Functional Independence Measure (FIM)

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Tool Description

  • often considered the gold standard for assessing basic activities of daily living (ex. self care).
  • consists of two subscales, motor and socio-cognitive.

ICF Domain:

Activity – Subcategory: Self-Care

Number of Items:

18

Brief Instructions for Administration & Scoring

Administration:

  • clinician-administered; completed by observation of performance.
  • The motor subscale includes 13 items: eating, grooming bathing, dressing upper extremity, dressing lower extremity, bowel management, bladder management, transfers to bed, chair or wheelchair, transfer to tub, toilet and shower, walking or wheelchair propulsion and stair climbing.
  • The socio-cognitive subscale includes 5 items: comprehension, expression, social interaction, problem solving and memory.
  • administration is typically conducted by interdisciplinary team members
  • Administration usually takes approximately 45 minutes, though short and phone versions also exist and may take more/less time to administer.

Equipment:Items that the patient uses to carry out activities of daily living.

Scoring:

  • Each item is scored on a 7 point ordinal scale ranging from 1 (total dependence) to a score of 7 (total independence).
  • The scoring considers the use of adaptive equipment and/or the extent of personal assistance or supervision required to complete the task. If assistive equipment (ex. raised toilet seat) is used, the individual cannot achieve a score of 7 on the item.
  • FIM motor, cognitive and/or total scores can be derived by summing items.
  • Total FIM scores range from 18 (totally dependent) to 126 (totally independent); motor scores range from 13 (total dependence) to 91 (total independence); and cognitive scores range from 5 (total dependence) to 35 (total independence).

Interpretability

MCID: not established for the SCI population, but for an acute stroke sample, MCID = 22 points (for FIM Total score), 17 points (for FIM-Motor subscale) and 3 points (for FIM-Cognitive subscale). [Beninato et al. 2006, “Determination of the minimal clinically important difference in the FIM instrument in patients with stroke”, n=113]
SEM: not established
MDC: not established

  • Higher scores reflect fewer care hours required upon discharge.
  • No normative data for the SCI population has been established.
  • Published data for the SCI population is available for comparison for the FIM (see Interpretability section of the respective Study Details sheets).

Languages:

English, German, Italian, Spanish, Swedish, Finnish, Portuguese, Afrikaans, Turkish and French.

Training Required:

Certification for FIM administration is required.

Availability:

Can be purchased through http://www.udsmr.org/WebModules/FIM/Fim_About.aspx

Clinical Considerations

  • Though it is the best researched measure of basic function, it may not be sensitive to the subtle important changes in function for SCI individuals.
  • The FIM is not SCI specific. It has limitations in sensitivity to component abilities within tasks for people with SCI. There is a ceiling effect with the socio-cognitive subscale for individuals with and it does not measure the social, psychological, or vocational impact of disability experienced by those living with SCI.
  • Punitive scoring for individuals who use assistive technology occurs although these individuals may be independent
  • Typically requires individuals from a number of different backgrounds (nurse, physical therapy, occupational therapy) to complete

Measurement Property Summary

# of studies reporting psychometric properties: 27

Reliability:

  • Overall reliability is High for the total FIM (ICC=0.96), the FIM motor scale (ICC=0.90-0.96) and the FIM cognitive scale (ICC=0.91-0.98).
  • Test-retest reliability of the FIM is High (ICC=0.89).

[Segal et al. 1993, Kucukdeveci et al. 2001, Lundgren-Nilsson et al. 2006, Morganti et al. 2005, Hall et al. 1999, Hamilton 1994, Dodds 1993, Nilsson 2005, Hamilton 1999, Heinemann et al. 1997]

Validity:

  • Correlation of the FIM is High with the:
    • Quadriplegia Index of Function (Spearman’s ρ= 0.97)
    • Quadriplegia Index of Function – Modified (Spearman’s ρ=0.93)
    • Upper Extremity Motor Score (Spearman’s ρ=0.84)
    • Rivermead Mobility Index (Spearman’s ρ=0.9)
    • Barthel Index (Spearman’s ρ=0.7)
    • Spinal Cord Independence Measure (Spearman’s ρ=0.8)
    • Walking Index for Spinal Cord Injury (Spearman’s ρ=0.70-0.77)
    • Berg Balance Scale (Spearman’s ρ=0.72-0.77)
    • American Spinal Injury Association (ASIA) motor score (Spearman’s ρ=0.91)
  • Correlation of the FIM is Moderate with the:
    • ASIA light touch (Spearman’s ρ=0.58)
    • ASIA pinprick (Spearman’s ρ=0.55)
    • 50-Foot Walking Speed Test (Spearman’s ρ=0.57).

[Marino et al. 1993, Yavuz et al. 1998, Dijkers et al. 1999, Beninato et al. 2004, Kucukdeveci et al. 2011, Dijkers 1999, Donnelly et al. 2004, Ditunno et al. 2007, Middleton et al. 2006, Itzkovich et al. 2007, Lawton et al. 2006, Morganti et al. 2005, Marino 2004, Heinemann 1997, Graves 2005, Dodds 1993, Nilsson 2005, Hamilton 1999, Marino 1998, Mulcahey et al. 2004, Anderson et al. 2011]

Responsiveness:

  • Significant improvements in FIM score were detected between admission and discharge FIM scores (effect size for total FIM = 1.36).

[Middleton et al. 2006, Spooren et al. 2006, Dodds et al. 1993, Anderson et al. 2011]

Floor/ceiling effect:

  • Ceiling effects were reported on FIM-cognition items.
  • For bed transfer, toilet transfer and bath transfer, a ceiling effect was detected in the paraplegia group and a floor effect was detected in the tetraplegic group.

[Davidoff 1990, Middleton et al. 2006, Hall et al. 1999]

Reviewer

Dr. William Miller, Christie Chan

Date Last Updated:

Feb 1, 2013

Download the measure

Download Worksheet:
Can be purchased through http://www.udsmr.org/WebModules/FIM/Fim_About.aspx

Video

n/a

Scoring

n/a

Equipment Needed

FIM:

Almeida Cd, Coelho JN, Riberto M. Applicability, validation and reproducibility of the Spinal Cord Independence Measure version III (SCIM III) in patients with non-traumatic spinal cord lesions. Disabil Rehabil. 2016;38(22):2229-34.
http://www.ncbi.nlm.nih.gov/pubmed/26800790

Anderson KD, Acuff ME, Arp BG, Backus D, Chun S, Fisher K, Fjerstad JE, Graves DE, Greenwald K, Groah SL, Harkema SJ, Horton III JA, Huang M-N, Jennings M, Kelley KS, Kessler SM, Kirshblum S, Koltenuk S, Linke M, Ljungberg I, Nagy J, Nicolini L, Roach MJ, Salles S, Scelza WM, Read MS, Reeves RK, Scott MD, Tansey KE, Theis JL, Tolfo CZ, Whitney M, Williams CD, Winter CM, Zanca JM. United States (US) multi-center study to assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III). Spinal Cord, 2011; 49: 880-885.
http://www.ncbi.nlm.nih.gov/pubmed/21445081

Barbetta DC, Cassemiro LC, Assis MR. The experience of using the scale of functional independence measure in individuals undergoing spinal cord injury rehabilitation in Brazil. Spinal Cord. 2014;52(4):276-81.
http://www.ncbi.nlm.nih.gov/pubmed/24492639

Beninato M, O’Kane KS, Sullivan PE. Relationship between motor FIM and muscle strength in lower cervical-level spinal cord injuries. Spinal Cord, 2004; 42: 533-540.
http://www.ncbi.nlm.nih.gov/pubmed/15224086

Bonavita J, Torre M, China S, et al. Validation of the Italian version of the Spinal Cord Independence Measure (SCIM III) Self-Report. Spinal Cord. 2016;54(7):553-60.
http://www.ncbi.nlm.nih.gov/pubmed/26481705

