Rehab Measures - Functional Independence Measure

Link to instrument

Uniform Data System for Medical Rehabilitation (external link)

Title of Assessment

Functional Independence Measure

Acronym

FIM^TM

Instrument Reviewer(s)

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.

Summary Date

1/18/2013

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.

Description

Contains 18 items composed of:

13 motor tasks
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:

Eating
Grooming
Bathing
Upper body dressing
Lower body dressing
Toileting
Bladder management
Bowel management
Bed to chair transfer
Toilet transfer
Shower transfer
Locomotion (ambulatory or wheelchair level),
Stairs
Cognitive comprehension
Expression
Social interaction
Problem solving
Memory

FIM Scoring Criteria : (refer to the users manual for more information)

FIM Scoring Critieria:
No Helper Required
Score	Description
7	Complete Indepedence
6	Modified Independence (patient requires use of a device, but no physical assistance)
Helper (Modified Dependence)
Score	Description
5	Supervision or Setup
4	Minimal Contact Assistance (patient can perfrom 75% or more of task)
3	Moderate Assistance (patient can perform 50% to 74% of task)
Helper (Complete Dependence)
Score	Description
2	Maximal Assistance (patient can perform 25% to 49% of taks)
1	Total assistance (patient can perform less than 25% of the task or requires more than one person to assist)
0	Activity does not occur

Area of Assessment

Activities of Daily Living

Body Part

Not Applicable

ICF Domain

Activity

Domain

ADL; Cognition; Motor

Assessment Type

Patient Reported Outcomes

Length of Test

31 to 60 Minutes

Time to Administer

30- 45 minutes

Number of Items

Equipment Required

May vary based on level and impairment category measured

Training Required

Yes, Certification in administering the FIM is required prior to use of the FIM. Training is available through UDSMR at: www.udsmr.org.

Type of training required

Reading an Article/Manual

Cost

Not Free

Actual Cost

The FIM is available for purchase through www.udsmr.org

Age Range

Adult: 18-64 years; Elderly adult: 65+

Administration Mode

Paper/Pencil

Diagnosis

Geriatrics; Multiple Sclerosis; Pain; Spinal Cord Injury; Stroke

Populations Tested

Stroke
Spinal Cord Injury
Brain Injury
Multiple Sclerosis
Orthopedic Conditions including Low Back Pain
Geriatrics

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

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

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

Cut-Off Scores

Not Established

Normative Data

Acute Stroke: (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)

	Admission Mean (SD)	Median	Discharge Mean (SD)	Median
FIM Total	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

Acute 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)

Mean (SD) Motor 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

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

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

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)

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

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)

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)

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

Chronic SCI : (Masedo, et al., 2005; n = 84; mean age = 41.43 (10.02) years; mean time since injury = 13.96 (9.36) years; data from medication trials to treatment of chronic pain; assessed at entry and 6 weeks post; FIM-self reported [FIM-SR] used)

Excellent test-retest reliability for total FIM-SR (ICC = 0.89), Motor FIM (ICC = 0.91), and Cognitive FIM (ICC = 0.75)

Elderly: (Hobart et al. 2001)

Excellent: ICC = 0.98 for total FIM, 0.95 and 0.89 for motor FIM and cognitive FIM, respectively

TBI: (Donaghy & Wass, 1998)

Excellent: ICC = 0.85 for total FIM, 0.92 for motor FIM and 0.69 for cognitive FIM

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)

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)

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

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

Excellent inter-rater reliability for total FIM scores across two settings (r = 0.83)
Poor to Excellent inter-rater reliability for individual items (r = 0.02 – 0.77)
Excellent inter-rater 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 inter-rater reliability for patients with incomplete quadriplegia (n = 17, r = 0.49)

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

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

Chronic 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)

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)

Chronic SCI: (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%)

Excellent motor FIM interrater reliability (ICC = 0.90)
Excellent cognitive FIM interrater reliability (ICC = 0.98)

Internal Consistency

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

Excellent internal consistency: Cronbach's alpha = 0.93 admission; 0.95 discharge.

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

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

Neurological disorders: (Hobart et al, 2001)

Excellent internal consistency: Cronbach's alpha = 0.95 Total FIM; 0.95 Motor-FIM; 0.89 Cognitive FIM.

