Functional Independence Measure Motor Items Research Articles

Hospital-associated sarcopenia and the preventive effect of high energy intake along with intensive rehabilitation in patients with acute stroke

ObjectivesHospital-associated sarcopenia is prevalent and associated with poor outcomes in acutely admitted patients. Prevention of developing sarcopenia during hospitalization is an important factor in stroke management. Therefore, this study aimed to investigate whether energy intake and rehabilitation duration contribute to the prevention of hospital-associated sarcopenia in patients with acute stroke. MethodsPatients with acute stroke were included in this study. Energy intake during the first week of hospitalization was classified as “high” or “low” based on the reported cutoff value. Rehabilitation time during hospitalization was classified as “intense” or “mild” based on the median. The four groups were compared based on the combinations of high or low energy intake and intense or mild rehabilitation. The primary outcome was the development of sarcopenia during hospitalization. The secondary outcome was the Functional Independence Measure motor item gain during hospitalization. Multivariate analysis was performed with the primary or secondary outcome as the dependent variable and the effect of each group on the outcome was examined. ResultsA total of 112 participants (mean age = 70.6 y; 63 men) were included in the study. Multivariate analysis found that high × intense (odds ratio = 0.113; P = 0.041) was independently associated with the development of sarcopenia during hospitalization (i.e., hospital-related sarcopenia). High × intense (β = 0.395; P < 0.001) was independently associated with the gain of Functional Independence Measure motor items. ConclusionsIn patients with acute stroke, the combination of high energy intake and adequate rehabilitation time is associated with prevention of hospital-associated sarcopenia.

Combination of High Energy Intake and Intensive Rehabilitation Is Associated with the Most Favorable Functional Recovery in Acute Stroke Patients with Sarcopenia.

Energy intake and rehabilitation time individually contribute to the improvement of activities of daily living (ADL). This study aimed to investigate the additive effect of energy intake and rehabilitation time on ADL improvement in acute stroke patients with sarcopenia. The study included 140 patients (mean age 82.6 years, 67 men) with stroke. Energy intake during the first week of hospitalization was classified as "Sufficiency" or "Shortage" based on the reported cutoff value and rehabilitation time was classified as "Long" or "Short" based on the median. The study participants were categorized into four groups based on the combination of energy intake and rehabilitation time. The primary outcome was the gain of functional independence measure (FIM) motor during hospitalization. The secondary outcomes were length of stay and home discharge rates. Multivariate analysis was performed with primary/secondary outcomes as the dependent variable, and the effect of each group on the outcome was examined. Multivariate analysis showed that "long rehabilitation time and sufficient energy intake" (β = 0.391, p &lt; 0.001) was independently associated with the gain of FIM motor items. The combination of high energy intake and sufficient rehabilitation time was associated with ADL improvement in acute stroke patients with sarcopenia.

Relationship between trunk muscle mass and activities of daily living at discharge in acute stroke patients

ObjectiveThe aim of this study was to evaluate the effects of trunk muscle mass on functional prognosis, including activities of daily living (ADLs), at hospital discharge in patients with acute stroke. MethodsThis retrospective cohort study included hospitalized patients with acute stroke. Trunk muscle mass was measured using bioelectrical impedance analysis within 5 d of admission. The primary outcome was ADLs at hospital discharge, assessed using the Functional Independence Measure-motor items (FIM-motor). The secondary outcomes were hospital length of stay and discharge to home. Multivariate analyses were performed to determine the association between trunk muscle mass and FIM subitems. ResultsData from 212 patients (mean age 72.7 y; 143 men) were included in the analysis. The median trunk muscle mass index (TMI) was 8.2 kg/m2 in men and 6.7 kg/m2 in women. Patients in the high TMI group were younger and had a higher FIM-motor score at discharge (P < 0.001). In multivariate analyses, TMI was positively associated with the FIM-motor score at discharge (β = 0.240, P < 0.001). FIM-self-care (β = 0.351, P < 0.001) and locomotion (β = 0.331, P < 0.001) were positively associated with the TMI. ConclusionsTrunk muscle mass is associated with ADLs at hospital discharge after acute stroke. TMI is important for evaluating functional prognosis in patients with acute stroke.

