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Functional assessments have been performed over the years but it has not been until recently that they have become and integral part of the comprehensive rehabilitation medicine evaluation.

Descriptions of improvements in function of individuals undergoing rehabilitation have been consistently performed since rehabilitation medicine developed after World War II. However, this method of measuring improvement, an individual’s ability to perform a task, or response to treatment has lacked the consistency needed for making comparisons and for tracking changes over time to study their real rehabilitation outcomes.1

Functional assessment measures an individuals level of function and ability to perform functional or work related tasks on a safe and dependable basis over a defined period of time. Assessment should include an examination consisting of a pertinent clinical history, behaviors that might impact physical performance, musculoskeletal, neuromuscular, functional testing, and an assessment of effort.2

In the rehabilitation setting these instruments are commonly used to set rehabilitation goals, to develop specific therapeutic interventions and to monitor clinical changes.3 They can assist in the evaluation of whether an injured worker is able to work and when that individual is able to return back to work.4 From a research point of view, it has assisted in providing supporting evidence in order to develop, improve and attest to different evidence based treatments.

Functional assessments evaluate specific things, such as grooming, bathing, dressing or more general aspect such as quality of life.1 Assessments have to be valid, reliable and reproducible. They can be self-administered questionnaires or clinician administered. Each type of tool has its advantages and disadvantage, but what it is important is to be knowledgeable in regards to the tool being used, the variables that are intended to be measured and the instruments limitations.

Currently and depending on the setting, functional assessments serve as a complementary tool for the management and treatment adjustment in rehabilitation.


The scope of practice in Rehabilitation Medicine is wide and includes an array of conditions such as neurological (stroke, TBI, neurodegenerative), musculoskeletal (joint pain, tendinopathies, ligamentous injuries, balance dysfunction) pain syndromes, medical (deconditioning, cardiopulmonary), rheumatologic (Rheumatoid Arthritis, Osteoarthritis, Connective Tissue Disorders) among others.

Commonly used assessments include:

Activities of daily living: which measure the performance of basic functional skills needed to care for oneself independently. They measure activities of daily living (eating, grooming, bathing, dressing, continence) mobility (gait, transfers) and cognition. Examples include5:

  • Barthel Index
  • Functional Independence Measure,
  • Patient specific Functional Scale
  • Canadian Occupational Performance Measure
  • Lawton’s Instrumental Activities of Daily Living among others

Aerobic/Functional Capacity: assessment of functional capacity reflects the ability to perform activities of daily living that require sustained aerobic metabolism. Examples are5:

  • Six-minute walk test
  • Maximal oxygen uptake-VO2 max
  • VO2 peak-aerobic capacity

Balance evaluation: the primary purpose is to identify whether or not a problem exist in order to predict risk of a fall, determine the underlying cause of the balance dysfunction and to determine if treatment is needed or has been effective. Examples are5:

  • Functional Reach
  • Multi-directional reach test
  • Get up and Go test
  • Timed up and go test
  • Berg Balance test
  • POMA
  • History of Falls Questionnaire and Functional Gait Assessment

Cognition: evaluation includes memory, attention, language, perception, orientation, learning capacity and overall executive functioning. Computerized tests available promote a more standardized administration of the instruments and ease for interpretation. Examples include5:

  • The Glasgow Coma Scale
  • Mini Mental Evaluation
  • MACE
  • Neuropsychological batteries
  • Glasgow Outcome Scale among others

Quality of life and community re-integration are pivotal rehabilitation goals. Some of these instruments also evaluate the effects of executive function deficits on every day functioning through real world task. Examples are5:

  • Standardized Form-36
  • Community Integration Questionnaire
  • Reintegration to Normal Living Index
  • The Multiple Errands Test.

Pain functional assessments assist in evaluation of the severity of pain, how effective treatment interventions have been, and any associated psycho-emotional/behavioral component. Commonly used examples include5:

  • Visual Analog Scale,
  • The Mc Gill Pain Questionnaire
  • Pain Disability questionnaire.

