1 1 0.96 0.91 1 0.97 0.94 1 0.95 1 1 0.98 0.91
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Feeding Bathing upper body Bathing lower body Dressing upper body Dressing lower body Grooming Respiration Bladder management Bowel management Use of toilet Mobility in bed Transfers bed/wheelchair Transfers wheelchair/toilet/tub Mobility indoors Mobility moderate distances Mobility outdoors Stair management Transfers wheechair/card Transfers ground/wheelchair
eSCIM: Spanish Spinal Cord Independence Measure.
Table 3. Reliability: inter-observer reliability. Intra-class correlation coefficient: admission.
eSCIM
1 evaluator Mean (sd)
2 evaluator Mean (sd)
ICC
Self-care Respiration/sphincter Mobility in the room Mobility indoors/outdoors eSCIM total
11.08 24.77 4.9 6.9 47.77
10.74 24.77 5.4 7.4 46.57
0.97 0.99 0.97 0.7 0.97
(7.01) (8.42) (3.4) (5.3) (23.64)
eSCIM: Spanish Spinal Cord Independence Measure. sd: standard deviation. ICC: Intra-class correlation coefficient.
(6.84) (8.42) (3.4) (5.4) (24.13)
Development of the Spanish version SCIM version III
DOI: 10.3109/09638288.2013.864713
scale homogeneity was intended to be improved after systematic elimination of the items. Cronbach’s a coefficient at discharge for the eSCIM III was 0.93. Cronbach’s a for different subscales was higher than 0.80 (Table 5), except in the ‘‘Respiration – sphincter management’’ subscale with an a value of 0.63. In this subscale, a-value increased when ‘‘Respiration’’ item was eliminated, and decreased when any of the other items of the scale were eliminated. In the mobility scale, Cronbach’s a also improved after elimination of the ‘‘Transfer bed – chair’’ item. Validity study
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eSCIM III showed a significant correlation with FIM, as described in Table 5. The correlation between the eSCIM III and FIM was lower at admission in rehabilitation (r ¼ 0.87, Table 4. Reliability: inter-observer reliability. Intraclass correlation coefficient: discharge.
eSCIM
2 evaluator Mean (sd)
ICC
Self-care Respiration/sphincter Mobility in the room Mobility indoors/outdoors eSCIM total
13.95 28.89 6.85 9.43 59.07
13.59 29.07 6.89 9.5 58.65
0.95 0.94 0.96 0.96 0.96
(6.87) (8.72) (3.75) (7.52) (23.57)
eSCIM: Spanish Spinal Cord Independence Measure. sd: standard deviation. ICC: Intra-class correlation coefficient.
p50.0001) than at discharge (r ¼ 0.94, p50.0001). A significant correlation (p50.0001) was also obtained between the eSCIM III subscales and FIM (Table 6), with a higher correlation at discharge of rehabilitation (0.85–0.91). Sensitivity to change eSCIM III showed sensitivity to functional changes of the patients with spinal cord injury (p50.0001). Comparison of the differences between eSCIM III scale at admission and discharge of the rehabilitation period, and FIM showed that values obtained were higher for eSCIM III than for FIM (p50.0001).
Discussion Functional assessment with specific tools is fundamental in patients with spinal cord injury. The SCIM III scale, designed specifically for these patients, assessed the most relevant areas, including self-care, sphincter management and mobility [9,10]. Table 6. Validity: correlation between FIM and eSCIM III at admission and discharge.
1 evaluator Mean (sd) (6.81) (8.59) (3.71) (7.63) (23.63)
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eSCIM III Self-care Respiration-sphincter management Mobility in the rooms Mobility indoors/outdoors eSCIM total
Admission Rho Spearman
Discharge Rho Spearman
0.89 (p50.0001) 0.86 (p50.0001)
0.90 (p50.0001) 0.87 (p50.0001)
0.87 (p50.0001) 0.81 (p50.0001) 0.87 (p50.0001)
0.90 (p50.0001) 0.85 (p50.0001) 0.94 (p50.0001)
Table 5. Internal consistency: Cronbach’s coefficient a and scale homogeneity.
