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RehabMeasures Instrument

Stroke Impact Scale

Last Updated

Purpose

The SIS assesses health status following stroke.

Link to Instrument

Instrument Details

Acronym SIS

Area of Assessment

Activities of Daily Living
Cognition
Communication
Depression
Functional Mobility
Gait
General Health
Life Participation
Quality of Life
Social Relationships
Social Support
Upper Extremity Function

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Free to non-profit users via link above.
Contact information and permission to use:
MAPI Research Trust, Lyon, France:
Email: PROinformation@mapi-trust.org
Internet: www.mapi-trust.org
Scale: http://www.mapi-trust.org/services/questionnairelicensing/catalog-questionnaires/298-sis

Diagnosis/Conditions

  • Stroke Recovery

Populations

Key Descriptions

  • SIS is a 59-item measure.
  • 8 domains assessed:
    1) Strength (4 items)
    2) Hand function (5 items)
    3) ADL/IADL (10 items)
    4) Mobility (9 items)
    5) Communication (7 items)
    6) Emotion (9 items)
    7) Memory and thinking (7 items)
    8) Participation/Role function (8 items)
  • Each item is rated in a 5-point Likert scale in terms of the difficulty the patient has experienced in completing each item.
  • Summative scores are generated for each domain, scores range from 0-100.
  • An extra question on stroke recovery asks that the client rate on a scale from 0-100 how much the client feels that he/she has recovered from his/her stroke.
  • Formula for scoring domains:
    Transformed Scale = [(Actual raw score - lowest possible raw score) / Possible raw score] * 100 (free scoring software available)
  • 3 items change polarity in the "emotion" domain: 3f, 3h, and 3i; when manually scoring items must be reverse-scored.
  • A proxy version is available if patients are unable to answer (Duncan et al., 2002).
  • SIS is designed for repeated administration to track changes over time (refer to manual).
  • SIS can be used in both in clinical and research applications (Refer to manual).
  • Factor analysis of the SIS 2.0 revealed that the 4 domains (strength, hand function, mobility, and ADL/IADL) could be summed together to create a physical dimension score (the SIS-16).
  • The SIS-16 consists of 16 items capturing daily activities.
  • For each item, the individual is asked to rate the level of difficulty of the item in the past 2 weeks using the following scale:
    1 = could not do it at all
    2 = very difficult
    3 = somewhat difficult
    4 = a little difficult
    5 = not difficult at all

Number of Items

59

Equipment Required

  • Score sheet
  • Computer scoring requires Microsoft Access
  • find it free at the instruments website

Time to Administer

15-20 minutes

Required Training

Reading an Article/Manual

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS and Jennifer Moore, PT, DHS, NCS and the Rehabilitation Measures Team; Updated by Jane Sullivan, PT, DHS and the Stroke EDGE taskforce of the Neurology Section of the APTA; Updated by Jill Smiley, MPH and the Rehabilitation Measures Team in June 2013.

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living
Cognition
Emotion
General Health
Motor

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:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

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)

StrokEDGE

NR

HR

HR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

NR

UR

HR

HR

HR

 

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)

StrokEDGE

Yes

Yes

Yes

Not reported

Considerations

  • The respondent must be able to follow a 3-step command
  • The author recommends that patients score at least 16 on the Mini-Mental Exam 
  • The SIS can be mail administered, completed by proxy, completed by proxy by mailed administration, or be administered by telephone
  • Proxies (if used) are more likely to rate a patient as impaired (Duncan et al, 2002)
  • The SIS should be used with caution in individuals with mild impairment as the items in the communication, memory, and emotion domains are considered easy and only capture liitation in most impaired individuals
  • Would be appropriate in these settings provided the client has spent time living in the community since stroke diagnosis as many items relate to living at home
  • Alternately, the tool could be used and a percentage score calculated omitting "home-based" items

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

Stroke

back to Populations

Standard Error of Measurement (SEM)

Stroke: 

