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Extended Details
1 General Information
2 History
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3 Cost
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4 Classification
Domain Physical
FUNCTIONAL STATUS
f. FIM™ Instrument
i. Conceptual and Measurement model. (Does the scale represent a single domain or
do model scales measure distinct domains? Is the variability of the scale reported? If so,
please document it. What is the intended level of measurement, i.e., ordinal, interval,
ratio or category?)
Empirically, the six activities included in the index were found to lie in a hierarchical
order while other items, such as mobility, walking, or stair climbing, did not. The scale
represents a natural progression in both the loss of ADL capacities and the return of
these abilities upon recovery or rehabilitation.
Little formal reliability (or validity) testing has been reported. Katz et al. assessed inter-
rater reliability, reporting that differences between observers occurred once in 20
evaluations or less. Guttman analyses on 100 patients in Sweden yielded coefficients of
scalability ranging from 0.74 to 0.88, suggesting that the index forms a successful
cumulative scale.
iii. Validity (how did they address content validity? construct validity? criterion validity?)
Despite the widespread use of the scale, there is little evidence of the validity of the
measure. Content validity: Katz presents some theoretical justification for the selection
and inclusion of items on the scale. Construct validity: Katz et al. applied the index to
270 patients at discharge from a hospital for the chronically ill. Index scores were found
to correlate (0.50) with a mobility scale and with a house confinement scale (0.39),
evidencing a somewhat low degree of validity to not very well known instruments. The
index of ADL was shown to predict the long- term course and social adaptation of
patients with a number of conditions, including strokes and hip fractures, and was used
to evaluate out-patient treatment for rheumatoid arthritis (Katz 1964; 1966; 1968).
iv. Responsiveness (Has scale been used as an outcome measure? What populations)
The scale has been used as an outcome by Asberg (1987) to predict length of hospital
stay, likelihood of discharge home, and death (N=129). In predicting mortality, sensitivity
was 73% and specificity, 80%; in predicting discharge, sensitivity was 90% and
specificity, 63%. Similar results were obtained from ratings by physicians. Kane (1985)
reports an unpublished study by Sherwood et al (1977) that showed the scale highly
reproducible (coefficients .948 for patients in Worchester Home Care Study and .976 for
the Fall River Sheltered Housing sample. However, such concise indices tend to be
insensitive to small changes in disease severity and to focus on physical- performance
measures which does not take adaptation to the environment into account.
Donaldson, Wagner and Gresham (1973) evaluated 100 patients using the Kenny Self-
Care measure, the Barthel Self-Care measure, and the Katz ADL measure. The
patients were re- evaluated one month later. The results demonstrated that the three
scales moved in a parallel fashion for 68 of the patients. In 32 divergent scores, the
expected hierarchy of sensitivity prevailed: the Kenny was most sensitive to change,
followed by the Barthel Index (see below) and then by Katz. Most of the 8 unexpected
patterns were accounted for because the Kenny Index does not include continence.
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
Scoring of the Katz version has been criticized by Chen and Bryant (1975) and Kane
(1985). Scores on ADL are usually based on the degrees of independence attained for
each function. There is a need to establish decision rules for subjects who do not
perform the activity or have no opportunity to perform the activity and Williams et al.
(1976) questioned whether the Index actually functions as a Guttman scale.
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
Katz’s version or some variant has used in the ill elderly, stroke patients, polio patients,
rehabilitation, rheumatoid arthritis, Down’s syndrome individuals, home care patients,
and hip fracture patients to name a few.
None reported.
ix. Conclusion
The measure is most appropriate for patients who are severely sick since minor
disability frequently does not translate into the limitations in basic activities of daily living
covered in the scale. It is not suitable for health surveys or in general practice as they
are not sensitive to minor deviations from complete well-being. Issues of “in institutional
setting” can be addressed in the response set, i.e., like PACE II for nursing homes
including a response as “against nursing home policy” such as bathing. It is a useful
index with a restricted range of patients though the range of disabilities included in the
instrument is not comprehensive. The single index with a dichotomous score is limited
due to loss of information about variability. Not Recommended.
i. Conceptual and Measurement model. (Does the scale represent a single domain or
do model scales measure distinct domains? Is the variability of the scale reported? If so,
please document it. What is the intended level of measurement, i.e., ordinal, interval,
ratio or category?)
