RESEARCH PAPER

The Spinal Cord Independence Measure (SCIM) version III:Reliability and validity in a multi-center international study

M. ITZKOVICH1,2, I. GELERNTER2,3, F. BIERING-SORENSEN4, C. WEEKS5,

M. T. LARAMEE6, B. C. CRAVEN7, M. TONACK7, S. L. HITZIG7, E. GLASER8,

G. ZEILIG2,9, S. AITO10, G. SCIVOLETTO11, M. MECCI12, R. J. CHADWICK12,

W. S. EL MASRY13, A. OSMAN13, C. A. GLASS14, P. SILVA14, B. M. SONI14,

B. P. GARDNER15, G. SAVIC15, E. M. BERGSTROM15, V. BLUVSHTEIN1,

J. RONEN1,2 & A. CATZ1,2

1Spinal Department, Loewenstein Rehabilitation Hospital, Raanana, Israel, 2Tel Aviv University, Tel Aviv, Israel, 3The

Statistical Laboratory, School of Mathematics, Tel Aviv University, Tel Aviv, Israel, 4Clinic for Spinal Cord Injuries, The

NeuroScience Centre, Copenhagen University Hospital, Copenhagen, Denmark, 5GF Strong Spinal Cord Injury Program,

Vancouver, Canada, 6Institut de Readaptation de Montreal, Montreal, Canada, 7Toronto Rehab’s Spinal Cord Rehabilitation

Program, Toronto, Canada, 8Neurological Rehab-Centre, Greifswald, Germany, 9Neurological Rehabilitation, Sheba Medical

Center, Tel-Hashomer, Israel, 10Spinal Unit, Careggi Hospital, Florence, Italy, 11Spinal Cord Unit, IRCCS Fondazione,

Santa Lucia, Rome, Italy, 12The North of England Spinal Cord Injuries Centre, Middlesbrough, UK, 13Midlands Centre for

Spinal Injuries, RJ & AH Orthopaedic Hospital, Oswestry, UK, 14North West Regional Spinal Injuries Centre, Southport,

UK, and 15National Spinal Injuries Centre, Stoke Mandeville Hospital, UK

Accepted August 2006

AbstractPurpose. To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in amulti-center cohort study.Method. Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries fromthree continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission torehabilitation and before discharge.Results. Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statisticallysignificant (P5 0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclasscorrelation coefficients were above 0.94. Cronbach’s a was above 0.7. The coefficient of Pearson correlation between FIMand SCIM III was 0.790 (P5 0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration andsphincter management and Mobility indoors and outdoors.Conclusions. The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitationsof the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can besafely used for clinical and research trials, including international multi-center studies.

Keywords: SCIM, reliability, validity, responsiveness

Introduction

Use of standardized tools for measuring the effec-

tiveness of clinical interventions is widely accepted

as a prerequisite for good clinical practice and for

the provision of evidence-based health care [1].

In rehabilitation medicine evaluating therapeutic

effectiveness is particularly important as it is a

labor-intensive and costly intervention [2]. Although

there is a tendency in rehabilitation medicine to

move toward quality of life measures [3], there is still

an overall agreement that skills involved in self-care

Correspondence: Prof. Amiram Catz, MD, PhD, Medical Director, Department IV, Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, 278 Achuza

St., P.O. Box 3, Raanana 43100, Israel. Fax: 972 9 7654897. E-mail: amcatz@post.tau.ac.il

Disability and Rehabilitation, December 2007; 29(24): 1926 – 1933

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.

DOI: 10.1080/09638280601046302

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and mobility are basic to higher levels of functioning

[4], and improvement of these abilities is likely to

have considerable impact on the patients’ level of

handicap and health related quality of life [2].

Therefore the development and refinement of reli-

able, valid, user-friendly, standardized ability rating

scales is of major importance [5].

The Spinal Cord Independence Measure (SCIM)

scale has been designed specifically for patients with

spinal cord lesions (SCL) and is the only compre-

hensive ability rating scale for this patient population.

SCIM focuses on the ability of performing basic

everyday tasks and takes into consideration the

economic burden of disability as well as the impact

of disability on the patient’s overall medical condi-

tion and comfort [6]. The validity, reliability, and

advantages of the first two versions (SCIM I and

SCIM II) have been demonstrated in several pub-

lications [5 – 10], showing that SCIM II can be used

for clinical purposes and outcome assessment in

research [11,12] and that it therefore contributes to

evidence-based practice with SCL patients.

