Functional Independence Measure (FIM)

Evidence Reviewed as of before: 15-10-2011
Author(s): Lisa Zeltzer, MSc OT;
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Functional Independence Measure (FIM) was developed to address the issues of sensitivity and comprehensiveness that were criticized as being problematic with the Barthel Index (another measure of functional independence). The FIM was also developed to offer a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps for use in the medical system in the United States (McDowell & Newell, 1996). The level of a patient’s disability indicates the burden of caring for them and items are scored on the basis of how much assistance is required for the individual to carry out activities of daily living.

In-Depth Review

Purpose of the measure

The Functional Independence Measure (FIM) was developed to address the issues of sensitivity and comprehensiveness that were criticized as being problematic with the Barthel Index (another measure of functional independence). The FIM was also developed to offer a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps for use in the medical system in the United States (McDowell & Newell, 1996). The level of a patient’s disability indicates the burden of caring for them and items are scored on the basis of how much assistance is required for the individual to carry out activities of daily living.

The FIM assesses six areas of function (Self-care, Sphincter control, Transfers, Locomotion, Communication and Social cognition), which fall under two Domains (Motor and Cognitive). It has been tested for use in patients with stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, and elderly individuals undergoing inpatient rehabilitation and has been used with children as young as 7 years old.

Available versions

The FIM was developed between 1984 and 1987 by a national task force sponsored by the American Academy of Physical Medicine and Rehabilitation and the American Congress of Rehabilitation Medicine and was published by Keith, Granger, Hamilton, and Sherwin in 1987.

Features of the measure

Items:

The FIM consists of 18 items assessing 6 areas of function. The items fall into two domains: Motor (13 items) and Cognitive (5 items). The motor items are based on the items of the Barthel Index. These domains are referred to as the Motor-FIM and the Cognitive-FIM.

The items of the FIM are listed as follows:

Motor Domain:

  1. Self-care (6 items)

    • Eating
    • Grooming
    • Bathing
    • Dressing – Upper body
    • Dressing – Lower body
    • Toileting
  2. Sphincter control (2 items)

    • Bladder management
    • Bowel management
  3. Transfers (3 items)

    • Bed/Chair/Wheelchair
    • Toilet
    • Tub/Shower
  4. Locomotion (2 items)

    • Walk/Wheelchair
    • Stairs

Cognitive Domain:

  1. Communication (2 items)

    • Comprehension
    • Expression
  2. Social cognition (3 items)

    • Social interaction
    • Problem solving
    • Memory

For the Motor-FIM, the Eating, Grooming, and Bowel management items are known to be the easiest items for patients with stroke to accomplish, whereas Tub/Shower transfers and Locomotion (Walk/Wheelchair, Stairs) are the most challenging items (Granger, Cotter, Hamilton, & Fiedler, 1993; Grimby, Gudjonsson, Rodhe, Sunnerhagen, Sundh, & Ostensson, 1996). For the Cognitive-FIM, performance of the Expression item has been found to be the easiest for patients to accomplish, and Problem solving has been found to be the most challenging (Granger et al., 1993).

Time:

The FIM is reported to take between 30-45 minutes to administer and score, with 7 minutes to gather demographic information.

Scoring:

Each item on the FIM is scored on a 7-point Likert scale, and the score indicates the amount of assistance required to perform each item (1 = total assistance in all areas, 7 = total independence in all areas). The ratings are based on performance rather than capacity and can be acquired by observation, patient interview, telephone interview or medical records. The developers of the FIM recommend that the scoring be derived by consensus with a multi-disciplinary team.

A final summed score is created and ranges from 18 – 126, where 18 represents complete dependence/total assistance and 126 represents complete independence. The single summed raw score may be misleading as it gives the appearance of a continuous scale. However, intervals between scores are not equal in terms of level of difficulty and cannot provide more than ordinal level information (Linacre et al., 1994). Kidd et al. (1995) suggested using the summed scores as though on an interval scale while the individual items remain ordinal. Granger, Deutsch, and Linn (1998) have applied a Rasch rating scale in order to transform the FIM’s ordinal ratings to an equal-interval rating scale so that it can be used for linear regression models.

Subscale scores for the Motor and Cognitive domains can also be calculated (Linacre, Heinemann, Wright, Granger, & Hamilton, 1994).

Equipment:

Any items that the patient uses to carry out their activities of daily living.

Subscales:

There are two subscales for the FIM: the Motor-FIM and the Cognitive-FIM.

Training:

The FIM must be administered by a trained and certified evaluator.

Grey and Kennedy (1993) found that the FIM could be completed as a self-report questionnaire in patients with spinal cord injury. Segal and Schall (1994) found that the FIM can be used reliably by in-person proxy for patients with stroke. Segal, Gillard, and Schall (1996) further established that the FIM can be used reliably by proxy over the telephone in patients with stroke (total FIM, intraclass correlation coefficient (ICC) = 0.91, Motor-FIM, ICC = 0.94; Cognitive-FIM, ICC = 0.52), and closely resembles results obtained for the in-person administration.

Alternative Forms of the Functional Independence Measure

  • The Functional Independence Measure for Children (WeeFIM). This measure was developed to track disability in children who are between the ages of 6 months and 7 years. The WeeFIM can be administered to children over the age of 7 if their functional abilities are below those expected of children aged 7 who do not have disabilities. It measures the impact of developmental strengths and difficulties on independence at home, in school, and in the community (Msall et al., 1994). The scale has 18 items measuring functional performance in 3 domains: Self-care, Mobility, and Cognition (Uniform Data System for Medical Rehabilitation, http://www.udsmr.org/).
  • Modified 5-level FIM. Gosman-Hedström and Blomstrand (2004) examined whether a 5-level FIM would be more useful than the standard 7-level version in large population studies. They used a sample of elderly stroke survivors and found that a 5-level FIM would most likely increase the reliability of the FIM without losing sensitivity.

