Journal of Rehabilitation Medicine 51-1CompleteIssue | Page 47

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S. Tarvonen-Schröder et al.
activities) in our study population. These findings are,
in many aspects, in agreement with the only previous
WHODAS study evaluating these associations between
objective and subjective parameters in SCI (17).
The correlation between the assessments made by
a physician (the WHO minimal generic set) and by
the patients themselves (WHODAS) was moderate
to strong. This study is in line with previous studies
showing this kind of positive correlation between
WHODAS 2.0 and other measures of activity limi-
tations (30), in our study the WHO minimal generic
set. As the correlations between the patient and proxy
WHODAS scores on the whole and in single items
were mostly very strong, it seems possible that, when
assessing functioning in patients with SCI who do not
have cognitive problems or concomitant neurological
diseases, as in our study, the patient is able to make as-
sessments reliably without reflecting his or her opinion
with that of his or her significant others.
Although the physician who rated functioning using
the generic set score was not blinded to background
information, their ratings seemed reasonable, and
might be even more reliable due to their good insight
into the clinical history of the participants. Physician-
rated functioning was correlated more clearly with le-
sion severity, walking ability and current employment
status than when rated by the patients themselves. A
physician rated the overall functioning severely im-
paired in tetraplegia and more moderately in the other
3 groups, showing between-group differences also in
mobility and daily activities. The fact that working
ability was rated more impaired by a physician than by
the patients is interesting. Few of the patients were ac-
tually employed. Patients may have a more subjective
view of employment possibilities and the functioning
ability they still possess with diverse voluntary work
possibilities, as a physician may think more of the real
requirements in the open labour market reflected with
the activity restrictions and participation limitations
the patients may have.
In this study, both WHODAS and the WHO minimal
generic set were found to differentiate varying seve-
rities and levels of SCI from each other. Previously,
WHODAS has been shown to be useful in assessing
disability in several health conditions, both in psychia-
tric and somatic conditions. While the burden of more
time-consuming functioning tools is challenging for
clinicians and patients, these simple tools appeared
to be practical and useful in our clinical setting. In
the wide field of rehabilitation of patients with SCI,
developing cost-effective client-centred rehabilita-
tive services is important. In this development, it is
essential to assess perceived functioning, patients’
needs and participation restrictions using reliable
www.medicaljournals.se/jrm
tools. Although previous recommendations regarding
evaluating functioning have suggested using the 7-item
WHO minimal generic set together with other wider
ICF-based tools, based on our results we would also
recommend using the 12-item WHODAS 2.0 alone.
It is, however, possible that the 12-item WHODAS
is not adequate in finding between-group differences
in mobility of patients with SCI, as the description of
the mobility items in WHODAS includes “walking a
long distance” and “standing a long time”, which are
not usually possible for any patients with SCI (38). In
contrast, the 7-item minimal generic set does not define
the time or the distance of these activities thus allowing
better clinical adjustment of moving difficulties than
WHODAS. Even if WHODAS has many advantages,
it does not substitute for other generic measures of
both capacity and performance (capability without and
with assistance) in real-life situations. In an outpatient
clinic, as in our study, keeping the number of separate
items minimal probably ensures the compliance of
patients to complete the assessment scale. The 7-item
WHO minimal generic set may, however, be too brief
if used as the only functioning measure. When planning
individual rehabilitative services for patients with SCI
and their significant others, we primarily recommend
using the 12-item WHODAS 2.0 as a screening tool.
Limitation
One limitation of the study is a cross-sectional design
preventing confirming causal relationships of disabi-
lity. Even if we included all consecutive 142 patients,
the study population of a tertiary outpatient clinic is
always selected. Even if the severity and level of the
SCI was evaluated retrospectively, we had access to
electronic patient records from the beginning of the
medical history. As 2 different generic functioning
scales (WHODAS and the WHO minimal generic set)
were used, straight comparisons were not possible for
all sub-items. Both measures are, however, ICF-based
and have many identical items. Even if WHODAS and
the WHO minimal generic set seemed to be adequate
in the chronic phase as in our study, these results are
not directly generalizable to the acute or subacute
phase (39). Patients and their significant others were
not blinded to each others’ evaluations; however, in the
vast majority their responses differed from each other.
Conclusion
Both ICF-based tools were easy to use in assessing
functioning in SCI. Of these 2 tools, we recommend
using the 12-item patient-completed WHODAS 2.0,
as this can, with little effort, be used to detect activity
limitations and participation restrictions in SCI, and to