The clinical use of SCIM II has been accompanied

by statistical analysis through Rasch modeling [6],

and enriched by comments from staff members

who used it, and by expert opinions from several

countries. These led to the formulation of the third

version of SCIM (SCIM III), which consists of three

complementary subscales: ‘Self care’ (with a score

range of 0 – 20) including six tasks; ‘Respiration and

sphincter management’ (with a score range of 0 – 40)

including 4 tasks; and ‘Mobility’ (with a score range

of 0 – 40) including nine tasks. The mobility subscale

consists of two subscales: one for ‘room and toilet’

and the one for ‘indoors and outdoors, on even

surface’. Total score ranges between 0 and 100

(Appendix 1).

To examine the reliability and validity of SCIM III

in a multicultural setup, the SCIM III subscales were

tested in a multi-center international study.

Method

Participants

Four hundred and twenty-five patients from 13

spinal rehabilitation units in six countries in North

America, Europe, and the Middle-East were in-

cluded in the study. Inclusion criteria were a spinal

cord lesion (ASIA impairment grade A, B, C, or D),

age �18 years, and no concomitant impairments that

might influence everyday function, such as brain

injury or mental disease.

The sample included 309 males and 116 females.

Their mean age was 46.93 years (SD¼ 18.17); 188

had tetraplegia and 237 paraplegia. ASIA grades

were: A in 151 patients (35.5%), B in 59 (13.9%),

C in 92 (21.6%), and D in 119 (28%). In 261

participants (61.4%) lesion etiology was trauma and

in 164 (38.6%) it was non-traumatic.

The non-traumatic etiologies were spinal stenosis

in 23 patients (5.4%), benign tumor in 27 (6.3%),

disc protrusion in 25 (5.9%), myelopathy of un-

known origin in 16 (3.8%), vascular impairment in

16 (3.8%), syringomyelia in five (1.2%), decompres-

sion sickness in three (0.7%), multiple sclerosis in

two (0.5%), congenital anomaly in two (0.5%),

spinal abscess in two (0.5%), metastatic disease in

two (0.5%), and other in 41 patients (9.6%).

Procedure

The study began in October 2002. The patients’

functional performance was assessed with the SCIM

III questionnaire within the first week after admis-

sion to the rehabilitation department and within the

last week before discharge from the department.

SCIM III items were scored according to actual

direct observation of patient performance by two

expert professionals selected at each unit (physicians,

nurses, occupational therapists, or physical thera-

pists). When scoring items by direct observation was

not practical (for example bowel habits, voiding, or

transfers wheelchair/ground), information was ob-

tained from a staff member who had been observing

the patient during routine care. Patient evaluation

with the Functional Independence Measure (FIM)

was performed by a third staff member at the same

time intervals.

Patient data and SCIM III scores were collected

in each participating unit, entered into Excel files,

e-mailed to the first two authors, and pooled for

analysis.

Data analysis

SCIM III was tested for inter-rater reliability and the

internal consistency of the scale. Inter-rater reliability

of SCIM III was demonstrated by: (a) the percentage

of total agreement between the paired raters; (b) kappa

coefficients of SCIM tasks (chance corrected agree-

ment); (c) Pearson correlation and paired t-test of

SCIM subscales; and (d) intraclass correlation coeffi-

cient (ICC), which estimates the proportion of

variability between subjects within the total variability

in scores. This proportion assesses the average

similarity of the subjects’ actual scores on the two

ratings [13]. The desired ICC value is above 0.75 [14].

Internal consistency of the scale was tested using

Cronbach’s a coefficient. The internal consistency of

a scale stands for the extent to which the different

items of a scale relate to the same underlying

dimension. Values of Cronbach’s a exceeding 0.7

support reasonable internal consistency [14].

Reliability and validity of SCIM-III 1927

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SCIM III validity was evaluated by: (a) Pearson

correlation between total FIM and SCIM III scores

on admission to rehabilitation (criterion validity); (b)

Responsiveness to change evaluated by McNemar

test comparing SCIM III subscales scores to FIM

tasks that match those subscales.

The level of significance was set at 0.05. The

statistical analysis was performed using SPSS 12.01

for Windows.

Results

SCIM III reliability

1. Inter-rater reliability: Total agreement between

the paired raters ranged between 74.5 and 96.2%, in

13 of the 18 tasks total agreement was above 80.0%.

Kappa coefficients ranged between 0.631 and 0.823,

and were statistically significant for all tasks

(P5 0.001, Table I).