The Barthel Index is an ordinal scale that measures functional independence in the
domains of personal care and mobility. It was designed to monitor performance in
chronic patients and long-term hospital patients with paralytic conditions before and
after treatment. It has been used with rehabilitation patients to predict length of stay and
to indicate the amount of nursing care needed. Two main versions exist: the original 10-
item form and expanded 15-item versions (Granger 1979,1984; Fortinsky 1981).
Granger’s 15 item scale added 4 point scale of intact/limited/helper required/null.
10-item version: Shah reported alpha internal consistency coefficients of 0.87 to 0.92
(admission and discharge) for the original scoring system and 0.90 to .93 for a revised
scoring system. Wartski and Green (1971) retested 41 patients after a 3 week delay.
For 35 patients, scores fell within ten points; in six cases of discrepant scores, two could
be explained. Collin et al. (1988) studied agreement among four ways of administering
the scale: self-report, RN clinical observation, testing by a nurse, and testing by a
physiotherapist. Concordance among the four rating methods was 0.93 (no major
disagreement for 60% of patients, disagreement on 1 rating for 28%, 12% had more
discrepancies). Self-report accorded least well with the other methods; agreement was
lowest for items on transfers, feeding, dressing, grooming, and toileting. Roy et al.
(1988) found an inter- rater correlation of 0.99 and with patient self-report, 0.88.
Sherwood et al (1977) reported high alpha reliability’s (ranging from .953 to .965) for
three samples of hospital patients suggesting that the test is consistent internally as a
measure of self-care activities.
iii. Validity (how did they address content validity? construct validity? criterion validity?)
10-item version: Wade (1987) reported validity correlation’s between 0.73 and 0.77 with
an index of motor ability for 976 stroke patients. A factor analysis identified two factors,
which approximate the mobility and personal-care groupings. Construct Validity:
Granger et al (1979) found the 15-item version correlated with the PULSES Profile (-
0.74 to -0.90). Wylie and White (1964) and Wylie (1967) found that the Barthel Index
correlated well with clinical judgment and was shown to predict mortality and ability to
be discharged to a less restrictive environment.
See above.
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
The original ten activities cover personal care and mobility, omitting everyday tasks
essential for life in the community (e.g., cooking, shopping). The original Index is a 3-
item ordinal rating scale completed by a therapist or other observer in 2-5 minutes.
Each item is rated in terms of whether the patient can perform the task independently,
with some assistance, or is dependent on help based on observation (0=unable,
1=needs help, 2=independent). An overall score is formed by adding scores on each
rating. Scores range from 0 to 100, in steps of 5, with higher scores indicating greater
independence. Items are weighted and includes instructions for assessing the time it
takes a subject to perform a task as a dimension of ability (although the utility of this
score is open to question).
Scoring: different values are assigned to different activities. Individuals are scored on
ten/fifteen activities which are summed to give a score of 0 (totally dependent) to 100
(fully independent). The scores are designed to reflect the amount of time and
assistance a patient requires. However the scoring method is inconsistent in that
changes by a given number of points do not reflect equivalent changes in disability
across different activities.
Several authors have proposed guidelines for interpreting Barthel scores. Shah et al
suggested that scores of 0-20 (on either the ten or 15 item version) indicate ‘total’
dependency, 21- 60 indicate ‘severe’ dependency, 61-90 indicate ‘moderate’
dependency, and 91-99 indicates ‘slight’ dependency. Lazar et al proposed the
following for the 15-item version: 0-19: dependent; 20-59: self-care assisted; 60-79:
wheelchair assisted; 80-89: wheelchair independent; 90-99: ambulatory assisted; 100
indicates independence. Granger takes a score of 60 as the threshold between more
marked dependence and independence. Forty or below indicates severe dependence,
with markedly diminished likelihood of living in the community. Twenty or below reflects
total dependence in self-care and mobility. Most studies apply the 60/61 cutting point,
with the recognition that the Barthel Index should not be used alone for predicting
outcomes.
