Functional Assessment

Jennifer Lui
 Functional assessment
• Granger defines functional assessment as
– a method for describing abilities and limitations
– to measure an individual’s use of skills in
performing tasks necessary to daily living, leisure
activities, vocational pursuits, social interactions,
and other required behaviors
Why do we need functional
assessment?
ICF model of functioning and disability
Acute/chronic diseases
Disorders
Injury
Trauma
Pregnancy, Ageing etc

Functioning
Disability

Disability is a result of interaction between the person’s physical

capacities and characteristics of a setting or environment
 Set up
ADL Goals

Functional
assessment

Functional
Evaluation
assessment
 Functional assessment
• Assess the functional consequences of the
diseases and to identify remaining functional
capabilities
• Assist intervention and discharge planning
• Monitor the progress or change in functional
status
 Functional assessment
• Direct or indirect means
• Direct evaluation
– First hand observation of skill performance
– Judgement based on subjective observation
• Indirect evaluation
– By client report (mailed survey, face-to-face or
telephone interviews)
– Reported by proxies (family members)
– Evidence of validity of indirect approaches is equivocal
 Assessment tests
• Most commonly in forms of scales
• Allows objective measurement which provides
a scientific basis for communication between
professionals, documentation of treatment
efficacy, and scientific credibility
• A set of criteria for evaluating the quality and
suitability of scales
 Evaluation criteria and standards
• Standardization
• Scalability
• Reliablity
• Validity
• Comprephensive
• Performance based
• Practical
 Level of measurement
• 4 basic level of measurements:
– Nominal, ordinal, interval and ratio
• Nominal and ordinal
– classify discrete measures as score produced fall
into discrete categories
• Interval and ratio scales
– Classify continuous measures as scores produced
can fall anywhere alone a continuum within range
of possible scores
Nominal - Classify data that do not have a rank order e.g diagnosis
- Categorize people or objects into different groups based on specific
variable

Ordinal - Assign individual to categories that are mutually exclusive and discrete
- Categories have a logical hierarchy
- Cannot assume intervals are equal between each category, even the
scale appears to have equal increments
- Commonly used in clinical practice e.g FIM

Interval - Has sequential units with numerically equal distance between them
- E.g range of motion scores, visual analogue pain scale

Ratio - An interval scale on which zero point represents a total absence of

quantity being measure
-
 ADL/
IADL

Cognitive Physical

Functional
assessment

Psychosocial Communication
 Commonly used assessment tools
Impairment Activities limitations
MFAC Barthel Index/Modified Barthel Index
EMS Lawton IADL
Berg Balance Scale Functional Independence Measure (FIM)
Time Up and Go
Six minute walk test
 Modified Functional Ambulatory
Categories (MFAC)
• Designed to categorize functional ambulation ability
• 7-point Likert Scale (I to VII) used to classify a patient’s
walking capacity
• Gait is divided into seven categories, ranging from no ability to
walk and requires manual assistance to sit or is unable to sit
for 1 minute without back or hand support (MFAC I) to the
ability to walk independently on level and non-level surfaces,
stairs, and inclines (MFAC VII)
• Significantly correlated with the EMS scores
Categories Stage Definition
I Lyer Walk Sit without support > 1min
Assist to sit
II Sitter Sit without support > 1min
 Walk with 1 person
III Dependent walker Walk with 1 person (level ground)
Continuous manual contact to support body weight
IV Assisted walker Walk with 1 person (level ground)
Continuous /intermittent manual contact
V Supervised walker Walk with standby guarding from 1 person (level
ground)
VI Indoor walker Transfer, turn and walk on level ground
independently
Assistance on stairs/ inclines
VII Outdoor walker Walk independently on level or non level surfaces

The classification does not take account of any aid used

 Elderly Mobility Scale (EMS)
• Assessment of mobility
• Measured on an ordinal scale
• 20 point validated assessment tool for the
assessment of frail elderly subjects (Smith
1994)
Score
<10 Dependent in mobility
maneuvers
Require help with basic ADL,
e.g. transfer, dressing

10-13 Borderline in terms of safe

mobility and independence
in ADL
Require some help with
some mobility maneuvers

>=14 Independent in basic ADL

Able to perform mobility
maneuvers alone and safely
Uses Limitations
Considered functional 6 metres not often av in community
environment
Has clinical and personal significance Functional reach distance inconsistent
with original Functional Reach test
Little training required Ceiling effect achieved quickly for those
recovering from acute illness/who are
more able
Tests for both leg power and strength
As both assessment tool and outcomes Not a very sensitive tool for people with
measure with appropriate patients issues of poor confidence
 Duncan Functional Reach Test
•
(1990)
Tested by placing a yardstick or tape measure on the
wall, parallel to the floor, at the height of the
acromion of the subject's dominant arm

