Review article 111
Health-related quality of life after stroke:
what are we measuring?
Katherine L. Saltera, Matthew B. Mosesa, Norine C. Foleya and
Robert W. Teasella,b
As there is no single, accepted definition of health-related
quality of life (HRQOL), it is assumed to be a broad,
multidimensional construct referring to those aspects of
people’s lives that reasonably relate to their health.
Although many scales are used to assess HRQOL, the
operationalization of this construct within each tool is
unclear. To clarify what each tool is measuring, this study
c 2008
reviewed eight scales commonly used to evaluate HRQOL
after stroke. Two reviewers classified scale items from five
generic and three stroke-specific scales within an
established framework with nine dimensions; physical
functioning, symptoms, global judgments of health,
psychological well-being, social well-being, cognitive
functioning, role activities, personal constructs, and
satisfaction with care. All scales reviewed provide
multidimensional assessment, but vary in number and
combination of dimensions. All include assessment of
physical functioning and most incorporate concepts, such
as psychological well-being, social well-being, and role
activities. One generic (Sickness Impact Profile) and two
stroke-specific scales (Stroke Impact Scale and Stroke-
Specific Quality of Life Scale) seemed most
Introduction
Interventions in stroke rehabilitation focus on the
alleviation of symptoms and restoration of function.
Traditionally, outcome assessment has reflected this
focus. In recent years, there has been increasing interest
in patient-centered assessment inclusive of an expanded
range of outcomes, such as health status, social participa-
tion, or quality of life. Evaluation of the effectiveness of
interventions should take into account not only the
perspective of the healthcare professional or clinician,
but also that of the patient. As it is important to know
whether an intervention has resulted in a clinically
significant difference in symptoms or function, the
impact of treatment on individual quality of life is the
key (Gladis et al., 1999). Patient-reported outcomes
enhance our understanding of treatment outcomes and,
in effect, translate clinical improvement into patient-
centered results (Wiklund, 2004).
The effectiveness of rehabilitation interventions should
be assessed relative to the probability that they will result
in improved quality of life, as it pertains to the experience
of illness as well as physical, emotional, and social well-
0342-5282
c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
comprehensive. Evaluated against a common framework of
dimensions, scales commonly used in the assessment of
HRQOL after stroke provide varying multidimensional
assessments of aspects of life function related to health.
Whether any of these assessments are sufficient to
describe HRQOL in its entirety is unclear. International
Journal of Rehabilitation Research 31:111–117
Wolters Kluwer Health | Lippincott Williams & Wilkins.
International Journal of Rehabilitation Research 2008, 31:111–117
Keywords: assessment, quality of life, stroke
a
Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research
Institute, Parkwood Hospital site and bDepartment of Physical Medicine and
Rehabilitation, Schulich School of Medicine, University of Western Ontario,
London, Ontario, Canada
Correspondence to Katherine L. Salter, BA, Research Associate, Aging,
Rehabilitation and Geriatric Care Program, Room 3019b, Parkwood Hospital,
801 Commissioners Rd. East N6C 5J1, London, Ontario, Canada
Tel: + 42739 x519 685 4000; fax: + 42739 x519 685 4023;
e-mail: katherine.salter@sjhc.london.on.ca
Received 24 May 2007 Accepted 14 September 2007
being (Doyle, 2002; Garratt et al., 2002). Assessments
providing information of this nature have been variously
referred to as measures of health-related quality of life
(HRQOL), health status, functional well-being, subjec-
tive health status, or quality of life (Fitzpatrick et al.,
1998). Although definitions exist for each of these
constructs, there is no single, agreed-upon definition of
either quality of life or HRQOL. It is generally assumed
that HRQOL is a broad, multidimensional construct
referring to those aspects of people’s lives that reasonably
relate to their health (Fuhrer, 2000), whereas quality of
life is a much larger, superordinate construct (Ferrans,
1990; Post et al., 1999; Fuhrer, 2000).