Client suitability

Can be used with:

Patients with stroke of all ages, and can be used with patients with special conditions (e.g. aphasia or neglect).

Should not be used in:

No restrictions have been reported.

In what languages is the measure available?

The FIM has been translated in the following languages:

  • German
  • Italian
  • Spanish
  • Swedish
  • Finnish
  • Portuguese
  • Afrikaans
  • Turkish
  • French
  • Persian (Farsi)

Summary

What does the tool measure? Activities of Daily Living
What types of clients can the tool be used for? Patients with stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, and elderly individuals undergoing inpatient rehabilitation. Can be used with children as young as 7 years old.
Is this a screening or assessment tool? Assessment
Time to administer The FIM is reported to take between 30-45 minutes to administer and score, with 7 minutes to gather demographic information.
Versions WEE-FIM; Modified 5-level FIM
Other Languages German; Italian; Spanish; Swedish; Finnish; Portuguese; Afrikaans; Turkish; French; Persian (Farsi).
Measurement Properties
Reliability
  • Out of 4 studies examining internal consistency , all 4 reported excellent internal consistency.
  • Out of 5 studies examining test-retest reliability, all 5 reported excellent test-retest.
  • Out of 10 studies examining inter-rater reliability, 8 studies reported excellent; 1 reported adequate to excellent (except Social Interaction item which was poor); 1 reported overall poor kappa values, but excellent intraclass correlation coefficient (ICC).
Validity

Content:

The FIM was created based on the results of a literature review of published and unpublished measures and expert panels and was then piloted in 11 centers. The Delphi method was applied, using rehabilitation expert opinion to establish the inclusiveness and appropriateness of the items.

Criterion:

Excellent correlations with the Barthel Index; Modified Rankin Scale; Disability Rating Scale. FIM scores found to predict amount of home care required; admission scores predict FIM discharge scores; placement after discharge; functional gain; length of stay; depression, ability to return to work following stroke or traumatic brain injury.

Concurrent:

The Motor-FIM was found to demonstrate an excellent correlation with the Modified Rankin Scale (MRS) and the Disability Rating Scale (DRS); and adequate to excellent correlation with the Barthel Index. The Cognition-FIM was found to have an excellent correlation with the DRS; an adequate correlation with the Montebello Rehabilitation Factor Score (MRFS) (efficacy); and a poor correlation with the MRFS (efficiency).

Construct:

FIM scores discriminated between groups based on spinal cord injury and stroke severity, and the presence of comorbid illness both at admission and discharge. It has also been found to distinguish between patients with or without neglect and with or without aphasia at both admission and discharge.

Convergent/Discriminant:

The total FIM was found to demonstrate an excellent correlation with the Office of Population Censuses and Surveys Disability Scales disability scores; an adequate correlation with the London Handicap Scale and the Wechsler Adult Intelligence Test-verbal IQ test; and a poor correlation with the SF-36 Physical and Mental components, and the General Health Questionnaire. The Motor-FIM was found to demonstrate an excellent correlation with the Office of Population Censuses and Surveys Disability Scales disability scores; an adequate correlation with the London Handicap Scale; and a poor correlation with the Wechsler Adult Intelligence Test-verbal IQ test, SF-36 Physical and Mental components, and the General Health Questionnaire. The Cogntion-FIM was found to demonstrate an excellent correlation with the Mini-Mental State Examination (MMSE); an adequate correlation with the Lowenstein Occupational Therapy Cognitive Assessment (LOTCA), Office of Population Censuses and Surveys Disability scores, and the revised Wechsler Adult Intelligence Test-verbal IQ; and a poor correlation with the London Handicap Scale, SF-36 Physical and Mental components, and the General Health Questionnaire.

Ecological:

The Motor-FIM demonstrated poor correlations with the Occupational Therapy Adult Perceptual Screening Test (OT-APST). The Cognition-FIM demonstrated adequate correlations with the OT-APST.

Does the tool detect change in patients? A significant ceiling effect has been detected with the Cognitive domain of the FIM. Out of 7 studies examined, 3 reported that the FIM has an excellent ability to detect change in patients with stroke, 4 reported poor ability to detect change in patients with stroke or multiple sclerosis.
Acceptability The FIM is typically administered by interview. In patients with stroke, it can be reliability administered to proxy respondents.
Feasibility Training and education of persons to administer the FIM may represent significant cost. Use of interview formats may make the FIM more feasible for longitudinal assessment.
How to obtain the tool? Click here to find a copy of the FIM (the original comes from the following website: http://www.va.gov/vdl/documents/Clinical/Func_Indep_Meas/fim_user_manual.pdf)

http://www.udsmr.org

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the FIM.

Floor/Ceiling Effects

Van der Putten, Hobart, Freeman and Thompson (1999) compared the Motor-FIM and total FIM to the Barthel Index in 201 patients with multiple sclerosis and 82 post-stroke patients undergoing inpatient neurorehabilitation. The Cognitive-FIM had poor ceiling effects in patients with multiple sclerosis (36%) and adequate ceiling effects in patients with stroke. The total FIM showed no ceiling effect (0%) in both patients with stroke and patients with multiple sclerosis, as compared to 7% for the Barthel Index (1% for the Motor-FIM).

