Functional Tests

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Functional Tests

• Nancy V. Karp, Ed.D., P.T.
• nvkarp_at_gmail.com

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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?

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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?

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WHO Definition

• The World Health Organization defines health as
  a state of complete well-being in
• Physical status
• Psychological status
• Social status

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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.

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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.

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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.

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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

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Functional Limitations

• Functional limitations occur at the persons
  level, not the disease level.
• Example
• I have have a 100 degrees of shoulder flexion. I
  can do
• everything I need to do, in order to function in
  my lifes
• 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.

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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.

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Approaches to Clinical Diagnosis

• Decision Tree
• All 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

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Remember This?
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General Trends of Functional Limitations in the
Elderly

• The 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

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Community-Dwelling vs. Institutional-Dwelling
Elders

• General Trends
• Functional limitations are different
• Community dwellers are more limited in IADLs
• Institutional dwellers are more limited in ADLs
• There is a hierarchy to disabilities
• Walking
• Bathing
• Dressing
• Toileting
• Feeding

Lower-extremity functional limitations are early
markers of disability.
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Community-Dwelling vs. Institutional-Dwelling
Elders

• General 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 dont normally do housework.
• Women dont normally shovel snow.
• Functional tests are not appropriate for all
  populations.
• IADL is not appropriate for institutional
  dwellers.

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Functional Tests

• Functional tests help to identify functional
  limitations.
• Functional tests help to define the severity of
  an impairment in a patients life.

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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.

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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.

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Types of Functional Tests

• Mobility Tests
• Examines the patients ability to walk, roll
  wheelchair, transfer, etc.
• Examples
• Rivermead Mobility Index
• http//www.cebp.nl/media/m182.pdf
• Get Up And Go Test

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Types of Functional Tests

• Activities of Daily Living (ADL) tests
• Examines feeding, hygiene, and self-care
• Examples
• Barthel Index (OSullivan p. 316)
• Katz Index of ADL (OSullivan)

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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 (OSullivan p.324)
• IADL
• http//www.acsu.buffalo.edu/drstall/iadl.html
• From Merck Manual
• http//www.merck.com/mrkshared/mm_geriatrics/table
  s/4t4.jsp

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Types of Functional Tests

• Work or Employment Tests
• Measures competence in employment
• Example
• Pack Test for firefighters

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Pack Test
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Types of Functional Tests

• Recreation Tests
• Functional assessment of recreational
  activities

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Types of Instruments

• Performance Instruments
• Therapist observes the patient performing an
  activity.
• May be used to assess a patients current level
  of performance.
• May be used to identify the maximal level of
  performance.

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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?

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Response Formats

• The simplest format is a checklist.
• Only as good as the items listed.
• The list may not include the individuals
  limitations.
• Ordinal or Rank-Order Scales
• Scales grades in ascending or descending order.
• The intervals of the scale may not be equal.

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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.

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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.

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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?

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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

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Psychometric Properties
What is test reliability?

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

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Reliability
The consistency of items that measure the same
general characteristic.
Internal consistency
The consistency of measurements obtained by
different people.
Inter-rater reliability
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Reliability
The agreement of the tester with himself or
herself when administering the same test at
different times.
Intra-rater reliability
The consistency of the measurement when the same
test is repeated at different times.
Test-retest reliability
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Psychometric Properties
What is Validity ?
The degree to which a measure represents what it
intends to measure.
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Validity
The degree to which the measurement seems to
represent what it is supposed to measure.
Face Validity
The degree to which the measure covers the
meaningful elements of the construct being
measured.
Content Validity
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Validity
The degree to which a measurement represents the
underlying theoretical construct.
Construct Validity
Comparison with the gold standard for measuring
the same construct.
Criterion-related Validity
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Validity
Comparison with the gold standard measurement
obtained at approximately the same time.
Concurrent Validity
Comparison with the gold standard measurement
obtained at a later point in time.
Predictive Validity
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Psychometric Properties

• Sensitivity
• How well a test identifies people who truly have
  the condition measured by the test.
• Specificity
• How well the test identifies people who do NOT
  have the condition being measured.

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Functional Tests

• Katz Index of Activities of Daily Living
• Originally developed for institutionalized
  patients.
• Records direct observation of patients
  performance or patients self report.
• Looks at bathing, dressing toileting,
  transferring, continence, and feeding over a 2
  week period.

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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 OSullivan, p. 320.

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OARS Multidimensional Function Assessment
Questionnaire

• Older American Resources and Services Program
  was developed at Duke University
• Assesses 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.

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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.

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Omnibus Budget Reconciliation Act (OBRA) 1987,
1990

• Residents Bill of Rights
• The 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 staff
• The 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.

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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.

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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.

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Minimum Data Set version 2.0 (MDS)

• Developed as a result of the Omnibus Budget
  Reconciliation Act of 1987
• Used to monitor the care of Medicare and Medicaid
  residents in nursing homes
• The 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.

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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 .
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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, residents 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?

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Resident Assessment Instrument
MDS Assesses the patient in the areas of
cognition, communications, vision, physical
functioning, and activity programs. Identifies
patients strengths, weakness, and preferences.
triggers
RAPs (Resident Assessment Protocols) Identifies
problem
guidelines
Care plan
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Resident Assessment Instrument

• Consists of three parts
• MDS
• RAPs
• Guidelines
• Lets look at an example. We will look at how
  the three parts work together.

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MDS

• We will look at a resident who wanders the halls.
• MDS

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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
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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 residents 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

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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?

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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 OSullivan page 321
• FIM 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.

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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.

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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.

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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 patients
  status and identify the patients needs for
  further care.
• Each item may have a different set of responses.
  Familiarity with the form is essential

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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.

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Functional Tests

• The End