Validation of the Reintegration to Normal Living Index for Community-Dwelling Persons With Chronic Spinal Cord Injury

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ORIGINAL ARTICLE

Validation of the Reintegration to Normal Living Index for Community-Dwelling Persons With Chronic Spinal Cord Injury Sander L. Hitzig, PhD, E. Manolo Romero Escobar, MA, Luc Noreau, PhD, B. Catharine Craven, MD, FRCPC, MSc ABSTRACT. Hitzig SL, Romero Escobar EM, Noreau L, Craven BC. Validation of the Reintegration to Normal Living Index for community-dwelling persons with chronic spinal cord injury. Arch Phys Med Rehabil 2012;93:108-14. Objective: To determine the validity (construct, concurrent) of the Reintegration to Normal Living (RNL) Index for measurement of community participation in adults with chronic spinal cord injury (SCI). Design: Cross-sectional telephone survey. Setting: Rehabilitation institute. Participants: Community-dwelling adult men and women (N⫽617) with SCI who were at least 1 year postinjury. Interventions: Not applicable. Main Outcome Measures: RNL Index and Satisfaction With Life Scale (SWLS). Results: Reliability of the RNL Index was determined by using Cronbach ␣, and construct validity was established through confirmatory factor analysis (CFA). In addition, general linear models to predict RNL Index scores were conducted to establish concurrent validity. The RNL Index is a reliable measure of community participation (␣⫽.87). CFA analyses suggested that the RNL Index loads onto a 2-factor solution and is distinct from the SWLS. Significant predictors of RNL Index score included years post-injury, impairment, ambulatory status, employment, and poor health, which yielded R2⫽.26 (P⬍.001). Conclusions: The RNL Index is a valid and reliable measure of community participation for persons with chronic SCI of traumatic cause. Key Words: Community participation; Factor analysis; Quality of life; Psychometrics; Rehabilitation; Spinal cord injuries. © 2012 by the American Congress of Rehabilitation Medicine

ERSONS WITH SPINAL cord injury (SCI) are faced with P a number of challenges to participation (involvement in life situations). Identified barriers include the occurrence of sec1

ondary health conditions and declining health,2-5 reduced employment opportunities,6-8 limited social support and family role functioning,9 limited access to recreational and leisure activities,10-12 and lack of accessible transportation.13,14 Conceptualizations of participation have evolved to include both a societal perspective (objective) and the individual’s perspective (subjective).15 The objective perspective is focused on the degree to which people with chronic health conditions are restricted from participation by comparing their activities and lifestyles with those of persons of a similar age, sex, and background from the general population.16,17 Conversely, the subjective perspective accounts for an individual’s life experiences and preferences to obtain better understanding of his/her particular needs and problems and further provides information unobtainable by using other measures focused on disease, activity, or functional ability.18 To date, most assessment tools used to assess participation in persons with SCI have done so from an objective standpoint, which includes the widely used Craig Handicap Assessment and Reporting Technique (CHART).19 The CHART evaluates 5 domains: physical independence, mobility, occupation, social integration, and economic self-sufficiency; and collects information about the degree to which the respondent fulfills the roles typically expected of people without disabilities. Although the CHART is a reliable and valid measure for persons with SCI,19,20 it is limited to assessment of the extent of an individual’s social network and does not assess the quality of that support.21 In addition, the CHART assesses the construct of handicap (loss or limitation of opportunities to take part in

List of Abbreviations

From the Lyndhurst Centre, Toronto Rehabilitation Institute, Toronto, Ontario (Hitzig, Craven); Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre, Toronto, Ontario (Hitzig); Department of Psychology, York University, Toronto, Ontario (Romero Escobar); Departments of Medicine (Craven) and Health Policy Management and Evaluation (Craven), University of Toronto, Toronto, Ontario (Craven); Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec (Noreau); and Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec, (Noreau) Canada. Supported by the Toronto Rehabilitation Institute, which receives funding under the Provincial Rehabilitation Research Program from the Ministry of Health and LongTerm Care in Ontario; and the Ontario Neurotrauma Foundation and Rick Hansen Institute (grant no. 2010-RHI-MTNI-836). The views expressed do not necessarily reflect those of the Ministry. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Sander L. Hitzig, PhD, Toronto Rehab–Lyndhurst Centre, 520 Sutherland Dr, Toronto, ON, M4G 3V9, Canada, e-mail: hitzig.sander@ torontorehab.on.ca. 0003-9993/12/9301-00555$36.00/0 doi:10.1016/j.apmr.2011.07.200

