Quality of Life Concepts

Secondary Health Conditions

Craig Handicap Assessment and Reporting Technique (CHART)

Description: The CHART was developed to assess the degree of handicap experienced by persons with spinal cord injury (SCI) across 6 domains: Orientation, Physical Independence, Mobility, Occupational Functioning, Social Integration, and Economic Self-Sufficiency [1].

Format: 32 items that are combined to provide sub-scale scores.

Scoring: The scoring scale has been calibrated to yield 100 for non-disabled respondents and 0 for persons with maximal handicap. Each domain can receive a maximum score of 100. Domain scores also can be combined to form a total score.

Administration and Burden: The CHART is administered by interview, either in person or over the telephone, and takes approximately 15 minutes. It is also possible to use the instrument as a mailed or self-administered questionnaire, although some data could potentially be lost.

Psychometrics for SCI: Test-retest reliability coefficients for the different sub-scales of the CHART range between .80 and .95. Validity of the scale has been shown to be high for individuals with SCI.

Languages: The CHART has been translated from English into Spanish, Japanese, Chinese, Korean, and Italian.

QoL Concept: The CHART is a measure of handicap, which corresponds to Boxes B (societal standards and priorities) and C (achievements; activities of daily living; community reintegration) of Dijker’s Model.

Permissions/Where to Obtain: Public Domain; The CHART can be obtained at the Centre for Outcome Measurement in Brain Injury at: http://tbims.org/combi/chart/index.html.


  1. Whiteneck G, Charlifue SW, Gerhart KA,olser JD, Richardson GN. Quantifying handicap: A new measure of long-term rehabilitation outcomes. Arch Phys Med Rehabil 1992;73:519-26.


Pain SCI Studies: Three longitudinal studies, two cross-sectional survey, one randomized, double-blind, placebo-controlled trial.

  1. Ballinger  DA, Rintala DH, Hart KA. The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: A multifaceted longitudinal study. Arch Phys Med Rehabil 2000;81:1575-81.

  2. Rintala DH, Loubser PG, Castro J, Hart KA, Fuhrer MJ. Chronic pain in a community-based sample of men with spinal cord injury: prevalence, severity, and relationship with impairment, disability, handicap, and subjective well-being. Arch Phys Med Rehabil 1998;79:604-14.

  3. Richardson EJ, Richards JS, Sutphin SM. A longitudinal study of joint pain following SCI: Concurrent trends in participation, depression, and the effects of smoking. Top Spinal Cord Inj Rehabil 2007;12:45-55.

  4. Putzke JD, Richards, JS, Dowler RN. The impact of pain in spinal cord injury: A case-control study. Rehabil Psychol 2000;45:386-401.

  5. Putzke JD, Richards JS, Hicken BL, DeVivo MJ. Interference due to pain following spinal cord injury: important predictors and impact on quality of life. Pain 2002;100:231-42.

  6. Cardenas DD, Warms CA, Turner JA, Marshall H, Brooke MM, Loeser JD. Efficacy of amitriptyline for relief of pain in spinal cord injury: results of a randomized controlled trial. Pain 2002;96:365-73

Sensitivity to Impact: Ballinger and colleagues (2000) used the Craig Handiap Assessment and Reporting Technique (CHART), along with a non-standardized study-specific questionnaire to determine if shoulder pain and range-of-motion (ROM) problems can be predicted by demographic, injury-related, body weight, and radiographic data over 3 years, and to determine the relationships among these shoulder problems and functional limitations, disability, and perceived health in men with spinal cord injury (SCI; N = 89). CHART mobility subscale scores were lower for those who reported shoulder pain. Compared to those without ROM problems, men with shoulder ROM problems were less likely to push their own wheelchairs and less likely to perform transfers without maximum assistance.

Rintala and colleagues (1998) used a battery of tests, including the Zung Pain and Distress Scale, to assess the prevalence, severity, and correlates of chronic pain in a community-based sample of men with SCI (N = 77). Chronic pain was associated with more depressive symptoms, more perceived stress, and poorer self-assessed health. Life satisfaction was negatively correlated with perceived stress and depressive symptoms. There also was a significant continuous correlation between the CHART social integration score and the Perceived Stress Scale.

