An inter-rater reliability study of the Functional Assessment Measure (FIM+FAM)

Reliability of interview-based ADL ability measures in older adults obtained by occupational therapists, physical therapists, and nursing staff

Purpose: To examine the reliability of ADL interview (ADL-I) ability measures when administered by different health professionals (HPs).Materials and methods:Older adults with stable ADL ability were invited to participate in three ADL-I interviews, administered by occupational therapists (OTs), physical therapists (PTs), and nursing staff (NS), respectively. Methods based on classic and modern test theory were applied.Results:Overall, n = 36 older adults and n = 11 HPs participated. Intraclass Correlation Coefficients were acceptable for research purposes (> 0.7), but not for clinical use. Mean differences in ADL ability measures were significant when comparing measures based on interviews by OTs to measures based on interviews by PTs and NS. Further, in 25 to 47% of the individuals, ADL-I ability measures differed significantly across HPs. Limits of Agreement revealed that measures based on interviews by OTs were systematically lower compared to measures based on interviews by PTs and NS. Four ADL-I items displayed Differential Item Functioning based on HP.Conclusion:When using the ADL-I, it is recommended to only involve one profession, to increase the reliability of measures. Results highlight the importance of evaluating reliability of measures based on instruments administered across HPs before implementation in rehabilitation practice and research.

Predictive Validity of the Postural Assessment Scale for Stroke (PASS) to Classify the Functionality in Stroke Patients: A Retrospective Study

The analysis of the predictive validity of a scale allows us to establish objectives in rehabilitation and to make decisions in the clinical setting. The objective of this study was to determine the validity of the Postural Assessment Scale for Stroke (PASS) to predict functionality at each stage of recovery in stroke patients. Methods: A retrospective study was carried out collecting data from patients admitted to a neurorehabilitation hospital. All patients having suffered a stroke less than two months before hospital admission were included in the study. The balance was measured with the PASS scale and the functionality with the Functional Independence Measure (FIM) scale. Simple linear regressions were performed to model the relationship between the PASS and FIM scores in the acute, subacute and chronic stages (6 and 12 months), as well as between the PASS scores at admission and the FIM values in the chronic stage. Results: The PASS scale showed a good predictive validity (R2 values from 0.54 to 0.87; β values from 1.99 to 2.62; p < 0.001) for FIM scores at acute, subacute and chronic stages, with lower goodness-of-fit for PASS scores at admission and FIM scores at 12 months (R2 = 0.383; β = 1.61 (0.96−2.26); p < 0.001). Cut-off points in the PASS scale to predict high functional level were 17.5 for the acute stage and 16.5 for the subacute and chronic stages. A score of 8.5 on the PASS scale measured in the acute phase predicted a high functional level at 12 months. Conclusion: The PASS scale is a useful tool to classify the functionality of stroke patients in the acute, subacute and chronic phases. The PASS score upon admission into the hospital can predict the functionality of the stroke patients after 12 months. However, future studies should be carried out to corroborate our findings with larger sample sizes.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Exploring the efficacy of housing alternatives for adults with an acquired brain or spinal injury: A systematic review

Objective:

Housing for people with acquired brain injury (ABI) or spinal cord injury (SCI) remains a significant issue in Australia and internationally. This review examined the current research evidence regarding the efficacy of housing alternatives for adults with ABI or SCI in relation to four principal outcomes of interest: the person’s (1) community integration/participation, (2) independence, (3) psychosocial well-being and (4) quality of life. The review also sought to identify how the reported efficacy of the housing alternatives might be impacted by individual factors.

Method:

For this systematic review, quantitative empirical, peer-reviewed research published after 1 January 2003 was sought. Ten journal articles met the eligibility criteria. None of the included studies comprised an adult SCI sample.

Results:

The research identified lower levels of community integration/participation, independence, psychosocial well-being and quality of life for adults (particularly younger adults) with ABI living in ‘structured settings’ (i.e., residential care) compared to those living in ‘home-like’ environments (i.e., private homes) and ‘disability-specific’ settings (i.e., shared supported accommodation, group homes, foster care homes, cluster units).

Conclusion:

More research is needed to compare ‘home-like’ and ‘disability-specific’ settings, and individual housing models more generally (i.e., living at home with friends vs with family vs living in shared supported accommodation vs living in residential care). This review identified a number of limitations in the current evidence base and several important directions for future research. Policymakers, architects, designers, builders, developers, funding agencies, international researchers as well as people with ABI or SCI and their families may benefit from the findings of this review.

Evaluation of the content coverage of questionnaires containing basic and instrumental activities of daily living (ADL) used in adult patients with brain tumors

Background

Everyday functioning can be assessed using measures of basic activities of daily living (BADL) or instrumental activities of daily living (IADL). The aim of this review was to provide an overview of the scope and specific content of BADL and/or IADL covered by currently used questionnaires in adult brain tumor patient studies.

Methods

Electronic databases were searched up to April 2017 to identify all eligible questionnaires with items regarding BADL/IADL in studies with adult brain tumor patients. Articles were selected using predetermined in- and exclusion criteria. Items with similar content were clustered into domains based on type of activity.

