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  2. Utrecht Scale for Evaluation of Rehabilitation-Participation

Utrecht Scale for Evaluation of Rehabilitation-Participation

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Purpose

This questionnaire is about the patient’s daily life and consists of four parts: (1A) how much time you spend working, studying and attending to household duties, (1B) how often you undertake certain activities, (2) whether you experience any limitations in your daily life and (3) how satisfied you are with your daily life.

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Instrument Details

Acronym USER-Participation

Area of Assessment

Patient Satisfaction
Functional Mobility
Occupational Performance
Life Participation
Quality of Life
General Health
Social Relationships

Assessment Type

Patient Reported Outcomes

Cost

Free

Actual Cost

$0.00

Populations

Stroke
Spinal Injuries
Non-Specific Patient Population
Mixed Populations

Key Descriptions

  • 31 items
  • 3 scales (Frequency, Restrictions, Satisfaction)

Number of Items

31 items in 3 scales

Equipment Required

  • Paper and pen/pencil

Time to Administer

25-35 minutes minutes

Required Training

No Training

Instrument Reviewers

Instrument reviewed by MaryEllen Targonski, Emily Vosburg, John Justyn, Natalie McNerney, Mikela Nylander-French, Mohammed Chehata. Duke University in 2019.

Updated by Zayd Hayani in 2020.

ICF Domain

Body Function
Activity
Participation

Measurement Domain

Emotion
General Health

Considerations

Make sure to explain to the patient that this questionnaire is about normal daily life, and holidays and special occasions should not be taken into account.

Spinal Injuries

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Normative Data

Spinal Cord Injury: (Mader et al, 2016, n=1,549; mean age=52.4(14.8); time post injury in years=16.9 (12.7); Severity: 41.7% complete SCI, 57.7% incomplete SCI)

  •  Score distributions of USER-Participation

 

n

Mean (SD)

Median (IQR)

Frequency

1,474

34.2 (12.2)

34.3 (26.1-42.5)

Restrictions

1,491

70.0 (21.7)

72.7 (54.5-87.9)

Satisfaction

1,459

69.3 (18.0)

72.5 (58.3-80.6)

 

Spinal Cord Injury: (van der Zee et al, 2014; n=157; mean age=50.6 ±10.5; time post injury in years=25.3 ±26.8; Severity: 69.4% complete SCI, 30.6% incomplete SCI)

  • Score distributions of USER-Participation

 

n

Mean (SD)

Median (IQR)

Frequency

157

34.8 (10.0)

36.1 (29.1-41.4)

Restrictions

157

72.6 (19.3)

75.8 (60.3-87.9)

Satisfaction

156

69.9 (14.3)

72.2 (60.0-79.5)

Internal Consistency

Normative Sample: (Mader et al, 2016, n=1,549; mean age=52.4(14.8); time post injury in years=16.9 (12.7); Severity: 41.7% complete SCI, 57.7% incomplete SCI)

  • Excellent: Restrictions and Satisfaction scale (Cronbach’s alpha=0.9)
  • Poor: Frequency scale (Cronbach’s alpha=0.65)

 

Normative Sample: ( van der Zee et al, 2014; n=157; mean age=50.6 ±10.5; time post injury in years=25.3 ±26.8; Severity: 69.4% complete SCI, 30.6% incomplete SCI)

  • Excellent: Restrictions scale (Cronbach’s alpha=0.89)
  • Adequate: Satisfaction scale (Cronbach’s alpha=0.78)
  • Poor: Frequency scale (Cronbach’s alpha=.51)

 

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

Spinal Cord Injury: ( van der Zee et al, 2014; n=157; mean age=50.6 10.5; time post injury in years=25.3±26.8; Severity: 69.4% complete SCI, 30.6% incomplete SCI)

 

  • Concurrent validity between the three scales was demonstrated with a Spearman correlation coefficient below 0.60 for all 3 scales
    • 0.39 between frequency and restriction scales
    • 0.40 between frequency and satisfaction scales
    • 0.46 between restriction and satisfaction scales

Construct Validity

Discriminant Validity:

Spinal Cord Injury:  (van der Zee et al, 2014; n=157; mean age=50.6 10.5; time post injury in years=25.3 ±26.8; Severity: 69.4% complete SCI, 30.6% incomplete SCI)

 

  • Significant (P<0.05) discriminant validity between paraplegia and tetraplegia was shown for all 3 scales using Mann-Whitney U Test scores (z):
    • Frequency: z=-2.29
    • Restrictions: z=-3.17
    • Satisfaction: z=-1.99

Content Validity

The content validity of the USER-Participation may be affected by excluding domains related to work-related participation. “The anchor method was applied to appropriately account for items within the USER-Participation Restrictions and Satisfaction scales that are not applicable to some of the participants” (Mader et al, 2016).

