Functional Assessment

Overview and Description

Functional assessments have become an integral part of the comprehensive rehabilitation medicine evaluation. Descriptions of improvements in function have been consistently performed since rehabilitation medicine developed after World War II. Unfortunately, previously utilized methods lacked the consistency required to study rehabilitation outcomes accurately.¹

Functional assessment measures an individual’s level of function and ability to perform specific tasks on a safe and dependable basis over a defined period. A detailed assessment should include a pertinent clinical history; a neurologic and musculoskeletal evaluation, a physical effort determination, and a comprehensive evaluation of behaviors that might impact physical performance.² Assessments must be valid, reliable, and reproducible. They can be self-administered questionnaires or clinician administered.

From a research standpoint, functional assessments provide supporting evidence to develop, improve and attest to different evidence-based treatments. In the clinical setting, these instruments are commonly used to set rehabilitation goals, to develop specific therapeutic interventions and to monitor clinical changes.³

In 2014, functional assessments took a different direction when the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) was signed into law seeking to connect findings on the baseline assessment to functional outcomes. This required that Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs) to report and submit standardized patient assessment data, including quality measures and standardized patient assessment data elements. The collection of this information permitted the exchange of information among providers on specific functional domains that included functional status, cognitive function, and mental status among some. The final goal intended to enhanced rehabilitation outcomes through share decision making, care coordination and improved discharge planning.⁴

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 (Table 1A) measures the performance of basic functional skills required to care for oneself independently. They measure basic daily activities (eating, grooming, bathing, dressing, continence) mobility (gait, transfers) and cognition. Examples include ⁵: 

• Barthel Index
• Functional Independence Measure (FIM) (Table 1B)
• Functional Independence Measure for Children (WeeFIM)
• GG Functional Abilities and Goal ⁶ (Table 2)
• Patient specific Functional Scale
• Canadian Occupational Performance Measure
• Lawton’s Instrumental Activities of Daily Living among others
• WHO International Classification of Functioning, Disability, and Health (ICF) (Table 3)
• International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY)

Quality of life and community re-integration are pivotal rehabilitation goals (Table 4). Additionally, some of these instruments evaluate the effects of executive function deficits on everyday functioning through real world task. Examples include:⁵

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

Palliative Care assessment (Table 5) contains tools intended to measure aspects such as fatigue, functional performance, quality of life in severely ill/cancer and end of life patients. Examples are:

• 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

Pediatric scales (Table 6) are numerous and are usually standardized according to age groups. Areas of assessment include ¹:

• Developmental milestones
• Growth
• Motor skills
• Cognition skills
• Learning and self-help skills
• Communication skills
• Social/Emotional skills

Pain functional assessments (Table 7) assist in evaluation of the severity of pain, how effective treatment interventions have been, and the presence of associated psycho-emotional/behavioral components. Examples include ⁵:

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

Work Related Injuries (Table 8): 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

Aerobic/Functional Capacity (Table 9): reflects the ability to perform activities of daily living that require sustained aerobic metabolism. Examples include:⁵

• Field Tests: 6 Minute Walk Test, Shuttle Walk Test, Step Test.
• Laboratory Tests: Maximal Oxygen Uptake- VO2 Max, VO2 Peak-Aerobic Capacity.

Balance evaluation (Table 10): the primary purpose is to identify whether or not a problem exists in order to predict risk of a fall, determine the underlying cause of the balance dysfunction and to determine if a treatment is required or has been effective. Examples include:⁵

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

Cognition (Table 11): 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 include:⁵

• The Glasgow Coma Scale
• Mini Mental Evaluation
• Mini-Addenbrooke’s Cognitive Examination (MACE)
• Neuropsychological batteries
• Glasgow Outcome Scale among others

There are tools designed specifically for certain medical conditions (Table 12) such as:⁵

• 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

• Musculoskeletal (Table13):
  • Oswestry Disability Index
  • Western Ontario and McMaster Universities Arthritis Index (WOMAC)
  • Short Musculoskeletal Function Assessment (SMFA)

The decision as to which tool to use depends on the patient’s condition, his/her goals, the point in recovery at which the assessment is being used, the therapist’s training, as well as any restrictions/preferences from the facility where the assessment is taking place ⁷.

