Medical Outcomes Study Short Form 36

Link to instrument: Available for purchase at SF-36.org (external link)

Acronym:

SF-36; SF-36v2

Purpose:

The SF-36 is a generic patient-reported outcome measure aimed at quantifying health status, and is often used as a measure of health-related quality of life.

Description:

• 36 item measure divided into 8 subscales and 2 composite domains 
• The 8 subscales are:
  • (1) Physical Functioning
  • (2) Role Limitations due to Physical Problems
  • (3) General Health Perceptions
  • (4) Vitality
  • (5) Social Functioning
  • (6) Role Limitations due to Emotional Problems
  • (7) General Mental Health
  • (8) Health Transition
• Respondents are asked to answer items referring to the past 4 weeks
• Recommended scoring system for the SF-36 is a weighted Likert system for each item
• Items within subscales are totaled to provide a summed score for each subscale or dimension.
• Each of the 8 summed scores is linearly transformed onto a scale from 0 (negative health) to 100 (positive health) to provide a score for each subscale. Each subscale can be used independently.
• For each domain (physical and mental composite) mean score = 50 and standard deviation = 10
• Version 2 norms are based on the 1998 National Survey of Functional Health Status (NSFHS); more information on version 2 can be found on the SF-36 website: http://ift.tt/1VgEIZQ 

Area of Assessment: Activities of Daily Living, Quality of Life

Body Part: Not Applicable

ICF Domain: Body Function, Activity, Participation

Domain: ADL, General Health

Assessment Type: Patient Reported Outcomes

Length of Test: 06 to 30 Minutes

Time to Administer:

10 minutes; 41 and 47 minutes, respectively, for individuals with paraplegia & tetraplegia (Anderson, et al 1999)

Number of Items: 36

Equipment Required:

Suggests enlarged copy of item response options (Steffen & Seney 2008)

Training Required:

Acquire and reading manual needed for item administration and scoring.

Type of training required: No Training

Cost: Not Free

Actual Cost:

Contact QualityMetric Incorporated for information regarding licensing fees for your institution.

Age Range: Adult: 18-64 years, Elderly adult: 65+

Administration Mode: Paper/Pencil

Diagnosis: Arthritis, Cardiac Conditions, Geriatrics, Multiple Sclerosis, Pain, Spinal Cord Injury, Stroke, Traumatic Brain Injury

Populations Tested:

The following conditions each have 50 or more publications (Turner-Bowker et al, 2002):

• Arthritis
• Back pain
• Cancer of the Head & Neck
• Low back pain
• Multiple sclerosis
• Musculoskeletal conditions
• Neuromuscular conditions
• Osteoarthritis
• Parkinson Disease
• Rheumatoid arthritis
• Spinal injuries
• Stroke
• Trauma
• Traumatic Brain Injury (Nichol et al, 2011)

Standard Error of Measurement (SEM):

Not Established

Minimal Detectable Change (MDC):

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes):

(Steffen & Seney, 2008; n = 37 (PD n = 35, Parkinson-Plus n = 2); mean age = 71 (12); mean disease duration = 14 (6) years; Hoehn and Yahr stages median score = 2 (range = 1 to 4); Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; test-retest by same rater at 1-week interval; Administered SF-36 by direct interview.

MDC-95 for each subscale of SF-36 (V1)

SF-36 Subscale	MDC95
Physical Functioning	28
Role limits - Physical	45
Bodily pain	25
General health	28
Vitality	19
Social functioning	29
Role limits - emotional	45
Mental health	19

Minimally Clinically Important Difference (MCID):

Not Established

Cut-Off Scores:

Not Applicable

Normative Data:

Parkinson Disease:

(Banks and Martin, 2009; n = 339 with PD (164 male; 179 female); mean age = 54.6 (range 27-75); Version 2 of SF-36; tested multiple configurations to determine recommended model for use and if this scale useful for PD. Identified 8 subscales and 6 models: physical functioning [1], role-physical [2], bodily pain [3], general health [4], vitality [5], social functioning [6], role-emotional [7] and mental health [8]. Compared various models of subscale combinations and assessments and compared against typical recommendation that summary measures of physical health (scales 1–4) and mental health (scales 5–8) can also be calculated and used independently.)

 

SF-36 subscale scores			Mean	SD
Physical functioning			44.03	26.44
Role–physical			25.41	34.24
Bodily pain			50.22	34.24
General health			44.08	20.89
Vitality			36.08	20.12
Social functioning			57.05	25.81
Role–emotional			47.81	44.03
Mental health			61.10	19.57

 

(Leonardi et al, 2012. N = 96 (64 male); mean age = 64.1 (11.3; range 24-90); 74% were married; 79.2% were not employed; Hoehn & Yahr stages: 1 = 13, 2 = 55, 3 = 22, 4 = 6. Compared to normative data from general Italian population.)