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CFA CFI CHART CIHI GLM IPA LIFE-H LiSAT-11 PARTS/M QOL RMSEA RNL SCI SWLS TLI WLSMV VAS YPI

confirmatory factor analysis comparative fit index Craig Handicap Assessment and Reporting Technique Canadian Institute for Health Information general linear model Impact on Participation and Autonomy Assessment of Life Habits Life Satisfaction-11 Participation Survey/Mobility quality of life root mean square error of approximation Reintegration to Normal Living spinal cord injury Satisfaction With Life Scale Tucker Lewis Index weighted least squares for means and variances visual analog scale years postinjury

SCI REINTEGRATION TO NORMAL LIVING, VALIDATION, Hitzig

the life of the community on an equal level with others),22 and not participation per se.15 Although growing in number, few measures are available to assess participation after SCI from the subjective or personcentered viewpoint. Some measures that assess the subjective perspective include the Impact on Participation and Autonomy (IPA) Questionnaire,17 Assessment of Life Habits (LIFE-H),23 and Participation Survey/Mobility (PARTS/M).24 Unfortunately, LIFE-H and PARTS/M have not been widely adopted in research settings or clinical practice, largely because of their administrative burden, and the IPA has not been used widely within the SCI community. At this time, there is no routinely accepted outcome tool for measuring participation in persons with SCI from the subjective perspective. Hence, the development of conceptually and psychometrically valid measures of participation for routine use in the SCI population remains a priority.15 One promising participation measure from a subjective standpoint that is brief, has a low administrative burden, and has the potential for routine use in the clinical setting is the Reintegration to Normal Living (RNL) Index.25 The RNL Index covers such areas as involvement in recreational and social activities, perceived ability to move within their communities, and the degree of comfort people have with their roles in the family and other relationships. The RNL Index has been shown to be a valid and reliable tool for assessing participation in persons with stroke and cancer, proxies, and patients from acute-care and rehabilitation settings.25 Principal factor analysis showed that the RNL Index had 2 factors: (1) Daily Activities, including activities of daily living, mobility, and participation in work; and (2) Perceptions of Self, which encompassed comfort with relationships and coping skills. Subsequent analyses of the RNL Index have yielded similar results.26,27 Preliminary use of the tool in the community-dwelling chronic SCI population3,28,29 showed that the tool is sensitive to factors that influence participation after SCI, but there are no psychometric data supporting its use with chronic SCI. Hence, the objective of this study was to determine the construct and concurrent validity of the RNL Index for measurement of participation in community-dwelling persons with chronic traumatic SCI. METHODS Participants All participants (N⫽618) were former patients of Toronto Rehab’s Lyndhurst Centre, a tertiary SCI rehabilitation center in Ontario, Canada. A total of 2839 potentially eligible participants were identified from a Long-term Follow-up (LTF) database; 564 had died, 146 declined participation, and 1302 could not be located. Two hundred twenty-four participants with SCI of a nontraumatic cause and other mobility impairments from peripheral nerve, immunologic, or progressive diseases were excluded. Outcome Measures A.T. Jousse Long-Term Follow-Up questionnaire. The A.T. Jousse Long-Term Follow-Up questionnaire is a nonstandardized survey of (1) sociodemographics and impairment, (2) health status and secondary health conditions, and (3) mobility aids. Sociodemographics and impairment. Variables of interest were age at interview, sex, marital status, employment, and highest level of education achieved. Data were obtained re-

