Functional Independence Measure

Last Updated

October 06, 2015

Functional Independence Measure Infographic

Purpose

Provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps; measures the level of a patient's disability and indicates how much assistance is required for the individual to carry out activities of daily living.

Acronym FIM

Area of Assessment

Activities of Daily Living

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

A license to use the FIM instrument may be obtained at: http://www.udsmr.org.
Fees vary depending upon type of use.

Diagnosis/Conditions

Multiple Sclerosis
Pain Management
Spinal Cord Injury
Stroke Recovery

Stroke

Spinal Injuries

Parkinson's Disease

Older Adults and Geriatric Care

Multiple Sclerosis

Mixed Populations

Brain Injury

Contains 18 items composed of:
1) 13 motor tasks
2) 5 cognitive tasks (considered basic activities of daily living)
Tasks are rated on a 7-point ordinal scale that ranges from total assistance (or complete dependence) to complete independence.
Scores range from 18 (lowest) to 126 (highest) indicating level of function.
Scores are generally rated at admission and discharge.
Dimensions assessed include:
1) Eating
2) Grooming
3) Bathing
4) Upper body dressing
5) Lower body dressing
6) Toileting
7) Bladder management
8) Bowel management
9) Bed to chair transfer
10) Toilet transfer
11) Shower transfer
12) Locomotion (ambulatory or wheelchair level)
13) Stairs
14) Cognitive comprehension
15) Expression
16) Social interaction
17) Problem solving
18) Memory
FIM Instrument Scoring Criteria: (refer to the users manual for more information)

Number of Items

May vary based on level and impairment category measured

30-45 minutes

Required Training

Reading an Article/Manual

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team; Updated by Eileen Tseng, PT, DPT, NCS, Rachel Tappan, PT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Tammie Keller, PT, DPT, MS and the TBI EDGE task force of the Neurology Section of the APTA; Updated by Dev Kegelmeyer, PT, DPT, MS, GCS and the PD EDGE task force of the neurology section of the APTA in 2013. Updated by Maggie Bland, PT, DPT, NCS and Nancy Byl PT, MPH, PhD, FAPTA and the PD EDGE task force of the neurology section of the APTA in April of 2016.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living
Cognition
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

StrokEDGE

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

	I	II	III	IV	V
PD EDGE	NR	NR	LS/UR	LS/UR	LS/UR

Recommendations based on level of care in which the assessment is taken:

	Acute Care	Inpatient Rehabilitation	Skilled Nursing Facility	Outpatient Rehabilitation	Home Health
MS EDGE	NR	R	R	NR	NR
StrokEDGE	UR	HR	UR	UR	UR
TBI EDGE	LS	R	LS	LS	LS

Recommendations based on SCI AIS Classification:

	AIS A/B	AIS C/D
SCI EDGE	R	R

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependent	Moderately Dependent	Severely Dependent
TBI EDGE	LS	R	R	R

Recommendations based on EDSS Classification:

	EDSS 0.0 – 3.5	EDSS 4.0 – 5.5	EDSS 6.0 – 7.5	EDSS 8.0 – 9.5
MS EDGE	R	R	R	R

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
MS EDGE	Yes	Yes	Yes	No
PD EDGE	No	No	No	Not reported
SCI EDGE	Yes	Yes	Yes	Not reported
StrokEDGE	Yes	Yes	Yes	No
TBI EDGE	Yes	Yes	Yes	Not reported

Considerations

Motor items in the FIM instrument have been shown to have cross-diagnostic Differential Item Functioning (DIF), indicating varying level of difficulty of items pending diagnosis which reduces comparison between patients. (Lundgren-Nilsson, 2006; Kucukdeveci A, 2001)
Subjective reports of pain (15.5%) and loss of strength (17.9%) were most frequently identified as causes of change in FIM instrument activities and quality of life for individuals with chronic SCI (Price et al. 2004)
For assessment of individuals with SCI, Rasch analysis indicates a four-category rating scale vs. the original seven-category scale has increased reliability (Nilsson, et al. 2005)
With Rasch analysis, the FIM instrument had decreased cross-cultural validity of raw motor scores with 7 of 13 items suggesting that FIM Motor Subscale scores should not be pooled in their raw form or compared between countries. (Lawton et al, 2006)
Rasch analysis indicates decreased correlation for difficulty of bladder and bowel management and individuals’ ease of performing tasks. (Lundgren-Nilsson, 2006)
“The FIM instrument does not contain key activity or participation elements of patient recovery important for measuring outcome and burden of illness (e.g., return to work, relationships, social and recreational pastimes, etc.)”( Nichol et al., 2011)
The FIM instrument is appropriate for patients at all levels of EDSS; rating reflects limited responsiveness data, training required, and copyright issues (MS EDGE task force)
The FIM instrument must be administered by a trained and certified evaluator and ideally scored by consensus with a multi-disciplinary team. Although the FIM instrument was originally developed to address issues of sensitivity and comprehensiveness for Barthel Index (BI), subsequent studies demonstrated that psychometric properties of the FIM instrument and BI are similar (Hsueh et al, 2002; Stroke EDGE task force)

Rasch Analysis of FIM

Questions on the uni-dimensionality of the FIM Motor Scale have been raised. Thus, data from 340 patients involved in post stroke rehabilitation were fitted to a Rasch model. The FIM Motor Scale satisfied Rasch model expectations including the uni-dimensionality assumption without requiring deletion of any of the 13 items. This analysis reinforces that the FIM Motor Scale contains clinically important items. (Lungren Nilsson et al 2011)

A secondary Rasch analysis combning the FIM and the Nottingham Extended Activities of Daily Living (NEADL) assessment was done on 188 participants (average of 19.45 ± 15.96 months post-stroke) from an upper extremity intervention trial. The scoring on the FIM was recoded to a 3-point scale to indicate degrees of independence and the final model (from both assessments) contained 36-items, the bowel management item was removed as it was highly correlated (0.81) with the bladder management item (Chen, 2013).

Barthel Index is commonly administered by nursing and medical staff to measure functional recovery following an inpatient stay for patients post stroke or neurologic disorders while the rehabilitation staff use the FIM. Barthel Index can be measured directly or estimated from the Northwick Park Dependency Scale (NPDS) or the FIM. Following hospital discharge of 717 patients (TBI and stroke), there was excellent agreement of intra-class correlations between the total scores on the FIM and the NPDS (0.93; P<0.001; 95% CI 0.92-0.94). Item by item agreement ranged from adequate ( 0. 41;dressing) to excellent (0.77;mobility) with the average absolute item % agreement from 7l.l% (Dressing) to 90.6% (transfers). (Turner et al, 2010)

Comments from StrokEdge Task Force Members

The FIM instrument must be administered by a trained and certified evaluator and ideally scored by consensus with a multi-disciplinary team. Although the FIM instrument was originally developed to address issues of sensitivity and comprehensiveness for Barthel Index (BI), subsequent studies demonstrated that psychometric properties of the FIM instrument and BI are similar (Hsueh et al, 2002; Stroke EDGE task force)

“The FIM instrument does not contain key activity or participation elements of patient recovery important for measuring outcome and burden of illness (e.g., return to work, relationships, social and recreational pastimes, etc.)”( Nichol et al., 2011) The FIM instrument is appropriate for patients at all levels of EDSS; rating reflects limited responsiveness data, training required, and copyright issues (MS EDGE task force)

Diversity Sensitivity of FIM

The FIM instrument was examined in white, black, and Hispanic people post-stroke that were admitted to inpatient rehabilitation. FIM scores were tracked at admission, discharge, three and 12 months after discharge. At three months, black and Hispanic patients had lower FIM totals when compared to whites. In addition, total FIM ratings increased for all three group form discharge to three months post, but then showed little change after. Racial/ethnic group, age, length of stay and medical comorbidities were significant predictors of total FIM ratings over the four time points. (Berges et al, 2012; Stroke EDGE task force)

FIM converted to other Languages

et al, 2015). Internal consistency and reliability were measured with the Japanese FIM+FAM-J in 42 patients a mean 30.2 (± 21.2) days post CVA .

