edicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;-:-------

ORIGINAL ARTICLE

Emotional Vitality: Concept of Importance for Rehabilitation

Skye P. Barbic, MSc,a Susan J. Bartlett, PhD,a,b Nancy E. Mayo, PhDa,c

From the aSchool of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal; bDepartment of Medicine, McGillUniversity, Montreal; and cDivision of Clinical Epidemiology, McGill University Health Center, Montreal, Quebec, Canada.

Abstract

Objectives: To (1) provide a framework for the conceptualization of emotional vitality as an important construct for rehabilitation professionals;

(2) outline the existing scope and breadth of knowledge currently available regarding the definition and measurement of emotional vitality in

persons with chronic health conditions; and (3) identify the extent to which the components can be mapped to the International Classification of

Functioning, Disability and Health (ICF).

Design: Activities included a scoping review of the literature, and a Delphi mapping exercise using the ICF.

Setting: Not applicable.

Participants: Not applicable.

Intervention: Not applicable.

Main Outcome Measure: Not applicable.

Results: The results of this study suggest that emotional vitality is a complex latent construct that includes (1) physical energy and well-being, (2)

regulation of mood, (3) mastery, and (4) engagement and interest in life. Existing literature supported the presence of all 4 components of the

construct. The mapping exercise showed that 3 of these components could be readily mapped to the Body Function chapter of the ICF (energy,

mood, mastery).

Conclusions: Emotional vitality may influence both the physical and emotional adaptation to living with a chronic illness or disability and should

be included in both assessment and treatment planning to optimize rehabilitation outcomes. Future research is needed to refine the definition and

identify optimal methods of measuring this construct.

Archives of Physical Medicine and Rehabilitation 2013;-:-------

ª 2013 by the American Congress of Rehabilitation Medicine

Rehabilitation specialists work with individuals whose functionhas been altered by disease, injury, or natural processes such asaging. While the physical aspects of function have been welldefined and measured, facilitating the development of clinicallyeffective interventions, and understanding and addressing theemotional response to functional loss have not been systematicallyaddressed. Increasingly referred to as “hidden disabilities,”1 theemotional aspects are often described using heterogeneous termssuch as energy, personal mastery, regulation of mood, motivation,and resilience.2-5 While many of these domains fall within thescope of the disability literature and practice, in physical reha-bilitation they are often considered challenging to address.

Presented to the International Society for Quality of Life Research, October 28, 2011, Denver,

CO.

Supported by the Heart and Stroke Foundation of Canada (grant no. FD1568).

No commercial party having a direct financial interest in the results of the research supporting

this article has or will confer a benefit on the authors or on any organization with which the authors

are associated.

0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Re

http://dx.doi.org/10.1016/j.apmr.2012.11.045

Viewing physical and emotional adjustment to chronic illness andinjury as separate processes may result in overlooking the recip-rocal nature that each has on the other and increases the likelihoodthat emotional well-being may not be adequately addressed.

Emotional vitality is a term that has been used to characterizean individual’s emotional response to adjusting to life witha chronic illness or injury.2,4 While emotional vitality may serveas a critical buffer against the strain of living with a chronic illnessor disability, very little is known about what enables some indi-viduals to thrive and be emotionally vital in the process ofrecovery and adaptation. If emotional vitality is indeed associatedwith or predictive of positive health outcomes, it may serve asa valuable and modifiable new target for intervention. Emotionalvitality may be a construct within an individual’s control,6-10 andthere is much to learn about how an individual’s emotionalresources may optimize health and rehabilitation outcomes.

However, in order to support and enhance emotional vitality inindividuals with chronic health conditions, a definition and

habilitation Medicine

2 S.P. Barbic et al

measurement strategy are needed. A comprehensive under-standing of patient and provider-valued components of emotionalvitality is essential to developing the appropriate measurementapproach and the potential emergence of a focused rehabilitationresearch agenda informing practice.