Pediatric scales are numerous and are usually standardized according to age groups. Areas of assessment include1:

  • the developmental milestones
  • growth
  • intelligence
  • behavior
  • language

Palliative Care assessment include multiple tools which measure different aspects such as fatigue, functional performance, quality of life in severely ill/cancer and end of life patients. Examples are5:

  • Toolkit of Instruments to Measure End-of-Life Care
  • Edmonton Functional Assessment Tool
  • Palliative Performance Scale
  • fatigue scale
  • Missouta-VITAS Quality of Life Index
  • Karnosfky Performance Scale

Work Related Injuries: Standardized functional assessment that globally evaluates functional tolerance (based on a medical condition) that is safe for the worker to perform. Examples of these are2:

  • Functional Capacity Evaluation,
  • Targeted Functional Assessment

There are tools that are also specific to certain medical conditions such as5:

  • Stroke:
    • NIH Stroke Scale
    • Fugl-Meyer Assessment of Motor Recovery
    • Stroke Impact Scale, and the
    • Bordeaux Verbal Communication Scale
  • Traumatic Brain Injury
    • Rancho Los Amigos Scale
    • Agitated Behavior Scale
    • Neurobehavioral Rating Scale-revised
    • Comma Recovery Scale
    • Galveston Orientation Amnesia Test/Orientation-log
    • Dizziness Handicap Inventory, and the
    • Mayo Portland Adaptability questionnaire

The selection of the functional assessment is based on the outcome being evaluated. The development of even more precise tools help assists in specific treatment adjustments. For example, the use of the modified Ashworth scale or Tardieu Scale for spasticity or Kurtzke’s Extended Disability Status Scale (EDSS) which is considered the standard for following patients with multiple sclerosis.

When choosing a Functional assessment tool it is important to understand the sensitivity and specificity of the instrument. Many assessment tools are available through the web and are free of cost. Others might require the purchase of a license to administer prior to its use. In addition, some instruments require training while others don’t. Thus it is imperative that the functional assessment evaluator is familiar with the instrument being administered.


With the advancement of technology has come the possibility to perform functional assessments in new ways, therefore research is being developed in order to design new functional assessment tools that might provide accurate, valid, reliable and tangible data6

Functional assessments are an essential component in rehabilitation medicine assisting with quality assurance, ongoing quality improvement, cost/benefit analysis, education, and research.7 Challenges emerge with the interpretation of the data obtained from these instruments and its application on real life situations. In addition to this, third-party payers have been shaping how services are provided and what outcomes are to be expected.


Table 1. Quality of life and community re-integration assessment tools

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Medical Outcomes Study Short Form 36Generic patient-reported outcome measure aimed at quantifying health status, and is often used as a measure of health-related quality of life.


6 -30 min.No Training



10NoneNot Free


Arthritis, Back pain, Cancer of the Head & Neck, low back pain, Multiple sclerosis, Musculoskeletal conditions, Neuromuscular conditions, Osteoarthritis, Parkinson Disease, Rheumatoid arthritis, Spinal injuries, Stroke, Trauma, Traumatic Brain Injury
Community Integration QuestionnaireUsed to assess the social role limitations and community interaction of people with acquired brain injury.


15 min.No Training /Reading an Article/



15NoneFreeTraumatic Brain Injury, Acquired Brain Injury, Chronic Spinal Cord Injury, Brain tumor, Stroke


Reintegration to Normal Living IndexAssesses quantitatively the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities.6 -30 min.


No Training


11NoneFreeStroke, Traumatic Brain Injury Spinal cord injury, Cancer, Heart Disease


Multiple Errands Test (MET)Evaluates the effect of executive function deficits on everyday functioning through a number of real-world tasks.~60 min.No Training


8Access to hospital or communityFreeTest can be used with, but is not limited to, patients with stroke.

Table 2: Palliative Care assessment tools

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-
Edmonton Symptom Assessment SystemDesigned to assist in the assessment of nine symptoms common in cancer patients (pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath).VariableNo Training

Reading an Article/




11NoneFreeCancer patients
Karnofsky Performance Scale


Allows patients to be classified as to their functional

Impairment, to

compare effectiveness of different therapies and to assess the

prognosis in individual patients.

