RehabMeasures Instrument
  1. Rehabilitation Measures Database
  2. Functional Status Examination

Functional Status Examination

Last Updated

Purpose

The Functional Status Examination was designed to evaluate change in the activities of everyday life as a function of a sudden event or illness. It compares outcomes from current functional status to pre-injury status in physical, social, and psychological domains (Staudenmayer, Diaz-Arrastia, de Oliveira, Gentilello, & Shafi, 2007).

Link to Instrument

Acronym FSE

Area of Assessment

Activities of Daily Living
Life Participation

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Brain Injury Recovery

Populations

Brain Injury

Key Descriptions

  • The full-length FSE = 10 items
  • The test is administered by way of interview.
  • If an individual with a TBI is unavailable or has a severe cognitive impairment, then a person who knows the individual well, such as a significant other, may be interviewed in place of the individual (Wise et al., 2010).
  • Severity within each area is measured along a four-category ordinal scale:
    0) No change from preinjury
    1) Difficulty in performing the activity, but still total independencefor areas
    2) Dependence on others some of the time to perform activities in that area
    3) Completely dependent on others or that the individual does not perform that activity at all
  • Ratings from each domain are summed to give an FSE total score.
  • A lower score denotes a more independent individual and a higher score denotes a more dependent individual.
  • The ratings are summed from each domain to give a score between 0-30. Individuals who have passed away before the completion of the assessment are given a score of 31 (Shukla, Devi, & Agrawal, 2011).
  • Scores across 10 functional domains:
    1) Executive functioning (cognitive competency)
    2) Social integration (behavioral competency)
    3) Personal care
    4) Ambulation
    5) Standard of living
    6) Home management
    7) Travel
    8) Financial independence
    9) Major activity involving work or school
    10) Leisure and recreation

Number of Items

10

Equipment Required

  • Questionnaire
  • Pen

Time to Administer

15-20 minutes

Interview of patient or significant other if cognition and/or communication is an issue.

Required Training

No Training

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Tammie Keller Johnson, PT, DPT, MS and the TBI EDGE task force of the neurology section of the APTA in 6/2012   Updated by Sucha Chantaprasopsuk, OTS, Binyomin Kulek, OTS, and Stephanie Su, OTS

ICF Domain

Body Structure
Body Function
Activity
Participation

Measurement Domain

Activities of Daily Living
Cognition
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group / Unable to Recommend

NR

Not Recommended

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

LS

LS

LS

LS

 

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

Yes

Yes

Not reported

Considerations

  • The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials (Dikmen et al., 2001).

  • The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to pre-injury functioning. (Nichol et al., 2011).

  • Functional Status Examination (FSE); a new measure of change in activities of everyday life as a function of an event or illness, has demonstrated reliability, validity, and sensitivity for monitoring recovery and assessing functional status in TBI, even long after the injury and in a mostly moderately injured group, particularly family burden and depression (Dikmen, et al 2001) and quality of life and psychosocial function (Temkin, et al 2003). 

  • In the literature, there is conflicting information on how the measure is scored. Some authors report that the total score for the FSE ranges between 0-30 with 31 denoting death (Skula et al, 2011). The reviewers have not been able to obtain a copy of the measure to help resolve this discrepancy. 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Brain Injury

back to Populations

Test/Retest Reliability

Traumatic Brain Injury: (Dikmen et al., 2001; n= 105; mean age= 33.15 (n=133 total but 5 were untestable and 15 expired) 

 

  • Excellent: (R=0.80) Test-retest reliability

Test Retest Reliability Based on Patient Report:

 

 

 

n

Spearman

FSE

39

0.80

SIP

34

0.68

SF-36 (MCS)

37

0.79

SF-36 (PCS)

37

0.78

GOS

40

0.69

P < 0.001

FSE, Functional Status Examination; SIP, Sickness Impact Profile; SF-36, Short Form Health Survey–36; MCS, Mental Component Summary; PCS, Physical Component Summary; GOS, Glasgow Outcome Scale.