Our premise is that emotional vitality is an important constructin rehabilitation. If it is within the purview of rehabilitation,components of the construct should be represented in the nomen-clature already defined for the field. The World Health Organiza-tion’s International Classification of Functioning, Disability andHealth (ICF)11 provides a universal language and conceptualframework for describing health and disability. The ICF has beenused as a basis for establishing content validity for minimum datasets and measures in a variety of health conditions.12 Ourhypothesis is that if the ICF contains domains describing compo-nents of emotional vitality, then emotional vitality lies within thescope of measurement and practice of rehabilitation professionals.

The goal of this article is to lay a framework for the conceptu-alization of emotional vitality as an essential construct to address inboth the assessment and treatment of people experiencing functionalconsequences of a health event. In this article, we outline the scopeand breadth of knowledge currently available regarding the defini-tion and measurement of emotional vitality in persons with chronichealth conditions and identify the extent to which components ofemotional vitality can be mapped to the ICF classification system.11

Methods

The objectives were addressed using 2 different methodologies:(1) a scoping review of the literature, and (2) a Delphi mappingexercise among rehabilitation health professionals using the ICF.

Study 1: scoping review

The aim of the scoping review was to broadly map the key domainsunderpinning the construct of emotionalvitality and identify empiricalevidence currently available to measure emotional vitality in indi-vidualswith chronic health conditions.Scoping reviews can be used toexplore specific questions in the existent literature.13 As comparedwith systematic reviews, scoping reviews provide an overview ofcurrent knowledge and practices, but do not evaluate themethodologyor quality of studies currently available.13,14 The 5-stage methodo-logical framework13 to conduct this type of review was followed,including (1) identification of the research question; (2) identificationof all pertinent studies; (3) selectionof the studies for detailed analysis;(4) charting of the data according to key concepts; and (5) collationand summarization of the findings from selected studies.

Identification of the research questionThree questions were used to guide our review: (1) How isemotional vitality defined in the literature? (2) How is emotionalvitality measured? and (3) What is known from the existingliterature about the effectiveness of behavioral interventions thattarget components of emotional vitality in individuals withchronic health conditions?

List of abbreviations:

ICF International Classification of Functioning, Disability and

Health

Identification of pertinent studiesWe identified all relevant studies regardless of publication status(published, unpublished, in press, in progress). Four electronicdatabases were searched, including PsycINFO (1967 to June2012), MEDLINE (1966 to June 2012), EMBASE (1980 to June2012), and Cumulative Index to Nursing and Allied HealthLiterature (1960 to June 2012), using the terms “emotion*” AND“vitality” as keywords. The search was also conducted in theTrials Register of the Cochrane Depression, Anxiety, and NeurosisGroup, and the Cochrane Central Register of Controlled Trials(CENTRAL). The gray literature was also searched in theConference Papers Index, Dissertation Abstracts, and the Disser-tations and Theses database (United States, Canada, Scandinavia,United Kingdom) from 1980 to June 2012. The reference lists ofall the relevant articles were screened. We also contacted severalcolleagues in the field and asked them to identify any relevantpublished or unpublished articles on the topic that may have notbeen found in the initial search.

Selection of the studies for detailed analysisInitially, the titles and abstracts of all studies identified by elec-tronic searchers were independently screened by 2 investigators(S.B., D.B.) to shortlist studies for this review. We included allavailable articles published in English or French that described ormeasured emotional vitality in adults. Seven articles wereexcluded (5 were published in Chinese, 1 in Estonian, and 1 inGerman) because of the cost of translation. No methodologicallimitations were applied to screen for levels of evidence.

Charting of data according to key concepts and measurementstrategiesStudies were synthesized and sorted according to key issues andthemes.15 Author, year of publication, intervention (type,comparator, duration of intervention), study population, aims of thestudy, type of methodology, and outcome measures were recorded.Articles were then reviewed, sorted, and categorized in 3 ways: (1)definitions, (2) measurement strategy, and (3) study design.

Collation and summarization of the findings of selectedstudiesNext, we created a summary of each study without regard toassessment of study quality or the “weight” of evidence in relationto particular interventions.13

Study 2: ICF mapping exercise

The specific objective of this study was to estimate the extent towhich categories in the Body Function chapter of the ICF11 wereidentified as representing emotional vitality. This chapter waschosen for content purposes because we wanted to capture thephysiologic processes contributing to emotional vitality ratherthan the consequences of impaired emotional vitality that wouldbe represented in other chapters (Activity and Participation),recognizing that the domains in the other chapters would notuniquely be impacted by emotional vitality.