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garding date of injury, level of injury, and completeness (motor and sensory complete or incomplete). In addition, mobility aids used at home and in the community were recorded. Health and secondary health conditions. Participants were asked to rate their global health on a 10-point numeric scale used to assess health status, with 1 being poor and 10 being excellent. The presence of experienced secondary health conditions in the past year also was recorded. Satisfaction with life scale. The Satisfaction With Life Scale (SWLS) is a 5-item scale that assesses people’s satisfaction with their life as a whole.30 Items include (1) in most ways my life is close to my ideal, (2) the conditions of my life are excellent, (3) I am satisfied with my life, (4) so far I have gotten the important things I want in life, and (5) if I could live my life over, I would change almost nothing. Higher scores on the SWLS reflect more life satisfaction. The SWLS can be administered over the telephone, had test-retest reliability of .82 during a 2-month interval, and had internal consistency reliability of .87.30 The SWLS also is a widely used measure in the SCI population31 that was shown to be valid and reliable.32 RNL index. The RNL Index is an 11-item measure of community reintegration that covers such areas as participation in recreational and social activities, movement within the community, and degree of comfort the individual has in his/her role in the family and with other relationships.25 The RNL Index has 3 alternate scoring systems: (1) visual analog scale (VAS), (2) 3-point scoring system, and (3) 4-point scoring system. Higher scores represent higher levels of participation. We used the 3-point scoring system, in which each item is rated by using a 3-point scale (0 ⫽ does not describe my situation, 1 ⫽ partially describes my situation, 2 ⫽ fully describes my situation), which has been validated for collection over the telephone.33 Procedure After obtaining informed consent, participants were interviewed over the telephone by using the A.T. Jousse Long-Term Follow-Up questionnaire, RNL Index, and SWLS. Each interview lasted approximately 15 minutes. Randomly selected questionnaires were reviewed to assess reliability and consistency of the data by cross-referencing injury characteristics with health records. Missing data points regarding impairment were completed by means of chart abstraction. This study was approved by the Research Ethics Board of Toronto Rehab, and we certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed. Analysis Descriptive statistics (mean ⫾ SD) were calculated for total number of secondary health conditions, perceived health, and scores on the RNL Index and SWLS. In addition, Cronbach ␣ was calculated to determine the reliability (internal consistency) of the RNL Index. Factor structure is one of the basic forms to establish construct validity (the degree to which a scale possesses differing amounts of an underlying construct). Because a specific factor structure has been specified for the RNL Index,25 this 2-factor solution was compared with a 1-factor solution by using confirmatory factor analysis (CFA). The 1-factor solution served as a null model to compare the appropriateness of the bidimensionality of the scale. Items of the scale were declared as categorical indicators and model parameters were estimated by using weighted least squares for means and variances (WLSMV).34 CFA using Arch Phys Med Rehabil Vol 93, January 2012

