Stroke Impact Scale VERSION 3.0

1. Abstract

The Stroke Impact Scale VERSION 3.0 (SIS 3.0) is a premier, patient-centered psychometric instrument developed to evaluate health-related quality of life (HRQoL) and multidimensional functional disability in individuals following a cerebrovascular accident (stroke). Originating from the foundational work of Pamela W. Duncan and colleagues, the SIS 3.0 refines earlier iterations (Version 1.0 and Version 2.0) through rigorous application of Rasch analysis and classical test theory. The scale assesses 59 items organized across eight clinically distinct domains: Strength (4 items), Memory and Thinking (7 items), Emotion (9 items), Communication (7 items), Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL; 10 items), Mobility (9 items), Hand Function (5 items), and Social Participation (8 items). Additionally, a single visual analogue-type item measures perceived global stroke recovery on a 0–100 scale.

Items utilize distinct 5-point Likert-type scales with domain-specific recall windows (past 1 week, past 2 weeks, or past 4 weeks). Domain scores are transformed mathematically to a standardized metric ranging from 0 to 100, where higher scores represent superior functional capacity and lower perceived impact of stroke. The SIS 3.0 exhibits exceptional psychometric properties, including high internal consistency across all subscales (Cronbach’s α ranging from .83 to .96), robust test-retest reliability (intraclass correlation coefficients [κ / ICC] ranging from .70 to .92), and notable discriminant, convergent, and predictive validity against established external criteria, including the Barthel Index, the Functional Independence Measure (FIM), the Short-Form 36 Health Survey (SF-36), and the National Institutes of Health Stroke Scale (NIHSS). Clinically sensitive to subtle functional alterations across recovery trajectories, the SIS 3.0 is a gold-standard patient-reported outcome measure (PROM) for neurorehabilitation research and clinical care management.

2. Keywords

Stroke Impact Scale, SIS 3.0, patient-reported outcome measures, stroke rehabilitation, health-related quality of life, neurorehabilitation, psychometrics, Rasch analysis, functional mobility, social participation

3. Authors

The Stroke Impact Scale was conceptualized, developed, and refined by a multidisciplinary consortium of stroke rehabilitation researchers, physical therapists, neurologists, and psychometricians:

• Pamela W. Duncan, PhD, PT, FAPTA, FAHA: Professor of Physical Therapy and Health Policy, Department of Physical Therapy and Duke Clinical Research Institute, Duke University Medical Center; later Professor of Neurology at Wake Forest Baptist Health. Primary investigator leading the scale’s development.
• Rita K. Bode, PhD: Research Associate Professor and Psychometrician, Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago (RIC), Northwestern University Feinberg School of Medicine, Chicago, IL. Lead analyst for Rasch rating scale applications in SIS refinement.
• Sue Min Lai, PhD, MS, MBA: Professor of Biostatistics, Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS. Methodologist on longitudinal validation and responsiveness studies.
• Subashan Perera, PhD: Biostatistician and Associate Professor of Medicine and Biostatistics, Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA. Specialist in structural equation modeling and longitudinal change analyses for rehabilitation metrics.

4. Purpose

Cerebrovascular accidents represent a leading global cause of chronic adult disability, producing complex, heterogeneous neurological impairments that compromise motor control, cognitive processing, communicative fluency, emotional stability, and societal reintegration. Historically, stroke recovery and treatment efficacy were quantified through impairment-focused neurological examinations (such as the NIHSS) or generic basic functional measures (such as the Barthel Index and the FIM). While these instruments provide valuable clinical data regarding baseline severity and basic self-care independence, they exhibit substantial psychometric ceilings and floors. Crucially, generic and basic functional instruments fail to capture higher-level instrumental daily tasks, subtle sensorimotor deficits in the paretic upper extremity, communicative breakdowns in group dynamics, cognitive-executive lapses, emotional turmoil, or systemic restrictions in meaningful social participation.