Multiple Sclerosis: (Sharrack et al, 1999; n = 64; mean age = 40 years)

Excellent internal consistency: Cronbach's alpha = 0.98

SCI: (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])

Excellent internal consistency for nontraumatic spinal cord diagnosis: Cronbach’s alpha for total = 0.91; for motor-FIM = 0.91; for cognitive-FIM = 0.90
Excellent internal consistency for traumatic spinal cord diagnosis: Cronbach’s alpha for total FIM = 0.92; for motor-FIM = 0.94; for cognitive-FIM = 0.90

Chronic SCI : (Masedo, et al., 2005; FIM-SR)

Excellent pre- and post- intervention internal consistency: Cronbach’s alpha = 0.95 and 0.94, respectively

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

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

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)

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

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

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)

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

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:

Acute Stroke: (Hsueh et al, 2002)

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))

Chronic SCI: (Masedo, et al., 2005)

Poor correlation of FIM-SR and Craig Handicap Assessment and Reporting Technique (CHART) total scores (correlation coefficient = 0.26) and FIM-SR and CHART subscales for mobility (correlation coefficient = 0.26)
Adequate correlation of CHART physical subscale with FIM-SR self-care, sphincter, and motor subscales (correlation coefficient >0.51)

Rehabilitation patients: (Heinemann et al. 1994)

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

Construct Validity (Convergent/Discriminant)

Convergent Validity Evidence:

Acute Stroke: (Tur et al, 2003)

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)

SCI: 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)

Adequate correlation between admission and discharge scores of the FIM total 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 and FIM motor with COPM Performance (r = 0.364, r = 0.351) and Satisfaction (r = 0.497, r = 0.497) from admission to discharge

Acute 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)

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 to 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 to 0.92)
Excellent correlation between LFIM score and Berg Balance Scale (Spearman’s r = 0.86 to 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.

Subacute SCI : (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)

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)

Chronic SCI: (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 )

Excellent correlation of FIM score 2 years post injury with admission and discharge ASIA motor (Spearman’s r = 0.68 to 0.80), ASIA light touch (Spearman’s r = 0.75 to 0.76), ASIA pinprick (Spearman’s r = 0.73 to 0.76), and Computed Vibration (Spearman’s r = 0.64 to 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 to 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

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

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)

Discriminate Validity Evidence :

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

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.

Chronic SCI: (Masedo, 2005; FIM-SR)

FIM-SR scales indicate significant differences between individuals with amputation and SCI in 6/9 subscale scores (t = -4.92 to -6.89)
FIM-SR scales indicate significant differences between individuals with paraplegia and tetraplegia in 5/9 subscale scores (t = -5.93 to -6.88)

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

Simple 2-factor model of the FIM 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%)

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

FIM total and motor FIM 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)
Cognitive FIM correlated most strongly with OPCS Disability scores and WAIS-verbal IQ scores and weakly with LHS, SF36 physical and mental components, and the General Health Questionnaire (ABIEBR)

Content Validity

The FIM 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)

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%

Traumatic Brain Injury: (Hall et al. 2001)

Although the measure 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.

Face Validity

Chronic SCI: (Grey and Kennedy, 1993)

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

Rehab 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)

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

Acute Stroke: (Hsueh et al, 2002) 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%)

Acute Stroke: (Dromerick, Edwards, & Diringer, 2003; n = 95)

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

Acute Stroke: (Brock et al, 2002)

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

Acute SCI: (Hall et al., 1999)

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

Chronic SCI: (Masedo et al, 2005)

88% of subjects had a max score on FIM Cognition subscale
76% of subjects had a max score on the communication and social cognition subscales

Chronic SCI: ( Grey and Kennedy, 1993)

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

Responsiveness

Acute Stroke: (Hsueh et al, 2002, pg 189) Motor subscale

Large effect size with standardized response mean = 1.3

Rehab patients: (Coster et al, 2006)

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

Acute 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)

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)

Professional Association Recommendations

Considerations

SCI:

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

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Year published

1983

Instrument in PDF Format

Approval Status

Approved

Attachments