Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697801167256.pdf (Liberia)
01 LOEWENSTEIN HOSPITAL REHABILITATION CENTER Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University Department IV, Medical Director: Dr. Amiram Catz Tel: 972-9-7709090 Fax: 972-9-7709986 e-mail: amiramc@clalit.org.il Patient Name: ____________________ID:______________ Examiner Name: _________________ (Enter the score for each function in the adjacent square, below the date.

The form may be used for up to 6 examinations.)


תואירב שי יתור תואירב יתוריש ת י ל ל כ ת י ל ל כ Version III, Sept 14, 2002 EXam \ \ \ \ \ \ \ SCIM-SPINAL CORD INDEPENDENCE MEASURE Self-Care DATE 1.

Feeding (cutting, opening containers, pouring, bringing food to mouth, holding cup with fluid) 0.

Needs parenteral, gastrostomy, or fully assisted oral feeding 1.

Needs partial assistance for eating and/or drinking, or for wearing adaptive devices 2.
Eats independently; needs adaptive devices or assistance only for cutting food and/or pouring and/or opening containers 3.

Eats and drinks independently; does not require assistance or adaptive devices 2.

Bathing (soaping, washing, drying body and head, manipulating water tap).

A-upper body; B-lower body A.

0.

Requires total assistance 1.

Requires partial assistance 2.

Washes independently with adaptive devices or in a specific setting (e.g., bars, chair) 3.
Washes independently; does not require adaptive devices or specific setting (not customary for healthy people) (adss) B.

0.

Requires total assistance 1.

Requires partial assistance 2.

Washes independently with adaptive devices or in a specific setting (adss) 3.

Washes independently; does not require adaptive devices (adss) or specific setting 3.

Dressing (clothes, shoes, permanent orthoses: dressing, wearing, undressing).

A-upper body; B-lower body A.

0.

Requires total assistance 1.


Requires partial assistance with clothes without buttons, zippers or laces (cwobzl) 2.

Independent with cwobzl; requires adaptive devices and/or specific settings (adss) 3.

Independent with cwobzl; does not require adss; needs assistance or adss only for bzl 4.

Dresses (any cloth) independently; does not require adaptive devices or specific setting B.

0.

Requires total assistance 1.

Requires partial assistancewith clothes without buttons, zipps or laces (cwobzl) 2.
Independent with cwobzl; requires adaptive devices and/or specific settings (adss) 3.

Independent with cwobzl without adss; needs assistance or adss only for bzl 4.

Dresses (any cloth) independently; does not require adaptive devices or specific setting 4.

Grooming (washing hands and face, brushing teeth, combing hair, shaving, applying makeup) 0.

Requires total assistance 1.

Requires partial assistance 2.

Grooms independently with adaptive devices 3.


Grooms independently without adaptive devices SUBTOTAL (0-20) Respiration and Sphincter Management 5.

Respiration 0.

Requires tracheal tube (TT) and permanent or intermittent assisted ventilation (IAV) 2.

Breathes independently with TT; requires oxygen, much assistance in coughing or TT management 4.

Breathes independently with TT; requires little assistance in coughing or TT management 6.
Breathes independently without TT; requires oxygen, much assistance in coughing, a mask (e.g., peep) or IAV (bipap) 8.

Breathes independently without TT; requires little assistance or stimulation for coughing 10.

Breathes independently without assistance or device 6.

Sphincter Management - Bladder 0.

Indwelling catheter 3.

Residual urine volume (RUV) > 100cc; no regular catheterization or assisted intermittent catheterization 6.
RUV < 100cc or intermittent self-catheterization; needs assistance for applying drainage instrument 9.

Intermittent self-catheterization; uses external drainage instrument; does not need assistance for applying 11.

Intermittent self-catheterization; continent between catheterizations; does not use external drainage instrument 13.

RUV <100cc; needs only external urine drainage; no assistance is required for drainage 15.

RUV <100cc; continent; does not use external drainage instrument 7.
Sphincter Management - Bowel 0.

Irregular timing or very low frequency (less than once in 3 days) of bowel movements 5.