The primary purpose of the Stroke Impact Scale VERSION 3.0 is to provide a comprehensive, stroke-specific, multidimensional patient-reported assessment tool sensitive to the full continuum of post-stroke disability. By design, the SIS captures the consequences of stroke across the entire trajectory of recovery, ranging from severe inpatient hemiplegia to mild community-dwelling re-engagement. Grounded in contemporary disablement paradigms, the instrument bridges the gap between biological organ-level impairment, functional task limitation, and social-societal restriction.

The clinical and scientific rationales underpinning the SIS 3.0 encompass several key objectives:

• Multidimensional Profiling: Stroke rarely impacts an isolated domain. The SIS 3.0 evaluates eight distinct functional domains simultaneously, generating an individualized profile of strengths, deficits, and rehabilitation priorities rather than an oversimplified composite score.
• Enhanced Sensitivity to Change: Generic HRQoL measures such as the Medical Outcomes Study SF-36 frequently lack sensitivity to stroke-specific therapeutic interventions. The SIS items were generated directly from stroke survivors, caregivers, and rehabilitation professionals to detect clinically meaningful alterations following targeted therapies (e.g., constraint-induced movement therapy, aerobic ambulation protocols, cognitive-linguistic retraining).
• Direct Amplification of Patient Perspective: As a PROM, the SIS 3.0 privileges the lived phenomenological experience of the survivor, capturing subjective difficulties in everyday contexts that standardized clinician-administered performance tests fail to replicate.
• Benchmarking and Clinical Decision-Making: In both clinical trials and routine neurorehabilitation practice, the SIS 3.0 provides standardized interval-scaled metrics that facilitate goal setting, discharge planning, interdisciplinary communication, and longitudinal tracking of post-stroke trajectories.

5. Psychological Construct

The central psychological and physiological construct measured by the Stroke Impact Scale VERSION 3.0 is stroke-specific health-related quality of life operationalized through functional independence, psychological adaptation, and social role fulfillment. Rather than viewing disability as a monolithic entity, the SIS 3.0 conceptualizes stroke impact as an interdependent network of specific functional constructs:

Domain 1: Strength

This domain captures the individual’s subjective perception of muscle force generation and motor activation in the hemiparetic extremities. Comprising four items, it assesses the perceived strength of the affected upper arm, hand grip, leg, and foot/ankle. Rather than measuring objective dynamometric force, it quantifies the subjective somatic experience of paresis during functional intention.

Domain 2: Memory and Thinking

Evaluating perceived neurocognitive functioning, this 7-item subscale captures everyday executive capacity, working memory, retrospective episodic recall, orientation, mental processing speed, and problem-solving. Items reflect real-world cognitive failures, such as forgetting instructions just delivered, failing to remember the previous day’s events, losing track of appointments, or struggling to resolve quotidian household dilemmas.

Domain 3: Emotion and Mood

This 9-item domain addresses post-stroke affective disturbance, psychological distress, depressive symptomatology, emotional lability, and existential self-appraisal. It probes feelings of dysphoria, perceived burdensomeness toward family, interpersonal alienation, self-blame, nervousness, and anhedonia, balanced by positively phrased inquiries into retained humor and the perceived value of life. It reflects the deep psychological coping mechanisms and emotional adjustment essential to holistic stroke recovery.

Domain 4: Communication

Covering receptive and expressive linguistic functioning, this 7-item construct evaluates pragmatic, social, and functional communication. It assesses anomic difficulties (naming familiar individuals or objects), conversational comprehension, reciprocal responding, group dialogue navigation, and telephonic communication (both conversational maintenance and technical dialing execution).

Domain 5: Activities of Daily Living / Instrumental ADL (ADL/IADL)

Spanning 10 items, this domain assesses complex self-care and community living tasks. It evaluates fine-motor self-care (cutting food with utensils, upper-body dressing, bathing, clipping toenails), continence control (bladder and bowel regulation, reaching the toilet punctually), and instrumental domestic management (light chores, community grocery shopping, and heavy home maintenance/yard work).

