1. OVERVIEW AND DESCRIPTION
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.
2. RELEVANCE TO CLINICAL PRACTICE
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.
3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
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.
4. TABLES
Table 1. Quality of life and community re-integration assessment tools
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Medical Outcomes Study Short Form 36 | Generic 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
| 10 | None | Not 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 Questionnaire | Used to assess the social role limitations and community interaction of people with acquired brain injury.
| 15 min. | No Training /Reading an Article/ Manual
| 15 | None | Free | Traumatic Brain Injury, Acquired Brain Injury, Chronic Spinal Cord Injury, Brain tumor, Stroke
|
| Reintegration to Normal Living Index | Assesses quantitatively the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities. | 6 -30 min.
| No Training
| 11 | None | Free | Stroke, 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
| 8 | Access to hospital or community | Free | Test can be used with, but is not limited to, patients with stroke. |
Table 2: Palliative Care assessment tools
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip- ment | Cost | Population |
| Edmonton Symptom Assessment System | Designed 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). | Variable | No Training Reading an Article/ Manual
| 11 | None | Free | Cancer patients |
| Karnofsky Performance Scale Index | Allows patients to be classified as to their functional Impairment, to compare effectiveness of different therapies and to assess the prognosis in individual patients. | Variable | No Training Reading an Article/ Manual
| 3 | None | Free | Test can be used with, but is not limited to, patients with serious illnesses such as cancer. |
| Palliative Performance Scale | Provides a framework for measuring progressive decline over the course of illness, and serves as a communication tool for the team.
| Variable | No Training Reading an Article/ Manual
| 5 | None | Free | Test 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
| 5 | None | Free | Test can be used with, but is not limited to, patients with serious illnesses such as cancer. |
Table 3: Pediatric assessment tools
| Name of test | Purpose | Length of test | Training Required | Number of items | Equipment | Cost | Population |
| 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/ Manual
| 25 | Paper & Pencil; Stimulus card for the Card-sort Administration | Not Free | Pediatric |
| Pediatric Balance Scale | A 14-item criterion-referenced measure which examines functional balance in the context of everyday tasks.
| 6 -30 min. | Reading an Article/ Manual
| 14 | Adjustable 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
| Free | Children 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/ Manual
| 14 | None | Not Free
| Children ages 2-7 living with or without disability
|
Table 4: Pain functional assessments
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Numeric Pain Rating Scale | Measures the subjective intensity of pain. | <5 min. | No Training
| 1 | None | Free | Chronic 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 Inventory | Assesses chronic pain in individuals | 30-60 min. | No training | 61 | None | Free | Headache, Fibromyalgia, Cancer pain, Systemic lupus erythematosus, Chronic pelvic pain, Phantom limb pain and Whiplash disorders
|
| McGill Pain Questionnaire | A self-report measure of pain | 30 min. | No training | 20 | None | Free | Cancer, 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 test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Measure-ment of Quality of the Environ-ment | Assesses the role of environmental factors in one’s ability to maintain life habits in relation to their limitations and capacities. | 31-60 min. | Read manual | 109 | None | Pay a licensing fee | Any diagnosis that may impact a patient’s interaction with their environment. |
| Four Step Square Test | Test of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backwards | <5 minutes | No training | N/A | Stopwatch and Four canes
| Free | Geriatric, Parkinson’s Disease, Stroke, Transtibial amputation and Vestibular disorders |
Table 6: Activities of daily living scales
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Barthel index | Assesses the ability of an individual with a neuromuscular or musculoskeletal disorder to care for him/herself | 2-5 min. | No training | 10 | None | Free | Stroke, neurological disorders, geriatric, brain injury |
| Functional Independence Measure | Provides 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 min | Certification required | 18 | May vary based on level and impair-ment category measured. | Not free | Brain injury, geriatrics, multiple sclerosis, orthopedic conditions including low back pain, spinal cord injury, stroke |
| Patient specific Functional scale | Assess functional ability to complete specific activities | <4 min. | No training | N/A | None | Free | Joint 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 measure | Assesses an individual’s perceived occupational performance in the areas of self-care, productivity, and leisure. | 10-20 min. | No training | N/A | None | Free | Stroke, COPD, pain, Cerebral Palsy, TBI, Parkinson’s Disease, arthritis, pediatrics, ankylosing spondylitis |
Table 7: Aerobic/Functional capacity measurements
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| 6 min. walk | Assesses distance walked over 6 minutes as a sub-maximal test of aerobic capacity/endurance | 6 min. | No training | N/A | Stop watch, Measuring wheel to measure distance (recommended) | Free | Alzheimer’s Disease, Children Fibromyalgia, Geriatrics, Heart failure, Multiple sclerosis, Parkinson’s Disease, Pulmonary disease, Osteoarthritis, Spinal cord injury, Stroke |
| Maximal Oxygen Uptake: VO2max and VO2peak | To measure the aerobic fitness by assessing their VO2max and VO2peak. | 15-20 min. | No training | 1 | Open-circuit spirometer, treadmill or ergometer, computerized systems and equipment to monitor blood pressure and ECG changes | Free | Multiple sclerosis |
Table 8: Balance assessment scales