VariableNo Training Reading an Article/




3NoneFreeTest can be used with, but is not limited to, patients with serious illnesses such as cancer.
Palliative Performance ScaleProvides a framework for measuring progressive decline over the course of illness, and serves as a communication tool for the team.


VariableNo Training Reading an Article/



5NoneFreeTest can be used with, but is not limited to, patients with serious illnesses such as cancer.
Missoula-VITAS Quality

of Life Index (MVQOLI)


Gathers patient-reported information about

quality of life during

advanced illness.

10-15 min.Requires special training


5NoneFreeTest can be used with, but is not limited to, patients with serious illnesses such as cancer.


Table 3: Pediatric assessment tools

Name of testPurposeLength of testTraining RequiredNumber of itemsEquipmentCostPopulation
Child Occupational Self Assessment (COSA)Measures how competently children feel engaging in and completing activities and the values associated with these activities.25 min.Reading an Article/




25Paper & Pencil; Stimulus card for the Card-sort AdministrationNot FreePediatric
Pediatric Balance ScaleA 14-item criterion-referenced measure which examines functional balance in the context of everyday tasks.


6 -30 min.Reading an Article/



14Adjustable height bench,

Chair with back support and arm rests,

Stopwatch or watch with a second hand,

Masking tape one inch wide,

Step stool six inches in height,

Chalkboard eraser,

Ruler or yardstick,level


FreeChildren typically developing or with mild, moderate, and severe motor impairments


Pediatric Volitional Questionnaire (PVQ)Uses observation of the child’s daily behaviors and occupations to assess volition, provides information about the child’s motivational strengths and weaknesses, environmental supports and hindrances, and activities that maximize the child’s interests and motivation.10-30 min.Reading an Article/




14NoneNot Free


Children ages 2-7 living with or without disability



Table 4: Pain functional assessments

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Numeric Pain Rating ScaleMeasures the subjective intensity of pain.<5 min.No Training


1NoneFreeChronic pain, Acute pain, Postsurgical pain, Oncology, Pain of the neck, back, upper extremity or lower extremity, and Rheumatoid arthritis


West-Haven-Yale Multi-dimensional Pain InventoryAssesses chronic pain in individuals30-60 min.No training61NoneFreeHeadache, Fibromyalgia, Cancer pain, Systemic lupus erythematosus, Chronic pelvic pain, Phantom limb pain and Whiplash disorders


McGill Pain QuestionnaireA self-report measure of pain30 min.No training20NoneFreeCancer, Chronic Pelvic Pain, Fibromyalgia, Headaches, Herniated intervertebral discs, Ischemic muscular pain, Labor, Low back pain, Lumbago-sciatica, Rheumatic pain, Trigeminal neuralgia and atypical facial pain and Vulvar pain



Table 5: Work Related Injuries Functional Assessment

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Measure-ment of Quality of the Environ-mentAssesses the role of environmental factors in one’s ability to maintain life habits in relation to their limitations and capacities.31-60 min.Read manual109NonePay a licensing feeAny diagnosis that may impact a patient’s interaction with their environment.
Four Step Square TestTest of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backwards<5 minutesNo trainingN/AStopwatch and Four canes


FreeGeriatric,  Parkinson’s Disease, Stroke, Transtibial amputation and Vestibular disorders


Table 6: Activities of daily living scales

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Barthel indexAssesses the ability of an individual with a neuromuscular or musculoskeletal disorder to care for him/herself2-5 min.No training10NoneFreeStroke, neurological disorders, geriatric, brain injury
Functional Independence MeasureProvides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps; measures the level of a patient’s disability and indicates how much assistance is required for the individual to carry out activities of daily living.30-45 minCertification required18May vary based on level and impair-ment category measured.Not freeBrain injury, geriatrics, multiple sclerosis, orthopedic conditions including low back pain, spinal cord injury, stroke
Patient specific Functional scaleAssess functional ability to complete specific activities<4 min.No trainingN/ANoneFreeJoint replacement, knee dysfunction, low back pain, lower limb amputees, multiple sclerosis, neck dysfunction and whiplash, pubic symphysis pain in pregnancy, spinal stenosis, upper extremity musculoskeletal
Canadian occupational performance measureAssesses an individual’s perceived occupational performance in the areas of self-care, productivity, and leisure.10-20 min.No trainingN/ANoneFreeStroke, COPD, pain, Cerebral Palsy, TBI, Parkinson’s Disease, arthritis, pediatrics, ankylosing spondylitis