Effects of Dynamic Sitting Exercise with Delayed Visual Feedback in the Early Post-Stroke Phase: A Pilot Double-Blinded Randomized Controlled Trial.

Sitting ability in the early post-stroke phase affects functional balance ability and other prognoses. We investigated whether dynamic sitting exercise with delayed visual feedback in the mediolateral and anteroposterior directions affected postural control in the early post-stroke phase. In this pilot randomized controlled trial, 27 hemiparetic stroke patients were randomized to experimental (n = 13) and control (n = 14) groups. Dynamic sitting exercise (30 times/day, 5 days/week) in the mediolateral and anteroposterior directions, with 500-ms-delayed (experimental group) or real-time (control group) visual feedback on a computer, was added to usual physical therapy. We evaluated the postural assessment scale for stroke (PASS), static and dynamic sitting balance tasks, the five-times sit-to-stand test, trunk impairment scale, functional ambulation category, and functional independence measure–motor items. In intention-to-treat analysis, the experimental group demonstrated a significant intervention effect on the PASS score (p < 0.05). The mean percentage of body weight on the moving side in the lateral sitting task and the number of successes in the five-times sit-to-stand test were significantly higher in the experimental group than those in the control group (p < 0.05). Thus, the proposed exercise improves postural control, dynamic sitting balance, and sit-to-stand ability in early post-stroke patients.

Association between external ophthalmoplegia with diplopia due to brain injury and FIM motor items: a case-control study.

This study aimed to determine the association between the presence of external ophthalmoplegia with diplopia due to brain injury and Functional Independence Measure (FIM) motor items in a case-control study. The subjects were patients with brain injury, admitted to a convalescent rehabilitation ward, who were able to walk under supervision and had preserved intellectual function. The correlation between the strabismus angle of the external ophthalmoplegia group and the total points of FIM motor items were examined. In addition, the total points and sub-items were compared between the external ophthalmoplegia group and control group using statistical processing. There were 78 subjects: 34 in the external ophthalmoplegia group and 44 in the control group. Strabismus angle and the total points of FIM motor items of the external ophthalmoplegia group were significantly negatively correlated. Compared with the control group, the external ophthalmoplegia group had significantly lower levels of independence in bathing, dressing (lower body), toileting, transfer to the chair, transfer to the toilet, transfer to the bathroom, and locomotion (walking). External ophthalmoplegia with diplopia is associated with FIM motor items.

The relationship between energy expenditure and physical functions in patients hospitalised for stroke

We assessed the relationship between energy expenditure (EE) and Functional Independence Measure motor items (FIM-M) score, Berg Balance Scale (BBS) score, and comfortable walking speed (CWS) in patients hospitalised for stroke. The total EE per day (TEE), EE during rehabilitation (REE), and EE during activities other than rehabilitation (OEE) were measured using a single-axis acceleration sensor in 36 patients hospitalised for the first stroke episode. In addition, the relationships between each type of EE and FIM-M, BBS, and CWS were investigated. In these patients (mean age 66.2 ± 10.6 years), the median values of TEE, REE, and OEE were 41.8 kcal, 18.5 kcal, and 16.6 kcal, respectively. Correlations were observed between each EE type and all physical function indices. Following the stratification of patients into two groups (high and low) based on the level of physical function, a significant correlation between EE type and physical function was observed only in the low BBS group. EE was correlated with overall physical function indices, but the trend differed depending on physical ability. When patients were stratified based on ability, there were several groups with no significant correlation. Therefore, several patients were unable to achieve an appropriate EE for their level of physical function.

The multi-dimensionality of the FIM motor items precludes an interval scaling using Rasch analysis

Rasch analysis scaling is said to produce an interval scale of Functional Independence Measure (FIM) motor function items. Rasch analysis requires that the data to be analysed represent the influence of a single underlying unidimensional variable. A unidimensional interval scale of activities of daily living means that a person who can perform the most difficult item on a scale can also perform the easiest item. For a FIM motor function interval scale, the ability to climb stairs would imply necessarily and ability to eat normally. As this need not be the case, the FIM motor items do not constitute an adequate interval scale. Eating and walking are different activities, and a unidimensional construct linking them is unsatisfactory. A principal components analysis of the admission FIM motor function items of 515 consecutive patients admitted to an inpatient rehabilitation unit revealed that more than one significant factor was necessary to explain the variance in scores. The counter-factual and statistical evidence argues that a unidimensional construct does not underly the FIM motor function items, and the use of Rasch analysis will not lead to a description of interval properties of the FIM motor function items.

