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1.  Influence of Sport Participation on Community Integration and Quality of Life: A Comparison Between Sport Participants and Non-Sport Participants With Spinal Cord Injury 
To determine whether community integration and/or quality of life (QoL) among people living with chronic spinal cord injury (SCI) are superior among sport participants vs non-sport participants.
Study Design:
Cross-sectional study.
Persons (n = 90) living in the community with SCI (ASIA Impairment Scale A–D), level C5 or below, > 15 years of age, ≥ 12 months postinjury, and requiring a wheelchair for > 1 hours/day were divided into 2 groups based on their self-reported sport participation at interview: sport participants (n = 45) and non-sport participants (n = 45).
Independent-sample t tests revealed that both Community Integration Questionnaire (CIQ) and Reintegration to Normal Living Index (RNL) total mean scores were higher among sport participants vs non-sport participants (P < 0.05). Significant correlation between CIQ and RNL total scores was found for all participants (Pearson correlation coefficients, P < 0.01). Logistic regression analysis revealed that the unadjusted odds ratio of a high CIQ mean score was 4.75 (95% CI 1.7, 13.5) among current sport participants. Similarly, the unadjusted odds ratio of a high RNL score was 7.00 (95% CI 2.3, 21.0) among current sport participants. Regression-adjusted odds ratios of high CIQ and high RNL scores were 1.36 (95% CI 0.09, 1.45) and 0.15 (95% CI 0.04, 0.55), respectively. The odds ratio for pre-SCI sport participation predicting post-SCI sport participation was 3.06 (95% CI 1.23, 7.65).
CIQ and QoL scores were higher among sport participants compared to non-sport participants. There was an association between mean CIQ and RNL scores for both groups. Sport participants were 4.75 and 7.00 times as likely to have high CIQ and QoL scores. Both groups had a similar likelihood of high CIQ and RNL scores after adjusting for important confounders. Individuals who participated in sports prior to SCI were more likely to participate in sports post-SCI.
PMCID: PMC2678282  PMID: 19569458
Spinal cord injuries; Tetraplegia; Paraplegia; Disability; Sport participation; Wheelchair sports; Community reintegration; Quality of life
2.  Spinal cord injury and quality of life: a systematic review of outcome measures 
Study design: Systematic review.
Study rationale: According to current estimates, there are more than 1 million people living with a spinal cord injury (SCI) in the United States alone. Given the potentially devastating impact of SCI on health-related quality of life (QoL), we sought to gain an improved understanding of QoL outcomes in SCI.
Objective: To identify and describe common QoL outcomes measures in patients with SCI.
Methods: A systematic review of the English-language literature was undertaken for articles published from 1998 through December 2010. Electronic databases and reference lists of key articles were searched to identify measures or indices used to evaluate QoL outcomes in patients with SCI. The titles and abstracts of the SCI peer-reviewed literature were searched to determine which of these outcome measures were most commonly used to evaluate QoL in patients with SCI.
Results: We identified 27 outcome measures used to evaluate QoL in patients with SCI. In SCI literature, the six most commonly used objective outcome measures were the Short-form 36 (SF-36); Craig Handicap Assessment and Reporting Technique (CHART); Short-form 12 (SF-12); Sickness Impact Profile (SIP68); Reintegration to Normal Living Index (RNL); and Community Integration Questionnaire (CIQ). The six subjective measures that were most frequently used were the Satisfaction with Life Scale (SWLS); Quality of Life Index (QLI); Life Satisfaction Questionnaire (LISAT-9/-1); World Health Organization Quality of Life-BREF scale (WHOQOL-BREF); Perceived Quality of Life (PQOL); and global QoL. All six objective measures have been validated in an SCI population, and four of the six subjective measures have been similarly validated. Three of each of the objective and subjective measures have been reliability tested in a population with SCI.
Conclusion: In addition to neurological and functional changes after SCI, QoL outcomes should be routinely assessed. Choice of appropriate QoL measure should be influenced by the study objectives and design, as well as the psychometric properties of the particular measure within the context of SCI.
PMCID: PMC3427971  PMID: 22956935
3.  Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M) 
Physiotherapy Canada  2011;63(2):199-208.
Purpose: To further investigate the construct validity of the Community Balance and Mobility Scale (CB&M), developed for ambulatory individuals with traumatic brain injury (TBI).
Methods: A convenience sample of 35 patients with TBI (13 in-patients, 22 outpatients) was recruited. Analyses included a comparison of CB&M and Berg Balance Scale (BBS) admission and change scores and associations between the CB&M and measures of postural sway, gait, and dynamic stability; the Community Integration Questionnaire (CIQ); and the Activities-specific Balance Confidence (ABC) Scale.
Results: Mean admission scores on the BBS and the CB&M were 53.6/56 (SD=4.3) and 57.8/96 (SD=23.3) respectively. Significant correlations were demonstrated between the CB&M and spatiotemporal measures of gait, including walking velocity, step length, step width, and step time; measures of dynamic stability, including variability in step length and step time; and the ABC (p<0.05). Significant correlations between the CB&M and CIQ were revealed with a larger data set (n=47 outpatients) combined from previous phases of research.
Conclusions: In patients with TBI, the CB&M is less susceptible to a ceiling effect than the BBS. The construct validity of the CB&M was supported, demonstrating associations with laboratory measures of dynamic stability, measures of community integration, and balance confidence.
PMCID: PMC3076901  PMID: 22379260
balance; brain injuries; posture; mobility limitations; outcome assessment; équilibre; évaluation des résultats; limites à la mobilité; posture; traumatisme crânien
4.  Post-traumatic stress, depression, and community integration a long time after whiplash injury 
Mental Illness  2010;2(1):e4.
