** NOTE: this website will be shutting down in 2019. All resources have been moved to the Spinal Cord Injury Research Evidence (SCIRE) Project website: https://scireproject.com/outcome-measures/outcome-measure-tool/spinal-cord-independence-measure-scim/ and https://scireproject.com/wp-content/uploads/SCIM_Toolkit_Printable-1.pdf **
Please email clinical [AT] rickhanseninstitute [DOT] org with any questions.
TOOLKIT FOR SCIM III ASSESSMENT
Clinical guideline for performing the SCIM III assessment.
February 2016 (Version 6.0)
- Why is this information important?
- Resource Requirements
- Tips for administering the SCIM III
- References and additional resources
- Additional relevant RHSCIR data collection
This toolkit is supported by the Rick Hansen Institute and was created by the following collaborators:
Kristen Walden, BScPT
National Clinical Liaison
Rick Hansen Institute
Tova Plashkes, MScPT
National Clinical Liaison
Rick Hansen Institute
Shannon Sproule, BScPT
National Clinical Liaison
Rick Hansen Institute
Cynthia Morin, MCISc(OT)
National Clinical Liaison
Rick Hansen Institute
Occupational Therapists from L' Institut de réadaptation Gingras-Lindsay-de-Montréal
Antoinette De Iure
Physical Therapists from G.F. Strong Rehabilitation Centre
Finally, we would like to thank Dr. Amiram Catz, MD, Clinical Associate Professor, Tel Aviv University, Israel for his suggestions.
For questions or comments on this guideline, please contact clinical [AT] rickhanseninstitute [DOT] org.
The RICK HANSEN SPINAL CORD INJURY REGISTRY (RHSCIR) is a pan-Canadian prospective observational registry located at 31 major Canadian acute care and rehabilitation facilities. Across Canada, RHSCIR is collecting comprehensive SCI data for the purpose of improving SCI care and clinical outcomes. Using standardized research protocols and data collection forms, RHSCIR tracks the experiences and outcomes of people with traumatic SCI during their journey from injury, through acute care and rehabilitation to community reintegration. Details about participants' spinal cord injuries including extent of injury and level of paralysis, recovery, and success of various treatments are among the data recorded.
The data collected in RHSCIR contains powerful information that will help track the effectiveness of specific treatments, practices or programs for improving functional outcomes and quality of life after SCI. RHSCIR promotes, encourages and supports the pursuit of excellence in all areas of SCI health care management.
To learn more about RHSCIR, please visit www.rickhanseninstitute.org.
02 WHY IS THIS INFORMATION IMPORTANT?
The Spinal Cord Independence Measure (SCIM), now in its third iteration, is a disability scale developed to specifically assess the abilities of individuals with SCI to accomplish various functional activities of daily living (ADLs) (1). It is has become one of most frequently used research tools for assessing response to treatments in individuals with SCI. Many previous outcome measures used have not been specific or sensitive enough to detect important functional changes in individuals with SCI over time (2).
Benefits to Clinicians and Patients
Collection and reporting of this data can benefit clinicians and patients by:
Monitoring a patient’s functional progress.
Directing therapeutic interventions and priorities.
Setting realistic, timely goals with the patient.
Assisting with identifying the patient's equipment and care needs in preparation for discharge.
Assisting with the focus of patient education.
An SCI-specific validated outcome measure for evaluating clinical interventions and changes in the patient’s function.
Benefits to the Program
Collection and reporting of this data can benefit your program by:
Determining required equipment and supplies to optimize clinical practice and safety (e.g. walking aids, transfer aids, body weight support treadmills, orthoses, etc.).
Assisting with continuity between health care providers by providing a common language to talk about physical function.
Offering facilities comparators to national data.
Reporting metrics to facility administrators which may assist with determining staffing allocation and budget priorities.
Benefits to Research
Collection and reporting of this data can benefit your research by:
Collection of this data can assist with providing a larger sample size of data from the SCI population across Canada which will allow for more accurate and meaningful interpretation and analysis.
Assisting with assessment and evaluation of the effectiveness of treatment approaches.
What Happens Once I Collect the Data?
Providing invaluable data to RHSCIR: Once you collect the data, your facility’s Rick Hansen Spinal Cord Injury Registry (RHSCIR) coordinator will collect this information and input the data into the registry database along with additional relevant clinical information. The national RHSCIR team has developed a number of practices to ensure patient confidentiality is maintained and strict privacy policies and procedures are adhered to.
Providing a baseline for management of SCI across Canada: The de-identified data from your site will be aggregated and reported back on a quarterly basis and will provide information on your hospital's patients enrolled in RHSCIR.