Regular timing, but requires assistance (e.g., for applying suppository); rare accidents (less than twice a month) 8.

Regular bowel movements, without assistance; rare accidents (less than twice a month) 10.

Regular bowel movements, without assistance; no accidents 8.

Use of Toilet (perineal hygiene, adjustment of clothes before/after, use of napkins or diapers).

0.
0.

Requires total assistance 1.

Requires partial assistance; does not clean self 2.

Requires partial assistance; cleans self independently 4.

Uses toilet independently in all tasks but needs adaptive devices or special setting (e.g., bars) 5.

Uses toilet independently; does not require adaptive devices or special setting) SUBTOTAL (0-40) \ \ \ \ \ \ \ Mobility (room and toilet) DATE 9.

Mobility in Bed and Action to Prevent Pressure Sores 0.
Needs assistance in all activities: turning upper body in bed, turning lower body in bed, sitting up in bed, doing push-ups in wheelchair, with or without adaptive devices, but not with electric aids 2.

Performs one of the activities without assistance 4.

Performs two or three of the activities without assistance 6.

Performs all the bed mobility and pressure release activities independently 10.
Transfers: bed-wheelchair (locking wheelchair, lifting footrests, removing and adjusting arm rests, transferring, lifting feet).

0.

Requires total assistance 1.

Needs partial assistance and/or supervision, and/or adaptive devices (e.g., sliding board) 2.

Independent (or does not require wheelchair) 11.


Transfers: wheelchair-toilet-tub (if uses toilet wheelchair: transfers to and from; if uses regular wheelchair: locking wheelchair, lifting footrests, removing and adjusting armrests, transferring, lifting feet) 0.

Requires total assistance 1.

Needs partial assistance and/or supervision, and/or adaptive devices (e.g., grab-bars) 2.

Independent (or does not require wheelchair) Mobility (indoors and outdoors, on even surface) 12.

Mobility Indoors 0.
Mobility Indoors 0.

Requires total assistance 1.

Needs electric wheelchair or partial assistance to operate manual wheelchair 2.

Moves independently in manual wheelchair 3.

Requires supervision while walking (with or without devices) 4.

Walks with a walking frame or crutches (swing) 5.

Walks with crutches or two canes (reciprocal walking) 6.

Walks with one cane 7.

Needs leg orthosis only 8.

Walks without walking aids 13.

Mobility for Moderate Distances (10-100 meters) 0.


Requires total assistance 1.

Needs electric wheelchair or partial assistance to operate manual wheelchair 2.

Moves independently in manual wheelchair 3.

Requires supervision while walking (with or without devices) 4.

Walks with a walking frame or crutches (swing) 5.

Walks with crutches or two canes (reciprocal walking) 6.

Walks with one cane 7.

Needs leg orthosis only 8.

Walks without walking aids 14.

Mobility Outdoors (more than 100 meters) 0.


Requires total assistance 1.

Needs electric wheelchair or partial assistance to operate manual wheelchair 2.

Moves independently in manual wheelchair 3.

Requires supervision while walking (with or without devices) 4.

Walks with a walking frame or crutches (swing) 5.

Walks with crutches or two canes (reciprocal waking) 6.

Walks with one cane 7.

Needs leg orthosis only 8.

Walks without walking aids 15.

Stair Management 0.
Stair Management 0.

Unable to ascend or descend stairs 1.

Ascends and descends at least 3 steps with support or supervision of another person 2.

Ascends and descends at least 3 steps with support of handrail and/or crutch or cane 3.

Ascends and descends at least 3 steps without any support or supervision 16.

Transfers: wheelchair-car (approaching car, locking wheelchair, removing arm- and footrests, transferring to and from car, bringing wheelchair into and out of car) 0.

Requires total assistance 1.


Needs partial assistance and/or supervision and/or adaptive devices 2.

Transfers independent; does not require adaptive devices (or does not require wheelchair) 17.

Transfers: ground-wheelchair 0.

Requires assistance 1.

Transfers independent with or without adaptive devices (or does not require wheelchair) SUBTOTAL (0-40) TOTAL SCIM SCORE (0-100)