Excellent internal consistency was observed for the FIM+FAM-J (full scale [0.968], motor scale [0.954] and cognitive subscales [0.949])
Excellent intra rater reliability was observed within the FIM+FAM-J full scale, motor subscale and cognitive subscale ((0.83, 0.80 and 0.98 respectively).
Excellent criterion validity was measured between the FIM+FAM-j full scale and the Motor Scale with the Barthel Index [ BI], the National Institutes of Health Stroke Scale [NIHSS], modified Rankin Scale [mRS] and Brunnstrom Recovery State [BRS L/E] (r=0.83, -0.75, -0.82 and 0.79 respectively with the total scale and 0.88, -0.77, -0.87, and 0.83 respectively for the motor scale)
Adequate criterion validity of the FIM+FAM-J cognitive scale with the BI, NIHSS, mRS and BRSL/E (0.56, -0.53,-0.54 and 0.53 respectively)
Adequate correlations with the Mini Mental Status Examination [MMSE] and the Frontal Assessment Battery [FAB] ( 0.60 and 0.58) but a floor effect with the Catherine Bergego Scale [CBS].

(Naghdi et al, 2016) Two raters administered the Persian FIM and the Barthel Index to 40 patient, mean age of 60 (±14.9) years old and an average of 21 (± 23) months post first stroke .

Excellent intra-rater reliability was measured {0.88-0.98)
Internal consistency of the PFIM was excellent, ranging from 0.70 to 0.96
Construct validity was supported by a significant Pearson Correlation between the PFIM and the Persian Barthel Index (r=0.95)

Systematic Reviews

In a systematic review of outcome measures used with patients post stroke participating in robot-assisted exercise trials (RAET), the FIM^TM Motor Scale was used as a measure of activity level in 9 of 28 RAET trials. With scores ranging from 13-91, the MCID was 11. The FIM Motor Scale had high/excellent reliability (test-retest and inter-rater reliability) and high/excellent validity (>0.75) However, the FIM Motor Scale had only moderate responsiveness (0.4-0.74), with chronic stroke survivors with severe impairments (persisting beyond 6 months) demonstrating little change on the FIM Motor Scale. As a measure of global physical activities, the FIM Motor Scale may be impacted by many other factors beyond specific arm function. The CAHAI or the ARAT may be a more appropriate arm outcome measure for stroke survivors with severe impairments. (Sivan et al, 2011)

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Minimally Clinically Important Difference (MCID)

Stroke:

(Beninato et al, 2006; n = 113; mean age = 63.9 (14.3) years; mean FIM score at admission = 63.4 (24.4) points, Acute Stroke)

FIM Total Score = 22 points
FIM Motor Subscale = 17 points
FIM Cognitive Subscale = 3 points

Normative Data

Stroke:

(Inouye et al, 2001; n = 243; mean age = 64 (11) years; assessed at admission and discharge, Acute Stroke)

FIM scores of > 73 at admission were significantly younger (58 + 11 [SD] yr) than patients with FIM scores of 37 to 72 (64 + 11 yr) or scores < 36 (66 + 12 yr)
FIM total scores of 37 to 72 at admission showed higher gains (37 + 15) than patients who scored > 73 (20 + 10) or < to 36 (29 + 23)

(Tur et al, 2003; n = 102; mean age = 61.6 (10.9) yeas; 45-60 minutes of daily physical and occupational therapy, speech therapy daily as needed; Turkish sample, Acute Stroke)

	Admission Mean (SD)	Median	Discharge Mean (SD)	Median
FIM Total Score	69.2 (27.4)	69	83.2 (25.7)	86
FIM Motor	43.8 (20.7)	40	55.9 (20.3)	60
FIM Cognitive	25.9 (10.7)	31	27.2 (9.5)	32.5

Internal Consistency

Stroke:

(Hsueh et al, 2002; n = 118; mean age = 67.5 (10.9) years; measured at inpatient rehab admission and discharge, Acute Stroke)

Excellent internal consistency (FIM Motor Subscale) (Cronbach's alpha = 0.88 admission; 0.91 discharge)

Criterion Validity (Predictive/Concurrent)

Predictive Validity Evidence:

Stroke:

(Inouye et al, 2001; n = 243; mean age = 64 (11) years; assessed at admission and discharge, Acute Stroke)

Patients with FIM total scores of 37 to 72 at admission showed higher gains (37 + 15) than patients who scored > 73 (20 + 10) or < to 36 (29 + 23)

(Denti et al. 2004; n = 359; mean age = 80.8 (4.7) years; time between stroke onset and admission = 22.3 (14.6) days, Acute Stroke)

FIM total scores at admission were found to be the most powerful predictor of Montebello Rehabilitation Factor Scores (Beta coefficient = 0.42)

Concurrent Validity Evidence:

Stroke:

(Hsueh et al, 2002; Acute Stroke)

Excellent correlation between the FIM Motor Subscale and the 10-item version of the Barthel Index (BI) (r = 0.92 (at admission) - 0.94 (at discharge))
Excellent agreement between the FIM Motor Subscale and 5-item version of BI (r = 0.74 (at admission) - 0.94 (at discharge))

(Salter et al, 2010) 134 patients, a mean age of 68.64 (± 14.2) years old, and an average of 31.84 (± 59.2) days post-stroke, receiving care in an inpatient rehabilitation setting, were tested with the FIM at admission and discharge.

There was excellent, positive and significant correlations with performance at admission and discharge on the FIM (total and motor) with the Clinical Outcome Variables Scale [COVS] (0.823 and 0.771 respectively).
The COVS and FIM had excellent correlation (-0.61,-0.69)) with length of stay (P<0.01), such that lower scores at admission meant shorter length of stay.

(Ward et al, 2011) Thirty inpatients with first ischaemic stroke were evaluated with the FIM, the SIS-16 and the STREAM at admission:

The FIM score was significantly (P<0.001) and highly correlated (excellent) with the predicted length of stay (-0.9438 ) and the actual length of stay (-0.6846)
The validity of the FIM for predicting the LOS was higher (-0.9438) than the SIS-16 (-0.6743) and the STREAM (-0.8011)
The validity of the FIM associated with the actual LOS was lower (-0.6846) compared to the SIS-16 (-0.7953) and the STREAM Total (-0.7972).

(Yang et al, 2013). In a prospective observational study of 122 patients with a first time stroke admitted to a rehabilitation center over a 12 month period:

The FIM score on admission and discharge significantly predicted the Pittsburgh Rehabilitation Participation Scale [PRPS] (0.53; P<0.0001 and 0.40; P<0.001 respectively)
The level of participation on discharge (PRPS score) was predicted by functional status on admission (FIM; 0.309), cognitive impairment (Elderly Cognitive Assessment Questionnaire-ECAQ; 0.249) and fatigue (Fatigue Severity Scale-FSS; -0.304) .
Patients with lower levels of participation were more likely to be functionally dependent, cognitively impaired and have more fatigue.

(O’Brien et al, 2013). A sample of 371,211 Medicare beneficiaries who were receiving services in an inpatient rehabilitation facility (IRF) within 60 days post stroke (> 65 years of age, 43.7% male, 41.7% right sided impairment, 796% white) were evaluated with the FIM at admission and discharge. In addition, the change in LOS at the IRF and community discharge was compared over time with the implementation of a prospective payment system (PPS) for individuals on Medicare.