Hsueh, Lin, Jeng, and Hsieh (2002) compared the Motor-FIM, the original 10-item Barthel Index, and the 5-item short form Barthel Index in inpatients with stroke receiving rehabilitation. They reported a substantially larger floor effect for admission Barthel Index scores than for admission Motor-FIM scores (18.2% vs. 5.8% respectively).

Hobart and Thompson (2001) compared the modified Barthel Index, the FIM and the 30-item FIM plus Functional Assessment Measure (FIM + FAM) in 149 patients with various neurological disorders. No significant floor or ceiling effects were reported in this study for the total FIM, although there was a 16.1% ceiling effect noted for the Cognitive-FIM.

Brock, Goldie, and Greenwood (2002) examined the ceiling effects of the Motor-FIM and the Motor Assessment Scale in 106 rehabilitation inpatients with stroke at discharge. The ceiling effects for the Motor-FIM were adequate (16%), and 29% of the patients achieved the highest score on the hardest item of the Motor-FIM. In comparison, the Motor Assessment Scale had a ceiling effect of 25% (poor) and 35% of patients scored the highest score on the most difficult item.

Dromerick, Edwards, and Diringer (2003) assessed 95 consecutive admissions to a stroke rehabilitation service for disability on admission and discharge. No floor or ceiling effects were reported at admission to or discharge from rehabilitation with the FIM, whereas the Barthel Index demonstrated a large ceiling effect at discharge (27%).

Reliability

Internal consistency:

Dodds, Martin, Stolov and Deyo (1993) examined the psychometric properties of the FIM by analyzing Uniform Data System data on 11,102 general rehabilitation inpatients. Common diagnoses were stroke (52%), orthopedic conditions (10%), and brain injury (10%). The FIM demonstrated an excellent internal consistency, with a Cronbach’s alpha of 0.93 for overall admissions and 0.95 for discharges.

Hsueh, Lin, Jeng, and Hsieh (2002) examined the reliability of the FIM in 118 inpatients with stroke. Patients were administered the Motor-FIM subscale at admission to a rehabilitation ward of a hospital and before discharge from the hospital. The Motor-FIM demonstrated excellent internal consistency, with an alpha = 0.88 at admission and an alpha = 0.91 at discharge.

Hobart et al. (2001) examined the reliability of the FIM, the Barthel Index and the FIM plus Functional Assessment Measure in 149 rehabilitation inpatients with neurologic disorders. Item-to-total correlations were adequate and ranged from 0.53 to 0.87 for the FIM total, 0.60 for the Motor-FIM and 0.63 for the Cognitive-FIM. Mean inter-item correlations were also adequate, and were reported as 0.51 for the total FIM, 0.56 to 0.91 for the Motor-FIM and 0.72 to 0.80 for the Cognitive-FIM. Cronbach alpha levels were excellent for the total FIM (alpha = 0.95), the Motor-FIM (alpha = 0.95), and for the Cognitive-FIM (alpha = 0.89). The results of this study demonstrate the internal consistency of the total FIM and its Motor and Cognitive domains.

Sharrack, Hughes, Soudain, and Dunn (1999) assessed the internal consistency of the FIM in patients with multiple sclerosis. The internal consistency of the FIM was excellent, with a Cronbach’s alpha of 0.98.

Test-retest:

Chau, Daler, Andre and Patris (1994) examined the test-retest reliability of the FIM in 254 patients under 20 years old in a rehabilitation centre. The test-retest reliability was found to be excellent (ICC = 0.93 for total FIM).

Segal, Ditunno, and Staas (1993) examined the test-retest reliability of the FIM at discharge from an acute care rehabilitation setting and again at admission to an ongoing rehabilitation setting in 57 patients with spinal cord injuries. The two ratings were performed within 6 days of each other. The total FIM demonstrated excellent test-retest reliability (r = 0.83).

Kidd et al. (1995) compared the FIM to the Barthel Index in two groups of 25 patients undergoing neurorehabilitation. Test-retest reliability was found to be excellent for the FIM (r = 0.90).

Ottenbacher, Hsu, Granger, and Fiedler (1996) examined the test-retest reliability of the FIM by examining the results of 11 studies including a total of 1,568 patients. The median test-retest was excellent (r = 0.95).

Pollak, Rheault, and Stoecker (1996) assessed the test-retest reliability of the FIM in 49 individuals over the age of 80 years. Individuals were tested twice using the FIM. Excellent test-retest reliability was found for the Motor-FIM (ICC = 0.90), and for the Cognitive-FIM (ICC = 0.80).

Intra-rater:

Sharrack, Hughes, Soudain, and Dunn (1999) assessed the intra-rater reliability of the FIM (using both kappa and ICC statistics) in 35 patients with multiple sclerosis. Three raters followed patients for 9 months, with assessments every 3 months. The kappa value for the total FIM was poor (kappa = 0.28), however the ICC was excellent (ICC = 0.94). For individual items, kappa coefficients ranged from adequate (kappa = 0.55 for Dressing-lower body) to excellent (kappa = 1.00 for both Expression and Social interaction). ICC’s for individual items ranged from adequate (kappa = 0.60 for Bladder control) to excellent (ICC = 1.00 for both Expression and Social interaction).