 

	Mean score (SD)	Normative data	t-test	P-value
SF-36 (v2)
Physical Functioning	72.0 (22.6)	84.46	−5.04	P < 0.001
Role Physical	46.9 (38.9)	78.21	−7.88	P < 0.001
Bodily Pain	58.9 (29.9)	73.67	−4.83	P < 0.001
General Health	41.2 (20.5)	65.22	−11.44	P < 0.001
Vitality	56.7 (20.1)	61.89	−2.52	P = 0.013
Social Functioning	69.2 (27.6)	77.43	−2.93	P = 0.004
Role Emotional	68.4 (40.3)	76.16	−1.88	P = 0.063
Mental Health	64.6 (19.6)	66.50	−0.94	P = 0.350
PCS	40.0 (8.8)	50	−11.09	P < 0.001
MCS	46.7 (11.0)	50	−2.90	P = 0.005

 

Chronic Stroke:

(Anderson et al, 1996; n = 90; mean age = 72 (12) years; assessed 1 year post stroke; Australian version)

 

SF-36 Domain			Mean	SD
Physical functioning			48	33
Role limits–physical			76	34
Bodily pain			76	28
General health			64	22
Vitality			56	20
Social functioning			86	23
Role limits–emotional			83	31
Mental health			77	22

Chronic Spinal Cord Injury:

(Forchheimer et al, 2004; n = 215, mean age = 38.8 years; assessed > 1 year post traumatic SCI)

SF-36 Domain	Mean	SD
Physical functioning	26.6	11.5
Role Physical	40.7	10.9
Bodily pain	42.2	12.4
General Health	44.4	11.8
Vitalitiy	46.8	9.6
Social Functioning	43.0	13.3
Role Emotional	49.0	10.6
Mental Health	48.3	11.0
Physical Component Summary	33.5	10.1
Mental Component Summary	53.5	11.6

TBI:

(Colantonio et al., 1998; n = 51; mean age = 18.28 (2.04) years; assessed 5 years post TBI )

	Mild (n = 24)		Moderate / Severe (n = 27)
	Mean	SD	Mean	SD
Physical Functioning	84.91	22.02	75.43	35.43
Role Limits–physical	79.17	36.94	75.32	37.01
Bodily Pain	77.40	19.29	81.44	17.89
General Health	63.98	26.74	68.33	22.74
Vitality	53.54	9.83	52.90	13.79
Social Functioning	72.92	27.25	73.15	27.23
Mental Health	46.50	16.42	46.67	17.40
Role Limits–mental health	81.94	32.57	75.64	38.36

Mild Traumatic Brain Injury:

(Emanuelson et al, 2003; n = 117, patients assessed at 3 months post injury and n = 101, patients assessed 1 year post injury; age = 16-60)

Domain in SF-36	Patients 3 Months (n = 117) Mean, SEM, median	Patients 1 Year (n = 101) Mean, SEM, median	Mean	SD	Median	Minimum	Maximum
PF	85.4 (1.9), 95	87.5 (2.1), 95	0.85	12.93	0.00	−35.00	60.00
RF	72.5 (3.5), 100	74.7 (3.8), 100	−0.42	30.07	0.00	−100.00	100.00
BP	66.7 (3.0), 72	72.2 (3.1), 74	1.31	25.52	0.00	−69.00	69.00
GH	68.3 (2.4), 72	70.9 (2.5), 72	0.78	17.67	0.00	−52.00	48.00
VT	59.3 (2.4), 60	62.3 (2.6), 65	1.86	19.97	0.00	−70.00	60.00
SF	81.6 (2.5), 100	83.2 (2.4), 100	−0.12	20.35	0.00	−62.50	50.00
RE	72.7 (2.4), 80	77.2 (3.7), 100	3.00	33.87	0.00	−100.00	100.00
MH	71.2 (2.4), 80	74.9 (2.2), 84	1.74	17.87	0.00	−48.00	56.00
PCS	48.4 (1.2), 52	49.1 (1.1), 52	−0.02	6.80	−0.06	−23.16	18.94
MCS	44.8 (1.2), 48	46.5 (1.3), 51	1.09	10.43	0.47	−36.97	36.67

 

 

 

 

 

 

 

 

 

PF =physical functioning, RF =role physical, BP =bodily pain, GH =general health, VT =vitality, SF = social functioning, RE =role emotional, MH =mental health, PCS =physical composite score, MCS =mental composite score.