Psychological factors such as post-traumatic stress and depression may play an important role in the recovery after whiplash injuries. Difficulties in psychosocial functioning with limitations in everyday life may dominate for some time after the injury. Our study therefore investigates the relationships between pain, post-traumatic stress, depression, and community integration. A set of questionnaires was answered by 191 persons (88 men, 103 women) five years after a whiplash injury to assess pain intensity (visual analogue scale, VAS), whiplash-related symptoms, post-traumatic stress (impact of event scale, IES), depression (Beck depression inventory, BDI-II), community integration (community integration questionnaire, CIQ), life satisfaction (LiSat-11). One or more depressive symptoms were reported by 74% of persons; 22% reported scores that were classified as mild to severe depression. The presence of at least one post-traumatic symptom was reported by 70% of persons, and 38% reported mild to severe stress. Total scores of community integration for women were statistically significantly higher than for men. The total VAS score was correlated positively to the IES (r=0.456, P<0.456), the BDI (r=0.646, P<0.001), and negatively to the CIQ (r=−0.300, P<0.001). These results highlight the view that a significant proportion of people experience both pain and psychological difficulties for a long time after a whiplash injury. These findings should be taken into consideration in the management of subjects with chronic whiplash symptoms and may support a multi-professional rehabilitation model that integrates physical, psychological, and psychosocial factors.
PMCID: PMC4253351  PMID: 25478087
whiplash injuries; depression; stress disorders; post-traumatic.
5.  Development of the Computer-Adaptive Version of the Late-Life Function and Disability Instrument 
Having psychometrically strong disability measures that minimize response burden is important in assessing of older adults.
Using the original 48 items from the Late-Life Function and Disability Instrument and newly developed items, a 158-item Activity Limitation and a 62-item Participation Restriction item pool were developed. The item pools were administered to a convenience sample of 520 community-dwelling adults 60 years or older. Confirmatory factor analysis and item response theory were employed to identify content structure, calibrate items, and build the computer-adaptive testings (CATs). We evaluated real-data simulations of 10-item CAT subscales. We collected data from 102 older adults to validate the 10-item CATs against the Veteran’s Short Form-36 and assessed test–retest reliability in a subsample of 57 subjects.
Confirmatory factor analysis revealed a bifactor structure, and multi-dimensional item response theory was used to calibrate an overall Activity Limitation Scale (141 items) and an overall Participation Restriction Scale (55 items). Fit statistics were acceptable (Activity Limitation: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.03; Participation Restriction: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.05). Correlation of 10-item CATs with full item banks were substantial (Activity Limitation: r = .90; Participation Restriction: r = .95). Test–retest reliability estimates were high (Activity Limitation: r = .85; Participation Restriction r = .80). Strength and pattern of correlations with Veteran’s Short Form-36 subscales were as hypothesized. Each CAT, on average, took 3.56 minutes to administer.
The Late-Life Function and Disability Instrument CATs demonstrated strong reliability, validity, accuracy, and precision. The Late-Life Function and Disability Instrument CAT can achieve psychometrically sound disability assessment in older persons while reducing respondent burden. Further research is needed to assess their ability to measure change in older adults.
PMCID: PMC3670156  PMID: 22546960
Function; Disability; Computer-adaptive testing; Activity; Participation
6.  Cross-sectional validation of the Aging Perceptions Questionnaire: a multidimensional instrument for assessing self-perceptions of aging 
BMC Geriatrics  2007;7:9.
Self-perceptions of aging have been implicated as independent predictors of functional disability and mortality in older adults. In spite of this, research on self-perceptions of aging is limited. One reason for this is the absence of adequate measures. Specifically, there is a need to develop a measure that is theoretically-derived, has good psychometric properties, and is multidimensional in nature. The present research seeks to address this need by adopting the Self-Regulation Model as a framework and using it to develop a comprehensive, multi-dimensional instrument for assessing self-perceptions of aging. This study describes the validation of this newly-developed instrument, the Aging Perceptions Questionnaire (APQ).
Participants were 2,033 randomly selected community-dwelling older (+65 yrs) Irish adults who completed the APQ alongside measures of physical and psychological health. The APQ assesses self-perceptions of aging along eight distinct domains or subscales; seven of these examine views about own aging, these are: timeline chronic, timeline cyclical, consequences positive, consequences negative, control positive, control negative, and emotional representations; the eighth domain is the identity domain and this examines the experience of health-related changes.
Mokken scale analysis showed that the majority of items within the views about aging subscales were strongly scalable. Confirmatory factor analysis also indicated that the model provided a good fit for the data. Overall, subscales had good internal reliabilities. Hierarchical linear regression was conducted to investigate the independent contribution of APQ subscales to physical and psychological health and in doing so determine the construct validity of the APQ. Results showed that self-perceptions of aging were independently related to physical and psychological health. Mediation testing also supported a role for self-perceptions of aging as partial mediators in the relationship between indices of physical functioning and physical and psychological health outcomes.
Findings support the complex and multifaceted nature of the aging experience. The good internal reliability and construct validity of the subscales suggests that the APQ is a promising instrument that can enable a theoretically informed, multidimensional assessment of self-perceptions of aging. The potential role of self-perceptions of aging in facilitating physical and psychological health in later life is also highlighted.
PMCID: PMC1868732  PMID: 17462094
7.  The validation of a new measure quantifying the social quality of life of ethnically diverse older women: two cross-sectional studies 
BMC Geriatrics  2011;11:60.
To our knowledge, the available psychometric literature does not include an instrument for the quantification of social quality of life among older women from diverse ethnic backgrounds. To address the need for a tool of this kind, we conducted two studies to assess the initial reliability and validity of a new instrument. The latter was created specifically to quantify the contribution of a) social networks and resources (e.g., family, friends, and community) as well as b) one's perceived power and respect within family and community to subjective well-being in non-clinical, ethnically diverse populations of older women.
In Study 1, we recruited a cross-sectional sample of primarily non-European-American older women (N = 220) at a variety of community locations. Participants were administered the following: a short screener for dementia; a demographic list; an initial pool of 50 items from which the final items of the new Older Women's Social Quality of Life Inventory (OWSQLI) were to be chosen (based on a statistical criterion to apply to the factor analysis findings); the Single Item Measure of Social Support (SIMSS); and the Medical Outcome Study 36-item Short-Form Health Survey (MOS SF-36). Study 2 was conducted on a second independent sample of ethnically diverse older women. The same recruitment strategies, procedures, and instruments as those of Study 1 were utilized in Study 2, whose sample was comprised of 241 older women with mostly non-European-American ethnic status.