Although there is no single, accepted definition of
HRQOL, there is a substantial body of literature devoted
to discussing and identifying important domains to be
included within this construct. In 1998, Fitzpatrick et al.
systematically reviewed this literature and compiled from
it a list of nine dimensions identified as relevant for the
assessment of HRQOL or health status (Table 1). The
resulting framework represents an attempt to draw
together dimensions identified as important in the
112 International Journal of Rehabilitation Research 2008, Vol 31 No 2

Table 1 Assessment dimensions for patient-based, health-related quality of life (Fitzpatrick et al., 1998)
Dimensions May include items to assess

Physical functioning
Symptoms
Global judgments of health
Psychological well-being
Social well-being
Cognitive functioning
Role activities
Personal constructs
Satisfaction with care
Mobility, dexterity, range of movement, physical activity, basic activities of daily living
Pain, nausea, appetite, energy, vitality, fatigue, sleep
How the respondent perceives his or her health, in general
Psychological illness, anxiety, depression, coping and adjustment, sense of control, self-efficacy, self-esteem
Personal relationships (family and intimate), social contact, community integration and social opportunities, leisure activities,
sexual activities and satisfaction
Cognition, alertness, concentration, memory, confusion, communication
Employment (or similar purposeful role activities), household management, housework, financial concerns
Bodily appearance or image, stigma and stigmatizing conditions, life satisfaction, spirituality
Perceived overall satisfaction with care received

assessment of patient-centered outcomes and reflects the
complexity and diversity of domains implicated in the
assessment of HRQOL.
Although numerous tools are available to measure
HRQOL, it is unclear what each tool assesses, particularly
in terms of domains relevant to the construct. Therefore,
we undertook a review of eight tools used in stroke
rehabilitation settings for the evaluation of HRQOL,
within the framework provided by Fitzpatrick et al.
(1998).
Methods
Findings from recent studies examining scale use in
various settings, both clinical (Haigh et al., 2001;
Torenbeek et al., 2001; van Wijck et al., 2001) and research
(Roberts and Counsell, 1998; Sanders et al., 1998; Buck
et al., 2000; Garratt et al., 2002; Teasell et al., 2006), as well
as two reviews of the assessment of HRQOL after stroke
(Saladin, 2000; Golomb et al., 2001) were reviewed. Using
these sources, we selected the following measures with
which many stroke rehabilitation practitioners would be
familiar: Medical Outcomes Study Short-Form 36 (SF-
36), Nottingham Health Profile (NHP), Sickness Impact
Profile (SIP), London Handicap Scale (LHS), and the
EuroQol Quality of Life Scale (EQ). As the most
commonly cited measures were generic (i.e. not specific
to any one health state or condition), the following
stroke-specific measures were also included; the Stroke
Impact Scale (SIS), the 30-item Stroke-Adapted SIP, and
the Stroke-Specific Quality of Life Scale (SSQOL).
Two researchers (K.S. and M.M.) independently re-
viewed the eight selected scales placing each scale item
within the dimensions identified by Fitzpatrick et al.
(1998). The results of this classification process were
examined collectively. The results presented represent
consensus after discussion of discordant classifications.
Description of scales
Nottingham Health Profile
The NHP was designed to be a brief, subjective measure
of perceived health encompassing the social and personal
effects of illness (Hunt et al., 1980, 1981, 1984, 1985).
Items and weights used in scoring were derived from
statements regarding the effects of ill health collected
from more than 700 patients with acute and chronic
ailments (Hunt et al., 1981).
The NHP consists of two parts; however, part II is rarely
administered (Salter et al., 2005) and will not be
discussed here. Part I contains 38 items in six dimensions:
physical mobility, pain, sleep, social isolation, emotional
reactions, and energy level. Each item is a statement of a
potential problem, which is either endorsed or rejected
by the respondent. Endorsed items are scored with their
associated weight. Weighted responses within each
dimension are summed to give a score out of 100. Higher
scores correspond to poorer perceived health status.