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
Many modifications have been made to the Barthel scale, of which two have been
commonly used: a variant of the ten-item version proposed by Collin and Wade (1988),
which reordered the original ten items, clarified the rating instructions, and modified the
scores for each item (3 point score). Total scores range from 0 to 20. This version
moves from capacity rating to a performance rating. Shah et al (1989) retained the
original ten items but proposed five-point rating scales for each item to improve
sensitivity to detecting change. There is no consensus on what items are the “definitive”
ten-item version.
A 15-item version proposed by Granger et al (1977; 1979; 1982), the Modified Barthel
Index, which extended the index to cover 15 topics. The 1981 Granger version uses a
four-point response scales for most items, with overall scores ranging from 0 to 100 and
appears to be the more use version.
ix. Conclusion
The Barthel Index is widely used and refined and has been incorporated into broader
evaluation instruments such as the Long-Range Evaluation System, developed by
Granger et al. and the Uniform Data System for Medical Rehabilitation. The Barthel
Scale should always be applied as a rating scale, self-reports may differ from
professionals ratings.
The major criticism of the Index is the scoring system. While the original scale is simple
to administer and focuses on physical limitations, interpreting the middle categories of
the scale is difficult and inconsistent. The Collin and Wade and Shah approaches to
scoring improve it but a definitive scoring approach is needed.
Moreover, the scale is restricted in that low levels of disability may not be detected,
reflecting its origins as a measure for severely ill patients. Thus, while a score of 100
indicates independence in all ten areas, assistance may still be required with some
IADLs, which are not included in the Barthel Index. Other scales also cover broader
topics, such as communication, psychosocial, and situational factors. The 15 item
adaptations hold more promise. Lawton has suggested that the original weighted scale
is most useful for rehabilitation-center patients while the Likert self-care scales are a
better measure for geriatric patients. Validity data are more extensive than those for
many other ADL scales and the results appear superior to others that are reviewed.
Further testing is required before its use can be recommended for use in community
surveys and evaluations. However, there is literature supporting its use with specific
groups of patients, such as those with neurological disability (Collin 1988; Wade 1988).
While useful, the Barthel Index is not recommended since the Functional Status
Independence Measure incorporates the Barthel Index.
i. Conceptual and Measurement model. (Does the scale represent a single domain or
do model scales measure distinct domains? Is the variability of the scale reported? If so,
please document it. What is the intended level of measurement, i.e., ordinal, interval,
ratio or category?)
The Physical Self-Maintenance Scale is a Guttman scale containing 6 items of self-care.
The PSMS was designed as a disability measure for use in planning and evaluating
treatment in elderly people living in the community or in institutions. The scale is based
on the theory that human behavior can be ordered in a hierarchy of complexity, an
approach similar to that used by Katz for the Index of ADL. The hierarchy runs from
physical health through self-maintenance ADL and IADL, cognition, time use (hobbies),
and social interaction. Within each category, a further hierarchy of complexity runs from
basic to complex activities. The PSMS includes both ADL and IADL items.
Little validity or reliability information is reported on the 8 IADL items. Rating scale and
self-administered versions of the scale have been developed. Both were developed for
people over 60 years of age and concentrate on observable behaviors. The rating
version of the ADL may be administered by a variety of professionals. Inter-rater
reliability for the 6-item ADL scale was demonstrated among pairs of nurses who rated
36 patients (Pearson r=0.87); between research assistance rating 14 patients (0.91).
The 6 items fell on a Guttman scale when cutting points were set between independent
(code 1 in each item) and all levels of dependency. The rank order of the items was
feeding (77% independent), toilet (66%), dressing (56%), bathing (43%), grooming
(42%), and ambulation (27%). A Guttman reproducibility coefficient was 0.96 (N=263).
iii. Validity (how did they address content validity? construct validity? criterion validity?)
The PSMS was tested on elderly persons, some in institutions others living at home. It
moderately correlated (0.62) with a physician’s rating of functional health (N=130) and
with an IADL scale(0.61) (N=77). It correlated less well with the Kahn Mental Status
Questionnaire (r=0.38 and 0.38 with a behavioral rating of social adjustment).