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WLSMV was conducted in Mplus, version 5.1a which uses the matrix of polychoric correlations among items and precludes the assumption that items for the scales are normally distributed. Multiple fit indexes were used to determine the appropriateness of each model.35 Although chi-square is reported, it is a problematic fit index because it is sensitive to sample size and violations of normality.36 Hence, model fit was based on the following criteria: (1) root mean square error of approximation (RMSEA) values are less than .08 for a reasonable fit (⬃.05 for a close fit), (2) comparative fit index (CFI) values are .95 or greater, and (3) Tucker Lewis Index (TLI) values are .90 or greater.35,37-39 With regard to concurrent validity (correlation between the test and variables taken as representative of the construct), a generalized linear model (GLM) approach using a Poisson distribution to model the sum score of the RNL Index was selected to test the relationships of the scale with impairment (tetraplegia vs paraplegia, complete vs incomplete), years postinjury (YPI), self-perceived health, total number of secondary health conditions, vocational status (working [employed/student/volunteer] vs not working [unemployed/retired]), and ambulatory status (ambulatory vs nonambulatory). Ambulatory status was generated by reviewing the types of mobility aids participants used in the community and at home. These variables were selected given the evidence that poorer participation is associated with impairment,3 declines in functional and health status that arise over many years of living with SCI,21 accessibility issues,10-14 and unemployment.7,8 GLM parameter estimates were estimated by using the GLM function part of the stats package on Rb for both the total scale and the 2 subscales of the RNL Index. Poisson distribution GLM is more appropriate to fit linear models of sum scores, which are mainly counts of responses to items in which the assumption of normality of the dependent variable (in this case, the RNL Index) is not expected to be met. Using this type of GLM also allows potential floor and ceiling effects to be disregarded. Given that the distribution of sum scores of the full scale and subscales presented negative skewness, sum scores were reversed to fit the assumptions of the GLM by using Poisson distribution. Thus, lower scores on the RNL Index represent higher levels of participation. Finally, a second CFA was conducted on each item of the respective RNL Index subscales (mobility, social factors) and the SWLS to further establish the construct validity of the RNL Index. The SWLS was selected because the data collected primarily were for an ongoing cohort study designed to obtain a depiction of health status and quality of life (QOL) in persons aging with SCI (see Tonack et al3 for details). Regardless, Wood-Dauphinée et al25 used the Spitzer QOL Index40 in their validation study, which, like the SWLS, is a global measure of well-being. However, unlike the Spitzer QOL Index, the SWLS has been validated for use in the SCI population.32 In addition, the construct of participation was found to be an important component and contributor to QOL after SCI.41 Hence, it was anticipated that CFA analysis would highlight that the RNL Index and SWLS measure related yet distinct constructs of QOL. RESULTS Table 1 lists demographic, impairment, health, and QOL characteristics of the final sample of 618 participants. The RNL Index yielded Cronbach ␣ of .87. Item-total correlations were .37 to .67. Table 2 lists response frequencies to each item of the RNL Index, as well as standardized factor loadings obtained by using 2 competing CFA models. The 2-factor model (physical Arch Phys Med Rehabil Vol 93, January 2012

Table 1: Demographic and Impairment Characteristics Variable

Sex Men Women Impairment Incomplete tetraplegia Complete tetraplegia Incomplete paraplegia Complete paraplegia Mean age (y) Mean YPI Ambulatory status Nonambulatory Ambulatory Marital status Married/common law Single/divorced/separated/widowed Education ⱖPostsecondary ⬍Postsecondary Vocational status Working (full-/part-time/student/etc) Not working (unemployed/retired) Mean RNL Index score Mean SWLS score Mean perceived health score Mean no. of secondary health conditions

Value

501 (81.1) 117 (18.9) 203 (32.8) 102 (16.5) 156 (25.2) 157 (25.4) 49.2 (18–92) 16.3 (1–60) 438 (70.9) 180 (29.1) 314 (50.8) 304 (49.2) 275 (44.5) 343 (55.5) 421 (68.1) 197 (31.9) 17.2⫾4.4 21.4⫾7.4 6.9⫾1.9 5.8⫾2.8

NOTE. N⫽618. Values expressed as n (%), mean (range), or mean ⫾ SD.

and social) had better fit to the data, indicated by lower RMSEA and higher CFI and TLI values. To further evaluate the construct validity of the RNL Index compared with the SWLS, a 3 factor CFA model was fit to the combined items of both scales. A 1-factor CFA of items of both scales yielded poor fit (RMSEA⫽.173, CFI⫽.822, TLI⫽.908). The 3-factor model (fig 1) was an appropriate fit (RMSEA⫽ .067, CFI⫽.963; TLI⫽.986). Interfactor correlations showed a stronger relationship between the scores of the 2 factors of the RNL Index than between each factor and the SWLS. Hence, the 3-factor CFA supports our hypothesis that the SWLS and RNL Index assess distinct, although related, constructs. Three Poisson GLMs were estimated for each of the 2 factors (physical, social) of the RNL Index and total RNL Index score. Table 3 lists likelihood ratio significance test results for all predictors and pseudo-R2 for each model. Likelihood ratio significant tests can be seen as equivalent to the sum of squares in the common analysis of variance model and are used for both significance testing and effect size estimation. Pseudo-R2 represents the percentage of deviance (equivalent to variance) on a Poisson model. For the total score, all predictors were significant and all were in the expected direction. RNL Index scores increased with YPI and higher perceived health and decreased as the number of secondary health conditions increased. Being less impaired, ambulatory, and employed also predicted higher scores on the RNL Index. This suggests that the RNL Index has good concurrent validity. The same results were replicated for the Physical factor, whereas ambulatory status and impairment were not found to be significant predictors of the social factor.