Floor/Ceiling Effects

Spinal Cord Injury:    (Mader et al, 2016, n=1,549; mean age=52.4(14.8); time post injury in years=16.9 (12.7); Severity: 41.7% complete SCI, 57.7% incomplete SCI)

 

  • Excellent: Floor effects ranging from 0.0-0.3%
  • Excellent: No ceiling effect for Frequency scale (0.0%)
  • Adequate: Ceiling effect for Satisfaction (3.0%) and Restriction (9.5%) scales

Spinal Cord Injury:  (van der Zee et al, 2014; n=157; mean age=50.6 10.5; time post injury in years=25.3 ±26.8; Severity: 69.4% complete SCI, 30.6% incomplete SCI)

  • Excellent: No floor of ceiling effects for any scales

Stroke

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Test/Retest Reliability

Stroke: (Groeneveld, 2019; n=373, Mean age= 58.85 (12.3), Mean time between stroke and start of rehabilitation= 31 days (16))

  • Satisfactory test-retest reliability (ICC=. 65-.85)

 

Internal Consistency

Stroke:  (Groeneveld, 2019; n=373, Mean age= 58.85 (12.3), Mean time between stroke and start of rehabilitation= 31 days (16))

  • Satisfactory internal consistency (Cronbach’s alphas .7-.91)

Non-Specific Patient Population

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Internal Consistency

Rehabilitation Outpatients: (Post MWMet al., 2012; n = 395, Dutch sample)
  • Satisfactory: Cronbach's alpha range from 0.70–0.91

Construct Validity

Convergent Validity:

Rehabilitation Outpatients: (Post MWMet al., 2012; n = 395, mean age = 52.8(SD =13.5 years), Dutch Sample)

  USER-P Frequency USER-P Restrictions USER-P Satisfaction
Frenchay Activities Index (FAI) 0.59 0.51 0.42

ICF Measure of Participation and Activities Screener (IMPACT-SP)

 0.48 0.75 0.64
Participation Scale −0.40 −0.71 −0.73

 

 

Discriminant Validity:

Rehabilitation Outpatients: (Post MWMet al., 2012; n = 395, mean age = 52.8(SD =13.5 years), Dutch Sample)

USER-Participation scores differed between participants with different functional ability and between participants with different health conditions 

Frequency Restrictions Satisfaction
Diagnosis
Musculoskeletal (n = 69) 27.5 73.3 69.4
Brain injury (n = 138) 26.3 80.9 72.2
Neurological (n = 87) 28.7 66.7 66.7
Heart condition (n = 39) 32.5 100 80.6
Chronic pain (n = 58) 28.7 71.9 64.8
Kruskal–Wallis Chi-square 8.91 57.62 22.72
p value 0.063 < 0.001 < 0.001
Physical independence
Low (≤ 65) (n = 198) 26.3 70 63.9
High (66–70) (n = 191) 31.3 88.2 77.8
Mann–Whitney Z −6.34 −10.63 −7.27
p value < 0.001 < 0.001 < 0.001
Cognitive independence
Low (≤ 48) (n = 205) 25 71.8 63,9
High (49–50) (n = 184) 30 83.3 77.8
Mann–Whitney Z −3.74 −4.35 −6.58
p value < 0.001 < 0.001 < 0.001

Floor/Ceiling Effects

Rehabilitation Outpatients: (Post MWMet al., 2012; n = 395, mean age = 52.8(SD =13.5 years), Dutch Sample)

  • No  floor  effects were found and  only  the Restrictions scale showed a ceiling effect of 19.0.