In Study 1, exploratory factor analysis of the OWSQLI obtained robust findings: the total variance explained by one single factor with the final selection of 22 items was over 44%. The OWSQLI demonstrated strong internal consistency (α = .92, p < .001), adequate criterion validity with the SIMSS (r = .33; p < .01), and (as expected) moderate concurrent validity with the MOS SF-36 for both physical (r = .21; p < .01) and mental (r = .26; p < .01) quality of life. In order to confirm the validity of the 22-item OWSQLI scale that emerged from Study 1 analyses, we replicated those analyses in Study 2, although using confirmatory factor analysis. The total variance accounted for by one factor was about 42%, again quite high and indicative of a strong single-factor solution. Study 2 data analyses yielded the same strong reliability findings (i.e., α = .92, p < .001). The 22-item OWSQLI was correlated with the SIMSS (r = .27, p < .001) in the expected direction. Finally, correlations with the MOS SF- 36 demonstrated moderate concurrent validity for physical (r = .14; p < .01) and mental (r = .18; p < .01) quality of life, as expected.
The findings of these two studies highlight the potential for our new tool to provide a valid measure of older women's social quality of life, yet they require duplication in longitudinal research. Interested clinicians should consider using the OWSQLI in their assessment battery to identify older women's areas of lower versus higher social quality of life, and should establish the maximization of patients' social quality of life as an important therapeutic goal, as this variable is significantly related to both physical and mental health.
PMCID: PMC3221620  PMID: 21982161
8.  The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity 
BMC Public Health  2009;9:341.
The 12-item Short Form Health Survey (SF-12) as a shorter alternative of the SF-36 is largely used in health outcomes surveys. The aim of this study was to validate the SF-12 in Iran.
A random sample of the general population aged 15 years and over living in Tehran, Iran completed the SF-12. Reliability was estimated using internal consistency and validity was assessed using known groups comparison and convergent validity. In addition, the factor structure of the questionnaire was extracted by performing both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).
In all, 5587 individuals were studied (2721 male and 2866 female). The mean age and formal education of the respondents were 35.1 (SD = 15.4) and 10.2 (SD = 4.4) years respectively. The results showed satisfactory internal consistency for both summary measures, that are the Physical Component Summary (PCS) and the Mental Component Summary (MCS); Cronbach's α for PCS-12 and MCS-12 was 0.73 and 0.72, respectively. Known-groups comparison showed that the SF-12 discriminated well between men and women and those who differed in age and educational status (P < 0.001). In addition, correlations between the SF-12 scales and single items showed that the physical functioning, role physical, bodily pain and general health subscales correlated higher with the PCS-12 score, while the vitality, social functioning, role emotional and mental health subscales more correlated with the MCS-12 score lending support to its good convergent validity. Finally the principal component analysis indicated a two-factor structure (physical and mental health) that jointly accounted for 57.8% of the variance. The confirmatory factory analysis also indicated a good fit to the data for the two-latent structure (physical and mental health).
In general the findings suggest that the SF-12 is a reliable and valid measure of health related quality of life among Iranian population. However, further studies are needed to establish stronger psychometric properties for this alternative form of the SF-36 Health Survey in Iran.
PMCID: PMC2749829  PMID: 19758427
9.  Psychometric Evaluation of the Chinese Version of the Subjective Happiness Scale: Evidence from the Hong Kong FAMILY Cohort 
With China’s rapid economic growth in the past few decades, there is currently an emerging focus on happiness. Cross-cultural validity studies have indicated that the four-item Subjective Happiness Scale (SHS) has high internal consistency and stable reliability. However, the psychometric characteristics of the SHS in broader Chinese community samples are unknown.
We evaluated the factor structure and psychometric properties of the SHS in the Hong Kong general population.
The Chinese SHS was derived using forward–backward translation. Of the Cantonese-speaking participants aged ≥15 years, 2,635 were randomly selected from the random sample component of the FAMILY Cohort, a territory-wide cohort study in Hong Kong. In addition to the SHS, a single-item overall happiness scale, the Patient Health Questionnaire-9 (PHQ-9), the Family Adaptation, Partnership, Growth, Affection, Resolve (APGAR) scale, and the Medical Outcomes Study 12-item short-form version 2 (SF-12) mental and physical health scales were administered.
Exploratory and confirmatory factor analyses supported a single factor with high loadings for the four SHS items. Multiple group analyses indicated factor invariance across sex and age groups. Cronbach’s alpha was 0.82, and 2-week test–retest reliability (n = 191) was 0.70. The SHS correlated significantly with single-item overall happiness (Spearman’s rho [ρ] = 0.57), Family APGAR (ρ = 0.26), PHQ-9 (ρ = −0.34), and mental health-related quality of life (ρ = 0.40) but showed a lower correlation with physical health (ρ = 0.15). A regression model that included the PHQ-9 and Family APGAR scores explained 37 % of the variance in SF-12 mental health scores; adding the SHS raised the variance explained to 41 %.
Our results support the reliability and validity of the SHS as a relevant component in the measurement battery for mental well-being in a Chinese general population.
PMCID: PMC4107280  PMID: 24515396
Subjective Happiness Scale; Construct validity; Well-being; Family study; Public health; Chinese
10.  Item response theory-based measure of global disability in multiple sclerosis derived from the Performance Scales and related items 
BMC Neurology  2014;14(1):192.
The eight Performance Scales and three assimilated scales (PS) used in North American Research Committee on Multiple Sclerosis (NARCOMS) registry surveys cover a broad range of neurologic domains commonly affected by multiple sclerosis (mobility, hand function, vision, fatigue, cognition, bladder/bowel, sensory, spasticity, pain, depression, and tremor/coordination). Each scale consists of a single 6-to-7-point Likert item with response categories ranging from “normal” to “total disability”. Relatively little is known about the performances of the summary index of disability derived from these scales (the Performance Scales Sum or PSS). In this study, we demonstrate the value of a combination of classical and modern methods recently proposed by the Patient-Reported Outcome Measurement Information System (PROMIS) network to evaluate the psychometric properties of the PSS and derive an improved measure of global disability from the PS.
The study sample included 7,851adults with MS who completed a NARCOMS intake questionnaire between 2003 and 2011. Factor analysis, bifactor modeling, and item response theory (IRT) analysis were used to evaluate the dimension(s) of disability underlying the PS; calibrate the 11 scales; and generate three alternative summary scores of global disability corresponding to different model assumptions and practical priorities. The construct validity of the three scores was compared by examining the magnitude of their associations with participant’s background characteristics, including unemployment.