Domain 6: Mobility

Comprising 9 items, this subscale captures postural control, gross motor transfers, and ambulation within the home and the community. Items range from fundamental static balance (sitting and standing without falling) and transitional movements (bed-to-chair transfers, entering and exiting an automobile) to advanced locomotive tasks (walking one block, rapid walking, ascending single and multiple flights of stairs).

Domain 7: Hand Function

Focusing specifically on the paretic distal upper extremity, this 5-item domain measures manual dexterity, coordinated grasp, and fine motor manipulation. Activities include carrying heavy loads, turning doorknobs, opening sealed cans or jars, tying shoelaces, and performing high-precision pincer tasks such as retrieving a small coin (dime) from a flat surface.

Domain 8: Participation

The 8 items in this domain reflect the highest tier of disablement models: engagement in meaningful life roles. It evaluates subjective restrictions in competitive or voluntary employment, social interactions, quiet recreation (reading, crafts), active recreation (sports, travel), familial/friendship relational roles, spiritual/religious activities, general autonomy over life choices, and the altruistic capacity to assist others.

Item 9: Global Stroke Recovery

Measured via a single visual analogue / numerical rating scale from 0 (“No Recovery”) to 100 (“Full Recovery”), this item captures the survivor’s overarching gestalt appraisal of their recovery trajectory, integrating unmeasured internal psychological adaptations and physical improvements.

The SIS Physical Composite Score

In addition to individual domain profiles, researchers frequently aggregate Domains 1, 5, 6, and 7 (Strength, ADL/IADL, Mobility, and Hand Function) into an overarching SIS Physical Composite Domain, representing the global somatic and motor impact of the vascular lesion.

6. Theoretical Framework

The conceptual architecture of the Stroke Impact Scale VERSION 3.0 is fundamentally anchored in the International Classification of Functioning, Disability and Health (ICF) formulated by the World Health Organization, alongside foundational disablement models including Saad Nagi’s Disablement Paradigm and Verbrugge and Jette’s Disablement Process.

Prior to the adoption of these models, outcome assessment in neurology relied almost exclusively on the biomedical model, which presupposed a linear, deterministic relationship between anatomical brain injury (e.g., ischemic infarct volume) and clinical performance. The ICF framework revolutionized this paradigm by conceptualizing human functioning as a dynamic, bidirectional interplay across three systemic levels:

1. Body Functions and Structures (Impairments): Physiological and psychological functions of body systems (e.g., hemiparesis, cognitive slowing, affective dysregulation). In the SIS 3.0, this level is directly represented by the Strength, Memory and Thinking, and Emotion domains.
2. Activities (Execution of Tasks / Limitations): The nature and extent of functioning at the individual level, reflecting task performance in basic and instrumental realms. In the SIS 3.0, this level is operationalized by the Communication, ADL/IADL, Mobility, and Hand Function domains.
3. Participation (Involvement in Life Situations / Restrictions): Societal and environmental involvement reflecting personal fulfillment, interpersonal roles, and autonomous community reintegration. This is represented by the Participation domain.

The theoretical transition from SIS Version 2.0 to Version 3.0 was guided by Modern Psychometric Theory, specifically the application of the Rasch Measurement Model (a unidimensional formulation of Item Response Theory). Classical test theory assumes that total raw scores accurately reflect an underlying construct, despite ordinal response categories presenting unequal intervals. Duncan, Bode, Lai, and Perera (2003) recognized that adding ordinal ratings violates fundamental mathematical axioms. By deploying the Rasch Rating Scale Model, the authors subjected the 64 items of SIS 2.0 to rigorous calibration. Rasch modeling established that items within each domain represented a single underlying continuum (unidimensionality), identified items with redundant or invariant measurement properties, and eliminated items demonstrating psychometric misfit or severe item bias (differential item functioning across age, gender, or stroke severity).

Consequently, in SIS 3.0, problematic items from Version 2.0 (e.g., mathematical calculations in Memory; managing finances in ADL; getting out of a chair without arm support in Mobility; emotional connection in Participation) were eliminated or restructured. This transformation resulted in an optimized, mathematically robust 59-item structure capable of generating linear, interval-level measurement transformations for each domain.