(Lin et al, 2010; n = 74; mean age = 54.1 (11.4); mean time post-stroke = 17.5 (17.7) months, Chronic Stroke)

  • Strength = 8.7
  • ADL/IADL = 6.3
  • Mobility = 5.5
  • Hand function = 9.4

Minimal Detectable Change (MDC)

Stroke: 

Minimal Detectable Change (Lin et al, 2010, Chronic Stroke)

  • Strength = 24.0
  • ADL/IADL = 17.3
  • Mobility = 15.1
  • Hand function = 25.9

Minimally Clinically Important Difference (MCID)

Stroke: 

Clinically Important Differences (Lin et al, 2010, Chronic Stroke)

  • Strength = 9.2
  • ADL/IADL = 5.9
  • Mobility = 4.5
  • Hand function = 17.8

Normative Data

Stroke:

(Duncan et al, 2002; n = 287; mean age = 72.6 (10.0) years; < 28 days post-stroke; SIS Version 3.0, Acute Stroke)

 

SIS Domain

Mean (SD)

Strength

61.9 (22.0)

Memory 

77.8 (19.1)

Emotion

74.3 (18.1)

Communication

81.0 (19.1)

ADL/IADL

66.5 (23.2)

Mobility

60.2 (23.1)

Hand function

55.9 (34.5)

Social participation

58.9 (25.7)

SIS-16 physical

67.5 (21.2)

 

 

(Huang et al, 2010; n = 58; mean age = 56.42 (11.67) years; 17.85 months post stroke, range 7-88, Chronic Stroke)

 

SIS Domain

Mean (SD)

Strength

40.73 (20.05)

Memory 

81.54 (19.17)

Emotion

59.63 (17.25)

Communication

89.71 (16.87)

ADL/IADL

67.41 (20.10)

Mobility

79.25 (18.08)

Hand function

29.63 (25.39

Social participation

47.92 (25.13)

SIS-16 physical

61.98 (12.27)

Test/Retest Reliability

Stroke: 

(Duncan et al, 1999; n = 33 minor severity; n = 58 moderate severity; mean age minor severity = 69.3 (10.1); mean age moderate severity 71.9 (10.1); enrolled < 14 days post-stroke, Acute Stroke)

SIS version 2.0 (current version = 3.0) at 1, 3 and 6 months post-stroke:

  • Adequate to Excellent test-retest reliability ICC = 0.70 to 0.92 (except for the emotion domain, ICC = 0.57)

 

(Edwards and O'connell, 2003; n = 74 individuals who suffered from a stroke; mean age = 58.35(14.80) years; mean time since stroke = 56.8 months; Anglo-Saxon Australian sample, Chronic Stroke)

  • Adequate to Excellent  test-retest reliability in all domains except for the emotion domain
  • Poor test-retest reliability in the emotion domain

Interrater/Intrarater Reliability

Stroke:

(Carod-Artal et al, 2009; n = 180 proxy-stroke patient pairs; mean age = 57.9 (13.5) years; Gender = 100 males and 80 females; mean time since stroke = 20.3 (23.6) months, Chronic Stroke)

  • Excellent interrater reliability for hand function (ICC = 0.82) and mobility (ICC = 0.80) domains
  • Adequate interrater reliability for strength (ICC = 0.61), ADL/IADL (ICC = 0.74), and memory and thinking (ICC = 0.43) domains
  • Poor interrater reliability for communication (ICC = 0.39), emotion (ICC = 0.17), and social participation (ICC = 0.29) domains

Internal Consistency

Stroke:

(Duncan et al, 1999; SIS version 2.0, Acute Stroke)

  • Excellent: Cronbach's alpha ranged from 0.83 to 0.90 across the 8 domains

 

(Carod-Artal et al, 2009, Chronic Stroke)

  • Excellent internal consistency for 7 of the domains:
    • Strength (ICC = 0.82)
    • Hand function (ICC = 0.95)
    • Mobility (ICC = 0.94)
    • ADL/IADL (ICC = 0.87)
    • Memory (ICC = 0.92)
    • Communcation (ICC = 0.84)
    • Social participation (ICC = 0.85)
  • Adequate interrater reliability for emotion domain (ICC = 0.49)