eSCIM Self-care – Feeding – Bathing upper body – Bathing lower body – Dressing upper body – Dressing lower body – Grooming Respiration-sphincter management – Respiration – Bladder management – Bowel management – Use of toilet Mobility in the rooms – Mobility bed – Transfers bed/wheelchair – Transfer wheelchair/toilet Mobility indoors/outdoors – Mobility indoors – Mobility moderate distance – Mobility outdoors – Stair management – Transfer wheelchair/card – Transfer ground/wheelchair SCIM total –Self-care – Respiration-sphincter – Mobility in rooms – Mobility indoors/outdoors
Cronbach‘s coefficient a Admission
Item-total correlation Admission
Cronbach‘s coefficient a Discharge
Item-total correlation Discharge
0.87 a if item is deleted 0.86 0.83 0.87 0.87 0.86 0.83 0.63 a if item is deleted 0.42 0.9 0.99 0.42 0.93 a if item is deleted 0.93 0.52 0.59 0.93 a if item is deleted 0.68 0.66 0.85 0.85 0.84 0.92 0.93 a if item is deleted 0.81 0.82 0.8 0.81
0.58–0.83
0.92 a if item is deleted 0.91 0.9 0.9 0.89 0.91 0.9 0.79 a if item is deleted 0.44 0.81 0.72 0.65 0.79 a if item is deleted 0.91 0.63 0.62 0.91 a if item is deleted 0.87 0.86 0.87 0.89 0.91 0.92 0.93 a if item is deleted 0.82 0.81 0.8 0.82
0.75–0.84
eSCIM: Spanish Spinal Cord Independence Measure.
0.07–0.75
0.79–0.87
0.75–0.94
0.175–0.85
0.6–0.78
0.78–0.84
0.70–0.93
0.64–0.93
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Besides, this scale has shown greater sensitivity to change compared to FIM, particularly in areas like sphincter management [15]. This has led us to perform the adaptation of this tool to the Spanish language for its use in Spain. The use of an instrument in a different language and country requires performing the processes of translation and cultural adaptation, i.e. to create a tool equivalent to the original scale. This guarantees the assessment of the same concept in different cultures, allowing the comparison of the results [13,16,17]. The methodology used in this study assures the quality of the process, considering eSCIM III as a tool conceptually equivalent to the original version [13,18]. Moreover, eSCIM III is the first, specific assessment tool in patients with spinal cord injury adapted for its use in Spain. This study evaluated the clinimetric characteristics and demonstrated that eSCIM III is a valid and reliable scale to be used in spinal cord injury. Reliability has been shown by the high rate of agreement among raters. Moreover, our data support the inter-rater reliability, with values higher than those obtained in the original version [10], for the global scale and also for the subscales, although similar to those obtained during the cultural adaptation performed with this tool [19,20]. By analysis of the homogeneity of the scale, we verified that this instrument is designed to assess the same characteristic or functional area [10], and that elimination of the items of the scale is not required, with the exception of the item ‘‘Respiration’’. We confirmed that, similar to the original version, the subscale respiration-sphincter showed the lowest correlation values. The internal consistency of eSCIM III, as measured by Cronbach’s a coefficient, was shown to be higher than the usually accepted limit of 0.7 for the global eSCIM III (0.93 in our study) and also for the subscales, and is in agreement with values reported in previous studies [21]. However, the subscale ‘‘Respiration-Sphincter’’ showed Cronbach’s a value of 0.63, which is similar to that found in the original validation and also in the validity studies of the tool [20,22,23]. Despite the relevance of the assessment of the item ‘‘Respiration’’ in patients with spinal cord injury, the results show that this item is not clearly related to the ‘‘Sphincter Management’’ item, and does not contribute to the internal consistency of this subscale [10,23]. This was also confirmed by the increased Cronbach’s a value observed after elimination of the ‘‘Respiration’’ item. This exception had no influence on the internal consistency of SCIM III [22,24]. With regard to the validity study, it is important to notice that an attempt has been made to keep the idiomatic, semantic and conceptual equivalence with the original version during the translation and cross-cultural adaptation processes, in order to maintain the appearance and content of the new version of the tool. The validity of the eSCIM III is supported by the close correlation observed between this scale and FIM, a correlation previously reported [19,20]. However, higher values to those reported for the original version were found [10]. In our study, values probably could be affected by the small sample size used; however, it must be said that the adaptation and validation of SCIM to other countries have been performed using similar samples [19]. Other factor to take into account is the uniformity of the population in our study, with a large proportion of neurologically complete injuries. The neurological deficit of the patients, nearly 43.8% of the population presented a complete injury, while 56.2% had incomplete injury. In addition, a more proportional distribution was evidenced in comparison with previous studies [19,25], which might reasonably explain the same distribution as breathing–sphincter subscale. Despite the good correlation observed between FIM and SCIM III scales, differences between both tools should be considered.