Table 7: Aerobic/Functional capacity measurements

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
6 min. walkAssesses distance walked over 6 minutes as a sub-maximal test of aerobic capacity/endurance6 min.No trainingN/AStop watch, Measuring wheel to measure distance (recommended)FreeAlzheimer’s Disease, Children Fibromyalgia, Geriatrics, Heart failure, Multiple sclerosis, Parkinson’s Disease, Pulmonary disease, Osteoarthritis, Spinal cord injury, Stroke
Maximal Oxygen Uptake: VO2max and VO2peakTo measure the aerobic fitness by assessing their VO2max and VO2peak.15-20 min.No training1Open-circuit spirometer, treadmill or ergometer, computerized systems and equipment to monitor blood pressure and ECG changesFreeMultiple sclerosis


Table 8: Balance assessment scales

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Functional reach testAssesses a patient’s stability by measuring the maximum distance an individual can reach forward while standing in a fixed position.  The modified version of the FRT, requires the individual to sit in a fixed position.5 min.No training1 (3 in modified version)Yardstick Duct tape (to tape the yardstick to the wall)FreeCommunity, Dwelling Elderly Parkinson’s Disease, Peripheral Vestibular Disorders, Spinal Cord Injury, Stroke, Vestibular Disorders
Multi-directional reach testDetermine the limits of stability of individuals in 4 directions.< 5 min.No training4Yardstick LevelFreeCommunity dwelling adults and elderly, inner city older adult population, and personal care home residents
Berg Balance TestAssess static balance and fall risk in adult populations15-20minNo training14Stop watch, chair with arm rests, measuring tape/ruler, object to pick up off the floor and step stoolFreeBrain injury, community dwelling elderly, multiple sclerosis, orthopedic surgery, osteoarthritis Parkinson’s Disease, Spinal Cord Injury, stroke, traumatic and acquired brain injury and vestibular dysfunction
POMAQuestions the circumstances surrounding a fall, specifically, activities prior to falling, perceived cause, environmental factors and a description of injuries.10-15 min.No training16Hard, armless chair Stopwatch or wristwatch 15 ft (4.57 meter) walkwayFreeAmyotrophic Lateral Sclerosis, elderly, Normal Pressure Hydrocephalus, Parkinson’s Disease and stroke
Functional gait assessmentAssesses postural stability during various walking tasks5-10 minNo training10Stopwatch, marked walking area (length = 20 feet; width 12 inches), obstacle of 9 inch height, at least 2 stacked shoe boxes and set of steps with railingsFreeOlder adults ranging from 40-80 years, Parkinson’s Disease, Spinal Cord Injury, stroke, vestibular populations
History of Falls QuestionnaireQuestions the circumstances surrounding a fall, activities prior to falling, perceived cause, environmental factors and a description of injuries.5-10 minNo training17NoneFreeHealthy adults


Table 9: Cognitive

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
Mini MentalUsed as a screen for dementia or cognitive impairment<10 min.No Training





Mainly in geriatric population, but any population
Glasgow Coma ScaleAsses level of consciousness after injury. Can be used as initial assessment or to monitor changes in consciousness over time


10-15 min.No Training15NoneFreeTraumatic Brain Injury, Stroke, Cardiac/Pulmonary disorders, Infectious, GI, metabolic and renal disorders


Brief Cognitive Assessment toolAssesses orientation, verbal recall, visual recognition, visual recall, attention, language, executive functions and visuo-spatial processing.15-20 min.


Training course


21NoneNot FreeAssisted living and skilled nursing facility, adults, older adults with mood disorders, hospital and adult day care population


Short Orientation-Memory-Concentration Test of Cognitive Impairment


measure of cognitive impairment based on the5-10 min.No Training


6NoneFreeElderly and those with cognitive impairment.


