Quality of Life Concepts

Secondary Health Conditions

Short-Form Health Survey 36 (SF-36)

Description: A generic health status measure (health-related quality of life [QoL]) designed to be applied to all health conditions and to assess general health concepts, such as functional status and well-being [1].

Format: 36 items covering eight domains: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health.

Scoring: The scoring is norm-based, with a general population mean score of 50 and a standard deviation of 10. Higher scores indicate higher levels of health. There is published data and norms available for most health conditions as well as for the general population (in Canada and USA).

In addition, the SF-36 can be scored to produce a preference-based single index measure for health from these data using general population values (SF-6D). The SF-6D allows the analyst to obtain quality adjusted life years (QALYs) from the SF-36 for use in cost utility analysis.  The scoring for the SF-6D can be obtained at: http://www.shef.ac.uk/scharr/sections/heds/mvh/sf-6d.

Administration and Burden: Interviewer-administered; Self-administered. Approximately 5-10 minutes.

Psychometrics for SCI: The SF-36 has acceptable psychometric properties in both the physical and mental components for use in the SCI population with some limitations [2].

Language(s): Translated for use in more than 40 other countries.

QoL Concept: The SF-36 is a measure of Health-Related QoL, which corresponds to Boxes B (societal standards and priorities) and C (achievements; health-related QoL) of Dijker’s Model

If the SF-6D scoring algorithm is used, then the SF-36 produces a Utility outcome, which corresponds to Boxes A (objective evaluations; quality adjusted life years), B (societal standards and priorities) and C (achievements; health-related QoL) of Dijker’s Model.

Permissions/Where to Obtain: Copyrighted; The SF-36 can be purchased at the SF-36 website at: http://www.sf-36.org/.


  1. Ware JEJ, Kosinski M, Gandek B. SF-36 health survey: manual and interpretation guide. Lincoln: Quality Metric; 2001.

  2. Ku JH. Health-related quality of life in patients with spinal cord injury: review of the short form 36-health questionnaire survey. Yonsei Med J 2007; 30;48:360-70.


Pain SCI Studies: Seven cross-sectional surveys, one randomized, double-blind, placebo-controlled crossover trial.

  1. Westgren N, Levi R. Quality of life and traumatic spinal cord injury. Arch Phys Med Rehabil 1998;79:1433-9.  

  2. Molton IR, Stoelb BL, Jensen MP, Ehde DM, Raichle KA, Cardenas DD. Psychosocial factors and adjustment to chronic pain in spinal cord injury: replication and cross-validation. J Rehabil Res Dev 2009;46:31-42. 

  3. Turner JA, Jensen MP, Warms CA, Cardenas DD. Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury. Pain 2002;98:127-34.

  4. Martin Ginis KAM, Latimer AE, McKechnie K, Ditor DS, McCartney N, Hicks AL et al. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. Rehabil Psychol 2003; 48:157-64.

  5. Jensen MP, Hoffman AJ, Cardenas DD. Chronic pain in individuals with spinal cord injury: a survey and longitudinal study. Spinal Cord 2005;43:704-12.

  6. Finnerup NB, Sindrup SH, Bach FW, Johannesen IL, Jensen TS. Lamotrigine in spinal cord injury pain: a randomized controlled trial. Pain 2002;96:375-83.

  7. Noonan VK, Kopec JA, Zhang H, Dvorak MF. Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome. Arch Phys Med Rehabil 2008;89:1074-82.

  8. Raichle KA, Hanley M, Jensen MP, Cardenas DD. Cognitions, coping and social environment predict adjustment to pain in spinal cord injury. J Pain 2007;8:718-29.

  9. Middleton J, Tran Y, Craig A. Relationship between quality of life and self-efficacy in persons with spinal cord injuries. Arch Phys Med Rehabil 2007;88:718-29.

Sensitivity to Impact: Westgren and Levi used the Short-Form 36 (SF-36) to determine associations between major outcome variables after spinal cord injury (SCI) and quality of life (QoL).  In their sample of persons with SCI (N = 320), neurogenic pain was found to be the most pronounced denominator of low QoL. The effect size for neurogenic pain was large on the bodily pain subscale, and medium on the general health sub-scale.

