Functional Tests

1. Functional Tests Nancy V. Karp, Ed.D., P.T. nvkarp@gmail.com

2. 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?

3. 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?

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

6. 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.

7. 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.

8. 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.

9. 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

10. Functional Limitations Functional limitations occur at the person’s 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 life’s 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.

11. 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.

12. 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

13. Remember This?

14. 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

15. “Community-Dwelling” vs. “Institutional-Dwelling” Elders General Trends • Functional limitations are different • Community dwellers are more limited in IADL’s • Institutional dwellers are more limited in ADL’s • There is a hierarchy to disabilities • Walking • Bathing • Dressing • Toileting • Feeding Lower-extremity functional limitations are early markers of disability.

16. “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 don’t normally do housework. • Women don’t normally shovel snow. • Functional tests are not appropriate for all populations. IADL is not appropriate for institutional dwellers.

17. Functional Tests • Functional tests help to identify functional limitations. • Functional tests help to define the severity of an impairment in a patient’s life.

18. 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.

19. 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.

20. Types of Functional Tests • Mobility Tests • Examines the patient’s ability to walk, roll wheelchair, transfer, etc. • Examples • Rivermead Mobility Index • http://www.cebp.nl/media/m182.pdf • “Get Up And Go” Test

21. Types of Functional Tests • Activities of Daily Living (ADL) tests • Examines feeding, hygiene, and self-care • Examples • Barthel Index (O’Sullivan p. 316) • Katz Index of ADL (O’Sullivan)

22. 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 (O’Sullivan p.324) • IADL http://www.acsu.buffalo.edu/~drstall/iadl.html From Merck Manual http://www.merck.com/mrkshared/mm_geriatrics/tables/4t4.jsp

23. Types of Functional Tests • Work or Employment Tests • Measures competence in employment • Example Pack Test for firefighters

24. Pack Test

25. Types of Functional Tests • Recreation Tests Functional assessment of recreational activities

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

27. 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?

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

29. 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.

31. 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.

32. 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?

33. 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

34. Psychometric Properties Reliability is the consistency or reproducibility of test measurements. It is the degree of agreement of the measurements with each other after repeated tests. What is test reliability?

35. Reliability The consistency of items that measure the same general characteristic. Internal consistency The consistency of measurements obtained by different people. Inter-rater reliability

36. 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

37. Psychometric Properties What is Validity? The degree to which a measure represents what it intends to measure.

38. 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

39. 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

40. 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

41. 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.

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

43. 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 O’Sullivan, p. 320.

44. 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.

45. 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.

46. Omnibus Budget Reconciliation Act (OBRA) 1987, 1990 • Resident’s 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 comprehensiveplan 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.

47. 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.

48. 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.

49. 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.

50. 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 .