Results

Thirty-one unique questionnaires containing at least one BADL and/or IADL item were identified; 21 and 29 questionnaires containing ≥ 1 BADL or IADL item, respectively. The percentage of ADL items in these questionnaires ranged from 4 to 100%. Only two questionnaires were specifically developed to measure BADL (Barthel Index and Katz-ADL) and two specifically for IADL (Lawton-Brody IADL and preliminary IADL-BN). Content clustering revealed that IADL had a larger variation in content (31 domains, e.g. work or leisure time activities) compared to BADL (15 domains, e.g. mobility or bathing/washing).

Conclusion

Thirty-one questionnaires previously used in brain tumor studies contained items on BADL and/or IADL and covered a wide range of content, in particular for IADL. It is currently unclear which BADL/IADL are most relevant for brain tumor patients, and this should therefore be evaluated. Next, existing questionnaires could be adapted or validated, or new measures can be developed to meet these needs.

Electronic supplementary material

The online version of this article (10.1007/s11060-019-03136-9) contains supplementary material, which is available to authorized users.

The Mayo Portland Adaptability Inventory-4 outcome measure is superior to UK FIM+FAM in a British military population

OBJECTIVE

The aim of this study was to identify the most appropriate rehabilitation outcome measure for use in a young adult population with acquired brain injury.

METHODS

A 2-year prospective study of patients admitted to a UK military neuro-rehabilitation unit with acquired brain injury to compare the appropriateness of the Functional Independence Measure/Functional Assessment Measure (FIM+FAM) vs the Mayo-Portland Adaptability Inventory Version 4 (MPAI-4) in assessing outcomes. Patients were assessed at admission, discharge and at 4-month follow-up using FIM+FAM and MPAI-4.

RESULTS

The FIM+FAM total motor score showed a marked ceiling affect, 42% of patients scored the maximum on admission rising to 80% at discharge. The MPAI-4 did not show significant ceiling effects. The other sub-scales of FIM+FAM and MPAI-4 were generally comparable, no more than 17% achieved ceiling at follow-up.

CONCLUSIONS

This is the first comparative study of FIM+FAM and MPAI-4 in a young adult military population following acquired brain injury. All patients showed improvements in both outcome measures following intensive inpatient rehabilitation. However, the MPAI-4 did not show ceiling effects in motor scores. This measure was, therefore, found to be more appropriate in the cohort.

Successful outcomes following neurorehabilitation in military traumatic brain injury patients in the United Kingdom

BACKGROUND

The Defence Medical Rehabilitation Centre Headley Court is the UK military rehabilitation unit. A pilot study identified the Mayo-Portland Adaptability Inventory-4 (MPAI-4) as the most appropriate rehabilitation outcome measure in young military patients with acquired brain injury.

METHODS

MPAI-4 scores were prospectively recorded for patients on admission and discharge. At 4 months, independent living and employment status were recorded. Inclusion criteria were all new admissions with traumatic brain injury (TBI). Before injury, all patients were fully employed and lived independently.

RESULTS

In a 3-year period from April 2011, there were 91 TBI patients with complete admission-discharge episodes: by US Department of Defense criteria, 21 were mild, 35 were moderate, and 35 were severe. There was a significant positive relationship between TBI severity and MPAI-4 score on admission (χ = 12.77, df = 2, p = 0.0017).Median age was 27 years, and median duration of admission was 63 days. Employment and independent living status were available for 79 patients at 4 months. Seventy-three patients (92%) were in community-based employment, with 64 (81%) employed in a competitive or transitional work; 6 (8%) were unemployed or in sheltered work. Sixty-nine (87%) were living independently, and 10 (13%) were living with support in their own home, with no one requiring institutional care.Complete MPAI-4 scores were available for 79 patients. There were statistically and clinically significant improvements in MPAI-4 scores between admission and discharge for the overall group: median admission T score was 40.0 (95% confidence interval, 36.0-42.0) and on discharge was 31.0 (95% confidence interval, 27.0-36.0), a nine-point change (Z = 6.53, p < 0.0001). These improvements with rehabilitation were sustained when patients were subdivided by TBI severity or MPAI-4 limitations.

CONCLUSION

This study demonstrates significant functional improvements in military TBI patients following intensive inpatient multidisciplinary rehabilitation, which includes substantial vocational rehabilitation. At 4 months, 92% were employed, and 87% were living independently.

LEVEL OF EVIDENCE

Therapeutic study, level V; prognostic/epidemiologic study, level IV.

Mood after moderate and severe traumatic brain injury: a prospective cohort study

Objective

To evaluate the course of mood and identify its determinants up to 3 years after moderate to severe traumatic brain injury (TBI).

Design

Prospective cohort study.

Patients

Patients hospitalised with moderate to severe TBI, who survived until hospital discharge.

Methods

At 3, 6, 12, 18, 24, and 36 months post-injury, mood was assessed with the Wimbledon Self-Report Scale (WSRS) in the home environment. Motor and cognitive outcome were assessed with the Functional Independence Measure (FIM), and the Functional Assessment Measure (FAM), respectively. Repeated measurements analysis was performed to determine the course of mood over time and its determinants.