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However, analysis of the validity of a tool should be regarded as a successive verification, as one measurement is only considered valid after accumulation of the evidences was obtained, and needs to be fulfilled. New studies demonstrating the validity of the Spanish version of the SCIIM III are required, which has been already assessed in the original tool [26]. Our work has some limitations. The first is the small sample used, although a similar sample size was used for the adaptation of this tool to other cultures [19]. Lack of variability within the sample is another possible limitation, which may determine data generation. It could increase the reliability values. However, other published studies have also used samples with a similar distribution to ours [21]. In addition, in our work, the rater’s bias has been controlled because in the reliability study each patient was evaluated by two evaluators belonging to the same profession (physicians) and who knew the tool. The agreement between raters was confirmed in our results.
Conclusion The Spanish version of SCIM III is a tool culturally equivalent to the original version. The validity and reliability of the eSCIM III version have been demonstrated. The Spanish version of the SCIM III can be used as a tool for functional assessment of patients with spinal cord injury in our country (see Appendix).
Declaration of interest The authors report no conflicts of interest.
References 1. Furlan JC, Noonan V, Singh A, Fehings MG. Assessment of disability in patients with acute traumatic spinal cord injury: a systematic review of the literature. J Neurotrauma 2011;28:1413–30. 2. Granger CV, Hamilton BB, Keith RA, et al. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1: 59–74. 3. Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehabil Med 1994;26:115–19. 4. Lawton G, Lundgren-Nilsson A, Biering-Sorensen F, et al. Crosscultural validity of FIM in spinal cord injury. Spinal Cord 2006;44: 746–52. 5. Beninato M, O’Kane KS, Sullivan PE. Relationship between motor FIM and muscle strength in lower cervical-level spinal cord injuries. Spinal Cord 2004;42:533–40. 6. Davidoff GN, Roth EJ, Haughton JS, Ardner MS. Cognitive dysfunction in spinal cord injury patients: sensitivity of the functional independence Measure subscales vs. neuropsychologic assessment. Arch Phys Med Rehabil 1990;71:326–9. 7. Middleton JW, Harvey LA, Batty J, et al. Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury. Spinal Cord 2006;44:495–504. 8. Marino RJ, Huang M, Knight P, et al. Assessing selfcare status in quadriplegia: comparison of the quadriplegia index of function (QIF) and the functional independence measure (FIM). Paraplegia 1993;31:225–33. 9. Ackerman P, Morrison SA, McDowell S, Vazquez L. Using the spinal cord Independence measure III to measure functional recovery in a post-acute spinal cord injury program. Spinal Cord 2010;48:380–7. 10. Itzkovich M, Gelenter I, Biering-Sorensen F, et al. The spinal cord independence measure (SCIM) version III: reliability and validaty in a multi-center international study. Disabil Rehabil 2007;29: 1926–33. 11. Anderson K, Aito S, Atkin M, et al.; Functional outcome measure work group. Functional recovery measure for spinal cord injury. An evidence-based review for clinical practice and research. Spinal Cord Med 2008;31:133–44.
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12. Guillemin F, Bombardier CL, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol 1993;46:1417–32. 13. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross cultural adaptation of self report measures. Spine 2000;25:318–91. 14. Johnston MV, Keith RA, Hiderer SR. Measurement standards for interdisciplinary medical rehabilitation. Arch Phys Med Rehabil 1992;73:S3–23. 15. Catz A, Itzkovich M, Tamir A, et al. Spinal cord independence measure: a new disability scale for patients with spinal cord lesions. Spinal Cord 1997;35:850–6. 16. Guillemin F. Cross-cultural adaptation and validation of health status measures. Scan J Rheumatol 1995;24:61–3. 17. Bosi Ferraz M, Magalhaes Oliveira L, Araujo PMP, et al. Crosscultural reliability of the physical ability dimension of the Health Assessment Questionnaire. J Rheumatol 1990;17:813–17. 18. Streiner DL, Norman GR. Health measurement scales. A practical guide to their development and use. 4th ed. Oxford: Oxford University Press; 2008. 19. Kesiktas N, Paker N, Bugdayci D, et al. Turkish adaptation of spinal cord independence measure-version III. Int J Rehabil Res 2012;35: 88–91.
