Skip to main content
  

Rehab Measures: Functional Independence Measure

  Rehabilitation Measures Database

Title of Assessment

Functional Independence Measure

Link to instrument

Uniform Data System for Medical Rehabilitation (external link)

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

FIMTM

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; Updated by Dev Kegelmeyer, PT, DPT, MS, GCS and the PD EDGE task force of the neurology section of the APTA in 2013.

Summary Date

18 01 2013

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 Criteria:

No Helper Required

Score

Description

7

Complete Independence

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 perform 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

ICF Domain

Activity

Time to Administer

30-45 minutes

Number of Items

18

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.

Actual Cost

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

Populations Tested

  • Brain Injury 
  • Geriatrics 
  • Multiple Sclerosis 
  • Orthopedic Conditions including Low Back Pain 
  • Parkinson's Disease
  • Spinal Cord Injury 
  • Stroke

Standard Error of
Measurement (SEM)

Not Established

Minimal Detectable
Change (MDC)

Not Established

Minimally Clinically
Important Difference (MCID)

Stroke:

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

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

Cut-Off Scores

Not Established

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

C4

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

C5

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

C6

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

C7

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

C8

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

C4

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

C5

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

C6

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

C7

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

C8

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)

C4

13.6 (n = 288)

14.5

(n = 73)

17.5

(n = 156)

20.9

(n = 288)

24.8

(n = 54)

27.8

(n = 116)

C5

14.3 (n = 310)

16.2

(n = 127)

19.7

(n = 141)

28.3

(n = 236)

31.1

(n = 96)

38.4

(n = 101)

C6

15.3

(n = 173)

17.8

(n = 89)

21.1

(n = 51)

35.6

(n = 238)

37.6

(n = 93)

43.9

(n = 63)

C7

18.5

(n = 90)

18.8

(n = 52)

23.6

(n = 35)

49.4

(n = 123)

48.7

(n = 56)

53.5

(n = 57)

C8

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)

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

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

Parkinson's Disease:

(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
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
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 Motor-FIM test-retest reliability (ICC = 0.90)
  • Excellent Cognitive-FIM 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 motor FIM and cognitive FIM, respectively)

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, Chronic SCI)

 

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

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

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

TBI:

 

(Donaghy & Wass, 1998; TBI)

  • Excellent interrater reliability (ICC = 0.85 for total FIM, 0.92 for motor FIM, and 0.69 for cognitive FIM)

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

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)

Multiple Sclerosis:

 

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

 

  • Excellent internal consistency (Cronbach's alpha = 0.98)

Neurological Disorders:

 

(Hobart et al, 2001; Neurological Disorders)

 

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

SCI:

 

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

 

  • 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)

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

 

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

(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 [UDSMRSM], SCI)

 

  • 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)

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 (Motor-FIM Subscale) (Cronbach's alpha = 0.88 admission; 0.91 discharge)

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

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:

 

Rehabilitation Patients:

 

(Heinemann et al, 1994; Rehabilitation Patients)

 

  • 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

SCI:

 

(Masedo et al, 2005; Chronic SCI)

 

  • 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)

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))

Construct Validity

(Convergent/Discriminant)

Convergent Validity Evidence:

 

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 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

(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)

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:

 

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, SF-36 physical and mental components, and the General Health Questionnaire (ABIEBR)

SCI:

 

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

 

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

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 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%)

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, 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; TBI)

  • 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

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

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

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

(Masedo et al, 2005; Chronic SCI)

  • 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

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

(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

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

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)

Stroke:

 

(Hsueh et al, 2002; Acute Stroke)

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

Professional Association Recommendations

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 (VEDGE) 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

R

R

R

StrokEDGE

HR

UR

UR

 

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 dependant

Moderately Dependant

Severely Dependant

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

No

Yes

Yes

Not reported

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

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

Bibliography

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

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

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

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

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

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. 

Masedo, A. I., Hanley, M., et al. (2005). "Reliability and validity of a self-report FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain." Am J Phys Med Rehabil 84(3): 167-176; quiz 177-169, 198. 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

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

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

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

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

Link to instrument

Uniform Data System for Medical Rehabilitation (external link)

NIDRR
The contents of this database were developed under a grant from the Department of Education, NIDRR grant number H133B090024 (PI: Allen Heinemann, PhD).  However, the content does not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.  
 
 

© 2010 Rehabilitation Institute of Chicago