Functional Independence Measure (FIM) Is an 18-item, 7-level ordinal scale Is designed to assess areas of dysfunction in activities that commonly occur The scale has few cognitive, behavioral, and communication-related functional items Is not specific for spinal cord injuries but is designed to assess neurological, musculoskeletal, and other disorders.

1. Outcome Rating Scales in
Various Neurosurgical Ailments
Dr. Mandeep Singh Kataria

2. Why Outcome Scales?
• Objective measure of outcome
• Targeted outcome improvement
• Shared decision making
• Practice based learning
• Effective resource utilization

3. Performance scales
• Performance Status - a means of measuring the levels of ability and
disability experienced by patients after treatment rather than merely
the effects of drugs on tumours
• Karnofsky Scale
• Developed in 1940’s
• Nitrogen Mustard
• Lung Cancer
• Zubrod Scale (WHO/ECOG Scale)
• Published in 1982
• Simpler
Timmermann C. “Just give me the best quality of life questionnaire”: the Karnofsky scale and the history of quality of life
measurements in cancer trials. Chronic Illness. 2013;9(3):179-190.
Zubrod C, et al. Appraisal of methods for the study of chemotherapy in man: Comparative therapeutic trial of nitrogen
mustard and thiophosphoramide. Journal of Chronic Diseases; 1960:11:7-33

5. Scales In Head Injury
• Glasgow Outcome scale
• Commonly used before other scales were developed.
• Has been superceded by the Disability Rating Scale.
• GOS-E – Extended GOS
• Last three categories are subdivided into upper and lower disabilities
• More sensitive to change in mild to moderate TBI
Assessment of outcome after severe brain damage. A practical scale. Lancet, i, 480-484
B Jennett, M Bond – 1975
Santa Clara Valley Medical Center (2006). The Center for Outcome Measurement in Brain
Injury. http://www.tbims.org/combi

7. Ranchos Los Amigos Scale
• Rancho Los Amigos National Rehabilitation Center
• Cognitive progress of individuals after a closed head injury
• Levels of awareness
• Cognition
• Behavior
• Interaction with the environment
• Linear scale – patients may skip stages

9. Outcome Scales for Cerebrovascular Events
• Several scales – different aspects of functional outcome
• Barthel Index – Activities of daily living
• Original BI
• Unable to perform task
• Needs assistance
• Fully independent
• Modified BI -
• Code 1 – Unable to perform
• Code 2 – Attempts task but unsafe
• Codes 3 and 4 – Moderate and Minimal help required
• Code 5 – Fully independent
Mahoney FI, Barthel D. “Functional evaluation: the Barthel Index.” Maryland State Medical Journal 1965;14:56-61

11. Modified Rankin Scale
• Assess levels of independence
• Includes a comparison to previous activity levels
• Fairly good inter-observer consistency
• Not sensitive to subtle neurologic deficits

12. Modified Rankin Scale
The original Rankin scale :
• Did not have Grade 0
• Grade 1 did not include the words
“despite symptoms” and “and activities”
• Grade 2 as “unable to carry out some of
previous activities…”
Rankin J. Cerebral Vascular Accidents in Patients Over the Age of 60. 2. Prognosis. Scott Med J. 1957; 2:200–215

13. Spinal Cord Injury Outcome Assessment
• Functional Independence Measure (FIM)
• Is an 18-item, 7-level ordinal scale
• Is designed to assess areas of dysfunction in activities that commonly occur
• The scale has few cognitive, behavioral, and communication-related functional items
• Is not specific for spinal cord injuries but is designed to assess neurological,
musculoskeletal, and other disorders
• Functional Assessment Measure (FAM)
• Specifically addresses functional areas that are relatively less emphasized in FIM,
including cognitive, behavioral, communication, and community functioning
measures
• The scale has few cognitive, behavioral, and communication-related functional items
• Is not specific for spinal cord injuries but is designed to assess neurological,
musculoskeletal, and other disorders

15. Linacre JM, Heinemann AW, Wright BD, Granger CV, Hamilton BB. The structure and stability of the Functional Independence
Measure. Arch Phys Med Rehabil. 1994; 75:127–132

16. • FIM has the greatest number of publications among all instruments
used for the assessment of disability in the SCI population
• The reliability, internal consistency, and construct validity of FIM have
been inconsistently found to be adequate
• A negative ceiling effect
Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of Disability in Patients with Acute Traumatic Spinal Cord Injury: A
Systematic Review of the Literature. Journal of Neurotrauma. 2011;28(8):1413-1430. doi:10.1089/neu.2009.1148.

17. American Spinal Injury Association (ASIA)
International Standards for Neurological
Classification
• Analyzes the effect that the injury has on both motor and sensory
systems
• Is based on the extent of injury and muscle strength
• Uses an alphabetical score from A (the most severe) to E (the least
severe)
• Insensitive to small but significant changes in motor and sensory
functions
• May not be sensitive enough to detect even several spinal levels of
regeneration in thoracic injuries
• Does not assess pain, bowel, bladder, or sexual function

19. • Ten muscle groups represent the motor innervation by the cervical
and lumbosacral spinal cord
• The anal sphincter is innervated by the S4-5 cord and represents the
end of the spinal cord
• Level of injury
• Neurologists define the level of injury as the first spinal segmental level that
shows abnormal neurological loss
• Rehabilitation doctors tend to define level of injury as the lowest spinal
segmental level that is normal
• Orthopedic surgeons tend to refer to the bony level of injury as the level of
injury.

20. • Spinal Cord Independence Measure
(SCIM)
• Is specifically designed to assess spinal
cord injuries and to be sensitive to
changes
• Analyzes self-care, respiration, and
sphincter management and mobility
• Is more sensitive than FIM for spinal
cord injuries
SCIM-spinal cord independence measure: a new disability scale
for patients with spinal cord lesions. Catz et al. Spinal Cord
1998; 35: 850-56.[Spinal Cord. 1998]
Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of
Disability in Patients with Acute Traumatic Spinal Cord Injury: A
Systematic Review of the Literature. Journal of Neurotrauma.
2011;28(8):1413-1430. doi:10.1089/neu.2009.1148.

21. Modified Barthel Index
• The MBI is 10-item ordinal scale (range: 0 to 100) with ratings for
• Feeding
• Moving from wheelchair to bed and return
• Grooming
• Transferring to and from a toilet
• Bathing
• Walking on a level surface, going up and down stairs
• Dressing
• Continence of the bowels and bladder
Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index.Granger CV, Albrecht GL, Hamilton BB
Arch Phys Med Rehabil. 1979 Apr; 60(4):145-54.

23. The mJOA SCALE
• This 18-point investigator-administered scale separately addresses
• Motor dysfunction of the upper extremity (MDUE)
• Motor dysfunction of the lower extremity (MDLE)
• Sensory of the upper extremity
• Sphincter dysfunction (SD)
• An investigator-administered tool used to evaluate functional status
in patients with CSM
• Although strongly correlated with the original JOA score – no
interchangeable
Kato S, Oshima Y, Oka H, et al. Comparison of the Japanese Orthopaedic Association (JOA) Score and Modified JOA (mJOA) Score for the
Assessment of Cervical Myelopathy: A Multicenter Observational Study. Fehlings M, ed. PLoS ONE. 2015;10(4):e0123022.
doi:10.1371/journal.pone.0123022.

25. Thank You