Long-Term Outcomes of FIM Motor Items Predicted From Acute Stage NIHSS of Patients With Middle Cerebral Artery Infarct.

ObjectiveTo outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later.MethodsSeventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group.ResultsMultivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item.ConclusionIn combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living.

Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index

Purpose: To create a crosswalk between the Functional Independence Measure (FIM) motor items and the Korean version of the Modified Barthel Index (K-MBI).Method: Korean community-dwelling adult patients (n = 276) completed the FIM and K-MBI on the same day in outpatient rehabilitation hospitals. We used a single group design with the Rasch common person equating and conducted a factor analysis of the co-calibrated item pool using the two measures. Rasch analysis was used to investigate the psychometrics of the equated test items in the identified factor structure(s). The correlation between FIM raw scores and converted K-MBI scores was examined.Results: Three measurement constructs were identified: self-care, mobility, involuntary movement. The equated test items in the three constructs demonstrated good person separation reliability (r = 0.94–0.96) and good internal consistency (Cronbach’s alpha =0.93–0.97). The three crosswalks between the FIM raw scores and converted K-MBI scores demonstrated good correlations (r = 0.91–0.93, all p < 0.0001).Conclusions: The Rasch equating method successfully created three crosswalks between the FIM motor items and K-MBI, with the equated test items demonstrating good psychometrics. The crosswalks would address the incomparable scoring systems between the FIM motor items and K-MBI.Implications for RehabilitationThe three crosswalk tables (scoring tables) would allow clinicians to compare or translate a patient’s motor scores between the FIM and K-MBI.The crosswalk tables would allow health-care administrators to track patients’ functional status across various rehabilitation facilities that exclusively use the FIM or K-MBI.

Physical Disability After Injury-Related Inpatient Rehabilitation in Children

To determine the residual physical disability after inpatient rehabilitation for children 7 to 18 years old with traumatic injuries. This was a retrospective cohort study of patients aged 7 to 18 years who underwent inpatient rehabilitation for traumatic injuries from 2002 to 2011. Patients were identified from the Uniform Data System for Medical Rehabilitation. Injuries were captured by using standardized Medicare Inpatient Rehabilitation Facility Patient Assessment Instrument codes. Functional outcome was measured with the Functional Independence Measure (FIM) instrument. A validated, categorical grading system of the FIM motor items was used, consisting of clinically relevant levels of physical achievement from grade 1 (need for total assistance) to grade 7 (completely independent for self-care and mobility). A total of 13,798 injured children underwent inpatient rehabilitation across 523 facilities during the 10-year period. After a mean 3-week length of stay, functional limitations were reduced, but children still tended to have residual physical disabilities (median admission grade: 1; median discharge grade: 4). Children with spinal cord injuries, either alone or in combination with other injuries, had lower functional grade at discharge, longer lengths of stay, and more comorbidities at discharge than those with traumatic brain injuries, burns, and multiple injuries (P < .0001 for all comparisons). Children had very severe physical disability on admission to inpatient rehabilitation for traumatic injuries, and those with spinal cord injuries had persistent disability at discharge. These traumatic events during critical stages of development may result in a substantial care burden over the child's lifespan.