Hobart et al. (2001) examined the intra-rater reliability of the FIM, the Barthel Index and the FIM plus Functional Assessment Measure in 56 rehabilitation inpatients with neurologic disorders. Patients were examined by the same multidisciplinary team on two occasions. Intra-rater reliability was calculated using ICC statistics. The total FIM, Motor-FIM and Cognitive-FIM were all found to have excellent intra-rater reliabilities (ICC = 0.98, 0.98 and 0.95, respectively).

Inter-rater:

Chau, Daler, Andre and Patris (1994) examined the inter-rater reliability of the FIM between educators, occupational therapists and physiotherapists in 254 patients under 20 years old in a rehabilitation centre. Inter-rater reliability for the total FIM was excellent (ICC = 0.94).

Ottenbacher, Mann, Granger, Tomita, Hurren, and Charvat (1994) examined the inter-rater reliability of the FIM and the Instrumental Activities of Daily Living Scale in 20 community-dwelling older patients. Two raters administered the tests over a short (7-10 days) or long (4-6 week) interval. The ICCs for inter-rater reliability were excellent, ranging from 0.90 to 0.99.

Ottenbacher, Hsu, Granger, and Fiedler (1996) examined the inter-rater reliability of the FIM by examining the results of 11 studies including a total of 1,568 patients. The median inter-rater reliability for the total FIM was excellent (r = 0.95).

Hamilton, Laughlin, Fiedler and Granger (1994) examined the inter-rater reliability of the FIM in 1,018 patients. The total FIM ICC was excellent (ICC = 0.96), as was the Motor-FIM domain (ICC = 0.96), and the Cognitive-FIM domain (ICC = 0.91).

Jaworski, Kult, and Boynton (1994) compared the reliability of observed and reported FIM ratings. In this study, the inter-rater reliability of the FIM was found to be excellent (ICC = 0.99).

Kidd et al. (1995) compared the FIM to the Barthel Index in two groups of 25 patients undergoing neurorehabilitation. Inter-rater reliability was found to be excellent for the FIM (r = 0.92).

Segal and Schall (1994) examined the inter-rater reliability of the FIM in 38 patients with stroke. The inter-rater reliability of the measure was found to be excellent, with an ICC of 0.96.

Brosseau and Wolfson (1994) examined the inter-rater reliability of the FIM in patients with multiple sclerosis and found that the FIM has an excellent inter-rater reliability (ICC = 0.83).

Daving, Andren, Nordholm, and Grimby (2001) examined the reliability of the FIM in 63 patients with stroke, approximately 2 years after stroke onset. Two raters (between three occupational therapists and one nurse) conducted independent ratings of the FIM in the patient’s home, and the interview procedure was repeated within a week by another two raters in the clinic. The kappa values during the same interview exceeded 0.40 for 17 items, demonstrating adequate to excellent inter-rater reliability , however, the Social interaction item kappa value was poor (kappa = 0.26). In comparing the two interviews, kappa values were between 0.40-0.60 for Self-care items (except Bathing) and Sphincter control (except Bowel management), however, most of the Transfers, Locomotion and Social cogniton items had kappa values below 0.40. The two interviews were also studied using ICC statistics between all raters. ICC’s ranged from adequate (0.62 for Bowel management) to excellent (0.88 for Bathing) for the 13 motor items, and were adequate (ranging from 0.60 to 0.72) for the Cognitive domain, except for the Social interaction item which had an ICC of only 0.44. Significant differences were found between raters on the Wilcoxon test for the Dressing, Transfer Toilet, Transfer Tub/Shower, Walk/Wheelchair and the Cognitive domain. The results of this study show that the FIM demonstrates high inter-rater reliability in the same interview setting (whether at home or at the clinic), however the stability over time with a repeated interview by different raters is less reliable.

Sharrack, Hughes, Soudain, and Dunn (1999) assessed the inter-rater reliability of the FIM (using both kappa and ICC statistics) in 64 patients with multiple sclerosis. Each patient was assessed by three raters (2 neurologists, 1 neurology research nurse). The kappa value for the total FIM score was poor (kappa = 0.21), however the ICC was excellent (ICC = 0.99). For individual items, kappa coefficients were variable and ranged from poor (kappa = 0.26 for Comprehension) to excellent (kappa = 0.88 for Stairs locomotion). ICC’s for the individual items were excellent, ranging from 0.76 to 0.99 with the exception of the Comprehension item, which demonstrated adequate inter-rater reliability (ICC = 0.56).

Validity

Content:

The FIM was created based on the results of a literature review of published and unpublished measures and expert panels. To establish content and face validity, the FIM was then piloted in 11 centers (including 114 clinicians from 8 different disciplines and 110 patients evaluated) (Keith & Granger, 1987). Face and content validity were both determined by applying the Delphi method, using rehabilitation expert opinion to establish the inclusiveness and appropriateness of the items (Granger, Hamilton, Keith, Zielezny, & Sherwins, 1986).

Criterion:

Concurrent:

Hsueh, Lin, Jeng, and Hsieh (2002) examined the concurrent validity of the Motor-FIM by examining its interrelations with the original 10-item Barthel Index, and the 5-item short form Barthel Index in 118 inpatients with stroke receiving rehabilitation. Concurrent validity was measured using ICC and Spearman correlations. The Motor-FIM exhibited excellent concurrent validity at admission as measured by Spearman correlation (r = 0.74) and adequate validity as measured by ICC (ICC = 0.55). The Motor-FIM exhibited excellent concurrent validity at discharge (Spearman correlation = 0.92, ICC = 0.86).

