Functional Assessment in Physiotherapy

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Functional assessment in physiotherapyA literature review

J.-L. THONNARD, M. PENTA

The present literature review on functional assessmentin physiotherapy was carried out for the following rea-sons: 1) to identify the functional instruments used inthe field of physiotherapy that were supported by pub-lished evidence of their psychometric qualities; 2) toinvestigate how these instruments relate to theInternational Classification of Functioning, Disabilityand Health (ICF); and 3) to investigate the use of func-tional instruments in the financing of physiotherapy.A search of Medline from 1990 to December 2005, in thedomains of functional evaluation, psychometric qual-

ities, functional classification, and health policy in rela-tion to physiotherapy resulted in a list of 1,567 stud-ies. Two reviewers examined the resulting references onthe basis of their title and abstract, in order to select thestudies that presented data on the psychometric qual-ities of functional evaluation tests, leading to a finalselection of 44 such studies. A selection of functionaltests was identified in four major diagnostic groupstreated in community physiotherapy: musculoskeletaldisorders (including lower back pain), stroke, the elder-ly, and traumatic brain injuries. The functional testsauthors identified essentially cover the body and activ-ities dimension of the ICF. The selected tests could beused as a basis for the standardisation of functionalevaluation of the major diagnostic groups treated incommunity physiotherapy. This means that standardsare available for reporting and following the evolutionof patients both longitudinally and transversally.Nevertheless, in the current literature review no attempt

Funding.This study was funded by a grant from Centre FdraldExpertise des Soins de Sant in Belgium.

Address reprint requests to: J.-L. Thonnard, Universit Catholiquede Louvain, Unit de Radaptation, Tour Pasteur (5375), AvenueMounier, 53, BE-1200 Bruxelles, Belgium.E-mail: [email protected]

Vol. 43 - No. 4 EUROPA MEDICOPHYSICA 525

Physical Medecine and Rehabilitation UnitCatholic University of Louvain, Belgium

at using functional outcomes as a rationale for financ-ing physiotherapy could be found to date.

KEY WORDS: Physical therapy modalities - Rehabilitation -Physiotherapy.

Physiotherapy is based on an evaluation of thepatients functional health. This evaluation sup-plements the medical diagnosis, which is primarilyconcerned with pathology. For example, in additionto the medical diagnosis of osteoarthritis, the physicaltherapist needs information on pain, joint range ofmotion, muscle strength, etc. This information is usedto select appropriate interventions, follow the patien-ts recovery and assess treatment outcome.

The International Classification of Functioning,Disability and Health (ICF, World Health Organisation

2001) has been developed to offer an excellent con-ceptual framework for envisioning the consequencesof health condition or pathology on the function ofindividuals. It establishes a common language fordescribing the consequences of health that facilitatesthe comparison of data across countries, health care dis-ciplines, services and time. This extensive systemallows up to 1 424 ICF codes to be scored to describean individuals functional health Three separate butrelated dimensions of functioning are defined: bodyfunctions and structures (body dimension) activity

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THONNARD FUNCTIONAL ASSESSMENT IN PHYSIOTHERAPY

(individual dimension), and participation (social dimen-

sion). 1) Body functions are the physiologic or psy-chologic functions of body systems (e.g., mental, sen-sory, neuromusculoskeletal and movement relatedfunctions). Body structures are anatomical parts of thebody such as organs, limbs and their components.Impairments refer to anomaly, defect, loss or othersignificant deviation in body functions and structures.2) An activity is the execution of a task or action by thepatient. This dimension deals with all aspects of dai-ly life, envisioning human activities as the purposeful,integrated use of body functions (e.g., activities relat-ed to moving about and self-care, and communica-tion, domestic, or interpersonal activities). Activity lim-

itations are difficulties the patient may have in the per-formance of these daily activities, whatever the extentand magnitude of the underlying impairments. Hence,contextual factors such as the use of assisting devices,alternative strategies or another persons help do noteliminate the impairment, but might reduce limita-tions on activities in specific domains. 3) Participationis defined as the patients involvement in life situa-tions in relation to health conditions, body functionsand structures, activities and contextual factors. It refersto the experience of the patient in the actual contextof life (e.g., social relationships, employment and eco-nomic life) and it also includes societys response to the

patients level of functioning. Participation restrictionsare the problems the patient may experience in theirinvolvement in life situations.

Rehabilitation can be defined as a reiterative prob-lem solving and educational process that focuses ondisability (altered activities) and aims to maximiseparticipation in society while minimising the stresson and distress of the patient and family.1

Community, is used to refer to the physical andsocial environment of the patient in the place whereshe or he lives. It is usually set in contrast to a hospital,or another institutional setting where the patient maygo or reside for short periods while receiving a service.

The community might include a nursing home or res-idential care home if it is the patients long-term res-idence, but would not normally include a hospital orshort-term stays in a nursing home. The economico-political profile of rehabilitation in the communityhas increased in the last decade. Three factors havecontributed to this rise in interest: 1) the increasingawareness of disability; 2) the increasing evidencethat active rehabilitation has a beneficial effect interms of reducing dependence and care costs, and

in terms of improving the patients quality of life; and

3) the increasing pressure to shorten the time patientsspend in hospital beds. Politicians and health-carefunding agencies have seen an opportunity to controlhealthcare expenditure while also appearing toimprove rehabilitation services to disabled people.They have started to champion community rehabili-tation in the hope that this will contain or reduceexpenditure by shortening the time patients spend inthe hospital while also improving patient outcomes.

While the outcome of physiotherapy can beassessed with functional tests, the clinical purpose ofmeasurement is an important issue that should beconsidered. For instance, a diagnostic test should eval-

uate patient functioning in relation to the diagnosis inquestion, and variation across repeated measurementsshould be minimized. In order to monitor the progressof patients, the test should provide reproducible resultsover time, but also a sufficient range of measurement

with enough sensitivity to detect meaningful changes.Psychometric qualities of measures are encompassedunder the umbrella terms of validity, reliability (includ-ing sensitivity and specificity) and responsiveness 2 todetermine if they are meaningful for diagnosis or forthe evaluation of progress.