 

 

 

Traumatic Brain Injury: (Nichol et al, 2011; Dikmen et al, 2001)

  • “the FSE has good test-retest reliability and is responsive to changes over the first 6 months following injury”

 

Traumatic Brain Injury: (Hudak et al, 2005; n=177)

  • The FSE has been demonstrated to be reliable and sensitive in monitoring recovery after TBI.
  • The Functional Status Examination (FSE) and the Glasgow Outcome Scale (GOS-E) are reliable outcome measures for TBI survivors, and FSE may offer some advantages over GOS-E due its ability to provide a more detailed description of deficits (Hudak et al, 2005).

 

Traumatic Brain Injury: (Hudak et al, 2012, n=471)

  • Excellent test-retest reliability (ρ = 0.8)

Internal Consistency

Traumatic Brain Injury: (Nichol et al, 2011; Hudak et al. 2005; Dikmen et al., 2001)

  • The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.

Criterion Validity (Predictive/Concurrent)

Traumatic Brain Injury: (Powell et al., 2007; n= 164 rehabilitation inpatients (mean age 35.4 years, 77% men, 75% white) with moderate to severe TBI were examined in relation to demographics, injury severity, neuropsychological functioning, and living situation)

  • Home management performance: 59% reported more difficulty or more assistance with home management at 1 year. 

  • Nonperformance of individual activities before injury ranged from 16% to 76%. Age (p = .001), living situation after injury (p = .002), and neuropsychological function at 1 year (p = .001) were associated with more limited home management performance after injury as compared to premorbid function.

Construct Validity

Traumatic Brain Injury: ( Dikmen et al., 2001; n= 105; mean age= 33.15, 5 were un-testable)

 

Relationship of FSE to other Measures

 

 

 

 

 

Patient

Patient

Significant Other

Significant Other

 

n

Spearman

n

Spearman

SIP

94

0.81*

85

0.80*

SF-36 (mental component summary)

44

-0.17

35

-0.27

SF-36 (physical component summary)

44

-0.68*

25

-0.64*

GOS (testable patients only)

102

-0.72*

102

-0.72*

GOS (including untestable and expired patients)

122

-0.84

122

-0.86

* p≤ 0.001

 

 

 

 

 

Traumatic Brain Injury:

  • Sensitive to the range of recovery at 6–12 months post-injury (Dikmen, Machamer, Powell, & Temkin 2003).
  • FSE and GOS-E scores correlate well with each other (r= -0.38, P = ≤ 0.001 (Dikmen et al., 2001).
  • FSE scores and GOS-E scores showed a strong correlation of 0.83 (Hudak et al., 2005).

Content Validity

Traumatic Brain Injury:

  • The FSE is a self-report measure thus, it will have biased perceptions. (Wise et al., 2010)

Face Validity

Designed to cover domains of everyday functioning as defined by the World Health Organization. Also, creators of the FSE chose items based on their experiences with outcome measures and clinical research involving individuals with traumatic brain injury. (Dikmen et al, 2001)
The FSE is shown to demonstrate face validity (Temkin, Machamer, and Dikmen 2003; n=209).

Floor/Ceiling Effects

Traumatic Brain Injury: (Dikmen et al, 2001) 

  • Excellent: Total FSE did not show any floor or ceiling effects 

 

Traumatic Brain Injury: (Shukla, 2011; Hudak, 2005; n=177)

  • Excellent: FSE scores are distributed throughout the range, indicating that ceiling and floor effects are not present.

Responsiveness

Traumatic Brain Injury: (Dikmen et al., 2001; n= 105; mean age= 33.15, 5 were untestable)

Average Change from 1 to 6 Months for FSE

 

 

 

 

 

 

 

FSE

n

Mean

SD

Mean Difference

SD of Difference

Mean Difference SD of Difference

Significance

Patient 1 month

 

25

15.58

3.7

8.0

5.7

1.40

0.001

Patient 6 months

25

7.53

3.5

 

 

 

 

Significant other 1 month

25

14.41

5.2

6.7

5.7

1.18

0.001

Significant other 6 months

25

7.74

4.8

 

