Original research| Volume 101, ISSUE 11, P1961-1972, November 2020

Psychometric Testing and Clinical Utility of a Modified Version of the Function in Sitting Test for Individuals With Chronic Spinal Cord Injury



      Seated balance (SB) is substantially compromised and greatly impacts the function of individuals living with a spinal cord injury (SCI). A clinically applicable criterion standard measure for SB does not exist for this population. Initial validation and reliability analysis of the Function in Sitting Test (FIST) in SCI has been published, but the authors of this study report that modifications to the tool may be necessary. This study aimed to explore the psychometrics and clinical utility of a modified version of the FIST to better measure SCI-specific functional tasks in sitting.


      The FIST was modified (FIST-SCI) by an expert panel and used by 2 graders to evaluate the SB of individuals with chronic SCI (cSCI) on 2 separate days. The Motor Assessment Scale item 3 (MAS-SCI) was included as a comparison measure.


      Research facility.


      Individuals with cSCI longer than 1 year (N=38) participated in the study. Injury levels of individuals participating in this study spanned C1 to T10 (American Spinal Injury Association Impairment Scale A, 17 subjects; B, 12 subjects; and C, 9 subjects). Thirteen individuals required assistance to transfer.


      Not applicable.

      Main Outcome Measures

      Validity, reliability, internal consistency, sensitivity, specificity, and responsiveness.


      Validity testing found a moderate relationship between the MAS-SCI and the FIST-SCI (ρ, .522; P<.05). FIST-SCI scores distinguished individuals requiring assistance to transfer from those who were independent (t=4.51; P<.05). Inter- and intra-rater reliability were excellent (intraclass correlation coefficient (2,k)=.985 and .983, respectively) and internal consistency was excellent (α=.94). A FIST-SCI cutoff score of 45 or greater was 92% sensitive and specific in characterizing transfer ability. Standard error of the measure (1.3) and minimal detectable change (3.5) were similar to previous work.


      Initial validity of the FIST-SCI is reported, but further assessment is required. Reliability is excellent in the cSCI population. FIST-SCI scores provide clinical insight into the seated functional ability of individuals with cSCI.


      List of abbreviations:

      AIS (American Spinal Injury Association Impairment Scale), AT (assisted transfer), (Cronbach’s alpha), CI (confidence interval), FIST (Function in Sitting Test), FIST-SCI (SCI version of the FIST), FSB (functional sitting balance), IC (internal consistency), ICC (intraclass correlational coefficient), IT (independent transfer), KGV (known-groups validity), LOI (level of injury), MAS-SCI (Motor Assessment Scale item 3), MDC (minimal detectable change), OM (outcome measure), SCI (spinal cord injury)
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        • Abou L.
        • de Freitas G.R.
        • Palandi J.
        • Ilha J.
        clinical instruments for measuring unsupported sitting balance in subjects with spinal cord injury: a systematic review.
        Top Spinal Cord Inj Rehabil. 2018; 24: 177-193
        • Anderson K.D.
        Targeting recovery: priorities of the spinal cord-injured population.
        J Neurotrauma. 2004; 21: 1371-1383
        • Chen C.L.
        • Yeung K.T.
        • Bih L.I.
        • Wang C.H.
        • Chen M.I.
        • Chien J.C.
        The relationship between sitting stability and functional performance in patients with paraplegia.
        Arch Phys Med Rehabil. 2003; 84: 1276-1281
        • Jorgensen V.
        • Elfving B.
        • Opheim A.
        Assessment of unsupported sitting in patients with spinal cord injury.
        Spinal Cord. 2011; 49: 838-843
        • Lynch S.M.
        • Leahy P.
        • Barker S.P.
        Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury.
        Phys Ther. 1998; 78: 128-133
        • Sprigle S.
        • Maurer C.
        • Holowka M.
        Development of valid and reliable measures of postural stability.
        J Spinal Cord Med. 2007; 30: 40-49
        • Quinzanos J.
        • Villa A.R.
        • Flores A.A.
        • Perez R.
        Proposal and validation of a clinical trunk control test in individuals with spinal cord injury.
        Spinal Cord. 2014; 52: 449-454
        • Boswell-Ruys C.L.
        • Sturnieks D.L.
        • Harvey L.A.
        • Sherrington C.
        • Middleton J.W.
        • Lord S.R.
        Validity and reliability of assessment tools for measuring unsupported sitting in people with a spinal cord injury.
        Arch Phys Med Rehabil. 2009; 90: 1571-1577
        • Dallmeijer A.J.
        • van der Woude L.H.V.
        Health related functional status in men with spinal cord injury: relationship with lesion level and endurance capacity.
        Spinal Cord. 2001; 39: 577-583
        • Arora T.
        • Oates A.
        • Lynd K.
        • Musselman K.E.
        Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: a systematic review.
        J Spinal Cord Med. 2018; 43: 10-23
        • Kahn J.H.
        • Tappan R.
        • Newman C.P.
        • et al.
        Outcome measure recommendations from the Spinal Cord Injury EDGE Task Force.
        Phys Ther. 2016; 96: 1832-1842
      1. Audu ML, Murphy JO, Triolo RJ. Trunk stability after spinal cord injury. Paper presented at: 17th Annual Meeting of the International Functional Electrical Stimulation Society; September 9-12, 2012; Banff, Alberta, Canada. Available at: Accessed August 19, 2020.

