Functional Assessment Measure

The Functional Assessment Measure (FAM) was created specifically for use with patients who have sustained a brain injury, in an attempt to enhance the appropriateness of the FIM for this specific population (Alcott et al. 1997; Hall et al. 1993; Hobart et al. 2001). The FIM contains only five cognitive items, which may limit its content validity in TBI populations (Hall & Johnston 1994). The FAM does not stand alone as an assessment tool, but rather consists of 12 items that are added to the 18 FIM items. The 12 additional items were developed by a team of clinicians representing each of the disciplines in a rehabilitation model (Hall et al. 1993) and are intended to emphasize cognitive, communicative and psychosocial function (McPherson et al. 1996).

The 12 FAM items include swallowing, car transfer, community access, reading, writing, speech intelligibility, emotional status, adjustment to limitations, employability, orientation, attention, and safety judgement. Each item is rated using the same 7-point scale used on the FIM. Like the FIM, the FIM+FAM also consists of two subscales, one representing physical or motor functioning and one representing cognitive/psychosocial function. The total score for the FIM+FAM is 210, 112 for the motor FIM+FAM and 98 for the cognitive subscale (Gurka et al. 1999). Higher scores signify greater independence.

The FIM must be purchased from UDS and use of the FIM requires training and certification. A FIM+FAM rating form is available along with decision trees, training and testing vignettes specific to the FAM items from the website. The FIM+FAM requires approximately 35 minutes to administer (Hall & Johnston 1994).

Table: Characteristics of the Functional Independence Measure+Functional Assessment Measure

Advantages. The FIM was intended specifically for assessment during inpatient rehabilitation. The FAM items are better suited to evaluation post discharge from inpatient rehabilitation and may extend the applicability of the scale beyond the timeframe of the original FIM (Gurka et al. 1999). Addition of the FAM items to the FIM appeared to expand the range of abilities assessed (Hall et al. 1993). 

Limitations. Use of the FIM+FAM still requires the use of trained raters who ideally complete ratings after a period of observation and contribute to a team consensus process (Hobart et al. 2001). The use of untrained raters may result in lower scale reliability (Hall et al. 1993).

Many of the FAM items have been identified as difficult to score (adjustment to limitations, emotion, employability, community mobility, safety judgement, attention and speech intelligibility) (Turner-Stokes et al. 1999). Items in the expanded psychosocial/cognitive subscale seem to include more abstract concepts requiring raters to make more subjective assessments than was necessary for the more objective and observable behavioural items included on the original FIM (Hall et al. 1993; McPherson et al. 1996). The abstract nature of items could have a deleterious effect on the reliability of those items (Alcott et al. 1997). Additional training together with more explicit definitions and/or content modification of the most abstract items could assist raters in the provision of reliable evaluations (Alcott et al. 1997; McPherson et al. 1996).

While the FAM items were intended to provide additional assessment of the psychosocial aspects of disability following brain injury (Hall et al. 1993), the validity of the assessment has not been clearly established (Hobart et al. 2001). The psychosocial/cognitive FIM+FAM does not correlate well with measures of handicap, such as the LHS or as strongly as one might expect with the mental component summary of the MOS SF36 (Hobart et al. 2001). Overall, the added length and increased training requirements associated with the FIM+FAM do not seem to offer any substantial advantage over the FIM (Hobart et al. 2001; McPherson & Pentland 1997). While the FIM+FAM appears to evaluate a somewhat broader range of abilities (Hall et al. 1993), reports of ceiling effects associated with the FIM+FAM are varied and reported effect sizes are approximately the same as those reported for the FIM  (Hobart et al. 2001). 

 

Summary-Functional Independence Measure + Functional Assessment Measure

Interpretability: The 18-FIM items are widely used and recognized. However, the FAM items are more difficult to rate reliably and the validity of FAM is not well established. 

Acceptability: Alternate modes of administration have not been examined and FAM items have not been evaluated for use in assessment by proxy.

Feasibility: The addition of FAM items to the FIM creates a longer assessment requiring the involvement of additional raters in team consensus and more training for these raters. While the FAM items are freely available, use of the FIM items requires purchase of the scale, training and certification.

 

Table: Functional Independence Measure+Functional Assessment Measure Evaluation Summary

Reliability

Validity

Responsiveness

Rigor

Results

Rigor

Results

Rigor

Results

Floor/ceiling

++

 

 

+++ (TR)

++(IO)

+++(IC)

+

++

++

++

varied

NOTE: +++=Excellent; ++=Adequate; +=Poor; N/A=insufficient information; TR=Test re-test; IC=Internal Consistency; IO=Interobserver; Varied (re. floor/ceiling effects; mixed results).