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20. Invernizzi M, Carda S, Milani P, et al. Development and validation of the Italian versio´n of the spinal cord Independence measure III. Disabil Rehabil 2010;32:1194–203. 21. Anderson KD, Acuff ME, Arp BG, et al. United States (US) multicenter study to assess the validity and reliability of the spinal cord independence measure (SCIM III). Spinal Cord 2011;49:880–5. 22. Bluvshtein V, Front L, Itzkovich M, et al. SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions. Spinal Cord 2011;49:292–6. 23. Glass CQ, Tesio L, Itzkovich M, et al. Spinal cord Independence measure versio´n III: applicability to the UK spinal cord injured population. J Rehabil Med 2009;41:723–8. 24. Catz A, Itzkovich M, Tesio L, et al. A multicenter international study on the spinal cord Independence Measure Version III: Rasch psychometric validation. Spinal Cord 2007;45:275–91. 25. Aidonoff E, Front L, Itzkpvich M, et al. Expected spinal cord independence measure, third version, scored for various neurological levels after complete spinal cord lesions. Spinal Cord 2011; 49:893–6. 26. Ackerman P, Morrison SA, McDowell S, Vazquez L. Using the spinal cord independence measure III to measure functional recovery in a post-acute spinal cord injury program. Spinal Cord 2010;48:380–7.
Appendix SPANISH VERSION OF THE SPINAL CORD INDEPENDENCE MEASURE VERSION III (eSCIM III) Unidad de Lesionados Medulares. Hospital Universitario Virgen del Rocı´o, Sevilla CUIDADO PERSONAL ´N 1. ALIMENTACIO œœœœœœ (Cortar, abrir envases, servirse, llevarse la comida a la boca, sostener una taza con lı´quido) 0. Requiere nutricio´n parenteral, gastrostomı´a o asistencia total para la alimentacio´n oral. 1. Requiere ayuda parcial para comer y/o beber, o para utilizar ayudas te´cnicas. 2. Come independientemente; necesita ayudas te´cnicas o asistencia so´lo para cortar los alimentos y/o servir y/o abrir recipientes. 3. Come y bebe independientemente; no requiere asistencia o ayudas te´cnicas. ˜O 2. BAN (Enjabonarse, lavarse, secarse cuerpo y cabeza, manejar el grifo) A. Parte superior del cuerpo 0. Requiere asistencia total. 1. Requiere asistencia parcial. 2. Se lava de forma independiente con ayudas te´cnicas o accesorios especı´ficos (por ej. silla, barras. . .). 3. Se lava de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos (no habituales para personas sanas). B. 0. 1. 2. 3.
Parte inferior del cuerpo Requiere asistencia total. Requiere asistencia parcial. Se lava de forma independiente con ayudas te´cnicas o accesorios especı´ficos. Se lava de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos.
œœœœœœ
œœœœœœ
3. VESTIDO (Ropa, zapatos, ortesis permanentes: pone´rselos, llevarlos puesto y quita´rselos) A. Parte superior del cuerpo œœœœœœ 0. Requiere asistencia total. 1. Requiere asistencia parcial con prendas de ropa sin botones, cremalleras o cordones. 2. Independiente con prendas de ropa sin botones, cremalleras o cordones; requiere ayudas te´cnicas y/o accesorios especı´ficos. 3. Independiente con prendas de ropa sin botones, cremalleras o botones; no requiere ayudas te´cnicas ni accesorios especı´ficos; requiere asistencia o ayudas te´cnicas o accesorios especı´ficos so´lo para botones, cremalleras o cordones. 4. Se pone (cualquier prenda) independientemente; no requiere ayudas te´cnicas o accesorios especı´ficos. Parte inferior del cuerpo œœœœœœ Requiere asistencia total Requiere asistencia parcial con prendas de ropa sin botones, cremalleras o cordones. Independiente con prendas de ropa sin botones, cremalleras o cordones; requiere ayudas te´cnicas y/o accesorios especı´ficos. Independiente con prendas de ropa sin botones, cremalleras o botones sin ayudas te´cnicas ni accesorios especı´ficos; requiere asistencia o ayudas te´cnicas o accesorios especifico so´lo para botones, cremalleras o cordones. 4. Se pone (cualquier prenda) independientemente; no requiere ayudas te´cnicas o accesorios especı´ficos. B. 0. 1. 2. 3.