• The subject is asked to stand with the feet a

comfortable distance apart, make a fist, and forward
flex the dominant arm to approximately 90 degrees

• The subject is asked to reach forward as far as

possible without taking a step or touching the wall

• The distance between the start and end point is then

measured using the head of the metacarpal of the
third finger as the reference point

• Functional Reach norms affected by Age and Sex

 Berg Balance Scale
• A five-point ordinal scale, ranging from 0-4
• “0” indicates the lowest level of function and
“4” the highest level of function
• Score the LOWEST performance

• 14 items
• Total Score = 56
Berg Balance Scale
 Berg Balance Scale
• Cut Off Scores:

– 41-56 = independent, low fall risk

– 21-40 = walking with assistance, medium fall risk
– 0 –20 = wheelchair bound, high fall risk
– Score of < 45 indicates individuals may be at greater risk of falling
(Berg, 1992)
Berg K, Wood-Dauphinee S, Williams JI, Maki, B. (1992). Measuring balance in the elderly: validation of an instrument. Can. J. Pub.
Health July/August supplement 2:S7-11

– History of falls and BBS < 51, or no history of falls and BBS < 42 is
predictive of falls
(91% sensitivity, 82% specificity) (Shumway-Cook, 1997)

– Score of < 40 on BBS associated with almost 100% fall risk (Shumway-
Cook, 1997)
 Berg Balance Scale
• Cons:
• Potential ceiling effect with higher level
patients
• Scale does not include gait items
• take 15-20 minutes to complete, depending
on the level of function
• with a threshold of ≤45, with sensitivities of
25% and 45% for any fall and for multiple falls,
respectively Muir et al (2008)
Timed Up and Go Test (TUG)
 Timed Up and Go Test (TUG)
• Measures, in seconds, the time taken by an individual to stand up from a standard arm chair
(approximate seat height of 46 cm [18in], arm height 65 cm [25.6 in]), Walk a distance of 3
meters (approximately 10 feet), turn, walk back to the chair, and sit down

• The subject wears their regular footwear and uses their customary walking aid

• No physical assistance is given

• They start with their back against the chair, their arms resting on the armrests, and their
walking aid at hand

• Instructed that, on the word “go” they are to get up and walk at your normal pace to a line
on the floor 3 meters away

• The subject walks through the test once before being timed in order to become familiar with
the test
 Timed Up and Go Test (TUG)
• The cutoff levels for TUG is 13.5 seconds or
longer with an overall correct prediction rate of
90%;
• Older adults who take longer than 13.5 seconds
to complete the TUG have a high risk for falls

• Form of instrument:
• Hazard/Risk Assessment Tools
• To identify/screen elderly individuals who are prone to falls
Time used
<10 sec Freely independent individual
<20 sec Independent with basic transfer (tub and shower)
Going outdooor and stairs
20-29 sec Great variance in balance, gait speed and function
capacity
>= 30 sec Need help with chair, toilet transfer & stairs, unable to go
alone, complementary examination necessary
Six-Minute Walk Test
 Six-Minute Walk Test
American Thoracic Society (2002). Guidelines for the Six-Minute Walk Test. American Journal of Respiratory and Critical Care
Medicine. 166:1, 111-117.

• Submaximal measure of aerobic capacity.

• May use an ambulation aid and oxygen if they do so normally.

• “The 6MWT is a useful measure of functional capacity

targeted at people with at least moderately severe
impairment. The test has been widely used for preoperative
and postoperative evaluation and for measuring the response
to therapeutic interventions for pulmonary and cardiac
disease” (ATS, 2002)
 Six-Minute Walk Test
• Absolute contraindications:
– unstable angina during the previous month
– myocardial infarction during the previous month

