Stoke Mandeville Spinal Needs Assessment Checklist - Adult

Last Updated

June 27, 2025

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Adult NAC revised Jul 08.pdf

Goal planning.pdf

Purpose

The Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) is a rehabilitation outcome measure that assesses patient attainment of changes in rehabilitation outcomes through self-rating of perceived physical and/or verbal independence (also known as verbally instruction). This measure is used specifically for patients with a spinal cord injury or disorder (SCI/D). The SMS-NAC is completed with the patient by a member of the multidisciplinary team following mobilization/admission and prior to discharge. The SMS-NAC can be used to identify the patient’s current level of physical/verbal independence, as well as identifying specific targets for rehabilitation goals.

For further information on the theoretical background of the SMS-NAC and associated goal planning program, please contact bht.nsicpsychology@nhs.net for further information.

Link to Instrument

Instrument Details

Acronym SMS-NAC

Area of Assessment

Activities & Participation
General Health & Development
Bodily Functions
Mental Functions
Movement

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

The SMS-NAC is free to use. Please contact bht.nsicpsychology@nhs.net for agreement to obtain permission to use.

CDE Status

Not a CDE—last searched June 2025.

Diagnosis/Conditions

Spinal Cord Injury

Spinal Cord Injuries

The Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) consists of ten rehabilitation domains, each with specific indicators:

DOMAIN (# of indicators/Minimum score/Maximum score)
1. Physical Healthcare (56/0/172)
2. Daily Living Activities (24/0/72)
3. Skin and Posture Management (26/0/78)
4. Bladder Management (27/0/81)
5. Bowel Management (13/0/39)
6. Mobility (21/0/63)
7. Wheelchair and Equipment (60/0/138)
8. Community Preparation (33/0/84)
9. Psychological Health (35/0/117)
10. Discharge Coordination (36/0/108)
TOTAL (331/0/952)
The scores for each domain are derived by summing the sub-scale item indicators. All items are scored from 0 to 3, with higher scores indicating full physical/verbal independence in or knowledge of that task. Not applicable is used depending on the level of injury e.g. autonomic dysreflexia. The items that are non-applicable are scored as ‘3’ or fully independent so that all patients can score fully despite differences in injury aetiology. From the summed sub-scales, a ‘percentage achieved’ is calculated for each of the ten domains ranging from 0-100% with higher scores indicating a greater level of physical/verbal independence.
Items in each section of the SMS-NAC are hierarchical, so that behavioral items that come first in the section will usually be the areas in which the first rehabilitation goals need to be set, e.g. bed to wheelchair transfers before car transfers.
Unlike other rehabilitation outcome measures for people with SCI/D, the SMS-NAC can be scored in relation to physical or verbal ability, enabling patients to achieve full independence irrespective of the severity of their injury and therefore demonstrate for services outcome for people with higher injuries and parity of rehabilitation provision (Wallace, Duff & Grant, 2023).
Following contacting bht.nsicpsychology@nhs.net and signing a license agreement for using the SMS-NAC, a pack containing additional associated documentation is provided. This includes a ‘Manual’ and ‘Information for Use Guide’ containing background on the SMS-NAC and administration instructions. Additionally, a scoring tool is provided which enables the answers to be automatically scored and a graph displaying the ‘percentage achieved’ for each domain is created.
The percentage achieved scores are used in Goal Planning Meetings to establish rehabilitation goals that include explicit behavioral targets.

Number of Items

372 (Depending on the level of injury, not all items are administered--these are clearly indicated on the SMS-NAC)

60 minutes

Required Training

Reading an Article/Manual

Required Training Description

Following contacting bht.nsicpsychology@nhs.net and signing a license agreement for using the SMS-NAC, a pack containing additional associated documentation is provided. This includes a ‘Manual’ and ‘Information for Use Guide’ containing background on the SMS-NAC and administration instructions.