We derived structurally valid measures of global disability from the PS through the proposed methodology that were superior to the PSS. The measure most applicable to clinical practice gives similar weight to physical and mental disability. Overall reliability of the new measure is acceptable for individual comparisons (0.87). Higher scores of global disability were significantly associated with older age at assessment, longer disease duration, male gender, Native-American ethnicity, not receiving disease modifying therapy, unemployment, and higher scores on the Patient Determined Disease Steps (PDDS).
Promising, interpretable and easily-obtainable IRT scores of global disability were generated from the PS by using a sequence of traditional and modern psychometric methods based on PROMIS recommendations. Our analyses shed new light on the construct of global disability in MS.
Electronic supplementary material
The online version of this article (doi:10.1186/s12883-014-0192-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4195863  PMID: 25278315
Multiple sclerosis; Disability evaluation; Patient-reported outcome measure; North American Research Committee on Multiple Sclerosis (NARCOMS) registry; Factor analysis; Bifactor model; Item response theory
11.  Impact of Alzheimer’s Disease on Caregiver Questionnaire: internal consistency, convergent validity, and test-retest reliability of a new measure for assessing caregiver burden 
There is a lack of validated instruments to measure the level of burden of Alzheimer’s disease (AD) on caregivers. The Impact of Alzheimer’s Disease on Caregiver Questionnaire (IADCQ) is a 12-item instrument with a seven-day recall period that measures AD caregiver’s burden across emotional, physical, social, financial, sleep, and time aspects. Primary objectives of this study were to evaluate psychometric properties of IADCQ administered on the Web and to determine most appropriate scoring algorithm.
A national sample of 200 unpaid AD caregivers participated in this study by completing the Web-based version of IADCQ and Short Form-12 Health Survey Version 2 (SF-12v2™). The SF-12v2 was used to measure convergent validity of IADCQ scores and to provide an understanding of the overall health-related quality of life of sampled AD caregivers.
The IADCQ survey was also completed four weeks later by a randomly selected subgroup of 50 participants to assess test-retest reliability. Confirmatory factor analysis (CFA) was implemented to test the dimensionality of the IADCQ items. Classical item-level and scale-level psychometric analyses were conducted to estimate psychometric characteristics of the instrument. Test-retest reliability was performed to evaluate the instrument’s stability and consistency over time.
Virtually none (2%) of the respondents had either floor or ceiling effects, indicating the IADCQ covers an ideal range of burden. A single-factor model obtained appropriate goodness of fit and provided evidence that a simple sum score of the 12 items of IADCQ can be used to measure AD caregiver’s burden. Scales-level reliability was supported with a coefficient alpha of 0.93 and an intra-class correlation coefficient (for test-retest reliability) of 0.68 (95% CI: 0.50–0.80). Low-moderate negative correlations were observed between the IADCQ and scales of the SF-12v2.
The study findings suggest the IADCQ has appropriate psychometric characteristics as a unidimensional, Web-based measure of AD caregiver burden and is supported by strong model fit statistics from CFA, high degree of item-level reliability, good internal consistency, moderate test-retest reliability, and moderate convergent validity. Additional validation of the IADCQ is warranted to ensure invariance between the paper-based and Web-based administration and to determine an appropriate responder definition.
PMCID: PMC4265347  PMID: 25186634
Alzheimer’s disease; Caregivers; Burden; Psychometrics; Questionnaire
12.  Reliability and validity testing for the Child Oral Health Impact Profile-Reduced (COHIP-SF 19) 
This study assessed the reliability and validity of the Child Oral Health Impact Profile–Short Form 19 (COHIP-SF 19) from the validated 34-item COHIP.
Participants included 205 pediatric, 107 orthodontic, and 863 patients with craniofacial anomalies (CFAs). Item level evaluations included examining content overlap, distributional properties, and use of the response set. Confirmatory factor analysis identified potential items for deletion. Scale reliability was assessed with Cronbach's alpha. Discriminant validity of the COHIP-SF 19 was evaluated as follows: among pediatric participants, scores were compared with varying amounts of decayed and filled surfaces (DFS) and presence of caries on permanent teeth; for orthodontic patients, scores were correlated with anterior tooth spacing/crowding; and for those with CFA, scores were compared with clinicians’ ratings of extent of defect (EOD) for nose and lip and/or speech hypernasality. Convergent validity was assessed by examining the partial Spearman correlation between the COHIP scores and a standard Global Health self-rating. Comparisons between the COHIP and the COHIP-SF 19 were completed across samples.
The reduced questionnaire consists of 19 items: Oral Health (five items), Functional Well-Being (four items), and a combined subscale named Socio-Emotional Well-Being (10 items). Internal reliability is ≥0.82 for the three samples. Results demonstrate that the COHIP-SF 19 discriminates within and across treatment groups by EOD and within a community-based pediatric sample. The measure is associated with the Global Health rating (P < 0.05), thereby indicating convergent validity.
Reliability and validity testing demonstrate that the COHIP-SF 19 is a psychometrically sound instrument to measure oral health-related quality of life across school-aged pediatric populations.
PMCID: PMC3425735  PMID: 22536873
quality of life; pediatrics; global health rating; orthodontics; craniofacial; oral health-related quality of life
13.  Exploratory factor analysis of the Dizziness Handicap Inventory (German version) 
The Dizziness Handicap Inventory (DHI) is a validated, self-report questionnaire which is widely used as an outcome measure. Previous studies supported the multidimensionality of the DHI, but not the original subscale structure. The objectives of this survey were to explore the dimensions of the Dizziness Handicap Inventory - German version, and to investigate the associations of the retained factors with items assessing functional disability and the Hospital Anxiety and Depression Scale (HADS). Secondly we aimed to explore the retained factors according to the International Classification of Functioning, Disability and Health (ICF).
Patients were recruited from a tertiary centre for vertigo, dizziness or balance disorders. They filled in two questionnaires: (1) The DHI assesses precipitating physical factors associated with dizziness/unsteadiness and functional/emotional consequences of symptoms. (2) The HADS assesses non-somatic symptoms of anxiety and depression. In addition, patients answered the third question of the University of California Los Angeles-Dizziness Questionnaire which covers the impact of dizziness and unsteadiness on everyday activities. Principal component analysis (PCA) was performed to explore the dimensions of the DHI. Associations were estimated by Spearman correlation coefficients.