Results from the six dimensions should not be combined
to provide a total score.
The EuroQol Quality of Life Scale-5D
The EQ-5D is an internationally developed, generic
index used to value and describe health states (The
EuroQol Group, 1990; Euroqol Group, 2004). The EQ-5D
is a self-administered, two-part questionnaire. The first
part contains a simple descriptive profile of health in five
dimensions (mobility, self-care, usual activities, pain/
discomfort, and anxiety/depression). Each dimension is
represented by three descriptive statements reflective of
three levels of difficulty in that area. The respondent
chooses the statement most applicable to him/herself at
present within each dimension. Each statement selected
receives a numerical rating corresponding to the state-
ment’s level of difficulty; 1 = some or no problems,
2 = moderate problems, or 3 = extreme problems. These
ratings are combined such that each combination of
choices creates a five-digit expression of a health state.
Theoretically, there are 243 such representations pos-
sible. By applying scores from a standard set of values,
each of these health states can be transformed into a
utility value from 0 (worst possible) to 1 (best possible).
Standard weights or preferences were derived from
population data obtained using time trade-off techniques
(Finch et al., 2002). Part 2 of the EQ-5D consists of a
single visual analog scale item on which the respondent is

asked to rate his/her current state of health. Scores on
part 2 range from 0 (worst imaginable) to 100 (best
possible).
London Handicap Scale
The LHS was developed to provide an assessment based on
the descriptive system of the World Health Organization’s
International Classification of Impairments, Disabilities,
and Handicaps. The LHS classifies handicap according
to disadvantages on six dimensions; mobility, physical
independence, occupation, social integration, orientation,
and economic self-sufficiency (Harwood et al., 1994a, b).
Each dimension consists of a single question accompanied
by six descriptive statements, which represent a six-point
hierarchical scale of perceived disadvantage ranging from 0
(extreme disadvantage) to 6 (no disadvantage). Statements
are presented in terms of what someone is able to do with-
in his/her normal environment, regardless of human or
technical assistance that is required. Respondents are
instructed to select the descriptive statement most
representative of their situation over the past week
(Harwood et al., 1994a, b).
The LHS provides a profile of handicap based on
responses within each of the six dimensions as well as a
weighted total handicap score. Scale weights were
derived through interviews with 79 randomly selected,
community-dwelling adults who were asked to evaluate a
series of possible health states that could be described by
the LHS (Harwood et al., 1994a, b). The overall weighted
score should be interpreted as an estimate of the
desirability of the health state described by the
respondent’s profile (Harwood and Ebrahim, 2000a, b).
Medical Outcomes Study Short-Form 36
The SF-36 is a 36-item, generic health survey created to
assess health status (Ware and Sherbourne, 1992). Items
are organized into eight dimensions as follows: physical
functioning, role limitations – physical, bodily pain, social
functioning, general mental health, role limitations –
emotional, vitality, and general health perceptions. A
single question assesses perceived change in health status
over the past year; however, this item is not scored. With
this one exception, respondents are asked to complete
items, by circling the most appropriate response choice,
with reference to the past 4 weeks. An acute version of
the SF-36 refers to problems in the past week only
(McDowell and Newell, 1996). Items within subscales
are summed and expressed as a score ranging from 0 to
100 to provide a score for each subscale. In addition, a
physical component score and a mental component score
can be calculated. Standardized population data for
several countries are available for the SF-36 (McDowell
and Newell, 1996). Component scores have also been
standardized with a mean of 50 and standard deviation of
10 (Finch et al., 2002).
HRQOL: what are we measuring? Salter et al. 113
Sickness Impact Profile
The SIP is a comprehensive, behavior-based measure of
perceived health status originally intended for use in
health surveys, program planning, policy formation, and
monitoring patient progress in terms of sickness (Bergner
et al., 1976, 1981). The scale consists of 136 items or
statements about health-related dysfunction in 12
categories: sleep and rest, eating, work, home manage-
ment, recreation and pastime, ambulation, mobility, body
care and movement, social interaction, alertness/intellec-
tual functioning, emotional behavior, and communication.