Table 10: Stroke and Traumatic Brain Injury

Name of testPurposeLength of testTraining RequiredNumber of itemsEquip-mentCostPopulation
National Institute of Health scaleMeasures the severity of symptoms associated with cerebral infarct ; quantitative measure of deficits5 min.Training course





Stroke impact ScaleAssessment of health related quality of life specific to stroke survivors10-15 min.No Training49NoneFreeStroke
Fugl-Meyer Assessment of Motor Recovery after strokeQuantitative measure of motor impairment used in post-stroke hemiplegic patients30minReview of manual226 items across 5 domainsTennis ball, spherical container, tool for reflex test, quiet spaceFreePost-stroke hemiplegic patients of all ages
Rancho Los amigosAssessment of cognition and behavior as one emerges from coma; progressive sequential recovery from brain damage5-10min min.


No training8NoneFreeTraumatic Brain Injury(TBI)
Agitated behavior ScaleAssess the nature and extent of agitation during the acute phase of recovery from injury6-30 min.No


14NoneFreeAcquired brain injury; others with agitation.
Galveston Orientation Amnesia TestMeasures attention and orientation marking emergence of PTA5-30 minNo training10NoneFreeTBI
Modified Ashworth ScaleMeasures spasticity in patients with lesions of the Central Nervous System(CNS)<5minNo training6NoneFreeAdults and children with lesions of CNS, Cerebral Palsy, MS, pediatric hypertonia, SCI, Stroke, TBI
Mayo Portland adaptability Inventory-4Assist in the clinical evaluation and rehabilitation planning of physical, cognitive, emotional, behavioral and social problems after brain injury30 minReading manual35NoneFreeIndividuals with acquired brain injury
Coma Recovery ScaleAssist in the differential diagnosis, prognostic assessment, treatment planning in patients with disorders of consciousness25 minReading article/manual23NoneFreeTBI, brain tumor, TBI with CVA, Hypoxic/ brain injury, disorders of consciousness


Gaps have been observed in the use of functional assessment tools such as errors and/or bias as information is being conveyed. Therefore, accurate completion of the different instruments is imperative. On the other hand, it has also has been proposed that some functional assessment tools may not provide an objective or accurate account of the patient’s status.

Evidence based research supporting functional assessments is still limited and in many instances sample sizes are small. However, in recent years the use of these tools has led to development, improvement and approval of rehabilitation treatment modalities and third payer recognition.8


  1. Granger Carl V, MD. Quality and outcome measures in Rehabilitation Programs. Available at: http://emedicine.medscape.com/article/317865-overview#a1
  2. Functional Assessments. Available at: http://www.whscc.nf.ca/healthcare/HC_FunctionalAssessment.whscc
  3. William B Applegate, MD , John P. Blass, MD and T. Franklin Williams, MD. Instruments for the functional assessment of older patients. New England Journal of Medicine 1990; 322:1207-1214
  4. Chen, Joseph J, MD. Functional Capacity evaluation and disability. The IOWA Orthopedic Journal. 2007; 27:121-127
  5. Rehabilitation Measures Database. Rehabilitation Institute of Chicago. Available at: http://www.rehabmeasures.org/default.aspx
  6. Lowe, S., Rodriguez, A., and Glynn, L. New technology–based functional assessment tools should avoid the weaknesses and proliferation of manual functional assessments. Journal of Clinical Epidemiology.66:6 (2013):619–632
  7. Ring H. Functional assessment in rehabilitation medicine: clinical applications. Eura Medicophys.  2007; 43(4):551-5(ISSN: 0014-2573)
  8. B. Iwata, De Leon, I. Reliability and Validity of the Functional Analysis Screening Tool. Journal of Applied Behavior Analysis.46 (2013):271-28.
  9. Barat, Michael, Franchignoni, Franco. Assessment in Physical Medicine and Rehabilitation, Views and Perspectives. 2004. Volume 16

Author Disclosure

Isabel Borras-Fernandez, MD
Nothing to Disclose

Nataly Montes-Chinea, MD
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Brenda Castillo, MD
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Maricarmen Cruz, MD
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