One hundred ninety-four patients with dizziness or unsteadiness associated with a vestibular disorder, mean age (standard deviation) of 50.6 (13.6) years, participated. Based on eigenvalues greater one respectively the scree plot we analysed diverse factor solutions. The 3-factor solution seems to be reliable, clinically relevant and can partly be explained with the ICF. It explains 49.2% of the variance. Factor 1 comprises the effect of dizziness and unsteadiness on emotion and participation, factor 2 informs about specific activities or effort provoking dizziness and unsteadiness, and factor 3 focuses on self-perceived walking ability in relation to contextual factors. The first factor correlates moderately with disability and the HADS (values ≥0.6). The second factor is comparable with the original physical subscale of the DHI and factors retained in previous studies.
The results of the present survey can not support the original subscale structure of the DHI. Therefore only the total scale should be used. We discuss a possible restructuring of the DHI.
PMCID: PMC2850321  PMID: 20230621
14.  The 14-item health literacy scale for Japanese adults (HLS-14) 
Most existing tools for measuring health literacy (HL) focus on reading comprehension and numeracy in English speakers. The aim of this study was to develop a generic HL measure for Japanese adults.
A questionnaire survey was conducted among participants in multiphasic health examinations at a Japanese healthcare facility. HL was measured using the 14-item health literacy scale (HLS-14) that was adapted from the HL scale specific to diabetic patients developed by Ishikawa and colleagues. The 14 items consist of five items for functional HL, five items for communicative HL, and four items for critical HL. The reliability and validity of the HLS-14 were assessed among 1,507 eligible respondents aged 30–69 years.
Explanatory factor analysis produced a three-factor solution that was very similar to the original HL scale. Cronbach’s alpha indicated satisfactory internal consistency of the functional, communicative, and critical HL scores (0.83, 0.85, and 0.76, respectively). There were no floor or ceiling effects in each HL score. Confirmatory factor analysis revealed an acceptable fit of the three-factor model (comparative fit index = 0.912, normed fit index = 0.905, root mean square error of approximation = 0.082). When the two groups with a total HL score above and below the median (50), respectively, were compared, those who could obtain medication information satisfactorily and those who wanted to participate in making medication decisions were more frequently observed in the group with the higher score.
The HLS-14 demonstrated adequate reliability and validity as a generic HL measure for Japanese adults. This scale can be utilized for measuring functional, communicative, and critical HL in the clinical and public health contexts.
PMCID: PMC3773092  PMID: 23689952
Health literacy; Adult; Japan; Questionnaire; Validity
15.  A comprehensive psychometric evaluation of the UK FIM + FAM 
Disability and Rehabilitation  2013;35(22):1885-1895.
To evaluate the psychometric properties of the UK FIM + FAM.
(a) A systematic literature review integrating the evidence for psychometric qualities of both the original and UK versions, and (b) exploratory and confirmatory factor analysis of admission/discharge data from an inpatient general neuro-rehabilitation cohort using parametric and non-parametric techniques. A prospective cohort of 459 patients with a male:female ratio of 57:43 and mean age of 44.5 (SD 14.3) years participated in this study.
Seven published articles together demonstrated acceptable utility, concurrent validity, inter-rater reliability and responsiveness of the UK FIM + FAM. Factor analysis demonstrated that all items loaded high (>0.58) on the first principal component and distinct motor and cognitive factors emerged after rotation. A four-factor solution also demonstrated four distinct, interpretable dimensions (Physical, Psychosocial, Communication and Extended Activities of Everyday Living (EADL)). Mokken analysis of the second data set confirmed these dimensions. Cronbach’s αs were 0.97 and 0.96 for the motor and cognitive domains and 0.90–0.97 for the subscales. Analysis of responsiveness demonstrated “large” effect sizes (0.86–1.29).
The UK FIM + FAM, including the newer EADL module, is a valid, reliable scale of functional independence. It has high internal consistency in two domains and four subscales and is responsive to changes occurring in a general inpatient neuro-rehabilitation population.
Implications for Rehabilitation
The UK FIM + FAM is a valid, reliable scale of functional independence, which is responsive to changes occurring in a general inpatient neuro-rehabilitation population.
Physical, Psychosocial, Communication It can be used to derive a reliable, single score of overall independence and also yields specific information in two main domains and four separate subscales of independence: Physical, Psychosocial, Communication and Extended Activities of Daily Living (EADL).
The newer EADL item module provides added value, measuring functional independence for community-based activities.
PMCID: PMC3812697  PMID: 23384240
Extended activities of daily living; factor analysis; Mokken analysis; neurological rehabilitation; psychometrics; UK FIM + FAM
16.  Development and preliminary validation of the 'Caring for Country' questionnaire: measurement of an Indigenous Australian health determinant 
'Caring for Country' is defined as Indigenous participation in interrelated activities with the objective of promoting ecological and human health. Ecological services on Indigenous-owned lands are belatedly attracting some institutional investment. However, the health outcomes associated with Indigenous participation in 'caring for country' activities have never been investigated. The aims of this study were to pilot and validate a questionnaire measuring caring for country as an Indigenous health determinant and to relate it to an external reference, obesity.
Purposively sampled participants were 301 Indigenous adults aged 15 to 54 years, recruited during a cross-sectional program of preventive health checks in a remote Australian community. Questionnaire validation was undertaken with psychometric tests of internal consistency, reliability, exploratory factor analysis and confirmatory one-factor congeneric modelling. Accurate item weightings were derived from the model and used to create a single weighted composite score for caring for country. Multiple linear regression modelling was used to test associations between the caring for country score and body mass index adjusting for socio-demographic factors and health behaviours.
The questionnaire demonstrated adequate internal consistency, test-retest validity and proxy-respondent validity. Exploratory factor analysis of the 'caring for country' items produced a single factor solution that was confirmed via one-factor congeneric modelling. A significant and substantial association between greater participation in caring for country activities and lower body mass index was demonstrated. Adjusting for socio-demographic factors and health behaviours, an inter-quartile range rise in caring for country scores was associated with 6.1 Kg and 5.3 Kg less body weight for non-pregnant women and men respectively.
This study indicates preliminary support for the validity of the caring for country concept and a questionnaire designed to measure it. This study also highlights the importance of investigating Indigenous-asserted health promotion activities. Further studies in similar populations are merited to test the generalisability of this questionnaire and to explore associations with other important Indigenous health outcomes.