Items were derived from descriptions of illness-related
behavioral dysfunction obtained from patients, indivi-
duals caring for patients, apparently healthy individuals,
and healthcare professionals. Item statements are
weighted based on the relative severity of dysfunction
associated with each statement (Bergner et al., 1976).
Respondents are asked to endorse items that are
(i) descriptive of themselves on the day of testing and
(ii) related to their health. Endorsed items are scored by
applying their associated scale value or weight. Scores are
calculated by expressing the summed value of endorsed
items as a percentage of the total possible item values
and may be calculated for the total scale, each subscale or
for each of two domains (physical and psychosocial).
Stroke-Adapted Sickness Impact Profile
The Stroke-Adapted SIP (SA-SIP-30) was derived directly
from the SIP following a three-stage process to eliminate
(i) items and subscales of least relevance to stroke survivors
and (ii) those with the lowest levels of reliability (van
Straten et al., 1997). The end result is a scale comprised of
30 items in eight subscales (body care and movement, social
interaction, mobility, communication, emotional behavior,
household management, alertness behavior, and ambula-
tion). Weights used in the SA-SIP-30 are the same as those
used in the parent scale (de Bruin et al., 1992).
Each item takes the form of a statement describing
changes in behavior that reflect the impact of illness on
some aspect of daily life. Respondents are asked to mark
items most descriptive of themselves on a given day. To
score the SA-SIP-30, weights are applied to marked
items, summed for each subscale, and expressed as a
percentage for each subscale. Higher scores are indicative
of poorer health outcome (van Straten et al., 1997).
Subscales can be combined to form two dimensions;
physical (body care and movement, ambulation, house-
hold management, and mobility) and psychosocial (alert-
ness behavior, communication, social interaction, and
emotional behavior) (van Straten et al., 1997).
Stroke Impact Scale
The SIS is a stroke-specific assessment of health status.
The scale was developed with input from both patients
114 International Journal of Rehabilitation Research 2008, Vol 31 No 2
and caregivers (Duncan et al., 1999), and is intended to
include domains from across the full impairment-
participation continuum (Duncan et al., 2000). The
current SIS 3.0 (Duncan et al., 2003) is comprised of 59
items in eight domains (strength, hand function,
Activities of Daily Living/Instrumental Activities of Daily
Living (ADL/IADL), mobility, communication, emotion,
memory and thinking, and participation) and a single
visual analog scale item used to rate perceived overall
recovery from stroke. Items are rated on a five-point
Likert scale in terms of the difficulty the patient has
experienced in completing them during the past week.
Aggregate scores, ranging from 0 to 100, are generated for
each domain. The four physical domains (strength, hand
function, mobility, and ADL/IADL) can be summed
together to create a single, physical dimension score,
whereas all other domains should remain separate
(Duncan et al., 1999).
Stroke-Specific Quality of Life Scale
The SSQOL is a patient-centered outcome measure
intended to provide an assessment of HRQOL specific to
stroke survivors. Scale domains and items were derived
from a series of focused interviews with survivors of
ischemic stroke (Williams et al., 1999b; Kelly-Hayes,
2000). The SSQOL consists of 49 items in 12 domains:
mobility, energy, upper extremity function, work/produc-
tivity, mood, self-care, social roles, family roles, vision,
language, thinking, and personality. Each item is rated on
a five-point Likert scale on one of three keyed response
sets (Williams et al., 1999b). Higher scores indicate better
function. The SSQOL yields both domain scores and an
overall SSQOL summary score. The domain scores are
unweighted averages of the associated items, whereas the
summary score is an unweighted average of all 12 domain
scores (Williams et al., 1999a).