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SCI REINTEGRATION TO NORMAL LIVING, VALIDATION, Hitzig Table 2: Response Frequencies of the RNL Index: Factor Loadings for the 1- and 2-Factor CFA Models Response Frequencies

1 Factor

RNL Index Items

0*

1†

2‡

RNL

Physical

I move around my living quarters as I feel necessary. I move around my community as I feel necessary. I am able to take trips out of town as I feel are necessary. I am comfortable with how my self-care needs are met. I spend most of my days occupied in a work activity that is necessary or important to me. 6. I am able to participate in recreational activities as I want to. 7. I participate in social activities with family, friends, and/or business acquaintances as is necessary or desirable to me. 8. I assume a role in my family that meets my needs and those of other family members. 9. In general I am comfortable with my personal relationships 10. In general I am comfortable with myself when I am in the company of others. 11. I feel that I can deal with life events as they happen. ␹2 (P⬍.0001) RMSEA CFI TLI

11 57 128 32 124

70 181 109 144 144

532 375 377 439 347

.637 .648 .705 .568 .632

.651 .659 .716 .576 .642

165 58

193 152

257 405

.581 .797

.591 .813

69

137

406

.753

.767

40 31

108 121

466 463

.746 .719

18 NA

106 NA

490 NA

.739 ␹232⫽137.68 .073 .945 .965

1. 2. 3. 4. 5.

2 Factors Social

.816 .778 .805 ␹232⫽97.40 .058 .966 .979

NOTE. All factor loadings, P⬍.001. *Indicates “Does not describe my situation.” † Indicates “Partially describes my situation.” ‡ Indicates “Fully describes my situation.”

RNLI1 RNLI2 RNLI3 RNLI4 RNLI5 RNLI6 RNLI7 RNLI8 RNLI9 RNLI10 RNLI11 SWLS1 Fig 1. CFA (CFIⴝ.977; TLIⴝ.988; RMSEAⴝ.051) of subscales of the RNL Index (RNLI) and SWLS. Double-headed arrows represent interfactor correlations (estimates shown). One-headed arrows represent loadings (estimates shown) from latent factors to respective scale items. All loadings and interfactor correlations, P<.001.

SWLS2 SWLS3 SWLS4 SWLS5

0.648 0.658 0.713 0.582 0.677 0.564 0.781 0.792

RNL Physical 0.826

0.838 0.774 0.785 0.793 0.850 0.885 0.751 0.538

0.640

RNL Social 0.675 SWLS

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SCI REINTEGRATION TO NORMAL LIVING, VALIDATION, Hitzig Table 3: Concurrent Validity of the RNL Index Poisson Regression Analysis of Deviance LR ␹2 Tests Physical Factor Effects

YPIs Perceived health No. of health conditions Ambulatory Employment Complete/incomplete Tetraplegia/paraplegia Pseudo R2

LR ␹

Social Factor

Pseudo-␩ * (%)

2

2

df

␹21⫽32.26† ␹21⫽100.66† ␹21⫽35.61† ␹21⫽20.24† ␹21⫽117.99† ␹21⫽4.47§ ␹21⫽12.19†

5.1 14.2 5.6 3.2 16.3 0.7 2.0 .254

LR ␹

2

Total Scale

Pseudo ␩ * (%) 2

df

␹21⫽31.42† ␹21⫽30.46† ␹21⫽36.69† ␹21⫽0.18 ␹21⫽8.27‡| ␹21⫽0.74 ␹21⫽0.83

4.9 4.8 5.7 0.0 1.3 0.1 0.1 .154

LR ␹

2 df

Pseudo ␩2* (%)

␹21⫽55.44† ␹21⫽130.32† ␹21⫽63.77† ␹21⫽17.56† ␹21⫽123.01† ␹21⫽5.29§ ␹21⫽12.46†

8.4 17.7 9.5 2.8 16.9 0.9 2.0 .262

NOTE. Dependent variable: RNL Index. Abbreviations: LR, likelihood ratio; pseudo-␩2, pseudo partial ␩2. *Residual sum of squares⫽605. † P⬍.001; ‡P⬍.01; §P⬍.05.

