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Functional Independence Measure.

General description: The Functional Independence Measure (FIM[R]) is an outcome measure of the severity of disability for an inpatient rehabilitation setting. It rates 18 activities of daily living on a 7- point scale ranging from fully dependent (1) to independent with no aids (7). The maximum total score is 126, indicating functional independence, and the lowest score 18, suggesting complete functional dependence. The items are grouped into two themes; 13 motor items (personal care, sphincter control, mobility, and locomotion), and five cognitive items (communication and social cognition).

Information about the FIM[R] is available from the Uniform Data Set for Medical Rehabilitation (UDS-MR) in the USA ( and in Australia, information and training in the use of the FIM[R] is available through the University of Wollongong at In addition to the original FIM[R], the UDS-MR have developed variations specifically for paediatric populations (WEEFIM[R]), acute settings (AlphaFIM[R]), and outpatient settings (LIFEware[SM] System).

Scoring and administration: For inpatient rehabilitation settings, assessment is designed to be performed by a multidisciplinary team over 72 hours. A patient's ability to perform everyday tasks is observed and team input across all disciplines is used to rate the FIM[R]. Each task has an operational definition and no special equipment is required.

Validity, reliability and sensitivity to change: Good construct and concurrent validity has been established. FIM[R] scores discriminate between disabilities and levels of severity of impairment (Heinemann et al 1994); correlate with the time taken for care (Disler et al 1993); and correlate highly with Barthel Index scores in people with stroke (Fricke and Unsworth 1996). High internal consistency has been reported (Cronbach's [alpha] = 0.93-0.95, Ravaud et al 1999).

Ottenbacher et al (1996) performed a meta-analysis of 11 papers investigating reliability of the FIM[R] and reported median correlations coefficients between total scores equal to 0.95 for inter-rater reliability, 0.95 for test retest reliability, and 0.92 for equivalence reliability. The minimum detectable change score of 90% has been reported to be 23 points (Stineman et al 1996).

Predictive usefulness: An admission FIM[R] score > 70 has been associated with achieving non-dependence by discharge whereas those with an admission score < 50 remained dependent (Ween et al 2000).


The FIM[R] is used widely in rehabilitation settings. However, there are some limitations to the FIM[R]. Ceiling effects have been reported (Cohen and Marino 2000) suggesting the FIM[R] may be more useful in an inpatient setting than an outpatient setting. Questions have been raised about bias in clinical judgement affecting accuracy (Wolfson et al 2000), as there was a tendency to overestimate ratings if other domains have high scores and underestimate ratings if they were low. Variations in reliability have been reported with different rater groups. People with spinal cord injury rated themselves lower than staff ratings, nurses score patients lower than physiotherapists or occupational therapists, and differences have been noted between institutions (Cohen and Marino 2000).

The main competitor to the FIM[R] has been the Barthel Index. Both measures have literature to support their use but at this stage the FIM[R] appears to have the edge, mainly because it includes communication and social cognition issues (Cohen and Marino 2000). The Australasian Rehabilitation Outcomes Centre (AROC), a joint initiative of the Australian rehabilitation sector, has chosen to use the FIM as one of its suite of measures and increasingly this is becoming the common benchmark measure in rehabilitation settings.

The mode of testing for the FIM[R] also needs to be considered. In an inpatient setting, the mode is usually by observation over a 72-hour period, however, in outpatient settings this may change to self report (either in person or over the telephone), one off observation, or reports from carers. One Concerns have been raised about the validity of using a total FIM[R] score to represent a single concept, functional independence, after FIM data have been subjected to multidimensional statistical analyses (Ravaud et al 1999). However, the high levels of internal consistency reported for the FIM suggests that the FIM[R] does represent a single concept. The debate continues unresolved.

Despite these limitations or precautions, at this stage, the FIM[R] represents the most robust global outcome measure of disability.

Shylie Mackintosh

University of South Australia


Cohen M, Marino R (2000) Arch Phys Med Rehabil 81 Suppl 2: S21-S29.

Disler P et al (1993) Arch Phys Med Rehabil 74:139-143

Fricke J, Unsworth C (1996): AOTJ 43: 22-29.

Heinermann A et al (1994) Topics in Stroke Rehabilitation 1: 1-5.

Ottenbacher K et al (1996) Arch Phys Med Rehabil 77: 1226-1232.

Ravaud J-F et al (1999) Scand J Rehab Med 31: 31-41

Smith P et al (1996) Arch Phys Med Rehabil 77: 431-435.

Stineman M et al (1996) Arch Phys Med Rehabil 77: 1101-1108.
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Title Annotation:Appraisal: Clinimetrics
Publication:Australian Journal of Physiotherapy
Geographic Code:8AUST
Date:Mar 1, 2009
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