A YouTube video should be accessed before completing an SMS-NAC for the first time as it provides context on the SMS-NAC and associated goal planning program. YouTube Link: https://www.youtube.com/watch?v=yPt7cvqzSKk

However, the National Spinal Injuries Centre (NSIC) runs an optional one-day training course on the SMS-NAC and goal planning program. In addition to specific training on administering the SMS-NAC, training on the rehabilitation process and how to set specific, achievable goals based on an individual’s strengths and needs is provided. If you are interested in attending this training, please contact the NSIC psychology service at bht.nsicpsychology@nhs.net.

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team; Updated by Jennifer Kahn, PT, DPT, NCS, Candy Tefertiller, PT, DPT ATP, NCS, and SCI EDGE task force of the Neurology Section of the APTA in 2012. Updated in August 2025 by Amy Black, Dept. of Clinical Psychology, National Spinal Injuries Centre, Stoke Mandeville Hospital, UK.

ICF Domain

Body Function
Activity
Participation

Measurement Domain

Activities of Daily Living
Motor
Sensory
Emotion
General Health

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: ANPT Outcome Measures Recommendations (EDGE)

Abbreviations:
HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

Recommendations based on SCI AIS Classification:

	AIS A/B	AIS C/D
SCI EDGE	R	R

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
SCI EDGE	No	No	No	Not reported

Considerations

The SMS-NAC should be completed with the patient by a member of the multidisciplinary team. It should not be given to the patient to complete independently without staff support.
SMS-NAC is a measure of an individual’s perceptions of their own independence and may be subjective and influenced by other factors.
SMS-NAC assesses both verbal and physical independence, so individuals have potential to reach 100% on all subscales.
The Professional Association Recommendations in this summary are based upon the older version of the SMS-NAC, which was since updated in 2020.
The Child Needs Assessment Checklist (ChNAC) is also available (see Webster & Kennedy, 2007; for more information), to obtain a copy please also contact bht.nsicpsychology@nhs.net to obtain a user agreement.
The SMS-NAC is a rehabilitation outcome measure that is used globally including SCI/D providers within India, Peru, the UK, Venezuela and Australia (Duff, Grant, Gilchrist, & Jones, 2022). There are over 30 publications using the SMS-NAC relating to rehabilitation outcomes, injury aetiology, mental health outcomes, and reliability and validity studies. A list of these publications can be accessed on the google drive (QR code below).

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Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Normative Data

Subacute, Chronic SCI/D: (Eaton et al., 2022; n = 195, mean age at injury = 53 (17.5) years, age range = 15.3 – 88.0 years, male = 139 (71%), injury level: complete tetraplegia (26%), complete paraplegia (40%), all levels incomplete (34%)).