To access your site’s data reports, click here. Please see your local RHSCIR coordinator, or designated representative, to receive this login information. If you are not sure who that is, please contact us at clinical [AT] rickhanseninstitute [DOT] org.
03 RESOURCE REQUIREMENTS
Performing the SCIM requires minimal staff burden as the variables collected are important to patient care, reflect basic areas of patient concern and are routinely collected as a component of clinical practice (3).
To complete collection of data as outlined in this toolkit, the following resources are required:
The estimated time required to perform SCIM III is approximately 30-45 minutes; however, often the SCIM can be completed as part of initial and discharge assessments that may already be practiced by your facility.
There is also a self-report version of the SCIM (SCIM-SR), which is completed by patient interview. The SCIM-SR is estimated to take less time to complete than the clinician administered SCIM III (4).
The assessment should be performed within 72 hours of admission and repeated within 72 hours of discharge.
Clinical Assessment Form
Once the SCIM III or the SCIM-SR has been done at admission to rehab, it is only required to be repeated at discharge. Of course, some therapists and patients may find it useful to repeat it more frequently to assess or demonstrate progress.
Also available is the Self-Report version of the SCIM III. This measure may take less time to complete and is scored so it can be compared with the clinician-collected version (4). It has been validated and correlates well (Pearson’s r for total score = 0.87) with the clinician collected version described here (4).
This form meets the minimum requirements for data collection; please add any additional facility specific information to the form. If you would like assistance with incorporating your facility information on the form, please contact us at clinical [AT] rickhanseninstitute [DOT] org.
Looking for examples of other facilities' assessment forms and policies? Click here to login.
05 TIPS FOR ADMINISTERING THE SCIM III
The SCIM III is very user friendly. The authors of the SCIM intended administration and scoring of the assessment to be self-explanatory and therefore, they didn’t include an instructional manual for the assessment. Although no instruction manual is available from the authors of the SCIM, some guidelines and “tips” were developed by the clinical team at RHI to improve scoring clarity and inter-rater reliability with clinicians using the measure. These guidelines were developed with consultation and feedback from clinicians and researchers who work with patients with SCI.
General Comments for Scoring the SCIM III
There are a total of 19 items on the SCIM III, which are divided into 3 subscales (self-care, respiration and sphincter management, and mobility). A total score out of 100 is achieved, with the subscales weighted as follows: self-care: scored 0-20; respiration and sphincter management: scored 0-40; and mobility: scored 0-40 (5).
Scores are higher in patients that require less assistance or fewer aids to complete basic activities of daily living and life support activities.
The SCIM III ideally is administered by clinical observation, however chart abstraction or clinical consultation can also be used to score the items when necessary (6). More than one clinical team member can contribute to the scoring as necessary (3).
Each of the 19 items should be assessed within a 72-hour period. All questions should be answered. 'Not tested' (NT) is not an option in any of the 19 questions.
More than one clinical team member can contribute to the scoring as necessary (3).
Record the score that best describes the patient’s level of function at the time of assessment, as the score should reflect how the patient typically performs the task. For example, if the patient’s function is affected on short-term basis due to an acute illness (i.e. influenza) when performing the assessment, then scoring would reflect the patient’s function when he/she is healthy. However, the intent of the SCIM is to assess and show change in function; therefore if the patient’s function is compromised by health issues that have longer healing times (such as a fracture or a wound), then the patient is scored on how he/she performs at the time of the assessment.
If significant differences in function occur throughout the day the task should be scored according to the patient’s baseline function.
'Assistance' refers to physical assistance, (including assistance with set-up); and 'adapted aids' refers to any equipment the patient requires to complete the task.
Q1. Feeding: The patient’s level of independence with this task should be assessed at the location where they most typically eat and drink.The patient’s ability to get to an eating location through wheeling or walking is not considered when scoring this task. The patient is scored on their ability to eat and drink, and if adaptive aids or assistance is required. If the patient is independent with eating and drinking, but requires assistance with set-up, then they would achieve a score of 2. Assistance throughout the day to ensure adequate fluid intake, should also be considered. A camelback or customized cup would be considered an adapted aid.
Q2. Bathing (upper and lower body): This is an assessment of a patient’s ability to perform bathing tasks including soaping, washing, drying the body and head and manipulating the water tap and shower handle. Shower, tub or commode transfers are not considered when scoring this task. The patient's function in their present home or institutional setting should be assessed, and not in novel settings (such as when travelling). Stand-by assistance or supervision for safety reasons such as checking water temperature, should be considered partial assistance.
