Functional measures after traumatic brain injury: Ceiling effects of FIM, FIM+FAM, DRS, and CIQ

Objective: The characteristics of the Disability Rating Scale (DRS), Functional Independence Measure (RM), Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and Community Integration Questionnaire (CIQ) are examined, especially in regard to a ''ceiling effect'' after rehabilitation discharge (ie, how well each of the instruments detects meaningful change in level of function). Design: Data were collected prospectively at admission and discharge from acute inpatient rehabilitation and at pears 1 and 2 after injury (the CIQ was collected only at years 1 and 2). Analyses are reported on a subsample of cases with listwise deletion, although the analyses were also done using all data available, and results compared to ensure stability of findings between samples. Setting: National database of the four Traumatic Brain Injury (TBI) Model Systems in San Jose, Calif; Detroit, Mich; Richmond, Va; and Houston, Tex. Patients: All consenting patients with TBI age 16 and older admitted to a Model System within 24 hours of injury and receiving inpatient rehabilitation within the Model System qualified for the study. Data on 612 individuals were collected, with a minimum of 80 cases having complete data over time. Main Outcome Measures: The DRS, FIM. FIM+FAM, and CIQ. Results: There is a substantial ceiling effect of the FIM, even by inpatient rehabilitation discharge (ie, one half of the cases have an average score of 6 to 7 [''independent or modified independence-no helper''] across the 18 FIM items). The FIM+FAM shows a ceiling effect in one third of the cases. The DRS shows less ceiling effect at discharge, 1 fear, and 2 years than the FIM or the FIM+FAM. CIQ scores have a ceiling effect on home and social integration subscales when compared with scores from a sample of individuals without disabilities. The productivity subscale remains well below the norm. Conclusions: Ceiling effects for the FIM, FIM+FAM, and two of the three CIQ subscales indicate that these measures are not as sensitive to changes, especially in the community, as may be needed to assess progress in areas most commonly causing dysfunction for the TBI population. More emphasis must be placed on improved measurement of relevant goals in the postacute and home settings with brief and precise scales.