Validity describes how well a functional test mea-sures what it purports to measure. Ideally, validity is

assessed against a gold standard, even though such astandard is not always available for tests measuring

variables that were not previously defined. Whilethere are many ways to address the issue of validity,it is generally appraised in terms of the content ofthe test or by examining the behaviour of the mea-surement scale in regard to the underlying theoreticalconstruct. Reliability refers to the reproducibility ofthe measure, and is therefore dependent upon theamount of measurement error associated with themeasure. A reliable test has items that are internallyconsistent (i.e., related to one another) and minimis-es measurement errors in order to provide the same

results (within confidence limits) regardless of theparticular circumstances in which the measure wasobtained (e.g.,rater, time of evaluation). Finally, mea-sures intended to measure a patients recovery or lackof regression should be sensitive to change (have theability to detect change given the range of measure-ment and the measurement error), as well as showresponsiveness (the ability to detect meaningfulchange).

The purpose of this literature review on function-

526 EUROPA MEDICOPHYSICA December 2007


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FUNCTIONAL ASSESSMENT IN PHYSIOTHERAPY THONNARD

al assessment in physiotherapy is: 1) to identify the

functional instruments used in the field of physio-therapy that are supported by published evidence oftheir psychometric qualities; 2) to investigate howthese instruments relate to the ICF; and 3) to investi-gate the use of functional instruments in the financingof physiotherapy.

Methods

A literature search of Medline was undertakenbetween October and December 2005 in order toidentify functional evaluation methods of potential

utility for physiotherapy practice within the Belgianhealth care system. The literature search focused onfour specific areas: 1) the identification of functionaltests; 2) psychometric qualities of the tests; 3) the ICFdimensions covered by a functional test; and 4) the useof functional tests in health care policy. The followingkeywords were preliminarily identified in order tocover the scope of the study: physiotherapy, func-tional, evaluation, assessment, outcome, disability,impairment, handicap, participation, quality of life,life satisfaction, validation, reliability, psychometrics,health care financing, ICF and ICIDH. The keywords

were then entered into the Medical Subject Heading

(MeSH) in order to find their most relevant counter-part. The following MeSH terms were retained: phys-iotherapy, activities of daily living, disability evalua-tion, outcome assessment, quality of life, evaluationstudies, psychometrics, reproducibility of results, val-idation studies, ICF, delivery of health care, econom-ics, health planning guidelines, health policy, healthservices research, health services, national health pro-grams and program evaluation. Each MeSH term wasthen combined with the keyword physiotherapy and

with a fixed list of qualifiers (valid*, reliab*, repro-ducib*, repeatab*, responsiv*, sensitiv*, specificity,psychometr*) representing psychometric qualities, in

order to limit the search to a manageable number ofreferences. The complete literature search resulted in1,567 studies matching these criteria. No systematicreview was found: only papers reporting primaryresearch were obtained in conducting this literaturereview.

Two reviewers examined the resulting referencesand selected the studies that presented data on thepsychometric qualities of functional evaluation testsused in physiotherapy. The references were selected

on the basis of their title and the abstract was consulted

when necessary. Studies with a title or abstract includ-ing discussion of the psychometric aspects of func-tional tests or other data relating to functional assess-ment in community-based physiotherapy were includ-ed. If studies were published earlier than 1990, werenot written in English, were specific to hospital reha-bilitation, required the use of sophisticated devices(e.g.,goniometer, dynamometer), related to psychi-atric or scar care or focused on country-specific adap-tations of previously validated scales, they wereexcluded. This process allowed 60 references to beselected for the review.

Two independent readers reviewed the selected

list of references in order to collect data from eachstudy and encoded them in a standard way. The read-ers performed a preliminary assessment of 10 studiestogether in order to standardise the data collection.Functional tests were reviewed systematically in orderto describe the clinical utility of each test, identify theICF dimension covered by the test and extract thepublished data on the tests psychometric qualities,including its validity, reliability and responsiveness.

Results

Four types of studies were identified among the 60references reviewed. Forty-four studies presented psy-chometric qualities of functional tests used in phys-iotherapy. Fifteen studies discussed clinical, method-ological or organisational issues, not directly pre-senting evidence of functional test qualities. One studydiscussed issues related to patient satisfaction withphysiotherapy services. The latter 16 studies were notformally used to review the psychometric qualities offunctional tests (e.g.,clinical utility, metric properties);instead they were used to develop the arguments pre-sented in the introduction and in the general discus-sion of the study.

Each of the 44 studies investigating functional testshad addressed the metric qualities of one or multipletests. The tests were evaluated for validity, reliabilityand/or for responsiveness in the following diagnosticgroups: patients with musculoskeletal disorders (N=24)including lower back pain, spine disorders, chronicpain, lower limb amputees, lower limb dysfunctionand ankilosing spondylitis; stroke patients (N=16);elderly patients (N=4) and patients with brain injury(N=3). Evidence of clinical utility, ICF dimension cov-



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ered and metric qualities of functional tests are

described as they were found in the literature.In the papers we selected, content validity wasassessed using either experts or patients advice orthrough a literature review. Concurrent and construct

validity was generally assessed by correlation analy-ses. The internal consistency was assessed withChronbachs alpha.2A higher diversity of methods

were used to assess test/re-test reliability: paired t-test, correlation analysis, percentage of agreement,intraclass correlation coefficient,3 weighted orunweighted Cohens kappa coefficient 4, 5 andKendalls coefficient of concordance.6 Inter-rater reli-ability was generally assessed by comparing blinded

rater evaluations of videotaped patient performance.Multiple rater assessments were compared with thesame methods used to address test/re-test reliability.Responsiveness was generally assessed with analysisof variance (with or without repeated measures), per-centage change score, effect size,7 standardisedresponse mean (Liang et al 1990) or with the respon-siveness index.8

A summary of the functional tests used in muscu-loskeletal disorders is presented in Table I. Among the24 studies reviewed, 16 investigated patients with low-er back pain, two with spine disorders non-specific tothe lower back, two with chronic pain non- specific to

the lower back, two with lower extremity dysfunction,one with lower limb amputation and one with anky-losing spondylitis. Three main types of functional tests

were identified. Patient classification based on anato-mo-pathological or treatment criteria were used by thephysical therapist mostly for treatment planning. Clinicaltests carried out by the physical therapist as part of theclinical examination (N=8) were used essentially toevaluate the body structures and functions. Patient-reported questionnaires, either self-administered orinterview-based, were used essentially to evaluate theactivities of the patient, though some of them alsoaddress the body or participation dimension.

