Functional

Assessment
Prepared by: Vince Carlos Bondal
Supervised by: Roselle Joanne Tarranza, DPT, PTRP
Function
● The construct of function encompasses all those tasks,
activities, and roles that identify a person as an
independent adult or as a child progressing toward adult
independence.

● Functional activity is a patient -referenced concept and is

dependent on what the individual self -identifies as
essential to support physical and psychological well
-being, as well as to create a personal sense of meaningful
living
Function in the ICF is an umbrella term encompassing
all body functions and structures, activities, and
participation, whereas disability is a term that
encompasses impairments in body functions and
structures, activity limitations, and participation
restrictions. Both function and disability are
represented in the ICF, in contrast to previous
frameworks, to provide for the description of a
continuum of the components of health from positive
aspects to items an individual is not able to perform or
perform in a limited manner or with assistance..
ICF MODEL
 Purpose of Examination of Function
- Used to measure how a person does certain tasks or fulfills certain
roles in the various dimensions described by the ICF
Application of selected functional tests and measures yield data that can
be used as:
(1) Baseline information for setting function-oriented goals and outcomes of intervention
(2) Indicators of a patient’s initial abilities and progression toward more complex functional levels
(3) Criteria for placement decisions (e.g., the need for inpatient rehabilitation, extended care, or
community services)
(4) Manifestations of an individual’s level of safety in performing a particular task and the risk of injury
with continued performance
(5) Evidence of the effectiveness of a specific intervention (medical, surgical, or rehabilitative) on
function; and
(6) Documentation to support payer requirements of change in functional status during an episode of
care
 General Considerations

● Physical therapists are typically responsible for the testing of aspects of function
related to mobility, such as bed mobility, transfers, and locomotion. • Some formal
instruments were designed to be completed collectively by a team of HCPs.
● In these instances, testing should be coordinated to reduce duplication and
unnecessary patient stress.
● In noninstitutional settings or where there is no team, the physical therapist is often
responsible for determining all aspects of these instruments
 Testing Perspectives

● Function tests can utilize two highly divergent perspectives on what is to be tested or
measured by the physical therapist

**directly affects what types of tests and measures should be chosen and what parameters of
measurement are appropriate to yield data useful to making clinical judgments.
 Basic Considerations

● Setting - conducive to the type of testing and free of

distractions
● Instructions - should be precise and unambiguous
● Patient's Energy - Testing may be biased by fatigue
● Retesting - should occur at regular intervals during
treatment to document progress and before discharge
from the episode of care
 Performance-Based Tests

● May be used either to describe the patient’s current

level of function or to identify the maximum level of
function possible
○ 6-Minute Walk Test
○ Physical Performance and Mobility Examination
○ Functional Reach Test
○ Get Up and Go Test
○ RLA-OGA
○ Timed Up and Go Test
○ SSTREAM
○ UMCT
○ Short Physical Performance Battery
 6-Minute Walk Test

● The 6 Minute Walk Test is a sub-maximal exercise test used to

assess aerobic capacity and endurance. The distance covered
over a time of 6 minutes is used as the outcome by which to
compare changes in performance capacity.
○ Arthritis
○ Fibromyalgia
○ Geriatrics
○ Multiple Sclerosis
○ Parkinson’s Disease
○ Spinal Cord Injury
○ Stroke
○ Muscle disorders
○ Spinal Muscular Atrophy
6-Minute Walk Test
 Timed-Up and Go Test

● To determine fall risk and measure the progress of balance, sit to stand and walking.
Simple screening test that is a sensitive and specific measure of probability for falls
among older adults.
● A recent study published in 2022 found that the TUG test is a strong mortality
predictor, displacing other established risk factors such as chronic diseases in geriatric
populations of low and middle income countries.
● This test was initially designed for elderly persons, but is used for in other populations
eg Parkinson's - This tool is validated for a population with Parkinson’s Disease;
Multiple Sclerosis; Hip fracture; Alzheimers; CVA; TKR or THR; Huntington Disease
● It is one of the 4 tests used in the The Balance Outcome Measure for Elder
Rehabilitation (BOOMER)
 Timed-Up and Go Test

● To determine fall risk and measure the progress

of balance, sit to stand and walking.
● Simple screening test that is a sensitive and
specific measure of probability for falls among
older adults
● A recent study published in 2022 found that the
TUG test is a strong mortality predictor,
displacing other established risk factors such as
chronic diseases in geriatric populations of low
and middle income countries.
Timed-Up and Go Test
 S-STREAM