 

Mild Traumatic Brain Injury:

(Emanuelson et al, 2003; n = 117, patients assessed at 3 months post injury and n = 101, patients assessed 1 year post-injury; age = 16-60)

Domain in SF-36	Patients 3 Months (n = 117) Mean, SEM, median	Patients 1 Year (n = 101) Mean, SEM, median
Physical Function	85.4 (1.9), 95	87.5 (2.1), 95
Role Functioning:Physical	72.5 (3.5), 100	74.7 (3.8), 100
Bodily Pain	66.7 (3.0), 72	72.2 (3.1), 74
General Health	68.3 (2.4), 72	70.9 (2.5), 72
Vitality	59.3 (2.4), 60	62.3 (2.6), 65
Social Functioning	81.6 (2.5), 100	83.2 (2.4), 100
Role Functioning: Emotional	72.7 (2.4), 80	77.2 (3.7), 100
Mental Health	71.2 (2.4), 80	74.9 (2.2), 84
Physical Composite	48.4 (1.2), 52	49.1 (1.1), 52
Mental Composite	44.8 (1.2), 48	46.5 (1.3), 51

 

 

 

 

 

 

 

 

 

Previously untreated, primary HNC:

 

(Funk G.F., Karnell L.H., Dawson C.J., et al, 1997; n = 180, mean age 58.9 (range, 20-85))

 

	US Norms	95% CI	HNC Pre-Surgery	95% CI
45-64 years (n = 39)
PCS	49.64	49.58-49.70	42.64	39.00-46.28
MCS	50.53	50.47-50.59	41.97	38.25-45.69
55-64 years (n = 51)
PCS	45.90	45.82-45.98	43.82	40.94-46.70
MCS	51.05	50.98-51.12	44.68	41.52-47.84
65-74 years (n = 48)
PCS	43.33	43.28-43.38	42.33	39.05-45.61
MCS	52.68	52.54-52.72	49.87	46.88-52.86

 

	HND pre-surgery(n=180)	SC	HNC, 6 months post-surgery (n=109)	SD	P-value
PCS	43.61	11.49	42.88	10.61	0.0470
MCS	45.05	11.97	47.19	11.82	0.1463

 

General Population:

 

(Ware J.E., Kosinski M., Keller S.D., 1994)

• General population mean for SF-36 component scores (not specific to head and neck cancer) = 50 (SD, 10)

Test-retest Reliability:

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes): 

(Steffen & Seney, 2008; n = 37 (PD n = 35, Parkinson-Plus n = 2); mean age = 71 (12); mean disease duration = 14 (6) years; Hoehn and Yahr stages median score = 2 (range = 1 to 4); Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; test-retest by same rater at 1-week interval; mean number of falls in the past 6 months = 7; Administered SF-36 (v1) by direct interview.)

 

SF-36 Domain	Test-Retest reliability (ICC)
Physical Functioning	0.80 Adequate
Role Physical	0.85 Excellent
Bodily Pain	0.89 Excellent
General Health	0.85 Excellent
Vitality	0.89 Excellent
Social Functioning	0.71 Adequate
Role Emotional	0.84 Excellent
Mental Health	0.83 Excellent

 

Chronic Stroke:

(Dorman et al, 1998; n = 209; 3 weeks between assessments; mean time since stroke onset 64(30) weeks)

 

Domain	Patient ICC's	Proxy ICC's	Combined ICC's
Physical Functioning	0.80	0.59	0.74
Role Limits–physical	0.77	0.45	0.67
Bodily Pain	0.81	0.65	0.75
General Health	0.81	0.71	0.79
Vitality	0.77	0.55	0.70
Social Functioning	0.79	0.76	0.80
Role Limits–emotional	0.60	0.50	0.57
Mental Health	0.30	0.24	0.28

 

Chronic Traumatic Spinal Cord Injury:

(Lin et al, 2007; n = 187; 4 weeks between assessments; mean time since injury was 7.8 years)

20 random participants were selected to assess their original responses within 2 weeks; n = 10 by same interviewer (intra interviewer), n = 10 with a second interviewer (inter interviewer)

SF-36 Domain	Intra interviewer (ICC)	Inter interviewer (ICC)
Physical Functioning	0.71	0.67
Role Physical	0.89	0.90
Bodily Pain	0.87	0.70
General Health	0.85	0.41
Vitality	0.93	0.86
Social Functioning	0.93	0.52
Role Emotional	0.99	0.98
Mental Health	0.77	0.57
Excellent Intra ICC > 0.9 in BOLD; Excellent Inter ICC > 0.7 in BOLD

Interrater/Intrarater Reliability:

Not applicable

Internal Consistency:

Parkinsonism (included Parkinson Disease and Parkinson-plus syndromes):

(Steffen & Seney, 2008; n = 37; mean age = 71; mean disease duration = 14 (6) years); Hoehn and Yahr Stages range from 1-to-4. ; Stage 1: n = 3, Stage 2: n = 7, Stage 3: n = 9, Stage 4: n = 8; Test-retest by same rater at 1-week interval; mean number of falls in the past 6 months = 7)

 

Internal Consistency for SF-36 v1 (Cronbach's alpha):  [No source for this linked to SF-36v2]

SF-36 Domain	Internal Consistency Cronbach's alpha Strength
Physical Functioning	0.87 Excellent
Role Physical	0.74 Adequate
Bodily Pain	0.91 Excellent
General Health	0.80 Adequate
Vitality	0.91 Excellent
Social Functioning	0.84 Excellent
Role Emotional	0.89 Excellent
Mental Health	0.93 Excellent

 

(Brown et al, n = 96 total (n = 58 with follow-up data and 38 without); mean age = 72 (88% white, 84% male); years of school = 15.7 (2.4); via standardized telephone interview at baseline and ~18 months (mean = 17.9 (4.2) months In PD subjects, Hoehn & Yahr stages not reported.)