Results

A total of 98 patients (72% men), aged 33 (SD 12.9) years, 78% with severe TBI, was included. Mood did not change until 18 months post TBI, after which it significantly improved (p = 0.016). The FIM score significantly improved up to 18 months post-TBI (p = 0.012) and the FAM score up to 12 months post-TBI (p = 0.000), after which both remained stable. In univariable analyses, time post TBI (β = −0.04, p = 0.008), initial discharge destination (β = 2.13, p = 0.010), FIM (β = −0.22, p<0.001) and FAM (β = −0.29, p<0.001) were significant predictors of mood. In a multivariable mixed model, time post TBI, FAM score, and discharge destination were the strongest predictors of mood. Higher FAM scores were related to better mood scores (β = −0.28, p<0.001). Patients initially discharged home tended to have better mood scores over time than patients first treated in inpatient rehabilitation centers or nursing homes (β = 1.27; p = 0.071).

Conclusion

Mood starts to improve 18 months after TBI when motor and cognitive outcome have stabilized. Time post TBI, cognitive outcome and initial discharge destination are the strongest predictors of mood up to 3 years after TBI. These data suggest that mood scores of patients with moderate and severe TBI should be frequently monitored, especially in rehabilitation centers and nursing homes.

Reliability of the Clinical Dementia Rating with a traumatic brain injury population: a preliminary study

This study examined the inter-rater reliability (IRR) of the Clinical Dementia Rating (CDR) for patients with traumatic brain injury (TBI). The CDR is a commonly used rating of impairment, but there has been no research examining its utility in patients with TBI. It was hypothesized that the CDR would have good IRR when used with patients with TBI. Two hundred and fifty U.S. neuropsychologists were randomly selected from the National Academy of Neuropsychology's membership list and were mailed packets of information (e.g., CDR, patient vignette, mental status, neuropsychological test information, and history). Professionals were asked to complete the CDR for the described patient and return the information. IRR was calculated for the Global CDR score and each of the six CDR domains. Of those packets mailed, 53 were returned and completed as instructed (21.2% response rate). Clinician experience varied from 0 to 31 years. Global CDR score IRR was 73.6%. Domain IRRs were as follows: Orientation, 79.2%; Home and Hobbies, 71.7%; Personal Care, 71.7%; Memory, 56.6%; Judgment and Problem Solving, 49.1%; and Community Affairs, 54.7%. Results suggest the CDR Global score has acceptable IRR (>.70). Overall concordance (W = .527) among raters was significant with moderate-to-strong agreement. Further research to improve the utility of this instrument is discussed.

A comprehensive psychometric evaluation of the UK FIM + FAM

Purpose:

To evaluate the psychometric properties of the UK FIM + FAM.

Methods:

(a) A systematic literature review integrating the evidence for psychometric qualities of both the original and UK versions, and (b) exploratory and confirmatory factor analysis of admission/discharge data from an inpatient general neuro-rehabilitation cohort using parametric and non-parametric techniques. A prospective cohort of 459 patients with a male:female ratio of 57:43 and mean age of 44.5 (SD 14.3) years participated in this study.

Results:

Seven published articles together demonstrated acceptable utility, concurrent validity, inter-rater reliability and responsiveness of the UK FIM + FAM. Factor analysis demonstrated that all items loaded high (>0.58) on the first principal component and distinct motor and cognitive factors emerged after rotation. A four-factor solution also demonstrated four distinct, interpretable dimensions (Physical, Psychosocial, Communication and Extended Activities of Everyday Living (EADL)). Mokken analysis of the second data set confirmed these dimensions. Cronbach’s αs were 0.97 and 0.96 for the motor and cognitive domains and 0.90–0.97 for the subscales. Analysis of responsiveness demonstrated “large” effect sizes (0.86–1.29).

Conclusions:

The UK FIM + FAM, including the newer EADL module, is a valid, reliable scale of functional independence. It has high internal consistency in two domains and four subscales and is responsive to changes occurring in a general inpatient neuro-rehabilitation population.

Why use a connectivity-based approach to study stroke and recovery of function?

The brain is organized into a set of widely distributed networks. Therefore, although structural damage from stroke is focal, remote dysfunction can occur in regions connected to the area of lesion. Historically, neuroscience has focused on local processing due in part to the absence of tools to study the function of distributed networks. In this article we discuss how a more comprehensive understanding of the effects of stroke can be attained using resting state functional connectivity BOLD magnetic resonance imaging (resting state fcMRI). Resting state fcMRI has a number of advantages over task-evoked fMRI for studying brain network reorganization in response to stroke, including the ability to image subjects with a broad range of impairments and the ability to study multiple networks simultaneously. We describe our rationale for using resting state connectivity as a tool for investigating the neural substrates of stroke recovery in a heterogeneous population of stroke patients and discuss the main questions we hope to answer, in particular whether resting state fcMRI measures in the acute phase of stroke can predict subsequent recovery. Early results suggest that disruption of inter-hemispheric connectivity in the somatomotor network and the dorsal attention network is more strongly associated with behavioral impairment in those domains than is intra-hemispheric connectivity within either the lesioned or unaffected hemisphere. We also observe in the somatomotor network an interesting interaction between corticospinal tract damage and decreased inter-hemispheric connectivity that suggests that both processes combine to contribute to neuromotor impairment after stroke. A connectivity-based approach will provide greater insight into network reorganization in the acute and chronic phases after stroke and will contribute to improving prognostic ability and the development of therapeutic interventions.