Kwon, Hartzema, Duncan and Min-Lai (2004) examined the concurrent validity of the Barthel Index, the FIM and the Modified Rankin Scale in a sample of post-stroke patients. Spearman correlation coefficients were excellent between the Barthel Index and the Motor-FIM (r = 0.95) and between the Motor-FIM and the Modified Rankin Scale (r = -0.89)

Note: This correlation is negative because a high score on the FIM indicates functional independence, whereas a high score on the Modified Rankin Scale indicates severe disability).

Hall, Hamilton, Gordon, and Zasler (1993) examined the concurrent validity of the Disability Rating Scale, the FIM, and the Functional Assessment Measure. Excellent correlations were found between the Motor-FIM and Cognition-FIM and the Disability Rating Scale (r = 0.64 and 0.73, respectively).

Zwecker et al. (2002) examined the relationship between cognitive status and functional motor outcomes in 66 patients with stroke. Functional motor outcomes were measured from efficacy and efficiency of the FIM motor scores (isolated from total FIM scores) and the Montebello Rehabilitation Factor Score (MRFS). Using Pearson’s correlation, an adequate correlation was found between the FIM cognitive subtest and MRFS efficacy (r=0.34, p<0.01). A poor correlation was found between the FIM cognitive and MRFS efficiency (r=0.28, p<0.05). No significant correlations were found between the FIM cognitive and FIM motor efficacy or efficiency scores.

Predictive:

For an extensive review of the predictive validity of the FIM, please see:

Timbeck, R. J., Spaulding, S. J. (2003). Ability of the Functional Independence Measure to predict rehabilitation outcomes after stroke: A review of the literature. Physical & Occupational Therapy in Geriatrics, 22(1), 63-76.

Chumney, D., Nollinger, K., Shesko, K., Skop, K., Spencer, M., Newton, R.A. (2010). Ability of Functional Independent Measure to accurately predict functional outcome of stroke-specific population: Systematic review. Journal of Rehabilitation and Development, 47, 17-30.

Predictive validity of the FIM in the amount of care patients require in their homes:

Granger, Cotter, Hamilton, Fiedler, and Hens (1990) examined whether the FIM could predict the amount of help (measured in minutes of assistance provided per day by another person in the home) patients with multiple sclerosis required, using a bivariate regression analysis. Burden of care was assessed as help in minutes per day. It was found that a 1-point improvement in total FIM score predicted a 3.38-minutes reduction in help from another person per day. The FIM was found to be more predictive than the Barthel Index, the Incapacity Status Scale, and the Environmental Status Scale. The FIM was also found to contribute to the prediction of patient general life satisfaction.

Granger, Cotter, Hamilton and Fiedler (1993) examined whether the FIM could predict the physical care needs (measured in minutes of assistance provided per day by another person in the home) of patients with stroke. Burden of care was assessed as help in minutes per day. It was found that a 1-point improvement in total FIM score predicted a 2.19-minute reduction in help from another person per day. The FIM, along with the Brief Symptom Inventory, was found to contribute to the prediction of patient general life satisfaction.

Corrigan, Smith-Knapp and Granger (1997) examined the predictive validity of the FIM for patients with traumatic brain injury after discharge from acute rehabilitation. They found that the Motor-FIM predicted which patients required direct assistance with 83% accuracy, the Cognitive-FIM predicted which patients required supervision with 77% accuracy, and the Motor-FIM and Cognitive-FIM predicted which patients required any assistance with 78% accuracy. Further, the Motor-FIM score alone was the best predictor of the number of minutes of assistance needed.

Predictive validity of the FIM with discharge FIM scores, discharge destinations, length of stay, functional gain, depression, survival, and the ability to return to work following stroke or traumatic brain injury:

Inouye et al. (2000) performed a multivariate analysis on data from rehabilitation patients with stroke obtained from patient medical records to identify predictors of functional outcome using total FIM scores. It was found that total FIM admission scores was the strongest predictor of total FIM discharge scores. No relationship was found between total FIM scores at discharge and gender, hospital length of stay, or the nature of the stroke.

Oczkowski and Barreca (1993) examined whether the FIM could predict prognosis in 113 patients with stroke observed from admission to discharge. It was found that the admission FIM score was predictive of placement after discharge and of outcome disability. No patients with an admission FIM score below 36 were discharged home, while all of the patients with admission FIM scores above 96 were discharged home. However, discharge destination became difficult to predict in patients with a moderate range of disability (i.e. an FIM score > 36 or < 97). When individual FIM items were considered, a patient’s level of independence with bowel and bladder management was predictive of functional outcome and discharge destination.

Alexander (1994) examined the predictive validity of the FIM in a sample of 520 patients with stroke admitted to a rehabilitation hospital. It was found that an admission FIM score of < 40 resulted in an acute care stay almost twice as long as any other FIM score. Patients aged < 55 years all were discharged home regardless of their initial severity. Patients with an FIM score < 40 and who were > 55 years old had a 50% chance of being discharged to a long term care facility. This is in contrast to the findings by Oczkowski and Barreca (1993) who found that no patients with an admission FIM score < 36 were discharged to home. Patients with an admission FIM score between 40-60 who were > 74 years were at high risk for discharge to a long term care facility. Patients with an FIM score > 80 were discharged home.