PMCID: PMC2628914  PMID: 19094240
17.  Psychometric properties of the Centers for Disease Control and Prevention Health-Related Quality of Life (CDC HRQOL) items in adults with arthritis 
Measuring health-related quality of life (HRQOL) is important in arthritis and the SF-36v2 is the current state-of-the-art. It is only emerging how well the Centers for Disease Control and Prevention (CDC) HRQOL measures HRQOL for people with arthritis. This study's purpose is to assess the psychometric properties of the 9-item CDC HRQOL (4-item Healthy Days Core Module and 5-item Healthy Days Symptoms Module) in an arthritis sample using the SF-36v2 as a comparison.
In Fall 2002, a cross-sectional study acquired survey data including the CDC HRQOL and SF-36v2 from 2 North Carolina populations of adult patients reporting osteoarthritis, rheumatoid arthritis, and fibromyalgia; 2182 (52%) responded. The first item of both the CDC HRQOL and the SF-36v2 was general health (GEN). All 8 other CDC HRQOL items ask for the number of days in the past 30 days that respondents experienced various aspects of HRQOL. Exploratory principal components analyses (PCA) were conducted on each sample and the combined samples of the CDC HRQOL. The multitrait-multimethod matrix (MTMM) was used to compute correlations between each trait (physical health and mental health) and between each method of measurement (CDC HRQOL and SF36v2). The relative contribution of the CDC HRQOL in predicting the physical component summary (PCS) and the mental component summary (MCS) was determined by regressing the CDC HRQOL items on the PCS and MCS scales.
All 9 CDC HRQOL items loaded primarily onto 1 factor (explaining 57% of the item variance) representing a reasonable solution for capturing overall HRQOL. After rotation a 2 factor interpretation for the 9 items was clear, with 4 items capturing physical health (physical, activity, pain, and energy days) and 3 items capturing mental health (mental, depression, and anxiety days). All of the loadings for these two factors were greater than 0.70. The CDC HRQOL physical health factor correlated with PCS (r = -.78, p < 0.0001) and the mental health factor correlated with MCS (r = -.71, p < 0.0001). The relative contribution of the CDC HRQOL in predicting PCS was 73% (R2 = .73) when GEN was included in the CDC HRQOL score and 65% (R2 = .65) when GEN was removed. The relative contribution of the CDC HRQOL in predicting MCS was 56% (R2 = .56) when GEN was included and removed.
The CDC HRQOL appears to have strong psychometric properties in individuals with arthritis in both community-based and subspecialty clinical settings. The 9 item CDC HRQOL is a reasonable measure for overall HRQOL and the two subscales, representing physical and mental health, are reasonable when the goal is to examine those aspects.
PMCID: PMC1609101  PMID: 16995955
18.  Assessing an organizational culture instrument based on the Competing Values Framework: Exploratory and confirmatory factor analyses 
The Competing Values Framework (CVF) has been widely used in health services research to assess organizational culture as a predictor of quality improvement implementation, employee and patient satisfaction, and team functioning, among other outcomes. CVF instruments generally are presented as well-validated with reliable aggregated subscales. However, only one study in the health sector has been conducted for the express purpose of validation, and that study population was limited to hospital managers from a single geographic locale.
We used exploratory and confirmatory factor analyses to examine the underlying structure of data from a CVF instrument. We analyzed cross-sectional data from a work environment survey conducted in the Veterans Health Administration (VHA). The study population comprised all staff in non-supervisory positions. The survey included 14 items adapted from a popular CVF instrument, which measures organizational culture according to four subscales: hierarchical, entrepreneurial, team, and rational.
Data from 71,776 non-supervisory employees (approximate response rate 51%) from 168 VHA facilities were used in this analysis. Internal consistency of the subscales was moderate to strong (α = 0.68 to 0.85). However, the entrepreneurial, team, and rational subscales had higher correlations across subscales than within, indicating poor divergent properties. Exploratory factor analysis revealed two factors, comprising the ten items from the entrepreneurial, team, and rational subscales loading on the first factor, and two items from the hierarchical subscale loading on the second factor, along with one item from the rational subscale that cross-loaded on both factors. Results from confirmatory factor analysis suggested that the two-subscale solution provides a more parsimonious fit to the data as compared to the original four-subscale model.
This study suggests that there may be problems applying conventional CVF subscales to non-supervisors, and underscores the importance of assessing psychometric properties of instruments in each new context and population to which they are applied. It also further highlights the challenges management scholars face in assessing organizational culture in a reliable and comparable way. More research is needed to determine if the emergent two-subscale solution is a valid or meaningful alternative and whether these findings generalize beyond VHA.
PMCID: PMC1865551  PMID: 17459167
19.  Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers 
The aim of this study was to determine the validity of the Italian translation of the Tinnitus Handicap Inventory (THI) by Newman et al. in order to make this self-report measure of perceived tinnitus handicap available both for clinical and research purposes in our country and to contribute to its cross-cultural validation as a self-report measure of perceived severity of tinnitus. The Italian translation of the Tinnitus Handicap Inventory (THI) was administered to 100 outpatients suffering from chronic tinnitus, aged between 20 and 82 years, who attended the audiological tertiary centres of the University Hospital of Modena and the Regional Hospital of Treviso. No segregation of cases was made on audiometric results; patients suffering from vertigo and neurological diseases were excluded. Pyschoacoustic characteristics of tinnitus (loudness and pitch) were determined and all patients also completed the MOS 36-Item Short Form Health Survey to assess self-perceived quality of life and the Hospital Anxiety and Depression Scale as a measure of self-perceived levels of anxiety and depression. The THI-I showed a robust internal consistency reliability (Cronbach’s alpha = 0.91) that was only slightly lower than the original version (Tinnitus Handicap Inventory-US; Cronbach’s alpha = 0.93) and its Danish (Cronbach’s alpha = 0.93) and Portuguese (Cronbach’s alpha = 0.94) translations. Also its two subscales (Functional and Emotional) showed a good internal consistency reliability (Cronbach’s alpha = 0.85 and 0.86, respectively). On the other hand, the Catastrophic subscale showed an unacceptable internal consistency reliability as it is too short in length (5 items). A confirmatory factor analysis failed to demonstrate that the 3 subscales of the THI-I correspond to 3 different factors. Close correlations were found between the total score of the Italian translation of the Tinnitus Handicap Inventory and all the subscales of the MOS 36-Item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale scores indicating a good construct validity. Moreover, these statistically significant correlations (p < 0.005) confirmed that the self-report tinnitus handicap is largely related to psychological distress and a deterioration in the quality of life. On the other hand, it was confirmed that the tinnitus perceived handicap is totally independent (p > 0.05) from its audiometrically-derived measures of loudness and pitch thus supporting previous studies that focused on the importance of non-auditory factors, namely somatic attention, psychological distress and coping strategies, in the generation of tinnitus annoyance. Finally the results of the present study suggest that the THI-I maintains its original validity and should be incorporated, together with other adequate psychometric questionnaires, in the audiological examination of patients suffering from tinnitus and that psychiatric counselling should be recommended for the suspected co-morbidity between tinnitus annoyance and psychological distress.