Average LOS decreased a total of 3.8 days (from 17.9 in 2002 to 16.1 days in 2007)
Mean admission FIM scores decreased a total of 4.4 points ( from 57.2 to 53.8 points)
The mean discharge FIM sores decreased a total of 3.6 points ( from 80.1 to 76.5 points) in 4 of 5 years with no significant decline in 2004.
Frequency of community discharges declined steadily with an average overall decrease of 5.4 % (from 6.6% to 61.2%) over the 5.5 years of study
Controlling for study year and covariates, each day in IRF was associated with an increase of 0.50 discharge points (95% CI = 0.48, 0.52)
The association between LOS and discharge destination was excellent, averaging 0.997 (95% CI = 0.994, 0.999) based on the co-variates of admission FIM, age, gender, ethnicity, side of lesion, complications and year.

(Van Heugten et al, 2015) Systematic review of studies (51) investigating convergent, criterion and predictive validity of cognitive dysfunction in patients in the acute phase (4 weeks) post stroke using multi-domain instruments.

The Conistat, Montreal Cognitive Assessment [MOCA] and Functional Independence Measure-Cognitive showed adequate predictive validity

(Bates, 2015-Part 1) A retrospective analysis of 4020 veterans receiving consultative or comprehensive rehabilitation care post-stroke. The study examined initial characteristics of veterans predictive of grade IV achievement on the FIM.

The final model contained the following variables: age, initial physical grade, initial cognitive stage, renal failure, nutritional compromise, type of rehabilitation services, and recovery time between admission and discharge assessments. A point system was assigned to each of the above variables, such that the clinician could enter in the above information and determine the likelihood of a patient achieving a grade IV. The area under the ROC curve was adequate of the derivation and validation cohorts (0.84 and 0.83, respectively). The Hosmer-Lemeshow statistic was not significant (ρ = 0.93).

(Bates, 2015-Part 2)

The above model (Bates, 2015-Part1) was enhanced to become a prognostic index, predicting likelihood of recovery to or above the grade VI benchmark (Modified Independent). There was adequate fit with a nonsignificant Hosmer-Lemeshow statistic of P = 0.38 and Adequate area under the curve of 0.83 in the derivation cohort and 0.82 in the validation cohort. A similar predictive equation was derived with the sum score quartiles slightly modified.
(Huang, 2010) Fifty-eight participants an average of 17.85 (range, 7-88) months post-stroke participated in distributed constraint induced therapy two hours per day, five days a week for three weeks. Assessments were administered prior and after therapy, and a Chi-squared Automatic Interaction Detector method was used to identify the strongest predictors of change on the Stroke Impact Scale. Participants with an initial Total FIM score ≤ 109 at admission, improved significantly more (P = 0.006) on the Stroke Impact Scale and on measures of activities of daily living and instrumental activities of daily living at completion of the intervention.

(Lin, 2010) Seventy-four participants an average age of 54.11 (± 11.44) years old and 17.46 (± 17.67) months post-stroke were seen for upper extremity intervention. Participants received constraint-induced movement therapy, bilateral arm training, or conventional rehabilitation for two hour sessions, five times per week for three weeks. Assessments were done at baseline and post-intervention.
Poor to excellent predictive validity was found between the domains of the Stroke Impact Scale and the FIM (0.26-0.70, p < 0.05)
Poor to excellent predictive validity was found between the domains of the Stroke Specific Quality of Life Scale and the FIM (0.22-0.63, p < 0.01). The language, personality, thinking, and vision domains were not significant.

(Ward et al 2011) On admission to the acute rehabilitation ward, the FIM and the STREAM were found to be highly correlated in thirty patients acute post ischemic stroke.(ρ=0.7766; P<0.0001)

(Shindo et al, 2015) To explore the concurrent validity of the FIM scale with the Simple Test of Evaluation Hand Function [STEF], 34 inpatients (33-86 years of age) sub acute post stroke (less than 60 days post episode) were evaluated at admission. The STEF had statistically significant, adequate correlations with the FIM^TM: FIM Total score (0.444;P<0.009), FIM motor (0.411;P<0.016) and FIM self care (0.402; P<0.019) .

et al, 2014) The aim of this study was to explore the validity of the Cognitive Behavioral Rating Sale ( CBRS) with the FIM discharge data on 100 patients, mean age of 72.2 (± 10.9) years old and 61.0 (±61.2) days post-stroke. The Spearman Rank Correlation Coefficient was excellent between the CBRS and the FIM total Score (-0.70; p<0.01), the Cognitive FIM (-0.72; P<0.01), and the Motor FIM (-0.63; p<0.01) for patients post stroke.

(Caglar, 2014) A retrospective analysis on 142 patients post-stroke that went to an IRF. A linear regression was run to determine which factors contributed to Motor-FIM (M-FIM) gain and Cognitive-FIM (C-FIM) gain.

The adjusted R² was 0.173 (p = 0.000) for M-FIM gain and the significant factors were the admission M-FIM (B = 0.809, SE = 0.199, β = -0.446, p = 0.000) and if the patient had diabetes Mellitus (B = 14.269, SE = 6.775, β = -0.177, p = 0.037).
The adjusted R² was 0.146 (p = 0.001) for C-FIM gain and the significant factors were the admission C-FIM (B = -4.068, SE = 1.048, β = -0.369, p = 0.000) and if the patient had diabetes Mellitus (B = 36.226, SE = 17.904, β = -0.175, p = 0.045).

(Cooke, 2010) One hundred and ninty-seven, first stroke participants were included an average of 45.4 ± 67.6 days post-stroke to examine the relationship of clock drawing post-stroke.

A significant relationship was found between the FIM-Motor and the Clock Drawing Test (Exp (B) = 0.984, p = 0.030).

Construct Validity

Convergent Validity Evidence:

Stroke:

(Tur et al, 2003; Acute Stroke)

Adequate correlation with length of hospital stay (r = -0.39)
Adequate to Excellent correlation with Brunnstrom’s motor recovery stages in upper extremity, lower extremity, and hand at admission and discharge (r = 0.51 - 0.68)

Discriminate Validity Evidence:

Stroke:

(Brock et al, 2002; Rasch analysis; n = 106; mean age = 68.7 (11.3) years; median time since onset = 11 days, Acute Stroke)

Difficult items on motor portion of the scale discriminated better among higher functioning patients
Raw FIM scores (as opposed to score subjected to Rasch analysis) may underestimate change

(Cavanagh et al, 2000; ischemic and hemorrhagic stroke patients, Stroke)

Simple 2-factor model of the FIM instrument may not be sufficient to describe disability following stroke (66% of variance)
May not adequately measure within patient change whereas a 3-factor model (self-care, cognition and elimination) accounted for more variance (74.2%)

No instrument (including the FIM) assessed all of the commonly affected cognitive domains after a stroke
Strong significant intercorrelations were found between the Occupational Therapy Cognitive Assessment (LOTCA), the MMSE and the FIM-Cognitive subscale

(Canbek, 2013) Fifty-five participants who experienced their first-ever stroke and went to an IRF an average of 8± 5 days post-stroke.

Poor to Excellent construct validity was seen between the FIM-Motor and the Tinetti POMA

	Tinetti POMA	Balance Domain	Gait Domain
Admission FIM-Motor	0.688	0.616	0.610
Discharge FIM-Motor	0.609	0.588	0.536
Change FIM-Motor	0.389	0.277	0.396

(Kucukdeveci, 2013) One hundred and eighty-eight community dwelling participants (mean age 63.1 ±12 years), a median of 27 (range 3-240) months post-stroke were evaluated on the FIM and the World Health Organization Disability Assessment Schedule (WHODAS-II).

Adequate to Excellent convergent validity was found. All correlations significant at p < 0.001.