 

Subscale (item #)	Cronbach's alpha (strength)
Physical Functioning (10)	0.94 (Excellent)
Role Limitations–Physical (4)	0.81 (Excellent)
Role Limitations–Emotional (3)	0.98 (Excellent)
Pain (2)	0.85 (Excellent)
Emotional Well-Being (5)	0.86 (Excellent)
Energy (4)	0.92 (Excellent)
General Health (5)	0.76 (Adequate)
Social Function (2)	0.98 (Excellent)
Physical Health (PCS)	0.93 (Excellent)
Mental Health (MCS)	0.97 (Excellent)

 

Acute Stroke:

(Hagen et al, 2003; n  = 136; mean age = 70 (11) years; assessed 1, 3 and 6 months post-stroke)

• Adequate to Excellent internal consistency across domains (alpha > 0.70) over multiple administrations (1, 3 and 6 months) except Vitality at 1 month post stroke (a = 0.6824) and General Health at 3 months post-stroke (a = 0.6650) 

Chronic Stroke:

(Anderson et al, 1996)

• Excellent internal consistency (Cronbach's alpha > 0.7, except Vitality section):

SF-36 Domain	Strength	alpha
Physical Functioning	Excellent	0.9
Role Limits–physical	Adequate	0.8
Bodily Pain	Excellent	0.9
General Health	Adequate	0.7
Vitality	Adequate	0.6
Social Functioning	Adequate	0.7
Role Limits–emotional	Excellent	0.9
Mental Health	Adequate	0.7

Spinal Cord Injury:

(Forchheimer,et al 2004)

• Adequate to Excellent internal consistency across all domains (Chronbach's α = 0.76 to 0.90, mean = 0.82)

SF-36 Domain	Internal Consistency (Cronbach's alpha)
Physical Functioning	0.98
Role Physical	0.94
Bodily Pain	0.79
General Health	0.82
Vitality	0.76
Social Functioning	0.72
Role Emotional	0.89
Mental Health	0.78
Excellent internal consistency > 0.80 in BOLD; Adequate internal consistency 0.70-0.80

Chronic SCI:

(van Leeuwen et al 2012, n = 145, AIS A-D, 5 years post injury)

• Adequate internal consistency of the Mental Health subscale of SF-36 (MHI-5), Cronbach's α = 0.79

 

Traumatic Brain Injury: (Mackenzie, et al 2002, n =1230 (1197 without proxy, 33 by proxy), age range 18-54 years, gender=male 66%) The α coefficient for the SF-36 health survey with the cognitive function scale SF-36 Domain α coefficient Strength Physical Functioning 0.93 Excellent Role Limits–physical 0.88 Excellent Bodily Pain 0.89 Excellent General Health 0.77 Adequate Vitality 0.84 Excellent Social Functioning 0.82 Excellent Role Limits–emotional 0.87 Excellent Mental Health 0.88 Excellent

Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8) Cronbach's alpha ranged from 0.68-0.87 (adequate to excellent) for the comparison group , from 0.83-0.91 (excellent) for the mild TBI group, and from 0.79-0.92 (adequate to excellent) for the moderate-severe TBI group Traumatic Brain Injury: (Guilfoyle et al, 2011; n=514; mean age=36.6 (16.1) years; gender=male 76.3%) SF-36 domain Alpha coefficient Strength Physical Function 0.95 Excellent Role Physical 0.89 Excellent Bodily Pain 0.90 Excellent General Health 0.83 Excellent Vitality 0.83 Excellent Social function 0.82 Excellent Role Emotional 0.90 Excellent Mental Health 0.86 Excellent

Patients undergoing surgery for oral or oropharyngeal SCCA:

 

(Rogers S., Humphris G., Lowe D., Brown J., Vaughan E., 1998; n = 48, mean age (SD), 61 (12))

 

Subscale	Cronbach's alpha
Physical functioning	0.95
Role limitation, physical	0.92
Role limitation, mental	0.86
Social functioning	0.77
Mental health	0.78
Energy/Vitality	0.72
Pain	0.81
General health perception	0.79

 

Laryngeal cancer (Italian version):

 

(Mosconi P., Cifani S., Crispino S., Fossati R., Apolone G., 2000; n = 165, 64 (9.2), patients 0-262 months post-treatment)

 

Subscale	Cronbach's alpha
Physical functioning	0.88
Role limitation, physical	0.83
Role limitation, mental	0.84
Social functioning	0.91
Mental health	0.81
Energy/Vitality	0.81
Pain	0.85
General health perception	0.69