Molton and colleagues (2009) used the Brief Pain Inventory (BPI) and the SF-36 to replicate and extend previous work demonstrating associations among specific pain-related beliefs, coping, mental health and pain outcomes in persons with SCI (N = 130). Beliefs about pain and pain-related coping strategies significantly predicted pain outcomes and accounted for 21 to 25% of the variance. Pain accounted for 11% of the variance in predicting the SF-36 mental health score.

Turner and colleagues (2002) examined associations of catastrophizing and specific pain coping strategies with pain intensity, psychological distress, and pain-related disability in persons with SCI and chronic pain (N = 174). Their main outcome measures included the SF-36, the Coping Strategies Questionnaire (CSQ), and the Chronic Pain Grade Scale (CPGS). Results showed that pain coping and catastrophizing measures explained an additional 29% of the variance in pain intensity after adjusting for the demographic and SCI variables. The coping and catastrophizing scales accounted for an additional 30% of the variance in psychological distress and 11% of the variance in pain-related disability, after controlling for pain intensity and demographic and SCI variables.

Jensen and colleagues (2005) compared the severity of pain after SCI to national norms, and examined the association between pain measures and the prevalence and intensity of pain over time in patients with SCI (N = 147). Their battery included the SF-36, the Community Integration Questionnaire (CIQ), and a modified version of the BPI. Results showed an association between presence of pain and trends toward poorer psychological functioning and social integration. On average, pain severity, as measured by the SF-36, and pain interference were greater in the sample than in the normative population.

Finnerup and colleagues (2002) used the SF-36 to investigate the effectiveness of lamotrigine for the treatment of SCI pain and clinical signs of neuronal hyperexcitability in patients with SCI (N = 22). Changes in the physical and mental sub-scales of the SF-36 did not change from baseline to end-point for either the experimental or placebo control group.

Noonan and colleagues (2008) used the SF-36 and the Numeric QoL Rating Scale from the European Organization for Research and Treatment of Cancer (QLQ-C30) to determine the effect of associated SCI conditions on health status and QoL in a sample of persons with SCI (N = 70). There was a significant association between neuropathic pain and symptom satisfaction. Persons without pain were 3.7 times more likely to report symptoms satisfaction than those with pain.

Raichle and colleagues (2007) used a battery of tests, including the CPGS, the BPI, and the mental health sub-scale of the SF-36 to study the associations between specific pain-related beliefs, coping, and social support and both mental health and pain interference in persons with SCI (N = 157). They found that the interference sub-scale of the CPGS was significantly correlated with the SF-36.

Middleton and colleagues (2007) used the SF-36 and the Multidimensional Scale of Perceived Social Support (MSPSS) to study the interaction between QoL and expectations of daily living (self-efficacy) and pain. Low self-efficacy and pain intensity were found to reduce QoL across all SF-36 domains even further. A combination of low self-efficacy and pain intensity was associated with a higher rduction in QoL compared with reductions seen for these factors by themselves.

Suggestions for Use: The SF-36 demonstrates sensitivity to the impact of SCI-related chronic pain, but there are a number of advantages and disadvantages associated with the SF-36 that should be considered.

The SF-36 and its derivative (SF-12) are the most widely used measures of health status, which allows for the evaluation of various patient populations. The SF-36 has therefore been used widely in the SCI literature. However, there is some controversy regarding this measure of health-related QoL, which are not well-suited (e.g., items related to walking), or are viewed as demeaning to persons with SCI. There are also reported floor and ceiling effects. For a full review of the issues associated with the SF-36, refer to Hays et al. [1] and/or Andresen et al. [2]. 

The limitations associated with the SF-36 may be minimized by using it in conjunction with condition-specific tools (e.g., BPI and/or other measures of symptom impact). The SF-36 has been endorsed by the Spinal Cord Outcomes Partnership Endeavor (SCOPE) [3], which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations. The endorsement, however, is not specific for assessing the impact of pain.

Additional References:

  1. Hays RD, Hahn H, Marshall G. Use of the SF-36 and other health-related quality of life measures to assess persons with disabilities. Arch Phys Med Rehabil 2002;83:S4-S9.

  2. Andresen EM, Fouts BS, Romeis JC, Brownson CA. Performance of health-related quality-of-life instruments in a spinal cord injured population. Arch Phys Med Rehabil 1999;80:877-84.

  3. Alexander MS, et al. Outcome measures in spinal cord injury: Recent assessments and recommendations for future directions. Spinal Cord 2009:1-10.

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