	FIM Motor	FIM Cognitive
WHODAS-II understanding and communicating	-0.54	-0.74
WHODAS-II getting around	-0.86	-0.45
WHODAS-II self-care	-0.88	-0.46
WHODAS-II getting along with people	-0.55	-0.71
WHODAS-II life activities (work items removed)	-0.74	-0.45
WHODAS-II participation in society	-0.72	-0.52
WHODAS-II total (work items removed)	-0.85	-0.68
WHODAS-II activities	-0.85	-0.64
WHODAS-II participation	-0.77	-0.67
WHODAS-II -12 (work items removed)	-0.86	-0.65
WHODAS-II-10	-0.83	-0.65

(Ottiger et al A new multidisciplinary observation scale for inpatients post stroke based on the ICF model of activity and participation was created to document outcomes post stroke (LIMOS). This scale included four components of the ICF:1). interpersonal activities, [mobility and self-care,; 2}. Communication; 3} Knowledge and general tasks; 4) domestic life. The activities were rated as limitations or restriction in domains as: none, slight, moderate, severe or complete. This new scale was correlated with FIM scores.

Excellent convergent validity was found between the LIMOS and the FIM (r=0.89; P<0.0001)
An excellent association was reported between the FIM mobility subscale and the LIMOS mobility subscale (r=0.90; P<0.0001)
Adequate to excellant associations were found between the subscales of the LIMOS (self care, general tasks, domestic life) and the subscales of the FIM (r=0.36-0.79)

Floor/Ceiling Effects

Stroke:

(Brock et al, 2002; Acute Stroke)

Minimal ceiling effect: 16% achieved ceiling on FIM Motor Subscale during inpatient rehabilitation

(Dromerick et al, 2003; n = 95, Acute Stroke)

No floor or ceiling effects at either time using the FIM instrument

(Hsueh et al, 2002; Acute Stroke)

FIM Motor subscale:

Minimal floor effect at admission to inpatient rehab (5.8%) and at discharge from inpatient rehab (3.5%)
No ceiling effect at admission to inpatient rehab (0%) and at discharge from inpatient rehab (0%)

Responsiveness

Stroke:

(Hsueh et al, 2002; Acute Stroke)

Motor subscale:
- Large effect size with standardized response mean = 1.3

(Ward et al, 2011) A prospective cohort study of 30 subjects newly diagnosed with ischemic stroke (mean days since stroke onset 7.8 days (± 3.5)) was designed to demonstrate sensitivity of the FIM to change in an acute rehabilitation setting.

The FIM score on admission was significantly associated (adequate to excellent correlations) with discharge destination as well as predicted and actual length of stay.
The SRM (admission to discharge change score) was 2.34 for the motor FIM (P<0.0001). This FIM SRM was greater than the SRM for the SIS-16 and SRM for the STREAM.

(Salter et al, 2010) Following admission and discharge of 292 patients post stroke (134 with complete data and 158 with incomplete data, respectively an average of 31.8 and 67.3 days post stroke), FIM^TM scores improved significantly (P<0001) from admission to discharge from a mean of 73.86 (24.13) to 95.70 (24.65) . The SRM was 1.36.

Normative Data

SCI:

(Hall et al, 1999; cross-sectional data from SCI Model Systems National Database; average of 8 days post injury [SD = 13 days]; sample size varying pending time post injury, Acute SCI)

Mean (SD) Motor FIM Scores at Rehabilitation Admission, Discharge, and 1, 2, and 5 Years Post Injury: All Cases at AIS Grades A, B, C

FIM Motor

Admission

Discharge

1 yr status post

2 yr status post

5 yr status post

C1-C3

14.1(4.7)

n = 156

18.6 (7.8)

n = 115

25.4 (22.2)

n = 29

26.5 (26)

n = 17

22.1 (15.0)

n = 18

14.9 (6.1)

n = 517

23.1 (11.6)

n = 458

26.9 (19.6)

n = 118

25.4 (17.0)

n = 87

24.9 (14.9)

n = 52

16.0 (7.9)

n = 578

31.3 (15.0)

n = 433

35.6 (20.7)

n = 91

37.5 (22.7)

n = 81

38.5 (22.6)

n = 67

16.9 (7.8)

n = 313

37.4 (14.3)

n = 394

39.7 (19.6)

n = 89

46.7 (21.9)

n = 75

42.2 (20.2)

n = 63

19.6 (9.0)

n = 177

50.2 (15.8)

n = 236

59.6 (22.3)

n = 56

58.3 (22.6)

n = 46

56.9 (20.5)

n = 42

22.6 (8.2)

n = 55

61.9 (16.4)

n = 76

68.7 (18.7)

n = 21

68.4 (16.4)

n = 14

73.3 (17.2)

n = 14

Thoracic

32.5 (12.0)

n = 1718

69.3 (13.1)

n = 1869

72.2 (14.4)

n = 402

74.7 (12.8)

n = 320

77.4 (10.0)

n = 256

Lumbar/

Sacral

36.7 (12.6)

n = 457

73.2 (11.9)

n = 452

79.8 (12.4)

n = 97

83.2 (5.9)

n = 72

82.4 (5.5)

n = 58

Divide the score by 13 (i.e. 13 motor items) to obtain the average ratings on the 1 to 7 scale

Mean (SD) Cognitive FIM Scores at Rehabilitation Admission, Discharge, and 1, 2, and 5 Years Postinjury: All Cases at AIS Grades A, B, C

FIM Motor

Admission

Discharge

1 yr status post

2 yr status post

5 yr status post

C1-C3

26.8(9.7)

n = 131

29.8 (8.2)

n = 95

33.8 (2.4)

n = 17

33.4 (2.1)

n = 10

34.5 (1.2)

n = 12

29.0 (7.2)

n = 456

32.2 (4.8)

n = 380

33.2 (5.2)

n = 67

34.3 (1.7)

n = 47

34.3 (1.4)

n = 37

29.5 (7.3)

n = 541

32.5 (4.9)

n = 371

33.8 (4.2)

n = 55

34.4 (1.7)

n = 55

34.1 (2.1)

n = 55

29.4 (7.1)

n = 290

32.9 (3.5)

n = 351

33.5 (3.5)

n = 56

34.2 (3.3)

n = 53

34.6 (1.3)

n = 48

30.1 (7.1)

n = 165

32.9 (4.4)

n = 212

34.7 (0.8)

n = 40

34.9 (0.3)

n = 27

34.6 (0.8)

n = 30

30.5 (6.8)

n = 52

32.3 (4.5)

n = 70

34.5 (0.9)

n = 14

35.0 (0.0)

n = 6

35.0 (0.0)

n =7

Thoracic

31.2 (5.9)

n = 1594

33.3 (3.5)

n = 1644

34.4 (2.0)

n = 249

34.5 (1.5)

n = 199

34.8 (0.9)

n = 180

Lumbar/

Sacral

32.1 (5.2)

n = 431

33.5 (3.4)

n = 405

34.6 (1.5)

n = 59

35.0 (0.2)

n = 41

34.1 (4.2)

n = 38

Divide the score by 5 (i.e. 5 cognitive items) to obtain the average ratings on the 1 to 7 scale

Mean Motor FIM Scores at Rehabilitation Admission and Discharge by Level and Completeness of Injury

Admission*

Discharge*

Level

AIS A

AIS B

AIS C

AIS A

AIS B

AIS C

C1-C3

13.2 (n = 88)

13.0

(n = 14)

15.8

(n = 54)

17.7

(n = 75)

21.0

(n = 13)

20.0

(n = 27)

13.6 (n = 288)

14.5

(n = 73)

17.5

(n = 156)

20.9

(n = 288)

24.8

(n = 54)

27.8

(n = 116)

14.3 (n = 310)

16.2

(n = 127)

19.7

(n = 141)

28.3

(n = 236)

31.1

(n = 96)

38.4

(n = 101)

15.3

(n = 173)

17.8

(n = 89)

21.1

(n = 51)

35.6

(n = 238)

37.6

(n = 93)

43.9

(n = 63)

18.5

(n = 90)