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œœœœœœ
4. CUIDADOS Y APARIENCIA (Lavarse las manos y la cara, cepillarse los dientes, peinarse, afeitarse, maquillarse) 0. Requiere asistencia total. 1. Requiere asistencia parcial. 2. Se arregla independientemente con ayudas te´cnicas. 3. Se arregla independientemente sin ayudas te´cnicas.
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SUBTOTAL (0–20) œœœœœœ ´ N Y MANEJO ESFINTERIANO RESPIRACIO ´N 5. RESPIRACIO œœœœœœ 0. Requiere ca´nula de traqueostomı´a y ventilacio´n asistida permanente o intermitente. 2. Respiracio´n esponta´nea con ca´nula de traqueostomı´a; requiere oxı´geno, gran asistencia para toser o para el manejo de la ca´nula de traqueostomı´a. 4. Respiracio´n esponta´nea con ca´nula de traqueostomı´a; requiere pequen˜a asistencia para toser o para el manejo de la ca´nula de traqueostomı´a. 6. Respiracio´n esponta´nea sin ca´nula de traqueostomı´a; requiere oxı´geno, gran asistencia para toser, mascarilla (p.e. ma´scara de presio´n positiva espiratoria (PPE) o ventilacio´n asistida intermitente (BiPAP). 8. Respiracio´n esponta´nea sin ca´nula de traqueostomı´a; requiere pequen˜a asistencia o estimulacio´n para toser. 10. Respiracio´n esponta´nea sin asistencia ni dispositivos. 6. MANEJO ESFINTERIANO - VEJIGA œœœœœœ 0. Sonda permanente. 3. Volumen de orina residual 4100 cc; no cateterismo regular o cateterismo intermitente asistido. 6. Volumen de orina residual 5100 cc o autocateterismos intermitentes; necesita asistencia para utilizar los instrumentos de drenaje. 9. Autocateterismos intermitentes; usa instrumentos de drenaje externo; no necesita asistencia para coloca´rselos. 11. Autocateterismos intermitentes; continente entre sondajes; no utiliza instrumentos de drenaje externos. 13. Volumen de orina residual 5100 cc; necesita u´nicamente instrumento de drenaje externo de orina; no requiere asistencia para el drenaje. 15. Volumen urinario residual 5100 cc; continente; no utiliza instrumento de drenaje externo. 7. MANEJO ESFINTERIANO - INTESTINO œœœœœœ 0. Cadencia irregular o frecuencia muy baja (menos de una vez cada 3 dı´as) de deposiciones. 5. Cadencia regular pero requiere asistencia (por ej. para aplicarse un supositorio); accidentes espora´dicos (menos de dos al mes). 8. Evacuacio´n regular, sin asistencia; accidentes espora´dicos (menos de dos al mes). 10. Evacuacio´n regular, sin asistencia; no accidentes. 8. WC - INODORO (Higiene perineal, ajuste de prendas antes/despue´s, uso de compresas o pan˜ales) 0. Requiere asistencia total. 1. Requiere asistencia parcial: no se limpia solo. 2. Requiere asistencia parcial: se limpia independientemente. 4. Usa el WC de forma independiente en todas las tareas pero necesita ayudas te´cnicas o accesorios especı´ficos (por ej. barras). 5. Usa el WC de forma independiente; no requiere ayudas te´cnicas o accesorios especı´ficos. SUBTOTAL (0–40)
œœœœœœ
œœœœœœ
˜ O) MOVILIDAD (DORMITORIO Y BAN ´ N DE U ´N ´ LCERAS POR PRESIO 9. MOVILIDAD EN CAMA Y ACTIVIDADES DE PREVENCIO œœœœœœ 0. Necesita asistencia en todas las actividades: voltear la parte superior del cuerpo en la cama, voltear la parte inferior del cuerpo en la cama, sentarse en la cama, pulsarse de la silla de ruedas, con o sin ayudas te´cnicas, pero no con adaptaciones ele´ctricas. 2. Realiza una de las actividades sin asistencia. 4. Realiza dos o tres de las actividades sin asistencia. 6. Realiza todas las movilizaciones en la cama y las actividades de liberacio´n de presio´n de forma independiente. 10. TRANSFERENCIAS CAMA - SILLA DE RUEDAS (Frenar silla de ruedas, subir reposapie´s, retirar y ajustar reposabrazos, transferirse, subir los pies) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n, y/o ayudas te´cnicas (por ej. tabla de transferencias). 2. Independiente (o no requiere silla de ruedas).