Assessing adaptive behaviour in the post-acute setting following traumatic brain injury: Initial reliability and validity of the Adaptive Behaviour and Community Competency Scale (ABCCS)

PRIMARY OBJECTIVE

Present the rationale for adaptive behavior rating and introduce the Adaptive Behaviour and Community Competency Scale (ABCCS), a comprehensive and detailed measure of adaptive behaviour, for use with persons with traumatic brain injury (TBI) in the post-acute period.

METHODS AND PROCEDURES

Direct-care staff with limited exposure to the ABCCS, completed it twice, two weeks apart, about persons with TBI who were resident in diverse community settings. Other measures to assess validity were administered concurrently.

RESULTS

Intraclass Correlation Coefficients (ICC) for interrater and test-retest reliability of the ABCCS were excellent (ICC=0.9681 and 0.9860 respectively). Evidence for convergent and divergent validity with comparison measures was strong with highly significant correlations with scales measuring similar content (Rho=0.613-0.919) and weak correlations for scales measuring dissimilar content (Rho=0.318-0.397).

CONCLUSIONS

The ABCCS is a reliable and a valid indicator of functioning post-acute TBI and is straightforward enough to be used by direct-care staff.

Determinants of functioning of adolescents and young adults with cerebral palsy

PURPOSE

To describe the level of functioning of adolescents and young adults with cerebral palsy (CP) and study determinants of their level of functioning.

METHOD

In the CP Transition study, adolescents and young adults aged 16-20 years, diagnosed with CP without severe learning disabilities (n =103) participated. In this group we assessed subject characteristics, i.e., age, type of CP, gross motor function (GMFCS), level of education as well as outcome measures on functioning in daily activities and social participation (Life Habits questionnaire, Vineland Adaptive Behavior Scale, Functional Independence Measure). Multivariate regression analyses were performed.

RESULTS

About 20-30% of the participants encountered restrictions in daily activities (mobility, self-care, nutrition) and social participation (taking responsibility, community living, leisure activities and employment). The GMFCS level, level of education, and age proved to be important determinants of functioning in daily activities and social participation, explaining 70% and 66% of the variance in outcome respectively.

CONCLUSION

A significant number of adolescents and young adults with CP without severe learning disabilities are restricted in daily activities and social participation. These problems are mainly attributable to restricted gross motor functioning, a low level of education and younger age.

Ambulation Training With and Without Partial Weightbearing After Traumatic Brain Injury

OBJECTIVE

To test the hypothesis that 8 wks of partial weight-bearing gait retraining improves functional ambulation to a greater extent than traditional physical therapy in individuals after traumatic brain injury.

DESIGN

A randomized, open-label, controlled, cohort study was conducted at two inpatient university-based rehabilitation hospitals. A total of 38 adults with a primary diagnosis of traumatic brain injury and significant gait abnormalities received either 8 wks of standard physical therapy or physical therapy supplemented with partial weight-bearing gait training twice weekly.

RESULTS

Significant (P < 0.05) improvements were detected in both groups on Functional Ambulation Category, Standing Balance Scale, Rivermead Mobility Index, and FIM. However, no differences were found between the treatment groups.

CONCLUSIONS

Results did not support the hypothesis that 8 wks of partial weight-bearing gait retraining improves functional ambulation to a greater extent than traditional physical therapy in individuals after traumatic brain injury based on common clinical measures.

Physical therapy clinical management recommendations for children with cerebral palsy - spastic diplegia: achieving functional mobility outcomes

The purpose of this special report is to present recommendations for the clinical management of children with cerebral palsy, spastic diplegia when increased functional mobility is the identified outcome. These recommendations provide a framework that allows physical therapists to increase their accountability and promote effective interventions for improved patient outcomes. The key components of this special report on clinical management are: a) the Major Recommendations that provide the background and evidence for clinical management; b) a flow chart to assist in clinical decision-making; and c) a Table of Tests and Measures for information on useful tools in the management of children with spastic diplegia. These recommendations are suggestions for clinical management, not an all-inclusive document on physical therapy for children with cerebral palsy. These recommendations may help therapists develop systematic approaches to service delivery and documentation.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs.

OBJECTIVES

We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models.

RESEARCH DESIGN

A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting.

RESULTS

We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed.

CONCLUSION

We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

Reliability and validity of the Northwick Park Dependency Score (NPDS) Swedish version 6.0

OBJECTIVE

To translate, to test inter-rater and intra-rater reliability and concurrent validity of the Basic Care Needs (BCN) section of the Northwick Park Dependency Score (NPDS).

DESIGN

Test-retest reliability and validity testing. Observed data were collected by the staff (nursing staff, occupational therapists).

SETTING

Three rehabilitation units.

SUBJECTS

Forty inpatients between 16 and 65 years of age with brain injury were included.