Mokler, Sandstrom, Griffin, Farris, and Jones (2000) found that in the acute care phase of stroke recovery, the FIM scores for Eating, Bathing, Dressing – Lower body, Toileting, Bowel management and Social interaction and predicted discharge destination with 70% accuracy. In the later phase of recovery in rehabilitation, particularly in patients with a severe stroke, scores on admission FIM items including Bladder management, Toilet transfer, and Memory, and scores on the discharge FIM items including Dressing – Upper body, Bed/Chair/Wheelchair transfers and Comprehension were associated with predicting discharge destination with up to 75% accuracy. These three admission items and three discharge items correctly predicted discharge placement in 2/3 and 3/4 of the cases, respectively.

Black, Soltis, and Bartlett (1999) examined the FIM scores of 234 patients with stroke admitted to a rehabilitation facility over a 2-year period. Patients who were discharged home were less likely to have a caregiver who worked (20%) versus patients who were discharged to long-term care (65%). The availability of a non-working family member to provide assistance and supervision was a critical factor related to discharge home. Patients with a discharge FIM score > 80 had a high probability of being discharged home when social factors (e.g. availability of family support and non-working family member) were taken into consideration. Thus, both functional status and social factors, such as family availability and support, are critical elements in predicting the discharge destination of this patient population.

Ring et al. (1997) examined 151 patients with stroke admitted to a rehabilitation centre over a 2-year period. They found that admission FIM scores and length of stay were the most significant predictors of functional gain.

Heinemann, Linacre, Wright, Hamilton, and Granger (1994) examined the extent to which functional outcome measures could predict functional status in patients with traumatic brain injury. They report that admission FIM scores were related to discharge function and length of stay. Admission Motor-FIM scores were found to be a stronger predictor of length of stay than Cognitive-FIM scores and accounted for 52% of the variance in discharge motor function. Admission Cognitive-FIM scores accounted for 46% of the variance in discharge cognitive function.

Ween, Mernoff, and Alexander (2000) examined the predictive validity of the FIM in 244 patients with stroke at an acute rehabilitation centre. It was found that patients with an admission FIM score < 50 were dependent in their self-care activities upon discharge. Patients who scored < 70, nine days post-stroke, were highly likely to remain functionally dependent at discharge. Patients who scored > 70 were not dependent at discharge and had shorter than average length of stay. Patients who scored between 50 and 70 on the admission FIM had unpredictable outcomes. In terms of discharge destination, patients who were < 60 years old and had an admission FIM score > 70 were strongly associated with home discharge.

Stineman, Fiedler, Granger, and Maislin (1998) examined the records of 26,339 patients with stroke discharged from 252 inpatient rehabilitation facilities. They found that patients whose admission FIM scores were > 37 were able to eat, groom, dress their upper bodies and manage their bowels and bladder independently at discharge. Patients who scored > 55 were also able to bathe, dress their lower bodies and transfer onto a bed or chair and toilet. Additionally, most patients who had initial Motor-FIM scores > 62 and whose Cognitive-FIM scores were > 30 gained independence in most tasks, including transferring into the tub and climbing the stairs by the time of discharge. They also found that between 85% and 93% of patients with moderate stroke were discharged home.

Singh et al. (2000) administered the FIM to 81 patients with stroke at 1 month, 3 months, and 1 year post-stroke. Using stepwise linear regression, they found that lower total FIM scores at 1-month post-stroke were predictive of higher depression scores at 3 months post-stroke.

Cifu et al. (1997) compared 49 patients with traumatic brain injury who were employed at one-year follow-up with 83 patients who remained unemployed at one-year. They found that FIM scores at admission to rehabilitation were significantly associated with patients’ employment status one-year post head injury, such that patients who had returned to work one-year later had demonstrated significantly higher scores on the FIM at admission.

Tur, Gursel, Yavuzer, Kucukdeveci and Arasil (2003) examined the predictive validity of the FIM in 102 patients with stroke admitted to rehabilitation units. The FIM was administered within 72 hours of admission and at discharge. Using a stepwise regression analysis, FIM scores at admission were found to be excellent predictors of FIM scores at discharge (0.90; p<0.001), indicating that the FIM can be used to predict functional recovery in patients with stroke.

Whiting, Shen, Hung, Cordato & Chan (2010) examined predictors of 5-year survival in 166 patients with stroke (mean age 80 years), using the FIM. Using a logistic regression model, lower preadmission FIM scores were found to negatively predict 5-year survival of patients with stroke (OR 1.04, 95%CI 1.1-2.0, P=0.01). In addition, total FIM scores were found to remain relatively stable from baseline to 5-year follow up in the 5-year survival group, however, FIM cognition scores were lower than baseline scores at the 5-year follow-up.

Predictive validity of the FIM in patients with aphasia and neglect:

Granger, Hamilton, and Fielder (1992) found that at admission and discharge, functional scores for patients with right brain damage were slightly higher, but length of stay at the hospital and rate of community discharge were similar to that of patients who had left brain damage.

Alexander (1994) found that patients with stroke who had severe right brain damage had significantly less FIM change than patients with severe left brain damage.

Ring et al. (1997) found that patients with neglect or aphasia had significantly higher FIM gains despite lower FIM admission scores. However, these patients also had a much longer length of stay at the hospital. It was also found that 96% of patients with right brain damage without neglect and 88% of patients with right brain damage and neglect were discharged home.

Oczkowski and Barreca (1993) found that patients with any degree of hemianopsia, parietal neglect, aphasia, or cognitive impairment had significantly lower FIM scores than those without these impairments, but unlike the results of Ring et al. (1997), hemianopsia, side of lesion, neglect and aphasia were not predictive of discharge destination.