Results
All eight instruments address multiple aspects of an
individual’s experience of HRQOL, as defined here by
the Fitzpatrick et al. (1998) framework. No scale included
items to assess all identified dimensions. However, the
number and combination of dimensions, as well as the
comprehensiveness of assessment within each one, varies
substantially from tool to tool. Results of the item-level
classification process are presented in Table 2.
Most items included in all scales fit into the adopted
framework based on the examples provided (see Table 1),
with the following exceptions. In the case of both the
LHS and the EQ-5D, several of the single item subscales
instruct the respondent to consider activities falling
within more than one area. Therefore, these items have
been listed in each dimension to which they might apply.
In addition, the SIP and its derivative scale, the SA-SIP-
30, contain a number of items for which classification was
ambiguous. For example, in each scale, the mobility
subscale items ‘stay home most of the time’ and ‘not
going into town’ could reflect social well-being as easily as
physical function, but were placed by the scale reviewers,
with the rest of the mobility items, under the heading of
physical function. Finally, five of the eight scales
(NHP, SIP, SA-SIP-30, SIS, and SSQOL) include an item
addressing the feeling of being a burden to others. This
item appears in the social isolation subscale of the NHP
and the family roles subscale of the SSQOL. In the
remaining three scales, it appears in subscales assessing
emotion or emotional behavior. The present reviewers
classified all items assessing the feeling of being a burden
as belonging to the psychological well-being dimension.
All of the assessment tools reviewed include items
designed to assess physical functioning. On all scales,
physical function is assessed with the greatest number of
items and/or subscales. The most common areas of
assessment in physical functioning are mobility, self-care,
and ambulation. Both the SIS and SSQOL also include
items to assess hand and upper limb function, which may
be of particular concern to individuals with stroke.
All scales include assessment of social well-being also, but
with fewer items than physical function. In the case of
the EQ-5D, inclusion of social well-being is limited to
examples provided on the list of possible activities the
respondent is asked to reference in choosing an appro-
priate response statement. Assessment of psychological
well-being was identified in all but one scale (LHS), as
was role activities (NHP).
Five scales (NHP, EQ-5D, SF-36, SIP, and SIS) include
assessment of symptoms (most often energy level or
pain) and five scales (LHS, SIP, and all three stroke-
specific scales) include assessment of cognitive function.
Two scales include assessment of personal constructs;
spirituality (SIS – one item) and personality (SSQOL –
two items). Finally, the EQ-5D, SF-36, SIP, and SIS
include assessment of global health perceptions, but none
of the scales reviewed evaluates satisfaction with care.
Discussion
Lacking a universally-accepted, formal definition for
HRQOL, a framework of dimensions identified as
important to the assessment of this construct (Fitzpatrick
et al., 1998) was used to compare the operationalization of
HRQOL in eight scales. Although most scales include
items to assess a common core of dimensions (physical
function, social well-being, psychological well-being, and
role activities), there is considerable variability among
these tools with regard to the combination of dimensions
assessed and the comprehensiveness of assessment
within each dimension. Assessments of symptoms, global
perceptions of health, cognitive function, and personal
Table 2 Results of item-level scale reviewa
Assessment Global perception Psychological Role Personal Satisfaction
scale Physical function Symptoms of health well-being Social well-being Cognitive function activities constructs with care

NHP part 1 Eight items (physical Eight items (pain), One item (‘I feel I am Four items (social
abilities) five items (sleep), a burden’ – social isolation)
three items isolation), nine
(energy level) items (emotional
reactions)
EQ-5D One item (mobility), one One item (pain/ One item (VAS One item (anxiety/ One item (usual One item (usual
item (self-care) discomfort) current health depression) activities) activities)
state)
