17Japanese Journal of Comprehensive Rehabilitation Science (2020)

Brief Report

Evaluation of Functional Independence Measure item scores forpredicting home discharge after acute stroke rehabilitation
Keiichiro Aoki, OT, Ms,1,2 Akihiro Iguchi, PT, Ms,2,3 Takayuki Watabe, OT, PhD1,4
Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences, Showa University,Yokohama, Kanagawa, Japan2
Showa University Koto Toyosu Hospital, Koto-ku, Tokyo, Japan3
Department of Physical Therapy, School of Nursing and Rehabilitation Sciences, Showa University, Yokohama,Kanagawa, Japan4
Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Kanagawa, Japan1

ABSTRACT
Aoki K, Iguchi A, Watabe T. Evaluation of Functional
Independence Measure item scores for predicting
home discharge after acute stroke rehabilitation. Jpn J
Compr Rehabil Sci 2020; 11: 17‐20.
Objective: To determine whether certain Functional
Independence Measure (FIM) items assessed early
during acute-stage rehabilitation are predictive ofhome discharge for patients with stroke followingintervention.
Methods: Medical record data were retrospectively
compiled and analyzed for 103 patients with stroke
admitted to our hospital between December 2016 andMarch 2017. Patients were either discharged to theirown homes (n=41) or transferred to another facility(n=62) after acute-phase rehabilitation. Fisher’s exact
test was used to compare characteristics between thehome and transfer groups. Stepwise multiple logistic
regression analysis was also performed to identify
FIM items predictive of patients’ discharge destination.
Results: Significant differences between the home andtransfer groups were observed for all FIM items,
except for shower/tub transfer and stairs. Eating andsocial interaction were identified as significant
predictors of the post-rehabilitation destination in
multiple logistic regression analysis (p=0.001, odds
ratio [OR]: 10.956, 95% confidence interval [CI]:0.638‐1.755; p=0.008, OR: 4.273, CI: 0.182‐1.269,
respectively).
Correspondence: Keiichiro Aoki, OT, Master
Department of Occupational Therapy, School of Nursing
and Rehabilitation Sciences, Showa University, 1865
Tohkaichiba-machi, Midori-ku, Yokohama, Kanagawa
226-8555, Japan.
E-mail: k.a-0525@cmed.showa-u.ac.jp
Accepted: November 1, 2019.
Conflict of Interest: The authors declare no conflict ofinterest.
©Kaifukuki Rehabilitation Ward Association 2020
doi.org/10.11336/jjcrs.11.17

Conclusion: In some cases, early assessment of FIM
items, particularly eating and social interaction, after astroke can help predict a patient’s discharge destination
after rehabilitation.
Key words: acute phase, stroke, outcome
Introduction
Recent developments in stroke medicine have
reduced the length of patient stay in acute-care
hospitals; these include streamlining systems that
rapidly transport patients to a hospital after a stroke
and regional medical collaboration during the acute,recovery, and maintenance phases via a “community
medical partnership path” [1]. In tandem, efforts havebeen made to achieve shorter hospital stays forrehabilitation.
Multiple studies have claimed that certain
instruments, such as the National Institute of Health
Stroke Scale and Functional Independence Measure(FIM), which are administered when a patient firstarrives at a stroke rehabilitation center, can significantly
predict the outcome of time spent in recovery before
discharge/transfer [2‐7]. However, no studies haveexamined FIM item scores collected during the acutephase of a stroke as potential predictive factors. One
reason for this is the restriction placed on activities ofdaily living (ADLs) for patients with acute stroke
because of treatment policies, which limit the numberof FIM items that can be assessed.
However, it is the responsibility of physicaltherapists and occupational therapists involved inacute care to start rehabilitation as early as possible
after stroke onset based on a series of assessments, andto make decisions to recommend home discharge ortransfer to another medical facility for further care [8].
FIM items that could predict the potential for homedischarge at a patient’s first rehabilitation session
would serve as a helpful reference for clinical efforts.
Jpn J Compr Rehabil Sci Vol 11, 2020

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Aoki K et al.: FIM item scores can predict home discharge after acute stroke rehabilitation