Katz et al. (2000) examined correlations between the FIM (total, motor and cognitive scores) and the Lowenstein Occupational Therapy Cognitive Assessment (LOTCA – Orientation, Perception, Visuomotor Organisation and Thinking Operations subtest) in two subgroups of adults with right hemisphere stroke (n=40 vs. patients without unilateral spatial neglect, n=21), using Spearman’s correlation analysis. Measures were taken on admission to and discharge from rehabilitation, and at 6-month follow-up. In the neglect group, adequate correlations were reported between FIM total and FIM motor, and LOTCA Visuomotor Organisation and Thinking Operations (range r=0.48 to -.51) at admission. Adequate to excellent correlations were reported between FIM total and FIM motor, and LOTCA Perception, Visuomotor Organisation and Thinking Operations (range r=0.48 to 0.75) at discharge. Excellent correlations were reported between FIM total and FIM motor and LOTCA Visuomotor Organisation and Thinking Operations tasks (range r=0.61 – 0.77) at follow-up. In the non-neglect group, poor to excellent correlations were reported between FIM cognitive and LOTCA scores (range r=0.05 to -.67) at admission. Moderate to excellent correlations were reported between FIM total and FIM motor, and LOTCA Visuomotor Organisation and Thinking Operations tasks at discharge and follow-up (range r=0.43 to 0.62).

Note: The FIM cognitive was not readministered at discharge or follow-up with this subgroup.

Construct:

Linacre et al. (1994) applied Rasch analysis to the admission and discharge FIM scores of 14,799 patients. Two distinct aspects of disability were found within the FIM: Motor and Cognitive function.

Cavanagh, Hogan, Gordon, and Fairfax (2000) suggested that for post-stroke patients, a simple 2-factor model of the FIM may be insufficient to describe disability and may not measure within patient change adequately. The authors suggest that a three-dimensional FIM for patients with stroke be applied, which includes Self-care, Cognitive function, and Toileting as the major grouping of scales. They found that the 2-factor model only accounts for 66% of variance, whereas a 3-factor model accounted for more variance (74.2%).

Convergent/Discriminant:

Hobart et al. (2001) found that the total FIM and Motor-FIM scores correlated more strongly with the Office of Population Censuses and Surveys Disability Scales disability scores (r = 0.82 and 0.84, respectively), London Handicap Scale scores (r = 0.32 and 0.35, respectively), the SF-36 Physical component scores (r = 0.26 and 0.30, respectively) and the revised Wechsler Adult Intelligence Test-verbal IQ test (r = 0.35 and 0.27, respectively), than with measures of mental health status (SF-36 Mental component, r = 0.10 and 0.10, respectively) or psychological distress (General Health Questionnaire, r = 0.13 and r = 0.15, respectively). However, the Cognitive-FIM correlated most strongly with Office of Population Censuses and Surveys Disability scores (r = 0.43) and the revised Wechsler Adult Intelligence Test-verbal IQ scores (r = 0.51) and correlated poorly with the London Handicap Scale (r = 0.11), the SF-36 Physical and Mental components (r = 0.04 and r = 0.08, respectively), and the General Health Questionnaire (r = 0.01).

Giaquinto, Giachetti, Spiridigliozzi and Nolfe (2010) examined the convergent validity of the FIM, Hospital Anxiety Depression Scale (HADS) and the World Health Organization Quality of Life scale (WHOQOL-100) in 107 patients with stroke (mean 5.6 months post-stroke). Assessments were performed at admission and discharge from a two-month rehabilitation program. As measured by Pearson’s correlation coefficients, an excellent correlation was found between FIM admission and FIM discharge scores (r=0.656, p<0.0001) and was not significantly influenced by gender. However, correlations between FIM discharge scores and HADS and WHOQOL-100 scores were influenced by gender. Among females an adequate correlation was found between FIM discharge and HADS scores (r=-0.315, p<0.02) and FIM discharge and WHOQOL-100 scores (r=0.339, p<0.01), but the correlations among males’ scores were poor (r=0.139 and r=0.147 respectively).

Zwecker et al. (2002) reported an adequate correlation between the FIM cognitive subtest and the Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) (r= 0.471, p<0.001) and an excellent correlation between the FIM cognitive subtest and the Mini Mental State Examination (MMSE) (r=0.666, p<0.001) in 66 patients with stroke, using Pearson’s Correlation.

Known groups:

Dodds, Martin, Stolov and Deyo (1993) examined the construct validity of the FIM using data from 11,102 general rehabilitation inpatients (52% with stroke, 10% with orthopedic conditions, 10% with brain injury). FIM scores discriminated between groups based on spinal cord injury and stroke severity, and the presence of comorbid illness both at admission and discharge. The communication item of the FIM demonstrated most of the observed score difference.

Ring, Feder, Schwartz, and Samuels (1997) examined 151 patients with stroke admitted to a rehabilitation centre over a 2-year period. They found that the FIM was able to distinguish between patients with or without neglect and with or without aphasia at both admission and discharge.

Ecological validity:

Cooke, McKenna, Fleming & Darnell (2006) examined the ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) by comparing scores and completion time with the FIM motor and cognitive subtests in a sample of patients with stroke (n=208). Significant but poor correlations were reported between FIM motor scores and 6 of the 7 OT-APST subscales (range r=0.26 to 0.41, p<0.01). Significant adequate correlations were reported between FIM cognitive scores and all 7 OT-APST subscales (range r=0.36 to 0.50, p<0.01). Significant poor to adequate negative correlations were also reported between the time taken to complete the FIM motor and cognitive subtests and the OT-APST (r=-0.27 and -0.33 respectively, p<0.01).

