Journal of Rehabilitation Medicine 51-1CompleteIssue | Page 44

Disability in spinal cord injury
scales evaluate different items in the “activities and
participation” section of the ICF. While participation
is a crucial outcome of SCI rehabilitation (10, 23–25),
brief validated measures to evaluate participation are
needed.
As far as we know, there are no studies comparing
these 2 tools, the WHODAS 2.0 and the WHO mini-
mal generic set, in assessing functioning in patients
with SCI of different severities and injury levels. The
objective of this study was to compare the utility of
these 2 brief scales in assessing functioning in SCI.
PATIENTS AND METHODS
This observational cross-sectional study was conducted between
November 2015 and November 2017. The 12-item WHODAS
2.0 and personal background information (age, sex, accom-
modation, marital status, educational level, and working status)
questionnaires, along with informed consent and information
regarding the study were posted to 240 consecutively referred
patients with SCI (diagnosis according to the ICD-10 criteria)
and their significant others 2 weeks before their visit at a spe-
cialist outpatient clinic of a university hospital. The outpatient
clinic both evaluates patients with recent SCI and takes care of
patients with past SCI with ongoing problems and rehabilitative
needs. A total of 160 patients responded, of whom 18 were
excluded because they did not fulfil the inclusion criteria (age
under 18 years at the time of the SCI, a current major medical
or psychotic condition or another neurological diagnosis, and
inability to understand, co-operate, or complete the questionn-
aire or complete recovery without residual symptoms). Of the
142 participants, 85 had also responses from their significant
others; of whom 61 (72.6%) were spouses, 3 (3.6%) parents,
6 (7.1%) children, 3 (3.6%) siblings, 1 (1.2%) other relative, 3
(3.6%) close friends, and 7 (8.3%) trained caregivers.
Clinical information (date of diagnosis and comorbidities)
was gathered from the hospital records, and the total number
of comorbidities was counted (26, 27). The level and severity
(grade) of SCI was classified according to the American Spi-
nal Cord Injury Association (ASIA) (28). In this article, the
term tetraplegia is used to describe the change in motor and/or
sensory function when the injury is at the level of the cervical
segments. The term paraplegia is used when the lesion is more
caudal. A specialist in physical and rehabilitation medicine at the
outpatient clinic completed the 7-item WHO minimal generic
set aiming at assessing the level of functioning in a simple and
validated way (21).
The 12-item patient and proxy WHODAS 2.0 includes 12
items assessing 6 disability domains during the previous 30
days: cognition (learning and concentration), mobility (standing
and walking), self-care (washing and dressing oneself), getting
along (dealing with strangers and maintaining friendships), life
activities (doing housework and working ability), and participa-
tion (emotional functions and engaging in community). Each
of these 12 items is rated according to a 5-point Likert-type
scale, which grades the difficulty experienced by a participant
in performing a given activity. Each of the 12 items is scored
from 0 to 4, where 0 means no (0–4%), 1 means mild (5–24%),
2 means moderate (25–49%), 3 means severe (50–95%), and
4 means extreme or complete (96–100%) difficulty in this
specific activity. The total score of WHODAS is the sum of all
41
these 12 sub-scores, ranging from 0 to 48, with lower scores
indicating better functioning. Total scores of 1–4 indicate mild
disability, 5–9 moderate disability, and 10–48 severe disability
(14, 15, 22, 29, 30).
The WHO minimal generic set consists of 7 ICF domains:
energy and drive functions, emotional functions, sensation of
pain, carrying out daily routine, walking, moving around, and
remunerative employment. Generic means that this assessment
scale is applicable to all people despite their health conditions.
Minimal means that the scale consists of the least number of
domains of functioning that can be used to explain significant
differences between people with health issues. The scoring
system is similar to WHODAS, the sum score ranging from
0 to 28, with lower scores indicating better functioning (21).
Statistical analysis
The comparison between the 4 patient groups according to se-
verity and level (tetraplegia AIS A–B and C–D and paraplegia
AIS A–B and C–D) was carried out within categorical variables
using χ 2 test, or, in the case of small cell frequencies, Fisher’s
exact test. In numerical variables the comparisons between the
4 patient groups was carried out either by 1-way analysis of
variance (ANOVA), or by the non-parametric Kruskal–Wallis
test if the distribution of an outcome variable was too skewed.
The Spearman’s correlation coefficient was used to test the
correlation between variables. Patient and proxy WHODAS
responses were analysed pairwise; the patients with only 1 va-
lue were excluded. The correlations of 0–0.30 were considered
weak, 0.31–0.50 moderate, 0.51–0.70 strong, and greater than
0.70 very strong. No adjustment for multiple comparisons was
done, since in this exploratory study the search for patterns is
more important than formal statistical significance. In order to
reach enough statistical power we set a minimum target number
of patients to 140. Statistical analyses were performed using
SAS 9.4 for Windows. p-values below 0.05 (2-tailed) were
considered statistically significant.
RESULTS
Demographic and clinical background data for all
142 participants are shown in Table I. To compare
background data in different levels and severity groups
of SCI, participants were divided into 4 groups: (i)
complete tetraplegia AIS A–B (n = 13), (ii) partial te-
traplegia AIS C–D (n = 58), (iii) complete paraplegia
AIS A–B (n = 23), and (iv) partial paraplegia AIS C–D
(n = 48).
When disability was rated by a physician (Table
II), disabilities were severe in all patient groups, and
patients with a complete tetraplegia were rated the
most disabled. In all groups, energy and emotional
functions were rated mildly impaired, pain moderately,
daily activities at least moderately, and employment
severely impaired. The total disability (sum score of
the generic set) and 4 of the 7 separate functions were
more impaired in those with a complete motor plegia
(AIS A–B, n = 36) than in those with a partial plegia
(AIS C–D, n = 106). When those with a cervical lesion
J Rehabil Med 51, 2019