Pearson correlation coefficients of the paired raters

for SCIM III subscales and for the total SCIM scores

were above 0.9 (P5 0.001), and the mean differ-

ences between the paired raters scores were all

statistically non-significant (Table II). ICC values

were above 0.94 for the total SCIM III score and for

all SCIM III subscales (Table III).

2. Internal consistency: Cronbach’s a values for the

overall SCIM III scale were 0.847 and 0.849 for the

first and second raters. Cronbach’s a decreased when

any of the subscales was eliminated. The Cronbach’s

a coefficients of all subscales were higher than 0.7,

and elimination of most of the items in each of them

decreased the a coefficient of the subscale. Only

elimination of three items: respiration, mobility in

bed, and transfers ground/wheelchair, increased the

subscales’ a coefficient (Table IV).

SCIM III validity

1. Pearson correlation coefficients between SCIM III

and FIM were 0.790 (P5 0.01, n¼ 379) for the first

rater and r¼ 0.779 (P5 0.01, n¼ 375) for the

second rater.

2. The responsiveness of SCIM III was better than

that of FIM in the Respiration and sphincter manage-

ment and Mobility indoors and outdoors subscales,

in which SCIM III identified more changes in

function than FIM (P5 0.001). In the other two

subscales, Self care and Mobility in the room and

toilet, differences between the two scales were

statistically non-significant (Table V a – d).

Discussion

Studies of previous SCIM versions included

relatively small local samples. The present multi-

center study, however, included hundreds of SCL

patients from various units and countries. Because

of the size and heterogeneity of the present

sample of spinal cord injured patients the present

Table I. Total agreement and Kappa coefficients of SCIM III tasks

(n¼ 372).

Task Total agreement (%) Kappa

Feeding 89.8 0.823

Bathing upper body 75.5 0.671

Bathing lower body 79.0 0.643

Dressing upper body 74.5 0.668

Dressing lower body 80.6 0.651

Grooming 84.1 0.731

Respiration 91.4 0.754

Sphincter management – bladder 77.1 0.705

Sphincter management – bowel 79.8 0.691

Use of toilet 80.1 0.631

Mobility in bed 77.1 0.682

Transfers bed/wheelchair 86.5 0.782

Transfers wheelchair/toilet/tub 87.1 0.768

Mobility indoors 84.4 0.778

Mobility moderate distance 82.8 0.755

Mobility outdoors 80.4 0.705

Stair management 92.7 0.679

Transfers wheelchair/car 90.9 0.758

Transfers ground/wheelchair 96.2 0.751

Table II. Pearson correlation and paired t-test between raters (n¼ 372).

SCIM subscales Mean SD r P t P**

Self care – 1* 8.73 6.11 0.944 50.001 1.127 0.261

Self care – 2* 8.61 5.88

Respiration and sphincter – 1 19.88 10.77 0.902 50.001 0.955 0.340

Respiration and sphincter – 2 19.65 10.54

Mobility in the room – 1 3.72 3.73 0.924 50.001 0.108 0.914

Mobility in the room – 2 3.72 3.67

Mobility indoors/outdoors – 1 5.14 6.36 0.935 50.001 – 0.586

Mobility indoors/outdoors – 2 5.20 6.33 0.545

SCIM total – 1 37.47 23.90 0.955 50.001 0.800 0.424

SCIM total – 2 37.18 23.44

*1, first rater; 2, second rater.

**Significance two-tailed.

1928 M. Itzkovich et al.

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examination of SCIM III reliability and validity

contributes substantially to the development of

SCIM.

The results support the reliability and validity of

SCIM III in a multi-cultural setup. ICC values,

which were above 0.94 for the total SCIM III scores

and for all SCIM III subscales, indicate good inter-

rater reliability of the scale. Moreover, the high

values of total agreement and kappa coefficients in

SCIM III tasks, and of Pearson correlations

between raters in the subscales, imply an improve-

ment in inter-rater reliability compared with

SCIM II [5].

The internal consistency of the total SCIM III

scale was good. Values of Cronbach’s a were high for

SCIM III total and subscale scores. The decrease in

Cronbach’s a when any of the subscales or most

items in each of them were eliminated indicates

that all subscales and most items contribute to

the homogeneity of the scale. The increase in the

subscales’ a coefficient after elimination of the

respiration, mobility in bed, and transfers ground/

wheelchair items imply that these tasks may have a

weak relationship with the other items in their

subscales.