MAIN MEASURES

Inter-rater and intra-rater reliability was calculated by percentage agreement (PA) and unweighted kappa measure. Concurrent validity was examined by computing Goodman-Kruskal's gamma, a nonparametric statistic for degree of association between the BCN score and the total score of the Functional Independence Measure (FIM).

RESULTS

Inter-rater reliability showed a good percentage agreement between nursing staff. Between nursing staff and occupational therapists the percentage agreement was lower especially in one item. Intra-rater reliability showed a good percentage agreement for all assessors. Concordance was good with a gamma--0.83 and an asymptotic error (ase) of 0.04, for nursing staff and for occupational therapists -0.87, ase 0.04.

CONCLUSION

The BCN section of NPDS was found to be inter-rater and intra-rater reliable, to have concurrent validity. Further studies are needed on clinical utility. The instrument can be used for assessment of dependency for individual patients with brain injury, and information when transferring between different caregivers. Further studies need to investigate the sensitivity of the instrument.

Measuring High-Level Mobility After Traumatic Brain Injury

High-level mobility is important for participation in many pre-accident activities after traumatic brain injury (TBI). This review examined which measures are used to quantify physical status and mobility after TBI to determine their appropriateness for measuring high-level mobility. Electronic databases, hand searching of several TBI journals, and citation tracking from retrieved articles were used to identify all TBI outcome studies from 1990 through to May 2004. Preliminary screening identified articles that either reported on physical outcome or mobility after TBI or utilized measurement tools with a physical component. Studies were selected for detailed analysis if they reported on mobility or physical outcomes after TBI. The search identified 175 studies that met the inclusion criteria for further analysis. The FIM instrument is the most frequently used outcome measure, highlighting a trend toward using inpatient measures to evaluate long-term outcomes. Only one study used a measurement tool that incorporated a mobility item beyond independent walking and stairs. High-level mobility is seldom measured using standardized outcome measures after TBI, despite independent mobility being one of the major goals of rehabilitation. A high-level mobility scale is needed to address the ceiling effect of outcome scales currently used in TBI rehabilitation and to extend mobility to age-appropriate levels for return to leisure and sporting activities.

Beneficial behavioural effects of lamotrigine in traumatic brain injury

Anti-convulsant medications have been employed to treat behavioural disorders resulting from traumatic brain injury (TBI). However, there is a paucity of literature investigating the use of lamotrigine to treat aggression and agitation in patients with TBI. In a single case study design, the present study examined the effectiveness of lamotrigine to treat aggressive and agitated behaviour in a 40-year-old male who sustained a severe TBI. A substantial decrease in problematic behaviours and a significant improvement in neurobehavioural functioning were observed after lamotrigine treatment. This case study provides some support for the use of lamotrigine to treat aggression and agitation in patients with a TBI. Further research is needed to examine the relationship between lamotrigine and functional outcome after TBI.

Establishing the reliability of Mobility Milestones as an outcome measure for stroke

Baer GD, Smith MT, Rowe PJ, Masterton L. Establishing the reliability of mobility milestones as an outcome measure for stroke. Arch Phys Med Rehabil 2003;84:977-81.

OBJECTIVE

To establish intrarater, interrater, and test-retest reliability of a standardized measure of mobility, "mobility milestones," incorporating sitting balance, standing balance, and walking ability.

DESIGN

Repeated-measures reliability study by using video data of patients with stroke.

SETTING

Physiotherapy and rehabilitation departments in Scotland.

PARTICIPANTS

Forty physiotherapists recruited from within the Lothian region: 20 senior physiotherapists with at least 3 years of experience working with neurologic patients and 20 staff grade physiotherapists with less than 12 months of experience working with neurologic patients.

INTERVENTION

Videotape comprising 40 clips (36 original clips, 4 repeated clips) of stroke patients of differing levels of ability attempting the mobility milestones was produced. After a short training session in the interpretation and application of the mobility milestones, each physiotherapist viewed the tape separately and scored whether the milestone had been achieved or not. This was repeated at a separate test session 2 weeks later.

MAIN OUTCOME MEASURE

Score for each mobility milestone.

RESULTS

Kappa statistics were used to determine interrater reliability and showed good (.61-.80) to very good (.81-1.0) reliability for 3 of 4 milestones. Intraclass correlation coefficients (ICCs) were used to determine intrarater reliability of the 4 repeated clips and showed 75% of all subjects had high (ICC(2,1)=.91-1.0) reliability. The ICC(2,1) for test-retest reliability showed a similar pattern, with 70% of subjects showing good (.81-.90) or high (.91-1.0) reliability.

CONCLUSIONS

The mobility milestones showed favorable levels of reliability when used by experienced or novice physiotherapists. The milestones can be adopted as a simple clinical outcome measure for use with stroke. Further research is required to establish reliability levels when the measure is used by different rehabilitation professionals.

The associated reaction rating scale: a clinical tool to measure associated reactions in the hemiplegic upper limb

OBJECTIVE

To determine what items should be included in a clinical assessment tool developed to measure associated reactions in the hemiplegic upper limb and to assess the reliability of the resultant measure.