Q3. Dressing (upper and lower body): This is an assessment of the patient’s ability to don clothing. Their ability to transfer to a location to dress or obtain clothing from drawers or closets is not considered when scoring this task. The patient needs to be able to do all three of the difficultto-dress tasks of buttons, zippers and laces (bzl) without assistance or aids to be scored as independent. If the patient can dress without any assistance or aids, but they choose to have assistance with this task, they would be scored according to how they function in their present daily routine, which would be partial or full assistance. If the patient has never tried to do the bzl’s since their injury, they should be scored based on what they say their level of function would be for these activities. Examples of adaptive aids or specific equipment can be splints, adapted clothing, assistive devices (such as button hooks, reachers, dressing sticks, zipper pulls), overhead loops, bed railings, a wheelchair or an electric bed (if they position the wheelchair or bed in a specific position to enable them to dress).
Q4. Grooming: The patient should be evaluated on their ability to complete their typical daily grooming routine. Assessment of this task includes all activities pertaining to grooming, and managing objects such as toothbrushes, combs/hairbrushes, razors and make-up brushes. Wheeling or walking to the location of the activities is not considered when scoring this task.
Respiration and Sphincter Management
Q5. Respiration: Assistance with coughing refers to assistance with secretion clearance and can include positioning, suctioning and physical assistance with coughing. Frequency and time should be considered when scoring this question. If the patient requires frequent sessions for long periods of time for assisted coughs/secretion removal, then that would be considered 'a lot of assistance'. If someone requires assistance occasionally for short periods of time, then that would be considered 'a little assistance'.
Q6. Sphincter Management-Bladder: This question refers to how the patient manages their bladder. Transfers and positioning for bladder management is not considered when scoring this task. Residual volume is the amount of urine that remains in the bladder after voiding. Residual volumes can be abstracted from the patient's chart if measurement was not completed by the assessing clinician. An external drainage instrument is any equipment that is external to the body and is used to collect urine. This would include condom catheters, pads and adult diapers/briefs. Further explanation of the scoring options is as follows:
0. Indwelling catheter as the patient's primary method of managing their bladder.
3. This answer refers to patients who do not have an indwelling catheter and residual volumes are high or unknown. This can include patients who manually stimulate their bladder to urinate (for example, pressing on their lower abdomen to urinate), perform infrequent intermittent catheterizations, require assistance with intermittent catheterizations that are performed infrequently, or use an external drainage instrument AND have high or unknown residual volumes.
6. This answer refers to patients who have low residual volumes, perform regular intermittent catherizations throughout the day with assistance; OR use an external drainage instrument, have low residual volumes AND require assistance with applying the drainage device.
9. The patient has low residual volumes, performs intermittent catheterizations AND uses an external drainage instrument. The patient is independent with doing intermittent catheterizations and applying an external drainage device.
11. The patient is independent with performing regular intermittent catheterizations and does not require an external drainage instrument.
13. The patient has low residual volumes, uses an external drainage instrument and is independent with applying the instrument.
15. The patient is continent with low residual volumes, and does not require an external drainage instrument.
Q7. Sphincter management - Bowel: This question is about bowel emptying once a patient is in position to perform their bowel routine. The ability to transfer, perform peri-care or manage clothing is not considered when scoring this task. The patient would be scored '0' if they have infrequent bowel routines (less than once every three days), irregular timing of bowel movements or if they have more than 2 bowel accidents per month.
Q8. Using the Toilet: This question evaluates the patient's ability to clean themselves after toileting (either bowel or bladder), manage clothes and/or apply pads or diapers. This would include participants who manage their bladder from their wheelchair (such as catheterizing into a toilet bowl from a wheelchair). If the patient does their bowel routine in bed or on a commode with assistance and wears a drainage device for their bladder, then they would be scored at a '0' or '1', depending on the level of assistance they require. If the patient performs their bowel routine in bed, but are independent with this task, then they would score ‘4’ as they require a special setting.
Mobility (room and toilet)
Q9. Mobility in Bed and Action to Prevent Pressure Sores: 'Without assistance' means the patient can change their position in bed and perform weight shifts without physical assistance or the aid of an electric bed or an electric wheelchair. They can use bedrails, the side of a wheelchair, an overhead loop or a strap to move in bed. Doing a push up in wheelchair refers to doing a seat lift or a lateral lean. The patient needs to be able to lift their buttocks completely off of the cushion in their wheelchair, or completely unweight their right and left buttocks to score '6'. A patient can use their arms and/or legs as well as adaptive devices like a table or armrests to perform the seat lift.