The evidence table of the functional tests used instroke patients is presented in Table II. A total of 16functional tests were reviewed. Among them, 10 clin-ical tests carried out by the physical therapist addressedthe body dimension. Five tests addressed the wholebody functions after stroke, four were specific to bal-ance function and one to gait function. The evaluationof activities was carried out either with clinical tests or

with questionnaires (either self-administered or inter-view-based). Two test address activities of the whole

body, two tests were specific to the activities of the

upper limb, one to locomotor activity and one tomobility.The table of evidence of the functional tests used in

elderly patients is presented in Table III. The fourclinical tests identified addressed the dimension ofactivities. Two tests address the performance of wholebody activities and two were specific to locomotoractivities.

The table of evidence of the functional tests used inpatient with traumatic brain injury is presented inTable IV. Three functional tests were identified. Oneof them consists of a classification of functional goalsused for treatment planning. Two other clinical tests

address either whole body activities, though mainlyfocussed on locomotor and transfer activities.

Discussion

The literature review allowed a selection of func-tional tests to be identified in four major diagnosticgroups treated in community physiotherapy: muscu-loskeletal disorders (including lower back pain),stroke, elderly, and traumatic brain injuries. The func-tional tests identified cover essentially the body andactivities dimension of the ICF. Along with function-

al tests allowing one aspect of the patient functioningto be assessed, a few studies described patient clas-sification systems that were mostly used by a physi-cal therapist in order to establish treatment goals andplan patient treatment.

The primary observation is that most of the testsidentified cover the body and activity dimensions ofthe ICF, while very few tests address the participa-tion dimension. Note that tests addressing participa-tion have been developed more recently than tests forthe other dimensions of functioning. Although reha-bilitation aims at improving the performance of activ-ities and participation in society according to Wade,1

the clinical practice of physiotherapy puts a higheremphasis on the body dimension of functioning. Thistraditional approach is probably motivated by the factthat the selection of interventions of physical therapistsis related to the treatment goals that are pursued.50

Especially treatment goals at the level of impairments(body dimension) and at the level of activity limitations(individual dimension) are formulated.51 Thus, up tonow, treatment goals at the level of participationrestrictions (social dimension) seem to be less specific



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TABLE I.Evidence of functional tests used in patients with musculoskeletal disorders.

Functional test Clinical utility Metric properties General appraisal

Lower back pain

Diagnostic classificationsystem for non-specificlower back pain

Type: classification 9

Treatment based classifi-cation of lower backpain patients (TBC)


Classification of patientswith LOWER BACKPAIN

Type: clinical test 11

Modified-Modified Scho-ber Test (MMST)

Type: CLINICAL test 12

Physical ImpairmentIndex (PII)


Diagnostic subclassification ofnon-specific lower back painconsisting of pathoanatomical-ly labelled syndromes assumedto refer to a specific pathologi-cal condition

ICF dimension: body structure,body unction

Treatment-based classificationsystem, based on physicalexamination and patient self-reports of pain and disability,

for use in the evaluation andtreatment of patients with acutelower back pain

ICF dimension: body structure,body function

Impairment-based classificationsystem addressing 28 symptombehavioral items and 22 align-ment and movement items inan attempt to define mutuallyexclusive categories of lowerback pain problems


Test measuring range of motionof the lumbar spine in the fol-

low-up of lower back painpatients

ICF dimension: body function

Evaluate the physical impairmentin lower back pain patients,through 7 tests, each scoreddichotomously based on pub-lished cut-offs

ICF dimension: body function,body structure

Reliability: percentages of agreement ranged from74% to 100% and kappa coefficients ranged from0.26 to 1.00. Inter-tester reliability of categorisationof the syndromes was acceptable

Reliability: the interrater reliability was moderate (kap-pa=0.56) according to criteria of Landis and Koch.The percentage agreement between therapists was65%

Validity: content validated by 4 orthopaedic physicaltherapists

Reliability: experienced therapist who had trainedtogether were able to agree on the results of exam-ination and obtain acceptable level of reliability(kappa >=0.75 for all items related to symptomselicited and >=0.40 in 72% of items related to align-ment and movement)

Validity: Pearson correlation coefficient between theMMST measurements and the gold standard (Xray)

is 0.67 (95%CI: 0.44-0.84)Reliability: the intra-rater reliability was excellent

(ICC=0.95; 95%CI 0.89-0.97) The inter- rater relia-bility was excellent (ICC= 0.91; 95%CI 0.83-0.96)

Responsiveness: a change over 1 cm on the MMSTmust be observed to be 95% confident that a truechange in ROM occurred

Validity: convergent validity was supported by sig-nificant correlations with disability (r=0.51 with theRoland-Morris questionnaire), work loss in the past

year (r=0.43), pain (r=0.27), depression (r=0.26 withthe Zung depression inventory), somatisation (r=0.32

with the modified somatic perception questionnaire),nonorganic signs (r = 0.49) and nonorganic symp-toms (r = 0.35). The highest correlation were found

with pain ratings (r=047), the Oswestry disabilityquestionnaire (r=0.42), nonorganic signs (r=0.42)and nonorganic symptoms (r=0.36). Smaller but sig-nificant correlations were found with the physicalcomponent score of the SF-6 (r=-0.28) and the phys-ical activity subscale of the fear-avoidance beliefsquestionnaire (r=0.24)

Reliability: good to excellent reliability for individualitems (ICC or kappa coefficients ranging from 0.48to 0.96). The overall score demonstrated excellentinterrater reliability (ICC=0.89); the reliability coef-ficients for individual components rang

Not applicable since thisstudy proposes a diag-nostic classification sys-tem for non specific lo-

wer back pain, ratherthan functional evalua-tion

Not applicable since thisstudy proposed a clas-sification process forpatients in the acute

stage, rather than func-tional evaluation

Not applicable since thisstudy proposed a clas-sification of impair-ments in lower backpain patients, ratherthan functional evalua-tion

The metric properties ofthis test support its use

in community-basedphysiotherapy. The testtakes 5 minutes to beadministered in by thetherapist

Systematic clinical testusing published cut-off

values for scoring phys-ical impairment inacute lower back pain

(to be continued)


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TABLE I.Evidence of functional tests used in patients with musculoskeletal disorders (continued).