Davidoff GN, Roth EJ, Haughton JS, Ardner MS. Cognitive dysfunction in spinal cord injury patients: sensitivity of the Functional Independence Measure subscales vs. neuropsychologic assessment. Arch Phys Med Rehabil 1990;71:326-329.
http://www.ncbi.nlm.nih.gov/pubmed/2327886

Dijkers MP, Yavuzer G. Short versions of the telephone motor Functional Independence Measure for use with persons with spinal cord injury. Arch Phys Med Rehabil. 1999;80(11):1477-84.
http://www.ncbi.nlm.nih.gov/pubmed/10569444

Dijkers MP. Correlates of life satisfaction among persons with spinal cord injury. Arch Phys Med Rehabil, 1999; 80:867-76.
http://www.ncbi.nlm.nih.gov/pubmed/10453761

Ditunno JF Jr, Barbeau H, Dobkin BH, Elashoff R, Harkema S, Marino RJ, Hauck WW, Apple D, Basso DM, Behrman A, Deforge D, Fugate L, Saulino M, Scott M, Chung J, Spinal Cord Injury Locomotor Trial Group. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair 2007; 21: 539-550.
http://www.ncbi.nlm.nih.gov/pubmed/17507642

Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehabil, 1993; 74: 531-536.
http://www.ncbi.nlm.nih.gov/pubmed/8489365

Donnelly C, Eng JJ, Hall J, Alford L, Giachino R, Norton K, Kerr DS. Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury. Spinal Cord, 2004; 42:302-307.
http://www.ncbi.nlm.nih.gov/pubmed/14993893

Fujiwara T, Hara Y, Akaboshi K, Chino N. Relationship between shoulder muscle strength and functional independence measure (FIM) score among C6 tetraplegics. Spinal Cord. 1999;37(1):58-61.
http://www.ncbi.nlm.nih.gov/pubmed/10025698

Graham JE, Granger CV, Karmarkar AM, et al. The Uniform Data System for Medical Rehabilitation: report of follow-up information on patients discharged from inpatient rehabilitation programs in 2002-2010. Am J Phys Med Rehabil. 2014;93(3):231-44.
http://www.ncbi.nlm.nih.gov/pubmed/24088780

Granger CV, Hamilton BB, Keith RA et al. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1:59-74.
http://journals.lww.com/topicsingeriatricrehabilitation/Abstract/1986/04000/Advances_in_functional_assessment_for_medical.7.aspx

Graves D. The construct validity and explanatory power of the AISA Motor Score and the FIM: implications for theoretical models of spinal cord injury. Top Spinal Cord Inj Rehabil 2005;10:65-74.
http://thomasland.metapress.com/content/xa251uv2e6j6ngln/

Graves DE, Frankiewicz RG, Donovan WH. Construct validity and dimensional structure of the ASIA motor scale. J Spinal Cord Med 2006;29:39-45.
http://www.ncbi.nlm.nih.gov/pubmed/16572564

Grey N, Kennedy P. The Functional Independence Measure: a comparative study of clinician and self ratings. Paraplegia. 1993;31(7):457-61.
http://www.ncbi.nlm.nih.gov/pubmed/8371936

Hall KM, Cohen ME, Wright J, Call M, Werner P. Characteristics of the Functional Independence Measure in traumatic spinal cord injury. Arch Phys Med Rehabil 1999;80:1471-1476.
http://www.ncbi.nlm.nih.gov/pubmed/10569443

Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehab Med 1994;26:115-119.
http://www.ncbi.nlm.nih.gov/pubmed/7801060

Hamilton BB, Deutsch A, Russell C, Fiedler RC, Granger CV. Relation of disability costs to function: spinal cord injury. Arch Phys Med Rehabil 1999;80:385-391.
http://www.ncbi.nlm.nih.gov/pubmed/10206599

