Dr. Linda Isaac, PhD Director, Rehabilitation Research Center Santa Clara Valley Medical Center
Assistant Professor (Affiliated) Stanford University, School of Medicine Department of Orthopedic Surgery
Citation Wright, J. (2000). The
Functional Assessment Measure. The Center for Outcome
Measurement in Brain Injury. http://www.tbims.org/
combi/FAM ( accessed
This citation is for the COMBI web material. Mr. Wright is
not the scale author for the FAM.
Marosszeky (1992) investigated the relative contribution of the
FIM and FAM items within each of seven areas of function. He found
that the FAM items contributed significantly to the overall proportion
of disability in all categories and in the total score for the ratings
2 to 6. The FAM items did not contribute to extreme ratings of 1
or 7. He speculated that the FAM may become an even greater contributor
to a valid measure of disability during the follow up period, as
many of the FAM items relate to community functioning (i.e., car
transfers, employability, community mobility, adjustment to limitations).
Analyses were completed on the FAM items at rehabilitation admission
and discharge for data collected in the TBI National Database (Hall
et al., 1993). FAM items rated at rehabilitation admission correlated
significantly with indices of injury severity in a very similar
pattern as FIM items.
FAM does not appear to contribute beyond the FIM in predicting length
of inpatient stay or costs. The FAM does appear to have increased
sensitivity beyond the FIM alone for inpatient rehabilitation discharge
and post-acute rehabilitation functional assessment. There is evidence
that the FAM at rehabilitation discharge has less "ceiling effect"
than the FIM and is more strongly related to rehabilitation charges
than the FIM (TBI Model System National Database, Hall et al., 1996).
a prospective study of individuals with TBI at 6 months and 24 months
post-injury, FAM scores were predictive of return to work and community
integration (Gurka et al, 1999). Overall, the FAM did not provide
any additional information over the FIM except at 24 months where
the FAM cognitive scores slightly improved the prediction of return
Reliability: Preliminary data suggest that FAM items involving
abstract concepts such as "attention" tend to be less reliable than
directly observable behaviors (Hall, 1992). As a test of the FAM
items interrater reliability, FAM training and testing vignettes
(which also included the FIM items) were completed by trained raters,
including a PT, OT, COTA, Data Analyst and researcher. Each item's
three vignettes were written to cover low, intermediate, and high
functioning levels within the 1 to 7 scale. The percentage of rating
agreement was 89%. The Kappa score for the FIM was .87, and for
the FAM, .85, both within the "very good" Kappa range.
raters ranged in agreement with the "correct answer," from a high
of 94% to a low of 81% of composite percentages across items. Keep
in mind that these are ideal conditions, i.e., each rater is receiving
the same information and sufficient information on the patient to
do the rating, and each rater is trained and is using the definitions
of terms in the Decision Tree in making ratings. What the findings
do show is that FAM items can be rated with close to the same accuracy
as FIM items, given the conditions stated above. This is encouraging
because FAM items are generally more abstract (cognitive, psychological,
social) than FIM items.
another inter-rater reliability training endeavor, the four TBI
Model Systems were given the vignettes to train and test several
raters from different disciplines at each center. Each of the centers
passed with an overall accuracy hovering just above 80% for the
a recent study by Donaghy et al. (1998), all items of the FIM+FAM
showed excellent or good intraclass correlation coefficients (ICC),
with the exception of a FIM item, "Social Interaction" (.36). The
next poorest correlation was for the FAM item "Emotional Status"
(.62), considerably stronger than "Social Interaction." Consequently,
the addition of the nine FAM items to the cognitive/psychosocial
domain actually increased the overall reliability of this subscale
to .74 from .69 for the FIM items alone. The total average ICC values
for the 18 FIM items (.85) and for the 30 FIM+FAM items (.83) were
comparable, both falling in the excellent range.