Shuttle walking testType: clinical test 14

Standing flexion testType: clinical test 15

Aberdeen back painscale

Type: self-administeredquestionnaire 16

EuroQol (EuroQol)Type: self-administered

questionnaire 16

Jan Van Breemen Insti-

tuut pain and functionquestionnaireType: self-administered

questionnaire 17

Lower back SF-36 physi-cal functioning scale(Lower back SF-36 PF)


Measure of walking capacity inpatients with chronic airwayobstruction, chronic heart fail-ure and lower back pain, requir-ing the patient to shuttle on a10-meter course at speeds rang-ing from 1.8 to 8.53 km/h

ICF dimension: activitiesManual palpation of the sacroili-

ac joint in patients with lowerback pain


Clinical assessment of patientswith lower back pain made of19 items of either forced choiceor multiple choice, producinga back pain severity score

ICF dimension: body function,activities, participation

Generic instrument that incorpo-rates descriptions and valua-tions of health states, appliedin lower back pain patients

ICF dimension: participation

Self-administered questionnaire

consisting of 6 questions ad-dressing pain and 9 questionsaddressing functional capacityin lower back pain patients

ICF dimension: body function,activities

Back-specific version of the SF-36physical functioning scale, com-bining the advantages of bothgeneric and specific functionalquestionnaires into a single, par-simonious set of items from

Reliability: the test-reliability is excellent (ICC =0.99)with a mean difference of 2.5 m between assess-ments, and upper and lower limits of agreement of52 m and -47 m

Responsiveness: Patients undertaking fitness trainingreached an effect size of 1.2 compared to a controlgroup of 0.23 and 0.94 for a group undergoing var-ious orthopaedic treatments

Reliability: intraexaminer reliability data demonstrat-ed a mean percentage agreement of 68% and a kcoefficient of 0.46 indicating moderate reliability.Inter-examiner reliability data, with a mean per-centage agreement of 42% and a k coefficient of0.052, demonstrated statistically insignificant relia-

bility. These results suggest that the reliability of thestanding flexion test as an indicator of sacroiliacjoint dysfunction still remains questionable

Validity: developed through a review of the clinical lit-erature and selection of items that reflected areasof importance in the clinical assessment of patients

with lower back pain. Small but significant correla-tion (P


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Oswestry

Type: Self-administeredquestionnaire 17

Roland disability ques-tionnaire


Roland-Morris Question-naire (RMQ)


Roland-MorrisType: self-administered

questionnaire 17

Sickness Impact Profile(SIP)


which the original SF-36 PF10-item scale can still be extracted


Self-administered questionnaireof disability in lower back painpatients

ICF dimension: activities

Self-administered disability mea-

sure in lower back pain reflect-ing 24 activities of daily living


Self-administered disability mea-sure in lower back pain reflect-ing 24 activities of daily living


Self-administered disability mea-sure in lower back pain reflect-ing 24 activities of daily living


Self-administered disability mea-sure in lower back pain reflect-ing 24 activities of daily living.

ICF dimension: activities.

Behaviorally based measure ofperceived health status applic-able across a spectrum of ill-nesses and among variousdemographic and cultural sub-groups, applied in lower backpain patients

ICF dimension: participation

ceiling effects. Unidimensional and linear scale devel-oped with the Rasch partial credit model

Reliability: intrarater reliability of the PCBS test were.94 and .96, respectively. The test-retest of the low-er back SF-36 PF (ICC=0.91) was comparable to thatof the original SF-36 PF and of the Oswestry

Responsiveness: The responsiveness of the lower backSF-36 PF was slightly, though not significantly,improved compared to that of the original SF-36 PF.The minimum detectable change was improved, ascompared to the original SF-36 PF, from 16 to 12points on a 0-100 scale expressing a percentage ofthe maximum possible score

Responsiveness: sensitive to clinically important

change (%change =40) after treatment of 4 to 6weeks

Validity: 24 items selected form the Sickness ImpactProfile represent the areas of greatest relevance tolower back pain. Small but significant correlation(P


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Spine disorders

Fingertip-to-Floor TestType: clinical test 21

Passive intervertebralmotion of the cervicalspine


Chronic pain

Global PhysiotherapyExamination 52 (GPE-52)


Chronic pain intensitymeasuresType: telephone inter-view24

The finger-to-floor distance mightbe used to assess spine stiffnessand the effects of exercise onspine stiffness in persons withspine disorders


Passive motion between adjacentarticular segments is assessed

when diagnosing and treatingdysfunctions of the spine


Physical examination for muscu-loskeletal pain patients in 5domains: posture, respiration,movement, palpation muscle,palpation skin


Rating through telephone inter-view of current, worst, least andaverage pain intensity on Visual

Analog Scales over a deter-mined period of time in chron-ic pain patients


relation greater than 0.30. Seven of the 20 itemsidentified in this study appear in the Roland-Morrisdisability questionnaire

Validity: Spearmans correlation coefficient of trunkflexion assessed by the fingertip-to-floor test andthe radiologic measure was excellent (r=-0.96)

Reliability: The intra-observer reliability of the finger-tip-to-floor test was excellent with an ICC of 0.99. Theinterobserver reliability of the radiologic analysis

was excellent with an ICC of 0.99Responsiveness: The responsiveness of the fingertip-

to-floor test was evaluated by the SRM (0.97) and the

effect size (0.87)Reliability: the percentage agreement for both thera-

pists for all tests was 77% (7087%). The kappa coef-ficient varied between 0.28 and 0.43, considered tobe only fair to moderate. Even if two examinershave equivalent clinical experience and education-al backgrounds it is difficult to demonstrate accept-able inter-examiner reliability in the assessment ofpassive cervical joint motion. The results of this studyshowed lower concordance than expected in spiteof the optimal testing conditions

Validity: discriminates between patients with local-ized versus widespread pain. Discriminates betweenpatients with long-lasting musculoskeletal problemsand people who are healthy. Recently examined ondata from people who were healthy and patients

with long-lasting musculoskeletal painReliability: Good to excellent inter rater reliability of

the total score (ICC=0.91) and individual compo-nents (ICC=0.65 for posture, 0.60 for respiration,0.89 for movement, 0.83 for muscle palpation and0.76 for skin palpation)

Responsiveness: responsiveness to important change,defined in this study as return to work, was foundonly for the total GPE-52 score and within themovement and respiration domains. Responsivenessto important change was greater in patients withlocalized pain than in patients with widespreadpain

Reliability: the relatively low test-retest stability(0.550.65) of some of the individual ratings (aver-age, current and worst) between one pair of assess-ments (1-month to 2-month follow-up) raises someissues

Responsiveness: Each of the individual ratings wasable to detect expected changes in pain intensityfrom pre-treatment to various points after treatment.