Clinical Relevance of Action Observation in Upper-Limb Stroke Rehabilitation

Objective. A randomized controlled observer-blind trial was designed to evaluate the effectiveness of action observation as an add-on treatment to the standard rehabilitation of upper-limb function, early after stroke. Methods. Stroke survivors (N = 102) were consecutively recruited from 13 centers 30 days (±7) after a first-ever stroke and randomly assigned to the experimental (EG) or control group (CG). EG participants watched video footage of daily routine tasks (actions) carried out with the upper limb in order to prepare to imitate the presented action. At the end of each sequence, a therapist prompted the patient to perform the same movement for 2 minutes, providing help when needed. Static images without animals or human beings were shown to the CG. At the end of each sequence, the CG executed movements that simulated the shoulder and elbow joint mobilization activities performed by the EG. Results for the Fugl-Meyer test, Frenchay Arm test, Box and Block test (BBT), Modified Ashworth Scale, and Functional Independence Measure Motor items were recorded before treatment (T0), after 4 weeks of treatment (T1), and at the follow-up visit 4 to 5 months after the conclusion of treatment (T2). Results. An improvement over time was appreciated on all measures of impairment and functional ability with both treatment programs. A Time × Treatment interaction emerged from the generalized estimating equations analysis of BBT, showing significant T0–T1 and T0–T2 differences in favor of EG. Conclusion. This multicenter trial endorses the use of action observation in upper-extremity rehabilitation, along with a role for the mirror neuron system in poststroke recovery.

Motor scores on the functional independence measure after pediatric spinal cord injury

Retrospective descriptive analysis. The purpose of this study was to report the functional ability of children with spinal cord injury (SCI) as recorded on motor items of the functional independence measure (FIM) and to examine the factors associated with FIM motor admission and post-discharge gain scores. Scores on FIM motor items were analyzed from 941 children (age range: 0-21 years; mean: 13 years 4 months; s.d.: 4 years 8 months) admitted in acute-to-chronic time periods post-SCI to Shriners Hospitals for Children (USA). FIM motor scores at admission and gains at discharge were examined along with neurological level, completeness of injury, age, etiology of injury, and length of time between injury and admission and admission and discharge. The FIM motor scores at admission were negatively correlated with age, neurological level and completeness of injury. Gain in FIM motor scores was significant across neurological levels, and was associated with lower admission FIM motor scores, lower neurological level, incomplete injury, traumatic injury and less time between injury and admission. The motor function of children after pediatric SCI depends on neurological level and completeness of injury, among other factors. FIM motor scores can improve with intervention even several years after the injury.

Reliability of an interview approach to the Functional Independence Measure.

To establish the reliability of an interview approach to the Functional Independence Measure (FIM). Two raters were present at the same time during the interviews in the home and did independent ratings of the 18 FIM items. The interview procedure was repeated within a week by another two raters in the clinic. Sixty-three stroke survivors (median age 63 years, range 18-71 years) were studied approximately two years after onset. RATERS: Three occupational therapists and one nurse. Reliability was calculated as unweighted kappa statistics, percentage agreement (PA), and intraclass correlation coefficient (ICC). Best agreement was found in the motor items of FIM. The kappa statistics showed good to excellent inter-rater values during the same interview except for the Social interaction item. The ICCs based on sum-score for motor (0.92) and social-cognitive items (0.75) respectively, were similar to those reported in the literature. The repeated interview by different raters showed less stable agreement according to kappa values for the items dealing with transfers, locomotion and social-cognition. FIM assessments showed high inter-rater agreement for the same interview setting (home as well as clinic), but the stability of the measure over time with a repeated interview by different raters was somewhat less satisfactory.

Characteristics of the functional independence measure in traumatic spinal cord injury

Objectives: The characteristics of the Functional Independence Measure (FIM)™ were examined for spinal cord injury (SCI) in regard to norms over time by level and completeness of injury, differential benefit of motor and cognition subscales, and “ceiling effect” after rehabilitation discharge. Design: Descriptive study of raw FIM data collected prospectively at admission and discharge from acute inpatient rehabilitation, and at 1, 2, and 5 years after injury. Setting: National Database of the 18 Spinal Cord Injury Model Systems. Subjects: Persons with SCI, age 16 and over, with functionally complete injuries at inpatient rehabilitation admission (ASIA grades A, B, or C), admitted to Model System an average of 8 days after injury (standard deviation = 13, median = 1 day). Maximum sample sizes for which data were available were: at rehabilitation admission, 3,971 cases; at discharge, 4,033; at year 1 postinjury, 903; 2 years, 712; and 5 years, 570. Outcome Measures: The FIM motor and cognition subscales. Results: There is a substantial ceiling effect of the FIM cognition items even by inpatient rehabilitation discharge, ie, 80% to 90% of the cases average 6 to 7 (independent or modified independence) across the 5 FIM cognition items. At 1 year 89% to 97% of cases were rated independent. FIM motor items were consistent with level of injury and neurologic status. Motor items (excluding locomotion items) were highly intercorrelated (correlations range from .58 to .92 for self care, sphincter control, and mobility items). Trends over years 1, 2, and 5 were stable for both motor and cognition subscales. FIM motor gains were greatest between admission and discharge and gains continued through 1 year after injury, but at a much-decreased rate. Conclusions: The cognition items are not informative for detecting changes over time in SCI; at best, these items could serve as a crude cognition screening assessment. Motor items, in contrast, appear to reflect well the functional status of individuals. High correlations among several of the motor items suggest item redundancy. FIM motor scores illustrated the improvements in neurologic and ASIA scores in appropriate cases. Individuals with ASIA impairment grades of B or C at admission make the most gains in FIM motor scores.

