Why is the functional independence measure used to identify some rehabilitation needs in stroke survivors when there are better tools?

Abstract

CAROLEE WINSTEIN Department of Biokinesiology and Physical Therapy, University ofSouthern California, USAFollowing a stroke, once patients are stabi-lized, physiotherapists begin to focus ongetting them back to their normal activitiesand life roles as quickly as possible. But,since most strokes primarily affect one sideof the body, that job can become a compli-cated one. The question becomes whether toteach the individual to perform certainactivities using primarily the unaffected sideof the body — a compensatory approach —or to focus on ways to re-establish functionusing the affected side — a functionalrecovery approach (Barreca et al., 2003).With the shift toward evidence-basedpractice in twenty-first century physio-therapy, many therapists want to determinewhich approach is indicated for theirpatients. An examination of current practicepatterns, however, suggests that cliniciansare slow to incorporate the scientificevidence (De Weerdt and Feys, 2002). Thisis particularly true for determining whichapproach to take for upper extremity reha-bilitation after stroke (Van Vliet and Turton,2001). In most cases, the approach of choiceis determined by standard measures, such asthe functional independence measure(FIM), and is motivated primarily by thedesire to see quick changes in a person’sburden of care (that is, FIM change score).This situation has come about notbecause therapists are resistant to usingevidence to drive their practice, but becauseof the widespread adoption of the FIM asthe primary outcome measure for rehabilita-tion effectiveness. The FIM is designed tomeasure the burden of care, more so than‘function’. This is particularly true for theupper extremity. For example, we can obtaina perfect score (independent function) onthe upper extremity self-care subscale of theFIM by using only one arm and hand tocomplete tasks (Nakayama et al., 1994).The perfect score on self-care is interpretedas a positive outcome because the burden ofcare is reduced, but the paretic side has notchanged at all in this scenario (Oczkowskiand Barreca, 1993).In other words, if the therapist’s lonegoal is to see a patient improve his or herability to complete a limited set of tasksindependently, the therapist could train thatpatient to compensate for lost motor skillsby learning to do those tasks with the unaf-