Although the composite measures appeared moresensitive to treatment effects when compared to theindividual ratings, these differences were not statis-tically significant

The metric properties ofthis test support its usein community-basedphysiotherapy. The testtakes 1 min to beadministered in by thetherapist

The metric properties donot support the use ofthis test in community-based physiotherapy

This test requires a 3-daytraining which is a dis-advantage compared toother tests, and it takes30 min to be completed

The metric properties donot support the use ofthis test in community-based physiotherapysince it is not repro-ducible over time

(to be continued)


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to physiotherapy, and fall into the realm of other med-ical and paramedical specialities. This notwithstand-ing, participation remains one of the key researchareas in community rehabilitation according to Wade:1

Much research is needed to develop and evaluatethe expertise that community-based teams might have.For example there is minimal research into theprocesses of giving support to patients and their fam-

ilies, monitoring, prevention of complications, andfacilitation of social participation. This observationalso suggests that outcome evaluation in physiother-apy should be in keeping with this framework inorder to monitor functional recovery of the patientand treatment efficacy.

The functional tests reviewed appeared to addressthe dimensions most related to the clinical manage-




Lower Extremity Functio-nal Scale (LEFS)


Questionnaire Rising andSitting Down (QR&S)


Lower limb amputation

Functional Measure forAmputees (FMA)

Type: Self-administeredquestionnaire 27

Ankylosing spondylitis

World Health Organisa-tion Disability Assess-ment Schedule II(WHODAS II)

Type: Self-, Interviewer-or Proxy- administeredquestionnaire 28

Self-reported, condition-specific,functional measure applicableto a wide range of patients withlower-extremity orthopedic con-ditions


A self-administered questionnairethat measures perceived andactual functional limitations inrising and sitting down ofpatients with lower extremitydysfunction


A questionnaire collecting long-term functional and prostheticuse information following dis-charge in lower limb amputees


Generic instrument measuring thelevel of disability across variousconditions and interventions,applied in ankylosing spondyli-tis


Validity: correlations between the LEFS and the SF-36physical function subscale and physical componentscore were r=0.80

Reliability: Excellent internal consistency (Chronbach'salpha=0.96). Test-retest reliability of the LEFS scores

was excellent (r=0.94 [95% lower limit confidenceinterval = 0.89])

Responsiveness: The sensitivity to change of the LEFSwas superior to that of the SF-36 in this population

Validity : scale sum scores correlate 0.30 to 0.41(P


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TABLE II.Evidence of functional tests used in stroke patients.


Body dimension - globalFugl-MeyerType: clinical test 29

Rivermead Motor Assess-ment (RMA)


Stroke Impairment As-sessment Set (SIAS)


Stroke Physiotherapy In-tervention RecordingTool (SPIRIT)


Stroke RehabilitationAssessment of Move-ment (STREAM)


Body dimension - balance

Berg Balance Scale (BBS)Type: clinical test 34

Assess the physical impairmentfollowing stroke, in terms ofmotor performance, balance,sensation, range of movementand pain in 155 items


Detailed assessment of grossmotor control, upper limb con-trol and lower limb and trunkcontrol after stroke


The SIAS assesses various aspectsof impairment in hemiplegicpatients (e.g.,motor function,sensory function, pain)


Define and describe the contentof physiotherapy interventionfor postural control (posture,balance, walking) post stroke

ICF dimension: body function,body structure, activities

Objective and quantitative evalu-ation of the motor functioningof individuals with strokeamong 3 subscales: upper-limbmovements, lower-limb move-ments, and basic mobility items


Determine change in functionalstanding balance over time


Reliability: the standard error of measurement (com-bining, rater, occasion and error variance) may besignificant when only small changes in the patient'slevel of motor performance are expected. However,the overall inter-rater reliability was high (ICC=0.96)as well as the subscore (ICC=0.85 to 0.97), withexception of pain (ICC=0.61)

Reliability: reliability varied between questions (kap-pa=0.33 to 0.37), but agreements between assessorsand between observed and asked performance werealways better than expected by chance

Validity: standardized measure of stroke impairmentconsisting of subcategories of motor function, tone,sensory function, ROM, pain, trunk function, visu-ospatial function, speech, and sound side function.The scale has been validated with the Rasch model.The item difficulty patterns were similar for the right-and left-sided lesion groups

Reliability: Scale reliability is usually analyzed as inter-nal consistency or unidimensionality. The fit statis-tics were acceptable, except for a few items.

Justifications for these discrepancies are presented inthe study. The item difficulty patterns were identicalat admission and discharge

Validity: first study in the development of a recordingsystem for physiotherapy interventions in the reha-bilitation of postural control post-stroke. Contentbased on literature review and validated againstexpert advice

Validity: the total STREAM score was moderately tohighly associated with the score of the Barthel Index(rho=0.67) and Fugl-Meyer motor assessment scale(rho=0.95)

Reliability: Moderate to excellent agreement inter-rateron scores for individual items (weighted kappa=0.55to 0.94). Very high inter-rater reliability (ICC=0.96 forthe total score, 0.95 for upper extremity, 0.92 forlower extremity and 0.92 for mobility subscales)

Validity: in arm flexion condition, the force platform andaccelerometer outcomes were significantly related toBBS performance, with CP-flexion explaining 43% andpeak arm acceleration explaining 45% of the variancein BBS scores. It appears that the ability to show acti-

vation of postural muscles in advance of focal move-ment is associated with higher BBS scores. In quietstance condition, performance on the BBS was foundto be significantly related to CP-stance (r2=58%)

Reliability: Paired tests of difference failed to reveal anydifferences in the variables over the two days

This widely used test ishardly applicable, as itis composed of multi-ple sub-scales that can-not be summed in atotal score. The testtakes 30 min to beadministered by thetherapist


The metric properties ofthis test support its usein community-basedphysiotherapy. Thescores are expressed ona linear scale whichenables quantitativecomparisons of func-tional states. The testadministered by thetherapist in approx. 10min. Published scoringguidelines are available

Not applicable since thisstudy proposes a re-cording system forphysiotherapy inter-

ventions in posturalcontrol of acute strokepatients, rather thanfunctional evaluation

This test requires a 2-daytraining, and was most-ly validated on acutepatients. Moreover, thetotal score is composedof three sub-scales,

which is not suitable forfinancing purposes

There is evidence in theliterature to support theuse of the BBS.Established guidelinesallow the test to beadministered by thetherapist in 20 min

(to be continued)


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TABLE II.Evidence of functional tests used in stroke patients (continued).