 

Mixed Populations

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Normative Data

Brain Injury or Neuromuscular Disease

 

t1

t2

t3

 
 

n

Mean (SD)

Skewness

n

Mean (SD)

Skewness

n

Mean (SD)

Skewness

USER-Participation (0 – 100):

                  

 Frequency

47

32.0 (10.6)

0.119

47

31.3 (9.3)

–0.390

37

31.3 (10.0)

–0.215

 Restrictions

47

65.9 (20.8)

–0.328

45

69.5 (22.4)

–0.343

36

71.3 (19.6)

–0.762

 Satisfaction

45

61.1 (16.5)

–0.287

47

66.5 (18.8)

–0.110

37

67.2 (19.6)

–0.045

van der Zee, 2013; nT1=47, nT3 = 37; mean ageT1 = 53.0(12.9), mean ageT3= 53.4(14.0); time post injury not reported

Internal Consistency

Brain Injury or Neuromuscular Disease van der Zee, 2013; nT1=47, nT3 = 37; mean ageT1 = 53.0(12.9), mean ageT3= 53.4(14.0); time post injury not reported

  • Satisfactory internal consistency: 0.65 for the Frequency scale to 0.85 for the Restriction scale

Criterion Validity (Predictive/Concurrent)

Brain Injury or Neuromuscular Disease

van der Zee, 2013; nT1=47, nT3 = 37; mean ageT1 = 53.0(12.9), mean ageT3= 53.4(14.0); time post injury not reported

  • Good concurrent validity was demonstrated by Spearman’s correlation coefficient (r = 0.59 to 0.75).

Concurrent validity between the IPA and the USER-Participation at t2 (Pearson's r).

 

    IPA
    Autonomy indoors Family role Autonomy outdoors Social life & relationships Work & education
USER-Participation Frequency –0.43** –0.62** –0.50** –0.34* –0.43*
Restrictions –0.56** –0.71** –0.65** –0.40** –0.45*
Satisfaction –0.64** –0.71** –0.81** –0.78** –0.68**

Floor/Ceiling Effects

Brain Injury or Neuromuscular Disease

van der Zee, 2013; nT1=47, nT3 = 37; mean ageT1 = 53.0(12.9), mean ageT3= 53.4(14.0); time post injury not reported

Floor and ceiling effects were considered present if 15% or more of respondents scored respectively the worst possible or best possible score on a scale.

  • Small ceiling effect: The USER-Participation Restriction scale showed a ceiling effect at t2 (15.5%)

Responsiveness

Brain Injury or Neuromuscular Disease

van der Zee, 2013; nT1=47, nT3 = 37; mean ageT1 = 53.0(12.9), mean ageT3= 53.4(14.0); time post injury not reported

Moderately responsive with the standardized response mean ranging from 0.2 for the Frequency scale to 0.5 for the Restriction scale

Responsiveness of the USER-Participation scales between t1 and t2 and between t1 and t3.

 

t1–t2

t1–t3

 
 

n

Mean difference (SD)

ES

SRM

n

Mean difference (SD)

ES

SRM

 Frequency

47

–0.7 (10.5)

–0.07

–0.07

37

–2.4 (11.4)

–0.23

–0.21

 Restrictions

45

3.8 (17.6)

0.18

0.21

36

5.4 (17.2)

0.27

0.31

 Satisfaction

45

5.7 (17.5)*

0.34

0.32

36

4.0 (17.0)

0.26

0.24

Bibliography

Mader L, Post MWM, Ballert CS, Michel G, Stucki G, Brinkhof MWG. Metric properties of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation) in persons with spinal cord injury living in Switzerland. J Rehabil Med. 2016;48(2):165-174. doi:10.2340/16501977-2010.

 

van der Zee CH, Post MW, Brinkhof MW, Wagenaar RC. Comparison of the Utrecht Scale for Evaluation of Rehabilitation-Participation With the ICF Measure of Participation and Activities Screener and the WHO Disability Assessment Schedule II in Persons With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation. 2014;95(1):87-93. doi:10.1016/j.apmr.2013.08.236.

 

Groeneveld IF, Goossens PH, van Meijeren-Pont W, et al. Value-Based Stroke Rehabilitation: Feasibility and Results of Patient-Reported Outcome Measures in the First Year After Stroke. Journal of Stroke and Cerebrovascular Diseases. 2019;28(2):499-512. doi:10.1016/j.jstrokecerebrovasdis.2018.10.033.

Post MWM, Zee CH van der, Hennink J, Schafrat CG, Visser-Meily JMA, Berlekom SB van. Validity of the Utrecht Scale for Evaluation of Rehabilitation-Participation. Disability and Rehabilitation. 2012;34(6):478-485. doi:10.3109/09638288.2011.608148.

van der Zee CH, Baars-Elsinga A, Visser-Meily JMA, Post MWM. Responsiveness of two participation measures in an outpatient rehabilitation setting. Scandinavian Journal of Occupational Therapy. 2013;20(3):201-208. doi:10.3109/11038128.2012.754491.

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