Criterion Validity (Predictive/Concurrent)

Stroke:

(Duncan et al, 2002, Acute Stroke)

Measures Assessed

Patient r

Proxy r

Folstein MMSE and SIS memory

0.42

0.37

Barthel Index and SIS ADL/IADL

0.72*

0.78*

Barthel Index and SIS mobility

0.69

 0.7*

Lawton IADL and SIS ADL/IADL

0.77*

0.78*

Motricity and SIS strength

0.67

0.69

*indicates excellent correlation

 

 

 

Predictive Validity (Kwon et al, 2006, Acute Stroke)

  • Excellent correlation between FIM-motor correlation and SIS-ADL (r = 0.86*)

  • Excellent  correlation between SF-36V (Physical Component) and SIS-PHYSICAL (r = 0.77*)

*SIS at 12 weeks; FIM and SF-36v at 16 weeks

(Duncan et al, 1999; SIS version 2.0, Acute Stroke)

SIS Domain

Comparative Measure

Correlation

Rating

Hand function

FMA-Upper Extremity Motor

r = 0.81

Excellent

Mobility

FIM Motor

= 0.83

Excellent

 

Barthel Index

= 0.82

Excellent

 

Duke Mobility Scale

= 0.83

Excellent

 

SF-36 Physical Functioning

= 0.84

Excellent

Strength

NIHSS Motor

= -0.59

Adequate

 

FMA Total

= 0.72

Excellent

ADL/IADL

Barthel Index

= 0.84

Excellent

 

FIM Motor

= 0.84

Excellent

 

Lawton IADL

= 0.82

Excellent

Memory

MMSE

= 0.58

Adequate

Communication

FIM Social/Cognition

= 0.53

Adequate

 

NIHSS Language

= -0.44

Adequate

Emotion

Geriatric Depression Scale

= -0.77

Excellent

 

SF-36 Mental Health

= 0.74

Excellent

Participation

SF-36 Emotional Role

= 0.28

Poor

 

SF-36 Physical Role

= 0.45

Adequate

 

SF-36 Social Functioning

= 0.70

Excellent

Physical

Barthel Index

= 0.76

Excellent

 

FIM Motor

= 0.79

Excellent

 

SF-36 Physical Functioning

= 0.75

Excellent

 

Lawton IADL

= 0.73

Excellent

 

(Lin, Fu, et al, 2010, Chronic Stroke)

  • Adequate to Excellent criterion validity for the hand function subscale (rho = 0.51-0.68; p < 0.01)

 

(Huang et al, 2010; n = 58 patients with chronic stroke who were treated with CIT for 2 hours daily for 3 weeks, Chronic Stroke)

  • The initial FIM score predicted the overall and ADL/IADL subscale scores

Construct Validity

Stroke: 

Convergent validity (Doyle et al, 2007, Chronic Stroke)

  • Excellent correlation between Burden of Stroke Scale (BOSS) and SIS total scores (r = -0.83)

 

(Duncan et al, 1999, Acute Stroke)

  • Most domains of the SIS can differentiate between patients with varying degrees of stroke severity

 

(Carod-Artal et al, 2009, Chronic Stroke)

  • Correlation between proxy ratings and stroke functional measures tended to be slightly lower than for patient-based self assessment
  • Correlations were observed between functional status and the following SIS proxy-version domains:
    • Mobilty (r = -0.73) Excellent
    • ADL/IADL (r = -0.69) Excellent 
    • Strength (= -0.44) Adequate
    • Hand function (= -0.44) Adequate
  • Correlations were observed between the Barthel Index and the following SIS proxy-domains:
    • Mobility (= 0.80) Excellent
    • ADL/IADL (= 0.74) Excellent
    • Strength (= 0.52) Adequate
    • Hand function (= 0.52) Adequate
  • Poor correlation between the HADS-Depression subscale and the SIS emotion domain were observed (= -0.20)