Berg Balance Scale (BBS)Type: clinical test 35

Functional balance testspost stroke


Postural Control andBalance for Stroke test(PCBS)


Body dimension-gait

Rivermead Visual GaitAssessment (RVGA)


Activities - global

Mobility milestonesType: clinical test 39

Stroke Activity Scale(SAS)


Determine change in functionalstanding balance over time


Functional test of postural con-trol post stroke


Assess balance in terms of pos-tural changes, sitting balance,and standing balance in order tohelp physiotherapists in plan-ning balance interventions andin rehabilitation follow-up


The current study aims to devel-op a procedure and assessmentform which allows practising

therapists to record relevantaspects of the quality of gaitobserved in patients with neu-rological disease in a reliableand valid way


Evaluate mobility after stroke in 4simple functional tasks provid-ing a quick, simple, and stan-dardized outcome measure


Measure motor function at thelevel of disability in strokepatients


Validity: r=0.80 with gait speed, r>0.80 with BarthelIndex, r> 0.70 with Fugl-Meyer, r


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ment of patients in physiotherapy. All tests addressedeither the body or the activities dimension of thepatients functioning, which are the most related to theclinical management of patients in physiotherapy.

Nevertheless, some of the most widely used tests inrehabilitation (e.g.,the Functional IndependenceMeasure or the Barthel Index) were not listed, whichcontrasts with a recent inquiry on outcome measure-


TABLE II.Evidence of functional tests used in stroke patients (continued).


Activities - upper limb

ABILHANDType: self-administered

questionnaire 41

Motor Activity Log (forthe Assessment of ArmUse in HemipareticPatients) (MAL)

Type: semi-structuredinterview42

Activities-gait

Gait speedType: clinical test 30

Activities mobility

New mobility scaleType: open-ended ques-

tionnaire 43

Self-reported questionnaire onthe perceived difficulty of man-ual activities of daily living


Assess the use of the paretic armand hand during activities ofdaily living in terms of theamount of use (AOU) and ofthe quality of movement(QOM) of the paretic arm


Timed walk at the patient's pre-ferred speed, using the patien-t's own selection of walking aidor assistance, over a distance of5 m, including turn and walkback


Measure mobility inside and out-side the home and in the com-

munity


Validity: content validated against the involvement ofthe affected limb in each activity. The activities thatdefine the more difficult levels of the scale also tendto require a higher involvement of the affected limb,

while the easier activities can be achieved in a move-ment sequence that does not require the affectedlimb. ABILHAND measures are significantly corre-lated to grip strength (r=0.56), motricity (rho=0.73),dexterity (r=0.60), and depression (rho=-0.21). The

ABILHAND questionnaire results in a valid, unidi-mensional, person-centered measure of manual abil-ity in everyday activities. The stability of the item-dif-ficulty hierarchy across different patient classes fur-ther supports the clinical application of the scale

Reliability: The overall scale precision is summarizedby a good between-patient separation reliability of0.90 in this sample. It appears sufficient to discrim-inate across patients and, presumably, to captureeven subtle functional changes with time

Validity: The cross-sectional construct validity of theMAL is reasonable, but the results raise doubts aboutits longitudinal construct validity

Reliability: Internal consistency was high (Chronbach'salpha=0.88 for the AOU and 0.91 for the QOM). Thereproducibility is sufficient to detect an individualchange of at least 12% to 15% of the range of thescale

Responsiveness: The improvement on the MAL during

the intervention was only weakly related to theimprovement on the Action Research Arm test(rho=0.16 to 0.22)

Reliability: intercorrelations between 3 repetitions ofthe test, between 5m and 10m walks, and betweentest and retest were very high (r=0.95 to 0.99). Forindividual patients, the test-retest variability rangedfrom 0 to 40%, with 95% of the patients varying the

walking speed between tests by less than 25% ofthe slowest time

Validity: content of mobility scale assessed throughopen-ended questionnaire sent to 15 experienced

physiotherapists. They identified important mobili-ty tasks and important places to access inside thehouse, outside the house and in the community as

well as additional mobility abilities required for inde-pendent mobility in the house and community

The metric properties ofthis test support its usein community-basedphysiotherapy. Thescores are expressed ona linear scale whichenables quantitativecomparisons of func-tional states. The testcan be self-adminis-tered in 5 min

The use of the MAL as aprimary outcome mea-sure in clinical trials isnot recommended be-cause there are reasonsto doubt the longitudi-nal construct validity ofthe instrument

The metric properties ofthis test support its usein community-basedphysiotherapy. The testcan be administered in5 min

Preliminary study of testunder development;

not applicable


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ment in Physical Medicine and Rehabilitation acrossEurope.52 This observation might be explained by thefact that the current literature review was focussedon functional evaluation carried in the community,

where patients are able to live at home, and thereforelocated at the higher range of measurement of suchtests. While the tests mostly used in hospital rehabil-itation are pretty well documented, functional assess-ment in the community are less standardised.

Moreover, this literature review considered only paperspublished since 1990. Consequently, some standard-ised tests were not reported because they were vali-dated before 1990. This is particularly the case forsome functional tests in the body dimension like thenine-hole peg test or the Purdue pegboard test.

The body dimension was mostly addressed in termsof body function, except in lower back pain patientsor in other spinal disorders that primarily relied on test-ing body structures through skin palpation. The activ-

ities dimension was generally addressed with clini-cal tests performed by the physical therapist or by aself-reported questionnaire relating to the patientsperceived disability in daily life activities. Clinical teststypically address movement quality or a patients per-formance in standardized activities, and are consideredmore reliable than questionnaires. Nevertheless, ques-tionnaires present several advantages over clinicaltest. First, they address the perception of disability in

activities as they are actually realized by the patient intheir own environment. Second, they capture an aver-age perception of disability over a longer period oftime (one up to several weeks) and are probablymore representative of the patients disability thanthe performance of standardized activities in a con-sultation room. Third, they are very inexpensive andcan be completed by the patient in the waiting roomin order to reduce the burden of work of the physi-cal therapist. On the other hand, it can be discussed


TABLE III.Evidence of functional tests used in elderly patients.