7. Validity

The validity of the Stroke Impact Scale VERSION 3.0 has been extensively corroborated across diverse international cohorts, clinical trials, and epidemiological stroke registries.

Construct and Structural Validity (Rasch Calibration)

In the landmark Rasch psychometric analysis conducted by Duncan, Bode, Lai, and Perera (2003) on 285 stroke survivors evaluated at 1, 3, and 6 months post-stroke, each of the eight domains was evaluated for item-fit statistics using infit and outfit mean-square (MNSQ) calculations. All retained items demonstrated acceptable fit within the targeted range of 0.60 to 1.40, verifying that the items within each subscale map onto a single latent dimension without degrading measurement precision. Category functioning analysis confirmed that the 5-point Likert steps functioned monotonically, with step calibrations advancing progressively along the disability continuum.

Convergent Validity

Convergent validity has been established by correlating SIS 3.0 domains against corresponding legacy instruments:

• Physical Domains: The SIS Mobility, ADL/IADL, and Hand Function subscales demonstrate strong positive correlations with the Barthel Index (Pearson/Spearman coefficients $r = .74$ to $.84$) and the Physical Functioning subscale of the SF-36 ($r = .78$ to $.85$). The Hand Function domain correlates significantly with objective motor evaluations, including the upper extremity subscore of the Fugl-Meyer Assessment ($r = .82$).
• Cognitive Domain: The Memory and Thinking subscale exhibits moderate-to-strong correlations with the Mini-Mental State Examination (MMSE) ($r = .58$) and the Montreal Cognitive Assessment (MoCA) ($r = .64$).
• Affective Domain: The Emotion subscale correlates robustly in the expected inverse direction with standardized depression inventories, such as the Beck Depression Inventory (BDI) ($r = -.68$) and the Center for Epidemiologic Studies Depression Scale (CES-D) ($r = -.72$).
• Communication Domain: Exhibits high concordant validity with the Boston Diagnostic Aphasia Examination and the Western Aphasia Battery ($r = .65$ to $.79$).

Discriminant and Known-Groups Validity

The SIS 3.0 consistently discriminates between clinical subgroups stratified by stroke severity and neurological impairment. In comparative studies utilizing the NIHSS, individuals classified with mild strokes (NIHSS ≤ 5) score significantly higher across all eight domains ($p < .001$) than those with moderate-to-severe strokes (NIHSS ≥ 6). Similarly, the instrument effectively differentiates between individuals living independently in the community versus those residing in assisted care or inpatient skilled nursing facilities (Lai et al., 2003).

Predictive Validity and Responsiveness to Change

Longitudinal evaluation demonstrates that the SIS 3.0 exhibits superior sensitivity to change compared to generic measures such as the SF-36 and basic functional indices like the Barthel Index. Standardized Response Means (SRM) and Effect Sizes (ES) calculated from 1 to 6 months post-stroke reveal large magnitude changes for the Hand Function (SRM = 0.88), Mobility (SRM = 0.94), and ADL/IADL (SRM = 1.05) domains. Furthermore, baseline SIS 3.0 scores significantly predict 12-month community reintegration, functional ambulation speed, and return-to-work milestones.

8. Reliability

The Stroke Impact Scale VERSION 3.0 demonstrates excellent internal consistency, stability, and reproducibility across administrative modalities.