This study aimed to identify specific FIM items whosescores are predictive of a stroke patient’s discharge
destination after acute-phase rehabilitation.
Methods
Ethical statement
This study received approval from the Research
Ethics Committee of our facility (July 10, 2017;
approval number 17T7015).
Patients and study design
The subjects consisted of 138 patients with stroke
who were admitted to our hospital between December
2016 and March 2017. Patients were excluded if they
met any of the following criteria:(1) rehabilitation did not start within 3 days ofstroke onset,(2) clearly insufficient data; e.g., multiple missing
values, and(3) FIM not assessed/unavailable.
Ultimately, data from the medical records of 103
patients were retrospectively analyzed.
These patients were divided into two groups
according to whether they were discharged to theirown home (home group: n=41) or transferred toanother hospital (transfer group: n=62) after acuterehabilitation.
FIM assessment
FIM assessments were performed within 7 days ofstroke onset. The variables of interest were respectivescores of each of the 18 items of the FIM: eating,grooming, bathing, upper body dressing, lower bodydressing, toileting, bladder management, bowel
management, bed/chair/wheelchair transfer, toilet
transfer, shower/tub transfer, locomotion (walk/wheelchair), stairs, comprehension, expression, socialinteraction, problem solving, and memory. Each item
was analyzed in terms of a binary, dummy variable(independent/dependent) to characterize the degree offunctional independence/dependence: dependent, ≤5points; independent: ≥6 points. These cut-offs
correspond to established FIM criteria for requiring ahelper or not (no helper: ≥6 points; helper: ≤5 points)[9].
Statistical analysis
Fisher’s exact test was used to compare
characteristics between the home and transfer groups.
Predictors of the discharge destination were identified
using stepwise multiple logistic regression analysis
while controlling for multicollinearity by examining
correlations between FIM items. The postrehabilitation destination (home versus transfer) was
the dependent variable, and FIM item scores were theindependent variables. Statistical software JMP
version 13 (SAS Institute Inc., Cary, NC, USA) was
Jpn J Compr Rehabil Sci Vol 11, 2020

used to perform all analyses. The significance level
was set at 5%.
Results
Characteristics of the stroke patients are shown inTable 1. Significant differences were found in all FIM
items, except for shower/tub transfer and stairs,
between the home and transfer groups (Table 2).
Notably, eating and social interaction were identified
as significant predictors of post-rehabilitation
destination in a multiple logistic regression analysis(p=0.001, odds ratio [OR]: 10.956, 95% confidence
interval [CI]: 0.638‐1.755; p=0.008, OR: 4.273, CI:0.182‐1.269, respectively; Table 3). The correctclassification rate was 80.6%.
Discussion
This study showed that certain FIM items, whenassessed soon after a stroke patient begins acute-stage
rehabilitation, were predictive of home discharge.
Ischemic stroke accounted for a high percentage ofthe study population (66.0%). This rate was comparable
to national estimates of acute stroke in Japan [10].
More patients were transferred to another facility
for further care than discharged to their own homes(60.1% versus 39.8%). One study exhibited the same
trend [7], although another study reported that homedischarge accounted for the majority of patients [2].
These discrepancies may be attributable to regional
differences in disease prevalence or in the number ofhospitals available.
In some cases, FIM items assessed early after astroke can significantly correlate with a patient’s next
destination after discharge from rehabilitation; scoresfor eating and social interaction were especially
Table 1. Characteristics of the stroke patients (n=103).
Age (y)Duration from stroke onset to start ofrehabilitation (d)Duration of hospital stay (d)FIMTotal score
Motor score
Cognitive score
SexMaleFemale
Type of stroke
Ischemic stroke
Hemorrhagic stroke
Subarachnoid hemorrhage

67.1±12.9
1.1±0.622.8±13.2
60.9±34.0
38.4±24.3
22.3±11.9
64 (62.1%)
39 (37.8%)
68 (66.0%)
31 (30.1%)
4 (3.8%)FIM, Functional Independence Measure.
Data are presented as mean±standard deviation or
number and percentage.