● A simplified version of STREAM, arranged for purposes of ease and

efficiency of administration when assessing motor control of patients
with stroke
● Each subscale of the STREAM then was simplified by deleting
redundant items on the basis of expert opinion and the results of the
Rasch analysis
● Demonstrated high Rasch reliability, undimensionality, and concurrent
validity with the STREAM in patients with stroke.
● S-STREAM is efficient to administer, as it consists only of half the
number of items in the orignal STREAM
 SSTREAM
SSTREAM
Supine:
1. Protracts scapula in supine = 1a
2. Extends elbow in supine = 1a
3. Rolls onto side = 1b
4. Moves from lying supine to sitting (<20 sec) = 1a
Sitting: .
5. Raises arm overhead to fullest elevation = 1a
6. Closes hand from fully opened position = 1c
7. Opens hand from fully closed position = 1c
8. Flexes hip in sitting = 1a
9. Extends knee in sitting = 1c
10. Flexes knee in sitting = 1c
11. Plantarflexes ankle in sitting = 1a
12. Rises to standing from sitting = x - can’t perform
Standing:
13. Dorsiflexes affected ankle with knee extended = x - can’t perform standing
14. Walks 10 meters indoors (<20 sec) = x - can’t perform standing
15. Walks down 3 stairs alternating feet = x - can’t perform standing
Upper Extremity (Items 1,2,5,6,7) Total Score: 5/10
Transformed Score: 50%
Lower Extremity (Items 8,9,10,11,13) Total Score: 2/10
Transformed Score: 20%
Basic Mobility (Items 3,4,12,14,15) = 8/15
Transformed Score: 53%
 SSTREAM
SCORING
Voluntary Movements of the Limbs:
● Unable to perform movement through any appreciable range
● 1a - able to perform part of the movement with MARKED DEVIATION from normal pattern
● 1b - able to perform only PART of the movement COMPARABLE TO UNAFFECTED side
● 1c - able to COMPLETE the movement WITH MARKED DEVIATION from normal pattern
● 2 - able to COMPLETE the movement COMPARABLE TO UNAFFECTED SIDE
● X - Activity is not tested
BASIC MOBILITY

0 unable to perform the test activity through any appreciable range (ie, minimal active participation)
1a. able to perform only part of the activity independently (requires partial assistance or stabilization to complete), with or without an aid, and with
marked deviation from normal pattern
b. able to perform only part of the activity independently (requires partial assistance or stabilization to complete), with or without an aid, but with a
grossly normal movement pattern
c. able to complete the activity independently, with or without an aid, but only with marked deviation from normal pattern
2 able to complete the activity independently with a grossly normal movement pattern, but requires an aid
3 able to complete the activity independently with a grossly normal movement pattern, without an aid
X activity non tested (specify why; ROM, Pain, Other (reason))
 RLA-OGA

● The subject can be assessed through live observation or by

videotaping the subject and analyzing the recorded footage. The latter
might be beneficial in certain instances where repeated gait cycles
may induce fatigue in the subject and impede the reliability of results.
RLA-OGA
 Self-Reports

● Patient is asked directly either by the therapist or a

trained interviewer (interviewer report) or via a
selfadministered report instrument. • Outpatient
Physical Therapy Improvement in Movement
Assessment Log (OPTIMAL)
 Descriptive Parameters

● Therapists should use descriptive terms that are well

defined and unambiguous Often it is helpful to qualify a
person’s performance by linking observations with
nonspecific indicators of impairments.
○ HR, RR, BP, SPO2 (ā, during, p̄stressful activity)
○ Pain
○ Fluctuation accdg to time of day
○ Medical level
○ Environmental Influences
 Response Formats

Normal Measures “Checklist”; Scored as able to do/not able to

do, independent/ dependent,
completed/incompleteetc.

Ordinal Measures Describe a range of performance or the

degree to which a person can perform the
task; “no difficulty,” “some difficulty,” or
“unable to do”; or “always,” “sometimes,”
“rarely,” or “never.”