6-minute Walk TestType: clinical test 44

8-item Physical Perfor-mance Test (PPT-8)


Functional Gait Assess-ment (FGA)


General Motor FunctionAssessment Scale (GMF)


Measure of exercise capacity andendurance also used as an out-come measure


Evaluate the ability to use theupper and lower extremities inactivities of daily living


Assess postural stability duringgait tasks in the older adult(greater than 60 years of age)at risk for falling


Compound assessment of threecomponents (dependence, painand insecurity) of daily livingactivities among older rehabili-tation patients


Reliability: intraclass correlation coefficients for test-retest reliability were 0.93

Responsiveness: There was no change in 6-minutewalk test distance in the intervention group whencompared with the control group

Reliability: good internal consistency (Cronbach'salpha=0.78). Intraclass correlation coefficients fortest-retest reliability was 0.88. The intraclass corre-lation coefficient for interrater reliability was 0.96

Responsiveness: The responsiveness index was 0.8,indicating a significant difference of effect between

intervention and control groupValidity: Poor to moderate correlation with balance

measurements (rho=0.11 to 0.67)Reliability: Good internal consistency (Cronbach's

alpha=0.79). Good inter rater reliability (ICC=0.74).Good inter rater reliability (ICC=0.86)

Validity: Principal components factor analysis demon-strated individual FGA item loading across 3 extract-ed factors that may represent separate domains ofperformance on the total battery

Reliability: Analysis of reliability showed overall highvalues of percentage agreement (PA=0.70) and ofthe rank-order agreement coefficient (ra=0.82), andlow degrees of systematic disagreement

The test was unable tomeasure change in per-formance expected

with a functional train-ing intervention. Anindoor 32-meter courseis also required. Itsapplicability is limited

The metric properties aresupported by the me-thodology of the study.

A published test proto-col allows the test to beadministered by the

therapistThis test has been devel-

oped for a very specif-ic group of patients.The results of this studyshould be interpretedcautiously since thesample size was verysmall (6 patients)



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TABLEV.Selected tests according to the dimensions of the International Classification of Functioning, Disability and Health (ICF).

Body Activities Participation

Musculoskeletal disorders

Fingertip-to-floor test Low back SF-36 physical functioningModified-Modified Schber Test (MMST) Lower Extremity Functional Scale (LEFS)

OswestryQuestionnaire Rising and Sitting Down (QR&S)Roland-MorrisShuttle walking test

World Health Organisation Disability Assessment Sickness Impact Profile (SIP)

Schedule II (WHODAS II)Stroke

Berg Balance Scale (BBS) ABILHANDRivermead Visual Gait Assessment (RVGA) Gait speedStroke Impairment Assessment Set (SIAS)

Elderly

8-item Physical Performance Test (PPT-8)

Brain injury

Step length and step width measurement



TABLE IV.Evidence of functional tests used in patients with brain injury.


Clinical Outcomes Varia-ble Scale (COVS)


Step length and stepwidth measurement


Taxonomy of patientgoals in acquired braininjury comprising 21categories within fivedomains, utilizing 125descriptors


Evaluation of functional abilityfollowing traumatic brain injuryin a large range of motor tasksretrained by physiotherapistsincluding a measure for transferability to and from bed andfloor surfaces as well as wheel-chair skill


Walking performance after trau-matic brain injury assessed bystep length and step width mea-sures


Classification of client goals incommunity-based acquiredbrain injury rehabilitation allow-ing treatment focus and changesin service delivery to be inves-tigated

ICF dimension: activities, partici-pation

Reliability: the intra-class correlation coefficients (ICC)were very high for both inter-tester reliabil ity(ICC>0.97 for total COVS scores, ICC>0.93 for indi-

vidual COVS items) and intra-tester reliabil ity(ICC>0.97)

Validity: concurrent validity was excellent, with cor-relations between the procedures ranging from 0.93to 1.00

Reliability: the inter-rater reliability of step length and

width measurements was very high, with intraclasscorrelation coefficients between 0.94 and 1.00, forboth procedures

Reliability: the taxonomy demonstrated good inter-rater consistency and was able to discriminatebetween similar but related data sets comprisinggoal statements. Out of the 140 goal statements 128(92%) were placed in the same category by at leastthree of the four, and there was full agreementbetween all four on 91 of the goal statements (65%).This indicated that the taxonomy and descriptorstatements had been refined to a stage where there

was significant inter-rater consistency


Potentially interesting testfor neurological pa-tients, but its metricproperties should be

interpreted cautiouslysince the sample size

was small (20 patients).A 14-meter walk courseis required

Not applicable since thisstudy proposes a clas-sification of patientgoals, rather than func-tional evaluatio


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whether it is feasible to base reimbursement on self-

reported questionnaires.The psychometric qualities of the test were report-ed as presented in each study. These statistics can beinterpreted by the reader in order to make an optimalchoice of functional tests for their specific purpose..Some precautions, however, must be kept in mind inthe comparison of statistical indices. For instance,although validity was generally assessed by correla-tion analyses, it is well known that correlation coef-ficients are sensitive to the range and distribution ofthe values correlated.53 The intensity of the reportedcorrelations is therefore influenced by the differencein sampling strategies used between studies.

Moreover, different inclusion criteria were usedbetween studies (e.g.,elderly patients with or withouta previous stroke). The selection bias should be con-sidered from a clinical perspective in comparing sta-tistical indices since it influences the relation betweenthe functional test and the gold standard.

Responsiveness was also assessed with differenttypes of indicators. Responsiveness is generally definedas the ability of a test to elicit clinically meaningfulchange. Nevertheless, all evaluations with functionaltests are accompanied by a certain amount of mea-surement error, and some of the statistics used toassess responsiveness do not take the error of mea-

surement into account (e.g.,percentage of changescore). Thus, when assessing change with such sta-tistics, scores obtained at both occasions and regard-ed as significantly different might very well be with-in the error of measurement and therefore the possi-bility that the change is due to chance cannot beexcluded. Moreover, the reviewed functional testsused different levels of measurement.54 Though thelarge majority of results were reported at the ordinallevel (i.e.,allowing for ranking comparisons), sometests reported their results on nominal scales (i.e.,onlyallowing for equivalence comparison) or on intervalor ratio scale (i.e.,allowing difference, or change score,

to be computed on a linear scale). Misinferences dueto linear interpretation of data at the nominal or ordi-nal level of measurement has been largely reported inthe literature.55

Conclusions and perspectives

Functional evaluation is part of the process of reha-bilitation.1 This process involves identifying the prob-

lems and needs of individuals, defining therapy goals,

planning and implementing interventions and assess-ing the effect of interventions using measurementsof relevant variables.56 The literature review present-ed in this report provides a selection of functionaltests in the major diagnostic groups treated in com-munity physiotherapy. These functional tests essen-tially cover the body dimension and the activitiesdimension of the ICF, which are the dimensions thatare most pertinent to the current practice of physio-therapy.