Criterion Validity (Predictive/Concurrent):

Parkinson Disease:

(Leonardi et al, 2012; n = 86 all scales)

Pearson correlations all significant at p < 0.0001

N=86 all scales	SF-36 PCS / Correlation Strength	SF-36 MCS / Correlation Strength	NMS Questionnaire / Correlation Strength
WHO-DAS II summary score	-0.70 / Excellent	-0.52 / Adequate	0.65 / Excellent
NMS questionnaire	-0.54 / Adequate	-0.40 / Adequate	--

NMS = non motor symptoms questionnaire
WHO-DAS II = World Health Organization Disability Assessment Schedule

(Nilsson et al, 2010; n = 79 with diagnosis of idiopathic PD, 37 outpatient and 42 via survey; mean age 64 years (7.2) correlation study; 8.8 (2.3) days between testing sessions; duration of diagnosis = 15.9 (7.3) years; Hoehn & Yahr ratings not specified. Focus of study on FES (Swedish-13) & SAFFE (modified Survey of Activities and Fear of Falling in the Elderly))

• Adequate correlation SF-36v1 PF subscale and FES(s): rs = 0.66; p < 0.001
• Excellent SF-36v1 PF subscale and SAFFE:  rs = -0.76; p < 0.001

Chronic Stroke:

(Dorman et al, 1999; n = 688)

• Adequate concurrent validity between the EuroQol health-related quality of life and the SF-36's general health domain r = 0.66
• Poor concurrent validity between SF-36 mental health domain and the EuroQol psychological functioning subtest
• Excellent to Poor correlations between individual Barthel Index scores at five years and dimensions of the SF36. (Wilkinson et al, 1997; UK sample, n = 97, mean age at stroke = 61, mean follow-up 4.9 years)

SF36	r =
Physical functioning	0.810
Social functioning	0.481
Role: physical	0.415
Role: emotional	0.217
Mental health	0.332
Vitality	0.500
Bodily pain	0.356
General health	0.438

Chronic SCI:

(Van Leeuwen et al, 2012)

Concurrent Validity	Spearman Correlation
LiSat 9	0.531ᵃ
Neuroticism	-0.546ᵃ
SF- Vitality	0.528ᵃ
SF- general health	0.367ᵃ
Divergent Validity
FIM	0.094
SIP-mobility range	-0.283
Type of injury	-0.009
Completeness of injury	-0.008
Cause of injury	0.192
Demographics
Age	-0.020
Gender	-0.067
Education	0.028
ᵃ=Adequate validity 0.31-0.59; Poor validity ≤ 0.30; VanLeeuwen anticipated poor correlations with Demographics and injury

Patients within 2 years of diagnosis for head and neck cancer:

 

(Karvonen-Gutierrez C.A., Ronis D.L., Fowler K.E., Terrell J.E., Gruber S.B., Duffy S.A., 2008; n = 495)

• Predictive Validity:
  • When controlling for demographic, health behavior and clinical variables, QOL as measured by the SF-36, the PCS score is significantly associated with survival (hazard ratio 0.86, 95% CI 0.80-0.93).
  • For every 5-point increase in the PCS score, the risk of death decreased 0.14 times.

Construct Validity (Convergent/Discriminant):

Parkinson Disease: (Leonardi et al, 2012)

• Distinguish severity: SF-36v2 composite scores were significantly different between patients rated Hoehn & Yahr < 3 (n = 68) and those rated HY ≥ 3 (n = 28), with the more advanced group reporting lower composite scores on PCS (reduced by 16.8%) and MCS (reduced by 18.1%)

Chronic Spinal Cord Injury:

(Forchheimer, et al 2004)

• Excellent discriminant validity established between Physical capacity score (PCS) and Mental capacity score (MCS) constructs (-0.075)
• Excellent convergent validity between impairment severity and PCS (F = 5.62, df = 3, P = 0.001)
• Excellent Divergent validity between impairment severity and MCS scores (F = 0.175, df = 3, P = NS)

Chronic Spinal Cord Injury:

(Lin et al, 2007)

		WHOQOL-BREF
SF-36	Rating Scale	Overall	Physical Capacity	Psych	Social	Environ
Rating Scale	---	0.68	0.73	0.64	0.54	0.57
Physical Functioning	0.71	0.57	0.78	0.57	0.50	0.54
Role physical	0.47	0.35	0.51	0.40	0.33	0.48
Bodily pain	0.64	0.52	0.68	0.56	0.48	0.55
General Health	0.72	0.65	0.69	0.62	0.45	0.59
Vitality	0.59	0.59	0.67	0.65	0.48	0.62
Social Functioning	0.50	0.52	0.62	0.63	0.43	0.58
Role Emotional	0.32	0.30	0.41	0.37	0.24	0.39
Mental Health	0.36	0.51	0.52	0.59	0.40	0.56
Excellent correlation > 0.60 in BOLD; Adequate correlation 0.31-0.59; Excellent to Adequate convergent validity between SF-36 and WHOQOL-BREF subscales