ParticipantsTwenty-five health professionals and graduate students wererecruited from an academic health university setting. Professionalscame from a number of different backgrounds including medicine(nZ2), psychology (nZ4), occupational therapy (nZ3),

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Fig 1 Inclusion and exclusion criteria to identify selected studies. Abbreviations: EV, emotional vitality; SF-36, Medical Outcomes Study

36-Item Short-Form Health Survey.

Emotional vitality 3

physiotherapy (nZ8), epidemiology (nZ4), and exercise physi-ology (nZ4). The participants had an average of 10.2 years(range, 0e38y) in clinical experience, 2.9 years of researchexperience with the ICF (range, 0.5e10y), and 1.3 years (range,0e10y) of clinical experience with the ICF.

ProceduresParticipants were asked to identify ICF Body Function categoriesthat fit within their conceptualization of emotional vitality. In theICF classification, each category is given an alphanumeric code,with the number of digits reflecting the granularity of the category.A Delphi technique16 using a threshold of 70%17 was used to gainconsensus on the ICF categories related to emotional vitality. TheDelphi technique was chosen because it ensures the contributionof each participant is equally recognized, regardless of disciplineor years of experience.16,18,19

In the first round, a spreadsheet with all ICF codes from thefirst chapter of the ICF, along with a link to definitions on theelectronic version of the ICF, was provided, as well as a copy ofthe ICF book if desired. The participants were asked to indicate allcodes that they felt captured the construct of emotional vitality.

In round 2, a second spreadsheet containing frequency ofresponses for each category from round 1 was e-mailed to partici-pants 1 month later. Participants were asked to review the responses

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provided by other participants and consider whether they wished tochoose the same or a different category from the ones initiallyselected in round one, or alternatively remove a category.

Data analysis

All 25 spreadsheets were returned in both rounds. Each spread-sheet was assigned a code and entered, and the data were enteredinto a separate spreadsheet for analysis. Percent agreement wascalculated for each category as the number of people who iden-tified that category as a component of emotional vitality.

Results

Study 1: scoping review

From the initial 3109 citations, 87 were subjected to full text reviewand 11 were ultimately included in the scoping review (fig 1).Table 1 provides a summary of health conditions, samples sizes,definitions, and measurement strategies used by these 11 studies.All studies provided a definition and/or conceptual framework foremotional vitality, and 7 studies specified a measurement strategy.

Table 1 Included studies for the scoping review, including definition and measurement approach for capturing emotional vitality2-5,20-29

Study Population Definition of Emotional Vitality Measurement Strategy (if Applicable)

Boehm et al20 Coronary heart

disease (nZ7942)

Active engagement with the world,

effective emotional regulation,

and an overall sense of well-

being

Total score on 5 items:(1) I have a sense of direction and purpose in my

life.

(2) How often do you feel emotionally or mentally

exhausted at the end of the day?

(3) How much of the time during the past 4 weeks

did you feel full of life?

(4) How much of the time during the past 4 weeks

did you have a lot of energy?

(5) How much of the time during the past 4 weeks

have you been a happy person?

Deshpande et

al21Elderly women

(nZ926,

age �65)

Inferred by regulation of mood and

being in control of one’s life

circumstances (mastery)

Combination of the total score of the Center for

Epidemiological StudieseDepression Scale23 and

Pearlin and Schooler Mastery Scale24

Richman et al22 Coronary heart

disease (nZ1041)

A composite of positive emotions

that provides energy for

managing negative emotions

and solving problems effectively

Mental Vitality Instrument. Items derived from 2

existing measures of hope43 and curiosity44:(1) I feel hopeful.

(2) I feel challenged.

(3) I feel confident.

(4) I feel bored.

(5) I feel stimulated.

(6) I feel mentally active.

(7) I feel disinterested.