Mean (SD) Scores at Admission and Discharge for SMS-NAC Domains by Injury Level

SMS-NAC Domains	Complete Tetraplegia	Complete Paraplegia	All levels incomplete
Physical Health
Admission	54.63 (13.9)	74.25 (15.3)	70.09 (15.2)
Discharge	80.20 (14.1)	87.62 (12.3)	87.67 (11.9)
ADL
Admission	47.63 (29.0)	75.19 (16.3)	66.67 (24.8)
Discharge	76.76 (20.9)	95.45 (6.68)	89.58 (12.0)
Skin and Posture Mgt.
Admission	41.75 (21.5)	51.61 (24.2)	65.28 (24.1)
Discharge	87.37 (13.7)	90.01 (12.2)	93.43 (8.22)
Bladder Management
Admission	49.67 (16.6)	57.12 (19.3)	69.67 (18.8)
Discharge	79.02 (15.3)	84.17 (12.2)	88.09 (9.05)
Bowel Management
Admission	23.00 (22.3)	38.42 (32.0)	67.40 (31.0)
Discharge	71.00 (26.5)	80.21 (22.3)	88.16 (17.7)
Mobility
Admission	43.71 (19.4)	45.97 (16.2)	44.85 (25.8)
Discharge	76.49 (17.2)	77.22 (14.5)	80.76 (16.7)
Wheelchair & equipment
Admission	33.29 (19.1)	46.26 (19.6)	70.06 (20.4)
Discharge	70.06 (20.4)	80.31 (16.5)	83.75 (17.7)
Community preparation
Admission	31.27 (11.2)	38.9 (15.0)	38.46 (15.5)
Discharge	66.24 (14.9)	74.08 (13.5)	70.21 (13.5)
Psychological Health
Admission	59.76 (13.2)	64.64 (13.9)	66.90 (13.9)
Discharge	66.90 (16.5)	74.18 (14.6)	74.10 (16.7)
Discharge Coordination
Admission	24.35 (15.8)	34.78 (17.9)	41.60 (23.6)
Discharge	58.94 (19.8)	67.49 (19.8)	70.87 (18.5)
Concurrent Measure – Spinal Cord Injury Measure (SCIM)
Self-care
Admission	2.41 (3.87)	12.19 (4.26)	10.79 (6.00)
Discharge	6.12 (6.09)	16.71 (3.64)	16.16 (4.87)
Respiration & Sphincter Management
Admission	11.49 (4.03)	17.97 (7.83)	24.66 (10.5)
Discharge	16.96 (8.34)	29.86 (8.41)	32.13 (9.50)
Mobility (room & toilet)
Admission	0.45 (1.25)	3.66 (3.00)	5.52 (3.34)
Discharge	2.63 (3.45)	7.96 (2.66)	8.72 (2.03)
Mobility (indoors & outdoors)
Admission	1.49 (2.09)	5.06 (1.92)	7.87 (6.99)
Discharge	4.86 (4.61)	8.44 (4.36)	14.22 (7.65)
Total
Admission	1.49 (2.09)	5.06 (1.92)	7.87 (6.99)
Discharge	4.86 (4.61)	8.44 (4.36)	14.22 (7.65)

Subacute, Chronic SCI/D: (Berry & Kennedy, 2003; n = 43, mean age = 42.19 (14.6) years, male = 38 (88%), injury level: complete tetraplegia (13.9%), incomplete tetraplegia (37.2%), complete paraplegia (23.3%, incomplete paraplegia (25.6%)).

NAC Means (SD)
Subscale	Number of items	Scale mean	Scale SD	α
ADL	29	59.07	25.88	0.9697
Skin Management	14	25.67	10.54	0.8830
Bladder Management	10	22.81	7.23	0.8356
Bowel Management	7	13.91	6.27	0.8097
Mobility	17	24.28	13.30	0.8729
Wheelchair and Equipment	33	46.09	27.27	0.9527
Community Preparation	24	39.28	12.73	0.7805
Discharge Coordination	32	47.86	25.52	0.9251
Psychological Health	19	45.49	7.99	0.7347
Concurrent Measures
SCIM (Self-Care)	6	12.63	7.61	0.9608
SCIM (Respiration and Sphincter Management)	4	23.84	10.60	0.6454
SCIM (Mobility)	8	14.02	11.21	0.9288
SCIM (Full-Scale Score)	18	50.49	26.91	0.9227
HADS (Anxiety)	7	5.14	4.32	0.8463
HADS (Depression)	7	5.51	4.17	0.8122

Test/Retest Reliability

Subacute, Chronic SCI/D: (Berry & Kennedy, 2003; mean interval between tests = 7.2 (2.88) days, compared by correlating clinical NAC subscale scores with test-retest NAC subscale scores).

Acceptable to Excellent test-retest reliability for all NAC subscales except for Bladder Management

Test-retest reliability of NAC subscales (Pearson’s r correlations)

NAC Subscale	r value
ADL	0.884
Skin Management	0.904
Bladder Management	0.694
Bowel Management	0.783
Mobility	0.883
Wheelchair and Equipment	0.883
Community Preparation	0.830
Discharge Coordination	0.805
Psychological Health	0.748

All correlations significant at 0.01 level (two-tailed)

Internal Consistency

Subacute, Chronic SCI/D: (Berry & Kennedy, 2003; n = 43, complete tetraplegia (13.9%), incomplete tetraplegia (37.2%), complete paraplegia (23.3%, incomplete paraplegia (25.6%)).