18.8

(n = 52)

23.6

(n = 35)

49.4

(n = 123)

48.7

(n = 56)

53.5

(n = 57)

22.3

(n = 27)

22.4

(n = 17)

23.3

(n = 11)

64.1

(n = 34)

58.6

(n = 27)

63.0

(n = 15)

Thoracic

32.2

(n = 1324)

31.5

(n = 202)

35.5

(n = 192)

69.1

(n = 1482)

67.2

(n = 163)

71.7

(n = 224)

Lumbar/

Sacral

35.8

(n = 147)

36.6

(n = 105)

37.3

(n = 205)

71.5

(n = 161)

74.8

(n = 74)

74.0

(n = 217)

*All cases with level and completeness data available; These are not all the same sample of individuals across admission and discharge

(Kay et al, 2010; n = 1780; discharged from one of 479 inpatient rehab facilities in US; age 65-74 years; diagnosed with incomplete paraplegia, Acute SCI)

Demographic, rehabilitation stay, and discharge FIM self-care and mobility subscore by etiology of incomplete paraplegia
Characteristics	Degenerative Spinal Disorder	Benign Spinal Tumor	Malignant Spinal Tumor	Spinal Abscess	Vascular Ischemia
Subjects, n	1203	81	295	54	147
Age, mean	70.2	70.1	69.2	69.4	69.7
LOS in rehab, mean (SD)	13.2 (7.7)	17.2 (9.9)	17.8 (8.4)	21.3 (10.8)	26.4 (10.8)
Discharge self-care, mean (SD)	32.7 (5.8)	33.0 (6.2)	29.0 (6.9)	27.8 (7.9)	29.3 (6.6)
Discharge mobility, mean (SD)	22.5 (5.6)	22.1 (5.9)	17.4 (6.5)	16.9 (6.8)	17.1 (6.3

Interrater/Intrarater Reliability

SCI:

(Grey and Kennedy, 1993; n = 40; mean age at time of injury = 29.6 (9.57) years; mean time post-injury at discharge = 24.75 (8.57) weeks, Chronic SCI)

Excellent correlation between total FIM scores taken by clinician discharge report and self-report at one month (r = 0.828)
Poor to Excellent correlation between FIM subscales scores taken by clinician discharge reort and self-report at one month:
- Self care: r = 0.841 (Excellent)
- Sphincter control: r = 0.710 (Adequate)
- Mobility: r = 0.733 (Adequate)
- Locomotion: r = 0.454 (Adequate)
- Communication: r = 0.029 (Poor)
- Social cognition: r = 0.085 (Poor)

(Karamehmetoglu et al, 1997; n = 50; mean age = 33.94; 22% with tetraplegia and 78% with paraplegia, SCI)

Excellent intrarater correlation of FIM scores obtained by questioning the patient and by observation of patient performing the activity (r = 0.94)

(Kucukdeveci et al, 2001; FIM in Turkey; n = 62; mean age = 32.7; mean time since injury = 16.4 months; with cervical injury 21%; with thoracic injury 42%; with lumbar 37%, Chronic SCI)

Excellent FIM Motor interrater reliability (ICC = 0.90)
Excellent FIM Cognitive interrater reliability (ICC = 0.98)

(Segal et al, 1993, n = 57, discharging from acute care and admitting to rehab hospital; data collected within a max of 6 days, Subacute SCI)

Excellent interrater reliability for total FIM scores across two settings (r = 0.83)
Poor to Excellent interrater reliability for individual items (r = 0.02 - 0.77)
Excellent interrater reliability for patients with complete quadriplegia (n = 14, r = 0.87), complete paraplegia (n = 13, r = 0.74), and incomplete paraplegia (n = 9, r = 0.85)
Adequate interrater reliability for patients with incomplete quadriplegia (n = 17, r = 0.49)

Internal Consistency

SCI:

(Kucukdeveci et al, 2001; FIM instrument version in Turkey, Chronic SCI)

Excellent internal consistency at admission and discharge for FIM Motor (Cronbach’s alpha = 0.934 - 0.953) and FIM Cognitive (Cronbach’s alpha = 0.930 - 0.983)

(Stineman et al, 1996; with nontraumatic SCI, n = 2,609, mean age = 64.6 years; with traumatic SCI, n = 1,831, mean age = 43.0 years, sample from Uniformed Data System for Medical Rehabilitation [UDS_MR^SM], SCI)

Excellent internal consistency for nontraumatic spinal cord diagnosis (Cronbach’s alpha for total = 0.91; for FIM Motor = 0.91; for FIM Cognitive = 0.90)
Excellent internal consistency for traumatic spinal cord diagnosis (Cronbach’s alpha for FIM Total Score = 0.92; for FIM Motor = 0.94; for FIM Cognitive = 0.90)

Construct Validity

SCI:

(Ditunno, et al., 2007; n = 141, mean age = 32 years; Entered into study within 8 weeks of onset of SCI; data taken at entry, 3 and 6 and 12 months, subjects required to have score of < 4 on the Locomotor FIM (LFIM) at entry, Acute SCI)

Excellent correlation between total FIM score and WISCI at 3,6, and 12 months (Spearman’s r = 0.73 - 0.77)
Excellent correlation between total FIM score and Berg Balance Scale (Spearman’s r = 0.72 - 0.77) at 3, 6, and 12 months
Excellent correlation between LFIM score and Walking Index for Spinal Cord Injury (WISCI) at 3, 6, and 12 months (Spearman’s r = 0.88 - 0.92)
Excellent correlation between LFIM score and Berg Balance Scale (Spearman’s r = 0.86 - 0.89) at 3, 6, and 12 months
Excellent correlation between LFIM score and 50-Foot Walk Test at 3, 6, and 12 months (Spearman’s r= 0.66 - 0.80)
A comparison of simultaneous performance of the WISCI and the LFIM indicated 1 FIM level per multiple WISCI levels

(Donnelly et al, 2004; n = 41; mean age = 49(118.1); mean time since injury = 52 (73.1) days; with paraplegia, n = 18; with tetraplegia, n = 20; Incomplete, n = 27; complete, n = 11, SCI)

Adequate correlation between admission and discharge scores of the FIM Total Score and the Canadian Occupational Performance Measure (COPM) Performance (r = 0.388 - 0.452) and COPM Satisfaction (r = 0.513 - 0.514)
Adequate correlation between change scores of the FIM Total Score and FIM motor with COPM Performance (r = 0.364, r = 0.351) and Satisfaction (r = 0.497, r = 0.497) from admission to discharge

(Fujiwara et al, 1999; n = 14; C6 level of injury, mean age = 30.7 years; mean length of time from injury = 462.0 days, Chronic SCI)

Excellent correlation of FIM motor score and AIS motor score (Spearman’s rank correlation coefficient = 0.73)
Excellent correlation of shoulder strength (sum of MMT for serratus anterior, upper pectoralis major, and latissiums dorsi) and FIM motor score (Spearman’s rank correlation coefficient = 0.95)
Excellent correlation of AIS shoulder strength score (deltoid) and FIM transfer score (Spearman’s r = 0.93)

(Saboe et al, 1997; n = 160; mean age = 30 (13) years; assessed at admission, discharge, and 2 years post injury; Length of stay at tertiary care hospital 144 (111) days Chronic SCI)

Excellent correlation of FIM score 2 years post injury with admission and discharge ASIA motor (Spearman’s r = 0.68 - 0.80), ASIA light touch (Spearman’s r = 0.75 - 0.76), ASIA pinprick (Spearman’s r= 0.73 - 0.76), and Computed Vibration (Spearman’s r = 0.64 - 0.67)
Adequate correlation of FIM score 2 years post injury with admission bony injury level (Spearman’s r = 0.53) and admission and discharge ASIA Impairment (Spearman’s r = 0.50 - 0.53)
56% of the variance of FIM scores 2 years post injury is accounted for with ASIA admission light touch scores with age being the next largest contributing factor

(Yavuz et al, 1998; n = 29; mean age = 37 years; mean time between onset and rehab admission = 20 weeks, mean length of stay in inpatient rehab = 18 weeks, Subacute SCI)

Excellent correlation of FIM score with ASIA motor (r = 0.91)
Adequate correlation of FIM score with ASIA light touch (r = 0.58) and ASIA pinprick (r = 0.55)
Excellent correlation of Quadriplegia Index of Function and FIM (r = 0.97)

Content Validity

The FIM instrument was based on the results of a literature review of published and unpublished measures as well as input provided by an expert panel. Face and content validity were determined using subject matter experts (Granger, Hamilton, Keith, Zielezny, & Sherwins, 1986).