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
A 5-point rating scale, ranging from total independence to total dependence, is used for
all 6 ADL items, which fall on a Guttman scale. There are two scoring methods: a count
of the number of items on which any degree of disability is identified, or a severity scale
that sums the response codes for each item, resulting in an overall score ranging from 6
- 30. No cutpoints were reported.
Not reported.
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
A self-rating version of the PSMS ADL items were expanded for the OARS (both were
based on the Katz ADL items) as well as the self-rating version of the PSMS (Lawton
1988). The PSMS IADL items were also included in the OARS and further adapted in
the Multilevel Assessment Instrument.
None reported.
ix. Conclusion
The PSMS appears to be a reliable and valid ADL scale for clinical and survey
research. The PSMS has not been widely reported on in the literature on its own but
primarily when used in combination with other instruments. Not Recommended.
i. Conceptual and Measurement model. (Does the scale represent a single domain or
do model scales measure distinct domains? Is the variability of the scale reported? If so,
please document it. What is the intended level of measurement, i.e., ordinal, interval,
ratio or category?)
Based on Linn et al’s Cumulative Illness Rating scale, the instrument contains an
ordinal scale of 16 items that are rated by medical staff on a three-point scale: no
impairment or no special help (1); moderate impairment or assistance needed (2); and
substantial or complete impairment or assistance needed (3). RN’s can complete the
scale from first-hand knowledge of the patient in two minutes. The scale was developed
as a research tool for summarizing the functional capacity and mental status of elderly
chronic patients in hospital or community.
A revised scale of 18 items was published by Linn and Linn as the RDRS-2 in 1982 and
added three items covering mobility, toileting, and adaptive tasks (i.e., managing
money, telephoning, shopping) with a question on safety supervision omitted. A four-
point scale replaced the earlier three-point scale. The RDRS-2 included 8 items on
activities of daily living, three on mental capacity, and one on dietary changes,
continence, medications, and confinement to bed.
iii. Validity (how did they address content validity? construct validity? criterion validity?)
See above.
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
No formal reference standards are available but the scores range from 18 to 72, with
higher values indicating greater disability; items may be combined to provide three
subscores indicating the degree of assistance required with activities of daily living,
physical disabilities, and psychosocial problems. Linn and Linn (1982) reported that for
the RDRS-2 scores for elderly community residents with minimal disabilities, average
scores were 21 to 22. For hospitalized elderly patients, the average was around 32 and
for those transferred to nursing homes, it was about 36. Response categories are
phrased in terms of the amount of assistance the patient requires so that the instrument
indicates handicap rather than impairment.
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
ix. Conclusion
This is a broad scale that rates the amount of assistance required in 18 activities,
broader in scope than the PULSES, Barthel, and most ADL scales. It has been used in
several evaluative studies. Its research orientation is reflected in the reliability and
validity test, which is better than most scales. However, the validity of the measure
could be improved (i.e., correlations with physicians’ ratings were low). The use of
predictive validation is useful but rarely attempted with such scales and so the 20%
explained variance is difficult to judge as high or low. Granger expressed predictive
validity of the Barthel Index in terms of percentages of patients with low scores who
died.
Moreover, criticisms have been made of the scoring system, in which the same weight
is given to different degrees of disability (permanent confinement to bed and following a
special diet both rate 3 points). This limits the validity of the scale in giving absolute
indications of disability, although it may be less serious if the scale is used to monitor
change over time (McDowell 1996). Kane argues that the RDRS lacks the definitional
rigor that is preferred in a research instrument. However its utility may be in its ease of
administration. Recommended due to the broader scope of items and efficient
administration time requirements.
i. Conceptual and Measurement model. (Does the scale represent a single domain or
do model scales measure distinct domains? Is the variability of the scale reported? If so,
please document it. What is the intended level of measurement, i.e., ordinal, interval,
ratio or category?)