DISCUSSION The RNL Index appears to be a valid measure for community-dwelling persons with traumatic SCI. Similar to WoodDauphinée et al,25 our analysis showed that the RNL Index had high internal consistency and the scale correlated, but was distinct, with a measure of subjective well-being. In addition, regression analyses showed that the RNL Index is sensitive to factors that may affect participation for persons with SCI (ie, YPI, impairment, vocational, and ambulatory status; poor health). This is consistent with reports in the SCI literature that mobility and health issues are significant barriers to participation,4,6,42 Although our finding that increased YPIs predicted higher scores on the RNL Index may seem counterintuitive given that community participation potentially could decrease along with functional declines associated with aging with SCI,21 several studies found that restrictions on participation tended to occur earlier postinjury and then increase.14,43 As such, several factors (eg, finance, social network) likely influence one’s ability to participate in the community.18 Overall, our results were consistent with previous reports,25-27 which suggests that the RNL Index has good internal consistency and validity (construct/concurrent). Similar to previous findings,25,27 the CFA analysis used in the present study yielded a 2-factor structure for the RNL Index. For example, the validation study of the RNL Index by Stark et al27 assessed the tool with community-dwelling persons with mobility impairments, which included persons with acute SCI (23% of their sample), and identified a social (encompassing personal friendship, socialization, dealing with life events, social and recreational activities) and a physical factor (mobility in the home and community, ability to take trips, self-care, productive work activities). Findings from the GLM support that different factors are more influential on specific RNL Index items than others (eg, impairment and mobility are not predictors of the social factor). These outcomes support previous findings by Daverat et al,28 who used the RNL Index in a group of persons with chronic SCI dwelling in the community. In their study, they reported that impairment had no relationship to RNL Index score and items related to mobility correlated more strongly with measures of physical functioning (ie, the FIM44). Conversely, a measure of depression correlated more strongly with RNL Index items related to social aspects. Hence, physical limitations incurred from an SCI may not necessarily negatively affect an individual’s participation in social life if they have a strong sense of self and a network of social supports. Arch Phys Med Rehabil Vol 93, January 2012

However, slight differences exist across studies assessing the validity of the RNL Index,25-27 which likely have resulted from the use of various scoring systems. For example, Daneski et al26 modified the RNL Index for postal use with patients with stroke by adapting the scoring system to an agree/disagree format. Although they found the RNL Index to be reliable, internally consistent, and valid, they noted that the response format may be less sensitive and responsive to change than the original VAS. Similarly, use of the 3-point scale also may be less sensitive to change. However, the 3-point scale for the RNL Index has been adopted by the Canadian Institute for Health Information (CIHI), which is an independent not-forprofit organization that provides essential data and analysis of Canada’s health system and the health of Canadians.45 The CIHI is using the National Rehabilitation Reporting System, a national health information system for adult inpatient rehabilitation services. As such, use of the 3-point scale is a national standard that will allow for comparisons of outcomes across diverse patient populations. Overall, our findings highlight that further work is needed to assess the psychometric properties of the RNL Index, but the 3-point scale appears appropriate for routine use in persons with SCI. Study Limitations There are several potential method limitations that may have influenced our conclusions, including potential selection and reporting biases. Our data consist of self-reported impairment and secondary health condition occurrence. There also is the potential bias of using an existing cohort, and we may have inadvertently excluded persons who were too ill to participate or lost to follow-up. Finally, no comprehensive measure of participation (eg, LIFE-H) or life satisfaction was used to help establish the construct validity of the RNL Index. Future evaluations of the RNL Index may be improved if the Life Satisfaction-11 (LiSAT-11)46 is used as a comparator because it provides items that are domain specific and somewhat similar to items of the RNL Index. For example, the LiSAT-11 includes items related to satisfaction with physical and mental health, leisure and vocational activities, self-care, and friends and family. Use of the LiSAT-11 would help establish the discriminant validity of the RNL Index from the construct of life satisfaction because the term comfortable used in some RNL Index items is ambiguous and could be equated with the construct of satisfaction. In addition, the LiSAT-11 was found to be a valid and reliable measure for SCI and is endorsed widely by the SCI community.31,47 Regardless, our use of the