A selection of tests in each dimension of the ICF ispresented in Table V according to their metric prop-erties and quality appraisal for the four diagnostic

groups emerging from this review. The metric prop-erties include published evidence of reliability, valid-ity and responsiveness, but also the unidimensional-ity and linearity of each scale. The latter properties arerequisite for making quantitative comparisons of func-tional status over time. Quality appraisal includes ageneral evaluation of the methodology of each study,and the practical applicability of each test in com-munity physiotherapy (i.e., evaluation time, requiredequipment). It is important to emphasize that timeand quality of evaluation are not strictly related.Indeed, very short, well calibrated scales can be muchmore efficient than time consuming tests. The body

and activities dimensions of the ICF are the most well-represented. Musculoskeletal disorders are the diag-nostic groups for which the largest number of highquality tests have been identified. The body dimensionin musculoskeletal disorders is mostly evaluated withactive mobility tests. Although these tests are widelyused, one of their major drawbacks is that they mea-sure a maximal performance, i.e., maximal mobility,

which can be hindered by pain or other factors.57 Theactivities dimension in musculoskeletal disorders isthe most represented among the four diagnosticgroups. Most tests used in this domain are widelyused, validated questionnaires that can be easily and

inexpensively applied in community physiotherapy.The body dimension in stroke patients is addressedeither with global tests and/or tests of specific func-tions (e.g., balance). The activities dimension is eval-uated either with upper limb or with lower limb spe-cific tests; no global activity instrument was identi-fied in stroke community rehabilitation. Although fewtests are available for elderly and brain-injured patients,one test in each diagnostic group presented enoughquality to be retained in this selection. The summary




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15. Vincent-Smith B, Gibbons P. Inter-examiner and intra-examiner reli-ability of the standing flexion test. Man Ther 1999;4:87-93.

16. Garratt AM, Klaber Moffett J, Farrin AJ. Responsiveness of gener-ic and specific measures of health outcome in low back pain.Spine 2001;26:71-7.

17. Stratford PW, Binkley J, Solomon P, Gill C, Finch E. Assessingchange over time in patients with low back pain. Phys Ther1994;74:528-33.

18. Davidson M, Keating JL, Eyres S. A low back-specific version of theSF-36 Physical Functioning scale. Spine 2004;29:586-94.

19. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J.Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 1996;76:359-65.

20. Stratford P, Solomon P, Binkley J, Finch E, Gill C. Sensitivity ofSickness Impact Profile items to measure change over time in a low-back pain patient group. Spine 1993;18:1723-7.

21. Perret C, Poiraudeau S, Fermanian J, Colau MM, Benhamou MA,Revel M. Validity, reliability, and responsiveness of the fingertip-to-floor test. Arch Phys Med Rehabil 2001;82:1566-70.

22. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability inassessing passive intervertebral motion of the cervical spine. ManTher 2000;5:97-101.

23. Kvale A, Skouen JS, Ljunggren AE. Sensitivity to change andresponsiveness of the global physiotherapy examination (GPE-52) in patients with long-lasting musculoskeletal pain. Phys Ther2005;85:712-26.

24. Jensen MP, Turner JA, Romano JM, Fisher LD. Comparative relia-bility and validity of chronic pain intensity measures. Pain1999;83:157-62.

25. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower ExtremityFunctional Scale (LEFS): scale development, measurement prop-erties, and clinical application. North American OrthopaedicRehabilitation Research Network. Phys Ther 1999;79:371-83.

26. Roorda LD, Roebroeck ME, Lankhorst GJ, van Tilburg T, Bouter LM.Measuring functional limitations in rising and sitting down: devel-opment of a questionnaire. Arch Phys Med Rehabil 1996;77:663-9.

27. Callaghan BG, Sockalingam S, Treweek SP, Condie ME. A post-dis-charge functional outcome measure for lower limb amputees:test-retest reliability with trans-tibial amputees. Prosthet OrthotInt 2002;26:113-9.

28. van Tubergen A, Landewe R, Heuft-Dorenbosch L, SpoorenbergA, van der Heijde D, van der Tempel H et al.Assessment of dis-ability with the World Health Organisation Disability AssessmentSchedule II in patients with ankylosing spondylitis. Ann Rheum Dis2003;62:140-5.

29. Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C.Reliability of the Fugl-Meyer assessment for testing motor perfor-mance in patients following stroke. Phys Ther 1993;73:447-54.

30. Collen FM, Wade DT, Bradshaw CM. Mobility after stroke: relia-bility of measures of impairment and disability. Int Disabil Stud1990;12:6-9.

31. Tsuji T, Liu M, Sonoda S, Domen K, Chino N. The stroke impair-ment assessment set: its internal consistency and predictive valid-ity. Arch Phys Med Rehabil 2000;81:863-8.

32. Tyson SF, Selley A. The development of the Stroke PhysiotherapyIntervention Recording Tool (SPIRIT). Disabil Rehabil 2004;26:1184-8.

33. Wang CH, Hsieh CL, Dai MH, Chen CH, Lai YF. Inter-rater relia-bility and validity of the stroke rehabilitation assessment of move-ment (stream) instrument. J Rehabil Med 2002;34:20-4.

34. Stevenson TJ, Garland SJ. Standing balance during internally pro-duced perturbations in subjects with hemiplegia: validation of thebalance scale. Arch Phys Med Rehabil 1996;77:656-62.

35. Stevenson TJ. Detecting change in patients with stroke using theBerg Balance Scale. Aust J Physiother 2001;47:29-38.

36. Tyson SF, DeSouza LH. Reliability and validity of functional bal-ance tests post stroke. Clin Rehabil 2004;18:916-23.

37. Pyoria O, Talvitie U, Villberg J. The reliability, distribution, and

table presented here indicates that 1) high quality

functional tests were found for the main diagnosticgroups treated in community physiotherapy (e.g.,mus-culoskeletal disorders, stroke); 2) the functional testsidentified do not cover all dimensions of the ICF forall diagnostic groups, 3) in some dimensions, vari-ous valid scales are proposed, hence emphasising theneed for a standard in each diagnostic group.

This literature review has identified a selection ofvalid tests that could be used as a basis for the stan-dardisation of the functional evaluation of the majordiagnostic groups treated in community physiothera-py. This means that standards are available for report-ing and following the evolution of patients.

Nevertheless, no attempt in using functional outcomesas a rationale for financing physiotherapy was foundto date in the current literature review.

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