The scale measures twenty items on daily functioning during the past week: dressing
and grooming, rising, eating, walking, hygiene, reach , grip and outdoor activities. Each
component includes 2-3 questions each. The scale can be self-administered or
conducted by telephone or by personal interview. It can be completed in 5-8 minutes
and scored in less than one minute. Each response is scored on a four-point scale of
ability patterned after the American Rheumatism Association functional classification:
from “without any difficulty” to “unable to do” and a check list records any aids used or
assistance received. The highest score in each of the eight components is added to
form a total (0-24); this is divided by 8 to provide a 0-3 continuous score, termed the
Functional Disability Index.
Fries (1980) compared interview and self-administered versions of the disability scale
(N=20). Spearman correlation was 0.85, while correlations for individual sections ranged
from 0.5 (IADL activities and hygiene) to 0.85 (eating). An abbreviated version with
highly correlated items removed produced moderate item-total correlations, ranging
from 0.51 to 0.81. Pincus et al (1983) reported alpha coefficients ranging from 0.71
(reaching) to 0.89 (eating). Milligan et al (1993) found alpha coefficient of 0.94 for the
complete instrument, with maximum inter-item correlations of 0.75. Two-week test-
retest reliability of the disability section was examined with 37 rheumatoid arthritics,
showing no significant difference by t-test and a Spearman correlation of 0.87 (Fries
1990).
iii. Validity (how did they address content validity? construct validity? criterion validity?)
Laing et al (1985) compared the relative efficiency of five measures, indicating their
ability to identify change within subjects before and after hip or knee surgery. The HAQ
placed in fourth place among the five measures. Other studies confirm that the overall
and mobility scores on the HAQ require larger sample sizes to demonstrate a significant
effect of treatment than would the AIMS or the SIP. However, the HAQ may be more
sensitive to change than physical measures such as ESR, grip strength, or morning
stiffness. Hawley and Wolfe (1992) showed the HAQ more responsive than physical
measures or depression following rheumatoid arthritis treatment and the HAQ pain
score was especially sensitive. Fitzpatrick et al (1989) found sensitivity to improvement
in disease state over 15 months to be modest, at 65% (specificity 61%), with sensitivity
to deterioration was 60% (specificity 73%).
See above.
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
The hierarchic model expresses results at various levels of generality: question scores
may be combined to form component (e.g., eating or dressing) and dimension (e.g.,
disability) scores. However, Fries et al argue against combining dimension scores to
give an overall score as this involves value judgments of the relative importance of
dimensions that my not hold across patients. Empirically, correlations across
dimensions are lower than within dimensions so that disability, discomfort, psychological
outcomes, cost, and death are separable outcomes. The full number of dimensions
seems likely to be between 5 and 8.
Siegert et al suggested the following interpretations of overall scores: 0.0 - 0.5: the
patient is completely self-sufficient; 0.5-1.25: the patient is reasonably self-sufficient and
experiences some minor and even major difficulties in performing ADL; 1.25-2.0: the
patient is still self-sufficient, but has many major problems with ADL; 2.0-3.0: the patient
may be called severely handicapped.
The discomfort dimension of the HAQ includes a single question on physical pain in the
past week using a 15 cm. visual analogue pain scale. Fries noted that attempts to
elaborate pain activity by part of the body involved, times during the day which were
painful, and severity of pain in different body parts failed to yield indexes that
outperformed a simple analog scale.
vi. Burden (time/cost of administration)
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
Pincus et al abbreviated the HAQ by retaining only one question in each of the 8
disability components and added questions on satisfaction and change in activities, the
Modified HAQ (MHAQ). An AIDS-HAQ includes 14 items from the Medical Outcomes
Study instruments and 16 items from the HAQ. The items cover physical function,
mental health, cognitive function, energy levels, and general health.
The HAQ has been adapted for use in Britain, Sweden, Spanish-speaking countries,
Holland and France.
ix. Conclusion
The HAQ is a widely used instrument including use in the American Rheumatism
Association Medical Information system and the National Health and Nutrition Survey.
The design of the HAQ offers a scale that is broad in scope, yet brief. Compared to the
Functional Limitations Profile, the HAQ showed similar agreement with clinical
indicators and similar sensitivity to change over time but was much more quickly
administered. The available evidence shows the HAQ to have strong reliability and
validity (e.g., a correlation of 0.91 between the AIMS and HAQ physical scales).