PMCID: PMC2644986  PMID: 18646574
Tinnitus; Anxiety; Depression; Quality of life
20.  Modifications to the WHODAS-II for the World Mental Health Surveys: Implications of Filter Items 
Journal of Clinical Epidemiology  2008;61(11):1132-1143.
The WHODAS-II was substantially modified for use in the World Mental Health Surveys. This paper considers the modified WHODAS-II’s psychometric properties and implications of filter items employed to reduce respondent burden.
Study design and setting
Seventeen surveys in 16 countries administered a modified WHODAS-II to population samples (N=38,934 adults). Modifications included introducing filter questions for four sub-scales and substituting questions on the number of days activity was limited for the Life Activities domain. We evaluated distributional properties, reliability, and validity of the modified WHODAS-II.
Most respondents (77%–99%) had zero scores on filtered subscales. Lower bound estimates of internal consistency (alpha) for the filtered subscales were typically in the 0.70’s, but were higher for the Global scale. Loadings of subscale scores on a Global Disability factor were moderate-to-high. Correlations with the Sheehan Disability Scale were modest but consistently positive, while correlations with SF-12 Physical Component Summary were considerably higher. Cross-national variability in disability scores was observed, but was not readily explainable.
Internal consistency and validity of the modified WHODAS-II was generally supported, but use of filter questions impaired measurement properties. Group differences in modified WHODAS-II disability scores may be compared within, but not necessarily across, countries.
PMCID: PMC3277915  PMID: 18619808
Disability; Measurement; Reliability; Validity; Survey; Epidemiology
21.  Validity of the SF-12 for Use in a Low-Income African American Community-Based Research Initiative (REACH 2010) 
Preventing Chronic Disease  2008;5(2):A44.
The objective of our study was to assess the psychometric properties of the Medical Outcomes Study's 12-Item Short Form Survey Instrument (SF-12) for use in a low-income African American community. The SF-12, a commonly used functional health status assessment, was developed based on responses of an ethnically homogeneous sample of whites. Our assessment addressed the appropriateness of the instrument for establishing baseline indicators for mental and physical health status as part of Nashville, Tennessee's, Racial and Ethnic Approaches to Community Health (REACH) 2010 initiative, a community-based participatory research study.
A cross-sectional random residential sample of 1721 African Americans responded to a telephone survey that included the SF-12 survey items and other indicators of mental and physical health status. The SF-12 was assessed by examining item-level characteristics, estimates of scale reliability (internal consistency), and construct validity.
Construct validity assessed by the method of extreme groups determined that SF-12 summary scores varied for individuals who differed in self-reported medical conditions. Convergent and discriminate validity assessed by multitrait analysis yielded satisfactory coefficients. Concurrent validity was also shown to be satisfactory, assessed by correlating SF-12 summary scores with independent measures of physical and mental health status.
The SF-12 appears to be a valid measure for assessing health status of low-income African Americans.
PMCID: PMC2396981  PMID: 18341779
22.  The Health and Functioning ICF-60: Development and Psychometric Properties 
This paper describes the development and psychometric properties of the Health and Functioning ICF-60 (HF-ICF-60) measure, based on the World Health Organization (WHO) ‘International Classification of Functioning, Disability and Health: ICF’ (2001). The aims of the present study were to test psychometric properties of the HF-ICF-60, developed as a measure that would be responsive to change in functioning through changes in health and nutritional status, as a prospective measure to monitor health and nutritional status of populations and to explore the relationship of the HF-ICF-60 with quality of life measures such as the World Health Organization WHOQOL-BREF quality of life assessment in relation to non-communicable diseases.
The HF-ICF-60 measure consists of 60 items selected from the ICF by an expert panel, which included 18 items that cover Body Functions, 21 items that cover Activities and Participation, rated on five-point scales, and 21 items that cover Environmental Factors (seven items cover Individual Environmental Factors and 14 items cover Societal Environmental Factors), rated on nine-point scales. The HF-ICF-60 measure was administered to the Russian nationally representative sample within the Russian National Population Quality of Life, Health and Nutrition Survey, in 2004 (n = 9807) and 2005 (n = 9560), as part of the two waves of the Russian Longitudinal Monitoring Survey (RLMS). The statistical analyses were carried out with the use of both classical and modern psychometric methods, such as factor analysis, and based on Item Response Theory, respectively.
The HF-ICF-60 questionnaire is a new measure derived directly from the ICF and covers the ICF components as follows: Body Functions, Activities and Participation, and Environmental Factors (Individual Environmental Factors and Societal Environmental Factors). The results from the factor analyses (both Exploratory Factor Analyses and Confirmatory Factor Analyses) show good support for the proposed structure together with an overall higher-order factor for each scale of the measure. The measure has good reliability and validity, and sensitivity to change in the health and nutritional status of respondents over time. Normative values were developed for the Russian adult population.
The HF-ICF-60 has shown good psychometric properties in the two waves of the nationally representative RLMS, which provided considerable support to using the HF-ICF-60 data as the normative health and functioning values for the Russian population. Similarly, the administration of the WHOQOL-BREF in the same two waves of the nationally representative RLMS has allowed the normative quality of life values for the Russian population to be obtained. Therefore, the objective assessment of health and functioning of the HF-ICF-60 could be mapped onto the subjective evaluation of quality of life of the WHOQOL-BREF to increase the potential usefulness of the surveys in relation to non-communicable diseases. © 2014 The Authors. Clinical Psychology & Psychotherapy. Published by John Wiley & Sons, Ltd.