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Functional reach test | Assesses 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 training | 1 (3 in modified version) | Yardstick Duct tape (to tape the yardstick to the wall) | Free | Community, Dwelling Elderly Parkinson’s Disease, Peripheral Vestibular Disorders, Spinal Cord Injury, Stroke, Vestibular Disorders |
| Multi-directional reach test | Determine the limits of stability of individuals in 4 directions. | < 5 min. | No training | 4 | Yardstick Level | Free | Community dwelling adults and elderly, inner city older adult population, and personal care home residents |
| Berg Balance Test | Assess static balance and fall risk in adult populations | 15-20min | No training | 14 | Stop watch, chair with arm rests, measuring tape/ruler, object to pick up off the floor and step stool | Free | Brain injury, community dwelling elderly, multiple sclerosis, orthopedic surgery, osteoarthritis Parkinson’s Disease, Spinal Cord Injury, stroke, traumatic and acquired brain injury and vestibular dysfunction |
| POMA | Questions the circumstances surrounding a fall, specifically, activities prior to falling, perceived cause, environmental factors and a description of injuries. | 10-15 min. | No training | 16 | Hard, armless chair Stopwatch or wristwatch 15 ft (4.57 meter) walkway | Free | Amyotrophic Lateral Sclerosis, elderly, Normal Pressure Hydrocephalus, Parkinson’s Disease and stroke |
| Functional gait assessment | Assesses postural stability during various walking tasks | 5-10 min | No training | 10 | Stopwatch, 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 railings | Free | Older adults ranging from 40-80 years, Parkinson’s Disease, Spinal Cord Injury, stroke, vestibular populations |
| History of Falls Questionnaire | Questions the circumstances surrounding a fall, activities prior to falling, perceived cause, environmental factors and a description of injuries. | 5-10 min | No training | 17 | None | Free | Healthy adults |
Table 9: Cognitive
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| Mini Mental | Used as a screen for dementia or cognitive impairment | <10 min. | No Training
| 11 | None | Free
| Mainly in geriatric population, but any population |
| Glasgow Coma Scale | Asses level of consciousness after injury. Can be used as initial assessment or to monitor changes in consciousness over time
| 10-15 min. | No Training | 15 | None | Free | Traumatic Brain Injury, Stroke, Cardiac/Pulmonary disorders, Infectious, GI, metabolic and renal disorders
|
| Brief Cognitive Assessment tool | Assesses orientation, verbal recall, visual recognition, visual recall, attention, language, executive functions and visuo-spatial processing. | 15-20 min.
| Training course
| 21 | None | Not Free | Assisted 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 the | 5-10 min. | No Training
| 6 | None | Free | Elderly and those with cognitive impairment. |
Table 10: Stroke and Traumatic Brain Injury
| Name of test | Purpose | Length of test | Training Required | Number of items | Equip-ment | Cost | Population |
| National Institute of Health scale | Measures the severity of symptoms associated with cerebral infarct ; quantitative measure of deficits | 5 min. | Training course
| 15 | None | Free
| Stroke |
| Stroke impact Scale | Assessment of health related quality of life specific to stroke survivors | 10-15 min. | No Training | 49 | None | Free | Stroke |
| Fugl-Meyer Assessment of Motor Recovery after stroke | Quantitative measure of motor impairment used in post-stroke hemiplegic patients | 30min | Review of manual | 226 items across 5 domains | Tennis ball, spherical container, tool for reflex test, quiet space | Free | Post-stroke hemiplegic patients of all ages |
| Rancho Los amigos | Assessment of cognition and behavior as one emerges from coma; progressive sequential recovery from brain damage | 5-10min min.
| No training | 8 | None | Free | Traumatic Brain Injury(TBI) |
| Agitated behavior Scale | Assess the nature and extent of agitation during the acute phase of recovery from injury | 6-30 min. | No
| 14 | None | Free | Acquired brain injury; others with agitation. |
| Galveston Orientation Amnesia Test | Measures attention and orientation marking emergence of PTA | 5-30 min | No training | 10 | None | Free | TBI |
| Modified Ashworth Scale | Measures spasticity in patients with lesions of the Central Nervous System(CNS) | <5min | No training | 6 | None | Free | Adults and children with lesions of CNS, Cerebral Palsy, MS, pediatric hypertonia, SCI, Stroke, TBI |
| Mayo Portland adaptability Inventory-4 | Assist in the clinical evaluation and rehabilitation planning of physical, cognitive, emotional, behavioral and social problems after brain injury | 30 min | Reading manual | 35 | None | Free | Individuals with acquired brain injury |
| Coma Recovery Scale | Assist in the differential diagnosis, prognostic assessment, treatment planning in patients with disorders of consciousness | 25 min | Reading article/manual | 23 | None | Free | TBI, brain tumor, TBI with CVA, Hypoxic/ brain injury, disorders of consciousness |
GAPS IN KNOWLEDGE/EVIDENCE BASE
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
REFERENCES
- Granger Carl V, MD. Quality and outcome measures in Rehabilitation Programs. Available at: http://emedicine.medscape.com/article/317865-overview#a1
- Functional Assessments. Available at: http://www.whscc.nf.ca/healthcare/HC_FunctionalAssessment.whscc
- 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
- Chen, Joseph J, MD. Functional Capacity evaluation and disability. The IOWA Orthopedic Journal. 2007; 27:121-127
- Rehabilitation Measures Database. Rehabilitation Institute of Chicago. Available at: http://www.rehabmeasures.org/default.aspx
- 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
- Ring H. Functional assessment in rehabilitation medicine: clinical applications. Eura Medicophys. 2007; 43(4):551-5(ISSN: 0014-2573)
- B. Iwata, De Leon, I. Reliability and Validity of the Functional Analysis Screening Tool. Journal of Applied Behavior Analysis.46 (2013):271-28.
- 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
Nothing to Disclose
Brenda Castillo, MD
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Maricarmen Cruz, MD
Nothing to Disclose