Kubzansky and

Thurston4Coronary heart

disease (nZ6025)

A sense of positive energy, and the

ability to effectively regulate

emotion and behavior, and

positive well-being, which

includes feeling engaged and

interested in life

Selected questions from the General Well-Being

Schedule25:(1) How much energy, pep, vitality have you felt?

(2) How happy, satisfied, or pleased have you been

with your personal life?

(3) Has your daily life been full of things that were

interesting to you?

(4) Have you been in firm control of your behavior,

thoughts, emotions, or feelings?

(5) Have you been feeling emotionally stable and

sure of yourself?

Fredman et al26 Hip fracture

(nZ432)

A psychological characteristic

defined by a sense of emotional

well-being, self-confidence, and

optimism most of the time.

Authors use the term “positive

affect” interchangeably with

emotional vitality.

Depression measured using:(1) Total score from the CES-D23

(2) Positive affect inferred from total score of 4

positively worded items in the CES-D

(3) Four items from the CES-D

i. I felt that I was just as good as other

people.

ii. I felt hopeful about the future.

iii. I was happy.

iv. I enjoyed life.

Rozanski and

Kubzansky5Review A positive and restorative state

that is associated with

enthusiasm and energy. It is

further described as a composite

of positive emotions, including

a sense of joy and a sense of

interest.

Not applicable

Pitkala et al27 Elderly (nZ102) High sense of emotional mastery,

being happy, and not being

depressed or anxious

Measure of positive life orientation measured

using responses to the following items:(1) Are you satisfied with your life?

(2) Do you have zest for life?

(3) Do you feel needed?

(4) Do you have plans for the future?

(5) Do you suffer from loneliness?

(6) Do you feel yourself depressed?

(continued on next page)

4 S.P. Barbic et al

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Table 1 (continued )

Study Population Definition of Emotional Vitality Measurement Strategy (if Applicable)

Ble et al28 Inpatients of

internal medicine

unit (nZ65)

An overall high level of emotional

functioning

To be categorized as emotionally vital,

participants had to fulfill all of the following

criteria:(1) Have a high score (7/10) on the happiness scale

(2) Agree or strongly agree with “I can do just

about anything I really set my mind to,” and

disagree or strongly disagree with “I often feel

helpless in dealing with the problems of life”

(3) Not more than 1 out of 4 of a subset of anxiety

symptoms on the Hopkins Symptom Checklist45

(4) Lowscore(6/15)ontheGeriatricDepressionScale29

Penninx et al2 Community-

dwelling, disabled

women (nZ1002,

age �65)

High level of emotional mastery,

being happy, and having low

depressive and anxiety

symptomatology

To be categorized as emotionally vital,

participants had to fulfill all of the following

criteria:(1) Have a high sense of personal mastery by dis-

agreeing with the item “I often feel helpless in

dealing with the problems in life” and agree

with “I can do just about anything I set my

mind to”

(2) Report a high level of happiness by scoring �8

on the happiness scale (ranging from

0 [extremely unhappy] to 10 [extremely

happy])

(3) Have low depressive symptomatology (score

<10 on the 30-item Geriatric Depression

Scale29)

(4) Not more than 1 out of 4 of a subset of anxiety

symptoms on the Hopkins Symptom Checklist45

Penninx et al3 Community-

dwelling, disabled

women (nZ1002,

age �65)

High level of emotional mastery,

being happy, and having low

depressive and anxiety

symptomatology

Same as Penninx2

Schwartzberg30 Men with HIV (nZ7) Unhindered by undue depression or

anxiety, maintenance of

satisfying work and/or

interpersonal relationships,

active attendance to physical

health, and ability to prescribe

meaning to life in the chronic

health condition

None

Abbreviations: CES-D, Center for Epidemiological StudieseDepression Scale; HIV, human immunodeficiency virus.

Emotional vitality 5

No behavioral intervention studies were found that specificallytargeted emotional vitality.