LHS One item (mobility), One item One item One item (physical
one item (physical (occupation), (orientation) independence),
independence) one item (social one item (occu-
integration) pation), one item
(economic
self-sufficiency)
SF-36 Ten items (physical Two items (bodily Five items (general Five items (general Two items (social Four items (role
functioning) pain), four items health percep- mental health) functioning) limitations –
(vitality) tions) physical), three
items (role limita-
tions – emotional)
SIP Six items (#2–4, 7—9 – Seven items (sleep One item (‘express Seven items (emo- Eight items (recrea- Nine items 10 items (household
eating), 12 items (ambu- and rest), three concern over tional behavior) tion and (alertness and management),
lation), 10 items (mobi- items (#1,5,6 – what might be pastimes), intellectual nine items (role
lity), 23 items (body care eating), two items happening to my 19 items (social function), nine activities)
and movement), one item (‘moan and groan health’ — social interaction) items (communi-
(‘more minor accidents, in pain and rub- interaction) cation)
bump into things, trip bing or holding
and fall’ – alertness/ areas of my body
intellectual function) that hurt’ — emo-
tional behavior)
SA-SIP-30 Five items (body care and Four items Five items (social Three items (cogni- Four items (house-
movement), three items (emotional interaction) tive function), hold manage-
(mobility), three items behavior) three items (alert- ment)

HRQOL: what are we measuring? Salter et al. 115

(ambulation) ness behavior)
SIS Four items (strength), five One item (VAS Nine items (emotion) Five items (social Seven items One item (work – One item (spiritual/re-
items (hand function), recovery from one item (ability activities, quiet, (memory), seven participation) ligious activities–
nine items (mobility), stroke) to control life – and active recrea- items (communi- participation)
10 items (ADL/IADL) participation) tion, role as family cation)
member, ability to
help others —
participation)
SSQOL One item (‘did someone Four items (energy), One item (‘felt I was Two items (‘didn’t Seven items Three items (‘regular Two items (personality
else have to drive you’ one item (‘have to a burden’ – family join in activities (language), work around the has changed and
– family roles), 12 items stop and rest roles), eight items just for fun’, ‘phy- three items house’, ‘help to do not the same person
(mobility), eight items when working (mood), two items sical condition (thinking) the shopping’, – personality)
(self-care), nine items around the house’ (personality), one interfered in family ‘help taking care
(upper extremity func- — family roles) item (laughed or life’ – family of personal jobs’
tion), four items (vision) cried too easily — roles), seven – family roles),
thinking) items (social three items (work/
roles) productivity)

EQ-5D, EuroQol quality of life scale; LHS, London handicap scale; NHP, Nottingham health profile; SA-SIP-30, stroke-adapted sickness impact profile-30; SF-36, study short-form 36; SIP, sickness impact profile; SIS, stroke
impact scale; SSQOL, stroke-specific quality of life scale; VAS, Visual Analog Scale.
a
Results are reported as number of items (subscale). Where subscale items are distributed across domains, individual items are reported.
116 International Journal of Rehabilitation Research 2008, Vol 31 No 2
constructs are undertaken less frequently than any of
the core dimensions. Furthermore, none of the scales
includes items to assess satisfaction with care. Thus,
although all of the selected scales provide multi-
dimensional assessments of some aspects of life reason-
ably related to health, no single scale contains items
pertaining to all of the assessment dimensions identified
as important by Fitzpatrick et al. (1998).
If the dimensions identified by Fitzpatrick et al. (1998)
represent a reasonable operationalization of HRQOL,
then none of the scales reviewed in this study provides a
sufficiently broad assessment to describe this construct in
its entirety. Rather, they provide assessments of a variety
of subsets of HRQOL, made up of various combinations
of dimensions. The tools that come closest to the
assessment of HRQOL within this framework are the
SIP, the SIS, and the SSQOL. The SIP is a generic,
behavior-based measure of perceived health status,
whereas both the SIS and SSQOL are stroke-specific,
patient-based measures of HRQOL.