        • Chisholm A.E.
        • Alamro R.A.
        • Williams A.M.
        • Lam T.
        Overground vs. treadmill-based robotic gait training to improve seated balance in people with motor-complete spinal cord injury: a case report.
        J Neuroeng Rehabil. 2017; 14: 27
        • Gorman S.L.
        • Radtka S.
        • Melnick M.E.
        • Abrams G.M.
        • Byl N.N.
        Development and validation of the Function In Sitting Test in adults with acute stroke.
        J Neurol Phys Ther. 2010; 34: 150-160
        • Gorman S.L.
        • Harro C.C.
        • Platko C.
        • Greenwald C.
        Examining the function in sitting test for validity, responsiveness, and minimal clinically important difference in inpatient rehabilitation.
        Arch Phys Med Rehabil. 2014; 95: 2304-2311
        • Gorman S.L.
        • Rivera M.
        • McCarthy L.
        Reliability of the Function in Sitting Test (FIST).
        Rehabil Res Pract. 2014; 2014: 593280
        • Abou L.
        • Sung J.
        • Sosnoff J.J.
        • Rice L.A.
        Reliability and validity of the function in sitting test among non-ambulatory individuals with spinal cord injury.
        J Spinal Cord Med. 2019 Apr 18; ([Epub ahead of print])
        • Larson C.A.
        • Tezak W.D.
        • Malley M.S.
        • Thornton W.
        Assessment of postural muscle strength in sitting: reliability of measures obtained with hand-held dynamometry in individuals with spinal cord injury.
        J Neurol Phys Ther. 2010; 34: 24-31
        • Sung J.
        • Ousley C.M.
        • Shen S.
        • Isaacs Z.J.
        • Sosnoff J.J.
        • Rice L.A.
        Reliability and validity of the function in sitting test in nonambulatory individuals with multiple sclerosis.
        Int J Rehabil Res. 2016; 39: 308-312
        • Bland J.M.
        • Altman D.G.
        Statistics notes: Cronbach's alpha.
        BMJ. 1997; 314: 572
        • Carr J.H.
        • Shepherd R.B.
        • Nordholm L.
        • Lynne D.
        Investigation of a new motor assessment scale for stroke patients.
        Phys Ther. 1985; 65: 175-180
        • Carter R.
        • Lubinsky J.
        • Domholt E.
        Rehabilitation research, principles and applications. 3rd ed.
        Elsevier Saunders, Philadelphia2005
        • Henson R.K.
        Understanding internal consistency reliability estimates: a conceptual primer on coefficient alpha.
        Meas Eval Couns Dev. 2001; 34: 177-189
        • Trevethan R.
        Intraclass correlation coefficients: clearing the air, extending some cautions, and making some requests.
        Health Serv Outcome Res Meth. 2016; 17: 127-143
        • McGraw K.O.
        • Wong S.P.
        Forming inferences about some intraclass correlation coefficients..
        Psychol Methods. 1996; 1: 30-46
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research: applications to practice. 3rd ed.
        Pearson Education, Upper Saddle River2009
        • Sim J.
        • Wright C.C.
        The kappa statistic in reliability studies: use, interpretation, and sample size requirements.
        Phys Ther. 2005; 85: 257-268
        • Forslund E.B.
        • Jorgensen V.
        • Franzen E.
        • et al.
        High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: a prospective study of risk indicators.
        J Rehabil Med. 2017; 49: 144-151
        • Copay A.G.
        • Subach B.R.
        • Glassman S.D.
        • Polly Jr., D.W.
        • Schuler T.C.
        Understanding the minimum clinically important difference: a review of concepts and methods.
        Spine J. 2007; 7: 541-546