Trends in reviewed studiesOur scoping review identified several themes. First, although thedefinition of emotional vitality was not consistent across studies,key components such as regulation of mood were commonlyincluded in most definitions. Other common domains includedenergy and well-being (nZ5),4,5,20,22,30 engagement and interestin life (nZ4),4,5,20,30 and mastery (nZ4).2,3,21,27 To measureemotional vitality, 7 studies used items from validated scales toinfer emotional vitality.2-4,8,21,22,26

Study 2: mapping results

Eighteen domains were mapped to the ICF, reflecting 13% of thepossible codes available in the Body Structure/Function chapter.

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Almost all (17)weremapped at the 4-digit level, with 1 domain at the3-digit level (table 2). Common categories were identified including(1) energy, (2) mood, and (3) control of thought/mastery (fig 2).

Discussion

Taken together, the scoping review and ICFmappingDelphi exercisesupport the existence of emotional vitality as an important compo-nent of rehabilitation. The scoping review identified 4 domainsincluding (1) physical health, (2) regulation of mood, (3) mastery,and (4) engagement in other roles and activities. TheDelphimappingexercise showed that 3 of these components could be mappedusing the Body Function chapter of the ICF (energy, mood, mastery).

Emotional vitality is highly relevant to rehabilitation activitiesand warrants attention from our field. It has been suggested thataging, with or without a disability or chronic illness, should nolonger be defined solely as a freedom from physical or cognitive

Emotional Vitality

Physical Well-being & Energy

Interest/

Engagement in lifeRegulation of Mood Mastery

Fig 2 Theoretical model of emotional vitality.

6 S.P. Barbic et al

decline, but rather a level of satisfactory psychological functioningthat optimizes function and quality of life.31-33 This includesfreedom from depression, moderate levels of physical activity, andself-perceived wellness.32 Thus, attending to the emotional vitalityof individuals with chronic health conditions is essential to ensuringthe spectrum of rehabilitation care is comprehensive and effective.

One of the limitations in routinely addressing emotionalvitality in individuals with chronic illnesses or disabilities has beenthe lack of a consistent definition and measurement strategy tocapture this construct. Our results show that at least 4 componentspotentially make up the construct. However, further consensus andinclusion of patient perspective are needed to develop an agreed-on definition. Focus groups with individuals with chronic healthconditions and disabilities are needed to further ensure the patientperspective is included when defining this construct.

If indeed emotional vitality is modifiable and can contributeto achieving positive health outcomes, reliable and valid

Table 2 Mapping exercise results (nZ25 health care

professionals)

Component

Round 2

Agreement

(%)

% Change of

Participant

Agreement

Energy

Energy and drive functions

(B130)

92 4

Energy level (B1300) 100 4

Motivation (B1301) 96 4

Mood

Agreeableness (B1261) 76 0

Conscientiousness (B1262) 80 4

Psychic stability (B1263) 84 0

Openness to experience

(B1264)

84 0

Optimism (B1265) 96 20

Confidence (B1266) 92 0

Emotional functions (B152) 100 0

Appropriateness of emotion

(B1520)

100 0

Regulation of emotion

(B1521)

100 0

Range of emotion (B1522) 100 0

Control of thought/mastery

Control of thought (B1602) 80 4

Content of thought (B1603) 84 14

Cognitive flexibility (B1643) 72 0

Insight (B1644) 84 8

Judgment (B1645) 76 0

Problem-solving (B1646) 92 16

measurement is essential to further advancement. To date,measurement approaches have varied widely, hampering efforts tocompare results across studies. For example, some assessemotional vitality with a single index such as the General Well-Being Schedule,25 or by combining items from several subscalessuch as the Center for Epidemiological StudieseDepressionScale23 and the Geriatric Depression Scale,29 inferring thatemotional vitality is the inverse of depressive symptoms. Indeed,the term vitality is pervasive in the literature, perhaps reflective of2 commonly used measures, the Medical Outcomes Study 36-ItemShort-Form Health Survey34 and the Profile of Mood States,35

which label one of their constructs as “vitality.” In both of themeasures, this term is intended to reflect the continuum of energy,and fatigue is conceptualized as representing low levels ofenergy.36 However, our results suggest that emotional vitalityreflects more than simply energy/fatigue and should be assessedwith items that capture all relevant domains.