Content validity was established through a pilot study done at 11 centers (n = 110 patients evaluated; Keith & Granger, 1987).

SCI:

(Jackson et al, 2008; n = 54 expert raters assessed locomotion measures as: 1) valid or useful, 2) useful but requires validation or changes/improvements, or 3) not useful or valid for research in SCI, SCI)

FIM – Locomotion item was rated as Valid/Useful by 6%, Useful But Requires Validation or Changes by36% , and Not Useful or Valid for Research in SCI by 58%

Face Validity

SCI:

(Grey and Kennedy, 1993; Chronic SCI)

Face validity was evaluated by asking clinicians specific questions addressing:
- Difficulty of understanding (88% had no difficulty)
- Unnecessary items (97% reported no unnecessary items
- Items that should be added (83% felt no extra items needed)

Floor/Ceiling Effects

SCI:

(Grey and Kennedy, 1993; Chronic SCI)

92% of subjects and 88% of clinicians reported a max score on communication
75% of subjects and 73% of clinicians reported a max score on social cognition

(Hall et al, 1999; Acute SCI)

Percentage of Floor and Ceiling FIM Scores by Level of Injury
	Admission	Discharge	1 yr	2 yrs	5 yrs
High Tetraplegia: C1 (no motor ceiling effect)
Motor Floor effect(%)*	86	21	28	25	13
Cognitive Ceiling effect(%)~	59	80	89	96	98
Low Tetraplegia: C5-C8
Motor Floor effect(%)*	61	3	5	4	3
Motor Ceiling effect(%)~	0	4	15	18	16
Cognitive Ceiling effect(%)~	67	86	95	99	96
Paraplegia (no motor floor effect)
Motor Ceiling effect(%)~	0	36	55	66	75
Cognitive Ceiling effect (%)~	76	90	97	98	99
* Floor effect: Score of 1; Ceiling effect: Score of 6 or 7

Responsiveness

SCI:

(Spooren et al, 2006; n = 60; mean age = 38.9 years old; first measurement taken when subjects were first able to sit up in a chair for 3 hours, Acute SCI)

Large effect size for all subjects regardless of AIS classification between initial measurement (T1) and 3 months later (T2) as well as between initial measurement (T1) and discharge from rehab (T3)
Small to moderate effect size for subjects between T2 and T3 (ES = 0.37-0.79)

Interrater/Intrarater Reliability

TBI:

(Donaghy & Wass, 1998; TBI)

Excellent interrater reliability (ICC = 0.85 for total FIM Scores, 0.92 for FIM Motor, and 0.69 for FIM Cognitive)

Criterion Validity (Predictive/Concurrent)

(Heinemann et al, 1994; Rehabilitation Patients)

Admission FIM Motor Scores accounted for 52% of variance in discharge motor function among TBI patients, admission FIM Cognitive Scores accounted for 46% of variance in discharge cognitive function – admission motor FIM was the most significant predictor of length of stay

(Montecchi et al, 2013) In 59 patients with mean age of 48.90 (± 14.01) years old, admitted to the intensive care unit acutely post acquired brain injury (from trauma, hypoxia, haemorrhage or ischemia), a new Trunk Recovery Scale (TRS) was developed.

Excellent correlation between the FIM-Motor and the TRS (0.849)

Content Validity

Content validity was established through a pilot study done at 11 centers (n = 110 patients evaluated; Keith & Granger, 1987).

Traumatic Brain Injury:

(Hall et al, 2001; TBI)

Although the FIM instrument is reliable and key validity characteristics have been established, it has only 5 items directly addressing cognitive, behavioral, and communication issues, which limits its content validity for TBI

Responsiveness

(Ellis et al, 2008; n = 68; mean age - 74 (8) years; H&Y stages II - V, number in each stage: II - 1, III - 18, IV - 37, V - 2)

Mean Score (SD) at:
Measure	Admission	Discharge
FIM Total Score	45.5 (13.7)	77.0 (18.6)
FIM Motor	27.1 (10.4)	54.8 (14.0)
FIM Cognitive	18.0 (5.6)	22.1 (5.8)

(Marciniak et al, 2011; n = 89; mean age = 74.26 (9.38) years)

	Mean Score (SD) at:
Measure	Admission	Discharge
FIM Total Score	54.2 (17.4)	75.29 (21.9)
FIM Motor	34.47 (12.4)	51.45 (17.1)
FIM Cognitive	19.73 (7.0)	23.84 (6.8)

Test/Retest Reliability

Elderly Adults:

(Pollak et al 1996; n = 49 elderly residents of a continuing care retirement community; mean age 89.7 years; assessed twice 3 to 8 days apart, Elderly Adults)

Excellent FIM Motor test-retest reliability (ICC = 0.90)
Excellent FIM Cognitive test-retest reliability (ICC = 0.80) scores

(Hobart et al, 2001; Elderly Adults)

Excellent test-retest reliability (ICC = 0.98 for total FIM, 0.95 and 0.89 for FIM Motor and FIM Cognitive, respectively)

Interrater/Intrarater Reliability

Orthopedic Diagnoses and Stroke:

(Kohler et al, 2009; n = 143 patients (63% orthopedic and 13% stroke); mean age = 76 years; transferred and assessed from one Rehab unit to another; 1 to 3 days between assessments, Orthopedic Diagnoses and Stroke)

Adequate to Poor item-level interrater reliability (ICC = 0.124 to 0.661)
Poor agreement on 4 items:
- Stairs
- Dressing
- Walking
- Bowel management

Various Diagnoses (meta analytic findings):

(Ottenbacher et al, 1996; n = 11 studies published between 1993 and 1995; total sample size = 1,568 participants, Various Diagnoses)

Excellent overall consistency (median interrater reliability = 0.95) between raters across patients with different diagnosis and levels of impairment

Internal Consistency

Multiple Sclerosis:

(Sharrack et al, 1999; n = 64; mean age = 40 years, MS)

Excellent internal consistency (Cronbach's alpha = 0.98)

Internal Consistency

General Rehab:

(Dodds et al, 1993; n = 11,102 (52% Stroke, 10% Orthopedic; 10% Brain Injury); mean age = 65 years, General Rehab)

Excellent internal consistency (Cronbach's alpha = 0.93 admission; 0.95 discharge)

Neurological Disorders:

(Hobart et al, 2001; Neurological Disorders)

Excellent internal consistency (Cronbach's alpha = 0.95 FIM Total Score; 0.95 FIM Motor; 0.89 FIM Cognitive)

Criterion Validity (Predictive/Concurrent)

Predictive Validity Evidence:

Neurologic Disorders:

(Ng, et al., 2007; n= 1502; mean age of total = 61.3 ± 15.0 years; mean acute LOS = 14.5 ± 17.5 days; mean inpatient rehab LOS = 21.5 ±19.0 days, Neurological Disorders)

Admission motor FIM scores (β = 0.55) and admission cognitive FIM scores (β = 0.38) had the highest impact on discharge total FIM scores

Construct Validity

Discriminate Validity Evidence:

Rehabilitative patients:

(Hobart et al, 2001; n = 169; neurological rehab patient: MS, stroke, TBI, other)

FIM total and FIM motor scores correlated more strongly with OPCS disability scores, LHS scores, SF-36 physical component scores and WAIS – verbal IQ, than with measures of mental health status or psychological distress (SF36 mental component, General Health Questionnaire)
FIM Cognitive Scores correlated most strongly with OPCS Disability scores and WAIS-verbal IQ scores and weakly with LHS, SF-36 physical and mental components, and the General Health Questionnaire (ABIEBR)

Floor/Ceiling Effects

Rehabilitation Patients:

(Coster et al, 2006; n = 516 subjects with neurologic, orthopedic, or complex medical conditions; mean age = 68.3 (14.97) years; discharged from tertiary care or rehab hospital, Rehabilitation Patients)

Ceiling effect on FIM motor scale after discharge ranging from 10% at 1 month to 15% at 12 months
Ceiling effect on the FIM cognitive scale after discharge for 70% of subjects at 1 month, reducing to 53% at 12 months

Responsiveness

Rehabilitation Patients:

(Coster et al, 2006; Rehabilitation Patients)

Small, positive effect size observed for FIM motor (SRM = 0.73 to 1.05) and FIM cognitive (SRM = 0.34 to 0.35) Small to Moderate, negative effect size observed for FIM motor (SRM = 1.3 to 1.31) and FIM cognitive (SRM = 1.34 to 2.24)
For FIM motor, 15-36% of subjects presented with positive change exceeding the MDC and 15- 25% with negative change exceeding the MDC
For FIM cognitive, 8-9% of subjects presented with positive change exceeding the MDC and 20-24% presented with negative change exceeding the MDC

Bibliography

Bates, B.E., Xie, D., et al. (2015). “Development and validation of prognostic indices for recovery of physical functioning following stroke: part 1.” American Academy of Physical Medicine and Rehabilitation 7: 685-698. Find it on PubMed

Bates, B.E., Xie, D., et al. (2015). “Development and validation of prognostic indices for recovery of physical functioning following stroke: part 2.” American Academy of Physical Medicine and Rehabilitation 7: 699-710.Find it on PubMed.

Berges, I.M., Kuo, Y.F., et al. (2012). “Recovery of functional status after stroke in tri-ethnic population.” Physical Medicine and Rehabilitaiton 4(4): 290-295.Find it on PubMed

Beninato, M., Gill-Body, K. M., et al. (2006). "Determination of the minimal clinically important difference in the FIM instrument in patients with stroke." Arch Phys Med Rehabil 87(1): 32-39. Find it on PubMed

Brock, K. A., Goldie, P. A., et al. (2002). "Evaluating the effectiveness of stroke rehabilitation: choosing a discriminative measure." Arch Phys Med Rehabil 83: 92-99. Find it on PubMed

Caglar, N.S., Erdem, I.H., et al. (2014). “Where are we in terms of poststroke functional outcomes and risk factors.” NeuroRehabilitation 34: 391-399. Find it on PubMed.

Canbek, J., Fulk, G. et al. (2013). “Test-restest reliability and construct validity of the Tinetti Performance-Oriented Mobility Assessment in people with stroke.” J Neurol Phys Ther 37:14-19. Find it on PubMed.

Cavanagh, S. J., Hogan, K., et al. (2000). "Stroke-specific FIM models in an urban population." J Neurosci Nurs 32(1): 17-21. Find it on PubMed

Chen, H., Wu, C., et al. (2013). “Rasch validation of a combined measure of basic and extended daily life functioning after stroke.” Neurorehabilitation and Neural Repair 27(2):125-132. Find it on PubMed.

Cooke, D.M., Gustafsson, L., et al. (2010). “Clock drawing from the occupational therapy adult perceptual screening test: its correlation with demographic and clinical factors in the stroke population.” Australian Occupational Therapy Journal 57: 183-189. Find it on PubMed.

Coster, W. J., Haley, S. M., et al. (2006). "Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings." J Rehabil Med 38(4): 237-242. Find it on PubMed

Denti, L., Agosti, M., et al. (2008). "Outcome predictors of rehabilitation for first stroke in the elderly." Eur J Phys Rehabil Med 44(1): 3-11. Find it on PubMed

Ditunno, J. F., Jr., Barbeau, H., et al. (2007). "Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial." Neurorehabil Neural Repair 21(6): 539-550. Find it on PubMed

Dodds, T. A., Martin, D. P., et al. (1993). "A validation of the functional independence measurement and its performance among rehabilitation inpatients." Arch Phys Med Rehabil 74(5): 531-536. Find it on PubMed

Donaghy, S. and Wass, P. J. (1998). "Interrater reliability of the Functional Assessment Measure in a brain injury rehabilitation program." Arch Phys Med Rehabil 79(10): 1231-1236. Find it on PubMed

Donnelly, C., Eng, J. J., et al. (2004). "Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury." Spinal Cord 42(5): 302-307. Find it on PubMed

Dromerick, A. W., Edwards, D. F., et al. (2003). "Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials." Journal of Rehabilitation Research and Development 40(1): 1-8. Find it on PubMed

Ellis, T., Katz, D. I., et al. (2008). "Effectiveness of an inpatient multidisciplinary rehabilitation program for people with Parkinson disease." Physical therapy 88(7): 812-819.

Fujiwara, T., Hara, Y., et al. (1999). "Relationship between shoulder muscle strength and functional independence measure (FIM) score among C6 tetraplegics." Spinal Cord 37(1): 58-61. Find it on PubMed

Granger, C. V., Hamilton, B. B., et al. (1986). "Advances in functional assessment for medical rehabilitation." Topics in Geriatric Rehabilitation 1(3): 59-74.

Grey, N. and Kennedy, P. (1993). "The Functional Independence Measure: a comparative study of clinician and self ratings." Paraplegia 31(7): 457-461. Find it on PubMed

Hall, K. M., Bushnik, T., et al. (2001). "Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals." Arch Phys Med Rehabil 82(3): 367-374. Find it on PubMed

Hall, K. M., Cohen, M. E., et al. (1999). "Characteristics of the Functional Independence Measure in traumatic spinal cord injury." Arch Phys Med Rehabil 80(11): 1471-1476. Find it on PubMed

Heinemann, A. W., Linacre, J. M., et al. (1994). "Prediction of rehabilitation outcomes with disability measures." Arch Phys Med Rehabil 75(2): 133-143. Find it on PubMed

Hobart, J. C., Lamping, D. L., et al. (2001). "Evidence-based measurement: which disability scale for neurologic rehabilitation?" Neurology 57(11524472): 639-644. Find it on PubMed

Hsueh, I. P., Lin, J. H., et al. (2002). "Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke." Journal of Neurology, Neurosurgery and Psychiatry 73(2): 188-190. Find it on PubMed

Huang, Y., Wu, C. (2010). “Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke.” Neurorehabilitation and Neural Repair 24(6): 559-566.Find it on PubMed

Inouye, M., Hashimoto, H., et al. (2001). "Influence of admission functional status on functional change after stroke rehabilitation." Am J Phys Med Rehabil 80(2): 121-125; quiz 126, 146. Find it on PubMed

Jackson, A. B., Carnel, C. T., et al. (2008). "Outcome measures for gait and ambulation in the spinal cord injury population." J Spinal Cord Med 31(5): 487-499. Find it on PubMed

Karamehmetoglu, S. S., Karacan, I., et al. (1997). "The functional independence measure in spinal cord injured patients: comparison of questioning with observational rating." Spinal Cord 35(1): 22-25. Find it on PubMed

Kay, E., Deutsch, A., et al. (2010). "Effects of gender on inpatient rehabilitation outcomes in the elderly with incomplete paraplegia from nontraumatic spinal cord injury." J Spinal Cord Med 33(4): 379-386. Find it on PubMed