Chronic Spinal Cord Injury:

(Anderson et al, 1999 n = 181 veterans with SCI who were hospitalized within 6 months of assessment)

• Excellent to adequate correlations between SF-36 and Behavioral Risk Factor Surveillance System (BRFSS) subscales
• Mental Capacity Summary to all BRFSS subscales (r = -0.427-0.761 )
• Mental Health subscale to all BRFSS subscales (r= -0.446 - -0.795)
• Vitality subscale to all BRFSS subscales (r = -0.450 - -0.789)
• Social Functioning subscale to all BRFSS (r = -0.293 - -0.622)
• Role Emotional subscale to all BRFSS (r = -0.290- -0.610)
• Poor to adequate correlations between SF-36 subscales Physical Functioning, Role Physical, Bodily Pain, General Health and Physical Summary and all BRFSS subscales (r = 0.065- 0.597)
• Poor to adequate correlations between SF-36 and Quality of Well Being (r = 0.044 to 0.417) (poor ≤ 0.03; adequate 0.31-0.59)
• Adequate to Poor correlation between SF-36 and IADLs (r = -0.159- to -0.454)

Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8) Mild TBI: Adequate to excellent correlations (-0.50 to -0.63) were found between SF-36 scales pertaining directly to physical functioning (General Health, Physical Functioning, Physical Role, Bodily Pain, Vitality) and the Physical symptoms scale of the Symptoms Checklist (SCL) Excellent correlations between SF-36 scales and participants' Health Problems List (HPL) responses (-0.60 to -0.75) Emotional Role and Mental Health scores were more strongly related to psychological factors (Cognitive and Affective/Behavioral) than to physical factors on the Symptom Checklist (SCL) Adequate to excellent correlations (-0.52 to -0.77) were found between Beck Depression Inventory second edition (BDI-II) scores and the SF-36 subscales Moderate to Severe TBI: Correlations were lower and more uniform, strongest correlations found between the SF-36 Emotional Role scale and the SCL Affective/Behavioral scale (-0.53). Correlations between the Physical Functioning scale of the SF-36 and the Cognitive and Affective/Behavioural scales of the SCL were lower than other correlations between scales within this group (-0.11 and -0.19, respectively). Multiple Neurologic Diagnosis (polio, acute stroke, and TBI): McNaughton et al., 2005; n=308, Polio n=38, Stroke n=181, TBI n=89; mean age=polio 62.5 (11.3), stroke=74.4 (12.0), TBI=34.0 (17.8); gender, female=polio 27%, stroke 96%, TBI 32%) examined validity of the mental component score (MCS) and physical component score (PCS) Principal component analysis (PCA) on the 12-month measures for subjects with stroke and TBI: 2 dimensions might account for a large proportion of the variability in the data set Varimax rotation shows that the 2-factor model has 85% of the variance of the underlying variables with 1 factor loading mainly onto the Barthel Index, Functional Independence Meausre (FIM), PCS,Community Integration Questionnaire (CIQ), and London Handicap Scale (LHS) and the other factor mainly onto the MCS