DESIGN

Development through a structured consultative process using focus group methodology. Evaluation of inter- and intra-rater reliability between two independent observers.

SUBJECTS

Nineteen consecutive hemiplegic patients admitted to Northwick Park Hospital for rehabilitation following stroke.

METHODS

Focus groups were conducted in two centres, comprising physiotherapists experienced in the clinical management of brain injury. The groups identified four key characteristics related to severity of associated reactions, which became the items of the rating scale. Evaluation of inter- and intra-rater reliability was undertaken by comparison of agreement between ratings of associated reactions occurring during a single standardized task (sit-to-stand), by two senior physiotherapists in 19 subjects.

RESULTS

There were good correlations between the two raters in total (rho 0.89 p < 0.005) and modal scores (rho 0.88 p < 0.005). Reliability testing of each item revealed moderate to very good inter-rater agreement (weighted kappa values 0.43-0.85) and good to very good intra-rater agreement (weighted kappa values 0.61-0.87). A slight tendency for one rater to score more severely than the other only reached significance for one item (excursion). Overall (modal) severity scores showed a good level of agreement (kappa 0.76-0.81) both between and within raters.

CONCLUSION

Items to be included in a clinical assessment tool to measure associated reactions in the hemiplegic upper limb were determined. Reliability of the resultant measure was found to be encouraging. These results however apply only to observations made during a specific standardized task (sit-to-stand) and further study of sensitivity to change and reproducibility in different tasks is required before the findings can be extrapolated into routine practice.

Outcome measures for clinical trials in neurotrauma

Under the auspices of the American Brain Injury Consortium and the Joint Section of Neurotrauma and Critical Care of the American Association of Neurological Surgeons, the authors have reviewed and formulated opinions based on the evidence on protocol design and the outcome measures used for clinical trials in patients with a severe or moderate traumatic brain injury (TBI). First, in view of the heterogeneity of the population under study, the authors suggest that block randomization and stratification should always be used in the design of neurotrauma trials. Second, although the Glasgow Outcome Scale (GOS) remains the most widely used and accepted instrument for TBI trials, the authors believe the eight-point expanded scale that has recently been designed will ultimately provide greater discrimination, and narrower categories and will ultimately prove superior for detecting more subtle changes in outcome. Furthermore, the authors recommend, in view of the profound cognitive impairment in survivors of TBI, that neuropsychological tests be explored further as an adjunct to the GOS. Future research should focus on the development of more sensitive and specific surrogate outcome measures such as magnetic resonance imaging, neurochemical, neuropsychological, and quality of life measures in order to detect a neuroprotective effect in patients with TBI.

Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial

OBJECTIVE

Evaluation of multidisciplinary community based outreach rehabilitation after severe traumatic brain injury (TBI).

METHODS

A randomised controlled trial compared outreach treatment (mean of two sessions a week for 27.3 (SD 19.1) weeks) in community settings such as participants' homes, day centres, or workplaces, with provision of written information detailing alternative resources. Follow up for an average of 24.8 months after initial allocation was by a blinded independent assessor. Participants were aged 16-65, had sustained severe TBI between 3 months and 20 years previously, and had no other neurological conditions. Of 110 initially allocated, 48 outreach and 46 information participants were successfully followed up. Primary outcome measures (Barthel index (BI) and the brain injury community rehabilitation outcome-39 (BICRO-39)) focused on levels of activity and participation. Secondary measures were the functional independence measure and the functional assessment measure (FIM+FAM) and, in a subgroup of 46 participants, the hospital anxiety and depression scale. Analyses were non-parametric.

RESULTS

outreach participants were significantly more likely to show gains on the BI and the BICRO-39 total score and self organisation and psychological wellbeing subscales. There were likewise strong trends (p<0.10) for BICRO personal care and mobility, and on the FIM+FAM for personal care and cognitive functions. Differential improvements were not seen for indices of socializing, productive employment, anxiety, or depression. Median changes on individual subscales were small, reflecting the diversity of the clinical population; however, 40% of outreach but only 20% of information participants made a clinically significant improvement of 2+ points on at least one BICRO-39 scale. Time since injury was unrelated to the magnitude of gains.

CONCLUSIONS

This is the first RCT of multidisciplinary community rehabilitation after severe TBI, and suggests that even years after injury it can yield benefits which outlive the active treatment period.

Accuracy of prediction of walking for young stroke patients by use of the FIM

BACKGROUND AND PURPOSE

Clinical prediction of walking outcome after a stroke is essential for effective discharge planning. However, its accuracy has hardly been explored. This study took place in a regional unit admitting patients with complex neurological disabilities for specialist inpatient rehabilitation. The aim was to compare predicted outcome (goal score) with achieved outcome (discharge score) on the seven-point locomotion subscale of the Functional Independence Measure (FIM), to evaluate its precision and identify factors influencing accuracy.

METHOD

Admission, goal and discharge scores were analysed retrospectively for 141 subjects (90 M; 51 F) admitted consecutively to the Unit with median age 54 years (range 15-68 years) with median length of stay 13.6 weeks (range 3-35 weeks).