Keith, R. A., Granger, C. V., et al. (1987). "The functional independence measure: a new tool for rehabilitation." Adv Clin Rehabil 1(3503663): 6-18. Find it on PubMed

Kohler, F., Dickson, H., et al. (2009). "Agreement of functional independence measure item scores in patients transferred from one rehabilitation setting to another." Eur J Phys Rehabil Med 45(4): 479-485. Find it on PubMed

Kucukdeveci, A. A., Yavuzer, G., et al. (2001). "Adaptation of the Functional Independence Measure for use in Turkey." Clin Rehabil 15(3): 311-319. Find it on PubMed

Kucukdeveci, A. A., Sehim, K., et al. (2013). “The reliability and validity of the World Health Organization Disability Assessment Schedule (WHODAS-II) in stroke.” Disability & Rehabilitation 35(3): 214-220. Find it on PubMed

Lawton, G., Lundgren-Nilsson, Å., et al. (2006). "Cross-cultural validity of FIM in spinal cord injury." Spinal Cord 44(12): 746-752. Find it on PubMed

Lundgren-Nilsson, Å., Tennant, A., et al. (2006). "Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia." Health and Quality of Life Outcomes 4(1): 55. Find it on PubMed

Lundgren Nilsson, A. and A. (2011) Tennant, Past and present issues in Rasch analysis: the functional independence measure (FIM) revisited. J Rehabil Med 43(10): p. 884-91. Find it on PubMed.

Marciniak, C. M., Choo, C. M., et al. (2011). "Do co-morbidities and cognition impact functional change and discharge needs in Parkinson disease?" American Journal of Physical Medicine & Rehabilitation 90(4): 272-280.

Miki, E., et al. (2015) Validity and reliability of the Japanese version of the FIM + FAM in patients with cerebrovascular accident. Scand J Occup Ther. 1-7. Find it on PubMed.

Montecchi, M.G., et al.,(2013) Trunk Recovery Scale: a new tool to measure posture control in patients with severe acquired brain injury. A study of the psychometric properties. Eur J Phys Rehabil Med 49(3): p. 341-51.Find it on PubMed

Naghdi, S., et al. (2016) Cross-cultural validation of the Persian version of the Functional Independence Measure for patients with stroke. Disabil Rehabil. 38(3): p. 289-98. Find it on PubMed.

Ng, Y. S., Jung, H., et al. (2007). "Results from a prospective acute inpatient rehabilitation database: clinical characteristics and functional outcomes using the Functional Independence Measure." Ann Acad Med Singapore 36(1): 3-10. Find it on PubMed

Nichol, A. D., Higgins, A. M., et al. (2011). "Measuring functional and quality of life outcomes following major head injury: common scales and checklists." Injury 42(3): 281-287. Find it on PubMed

Nilsson, A. L., Sunnerhagen, K. S., et al. (2005). "Scoring alternatives for FIM in neurological disorders applying Rasch analysis." Acta Neurol Scand 111(4): 264-273. Find it on PubMed

O'Brien, S.R., et al. (2013) Shorter length of stay is associated with worse functional outcomes for medicare beneficiaries with stroke. Phys Ther 93(12): p. 1592-602Find it on PubMed

Ottiger, B., et al. (2015) Validation of the new Lucerne ICF based Multidisciplinary Observation Scale (LIMOS) for stroke patients. PLoS One 10(6): p. e0130925. Find it on PubMed.

Ottenbacher, K. J., Hsu, Y., et al. (1996). "The reliability of the functional independence measure: a quantitative review." Arch Phys Med Rehabil 77: 1226-1232. Find it on PubMed

Pollak, N., Rheault, W., et al. (1996). "Reliability and validity of the FIM for persons aged 80 years and above from a multilevel continuing care retirement community." Arch Phys Med Rehabil 77(10): 1056-1061. Find it on PubMed

Price, G. L., Kendall, M., et al. (2004). "Perceived causes of change in function and quality of life for people with long duration spinal cord injury." Clin Rehabil 18(2): 164-171. Find it on PubMed

Saboe, L. A., Darrah, J. M., et al. (1997). "Early predictors of functional independence 2 years after spinal cord injury." Arch Phys Med Rehabil 78(6): 644-650. Find it on PubMed

Salter, K., et al. 2010 Clinical Outcome Variables Scale: A retrospective validation study in patients after stroke. J Rehabil Med 42(7): p. 609-13.Find it in PubMed

Sasaki, T., et al. 2014 Reliability, validity, and factor structure of the Cognitive Behavioral Rating Scale for stroke patients. Int J Rehabil Res 37(4): p. 343-8. Find it on PubMed

Segal, M. E., Ditunno, J. F., et al. (1993). "Interinstitutional agreement of individual functional independence measure (FIM) items measured at two sites on one sample of SCI patients." Paraplegia 31(8259324): 622-631.

Sharrack, B., Hughes, R. A., et al. (1999). "The psychometric properties of clinical rating scales used in multiple sclerosis." Brain 122 ( Pt 1): 141-159. Find it on PubMed

Shindo, K., et al. (2015) Psychometric properties of the simple test for evaluating hand function in patients with stroke. Brain Inj 29(6): p. 772-6.Find it on PubMed

Sivan, M., et al. ( 2011) Systematic review of outcome measures used in the evaluation of robot-assisted upper limb exercise in stroke. J Rehabil Med 43(3): p. 181-9. Find it on PubMed.

Spooren, A. I., Janssen-Potten, Y. J., et al. (2006). "Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test." Spinal Cord 44(12): 772-779. Find it on PubMed

Stineman, M. G., Shea, J. A., et al. (1996). "The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories." Arch Phys Med Rehabil 77(11): 1101-1108. Find it on PubMed

Tur, B. S., Gursel, Y. K., et al. (2003). "Rehabilitation outcome of Turkish stroke patients: in a team approach setting." Int J Rehabil Res 26(4): 271-277. Find it on PubMed

Turner-Stokes, L., et al. (2010) Deriving a Barthel Index from the Northwick Park Dependency Scale and the Functional Independence Measure: are they equivalent? Clin Rehabil 24(12): p. 1121-6. Find it on PubMed.

Ward, I., et al., (2011) Validity of the stroke rehabilitation assessment of movement scale in acute rehabilitation: a comparison with the functional independence measure and stroke impact scale-16. PM R,. 3(11): p. 1013-21.Find it on PubMed

Van Heugten, C.M., L. Walton, and U. Hentschel 2015 Can we forget the Mini-Mental State Examination? A systematic review of the validity of cognitive screening instruments within one month after stroke. Clin Rehabil 29(7): p. 694-704Find it on PubMed

Yang, S.Y. and K.H. Kong, (2013) Level and predictors of participation in patients with stroke undergoing inpatient rehabilitation. Singapore Med J . 54(10): p. 564-8. Find it on PubMed.

Yavuz, N., Tezyurek, M., et al. (1998). "A comparison of two functional tests in quadriplegia: the quadriplegia index of function and the functional independence measure." Spinal Cord 36(12): 832-837. Find it on PubMed

Last Updated

Atomized Content

Purpose

Area of Assessment

Assessment Type

Administration Mode

Cost

Cost Description

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Minimally Clinically Important Difference (MCID)

Normative Data

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Floor/Ceiling Effects

Responsiveness

Normative Data

Interrater/Intrarater Reliability

Internal Consistency

Construct Validity

Content Validity

Face Validity

Floor/Ceiling Effects

Responsiveness

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Content Validity

Responsiveness

Test/Retest Reliability

Interrater/Intrarater Reliability

Internal Consistency

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Floor/Ceiling Effects

Responsiveness

Bibliography

Buss-Durkee Hostility Inve...

NIH Toolbox for Assessment...

Home and Community Environ...