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

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.

Acute single channel EEG predictors of cognitive function after stroke

BACKGROUND

Early and accurate identification of factors that predict post-stroke cognitive outcome is important to set realistic targets for rehabilitation and to guide patients and their families accordingly. However, behavioral measures of cognition are difficult to obtain in the acute phase of recovery due to clinical factors (e.g. fatigue) and functional barriers (e.g. language deficits). The aim of the current study was to test whether single channel wireless EEG data obtained acutely following stroke could predict longer-term cognitive function.

METHODS

Resting state Relative Power (RP) of delta, theta, alpha, beta, delta/alpha ratio (DAR), and delta/theta ratio (DTR) were obtained from a single electrode over FP1 in 24 participants within 72 hours of a first-ever stroke. The Montreal Cognitive Assessment (MoCA) was administered at 90-days post-stroke. Correlation and regression analyses were completed to identify relationships between 90-day cognitive function and electrophysiological data, neurological status, and demographic characteristics at admission.

RESULTS

Four acute qEEG indices demonstrated moderate to high correlations with 90-day MoCA scores: DTR (r = -0.57, p = 0.01), RP theta (r = 0.50, p = 0.01), RP delta (r = -0.47, p = 0.02), and DAR (r = -0.45, p = 0.03). Acute DTR (b = -0.36, p < 0.05) and stroke severity on admission (b = -0.63, p < 0.01) were the best linear combination of predictors of MoCA scores 90-days post-stroke, accounting for 75% of variance.

CONCLUSIONS

Data generated by a single pre-frontal electrode support the prognostic value of acute DAR, and identify DTR as a potential marker of post-stroke cognitive outcome. Use of single channel recording in an acute clinical setting may provide an efficient and valid predictor of cognitive function after stroke.

Using reliability of change analysis to evaluate post-acute neuro-rehabilitation

BACKGROUND

It is important to evaluate change in order to re-assure commissioners, staff and patients of the effectiveness of interventions, but also in order to identify areas for improvement.

OBJECTIVE

To consider whether analysis of improvement at the level of the individual, taking into account measurement error, may offer a further valuable way to assess change and inform service development over considering change at the group level in a post-acute neuro-rehabilitation unit.

METHOD

Pre and post intervention Scores on the FIM+FAM Full Scale and Cognitive and Motor subscales were considered for eighteen patients aged between 35 and 81 with mixed diagnoses who attended a post-acute inpatient neuro-rehabilitation unit for treatment.

RESULTS

Statistically significant improvements were achieved on the FIM+FAM Full Scale and Cognitive and Motor subscales in a whole group analysis. Reliable change analyses for each patient within each subscale however identified only half of the sample achieved reliable improvement within the Motor domain and just one person within the Cognitive domain (5.6%).

CONCLUSIONS

Findings are consistent with the emphasis of the rehabilitation unit on physical/motor function, and unsurprising as many of those assessed had multiple sclerosis, an often deteriorative condition. Use of reliable change analysis allowed a more detailed understanding of intervention impact, potentially identifying what services reliably work for whom, thereby informing future planning.

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.

Functional outcomes of standard dysphagia treatment in first time documented stroke patients

PURPOSE

This retrospective study investigated whether there were statistically and/or clinically significant changes in functional status for patients between admission and discharge as measured by (1) the assistive/independence levels on the swallowing portion of the functional assessment measure (SFAM), and (2) the food and liquid dietary ratings. Also investigated was the relationship between the assistive/independence levels of the SFAM and the specific dietary ratings.

METHOD

Treatment was given at Rancho Los Amigos National Rehabilitation Centre in Downey, California. Subjects for this study consisted of 100 first-time documented acute stroke patients with swallowing disorders. Descriptive statistics, the Wilcoxon signed ranks test and Spearman rho were used to investigate the proposed questions in this study.

RESULTS

There were statistically significant differences in both the dietary ratings and SFAM levels between admission and discharge and a high percentage of these differences were also determined to be clinically significant. In addition, it was found that there was a high level of variability in the dietary ratings at the majority of SFAM levels.

CONCLUSION

These results demonstrate that separate and specific dietary ratings in addition to the SFAM assistive/ independence levels are necessary to obtain a comprehensive assessment of the stroke patient with dysphagia.

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.

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.