11.4 Outcome Measures & Medical Complications
Key Takeaways
- FIM scores 18 items on a 7-point scale from 1 (Total Assistance, patient <25%) to 7 (Complete Independence, safe/no device).
- The Berg Balance Scale (0-56) assesses static and dynamic balance; scores <45 indicate high fall risk in elderly and stroke populations.
- Timed Up and Go (TUG) test times standing, walking 3 meters, turning, and sitting; times >12-14 seconds correlate with fall risk.
- Venous Thromboembolism (VTE) prophylaxis (LMWH or unfractionated heparin plus mechanical IPCs) is mandatory in acute SCI, TBI, and stroke rehabilitation.
Functional Rehabilitation Outcome Measures
Standardized outcome measures quantify patient impairment, functional disability, and burden of care across inpatient rehabilitation facilities (IRF).
Functional Independence Measure (FIM)
The Functional Independence Measure (FIM) has historically been the cardinal outcome tool in PM&R (now transitioned in IRF PPS to the Continuity Assessment Record and Evaluation [CARE] Item Set, though FIM scoring principles remain fundamental to board examination content).
- Structure: 18 items divided into 13 Motor items (Self-Care, Sphincter Control, Transfers, Locomotion) and 5 Cognitive items (Communication, Social Cognition).
- Scoring Scale: Each item is scored on an 8-point ordinal scale from 1 (Total Assistance) to 7 (Complete Independence). Total FIM score ranges from 18 to 126.
| FIM Level | Score Category | Operational Definition (% of Task Performed by Patient) |
|---|---|---|
| 7 | Complete Independence | Safe, timely execution without devices or modifications. |
| 6 | Modified Independence | Requires an assistive device, extra time, or safety risk considerations. |
| 5 | Supervision / Setup | Requires verbal cues, coaxing, setup of items, or orthosis application. |
| 4 | Minimal Assistance | Patient performs $\ge 75%$ of the work (helper performs $<25%$). |
| 3 | Moderate Assistance | Patient performs $50% ext{ to }74%$ of the work (helper performs $25% ext{--}50%$). |
| 2 | Maximal Assistance | Patient performs $25% ext{ to }49%$ of the work (helper performs $50% ext{--}75%$). |
| 1 | Total Assistance | Patient performs $<25%$ of the work (helper performs $>75%$). |
Barthel Index
- Consists of 10 ADL and mobility items (feeding, bathing, grooming, dressing, bowel/bladder control, toilet use, transfers, mobility, stairs).
- Total score ranges from 0 to 100 (or 0 to 20 depending on version). Higher scores indicate greater functional independence.
Balance and Gait Assessment Tools
| Assessment Tool | Items & Primary Focus | Clinical Cutoff Scores & Target Interpretation |
|---|---|---|
| Berg Balance Scale (BBS) | 14-item static and dynamic balance performance test (max score 56). | Score $<45$: High risk for falls. Score $<40$: 100% fall risk in elderly. Scores 41–56 indicate low-to-moderate fall risk. |
| Dynamic Gait Index (DGI) | 8-item dynamic gait test (gait speed change, head turns, pivot turns, stepping over obstacles, stairs; max score 24). | Score $\le 19$: Indicates high fall risk in community-dwelling elderly and patients with stroke/vestibular disorders. |
| Timed Up and Go (TUG) | Measures time to rise from chair, walk 3 meters, turn 180°, walk back, and sit down. | Time $>12 ext{--}13.5 ext{ seconds}$: Predicts high fall risk in community elderly and neurological disorders. |
| 6-Minute Walk Test (6MWT) | Submaximal aerobic endurance test measuring total distance walked in 6 minutes. | Measures functional exercise capacity. Average healthy elderly distance: 400–600 m; $<300$ m indicates poor prognosis in heart/lung/stroke populations. |
Venous Thromboembolism (VTE) Prophylaxis in Rehabilitation
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) represent major preventable causes of morbidity and mortality in acute neuro-rehabilitation populations, particularly acute Spinal Cord Injury (SCI), Stroke with hemiplegia, Traumatic Brain Injury (TBI), and major orthopedic procedures.
[VTE Prophylaxis Guidelines Summary]
│
┌───────────────┴───────────────┐
▼ ▼
[Acute Spinal Cord Injury] [Acute Ischemic Stroke]
• LMWH (Enoxaparin) • LMWH within 24-48h
preferred over UFH (after CT excludes bleed)
• Duration: Minimum • Duration: Throughout IRF
8 to 12 weeks until mobile
VTE Prophylaxis in Acute Spinal Cord Injury (SCI)
- Risk Profile: Acute SCI carries the highest risk of VTE among all rehabilitation admissions ($>50 ext{--}80%$ without prophylaxis). Risk peaks in the first 2 to 3 weeks post-injury and remains significantly elevated for 3 months due to venous stasis (paralyzed calf muscle pump), hypercoagulability, and endothelial dysfunction (Virchow's triad).
- First-Line Pharmacotherapy: Low Molecular Weight Heparin (LMWH) (e.g., Enoxaparin 30 mg SC BID or 40 mg SC daily) is strongly preferred over Unfractionated Heparin (UFH) (5000 units SC TID). LMWH demonstrates superior efficacy in reducing DVT/PE rates, lower risk of major bleeding complications, and lower incidence of Heparin-Induced Thrombocytopenia (HIT).
- Renal Impairment Modification: In severe renal failure (Creatinine Clearance $<30 ext{ mL/min}$), UFH is preferred due to hepatic elimination, or LMWH dosage must be adjusted (e.g., Enoxaparin 30 mg SC once daily with anti-Xa monitoring).
- Recommended Prophylaxis Duration: Pharmacological VTE prophylaxis must be continued for a minimum of 8 to 12 weeks post-injury for acute motor-incomplete or complete SCI.
VTE Prophylaxis in Acute Stroke
- Ischemic Stroke: Initiate low-dose LMWH or UFH within 24 to 48 hours of stroke onset, following neuroimaging confirming the absence of hemorrhagic transformation.
- Hemorrhagic Stroke: Defer pharmacological prophylaxis until intra-cranial hemorrhage stability is verified on repeat CT (typically 24–48 hours post-bleed); use Mechanical Prophylaxis immediately.
- Duration: Prophylaxis is continued throughout the acute inpatient rehabilitation stay until the patient regains independent functional ambulation.
Mechanical Prophylaxis (Sequential Compression Devices - SCDs / IPC)
- Intermittent Pneumatic Compression (IPC) devices are indicated as adjuncts to pharmacological prophylaxis, or as monotherapy ONLY when pharmacological anticoagulation is strictly contraindicated due to acute active bleeding, major coagulopathy, or acute spinal/intracranial hemorrhage.
A 74-year-old male recovering from a subacute ischemic stroke is undergoing functional mobility evaluation in inpatient rehabilitation. The physical therapist administers the Berg Balance Scale (BBS), and the patient scores 38 out of a maximum 56 points. How should the rehabilitation team interpret this specific test result?
A 24-year-old male sustains a complete T4 motor spinal cord injury (ASIA A) following a motor vehicle collision. Acute surgical stabilization was performed 4 days ago without hemorrhagic complications. Which of the following represents the consensus clinical guideline recommendation regarding anticoagulant choice and duration for venous thromboembolism (VTE) prophylaxis?
An occupational therapist evaluates a traumatic brain injury patient performing lower body dressing. The patient selects and gathers his clothing, puts on his socks independently, and pulls up his pants with assistance, performing 60% of the effort required for the total task while the therapist provides 40% of the physical assistance. Which Functional Independence Measure (FIM) level should be assigned for lower body dressing?