RESULTS

Ninety subjects (64%) gained from two to six points; 50 subjects (35%) gained one point or showed no change. One patient deteriorated by two points. Excluding patients admitted with the highest score (FIM level 7), the overall level of agreement between predicted and discharge scores was moderate (weighted kappa 0.47). Prediction was accurate to +/- 1 point in 113 subjects (80%). Overprediction by > or = 2 points occurred in 16 subjects (11%) and underprediction by > or = 2 points in 12 subjects (9%). Analysis of the most-disabled cohort, admitted with FIM levels 1 or 2 scores, revealed a higher sensitivity for predicting 'independence' (FIM levels 5-7) (78%) than 'dependence' (FIM levels 1-4) (65%). Accuracy was not affected by age, gender or side of stroke. Inaccurate predictions were associated with lower admission FIM level scores (p = -0.26; p = 0.002) and a greater length of stay (p = 0.36; p < 0.001). Subjects with quadriplegia were more likely to have inaccurate outcome predictions made than those with hemiplegia (p = 0.025) and those with neglect were more likely to have inaccurate outcome predictions made than those without neglect (p = 0.017).

CONCLUSION

Further investigation into clinical prediction and the variables which confound accuracy is needed for effective planning.

Reliability of an interview approach to the Functional Independence Measure

OBJECTIVE

To establish the reliability of an interview approach to the Functional Independence Measure (FIM).

DESIGN

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.

SUBJECTS

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.

METHODS

Reliability was calculated as unweighted kappa statistics, percentage agreement (PA), and intraclass correlation coefficient (ICC).

RESULTS

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.

CONCLUSIONS

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.

The Functional Assessment Measure (FIM + FAM) as part of the hospital discharge summary after brain injury rehabilitation

OBJECTIVE

To assess the value of providing Functional Assessment Measure (FIM + FAM) data as part of the hospital discharge information after brain injury rehabilitation.

DESIGN

Postal survey of general practitioners (GPs) and consultants.

SUBJECTS

Consecutive discharges (n = 117) from an early brain injury rehabilitation unit over one year.

RESULTS

Response rates were 81% from GPs and 54% from consultants. Eighty-four (89%) of GPs and 57 (82%) of consultants rated the information as useful; 87 (92%) and 51 (84%) respectively described the accompanying notes as easy to understand.

CONCLUSIONS

The incorporation of FIM + FAM data in discharge summaries is worthwhile but the utility of this practice is still to be established.

The UK FIM+FAM: development and evaluation. Functional Assessment Measure

BACKGROUND AND AIMS

The aim of this study was to develop and evaluate the UK version of the Functional Assessment Measure (UK FIM+FAM).

DESIGN

Before and after evaluation of inter-rater reliability.

DEVELOPMENT

Ten 'troublesome' items in the original FIM+FAM were identified as being particularly difficult to score reliably. Revised decision trees were developed and tested for these items over a period of two years to produce the UK FIM+FAM.

EVALUATION

A multicentre study was undertaken to test agreement between raters for the UK FIM+FAM, in comparison with the original version, by assessing accuracy of scoring for standard vignettes.

METHODS

Baseline testing of the original FIM+FAM was undertaken at the start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams) each rated the same three sets of vignettes - first individually and then as part of a multidisciplinary team. Accuracy was assessed in relation to the agreed 'correct' answers, both for individual and for team scores. Following development of the UK version, the same vignettes (with minimal adaptation to place them in context with the revised version) were rated by 28 individuals (nine teams).

RESULTS

Taking all 30 items together, the accuracy for scoring by individuals improved from 74.7% to 77.1% with the UK version, and team scores improved from 83.7% to 86.5%. When the 10 troublesome items were taken together, accuracy of individual raters improved from 69.5% to 74.6% with the UK version (p <0.001), and team scores improved from 78.2% to 84.1% (N/S). For both versions, team ratings were significantly more accurate than individual ratings (p <0.01). Kappa values for team scoring of the troublesome items were all above 0.65 in the UK version.

CONCLUSION

The UK FIM+FAM compares favourably with the original version for scoring accuracy and ease of use, and is now sufficiently well-developed for wider dissemination.

Interrater reliability of the Functional Assessment Measure in a brain injury rehabilitation program

OBJECTIVE

To examine the interrater reliability and completion time of the Functional Assessment Measure, which is the Functional Independence Measure (FIM) plus additional items (FIM+FAM).

DESIGN

Interrater reliability study.

SETTING

Inpatient rehabilitation units of a postacute care brain injury rehabilitation program.

PATIENTS

A convenience sample of 53 extremely severely impaired adult survivors of traumatic brain injuries (40 men, 13 women, mean age 38yrs).

MAIN OUTCOME MEASURES

Treatment team members' ratings of the 30 FIM +FAM items, and time taken to complete the FIM+FAM.

RESULTS

Intraclass Correlation Coefficients (ICCs) were within the good to excellent range (ICC > .60) for 29 of 30 items and for all subscales except psychosocial adjustment. Higher mean ICC values were obtained for motor domain items than for cognitive/psychosocial domain items. Treatment teams became progressively faster over a 12-week period in completing the FIM+FAM. The generally good to excellent range interrater reliability found in this study helps support the use of the FIM+FAM in rehabilitation settings. Further support was obtained for the finding that motor items are more reliable than cognitive and psychosocial items. Administration of the FIM+FAM can be done in a timely manner in a rehabilitation setting.