Commonly, health has been viewed as the absence of illnessonly, and research has been based on the untested assumption thathealth and illness form a dichotomous dimension.37 As early as1948, health was defined by the World Health Organization38 as “astate of complete physical, mental and social well-being and notmerely the absence of disease or infirmity.”38(p1) A mere halfcentury later, there is now a shift in thinking toward an under-standing of the complexity of health and the reciprocal influencesof psychological health on illness and disability.

Traditionally, emotional health has been conceptualized asthe relative freedom from depression and anxiety. However,increasingly mental health is viewed as more than just theabsence of symptoms, but the presence of positive affect aswell.39 There is evidence that it is possible to be diagnosed witha mental illness and yet still experience relatively good mentalhealth. Conversely, it is also possible to be free of a diagnosis,but be languishing emotionally and have poor mental health.37,39

This idea is very important when capturing the construct ofemotional vitality. Emotional vitality likely involves the regu-lation of both negative and positive mood, maintenance ofenergy and physical well-being, a strong sense of mastery, andengagement in meaningful activity. Each domain has thepotential to be assessed and addressed by rehabilitation profes-sionals. Consideration of a person’s emotional vitality whenassessing and treating health may help optimize how rehabili-tation services are delivered to individuals and improvehealth outcomes.

The scoping review also revealed substantial conceptual andempirical overlap between emotional vitality and other indicatorsof psychological well-being. For example, terms such asemotional function, emotional vigor, and emotional well-beinghave also been used interchangeably to describe positive emotionand energy. As well, emotional resilience,40 emotionalreserve,20,41 and human flourishing39 have also been usedsynonymously to describe an overall sense of emotional well-being that can lead to improved health outcomes and health-related quality of life. However, our results suggest thatemotional vitality reflects a broader, multidimensional constructthat goes beyond the presence/absence of emotional distress.

Study limitations

While this approach to offering proof of concept has severalstrengths, there are also limitations. Although we identified 11

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Emotional vitality 7

studies, it is possible that some were omitted by our searchstrategy. By searching the key terms of “emotion” and “vitality,”we may have missed those studies that examined the constructusing different terms such as mastery, mood, or energy. In addi-tion, in scoping reviews, the quality of each study is not formallyevaluated.13 Another limitation was the variable level of clinicalexperience and experience in using the ICF during the Delphiprocedure. Future studies should conduct qualitative work (eg,focus groups, individual interviews, or both) to provide insightinto how individuals with chronic health conditions and disabil-ities define emotional vitality. In addition, better definitions ofpotentially overlapping domains such as mastery, mood, andenergy are needed to help reduce redundancy and confusionamong these constructs.

Conclusions

For centuries, there has been acknowledgment that the way peoplefeel in their minds could influence the way they respond in theirbody.42 However, only recently has attention turned towardunderstanding how emotional well-being influences recovery,adaptation, and health outcomes. Rehabilitation professionalsrecognize the complexity of treating individuals with chronichealth conditions and disabilities. The extent to which emotionalvitality can be defined, measured, and modified may lead to thedevelopment of new interventions for individuals who experiencechronic illness or disability. The enhancement of patient emotionalvitality, identification of those at greatest risk for inability to cope,and the development of targeted interventions for emotionalvitality may optimize the rehabilitation process for many. As thenumber of individuals with disabilities and chronic illnessesincreases dramatically with the aging population, further under-standing of the impact of emotional vitality on the rehabilitationprocess may provide important evidence-based information toclinicians and researchers to enhance the overall experience of thisvulnerable population.

Keywords

Emotions; Mental health; Rehabilitation

Corresponding author

Skye P. Barbic, MSc, McGill University, Royal Victoria HospitalSite, Ross Pavillon, R4.27, 687 Pine Ave Ouest, Montreal, QC,H3A 1A1 Canada. E-mail address: skye.barbic@mail.mcgill.ca.

Acknowledgments

We thank David Barbic, MD, MSc for his efforts in screening thestudies for this scoping review, and the staff and students from theMcGill University Health Centre and the Department of ClinicalEpidemiology who participated in the International ClassificationMapping exercise.

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