Traumatic Brain Injury: (Guilfoyle et al; n=514; mean age=36.6 (16.1) years; gender=male 76.3%) Principal component analysis (PCA) of the correlation matrix of the eight SF-36 domains extracted a single PC with an eigenvalue exceeding unity, which explained 59.2% of the variance in the data The second PC extracted had an associated eigenvalue of 0.75, and accounted for only 9.4% of the variance Known Groups Traumatic Brain Injury: (Findler et al; n=597 (without disability, n=271; mild TBI, n=98; moderate-severe TBI, n=228); Mean age at interview=no disability, 38.5(12.7); mild TBI, 41.7(10.8), moderate-severe TBI, 35.7(9.8) mild TBI and moderate to severe TBI groups reported significantly lower health status across all scales compared to the comparison group mild TBI group reported significantly lower scores (poorer health)on all scales compared to the moderate± severe TBI group, with the exception of Physical Function, where there were no differences between the two groups Traumatic Brain Injury: (Jacobsson et al., 2010 n=67, mild TBI n=32, moderate to severe TBI n=35; mean age at time of injury=mild TBI:13 (13) years, moderate to severe TBI: 30 (12) years); gender=mild TBI: male75%, moderate to severe TBI: male 77%; Swedish version of the SF-36) SF-36PCS MCS SWLS Sex Age at Injury Injury Severity Time since injury Marital status Vocational situation SF-36: MCS -0.00 SWLS 0.41** 0.48** Sex -0.19 0.01 -0.02 Age at injury -0.14 0.29* 0.05 0.23 Injury severity 0.20 -0.10 -0.06 -0.03 0.32** Time since injury 0.13 0.06 0.30* -0.05 -0.15 0.10 Marital status 0.11 0.06 0.36** -0.01 -.18 -0.11 0.08 Vocational situation 0.48** -0.02 0.32** -0.11 -0.37** 0.13 0.11 0.21 Self appraisal of the TBI -0.54** -0.12 -0.46** 0.09 -0.05 -0.31** -0.04 -0.27* -0.35** Correlation (Spearman's rho) is significant (two-tailed) on *0.05, and **0.01 levels SWLS-Satisfaction With Life Scale Patients with cancer of the upper aero digestive tract:   (Chen A.Y., Frankowski R., Bishop-Leone J., et al., 2001)   Construct validity of the MD Anderson Dysphagia Index (MDADI) was determined through correlating the subscales of the SF-36 and MDADI. (Spearman correlation coefficient, greater than 0.60 - strong correlation, 0.40-0.60 - moderate to substantial, less than 0.40 - weak)     MDADI Subscales SF-36 Subscales Global Emotional Functional Physical Physical functioning 0.29 0.36 0.31 0.40 Role - physical 0.31 0.33 0.37 0.38 Bodily Pain 0.21 0.23 0.24 0.26 General Health 0.21 0.33 0.28 0.32 Vitality/Energy 0.34 0.50 0.45 0.52 Social Functioning 0.44 0.50 0.45 0.51 Role - Emotional 0.34 0.40 0.42 0.43 Mental Health 0.27 0.30 0.29 0.34   PCS 0.25 0.30 0.29 0.34 MCS 0.44 0.54 0.51 0.54   Patients with head and neck cancer who underwent selective or modified radical neck dissection:   (Taylor R.J., Chepeha J.C., Teknos T.N., Bradford C.R., Sharma P.K., Terrell J.E., Hogikyan N.D., Wolf G.T., Chepeha D.B., 2002; n = 54, patients had a minimum postoperative convalescence of 11 months)    Convergent validity of the Neck Dissection Impairment Index (NDII): (Spearmen or Pearson not specified) Subscale Correlation to NDII P-value Physical functioning 0.50 <0.001 Role limitation, physical 0.60 0.001 Role limitation, mental 0.59 0.001 Social functioning 0.62 0.001 Mental health 0.56 0.001 Energy/Vitality 0.44 0.001 Pain 0.32 0.001 General health perception 0.55 0.001   Patients undergoing surgery for oral or oropharyngeal SCCA:   (Rogers S., Humphris G., Lowe D., Brown J., Vaughan E., 1998)   Correlation between SF-36 and University of Washington Hand and Neck Questionnaire: Subscale Pearson's Correlation Physical functioning 0.61, P<0.001 Role limitation, physical 0.66, P<0.001 Role limitation, mental 0.47, P<0.01 Social functioning 0.54, P<0.001 Mental health -0.08 Energy/Vitality 0.43, P<0.01 Pain 0.61, P<0.001 General health perception 0.42, P<0.01   (Rogers S.N., Lowe D., Brown J.S., Vaughan E.D., 1998) Spearman correlation coefficients: SF-36 with European Organization for Research and Treatment of Cancer (EORTC): r = 0.83 SF-36 with University of Washington Head and Neck Disease-Specific Measure (UW-QOL): r = 0.80 Laryngeal cancer (Italian version):   (Mosconi P., Cifani S., Crispino S., Fossati R., Apolone G., 2000) Convergent Validity - within subscale coefficients all higher than 0.40 Discriminant Validity - higher item-scale correlations found within the subscale than between the subscales

Content Validity:

Items that compose the SF-36 were drawn from a number of prior measures including:

• The General Psychological Well-Being Inventory (GPWBI) (Dupuy, 1984)
• Physical and role functioning measures (Patrick, Bush, & Chen, 1973; Hulka & Cassel, 1973; Reynolds, Rushing, & Miles, 1974; Stewart, Ware, & Brook, 1981)
• The Health Perceptions Questionnaire (HPQ) (Ware, 1976)
• The Functioning and Well-Being Profile (FWBP) (Stewart & Ware, 1992)

Face Validity:

Not statistically assessed

Floor/Ceiling Effects:

Parkinson Disease:

(Brown et al, 2009) regarding SF-36v1 {not located for SF-36v2}

• Floor effects:SF-36v1 subscales: Role limitations – physical (51% scored min possible); Role limits – emotional (21.9% scored min possible).
• Ceiling effects: SF-36v1 subscale: Role limitations – Emotional (75% scored max possible); Pain (15.6% scored max possible); Social function (29.2% scored max possible).