Content Validity

Development of the SIS was based on a study at the Landon Center on Aging, University of Kansas Medical Center (Duncan, Wallace, Studenski, Lai, & Johnson, 2001) using feedback from individual interviews with patients and focus group interviews with patients, caregivers, and health care professionals

Floor/Ceiling Effects

Acute Stroke: (Duncan et al, 1999; SIS version 2.0)

% of sample who encountered Floor or Ceiling effects

 

 

 

 

 

 

 Minor Stroke (n = 96)

 

 

Moderate Stroke (n = 144)

 

SIS

%Floor

%Ceiling

%Floor

%Ceiling

Strength

0

13.5

1.4

2.1

Hand Function

2

14.6

40.2

4.9

Mobility

0

6

0.6

2.1

ADL/IADL

0

2.1

2.8

1.4

Memory

0

12.5

0.6

10.4

Communication

0

35.4

1.4

25.7

Emotion

0

4.1

0

4.2

Participation

0

15.6

3.5

1.49

Physical

0

1

0.6

0

Barthel

0

64.6

0

24.8

Responsiveness

Stroke:

(Duncan et al, 1999; SIS version 2.0, Acute Stroke) 

For minor and moderate strokes the SIS is sensitive to change from 1 to 3 and 1 to 6 months post-stroke.  However the SIS is not sensitive between 3 to 6 months for minor stroke, but does demonstrate sensitivity for this period with moderate stroke patients.

 

(Lin, Fu, et al, 2010, Chronic Stroke)

  • The hand function subscale showed medium responsiveness (SRM = 0.52; Wilcoxon Z = 4.24; p < 0.05)
  • Responsiveness of the SIS total score was significantly larger than that of the Stroke Specific Quality of Life Scale total (SRM difference = 0.36; 95% CI, 0.02-0.71)

Bibliography

Carod-Artal, F. J., Coral, L. F., et al. (2008). "The stroke impact scale 3.0: evaluation of acceptability, reliability, and validity of the Brazilian version." Stroke 39(9): 2477-2484. Find it on PubMed

Carod-Artal, F. J., Coral, L. F., et al. (2009). "Self-and proxy-report agreement on the stroke impact scale." Stroke 40(10): 3308-3314.  

Doyle, P. J., McNeil, M. R., et al. (2007). "The Burden of Stroke Scale (BOSS) provided valid, reliable, and responsive score estimates of functioning and well-being during the first year of recovery from stroke." Qual Life Res 16(8): 1389-1398. Find it on PubMed

Duncan, P. W., Bode, R. K., et al. (2003). "Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale." Arch Phys Med Rehabil 84(7): 950-963. Find it on PubMed

Duncan, P. W., Lai, S. M., et al. (2002). "Evaluation of proxy responses to the Stroke Impact Scale." Stroke 33(11): 2593-2599. Find it on PubMed

Duncan, P. W., Wallace, D., et al. (1999). "The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change." Stroke 30(10): 2131-2140. Find it on PubMed

Edwards, B. and O'Connell, B. (2003). "Internal consistency and validity of the Stroke Impact Scale 2.0 (SIS 2.0) and SIS-16 in an Australian sample." Qual Life Res 12(8): 1127-1135. Find it on PubMed

Huang, Y. H., Wu, C. Y., et al. (2010). "Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke." Neurorehabil Neural Repair 24(6): 559-566. Find it on PubMed

Lin, K. C., Fu, T., et al. (2010). "Psychometric comparisons of the Stroke Impact Scale 3.0 and Stroke-Specific Quality of Life Scale." Qual Life Res 19(3): 435-443. Find it on PubMed

Lin, K. C., Fu, T., et al. (2010). "Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients." Neurorehabil Neural Repair 24(5): 486-492. Find it on PubMed

Stewart, A. L. and Ware, J. E. (1992). Measuring functioning and well-being: the medical outcomes study approach, Duke University Press Books.

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