Q10. Transfers from the Bed to the Wheelchair: This question assesses the patient's ability to transfer between a bed and a wheelchair, which includes positioning of the wheelchair and manipulating any accessories (such as wheelchair brakes, armrests, caster locks). Scoring should also consider the patient's ability to position their legs and any adaptive aids such as a transfer board. If the patient uses a mechanical lift and are independent with parts or all of the transfer they would be scored a '1' (partial assist).
Q11. Transfers: Wheelchair-Toilet-Tub: This refers to the patient's ability to transfer to either a toilet, commode or shower surface (such as the bottom of a bathtub, shower bench, shower chair or bath board). It is assessing the patient's ability to transfer to surfaces they typically use for toileting or showering. If the patient uses a different surface for toileting and showering the lower score should be chosen if the transfers have different scores.
Q12 to 14. Mobility: Questions 12, 13 and 14 involve walking a variety of distances in both indoor and outdoor environments. The patient can use braces in all of the scoring options except the last one ('8': walk without aids'). The patient should be scored on the walking aid they use rather than their gait pattern (ie: if they step reciprocally but use a walker they would be scored a 4 not a 5). If the patient walks and uses a wheelchair scoring should reflect what the patient does typically and is safe for the patient at the time of the evaluation for the particular distance. A manual wheelchair with power assist wheels should be considered a power wheelchair. On Item 13 and 14, if the patient requires assistance with maneuvering on some terrains (such as grass or inclines) in a manual wheelchair, then they would score '1'.
Q15. Stair Management: Scoring should reflect the patient's ability to manage stairs. If the patient is learning to climb stairs in therapy but manages stairs differently in other settings, then they would be scored on their ability to manage stairs outside of therapy. A patient who ascends and descends stairs on their buttocks should be scored ‘0’ as this item assesses the patient’s ability to manage stairs using their legs.
Q16. Transfers: Wheelchair-Car: This question refers to the patient's ability to transfer in and out of a car. The patient's ability to manage their equipment once they have transferred into a car should be considered. If the patient is unable to transfer into a vehicle seat, they would be scored as '0' (requires total assistance). If the patient requires an adaptation to a vehicle to perform a vehicle transfer or requires assistance when transferring, then they would achieve a score of '1'.
Q17. Transfers: Ground-Wheelchair: If the patient does not use a wheelchair, but requires assistance to transfer from floor level, they would be scored '0'.
06 REFERENCES & ADDITIONAL RESOURCES
1. Itzkovich M, Gelernter I, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, Tonack M, Hitzig SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, El Masry WS, Osman A, Glass C a, Silva P, Soni BM, Gardner BP, Savic G, Bergström EM, Bluvshtein V, Ronen J, Catz A. The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study. Disabil Rehabil. 2007 Dec 30;29(24):1926–33.
2. Anderson K, Aito S, Atkins M, Otr L, Biering-sørensen F, Charlifue S, Curt A, Ditunno J, Glass C, Marino R, Marshall R, Mulcahey MJ, Post M, Savic G. Functional Recovery Measures for Spinal Cord Injury : An Evidence-Based Review for Clinical Practice and Research. J Spinal Cord Med. 2007;31(2):133–44.
3. Catz A, Itzkovich M, Steinberg F, Philo O, Ring H, Ronen J, Spasser R, Gepstein R, Tamir A, St A, Box PO. Disability Assessment by a Single Rater or a Team: A Comparative Study with the Catz-Itzkovich Spinal Cord Independence Measure. J Rehabil Med. 2002;35(4):226–30.
4. Fekete C, Eriks-Hoogland I, Baumberger M, Catz A, Itzkovich M, Lüthi H, Post MWM, von Elm E, Wyss A, Brinkhof MWG. Development and validation of a self-report version of the Spinal Cord Independence Measure (SCIM III). Spinal Cord. 2013 Jan;51(1):40–7.
5. Miller W, Chan C. Spinal Cord Independence Measure (SCIM) [Internet]. SCIRE. 2013 [cited 2014 Jul 24]. Available from: www.scireproject.com/outcome-measures-new/spinal-cord-independence-measure-scim.
6. Catz A, Itzkovich M. Spinal Cord Independence Measure: Comprehensive ability rating scale for the spinal cord lesion patient. J Rehabil Res Dev. 2007;44(1):65–8.
Spinal Cord Independence Measure (SCIM) [Internet]. Physiopedia. [cited 24 July 2014]. Available from: www.physio-pedia.com/Spinal_Cord_Independence_Measure_(SCIM).
07 ADDITIONAL RELEVANT RHSCIR DATA COLLECTED
The SCIM Self-Report is collected in the RHSCIR 2.0 Community Follow-up Questionnaire at one, two and five years post-injury, as well as every five years after that.
Questions or comments regarding this guideline? Email clinical [AT] rickhanseninstitute [DOT] org.