Subscale	% score min (0)	max (100)
Physical Functioning	4.2	3.1
Role Limitations—Physical	51.0	10.4
Role Limitations—Emotional	21.9	75.0
Pain	0.0	15.6
Emotional Well-Being	1.0	0.0
Energy	3.1	0.0
General Health	2.1	1.0
Social Function	6.3	29.2

 

Acute Stroke:

(Hagen et al, 2003; n = 153; 1 month post stroke)

 

SF-36 Domain

% Floor

% Ceiling

Physical Functioning

23

1

Role Physical

70

4

(Lack of) Bodily Pain

6

35

General Health

0

3

Vitality

4

0

Social Functioning

27

16

Role Emotional

37

26

Mental Health

0

2

 

Chronic Stroke:

(Anderson et al, 1996)

• The SF-36 avoids the "ceiling effect" of most disability scales:

SF-36 Domain	% floor	% ceiling
Physical Functioning	4	6
Role Physical	7	53
(Lack of) Bodily Pain	2	43
General Health	2	2
Vitality	1	1
Social Functioning	3	67
Role Emotional	7	72
Mental Health	1	4

 

 

Traumatic Brain Injury:

(Guilfoyle et al, 2011; n = 514; mean age = 36.6 (16.1) years; gender = male 76.3%)

• Floor effects were observed in two domains—Role Physical and Role Emotional—and ceiling effects were observed in four domains—Physical Function, Role Physical, Bodily Pain, and Role Emotional

SF-36 domain	Floor %	Ceiling %
Physical Function	4.7%	16.7
Role Physical	56.8	19.1
Bodily Pain	2.0	21.4
General Health	0.2	5.1
Vitality	2.2	2.8
Social function	7.3	0.0
Role Emotional	43.9	37.5
Mental Health	0.6	4.0

Patients undergoing surgery for oral or oropharyngeal SCCA:

 

(Rogers S., Humphris G., Lowe D., Brown J., Vaughan E., 1998)

• No floor or ceiling effects

Responsiveness:

Chronic spinal cord injury:

(Lin et al, 2007)

• Highly sensitive (ES = 0.60 & 0.92) with respect to employment status with Physical Functioning and Role Physical domains.
• Moderately sensitive (ES = 0.21-0.44) with respect to employment status with Social Functioning, Role Emotional and Mental Health domains
• Small responsiveness (ES = 0.00-0.16) with respect to employment status in Bodily Pain, General Health, and Vitality domains.

 

Mild Traumatic Brain Injury (mTBI): (Paniak et al.,1999; n=120 with mild TBI, 120 control group; mean age=mTBI 32.7 (11.9), control 30.4 (11.6)) SF 36 variable Effect Size Physical Functioning 3.5 Moderate change Social 1.98 Small change Role Functioning Physical 2.72 Moderate change Bodily Pain 2.04 Moderate change Mental Health 0.90 Small change Role Functioning Emotional 0.96 Small change Vitality 1.78 Small change General Health 0.18 Small change Mental 0.93 Small chage Physical 2.48 Moderate change

Traumatic Brain Injury: (Hawthorne et al, 2009; n=66; mean age at time of injury=36 (15); mean time since injury=32 months; utilized SF-36 version 2) SF 36 variable Effect Size Physical Functioning -0.56 Role Functioning Physical -0.77 Bodily Pain -0.38 General Health -0.44 Vitality -0.43 Social Function -0.81 Role Functioning Emotional -0.86 Mental Health -0.70 Physical -0.47 Mental -0.76 The largest effect sizes were for sub-scales assessing social, emotional, and mental health, but there were moderate to large effects across all of the eight sub-scales, suggesting that TBI may have very broad effects across many different life parts.

Laryngeal cancer (Italian version):

 

(Mosconi P., Cifani S., Crispino S., Fossati R., Apolone G., 2000)

 

Subscale	Effect Size
Physical functioning	0.45
Role limitation, physical	0.78
Role limitation, mental	0.40
Social functioning	0.66
Mental health	0.29
Energy/Vitality	0.04
Pain	0.88
General health perception	0.74
Component Summary Scores
Physical	1.1
Mental	0.09

(reference: first level of treatment extent, 0.60 indicates an important magnitude of change)

Considerations:

Physical function domain: significant floor effects for patients with SCI and other disabilities due to inability to perform some of the physical tasks described. Recommend the SF-36 state "walkwheel" to improve responsiveness for patients with spinal cord injury. (Lee et al., 2009)

Not recommended for:

• Patients who cannot understand written or spoken language
• Severely affected stroke survivors who require a proxy to complete the assessment
• To document patient change (Dorman et al., 1999)
• Some disadvantaged populations, slight declines in reliability may result (Turner-Bowker et al., 2002)
• Postal administration of the SF-36 is not recommended (O'Mahony et al, 1998)

• The Mental Health Subscale of SF-36 (MHI-5) VanLeeuwen, 2012 may be used in the future to determine mental health and severe mental health problems in persons with SCI. Cut off score ≤ 72 and ≤ 60 respectively.

• The SF-12 is a shorter version of the SF-36 containing 12 items;  covers the summary physical health and mental health scales, but no information about each of the eight dimensions of the SF-36
• The SF-12 is beginning to be  more commonly used in the TBI population however its psychometric properties in this population have not been specifically assessed (Nichol et al, 2011)

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Bibliography:

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Year published: 1992

Instrument in PDF Format: Yes

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