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.


Bowel Dysfunction SCI Studies: Two cross-sectional observational studies.

  1. 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.

  2. Liu CW, Huang CC, Yang YH, Chen SH, Weng MC, Huang MH. Relationship between neurogenic bowel dysfunction and health-related quality of life in persons with spinal cord injury. J Rehabil Med 2009;41:35-40.

Sensitivity to Impact: Noonan et al. (2008) examined the effect of associated spinal cord injury (SCI) secondary health conditions on health status and quality of life (Qo)L in SCI patients with traumatic central cord syndrome (N = 70). The physical component of the Short-Form Health Survey 36 (SF-36) was associated with bowel dysfunction, although the effect decreased when influencing factors were controlled for. These findings support prior studies showing that bowel dysfunction has an impact on Physical Functioning; it also helped to quantify the estimate of this effect.

Although this study had a number of limitations, including small sample size and lack of detail regarding severity of reported secondary health conditions, results were supported by Liu et al. (2009), who assessed the relationship between the severity of neurogenic bowel (using the Neurogenic Bowel Dysfunction [NBD] Score) and health-related QoL (using the SF-36) in persons with various degrees of SCI (N = 128). Results showed an inverse association between scores on the SF-36 and the NBD, in which persons with minor neurogenic bowel disorder had the highest scores on the SF-36, compared to persons with severe neurogenic bowel disorder, who had the lowest scores. Significant differences appeared on the physical functioning and physical component summary sub-scales.

Suggestions for Use: The evidence on the sensitivity of the SF-36 to bowel dysfunction after SCI is promising 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 has items that 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., NBD 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 bowel dysfunction.

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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