Functional Tests

Nancy V. Karp, Ed.D., P.T.nvkarp@gmail.com

Functional Tests

What are functional tests?How are they performed?How are they interpreted?How do you know a test is measuring what it is supposed of measure?What tests are used with a geriatric patient?

Functional Tests

What does a functional test mean to you?

You drive home after a party. An officer pulls you over to the side of the road and makes you walk a straight line. Is this a functional test?

WHO Definition

The World Health Organization defines health as a state of complete well-being in:

Physical status Psychological status Social status

Pathology/Pathophysiolgy

Refers to an ongoing state that is characterized by: A cluster of signs & symptoms Recognition by the patient/client as

abnormal

Primarily identified at the cellular level and is usually the physician's medical diagnosis.

Impairments

The consequence of disease, pathological conditions, and/or lesions.Impairments are alterations in anatomical, physiological, and psychological structures which: result in changes in the normal state. contribute to illness.

An impairment may predict the risk for a functional limitation or disability.

Impairments

Typically, impairments are measured by non-invasive procedures.Impairments occur at the tissue, organ, or system level. These levels may be: Cardiopulmonary Integumentary Musculoskeletal Neuromuscular

Impairments are identified by signs & symptoms.

Functional Limitations

Functional limitations occur when impairments result in a restriction in the ability to perform a physical action or task that is a usual activity for an individual.Functional limitations are not restricted to physical activities. Mental behaviors may result in functional limitations. confusion impaired judgment

Functional Limitations

Functional limitations occur at the person’s level, not the disease level.ExampleI have have a 100 degrees of shoulder flexion. I can do

everything I need to do, in order to function in my life’s

roles. I have no functional limitations.

A tennis star with the same shoulder limitation would have

difficulty playing tennis. This would limit his/her role in the

profession. The tennis star has a functional limitation.

Disability

A disability is the inability to perform the tasks and activities that are expected of the individual in his/her social environment.The diagnosis of a disability requires professional judgment.

Approaches to Clinical Diagnosis

Decision TreeAll contingencies must be examined.

Complete history and physical examination. Time-consuming Un-interpretable list of abnormal findings

Pattern Recognition Recognize a previously-learned pattern or picture. Can be reflexive- narrow set of premature

conclusions

Hypothetical-Deductive Strategy Short list of potential diagnoses

Remember This?

General Trends of Functional Limitations in

the ElderlyThe ability to function independently declines with age. This decline is a result of : Biological factors Psychological factors Social factors

Function is not a static phenomenon

“Community-Dwelling” vs. “Institutional-Dwelling”

EldersGeneral Trends

Functional limitations are different Community dwellers are more limited in IADL’s Institutional dwellers are more limited in ADL’s

There is a hierarchy to disabilities Walking Bathing Dressing Toileting Feeding

Lower-extremity functional limitations are early markers of disability.

“Community-Dwelling” vs. “Institutional-Dwelling”

EldersGeneral trends

Community dwellers show gender differences in functional limitations.

Women have greater numbers and severity of functional limitations.

Longer life spans Functional tests can have gender bias.

Men don’t normally do housework. Women don’t normally shovel snow.

Functional tests are not appropriate for all populations.IADL is not appropriate for institutional dwellers.

Functional Tests

Functional tests help to identify functional limitations.Functional tests help to define the severity of an impairment in a patient’s life.

Functional Tests

Functional tests are used to assess more than physical impairment. Other areas that may be assessed include: Cognition - ability to follow directions Judgment Motor planning, etc.

The “Six Minute Walk Test” is an example of a functional test.

Uses of Functional Tests

The use of functional tests may serve different purposes: May serve as a screening tool to identify

the need for more extensive testing. May be used to identify functional

limitations. May be used to help determine PT goals. May be used to measure the success or

failure of an intervention.

Types of Functional Tests

Mobility Tests Examines the patient’s ability to walk,

roll wheelchair, transfer, etc. Examples

Rivermead Mobility Index http://www.cebp.nl/media/m182.pdf “Get Up And Go” Test

Types of Functional Tests

Activities of Daily Living (ADL) tests Examines feeding, hygiene, and self-

care Examples

Barthel Index (O’Sullivan p. 316) Katz Index of ADL (O’Sullivan)

Types of Functional Tests

Instrumental Activities of Daily Living (IADL) Examines many areas of independent living, such

as cooking, washing, shopping, transportation, etc. Examples

Part of the OASIS (O’Sullivan p.324) IADL

http://www.acsu.buffalo.edu/~drstall/iadl.html

From Merck Manualhttp://www.merck.com/mrkshared/mm_geriatrics/tables/4t4.jsp

Types of Functional Tests

Work or Employment Tests Measures competence in employment Example

Pack Test for firefighters

Pack Test

Types of Functional Tests

Recreation TestsFunctional assessment of recreational activities

Types of Instruments

Performance Instruments Therapist observes the

patient performing an activity.