Interval/Ratio Measures Visual analog scales attempt to represent

measurement quantities in terms of a
straight line placed horizontally or vertically
on paper
 Interpreting Test Results

● Determining the Quality of Instruments Reliability

measures a phenomenon dependably, time after time,
accurately, predictably, and without variation
○ Test–retest reliability: is stable and will not indicate
change when none has occurred
○ Intrarater reliability: Tests performed by the same
therapist of the same performance should be highly
correlated
○ Interrater reliability: agreement among multiple
observers of the same event
 Interpreting Test Results

● Determining the Quality of Instruments

○ Validity
■ a multifaceted concept and established in many
different ways:
1. whether an instrument designed to measure
function truly does just that
2. what the appropriate applications of the
instrument
3. how the data should be interpreted
 Interpreting Test Results

● Face validity: appear to measure what it purports to

measure
● Content validity: measures all the important or specified
dimensions of function
● Criterion-related validity: results compared to the gold
standard
● Concurrent validity: degree to which the two instruments
agree
 Interpreting Test Results
● Determining the Quality of Instruments
● Validity
○ Sensitivity
- test refers to the proportion of individuals with a limitation in function
who are correctly classified
○ Specificity
- who do not have a limitation in function who are correctly classified
○ Positive predictive value
- proportion of people who have a positive finding on a test who actually
have a limitation in function as classified by the comparison test
○ Negative predictive value
- the proportion of people who have a negative finding on a test who do
not have a limitation in function
 Interpreting Test Results
- Determining the Quality of Instruments
Responsiveness
● meaningful change in a patient’s status
Minimal Detectable Change (MDC):
● the smallest amount of change in a measurement that exceeds the
measurement error of the instrument
● “TRUE CHANGE”
Minimal Clinical Important Difference (MCID):
● is the smallest difference in a measured variable that signifies an important
rather than a trivial difference in the patient’s condition
● “IMPORTANT CHANGE”
 INSTRUMENTS TO ASSESS FUNCTION

● The Functional Independence Measure

● The Outcome and Assessment
Information Set
● The SF-36
● The Patient-Specific Functional Scale
● ADL analysis
 FIM
● The FIM measures what the individual does, not what that person could do under
certain circumstances. he interrater reliability of the FIM has been established at an
acceptable level of psychometric performance (intraclass correlation coefficients
ranging from 0.86 to 0.88).53 he face and content validity of the FIM, as well as its
ability to capture change in a patient’s level of function, have also been determined.
Any clinical worker can administer the FIM after appropriate training in using the
response set for each item.
● The instrument lists six self care activities: feeding, grooming, bathing, upper body
dressing, lower body dressing, and toileting. Bowel and bladder control, aspects of
which some may consider as impairments rather than function, are categorized
separately. Functional mobility is tested through three items on transfers. Under the
category of locomotion, walking and using a wheelchair are listed equivalently,
whereas stairs are considered separately. he FIM also includes two items on
communication and three on social cognition.
FIM
SF-36
● The SF-36 contains 36 items based on questions used in the RAND Health
Insurance Study. hese 36 items were culled from the 113 questions used by
RAND in the Medical Outcomes Study (MOS) to explore the relationship
between physician practice styles and patient outcomes.62 hus, it was named
the SF-36, because it was a short form of the MOS instrument with only 36
questions.
● All but one of the 36 questions of the SF-36 are used to form eight different
scales: physical function, social function, role function, mental health,
energy/fatigue, pain, and general health perceptions. he last question
considers self-perceived change in health during the past year. Items are
scored on nominal (yes/no) or ordinal scales. Each possible response to an
item on a scale is assigned a number of points. he total points for all items
within a scale are then added and transformed mathematically to yield a
percentage score, with 100% representing optimal health.
SF-36
Barthel Index
● Although not as commonly used today in practice as some other instruments, this instrument is
still used to measure function in clinical research, and this assessment tool represents one of
the earliest contributions to the functional status literature and identifies physical therapists’
long-standing inclusion of functional mobility and ADL measurement within their scope of
practice.
● The Barthel Index specifically measures the degree of assistance required by an individual on
10 items of mobility and self-care ADL (Table 8.7). Levels of measurement are limited to either
complete independence or needing assistance. Each performance item Table 8.6 Items
Covered in Selected Multidimensional Functional Assessment Instruments FIM SF-36 OASIS
Symptoms – + + Physical function Transfers + – + Ambulation + + + ADL Bathing + + + Grooming + –
+ Dressing + + + Feeding + – + Toileting + – + IADL Indoor home – + + chores Outdoor home – + +
chores/shopping Community – + + travel/drive car Work/school – + – Affective function
Communication + – + Cognition + – + Anxiety – + + Depression – + + Social function Interaction + +
– Activity/leisure – + – General health – + – perceptions is scored on an ordinal scale with a
specified number of points assigned to each level or ranking. Variable weightings were
established by the developers of the Barthel Index for each item based on clinical judgment or
other implicit criteria.
Barthel Index