Acute SCI/D: (Kennedy et al., 2003; n = 192, mean age = 40.7 (16.5) years, male = 147 (77%), injury level (of 173 for whom data was available): complete tetraplegia (21%), incomplete tetraplegia (23%), complete paraplegia (34%), and incomplete paraplegia (22%)).

NAC Subscale	Berry & Kennedy, 2003 - α	Kennedy et al., 2003 – α
Across all subscales	Excellent 0.8587	Excellent 0.8306
ADL	Excellent 0.9697	Excellent 0.9467
Skin Management	Excellent 0.8830	Excellent 0.8478
Bladder Management	Excellent 0.8356	Adequate 0.7753
Bowel Management	Excellent 0.8097	Excellent 0.8741
Mobility	Excellent 0.8729	Excellent 0.8358
Wheelchair and Equipment	Excellent 0.9527	Excellent 0.9239
Community Preparation	Adequate 0.7805	Adequate 0.7146
Discharge Coordination	Excellent 0.9251	Excellent 0.8855
Psychological Health	Adequate 0.7347	Poor 0.6729

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Subacute, Chronic SCI/D: (Berry & Kennedy, 2003)

Adequate to Excellent correlations between NAC subscales, the SCIM, and the HADS

Pearson’s r correlations between NAC subscales, the SCIM, and the HADS

Subscale	SCIM (Self-care)	SCIM (Respiration and Sphincter Management)	SCIM (Mobility)	SCIM (Full Scale)	HADS (Anxiety)	HADS (Depression)	HADS (Combined scales)
ADL	0.850			0.783
Bladder and Bowel Management (combined scales)		0.681		0.754
Mobility			0.691	0.696
Psychological Issues (mood subsection)					-0.709	-0.633	-0.726
Psychological Issues (Full-Scale)					-0.501	-0.466	-0.523

All correlations are significant at the 0.01 level (two-tailed)

SCIM = The Spinal Cord Independence Measure

HADS = Hospital Anxiety and Depression Scale

Bibliography

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

Duff, J., Evans, M. J., & Kennedy, P. (2004). Goal planning: a retrospective audit of rehabilitation process and outcome. Clinical Rehabilitation 18(3): 275-286. Find it on PubMed

Duff, J., Grant, L. C., Gilchrist, H., & Jones, K. (2022). Building and sustaining inpatient-clinician collaboration in spinal cord injury rehabilitation: A case example using the Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) and goal planning program. Journal of Clinical Medicine, 11(13), 3730. https://doi.org/10.3390/jcm11133730

Eaton, R., Duff, J., Wallace, M., & Jones, K. (2022). The value of the whole picture: rehabilitation outcome measurement using patient self-report and clinician-based assessments after spinal cord injury. Spinal Cord, 60(1), 71-80. https://doi.org/10.1038/s41393-021-00677-7

Kennedy, P., Evans, M. J., Berry, C., & Mullin, J. (2003). Comparative analysis of goal achievement during rehabilitation for older and younger adults with spinal cord injury. Spinal Cord 41(1): 44-52. Find it on PubMed

Kennedy, P. and Hamilton, L. R. (1999). "The needs assessment checklist: a clinical approach to measuring outcome." Spinal Cord 37(2): 136-139. Find it on PubMed

Wallace, M., Duff, J., & Grant, L. C. (2023). The influence of psychological need on rehabilitation outcomes for people with spinal cord injury. Spinal Cord, 61(1), 83-92. https://doi.org/10.1038/s41393-022-00864-0

Webster, G. and Kennedy, P. (2007). Addressing children's needs and evaluating rehabilitation outcome after spinal cord injury: the child needs assessment checklist and goal-planning program. J Spinal Cord Med 30 Suppl 1: S140-145. Find it on PubMed