May be used to assess a patient’s current level of performance.

May be used to identify the maximal level of performance.

Types of Instruments

Self- Assessment Instruments The patient assesses his/her own

abilities. Therapist may interview the patient to

obtain the responses. The patient may fill out the

instrument. The clarity of the instrument is

important. Are you asking the patient what

he/she normally does?What time frame, i.e., within the last 24 hours, last week, last month etc.?

Are you asking the patient if he/she could he/she perform a task if he/she had to?

Response Formats

The simplest format is a checklist. Only as good as the items listed. The list may not include the individual’s

limitations.

Ordinal or Rank-Order Scales Scales grades in ascending or

descending order. The intervals of the scale may not be

equal.

Response Formats

Visual Analog Scales Intervals on a scale are represented

in a form of a line. The points along the line represent

different degrees of a descriptor. The patient marks on the scale the

point at which they feel they are. The “Pain Instrument” often has this

format.

Video Recordings

Used as a method of assessing or validating the effectiveness of an intervention.May also be used for training. The patient can see his/her

performance. Can be used to train staff in

observational techniques or scoring.

Selecting the Appropriate Test

Assess the instrument. For what was it designed?

To determine baseline description (gait analysis)? Screening (MME)? Identification of impairment (ROM measurements)? Setting therapeutic goals (MDS)? Monitoring clinical course (Berg Balance Test)?

Is the test multi-dimensional or focused on a single domain?

How is the test administered?

Selecting the Appropriate Test

The test should: Be easy to use. Be easy to obtain. Provide meaningful results. Be appropriate for the patient. Take a reasonable amount of time to

administer. Use equipment that is readily available

Psychometric Properties

Reliability is the consistency or reproducibility of test measurements. It is the degree of agreement of the measurements with each other after repeated tests.

What is test reliability?

Reliability

Internal consistencyThe consistency of items that measure the same general characteristic.

Inter-rater reliability The consistency of measurements obtained by different people.

Reliability

Intra-rater reliability

The agreement of the tester with himself or herself when administering the same test at different times.

Test-retest reliability

The consistency of the measurement when the same test is repeated at different times.

Psychometric Properties

What is Validity ?The degree to which a measure represents what it intends to measure.

Validity

Face Validity

The degree to which the measurement seems to represent what it is supposed to measure.

Content Validity

The degree to which the measure covers the meaningful elements of the construct being measured.

Validity

Construct Validity

The degree to which a measurement represents the underlying theoretical construct.

Criterion-related Validity

Comparison with the “gold standard” for measuring the same construct.

Validity

Concurrent Validity

Comparison with the “gold standard” measurement obtained at approximately the same time.

Predictive ValidityComparison with the “gold standard” measurement obtained at a later point in time.

Psychometric Properties

SensitivityHow well a test identifies people who truly have the condition measured by the test.SpecificityHow well the test identifies people who do NOT have the condition being measured.

Functional Tests

Katz Index of Activities of Daily Living Originally developed for institutionalized

patients. Records direct observation of patient’s

performance or patient’s self report. Looks at bathing, dressing toileting,

transferring, continence, and feeding over a 2 week period.

Katz Index of Activities of Daily Living

Scores patient as independent or dependent.

Another version of the test allows the patient to use an assistive device.Center for Evidence Based Physiotherapy

Scoring is defined according to the amount of assist for different ADL activities.See the test in O’Sullivan, p. 320.

OARS Multidimensional Function Assessment Questionnaire

“Older American Resources and Services Program” was developed at Duke UniversityAssesses functional activities and resources that the patient can use.Must have training to use the instrument.

You can purchase both the test and the training from Duke University.

Omnibus Budget Reconciliation Act (OBRA) 1987

To understand the next test, we need to look at the history of the test.OBRA was a result of recommendations of a government advisory panel examining nursing home care. The panel concluded that most nursing homes at the time were simply patient “warehouses.”The OBRA 1987 legislation made sweeping changes. Nursing Home Reform Act enforced OBRA OBRA 1990 strengthened the original act.

Omnibus Budget Reconciliation Act (OBRA) 1987, 1990

Resident’s Bill of RightsThe patient has a right to his or her own body.

Focus on “life quality.”The patient is called a resident because the NH is his or her home.

Role of the staffThe multidisciplinary staff must formulate a comprehensive plan to help the resident have a quality of life that enables reaching his/her highest potential.

The resident may participate in the comprehensive plan called a “Care Plan.”

The Care Plan must offer a CHOICE of activities,schedules, and health care decisions.

Omnibus Budget Reconciliation Act (OBRA)

Requires an LPN 24 hours/7 days a week.Requires an RN on duty 8 hours/7 days a week.States must monitor and enforce state licensing and federal standards for NH.Nursing assistants must have training and be certified.Established ombudsman units to protect the patients rights.