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.

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 to design new functional assessment tools that might provide accurate, valid, reliable and tangible data.⁸  

During COVID-19 pandemic, virtual home Telehealth has served as an important mechanism to conduct uninterrupted evaluations, particularly as a result of social distancing and social restrictions. As the response and impact of COVID-19 unfolds, targeted methods and approaches must be explored to improve quality and relevance of evaluations. These may be used with remote monitoring applications such as telehealth programs.

Functional assessments are an essential component in rehabilitation medicine assisting with quality assurance, ongoing quality improvement, cost/benefit analysis, education, and research.⁹ 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.

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. There is a need for uniformity in assessment tools that permit consistent assessment of disability across treatment sites, across disciplines and geographic locations. Accurate completion of the different instruments is imperative. On the other hand, it has also been proposed that some functional assessment tools may not provide an objective or accurate account of the patient’s status.

The assessment of any patient with a functional impairments regardless of the etiology should try to quantify such impairment taking into consideration physical, cognitive, behavioral, structural, environmental and social barriers.  It is important to note the complexity of the population due to the multiple subspecialties within the field, such as spinal cord injury, brain injury, palliative care, pediatric, pain management, sport medicine, cardiopulmonary rehabilitation. This diversity calls for a complex, detailed approach with a wide range of required skills and knowledge unique to those areas and with the primary goal of restoring function as well as independence. Standard components of a physiatrist history include chief complaint, history of present illness, allergies, medications, review of system, past/family/psychosocial history, functional history (at home, community, work current and prior to the illness). Emphasis on  motor skills(bed mobility, transitional mobility, ambulation, coordination, balance), activity of daily living(bathing, dressing, grooming, toileting, feeding),  cognition (alertness, orientation, memory, ability to encode new information, communication, etc.), vocational (current, past and future) and use of assistive devices/technology.¹⁰ Comprehensive functional assessment evaluations must reflect appropriate medical record documentation that justify the need for the rehabilitation services and evidence the improvement during those interventions.

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.¹¹ A national/international agreement is required to fulfill a uniform assessment of disability across treatment sites, disciplines, and geography. 

References

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. IMPACT Act of 2014 Data Standardization & Cross Setting Measures | CMS
5. Rehabilitation Measures Database. Rehabilitation Institute of Chicago. Available at: http://www.rehabmeasures.org/default.aspx 
6. Gupta_03.indd (wordpress.com)
7. Frontera, W. R., DeLisa, J. A., Basford, J., Bockenek, W. L., Chae, J., & Robinson, L. R. (2020). DeLisa’s physical medicine & rehabilitation: Principles and practice. Philadelphia: Wolters Kluwer.
8. 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  
9. Ring H. Functional assessment in rehabilitation medicine: clinical applications. Eura Medicophys.  2007; 43(4):551-5(ISSN: 0014-2573) 
10. The History and Physical Examination of a Patient with Disability | Musculoskeletal Key. Available at: https://musculoskeletalkey.com/the-history-and-physical-examination-of-a-patient-with-disability/
11. B. Iwata, De Leon, I. Reliability and Validity of the Functional Analysis Screening Tool. Journal of Applied Behavior Analysis.46 (2013):271-28.

Original Version of the Topic

Isabel Borras-Fernandez, MD, Nataly Montes-Chinea MD, Brenda Castillo, MD, Maricarmen Cruz, MD. Functional Assessment. 5/2/2016

Author Disclosure

Isabel Borras-Fernandez, MD
Nothing to Disclose

Maricarmen Cruz-Jimenez, MD
Nothing to Disclose

Francisco J. Irizarry-Rivera, MD
Nothing to Disclose