Aoki K et al.: FIM item scores can predict home discharge after acute stroke rehabilitation

Table 2. Scores for each FIM item in the home andtransfer groups.
FIM (18 items)

Home group,
n=41

Transfer group,
n=62p-Value

27
14656

<0.001*

1724260<0.001*9322600.006*

1229

359<0.001*

1625260<0.001*18
23260<0.001*

23
18755<0.001*22
19755<0.001*

14
27

260

<0.001*1427260<0.001*

635

260

0.056

1229

260

<0.001*

4
37

161

0.08

29
12

1745

<0.001*

28
13

16
46

<0.001*

34
7

2240

<0.001*

27
14

1349

<0.001*

27
14

1745

<0.001*

EatingIndependent
Dependent
Grooming
Independent
Dependent
Bathing
Independent
Dependent
Upper body dressing
Independent
Dependent
Lower body dressing
Independent
Dependent
Toileting
Independent
Dependent
Bladder management
Independent
Dependent
Bowel managementIndependent
Dependent
Bed/Chair/
Wheelchair transfer
Independent
Dependent
Toilet transfer
Independent
Dependent
Shower/Tub transfer
Independent
Dependent
Locomotion(walk/wheelchair)
Independent
Dependent
StairsIndependent
Dependent
Comprehension
Independent
Dependent
Expression
Independent
Dependent
Social Interaction
Independent
Dependent
Problem Solving
Independent
Dependent
MemoryIndependent
Dependent*: p<0.05, Fisher’s exact test.

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predictive. The model achieved a correct classification
rate of 80.6%, which is a high value comparable to theperformance of the models in other studies on acutephase stroke [4, 5].
Several factors account for the predictive power of
the FIM item eating in the model. The ability to eat
independently can be impeded by various factors,
ranging from physical ones (e.g., restrictions on joint
range of motion, dyscoordination, and chewing/swallowing disorders) to mental ones (higher-order
impairment and cognitive or volitional dysfunction)[11]. Patients who score highly on eating, by extension,
can be presumed to lack serious problems in any ofthese dimensions. Indeed, Okabayashi et al. previouslydemonstrated that the duration of fasting after a stroke
affects clinical outcomes [12]. Additionally, Okamoto
et al. stated that combined with aging, excessive
fasting in acute stroke patients can not only facilitate
disuse syndrome, but also have lasting effects onpatients’ ADL performance [13]. Patients with only
mild stroke would likely not go without food for longintervals during hospitalization, which would improvetheir hope for home discharge; this may help explain
the importance of eating in the model.
The second predictive FIM item identified wassocial interaction. Ezure et al. previously demonstrated
the need to assess cognitive ADLs in patients withstroke [14]. Similarly, Inoue found that a relatively
high score on social interaction assessed early in apatient’s hospital stay was predictive of greater
increases in the levels of several activities [15]. Thus,
stroke patients who are able to re-acquire ADL abilities
faster are more independent when admitted to hospitalfollowing the stroke episode.
A limitation of the present study is the risk of bias
inherent in the analysis of data due to the retrospective
study design. Our next task will be to prospectively
collect data for predefined variables based on theaforementioned findings.
Clinicians may have no choice but to limit ADL
assessments of patients with acute stroke to those
items that can be performed at rest; guidelines stipulate
bed rest for 1 to 3 days after a stroke because of therisk of exacerbation of the patient’s condition.
Fortunately, eating and social interaction are two FIM
items that can be easily evaluated at rest, supporting
their feasibility as clinical indicators of rehabilitationoutcomes. Our recommendations for clinicians are: 1)
to focus on a patient’s degree of independence in termsof eating and social interaction when conducting theFIM early after a stroke episode, even when they are
confined to bed rest; and 2) to support the patient’s
path to independence through interprofessional
collaboration.
Acknowledgments
We would like to express our sincere gratitude toJpn J Compr Rehabil Sci Vol 11, 2020

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Aoki K et al.: FIM item scores can predict home discharge after acute stroke rehabilitation

Table 3. Predictors of patients’ post-rehabilitation destination.

EatingSocial Interaction

B (SD)

p-Value

Odds ratio

1.196
0.726

0.001*
0.008*

10.956
4.273

95% CI
LowerUpper

0.638
0.182

1.755
1.269

*: p=0.05, logistic regression analysis.
Correct classification rate: 80.6%.
SD, standard deviation; CI, confidence interval.
the patients who were the subjects of this study and thehospital director who agreed with the purpose of thestudy and provided the information with ease.

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