What is an Ombudsman?

An ombudsman is an advocate for residents of nursing homes, personal care homes, and assisted living facilities.An ombudsman provides information about how to find a facility and what to do to get quality care.An ombudsman addresses complaints and advocates for improvements.The state certifies and trains ombudsmen.

Minimum Data Set version 2.0 (MDS)

Developed as a result of the Omnibus Budget Reconciliation Act of 1987Used to monitor the care of Medicare and Medicaid residents in nursing homesThe MDS is one part of the Resident Assessment Instrument.As a result of the Balanced Budget Act, the MDS is used to help determine the residents RUG III level.

Resident Assessment Instrument (RAI)

The purpose of the instrument is to provide individual care to the resident so he/she can reach the highest potential possible.

The use of the RAI is a continual process that provides caregivers with a systematic approach to assessing and making decisions about the resident's care .

Resident Assessment Instrument

Care plans are developed for a resident every three months, unless conditions call for changes earlier. The goals for a care plan are developed by a multidisciplinary team which includes the resident.Members of the multidisciplinary team may include anyone who comes into contact with the patient.

Resident, resident’s family, nurses, OT, PT, SLP, RT, RD activity therapist, restorative staff, dietary staff, housekeepers, maintenance people, administrators, social workers, physicians

Do you know how a housekeeper or maintenance person is involved in care plans?

Resident Assessment Instrument

MDSAssesses the patient in the areas of cognition, communications, vision, physical functioning, and activity programs. Identifies patient’s strengths, weakness, and preferences.

RAPs (Resident Assessment Protocols)

Identifies problem

Care plan

triggers

guidelines

Resident Assessment Instrument

Consists of three parts MDS RAP’s Guidelines

Let’s look at an example. We will look at how the three parts work together.

MDS

We will look at a resident who wanders the halls.

MDS

00

The fall protocol has been triggered

11. RESIDENT ASSESSMENT PROTOCOL: FALLS

GUIDELINES

To reach a decision on a care plan, begin by reviewing whether or not one or more of the major risk factors listed on the RAP KEY are present. Clarifying information on the nature of the risk or type of issue to be considered for the RAP KEY items follows.

Multiple Falls: Is There a Previous History of Falls, or was the Fall an Isolated Event?

Refer to the MDS, reports of the family, and incident reports.

Internal Risk Factors

Review to determine whether or not the items listed on the RAP KEY under the following headings are present. Each of these represents an underlying health problem or condition that can cause falls and may be addressed so as to prevent future falls.

• Cardiovascular

• Neuromuscular/Functional

• Orthopedic

• Perceptual

• Psychiatric or Cognitive

11. RESIDENT ASSESSMENT PROTOCOL: FALLS

For Residents at Risk of Future Falls, Review Environmental/Situational Factors to Determine Whether or Not Modifications are Needed.

•Observe resident’s usual pattern of interaction with his/her environment the way he/she gets out of bed, walks, turns, gets in and out of chairs, uses the bathroom. Observations may reveal environmental solutions to prevent falls.

•Observe him/her get out of bed, walking 20 feet, turn in a 360o circle, standing up from a chair without pushing off with his/her arms (fold arms in front), and using the bathroom.

Revised--December 2002 Page C-61

What are 3-month goals for this patient?

What goals would you suggest for this resident?Who should make the goals?How do we you know the goals are being met?How will the goals be measured?What interventions will help reach the goal?

Functional Independence Measure

(FIM)

The FIM is an 18 item measure of physical, psychological, and social function. The FIM measures the level of assistance an individual needs for functional status. Total independence to total dependence

See O’Sullivan page 321FIM is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

Collects data from participating rehabilitation facilities and issues summary reports.

Functional Independence Measure

The FIM that we have looked at is designed for the adult patient in a rehab facility.WeeFIM is available for pediatrics.

Each item on the test has a decision tree to help choose the appropriate response.Users of the test must take a training course.

The Outcome and Assessment

Information Set (OASIS)

This is a “discipline-neutral” instrument administered by any health professional.Used for adult patients in home health.An OASIS is being developed to measure outcomes related to home health. See your reading assignment for the OASIS.The OASIS is used for “start-of-care” and for re-certification of the patient who receives home health services through Medicare.

The Outcome and Assessment Information Set

The data from the OASIS is used to help define the reimbursement level of the Prospective Payment System (PPS) for home health. The instrument is meant to describe the patient’s status and identify the patient’s needs for further care.Each item may have a different set of responses. Familiarity with the form is essential

What are Functional Tests?

We have looked at functional status and the identification of functional limitations.We have looked at the different formats that test can have.We have discussed how you determine the validity, reliability, and sensitivity of tests.We have looked at tests designed for different uses in the geriatric population.

Functional Tests

The End