Key Practitioner Message
The HF-ICF-60 offers a new perspective in measuring change in functioning through changes in lifestyle and diet.
The HF-ICF-60 can be combined with the WHOQOL-BREF to map the objective assessment of health and functioning onto the subjective evaluation of quality of life.
Combined use of the HF-ICF-60 and the WHOQOL-BREF can be especially useful for national and global monitoring and surveillance of implementation of measures to reduce risk factors of non-communicable diseases and to promote healthy lifestyles and healthy diets.
PMCID: PMC4232882  PMID: 24931300
ICF; Health and Functioning; Nutrition; Quality of Life; Psychometrics; Population Surveys
23.  Quality of life of Chinese urban community residents: a psychometric study of the mainland Chinese version of the WHOQOL-BREF 
The short version of the World Health Organization's Quality of Life Instrument (WHOQOL-BREF) is widely validated and popularly used in assessing the subjective quality of life (QOL) of patients and the general public. We examined its psychometric properties in a large sample of community residents in mainland China.
The WHOQOL-BREF was administered to 1052 adult community residents in a major metropolitan city in southern China. The structural integrity of the 4-factor model in confirmatory factor analyses (CFA) and the relationship of QOL with demographic variables were examined. Validity was assessed using the known-group comparison (229 with vs. 823 without chronic illness), item-domain correlations, and CFA using the ML estimation in LISREL.
Internal consistency reliability of the whole instrument (26 items) was 0.89, and the psychological, social, and environment domains had acceptable reliability (alpha = 0.76, 0.72, 0.78 respectively), while that of the physical domain was slightly lower (α = 0.67). The respective mean scores of these domains were 13.69, 14.11, 12.33 and 14.56. Item-domain correlations were much higher for corresponding domains than for non-corresponding domains, indicating good convergent validity. CFA provided a marginally acceptable fit to the a priori four-factor model when two matching content item pairs were allowed to be correlated; χ2 (244) = 1836, RMSEA = 0.088, NNFI = 0.898, CFI = 0.909. This factorial structure was shown to be equivalent between the participants with and without chronic illness. The differences in means between these two groups were significant but small in some domains; effect size = 0.55, 0.15, 0.18 in the physical, psychological, and social relationship domains respectively. Furthermore, males had significantly higher QOL scores than females in the psychological domain, while individuals with a younger age, higher income, and higher education levels also had significantly higher QOL. Compared with the international data, the Chinese in this study had relatively low QOL scores with about 5% of males and 16% of females being at risk for poor QOL.
This study has provided psychometric properties of the WHOQOL-BREF as used in China and should definitely be useful for researchers who would like to use or further refine the instrument.
PMCID: PMC3364902  PMID: 22452994
24.  Psychometric Properties of Positive and Negative Affect Schedule (PANAS) Original and Short Forms in an African American Community Sample 
Journal of affective disorders  2013;151(3):942-949.
The Positive and Negative Affect Schedule (PANAS) has been widely used as a self-report measure of affect in community and clinical contexts. However, evaluations of the psychometric properties of PANAS scores have been limited in diverse ethnic groups. Several short forms of the PANAS have also been proposed, but very little is known about the psychometric properties of these versions.
The present study investigated the psychometric properties, including the factor structure of the original PANAS and two short forms in an African American community sample (N = 239). Descriptive, internal consistency reliability, factorial validity, and measurement invariance analyses were conducted.
All PANAS subscales from the original and short forms had adequate internal consistency. For the original PANAS, the model specifying three correlated factors (Positive Affect, Afraid, Upset) with correlated uniquenesses from redundant items provided the best fit to the data. However, the two-factor model (Positive Affect, Negative Affect) with correlated uniquenesses was also supported. For both short forms, the two-factor model with correlated uniquenesses fit the data best. Factors from all forms were generally invariant across age and gender, although there was some minor invariance at the item level.
Participants were from a limited geographic area and one ethnic group. Indicators of anxiety, depression, and cultural characteristics were not measured.
The factor structure was replicated, suggesting no immediate concerns regarding the valid interpretation of PANAS scores. The results support the reliability and validity of the PANAS and its short forms for use among African Americans.
PMCID: PMC3934411  PMID: 24051099
PANAS; short form; African American; psychometrics; confirmatory factor analysis
25.  Validation of Italian multiple sclerosis quality of life 54 questionnaire 
OBJECTIVES—Health related quality of life (HRQOL) inventories are multi-dimensional measures of patient-centred health status developed for clinical research. The MS quality of life 54 (MSQOL-54) is an MS-specific HRQOL inventory originally devised for English speaking patients. It consists of a core measure, the 36-item short form health survey (SF-36) previously adapted into Italian, and 18 additional items exploring domains relevant to patients with MS (MS-18 module). The authors translated and culturally adapted into Italian the MS-18 module of the MSQOL-54 questionnaire, and clinically validated the whole questionnaire.
METHODS—The MS-18 module was translated following the methodology of the International Quality of Life Assessment (IQOLA) project. The MSQOL-54 was validated in 204 consecutive patients with MS seen between April and September 1997 at three participating centres. The questionnaire was explained by the physician who also administered the expanded disability status scale (EDSS) and mini mental status scale examination, and the patient filled in the MSQOL-54 and Beck depression inventory questionnaires (BDI), with assistance if required. The contribution of impairments and disabilities to MSQOL-54 scores were assessed, and mean scores were compared with normative data for the general Italian population, and with the original sample of United States MS patients.
RESULTS—The mean age of the 204 patients was 42 years; mean EDSS score was 4.5 (range 0-8.5). Patients' participation in the assessment was satisfactory, and all scales satisfied the usual psychometric standards. The characteristics of the United States sample matched those of our patients in all but gender (72% United States patients v 52% Italian patients were women), and education (90% United States patients and 44% Italian patients completed high school); MSQOL-54 profiles were also similar. The EDSS was significantly associated with the physical health composite but not with the mental health composite score. Multiple linear regression modelling showed that age and BDI independently predicted physical health composite (p < 0.001), and mental health composite (p < 0.001). Clinical worsening in the previous year had an independent effect on the physical health composite (p < 0.001).
CONCLUSIONS—The Italian version of MSQOL-54 is easy to administer and is well accepted by patients. Neurological impairment has a limited influence on perceived quality of life, while age and depressive symptoms has a major influence.

PMCID: PMC1736469  PMID: 10406981

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