There is a need to establish population reference standards for people with a range of
disabilities and there is little information on its adequacy in non-arthritics. The major
criticisms are focused on the HAQ’s scoring-- designed for simplicity but with a loss of
precision. By counting only the highest score in each section, the HAQ summarizes the
patient’s major difficulty but does not use all the information collected. In comparing
scores over time, therefore, improvements in less severely affected areas of functioning
may be missed, which may account for the high test- retest reliability of the HAQ,
combined with its comparative insensitivity to measuring change. Liang et al concluded
that the HAQ and the Index of Well-Being are poor candidates for use when mobility
change is a major functional outcome. Thus, the HAQ is a good descriptive instrument
but may be less appropriate as a tool for measuring clinical change in outcome studies.
Recommended with caution.
The FIM™ Instrument assesses physical and cognitive disability in terms of burden of
care. It has been used to monitor patient progress and to assess outcomes of
rehabilitation. It is a rating scale applicable to patients of all ages and diagnoses, by
clinicians or by non-clinicians, and has been widely adopted by rehabilitation facilities in
the US and Europe.
The FIM™ was based on the Uniform Data System for Medical Rehabilitation (UDS) to
measure disability and estimating payments for rehabilitative medicine. The FIM™ is the
central measure in the UDS which also measures demographic data, diagnosis,
impairment groups, length of hospital stay, and charges. The UDS distinguishes
between alterations in structure or function (impairment), activity (disability), and role
(handicap). The FIM™ covers the activity and role levels, termed life functions. The
FIM™ is not a comprehensive instrument but a basic indicator of disability and focuses
on the burden of care: the level of a patient’s disability indicates the burden of caring for
them and items are scored on the basis of how much assistance is required for the
individual to carry out activities of daily living. Several stages of rehabilitation are
identified and efficiency of care may be estimated by dividing the increase in life
function (e.g., measured by improvement in FIM™ scores) by the cost of the
rehabilitation services.
Content validity has been assessed. A Rasch analysis supported the division into motor
and cognitive components; contrasting patterns of responses of different patient groups
reflected the types of disability to be expected. Granger et al examined the predictive
validity of the FIM™ in multiple sclerosis patients over a seven day period. The FIM™
items predicted the time required to provide help for personal care tasks (R2=0.77);
correlations for several items exceeded 0.80; a change of one point on the FIM™ total
score represented 3.8 minutes of care per day. Similar analyses for stroke patients
(N=21) yielded an R2 of 0.65. Of 11,102 patients, Dodds et al found that FIM™ scores
improved between admission and discharge and reflected the patients’ destinations.
Scores also reflected the presence of coexisting conditions and the severity of
impairments.
Correlations with other measures include 0.84 with the Barthel Index, 0.68 with Katz’s
Index of ADL, and 0.45 with Spitzer’s Quality of Life Index.
v. Interpretability (What populations has it been applied to? Is the score translated into a
clinically relevant event? Does the score predict outcome events?)
The scale has been applied to adults and children as young as 6 months to 7 years (the
WeeFIM™). Seven-point ordinal ratings represent gradations of independence and
reflect the amount of assistance a patient requires. For each item, two levels of
independent functioning distinguish complete independence from modified
independence--when the activity is performed with some delay, safety risk, or with an
assistive device. Two dependent levels refer to the provision of assistance: modified
dependence is when the assistant provides less than half the effort required to complete
the task, and complete dependence is when the assistant provides more than half the
effort. Finer gradations can be made within each level. A tool score sums the individual
ratings; higher scores indicate more independent function: scores range from a low of
18 to a maximum of 126.
Granger et al outline a analysis that translates the ordinal score into an interval scale.
An alternative scoring approach by Linacre and Heinemann argue that the 13 physical
items should be scored separately from the five cognitive items.
vii. Alternate Forms (What are the modes of administration? Alternatives? If any, what is
know for each of the above on the alternate versions?)