Generic versus stroke-specific scales
Typically, generic scales are designed to be broadly
applicable across diverse populations, allowing for com-
parison between various groups. Although certain core
assessment domains are significant to most patient
groups, others may be particular to the experiences of
individuals with a specific condition, such as stroke.
Generic assessments may fail to capture some of the more
‘condition-specific’ domains in stroke and thus, lose
sensitivity in terms of ability to detect important changes
in HRQOL during recovery or in response to intervention
(Buck et al., 2000; Doyle, 2002; Wiklund, 2004).
In general, the stroke-specific scales reviewed here
provide a broader assessment of HRQOL dimensions
than the generic scales. All of the stroke-specific scales
include an assessment of cognitive function and both the
SIS and SSQOL include items to assess other areas of
particular interest to individuals with stroke, such as
language or communication and upper extremity func-
tion. In contrast, only two of the five generic scales
include any assessment of cognitive function and only the
SIP includes items to assess language function.
Subjective versus objective assessment
Although the generic SIP was identified as providing a
broad assessment of dimensions identified as important
in HRQOL, it is a behavior-based measure constructed
specifically to provide an objective assessment of health
status (Bergner et al., 1981) and as such, does not reflect
the subjective experience associated with a given health
state. Indeed, it is the inclusion of patient values and
preferences that distinguishes quality of life assessment
from assessment that simply describes health or func-
tional status (Gill and Feinstein, 1994). In most
standardized scales, the content areas included are
presumed to be important to the individual to whom
the test is being administered (Bayley et al., 1995). Most
often, scale developers determine the domains, scale
items, and response sets to be included and, as a result,
scale content may have no particular relevance to the
respondent’s experience of HRQOL (Dijkers, 2003).
Although some scales report the use of patient-centered
development techniques (e.g. SIS and SSQOL), none
provide the opportunity for the individual to report
subjectively important areas of their life that are affected
by their health or to place a value of perceived
importance on the items that appear in the scales. Thus,
at best, these scales include items that may reflect some
subjective experience of some aspects of the content area
or dimension. Although providing means for the indivi-
dualization of assessment would fulfill the need for
subjectivity, measures that provide this opportunity are
associated with a larger burden of measurement for both
the patient and the assessor such that their application in
many clinical settings would be impractical (Dijkers,
2003).
Limitations
On the basis of a systematic review of the relevant
literature, Fitzpatrick et al. (1998) identified nine
dimensions important in the assessment of HRQOL.
However, this list has not been evaluated for its adequacy
in representing the construct of HRQOL. Although items
from each of the eight scales reviewed were assigned to
the various dimensions within the adopted framework,
there was no evaluation of the degree to which those
items were able to provide a comprehensive or adequate
assessment. Establishing the parameters that describe
what would constitute adequate assessment within each
possible dimension of HRQOL was beyond the scope of
this study.
Conclusion
Emphasis on the assessments that yield information
about the impact of stroke and stroke rehabilitation
interventions on individual quality of life is increas-
ing. Patient-centered outcomes, such as HRQOL,
provide valuable information to healthcare professionals
and policy makers in deciding upon appropriate treat-
ments and allocation of resources. However, universally
accepted definitions of quality of life and HRQOL do
not yet exist. On the basis of a common framework
of dimensions that are important for the assessment
of HRQOL, this study determined that five commonly
used generic scales and three stroke-specific scales
provide varying multidimensional assessments of aspects
of life function reasonably related to health. Whether any
of these assessments are sufficient to describe HRQOL
in its entirety is unclear. Further clarification of the
concept of HRQOL and the link between clinical care

and HRQOL is required. In addition, the way in which
this concept and its assessment relate to existing
comprehensive frameworks of individual health and
function, such as the International Classification of
Functioning Disability and Health, should be explored.
Acknowledgements
This work was funded by the Heart and Stroke
Foundation of Ontario and the Canadian Stroke Network.
Dr Teasell is a member of the Canadian Stroke Network
(http://www.canadianstrokenetwork.ca).
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