Functional Status Examination

Acronym:

FSE

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).

Description:

• 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. A rating of 0 signifies no change from preinjury; 1 signifies difficulty in performing the activity, but still total independence; for areas, 2 signifies dependence on others some of the time to perform activities in that area; and 3 signifies that the individual is 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:
  • Executive functioning (cognitive competency)
  • Social integration (behavioral competency)
  • Personal care
  • Ambulation
  • Standard of living
  • Home management
  • Travel
  • Financial independence
  • Major activity involving work or school
  • Leisure and recreation

Area of Assessment: Activities of Daily Living, Life Participation

Body Part: Not Applicable

ICF Domain: Body Structure, Body Function, Activity, Participation

Domain: ADL, Cognition, Motor

Assessment Type: Patient Reported Outcomes

Length of Test: 06 to 30 Minutes

Time to Administer:

Administration time is approximately 15-20 minutes. Interview of patient or significant other if cognnition and/or communication is an issue.

Number of Items: 10 items

Equipment Required:

• Questionnaire
• Pen

Training Required:

No Training Required

Type of training required: No Training

Cost: Free

Actual Cost:

Free

Age Range: Adolescent: 13-17 years, Adult: 18-64 years, Elderly adult: 65+

Administration Mode: Paper/Pencil

Diagnosis: Acquired Brain Injury, Traumatic Brain Injury

Populations Tested:

Traumatic Brain Injury, Aneurysmal Subarachnoid Hemorrhage (aSAH) (Macdonald, Hunsche, Schüler, Wlodarczyk, & Mayer 2012), possible use for conditions other than the ones listed previously, occurring with a sudden or demarcated onset (Dikmen, Machamer, Miller, Doctor, & Temkin, 2001).

Standard Error of Measurement (SEM):

Not Established

Minimal Detectable Change (MDC):

Not Established

Minimally Clinically Important Difference (MCID):

Not Established

Cut-Off Scores:

Not Established

Normative Data:

Not Established

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)

Interrater/Intrarater Reliability:

Not Established

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 (Convergent/Discriminant):

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".

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.

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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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed 

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

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. Find it on PubMed

Year published: 2001

Instrument in PDF Format: No

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