SCI REINTEGRATION TO NORMAL LIVING, VALIDATION, Hitzig

SWLS and variables taken to be representative and/or required of community participation provide a solid basis for exploring the construct validity of the RNL Index for the chronic traumatic SCI population. CONCLUSIONS Although there are a number of available measures (see Noonan et al48 for a review of existing participation measures), there is a strong need to develop conceptually and psychometrically valid measures of participation for the SCI population. More importantly, efforts to develop tools that can contribute to our understanding of the interplay between objective and subjective indicators of participation are a priority for the SCI community15 because participation is a key outcome in SCI rehabilitation.49 The RNL Index was not designed specifically for the purpose of measuring person-perceived participation, but it at least partially addresses this construct18 and is brief enough to complement established objective measures of participation after SCI, such as the CHART. Based on our results, the RNL Index is an appropriate measure for persons with SCI that can provide an understanding of participation that takes into account the individual’s perceived ability to have an active role in the community. The low respondent burden, ease of scoring, and clinimetric properties reported here make the RNL Index attractive for future use in both clinical and research settings. References 1. World Health Organization. International Classification of Functioning, Disability & Health (ICF). Geneva: World Health Organization; 2001. 2. Savic G, Short D, Weitzenkamp D, Charlifue S, Gardner B. Hospital readmission in people with chronic spinal cord injury. Spinal Cord 2000;38:371-7. 3. Tonack M, Hitzig SL, Craven BC, Boschen KA, McGillivray CF. Predicting life satisfaction after spinal cord injury in a Canadian sample. Spinal Cord 2008;46:380-5. 4. Rintala DH, Loubser PG, Castro J, Hart KA, Fuhrer MJ. Chronic pain in a community-based sample of men with spinal cord injury: prevalence, severity, and relationship with impairment, disability, handicap, and subjective well-being. Arch Phys Med Rehabil 1998:79;604-14. 5. Vogel LC, Krajci KA, Anderson CJ. Adults with pediatric-onset spinal cord injuries: part 3: impact of medical complications. J Spinal Cord Med 2002;25:297-305. 6. Anderson CJ, Vogel LC. Employment outcomes of adults who sustained spinal cord injuries as children or adolescents. Arch Phys Med Rehabil 2002;83:791-801. 7. Kennedy P, Lude P, Taylor N. Quality of life, social participation, appraisals and coping post spinal cord injury: a review of four community samples. Spinal Cord 2006;44:95-105. 8. Carpenter C, Forwell SJ, Jongbloed LE, Backman CL. Community participation after spinal cord injury. Arch Phys Med Rehabil 2007;88:427-33. 9. Noreau L, Fougeyrollas P. Long-term consequences of spinal cord injury on social participation: the occurrence of handicap situations. Disabil Rehabil 2000;38:498-503. 10. Kennedy P, Rogers BA. Reported quality of life of people with spinal cord injuries: a longitudinal analysis of the first 6 months post-discharge. Spinal Cord 2000;38:498-503. 11. Martin Ginis KA, Latimer AE, Arbour-Nicitopoulos KP, et al. Leisure time physical activity in a population-based sample of people with spinal cord injury: part I: demographic and injuryrelated correlates. Arch Phys Med Rehabil 2010;91:722-8. 12. Martin Ginis KA, Arbour-Nicitopoulos KP, Latimer AE, et al. Leisure time physical activity in a population-based sample of

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