• Relative contraindications:
– Resting HR > 120
– SBP > 180 mm Hg
– DBP > 100 mm Hg
 Six-Minute Walk Test
• At the end of the 6 minutes:
– Have participant sit down (portable chair)
– Immediately take vital signs, starting with HR
(because it drops more quickly than SBP)
– Have patient rate their Borg Rate of Perceived
Exertion (RPE), and dyspnea
– Calculate and record the distance walked
– Ask: "What, if anything, kept you from walking
farther?"
Borg Rating of Perceived Exertion Scale
(RPE)
Assessment for activities limitation
• Basic ADL /self care
– Elements for personal independence
– eating, grooming, bathing, toileting, dressing, bed
activities, transfers, and mobility within home
– Capacity to accomplish self –care represents the beginning
set of tasks necessary for participation
• Instrumental /Extended ADL
– Essential tasks for maintaining the living environment and
residing in community
– Food preparation, laundry, housekeeping, shopping, use of
telephone, use of transportation, use of medication and
financial arrangement
Modified Barthel Index (MBI)
Score Interpretation
0-20 Total dependence
21-60 Severe dependence
61-90 Moderate dependence
91-99 Slight dependence
100 Independence

Score Prediction
<40 Unlikely to go home
Dependent in mobility and self care
60 Pivotal score where patients move from
dependency to assisted independence
60-80 If living alone will probably need a
number of community services to cope
>85 Likely to be discharge to community living
Independent in transfer and able to walk
or use WC independently
Modified BI (MBI) BI
Measure 10 domains Measure 10 domains

Maximum score is 100 Score: 0- 20

Record of what a patient does, not as a Obtained from patient’s self report, a
record of what a patient could do separate party who is familiar with the
patient’s ability or by observation
Usually the patient's performance over
the preceding 24/48 hours is important,
but occasionally longer periods will be
relevant

Middle categories imply that the patient

supplies over 50% of the effort

Use of aids to be independent is allowed

Functional Independent Measure(FIM ™)
• An assessment of the severity of patient disability
• A basic indicator of patient disability
• FIM™ is used to track the changes in the functional
ability of a patient during an episode of hospital
rehabilitation care
• Assessment at the admission and discharge
• Admission assessment is collected within 72 hours of the start of a
rehabilitation episode
• Discharge assessment is collected within 72 hours prior to the end
of a rehabilitation episode.
 Comprised of 18 items, grouped into 2 subscales -
motor and cognition
Motor subscale (13 items) Cognition subscale (5 items)
Eating Comprehension
Grooming Expression
Bathing Social interaction
Dressing, upper body Problem solving
Dressing, lower body Memory
Toileting
Bladder management
Bowel management
Transfers - bed/chair/wheelchair
Transfers – toilet
Transfers - bath/shower
Walk/wheelchair
Stairs
 Function Independent Measure (FIM)
• Each item is scored on a 7 point ordinal scale,
ranging from a score of 1 to a score of 7

• The higher the score, the more independent

the patient is in performing the task
associated with that item.
 The Lawton Instrumental
Activities of Daily Living (IADL)
Scale
The Lawton Instrumental Activities
of Daily Living (IADL) Scale
• An appropriate instrument to assess independent living
skills (Lawton & Brody, 1969)
• 8 domains of function measured
• scored according to their highest level of functioning in
that category
• A summary score ranges from 0 (low function, dependent) to 8
(high function, independent)
• Limitation:
• Self-report or surrogate report method of administration rather
than a demonstration of the functional task -> over-estimation or
under-estimation of ability.
• May not be sensitive to small, incremental changes in function
 The Lawton
Instrumental
Activities of Daily
Living (IADL) Scale

• A useful
mnemonic is
SHAFT:
– S: Shopping
– H: Housekeeping
– A: Accounting
– F: Food
preparation/meds
– T:
Telephone/Transpo
rtation
Geriatric Depression Scale (GDS)
Geriatric Depression Scale
• A screening tool in the clinical
setting to facilitate assessment
of depression in older adults
especially when baseline
measurements are compared
to subsequent scores
• It does not assess for suicidality

Score Interpretation
0-4 Normal, depending on age,
education, and complaints
5-8 Mild depression
9-11 Moderate depression
12-15 Severe depression
 What patient can do (capability) ≠
What patient does (actual behaviour)
• Function cannot be considered in isolation from its
environment context
• Many self care assessment have been designed to
measure what a patient is capable of doing within
the care facility
• Environment can support or interfere the
performance
ICF model of functioning and disability
Acute/chronic diseases
Disorders
Injury
Trauma
Pregnancy, Ageing etc

Functioning
Disability

Disability is a result of interaction between the person’s physical

capacities and characteristics of a setting or environment
Consider the following situations…
• Patient with IHD for conservative treatment
– MBI 100
– Lives in 2/F (non-lift landing)
• Walking stairs requires 4 METs in slow pace and 8.8
METs in fast pace
• Patient suffered CVA
– ADL need assistance
– Lives alone
 Always take the environment and
personal factors into consideration
during management planning
Thanks