Clinical Scales - Indications, Contraindications, Precautions, Procedure, and Clinical Use

CARDIAC FUNCTIONAL CLASSIFICATION

New York Heart Association (NYHA) Functional Classification

• Class I: No limitation of physical activity. Ordinary physical activity does not cause symptoms.
• Class II: Slight limitation. Comfortable at rest, but ordinary physical activity results in symptoms.
• Class III: Marked limitation. Comfortable at rest, but less-than-ordinary activity causes symptoms.
• Class IV: Unable to carry on any physical activity without symptoms, or symptoms present at rest.
• Braunwald's Heart Disease, Table 48.1

ICU AND CRITICAL CARE SCALES

1. Medical Research Council (MRC) Muscle Strength Scale

• Detection and diagnosis of ICU-acquired weakness (ICUAW) in critically ill patients who have been mechanically ventilated for more than 3-7 days
• Monitoring neuromuscular function in patients with critical illness polyneuropathy or myopathy
• Assessing progression of weakness in Guillain-Barré syndrome, myasthenia gravis, and other neuromuscular conditions
• Guiding rehabilitation planning and exercise prescription in the ICU
• Predicting weaning from mechanical ventilation and ICU/hospital length of stay
• Baseline and serial neuromuscular assessment during early mobilization programs

• Patients who are unconscious, heavily sedated (RASS -3 to -5), or unable to follow commands - the standard MRC scale requires active patient participation
• Presence of delirium (assessed using CAM-ICU) invalidates voluntary strength testing
• Focal orthopaedic injuries, fractures, or immobilization devices at the joint being tested
• Peripheral nerve injuries or amputations affecting the limb being assessed
• Hemiplegia after stroke affecting the tested side (score the contralateral or proximal limb if more than two extrapolations are needed, the MRC Sum Score cannot be validly calculated)

• The test requires full patient cooperation; a score of 5/5 on five standardized orientation questions or a negative CAM-ICU is required before proceeding with voluntary muscle testing
• Interrater reliability is moderate at individual muscle level but improves significantly for the Sum Score (<48 threshold: kappa 0.68; <36 threshold: kappa 0.93)
• Bed position affects results: for movements against gravity (MRC ≥3), the head of the bed is at 45°; for gravity-eliminated positions (MRC <2), the bed is at 10°
• Results should be interpreted in context of the patient's pain level, fatigue, and medication effects (sedation, neuromuscular blocking agents)
• Half-grades (e.g., 4+, 4-) should be rounded to full numbers: 4+ = 4, 4- = 3, 5- = 4
• If a muscle group cannot be tested, use the contralateral limb's score; if unavailable, use the ipsilateral proximal group. If more than two extrapolations are necessary, the Sum Score is invalid.

1. Shoulder abductors
2. Elbow flexors
3. Wrist extensors
4. Hip flexors
5. Knee extensors
6. Foot dorsiflexors

• Grade 5: Normal strength, movement against maximum resistance
• Grade 4: Movement against gravity and some resistance
• Grade 3: Movement against gravity over full range but no resistance
• Grade 2: Movement with elimination of gravity (gravity-eliminated position)
• Grade 1: Visible contraction without movement of the limb
• Grade 0: No visible contraction

2. ICU Mobility Scale (IMS)

• Documenting and tracking functional mobility of adult ICU patients throughout their stay
• Guiding early mobilization programs and rehabilitation planning
• Assessing patient readiness for progressive mobility interventions
• Measuring responsiveness to physiotherapy or rehabilitation interventions
• Predicting discharge destination (home vs. facility) at ICU discharge

• Active hemodynamic instability precluding any movement (e.g., active vasopressor titration for shock, life-threatening arrhythmias)
• Unstable fractures or acute orthopaedic injuries that prevent movement of the tested regions
• Severe respiratory failure requiring complete bed rest
• Any medical contraindication to mobilization as determined by the treating team

• The IMS demonstrates significant floor effects when used early in the ICU (many patients score 0-1), which limits its ability to differentiate between very low-function patients at awakening
• It measures the highest level achieved, which may not reflect the patient's typical or sustainable function
• Careful safety monitoring is required during any active mobility tasks, including SpO2, heart rate, blood pressure, and patient-reported exertion
• Equipment and staffing requirements increase as level progresses; higher-level tasks (standing, walking) require adequate personnel