Responsiveness

The FIM is often compared to the Barthel Index, because the FIM was developed to be a more comprehensive and responsive measure of disability than the Barthel Index (van der Putten et al., 1999; Hobart & Thompson, 2001; Wallace, Duncan, & Lai, 2002; Hsueh et al., 2002).

  • Van der Putten et al. (1999) compared the Motor-FIM and total FIM to the Barthel Index in 201 patients with multiple sclerosis and 82 post-stroke patients undergoing inpatient neurorehabilitation. The Motor-FIM and total FIM demonstrated small effect sizes in the expected direction from admission to discharge in patients with multiple sclerosis (ES = 0.34 and ES = 0.30, respectively) and large effect sizes in patients with stroke (ES = 0.91 and ES = 0.82). The effect sizes for the Cognitive-FIM were not significant (ES = 0) in patients with multiple sclerosis and moderate in patients with stroke (ES = 0.61). Change scores for all scales in both disease groups were positive, indicating less disability on discharge than admission. Effect sizes on the Barthel Index were similar to those of the FIM in both patient groups, suggesting that the FIM might not have an advantage in terms of its responsiveness to change.
  • Wallace et al. (2002) compared the responsiveness of the Motor-FIM to the Barthel Index for stroke recovery between 1 and 3 months. The Barthel Index and Motor-FIM exhibited similar responsiveness to change in this patient population (Motor-FIM, ES = 0.28; Standardized Response Mean (SRM) = 0.62; AUC/ROC curve = 0.675).
  • Hsueh et al. (2002) compared the responsiveness of the Motor-FIM, the original 10-item Barthel Index, and the 5-item short form Barthel Index in inpatients with stroke receiving rehabilitation. The Barthel Index and Motor-FIM exhibited high responsiveness (SRM = 1.2), indicating significant change.
  • Dromerick et al. (2003) assessed 95 consecutive admissions to a stroke rehabilitation service for disability on admission and discharge. The Modified Rankin Scale and the International Stroke Trial Measure were compared with the Barthel Index and the FIM. The number of patients for which each scale detected a clinically significant change in disability was determined. The SRM of the FIM was superior to that of the Barthel Index (2.18 versus 1.72) (change from admission to discharge from rehabilitation). The FIM was the most sensitive measure, detecting change in 91/95 subjects, including change in 18 patients in whom the Barthel Index detected no change.
  • Hobart and Thompson (2001) compared the responsiveness of the modified Barthel Index, the FIM and the 30-item FIM plus Functional Assessment Measure (FIM + FAM) in 149 patients with various neurological disorders. The SRMs for the Barthel Index, the FIM, and the FIM + FAM scales measuring global, motor, and cognitive disability were found to be similar, suggesting that there is no advantage in responsiveness of one measure over another (total FIM, SRM = 0.48; Motor-FIM, SRM = 0.54; Cognitive-FIM, SRM = 0.17).

Sharrack et al. (1999) examined the responsiveness of the FIM in 25 patients with multiple sclerosis. Patients were followed for 9 months, with assessments every 3 months. The total FIM demonstrated a poor sensitivity to change (ES = 0.46). A number of motor items (i.e. Eating, Grooming, Sphincter control, Bed/Chair/Wheelchair and Toilet Transfers, and Locomotion) had small to moderate responsiveness (ES ranged from 0.25 for Toilet Transfer to 0.67 for Bed/Chair/Wheelchair Transfers). None of the cognitive items were responsive to change (ES ranged from 0.00 to 0.19).

Dodds, Martin, Stolov and Deyo (1993) examined the responsiveness of the FIM by analyzing the differences between admission and discharge FIM scores from 11,102 general rehabilitation inpatients (with stroke (52%), orthopedic conditions (10%), and brain injury (10%)). Significant functional gains were detected by the FIM (33% score improvement). The authors conclude that the FIM demonstrates some responsiveness, but its ability to measure change over time needs further examination.

Hammond, Grattan, Sasser, Corrigan, Bushnik, and Zafonte (2001) examined FIM score changes over time in patients with traumatic brain injury. Significant differences in total FIM, Motor-FIM and Cognitive-FIM scores were reported between discharge from rehabilitation and follow-up at one year post-injury. Change between one and two years and one and five years was reported to be distributed across all items with most change observed in cognitive function.

Beninato, Gill-Body, Salles, Stark, Black-Schaffer and Stein (2006) defined the minimal clinically important difference (MCID) when using the FIM in a stroke population. The study included 113 patients from a rehabilitation unit at a long-term acute care hospital. The FIM was administered at admission and discharge; patient function was also assessed by attending physicians at the same time points using a 15-point integer scale where -7 indicated that a patient was “a very great deal worse”, 0 indicated “no change” and +7 indicated “a very great deal better”. Based on physicians’ ratings of clinical change made at discharge, change scores of 22, 17 and 3 for total FIM, motor FIM and cognitive FIM (respectively), were deemed to differentiate patients who demonstrated clinically important change from those who had not. Generalization of results is cautioned as the study only included patients receiving treatment at one centre and patient, caregiver or family assessments were not included in the ratings of important change.

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See The Measure

Click here to find a copy of the FIM (the original comes from the following website: http://www.va.gov/vdl/documents/Clinical/Func_Indep_Meas/fim_user_manual.pdf)

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