Short versions of the telephone motor functional independence measure for use with persons with spinal cord injury

Objective: To determine if the motor ability of persons with spinal cord injury (SCI) can be reliably estimated using a subset of the 13 Functional Independence Measure (FIM) items. Study Design: FIM item subsets of 5, 6, or 7 items were selected using one of five strategies: random, coefficient alpha maximization, spread across the range of item difficulties, optimization by neurologic category, and individual optimization. Motor ability estimated by these 15 subsets was compared to the 13-item estimate, using intraclass correlation coefficient (ICC), Rasch calibration person reliability estimate, and other indices of reliability. Subjects: Subjects were 4,128 persons with SCI, 1 to 25 years postinjury, interviewed for annual research follow-up using the FIM. Results: All subsets had high ICC reliability (>.90). Subsets of 7 items performed generally better than those of 6 or 5 items. The best performance was provided by individual optimization subsets. The ICC for the 7-item set thus selected was .99. Conclusion: In annual follow-up, the number of FIM motor items can be reduced almost 50% while maintaining reliable estimates of subjects' motor ability. This approach may also be useful for other applications of interviewing to obtain FIM data, eg, for program evaluation.

Home alone: The role of cognition in return to independent living

Objective: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. Design: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. Setting: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. Patients: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. Main Outcome Measure: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). Results: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. Conclusion: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.

Reliability and validity of the FIM for persons aged 80 years and above from a multilevel continuing care retirement community

Objective: Development of accurate functional assessment instruments will help clinicians evaluate treatment outcome and plan realistic rehabilitation goals for elderly patients. The reliability, validity, and appropriateness of the Functional Independence Measure (FIM) were examined for a population aged 80 years and more from a multilevel, continuing care retirement community. Design: Forty-nine residents (average age 89.7 years, range 80 to 104 years; 46 women), were randomly selected. Setting: Subjects were grouped according to their residence in either an Independent community (18 subjects), Sheltered Care (16 subjects), or Skilled Nursing Facility (15 subjects). Measurements: Subjects were evaluated twice using the FIM. Motor and cognitive scores were converted into interval measures (logits) using Rasch Analysis with the BIGSTEPS statistical package. Parametric statistical procedures were utilized to further analyze data. Results: FIM motor and cognitive items formed 2 unidimensional and linear subscales. Hierarchical levels of FIM item difficulties were identified. Bladder management, bowel management, and grooming were misfitting motor items. Memory misfit for the cognitive subscale. High test-retest reliability for 45 repeated FIM assessment for the motor, (ICC = .9) and cognitive subscales (ICC = .8) was demonstrated. One way ANOVA for FIM ratings for the 3 groups demonstrated significant differences for both the motor subscale, F(2,46) = 34.71, p < .05, and the cognitive subscales, F(2,46) = 12.42, p < .05. Conclusion: Construct validity of the FIM was demonstrated. High test-retest reliability was demonstrated. Environmental context and operational definitions influenced FIM ratings. Subjects' FIM ratings, abilities, and time to complete the locomotor walking item correlated with their current residence in increasingly dependent environments. These findings suggest that with certain caveats, the FIM may be useful as a functional assessment instrument for persons who are 80 or more years old.