Heinemann AW, Kirk P, Hastie BA Semik,P, Hamilton BB, Linacre JM, Wright BD, Granger C. Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury. Arch Phys Med Rehabil 1997;78:143-149.
http://www.ncbi.nlm.nih.gov/pubmed/9041894

Horn SD, Smout RJ, Dejong G, et al. Association of various comorbidity measures with spinal cord injury rehabilitation outcomes. Arch Phys Med Rehabil. 2013;94(4 Suppl):S75-86.
http://www.ncbi.nlm.nih.gov/pubmed/23527775

Itzkovich M, Gelernter I, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, Tonach M, Hitzig SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, El Masry WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergstrom EM, Bluvshtein V, Ronen J, Catz A. The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study. Disability and Rehabilitation, 2007; 29(24): 1926-1933.
http://www.ncbi.nlm.nih.gov/pubmed/17852230

Jackson AB, Carnel CT, Ditunno JF, et al. Outcome measures for gait and ambulation in the spinal cord injury population. J Spinal Cord Med. 2008;31(5):487-99.
http://www.ncbi.nlm.nih.gov/pubmed/19086706

Karamehmetoğlu SS, Karacan I, Elbaşi N, Demirel G, Koyuncu H, Döşoğlu M. The functional independence measure in spinal cord injured patients: comparison of questioning with observational rating. Spinal Cord. 1997;35(1):22-5.
http://www.ncbi.nlm.nih.gov/pubmed/9025215

Koca I, U­çar M, Unal A, Tutoğlu, Boyaci A, BülBül F, Karakuş V, Gür A. Anxiety and depression level and related factors in patients with spinal cord injury. Acta Medica Mediterr. 2014; 30: 291-295.
http://www.actamedicamediterranea.com/year.php?y=2014

Kozlowski AJ, Heinemann AW. Using individual growth curve models to predict recovery and activities of daily living after spinal cord injury: an SCIRehab project study. Arch Phys Med Rehabil. 2013;94(4 Suppl):S154-64.e1-4.
http://www.ncbi.nlm.nih.gov/pubmed/23527771

Kucukdeveci AA, Yavuzer G, Elhan AH, Sonel B, Tennant A. Adaptation of the Functional Independence Measure for use in Turkey. Clin Rehabil, 2001; 15:311-319.
http://www.ncbi.nlm.nih.gov/pubmed/11386402

Lawton G, Lundgren-Nilsson A, Biering-Sorensen F, Tesio L, Slade A, Penta M, Grimby G, Ring H, Tennant A. Cross-cultural validity of FIM in spinal cord injury. Spinal Cord 2006; 44: 746-752.
http://www.ncbi.nlm.nih.gov/pubmed/16389268

Lundgren-Nilsson A, Tennant A, Grimby G, Sunnerhagen KS. Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia. Health and Quality of Life Outcomes, 2006;  4:55-62
http://www.ncbi.nlm.nih.gov/pubmed/16928268

Marino RJ, Graves DE. Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil 2004;85:1804-1810.
http://www.ncbi.nlm.nih.gov/pubmed/15520975

Marino RJ, Huang M, Knight P, Herbison GJ, Ditunno JF, Segal M. Assessing selfcare status in quadriplegia: comparison of the quadriplegia index of function (QIF) and the functional independence measure (FIM). Paraplegia. 1993;31(4):225-33.
http://www.ncbi.nlm.nih.gov/pubmed/8493037

Marino RJ, Shea JA, Stineman MG. The Capabilities of Upper Extremity Instrument: Reliability and Validity of a Measure of Functional Limitation in Tetraplegia. Arch Phys Med Rehabil 1998;79:1512-21.
http://www.ncbi.nlm.nih.gov/pubmed/9862292

McCabe MA, Granger CV. Content validity of a pediatric Functional Independence Measure. Appl Nurs Res 1990;3:120-122.
http://www.ncbi.nlm.nih.gov/pubmed/2400209

McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires. Oxford University Press, New York NY, 1996.
http://journals.lww.com/ajgponline/Citation/1998/02000/Measuring_Health__A_Guide_to_Rating_Scales_and.12.aspx

Middleton JW, Harvey LA, Batty J, Cameron I, Quirk R, Winstanley J. Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury. Spinal Cord 2006; 44: 495-504.
http://www.ncbi.nlm.nih.gov/pubmed/16331309

Middleton JW, Tate RL, Geraghty TJ. Self-Efficacy and Spinal Cord Injury: Psychometric Properties of a New Scale. Rehabil Psychol 2003; 48(4):281-8
http://psycnet.apa.org/doi/10.1037/0090-5550.48.4.281

Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking Index for spinal cord injury (WISCI): criterion validation. Spinal Cord 2005;43:27-33.
http://www.ncbi.nlm.nih.gov/pubmed/15520841

Mulcahey MJ, Smith BT, Betz RR. Psychometric rigor of the Grasp and Release Test for measuring functional limitation of persons with tetraplegia: a preliminary analysis. J Spinal Cord Med 2004; 27:41-6.
http://www.ncbi.nlm.nih.gov/pubmed/15156936

Nilsson AL, Sunnerhagen KS, Grimby G. Scoring alternatives for FIM in neurological disorders applying Rasch analysis. Acta Neurologica Scandinavica, 2005; 111(4):264-273.
http://www.ncbi.nlm.nih.gov/pubmed/15740579

Oleson CV, Marino RJ. Responsiveness and concurrent validity of the revised capabilities of upper extremity-questionnaire (CUE-Q) in patients with acute tetraplegia. Spinal Cord. 2014;52(8):625-8.
http://www.ncbi.nlm.nih.gov/pubmed/24891011

Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil 1996;77:1226-1232.
http://www.ncbi.nlm.nih.gov/pubmed/8976303

Ovechkin AV, Vitaz TW, Terson de paleville DG, Mckay WB. Quality of residual neuromuscular control and functional deficits in patients with spinal cord injury. Front Neurol. 2013;4:174.
http://www.ncbi.nlm.nih.gov/pubmed/24223568

Poncumhak P, Saengsuwan J, Kamruecha W, Amatachaya S. Reliability and validity of three functional tests in ambulatory patients with spinal cord injury. Spinal Cord. 2013;51(3):214-7.
http://www.ncbi.nlm.nih.gov/pubmed/23147127

Saboe LA, Darrah JM, Pain KS, Guthrie J. Early predictors of functional independence 2 years after spinal cord injury. Arch Phys Med Rehabil. 1997;78(6):644-50.
http://www.ncbi.nlm.nih.gov/pubmed/9196473

Segal ME, Ditunno JF, Staas WE. Interinstitutional agreement of individual functional independence measure (FIM) items measured at two sites on one sample of SCI patients. Paraplegia, 1993; 31: 622-631.
http://www.ncbi.nlm.nih.gov/pubmed/8259324

Soler MD, Cruz-almeida Y, Saurí J, Widerström-noga EG. Psychometric evaluation of the Spanish version of the MPI-SCI. Spinal Cord. 2013;51(7):538-52.
http://www.ncbi.nlm.nih.gov/pubmed/23608807

Spooren AI, Janssen-Potten YJ, Post MW, Kerckhofs E, Nene A, Seelen HA. Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test. Spinal Cord 2006; 44: 772-779.
http://www.ncbi.nlm.nih.gov/pubmed/16819555

Stineman MG, Shea JA, Jette A, et al. The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories. Arch Phys Med Rehabil. 1996;77(11):1101-8.
http://www.ncbi.nlm.nih.gov/pubmed/8931518

Yavuz N, Tezyurek M, Akyuz M. A comparison of two functional tests in quadriplegia: the quadriplegia index of function and the functional independence measure. Spinal Cord 1998;36:832-837.
http://www.ncbi.nlm.nih.gov/pubmed/9881732