The validity of the scale is supported by the high

correlation between FIM and SCIM III (criterion

concurrent validity). But the correlation between the

two scales is not too high, showing that both scales

can be appropriate for evaluation of SCL patients,

although they still differ. A difference between the

two scales was demonstrated in their responsiveness

in the sphincter and mobility indoors/outdoors

subscales: SCIM III is more responsive than FIM

to functional changes in these two areas, probably

reflecting the relatively higher weight attributed by

SCIM to everyday tasks in these functional areas [7].

We believe that successful management of these tasks

is particularly important for life expectancy and

the quality of life of SCL patients. The superior

responsiveness of SCIM III in these two areas is

meaningful for the rehabilitation outcome assess-

ment in SCL patients.

Enrollment of a large sample from six countries

provides a strong foundation for the results of the

study, but participation of units from other countries

may further challenge the cross-cultural validity of

SCIM. Another limitation of the study may be

attributed to the fact that a variety of professionals

were engaged in it, in unbalanced proportions, with

nurses and occupational therapists far outweighing

physiotherapists and physicians.

To conclude, the results support the reliability and

validity of SCIM III in a multi-cultural setup and

indicate that it is an efficient measure for functional

assessment of SCL patients, with a psychometric

advantage over FIM. The study has shown

that SCIM can be safely used for clinical and

research trials, including international multi-center

studies.

Table III. Intraclass correlation coefficients (ICC) within subscales

and total scores (n¼ 372).

Subscale ICC 95% CI*

Self care 0.971 0.964 – 0.976

Respiration and sphincter 0.948 0.937 – 0.958

Mobility in the room 0.961 0.952 – 0.968

Mobility indoors/outdoors 0.967 0.959 – 0.973

SCIM total scores 0.977 0.972 – 0.981

*CI, confidence interval.

Table IV. Internal consistency (Cronbach’s coefficient a) within

subscales.

1st rater N¼386

2nd rater

N¼379

Self care

a¼ 0.906 Alpha¼ 0.892

a if item deleted

Feeding 0.892 0.875

Bathing upper body 0.879 0.862

Bathing lower body 0.897 0.880

Dressing upper body 0.879 0.862

Dressing lower body 0.903 0.893

Grooming 0.883 0.866

Respiration and sphincter management

a¼ 0.701 Alpha¼ 0.704

a if item deleted

Respiration 0.733 0.747

Bladder management 0.586 0.577

Bowel management 0.538 0.519

Use of toilet 0.626 0.637

Mobility in the room and toilet

a¼ 0.724 Alpha¼ 0.739

a if item deleted

Mobility in bed 0.936 0.925

Transfers bed/wheelchair 0.595 0.606

Transfers wheelchair/toilet/tub 0.610 0.638

Mobility indoors and outdoors

a¼ 0.887 Alpha¼ 0.878

a if item deleted

Mobility indoors 0.837 0.829

Mobility moderate distances 0.825 0.813

Mobility outdoors 0.838 0.826

Stair management 0.878 0.866

Transfers wheelchair/car 0.881 0.870

Transfers ground/wheelchair 0.906 0.896

SCIM Total

a¼ 0.849 a¼ 0.847

a if item deleted

Self care 0.788 0.789

Respiration and sphincter

management

0.847 0.851

Mobility in the room and

toilet

0.822 0.817

Mobility indoors and

outdoors

0.792 0.785

Reliability and validity of SCIM-III 1929

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Acknowledgements

This study was supported by the Unit of Medical

Services, Rehabilitation Department, Israel Ministry

of Defense, by Toronto Rehab who receives funding

under the Provincial Rehabilitation Research Program

from the Ministry of Health and Long Term Care in

Ontario, and The Rick Hansen Man in Motion

Foundation Research Fund. We thank Hanne Vest

Hansen, RN, from Copenhagen, Denmark, Chris

Wilson (Consultant Clinical Psychologist), Mary

Watkins (Assistant Psychologist), Sister Maryse

Mackenzie, and Mr S Jallul, Specialist Registrar, from

Oswestry, UK, Ora Philo, RN, from Raanana, Israel,

the staff members of all participating units, and all

patient volunteers who took part in the study.

References

1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence

based medicine: what it is and what it isn’t. Br Med J

1996;312:71 – 72.

2. van der Putten JJMF, Hobart JC, Freeman JA, Thompson AJ.

Measuring change in disability after inpatient rehabilitation:

comparison of the responsiveness of the Barthel Index and the

Functional Independence Measure. J Neurol, Neurosurg

Psychiatry 1999;66:480 – 484.