Internal Consistency

Across validation studies (Duncan et al., 1999, 2003; Carod-Artal et al., 2008), the SIS 3.0 subscales demonstrate high internal consistency reliability as evaluated by Cronbach’s alpha (α), consistently surpassing the conventional clinical threshold of .80:

• Strength: α = .83 – .88
• Memory and Thinking: α = .86 – .90
• Emotion: α = .83 – .86
• Communication: α = .88 – .92
• ADL / IADL: α = .92 – .95
• Mobility: α = .94 – .96
• Hand Function: α = .95 – .97
• Participation: α = .88 – .93
• SIS Physical Composite Score: α = .96 – .98

Test-Retest Reliability and Absolute Measurement Error

The temporal stability of the SIS 3.0 has been corroborated in clinically stable post-stroke cohorts assessed over 1- to 2-week intervals. Intraclass correlation coefficients (ICC, two-way mixed effects, absolute agreement) range from .70 to .92 across all subscales. Specifically, the Physical domains (Mobility, Hand Function, ADL) exhibit ICC values exceeding .85, whereas the Emotion and Memory domains range between .70 and .81.

Investigation of absolute reliability metrics reveals low Standard Error of Measurement (SEM) values across domain transformations. The Minimal Detectable Change at the 95% confidence level ($MDC_{95}$) ranges from 4.5 to 15.0 points across individual domains:

• Hand Function $MDC_{95}$: ~12.2 points
• Mobility $MDC_{95}$: ~7.8 points
• ADL/IADL $MDC_{95}$: ~5.9 points
• Participation $MDC_{95}$: ~11.1 points
• Perceived Recovery (0–100) $MDC_{95}$: ~10.5 points

Proxy Reliability

Because cognitive-linguistic deficits (e.g., severe aphasia) may prevent self-completion in a subset of stroke survivors, proxy-patient agreement has been empirically investigated (Duncan et al., 2002). Concordance between stroke survivors and close family proxies is high for observable physical domains (Mobility, ADL/IADL, Hand Function: ICC = .78 to .88), but moderate for internal subjective domains (Emotion, Memory: ICC = .50 to .65), mirroring standard proxy trends in HRQoL research.

9. Factor Analysis

The structural dimensionality of the Stroke Impact Scale was examined through exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Rasch partial credit / rating scale structural modeling across its development.

Exploratory and Confirmatory Factor Analysis

During early instrument development (Duncan et al., 1999), principal components analysis with varimax rotation was conducted on the initial item bank. The scree plot and eigenvalue analysis (>1.0 criterion) demonstrated eight distinct, clinically coherent factors that accounted for more than 68% of the total cumulative variance. Subsequent CFA confirmed that an 8-factor oblique model exhibited superior goodness-of-fit compared to a unidimensional or orthogonal structure, supporting the multidimensional construct of stroke recovery. Fit indices from structural equation modeling confirmed excellent fit:

• Comparative Fit Index (CFI) = .94 – .96
• Tucker-Lewis Index (TLI) = .93 – .95
• Root Mean Square Error of Approximation (RMSEA) = .048 (90% CI: .042 – .054)
• Standardized Root Mean Square Residual (SRMR) = .051

Standardized factor loadings for items within their designated domains were robust, with all items loading between .62 and .94, confirming high convergent indicator validity.

Rasch Structural Invariance and Domain Optimization

The transition from Version 2.0 to Version 3.0 was governed by Rasch structural analysis (Duncan et al., 2003). Rasch calibration tested whether the items within each proposed domain formed an invariant, unidimensional hierarchy. The Rasch model calibrates item difficulty ($eta$) and person ability ($ heta$) on the same common log-odds interval scale (logits). Key findings from this structural evaluation included:

• Item Infit/Outfit Diagnostics: Several items in Version 2.0 displayed significant underfit or overfit (MNSQ outside the 0.60–1.40 range). For instance, in Version 2.0 Domain 2 (Memory and Thinking), item 2e (“Add and subtract numbers”) loaded inadequately and demonstrated multidimensional misfit; it was removed, refining the domain to 7 items in Version 3.0.
• Domain 5 (ADL/IADL) Refinement: In Version 2.0, items evaluating “Handle money” and “Manage finances” exhibited severe floor effects and high cross-loadings onto cognitive dimensions. Their deletion yielded the cohesive 10-item ADL/IADL scale in Version 3.0.
• Domain 6 (Mobility) Refinement: Item 6e in Version 2.0 (“Get out of a chair without using your hands for support”) displayed redundant item calibration with bed-to-chair transfer and stair climbing; its elimination preserved a 9-item scale with well-spaced difficulty thresholds.
• Domain 8 (Participation) Refinement: Item 8f in Version 2.0 (“Ability to feel emotionally connected to another person”) displayed cross-contamination with the Emotion domain and was removed, establishing the 8-item participation construct of SIS 3.0.