The Northwick Park Dependency Score (NPDS): a measure of nursing dependency in rehabilitation

BACKGROUND

Disability scores, such as the Functional Independence Measure (FIM) and Barthel Index, have been shown to correlate with care needs but cannot be used to assess them directly, as they do not indicate the number of people required to help with a task, nor the time taken. The Northwick Park Dependency Score (NPDS) is an ordinal scale that can be used to assess impact on nursing time. It takes 3-5 minutes to complete. Together with a short set of additional questions, it may be used directly to assess care needs in the community and to facilitate discharge planning.

AIMS

To develop and evaluate the NPDS for use in a rehabilitation setting.

METHODS

(1) DEVELOPMENT: Following a survey of existing instruments, tasks were selected on the basis of their impact on nursing time and divided into Basic Care Needs (BCN) and Special Nursing Needs (SNN). Cut-off points were devised to reflect the number of helpers needed and time taken. Following evaluation of the NPDS version 5, minor changes were made to produce version 6 which was re-evaluated on a smaller scale. (2) EVALUATION: Inter-rater and intra-rater reliability were tested in a cohort of 23 inpatients using five senior nurses. Analysis included assessment of degree of association, significant differences, absolute agreement, and agreement +1 level. Although there is no gold standard, the BCN section should correlate inversely with independently assessed Barthel scores. Re-evaluation of version 6 was undertaken using the same method of analysis in a cohort of 21 patients using three senior nurses.

RESULTS

On initial evaluation inter-rater reliability testing showed an excellent level of association in total composite score between each pair of nurses (rho = 0.73-0.92, p <0.01) and agreement +1 level for individual items ranged from 73 to 100%. Significant disagreements were in six items. On re-evaluation following minor modification, high levels of association were still seen for total BCN, SNN and composite scores both between and within raters, with very satisfactory levels of agreement for individual items. The BCN section of the NPDS showed good inverse correlation with Barthel scores (rho = 0.91, p <0.01).

CONCLUSION

The NPDS is simple and practical to use in a busy setting. It is shown to be reliable and valid in its assessment of nursing dependency on the ward. Its translation into a directly costable measure of continuing care needs in the community now requires evaluation.

Cognitive and functional assessments of stroke patients: an analysis of their relation

OBJECTIVES

To improve the assessment of stroke patients for the purpose of designing rehabilitation treatments and predicting rehabilitation outcomes. Specific objectives included the evaluation of the power of functional scales to properly assess both physical and cognitive disabilities, and the evaluation of the relations between functional, neurological, physical, and cognitive assessments. The hypothesis was that the relations between different assessment types (eg, functional, neurological, etc) can be assessed by the relations between the results of these assessments when administered to stroke patients.

DESIGN

Sixty-six stroke patients were administered a series of tests including functional assessments (Functional Independence Measure, barthel Index, Rankin Functional Scale), neurological assessments (Canadian Neurological Scale, National Institute of Health Stroke Scale), physical assessments (Stages of Motor Recovery, Clinical Outcome Variables Scale), and cognitive assessments (Stroke Unit Mental Status Examination, Mini Mental State, Raven Matrices, Boston Naming Test).

RESULTS

Analysis of correlation coefficients revealed that the stronger relationships were observed between functional assessments and physical assessments, and between functional assessments and neurological assessments. Cognitive tests did not correlate highly with any of the functional tests used in this study. Three factors were extracted using factor analysis. They were interpreted as being a physical disability factor (50% of the variance), a cognitive disability factor (23% of the variance), and a dementia factor (12% of variance). Functional scales obtained higher loads on the physical disability factor only.

CONCLUSIONS

Considering that cognitive functions are frequently affected in stroke patients, cognitive impairment needs to be more seriously considered when describing and/or predicting a patient's level of independence. In brain injured patients, such as stroke patients, we suggest that the total score provided by standardized functional scales should be interpreted with care. We believe that rehabilitation outcome could be better predicted if the results of functional assessment were coupled with in-depth cognitive assessment.

The reliability of the items of the Functional Assessment Measure (FAM): differences in abstractness between FAM items

The reliability of the Functional Assessment Measure (FIM+FAM) is an important issue with its increased use in the measurement of neurological disability and rehabilitation outcome. Although the Motor items have good reliability ratings, the Cognitive items are more difficult to complete and their reliability is not as good. This study tests the suggestion that this might be due to the Cognitive items being more abstract. A keyword from each of four Motor items was compared with a keyword from four Cognitive items. Abstractness was measured by measuring the 'imageability' of each keyword. The Motor items were found to have a significantly higher mean imageability rating than the Cognitive items. Thus, there is support for the suggestion that abstractness contributes to the poorer reliability of the Cognitive items. These results led to the proposal that the reliability of the Cognitive items might be improved by various methods of increasing the tangibility of these measures (e.g. subdivision of broad categories of disabilities, enhancing item descriptions, training raters to increase their recognition of relevant observations, and using specific assessment tasks to elicit relevant behaviours).