Table V. Responsiveness to functional changes of FIM and SCIM III within subscales.

a. Self care

Changes identified by SCIM

1st rater 2nd rater

No Yes Total No Yes Total

Changes identified by FIM No 18 25 43 19 23 42

Yes 18 220 238 18 234 252

Total 36 245 281 37 257 294

P5 0.360, P5 0.533.

b. Respiration and sphincter management

Changes identified by SCIM

1st rater 2nd rater

No Yes Total No Yes Total

Changes identified by FIM No 16 57 73 13 65 78

Yes 17 192 209 18 199 217

Total 33 249 282 31 264 295

P5 0.001, P5 0.001.

c. Mobility in the room and toilet

Changes identified by SCIM

1st rater 2nd rater

No Yes Total No Yes Total

Changes identified by FIM No 43 23 66 42 25 67

Yes 31 184 215 28 199 227

Total 74 207 281 70 224 294

P5 0.341, P5 0.784.

d. Mobility indoors and outdoors

Changes identified by SCIM

1st rater 2nd rater

No Yes Total No Yes Total

Changes identified by FIM No 18 59 77 17 68 85

Yes 7 197 204 6 203 209

Total 25 256 281 23 271 294

P5 0.001, P5 0.001.

1930 M. Itzkovich et al.

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.com

by

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tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/29/

14Fo

r pe

rson

al u

se o

nly.

3. Patrick DL, Deyo RA. Generic and disease-specific measures

in assessing health status and quality of life. Med Care

1989;27(Suppl.):S217 – S223.

4. Keith RA, Granger CV, Hamilton BB, et al. The functional

independence measure: a new tool for rehabilitation. In:

Eisenberg M, Grzesiack R, editors. Advances in clinical

rehabilitation. New York: Springer Verlag; 1987. pp 6 – 18.

5. Catz A, Itzkovich M, Steinberg F, Ring H, Ronen J,

Spasser R, Gepstein R, Tamir A. The Catz-Itzkovich SCIM:

a revised version of the Spinal Cord Independence Measure.

Disabil Rehabil 2001;23:263 – 268.

6. Itzkovich M, Tripolski M, Zeilig G, Ring H, Rosentul N,

Ronen J, Spasser R, Gepstein R, Catz A. Rasch analysis of the

Catz-Itzkovich Spinal Cord Independence Measure. Spinal

Cord 2002;40:396 – 407.

7. Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM –

spinal cord independence measure: a new disability scale for

patients with spinal cord lesions. Spinal Cord 1997;35:

850 – 856.

8. Catz A, Itzkovich M, Tamir A, Philo O, Steinberg F, Ring H,

Ronen J, Spasser R, Gepstein R. SCIM – spinal cord

independence measure (version II): sensitivity to functional

changes. Harefuah (Hebrew) 2002;141:1025 – 1031.

9. Catz A, Itzkovich M, Steinberg F, Philo O, Ring H, Ronen J,

Spasser R, Gepstein R, Tamir A. Disability assessment by a

single rater or a team: a comparative study with the Catz-

Itzkovich spinal cord independence measure. J Rehabil Med

2002;34:226 – 230.

10. Itzkovich M, Tamir A, Philo O, Steinberg F, Ronen J,

Spasser R, Gepstein R, Ring H, Catz A. Reliability of the

Catz-Itzkovich Spinal Cord Independence Measure assess-

ment by interview and comparison with observation. Am J

Phys Med Rehabil 2003;82:267 – 272.

11. Popovic MR, Thrasher TA, Adams ME, Takes V,

Zivanovic V, Tonack MI. Functional electrical therapy: re-

training grasping in spinal cord injury. Spinal Cord 2006;4:

143 – 151.

12. Grijalva I, Guizar-Sahagum G, Castaneda-Hernadez G, et al.

Efficacy and safety of 4-aminopyridine in patients with long-

term spinal cord injury: a randomized, double-blind, placebo-

controlled trial. Pharmacotherapy 2003;7:823 – 834.

13. McDowell I, Newell C. Measuring Health: A Guide to Rating

Scales and Questionnaires. Oxford: Oxford University Press;

1996.

14. Marino RJ, Stineman MG. Functional Assessment in Spinal

cord Injury. Topics Spinal Cord Injury Rehabil 1996;1:32 – 45.

Reliability and validity of SCIM-III 1931

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Appendix

1932 M. Itzkovich et al.

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