10. Instrument / Measurement Tool

• Instrument Name: Stroke Impact Scale VERSION 3.0 (SIS 3.0)
• Test Type: Multidimensional, Stroke-Specific Patient-Reported Outcome Measure (PROM) / Self-Report Questionnaire (proxy administration permissible where indicated)
• Format: Paper-and-pencil questionnaire, interviewer-administered protocol, mail-administered survey, or standardized computerized assessment
• Target Population: Adult individuals surviving ischemic or hemorrhagic stroke across acute, subacute, and chronic phases
• Number of Items: 59 items distributed across 8 core domains, plus 1 global perceived stroke recovery visual analogue / rating scale item (Total: 60 components)
• Domain Breakdown:
  • Domain 1: Strength (4 items: 1a–1d)
  • Domain 2: Memory and Thinking (7 items: 2a–2g)
  • Domain 3: Emotion (9 items: 3a–3i)
  • Domain 4: Communication (7 items: 4a–4g)
  • Domain 5: ADL / IADL (10 items: 5a–5j)
  • Domain 6: Mobility (9 items: 6a–6i)
  • Domain 7: Hand Function (5 items: 7a–7e)
  • Domain 8: Participation (8 items: 8a–8h)
  • Stroke Recovery: 1 visual/numerical rating scale (0–100)
• Recall Windows:
  • Past 1 week: Domains 1 (Strength), 2 (Memory), 3 (Emotion), and 4 (Communication)
  • Past 2 weeks: Domains 5 (ADL/IADL), 6 (Mobility), and 7 (Hand Function)
  • Past 4 weeks: Domain 8 (Participation)
  • Present time: Stroke Recovery visual rating
• Response Scales:
  • Strength: 5-point Likert scale (5 = A lot of strength, 4 = Quite a bit of strength, 3 = Some strength, 2 = A little strength, 1 = No strength at all)
  • Memory, Communication: 5-point difficulty scale (5 = Not difficult at all, 4 = A little difficult, 3 = Somewhat difficult, 2 = Very difficult, 1 = Extremely difficult)
  • ADL/IADL, Mobility, Hand Function: 5-point difficulty scale (5 = Not difficult at all, 4 = A little difficult, 3 = Somewhat difficult, 2 = Very difficult, 1 = Could not do at all)
  • Emotion: 5-point frequency scale (5 = None of the time, 4 = A little of the time, 3 = Some of the time, 2 = Most of the time, 1 = All of the time). Note: Positively phrased items (3f, 3h, 3i) must be reverse scored prior to calculation.
  • Participation: 5-point frequency of limitation scale (5 = None of the time, 4 = A little of the time, 3 = Some of the time, 2 = Most of the time, 1 = All of the time)
  • Stroke Recovery: Bounded visual analogue/numeric rating scale from 0 (“No Recovery”) to 100 (“Full Recovery”) in gradations of 10.
• Standardized Scoring Algorithm:

  Individual domain scores are calculated by deriving the arithmetic mean of all completed items within that domain, provided at least 50% of the domain items are answered. The mean raw score is then converted into a transformed domain score ranging from 0 to 100 using the standard linear equation:

  $$\text{Transformed Domain Score} = \left[\frac{\text{Actual Mean Item Score} – 1}{5 – 1}\right] \times 100 = \left[\frac{\text{Actual Mean Item Score} – 1}{4}\right] \times 100$$

  Where 0 indicates maximum perceived stroke impact (complete functional limitation) and 100 indicates zero stroke impact (full functional capacity).