The FIM™ has been used with children as young a 7 years old.
viii. Cultural and Language Adaptations
The FIM™ has been translated into French, German, Japanese, and Swedish.
ix. Conclusion
The FIM™ is a widely used scale with proven reliability and validity. Documentation for
the FIM™ is outstanding. The major strength of the FIM™ lies in its basis in the UDS.
The physical components of the FIM™ appear comparable to the best among the other
ADL instruments. The cognitive and social communication dimensions may have low
sensitivity. Overall, the FIM™ is a sound instrument which benefits from outstanding
support services. Viewed as a brief disability measure rather than a general health
instrument, it can be used as a patient assessment tool and also as an evaluative
instrument. Recommended.
Conclusion
The six highlighted instruments each have something to recommend them for the
measurement of functional status in the last month of life. Reliability, validity, brevity as
well as breadth of dimensions were important considerations in the evaluation of these
instruments. Of the six instruments, three had good potential for application in the
toolkit. Those instruments are: the Rapid Disability Rating Scale (RDRS), the Health
Assessment Questionnaire (HAQ), and the Functional Independence Measure (FIM™).
The Rapid Disability Rating Scale (RDRS-2) includes 8 items on activities of daily living,
3 on mental capacity, and one each on dietary changes, continence, medications, and
confinement to bed using a four-point scale. Thus, it is broader in scope than the
PULSES, Barthel, and most ADL scales. It is easy to administer: RN’s can complete the
scale from first-hand knowledge of the patient in a short two-five minutes. It has fairly
high reliability (0.68 - 0.98) where the three lowest correlations were for the mental
status items. Test-retest reliability on 50 patients after 3 days was between 0.58 and
0.96. However, the validity of the scale could be improved. Correlations of 0.27 were
obtained between the RDRS-2 and a physician’s rating scale of impairment and a low
correlation of 0.43 was obtained with a six-point self-report scale of health. The use of
predictive validation was useful but the 20% explained variance is difficult to interpret.
Criticisms have been made of the scoring system, where the same weight is given to
different degrees of disability. This limits the validity of the scale in giving absolute
indications of disability, although it may be less serious if the scale is used to monitor
change over time.
The Health Assessment Questionnaire (HAQ) is a widely used instrument with strong
reliability and validity (e.g., a correlation of 0.91 between the AIMS and HAQ physical
scales). The major criticisms are focused on the HAQ. By counting only the highest
score in each section, the HAQ summarizes the patient’s major difficulty but does not
use all the information collected. In comparing scores over time, therefore,
improvements in less severely affected areas of functioning may be missed. The HAQ is
a good descriptive instrument but may be less appropriate as a tool for measuring
clinical change in outcome studies. Moreover, there is little information on its adequacy
in non-arthritics.
The FIM™ is an ordinal scale covering 18 items measuring physical and cognitive
disability in terms of burden of care. It uses a 7-point rating scale and takes
approximately 30 minutes to administer and score each patient. The FIM™ has proven
reliability and validity. For the seven-point rating version, intraclass correlations for pairs
of clinicians rating 263 patients ranged from 0.93 (locomotion subscale) to 0.96 (self-
care and mobility). The mean kappa index of agreement between ratings for each item
was 0.71. Correlations with other measures include 0.84 with the Barthel Index, 0.68
with Katz’s Index of ADL, and 0.45 with Spitzer’s Quality of Life Index.
It has been applied to adults as well as children. The rating scale distinguishes
complete independence from modified independence as well as if the activity is
performed with some delay, safety risk, or with an assistive device. The physical
components of the FIM™ appear comparable to the best among the other ADL
instruments. The cognitive and social communication dimensions may have low
sensitivity. Overall, the FIM™ is a sound. Viewed as a brief disability measure rather
than a general health instrument, it can be used as a patient assessment tool and also
as an evaluative instrument.
All three scales are recommended. The differences are in terms of items included in the
scales and time to administer. The FIM™ is the more established (reliability, validity,
and discrimination). However, if time is a major consideration, then the HAQ or the
RSDS is recommended for brevity. Also recommended is the inclusion of an overall
“perceived” physical condition, such as the EORTC QLQ-C30:
“How would you rate your overall physical condition during the past week?”
Very Poor 1 2 3 4 5 6 7 Excellent
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