œœœœœœ
˜ ERA 11. TRANSFERENCIAS SILLA DE RUEDAS - WC - BAN œœœœœœ (Si utiliza silla con inodoro: realizar transferencias a y desde ella; si usa silla de ruedas convencional: frenar la silla de ruedas, subir reposapie´s, retirar y ajustar reposabrazos, transferirse, subir los pies) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n, y/o ayudas te´cnicas (por ej. barras de ban˜o). 2. Independiente (o no requiere silla de ruedas). MOVILIDAD (INTERIORES Y EXTERIORES, EN CUALQUIER SUPERFICIE) 12. MOVILIDAD EN INTERIORES 0. Requiere asistencia total. 1. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. 2. Se desplaza de forma independiente con silla de ruedas manual. 3. Requiere supervisio´n mientras camina (con o sin ayudas).
œœœœœœ
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4. 5. 6. 7. 8.
Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
13. 0. 1. 2. 3. 4. 5. 6. 7. 8.
MOVILIDAD EN DISTANCIAS MODERADAS (10–100 METROS) Requiere asistencia total. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. Se desplaza de forma independiente con silla de ruedas manual. Requiere supervisio´n mientras deambula (con o sin ayudas). Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
œœœœœœ
14. 0. 1. 2. 3. 4. 5. 6. 7. 8.
´ S DE 100 METROS) MOVILIDAD EN EXTERIORES (MA Requiere asistencia total. Necesita silla de ruedas ele´ctrica o asistencia parcial para utilizar silla de ruedas manual. Se desplaza de forma independiente con silla de ruedas manual. Requiere supervisio´n mientras deambula (con o sin ayudas). Deambula con andador o muletas (marcha pendular). Deambula con muletas o dos bastones (marcha recı´proca). Deambula con un basto´n. Necesita solamente ortesis de miembro inferior. Deambula sin ayudas para la marcha.
œœœœœœ
15. 0. 1. 2. 3.
MANEJO EN ESCALERAS Incapacidad para subir o bajar escaleras. Sube y baja al menos 3 escalones con soporte o supervisio´n de otra persona. Sube y baja al menos 3 escalones con soporte de barandilla y/o muleta o basto´n. Sube y baja al menos 3 escalones sin ningu´n soporte ni supervisio´n.
œœœœœœ
16. TRANSFERENCIAS SILLA DE RUEDAS - COCHE œœœœœœ (Acercarse al coche, frenar la silla de ruedas, retirar reposabrazos y reposapie´s, realizar transferencias a y desde el coche, introducir la silla de ruedas dentro y fuera del coche) 0. Requiere asistencia total. 1. Necesita asistencia parcial y/o supervisio´n y/o ayudas te´cnicas. 2. Se transfiere de forma independiente; no requiere ayudas te´cnicas (o no requiere silla de ruedas). œœœœœœ
17. TRANSFERENCIAS SUELO - SILLA DE RUEDAS 0. Requiere asistencia total. 1. Se transfiere de forma independiente con o sin ayudas te´cnicas (o no requiere silla de ruedas).
´ N SCIM (0–100) TOTAL PUNTUACIO
SUBTOTAL 0–40
œœœœœœ œœœœœœ