 

 

 


Traumatic Brain Injury: (Nichol et al., 2011; Dikmen et al., 2001)
 

  • “The FSE has good test-retest reliability and is responsive to changes over the first 6 months following injury” 

 

Traumatic Brain Injury: (Dikmen et al., 2003; n=210; TBI patients)

  • 3 to 5 years post severe brain injury: “The results of the FSE indicate substantial functional limitations in every area of everyday life examined. Recovery to preinjury levels, as perceived by the subjects, ranges from a high of 65% of the cases in personal care to lows of 40% in cognitive competency, major activity, and leisure and recreation. Not being able to perform the activity or needing help from others partially or totally occurs in all areas, but particularly in major activity (work, school), financial independence, cognitive competency, social integration, and leisure and recreation”.

Bibliography

Bell, K. R., Temkin, N. R., et al. (2005). "The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: a randomized trial." Arch Phys Med Rehabil 86(5): 851-856. 

Dikmen, S., Machamer, J., et al. (2001). "Functional status examination: a new instrument for assessing outcome in traumatic brain injury." J Neurotrauma 18(2): 127-140. 

Dikmen, S. S., Machamer, J. E., et al. (2003). "Outcome 3 to 5 years after moderate to severe traumatic brain injury." Arch Phys Med Rehabil 84(10): 1449-1457. 

Ding, K., Marquez de la Plata, C., et al. (2008). "Cerebral atrophy after traumatic white matter injury: correlation with acute neuroimaging and outcome." J Neurotrauma 25(12): 1433-1440.  

Hudak, A. M., Caesar, R. R., et al. (2005). "Functional outcome scales in traumatic brain injury: a comparison of the Glasgow Outcome Scale (Extended) and the Functional Status Examination." J Neurotrauma 22(11): 1319-1326. 

Hudak, A. M., Hynan, L. S., Harper, C. R., & Diaz-Arrastia, R. (2012). "Association of depressive symptoms with functional outcome after traumatic brain injury." The Journal of head trauma rehabilitation, 27(2), 87. 

Kirkness, C. J., Burr, R. L., et al. (2006). "Effect of continuous display of cerebral perfusion pressure on outcomes in patients with traumatic brain injury." Am J Crit Care 15(6): 600-609; quiz 610. 

Kirkness, C. J., Burr, R. L., et al. (2004). "Is there a sex difference in the course following traumatic brain injury?" Biol Res Nurs 5(4): 299-310. 

Macdonald, R. L., Hunsche, E., Schüler, R., Wlodarczyk, J., & Mayer, S. A. (2012). "Quality of life and healthcare resource use associated with angiographic vasospasm after aneurysmal subarachnoid hemorrhage." Stroke, 43(4), 1082-1088. 

Nichol, A. D., Higgins, A. M., et al. (2011). "Measuring functional and quality of life outcomes following major head injury: common scales and checklists." Injury 42(3): 281-287. 

Powell, J. M., Temkin, N. R., et al. (2007). "Gaining insight into patients' perspectives on participation in home management activities after traumatic brain injury." Am J Occup Ther 61(3): 269-279. 

Shukla, D., Devi, B. I., et al. (2011). "Outcome measures for traumatic brain injury." Clin Neurol Neurosurg 113(6): 435-441. 

Staudenmayer, K. L., Diaz-Arrastia, R., et al. (2007). "Ethnic disparities in long-term functional outcomes after traumatic brain injury." J Trauma 63(6): 1364-1369. 

Temkin, N. R., Machamer, J. E., et al. (2003). "Correlates of functional status 3-5 years after traumatic brain injury with CT abnormalities." J Neurotrauma 20(3): 229-241. 

Warner, M. A., O'Keeffe, T., et al. (2010). "Transfusions and long-term functional outcomes in traumatic brain injury." J Neurosurg 113(3): 539-546. 

Wise, E. K., Mathews-Dalton, C., et al. (2010). "Impact of traumatic brain injury on participation in leisure activities." Arch Phys Med Rehabil 91(9): 1357-1362. 

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