Functional assessment

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

Table 2: Palliative Care assessment tools

Table 3: Pediatric assessment tools

Table 4: Pain functional assessments

Table 5: Work Related Injuries Functional Assessment

Table 6: Activities of daily living scales

Table 7: Aerobic/Functional capacity measurements

Table 8: Balance assessment scales

Table 9: Cognitive

Table 10: Stroke and Traumatic Brain Injury

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