Richardson and colleagues (2007) used the CHART to examine the number of reported joint pain sites among persons with SCI (N = 370) across a 15-year span, and to examine changes in pain that were related to physical independence, mobility, social integration, depression, and smoking. Although the number of musculoskeletal pain sites increased over time, there was no effect on CHART mobility, physical independence, or social integration scores. All CHART scores remained relatively stable over time, across all levels of impairment. This may be due to the increased use of assistive technology or mobility aids, which compensates for the effect of increasing pain sites.

Putzke and colleagues (2000) examined the impact of pain on functioning across multiple quality of life (QoL) domains among males with SCI (N = 172; n = 86 with no pain interference, and n = 86 with extreme pain interference) using the CHART, the Satisfaction with Life Scale (SWLS), and the Short-Form 12 (SF-12). No group differences were found on the CHART physical independence and occupation subscales. Compared to the no pain interference group, the extreme pain interference group had significantly lower scores on the SWLS, the CHART total score, and the SF-12 physical health summary and mental summary.

Putzke and colleagues (2002) conducted two studies on the predictive validity of multiple demographic, medical, and QoL variables, including the CHART, the SWLS, and the SF-12. The first study examined the predictive validity of these variables at 1 year post-SCI to self-reported interference 2 years post-injury. The prevalence of interference in daily activities secondary to pain decreased from year 1 to year 2. Higher satisfaction with life, physical health, and mental health at year 1 were associated with lower likelihood of pain interference at year 2.

The second study examined the predictive validity of the same variables in four groups of participants: (1) pain-free at years 1 and 2; (2) pain-free at year 1 and in pain at year 2; (3) in pain at year 1 and pain-free at year 2; (4) in pain at years 1 and 2. Groups 1 and 4 had similar levels of self-reported QoL, whereas groups 2 and 3 showed considerable difference in self-reported QoL across several domains. Higher scores on the mobility and social integration scales of the CHART were associated with lower levels of self-reported pain interference.

A study by Cardenas and colleagues (2002) determined whether amitriptyline was efficacious in relieving chronic pain and improving pain-related physical and psychosocial function in persons with SCI (N= 84). Their battery of tests included the Brief Pain Inventory (BPI), the SWLS, and the CHART. Patients were assigned to either amitriptyline treatment or an active placebo. Regression analyses showed that pre-treatment scores explained a large and significant portion of variance of the post-treatment scores, and treatment group did not make a significant contribution.

Suggestions for Use: The CHART appears to be somewhat insensitive to the impact of pain since it may be that people with SCI-related pain may be able to push through necessary activities but may limit their ability to participate in elective activities [1, 2] 

A noted limitation of the CHART is that it only assesses the extent of an individual’s social network. It does not assess important dimensions such as frequency of supportive behaviours offered by support network or the individual’s personal evaluation of the quality of their social support [3].

In order to overcome these limitations, the CHART should be used with other measures of social support. In addition, it has a ceiling effect for high functioning people with SCI [4].

Because the method of scoring leads to distributions that are not normally distributed, it may be necessary to statistically remove the cap of 100 points. As well, the use of the total score may lead to a misleading summary assessment, it is important to examine scores from each of the domains.

Regardless, the tool is recommended by the Spinal Cord Outcomes Partnership Endeavor’ (SCOPE) [5], 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 specifically for assessing the impact of SCI-related chronic pain.

Additional References:

  1. Putzke JD, Richards, JS, Dowler RN. The impact of pain in spinal cord injury: A case-control study. Rehabil Psychol 2000;45:386-401.

  2. Henwood P, Ellis JA. Chronic neuropathic pain in spinal cord injury: The patient's perspective. Pain Res Management 2004;9:39-45.

  3. Hicken BL, Putzke JD, Richards JS. Bladder management and quality of life after spinal cord injury. Am J Phys Med Rehabil 2001;80:916-22.

  4. Hall KM, Dijkers M, Whiteneck G, Brooks CA, Krause JS. The Craig handicap assessment and reporting technique (CHART): metric properties and scoring. Top Spinal Cord Inj Rehabil 1998;4:16-30.

  5. 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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