  The optional SIS Physical Composite Score is calculated by summing the transformed scores of Domains 1, 5, 6, and 7 and dividing by 4:

  $$\text{SIS Physical Composite} = \frac{\text{Score}_{\text{Strength}} + \text{Score}_{\text{ADL/IADL}} + \text{Score}_{\text{Mobility}} + \text{Score}_{\text{Hand Function}}}{4}$$

• Administration Time: Approximately 15 to 20 minutes for self-administration; 20 to 30 minutes when conducted via structured interview.

11. Permissions & Fee and Test Year

The development of the Stroke Impact Scale spans several developmental milestones: Version 1.0 (1999), Version 2.0 (1999/2002), and the definitive Rasch-calibrated Stroke Impact Scale VERSION 3.0 published in 2003 by Pamela W. Duncan, Rita K. Bode, Sue Min Lai, and Subashan Perera.

The Stroke Impact Scale is copyrighted by Pamela W. Duncan, PhD, and the contributing authors/institutions. However, the authors and supporting bodies have generously placed the instrument in the public academic domain for non-commercial clinical, educational, and non-funded academic research applications without licensing fees. Clinicians and researchers are permitted to reproduce and administer the English version and established translations, provided appropriate attribution and bibliographic citation are maintained, and the integrity of item phrasing and scoring algorithms is preserved without alteration.

For commercial use, incorporation within proprietary digital electronic medical record (EMR) software platforms, sponsored clinical trials funded by pharmaceutical or device enterprises, or requests regarding authorized cross-cultural adaptations and linguistic validations, formal written permissions or commercial licensing agreements must be requested through the primary developer or academic technology licensing offices associated with the developers (e.g., Duke University Medical Center or the University of Kansas Medical Center Research Institute).

12. References

• Carod-Artal, F. J., Coral, L. F., Trizotto, D. S., & Moreira, C. M. (2008). The Stroke Impact Scale 3.0: Evaluation of acceptability, reliability, and validity of the Brazilian version. Stroke, 39(9), 2477–2484. https://doi.org/10.1161/STROKEAHA.107.513671
• Duncan, P. W., Bode, R. K., Lai, S. M., & Perera, S. (2003). Rasch analysis of a new stroke-specific outcome scale: The Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation, 84(7), 950–963. https://doi.org/10.1016/S0003-9993(03)00035-2
• Duncan, P. W., Reker, D. M., Horner, R. D., Samsa, G. P., Hoenig, H., LaClair, B. J., & Dudley, T. K. (2002). Performance of a mail-administered version of a stroke-specific outcome measure: The Stroke Impact Scale. Clinical Rehabilitation, 16(5), 493–506. https://doi.org/10.1191/0269215502cr517oa
• Duncan, P. W., Wallace, D., Lai, S. M., Johnson, D., Embretson, S., & Laster, L. J. (1999). The Stroke Impact Scale Version 2.0: Evaluation of reliability, validity, and sensitivity to change. Stroke, 30(10), 2131–2140. https://doi.org/10.1161/01.STR.30.10.2131
• Duncan, P. W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J. J., Graham, G. D., Katz, R. C., Lamberty, K., & Reker, D. (2005). Management of adult stroke rehabilitation care: A clinical practice guideline. Stroke, 36(9), e100–e143. https://doi.org/10.1161/01.STR.0000180861.54180.FF
• Lai, S. M., Perera, S., Duncan, P. W., & Bode, R. (2003). Physical and social functioning after stroke: Comparison of the Stroke Impact Scale and Short-Form-36. Stroke, 34(2), 488–493. https://doi.org/10.1161/01.STR.0000054162.94998.C0
• Vanhook, P. M. (2007). Comeback of Appalachian female stroke survivors: The interrelationships of cognition, function, self-concept, interpersonal, and social relationships [Doctoral dissertation, East Tennessee State University]. Electronic Theses and Dissertations, Paper 2246. https://dc.etsu.edu/etd/2246
• World Health Organization. (2001). International Classification of Functioning, Disability and Health: ICF. World Health Organization. https://apps.who.int/iris/handle/10665/42407

13. Items of the Scale (Questionnaire)