• 0: Lying in bed, passive repositioning only
• 1: Sitting in bed (exercises in bed or passive)
• 2: Passively moved to chair (no active participation)
• 3: Sitting over the edge of bed
• 4: Standing (with or without assistance)
• 5: Transferring to chair (walking with assistance)
• 6: Marching on spot (standing with assistance)
• 7: Walking with assistance from 2 or more people
• 8: Walking with assistance from 1 person
• 9: Walking independently with a gait aid
• 10: Walking independently without a gait aid

3. Physical Function ICU Test - Scored (PFIT-s)

• Objectively measuring physical function in mechanically ventilated patients (typically ≥4 days of MV) who are alert and able to follow commands
• Guiding exercise prescription within the ICU (including intensity via rate of perceived exertion during marching)
• Assessing functional recovery from ICU awakening through discharge
• Predicting discharge destination (home vs. facility)
• Tracking response to rehabilitation interventions
• Identifying ICU-acquired weakness as part of a functional battery alongside MRC Sum Score

• Patients who cannot follow commands or are heavily sedated (requires RASS 0 or positive, ability to follow instructions)
• Patients who cannot achieve sitting: if unable to sit over edge of bed, only limb muscle testing in bed is possible, and sit-to-stand and marching components cannot be assessed
• Active hemodynamic instability contraindicated for active functional testing
• Orthopaedic restrictions preventing lower limb weight-bearing (affects sit-to-stand and marching components)
• Severe respiratory compromise where any exertion is unsafe

• MRC Sum Score and grip strength should be tested before PFIT-s to confirm the patient has sufficient ability to participate; this also reduces duplication since MRC components overlap
• If the patient has limited range of motion, test strength within the available range
• Use the stronger side (right or left) for shoulder flexion and knee extension scoring
• The patient may use a walker during the marching component if required
• If sitting in a chair is possible, use the chair position for all components (preferred over bed-edge sitting)
• No adverse events have been documented during PFIT-s testing in the ICU, but safety monitoring (vital signs, SpO2) should be maintained throughout
• If the patient is in a gravity-eliminated position, maximum grade achievable is 2

1. Shoulder Flexion Strength: graded 0-5 using MRC criteria; the stronger side is used. Grades 0-2 score 0, grade 3 scores 1, grade 4 scores 2, grade 5 scores 3 on the PFIT.
2. Knee Extension Strength: graded 0-5 using MRC criteria; same conversion applied.
3. Sit-to-Stand Assistance: The patient attempts to stand from a seated position. Assistance level determines score: 0 = unable to stand; 1 = requires 2 people; 2 = requires 1 person; 3 = independent.
4. Marching on the Spot Cadence: The patient marches on the spot for up to 3 minutes. Steps are counted and time is recorded. Cadence = (number of steps / time in seconds) × 60. Score: 0 = unable; 1 = <40 steps/min; 2 = 40-79 steps/min; 3 = ≥80 steps/min or sustained for 3 minutes.

4. Functional Status Score for the ICU (FSS-ICU)

• Measuring physical function in adult ICU patients across a range of acuity levels, including mechanically ventilated patients
• Tracking functional changes from ICU awakening through ICU discharge
• Evaluating functional recovery as an outcome measure in clinical research
• Predicting discharge destination (home vs. facility) at ICU discharge
• Baseline assessment of pre-ICU functional status (via retrospective proxy version)

• Patients who are fully unconscious or non-cooperative cannot participate in active task performance
• Severe hemodynamic instability preventing any movement or repositioning
• Active surgical precautions or orthopaedic restrictions preventing the specific movement tasks (e.g., no weight-bearing, sternal precautions post-cardiac surgery limit rolling and transfer tasks)
• Note: Post-cardiac surgery patients with drains and infusions may have artificially lower scores due to restricted movement, reducing validity in this specific group

• Post-operative drains, catheters, and IV infusions can mechanically restrict movement and result in artificially low scores, reducing the validity of the FSS-ICU in cardiac and major surgical ICU patients
• Floor effect is minimal (<0.5%) but ceiling effect is present at hospital discharge (~21%), limiting sensitivity to improvement in higher-functioning patients
• The scale measures observed performance, not capacity; this should be considered when interpreting results in the context of environmental or equipment restrictions
• Monitoring of vital signs and SpO2 is required during active testing components

1. Rolling (side to side in bed)
2. Supine-to-sit transfer (lying to sitting at edge of bed)
3. Sitting at edge of bed (unsupported balance)
4. Sit-to-stand transfer
5. Walking (or ambulation attempt)

• 0: Unable to perform the activity
• 1: Total assistance (patient performs <25% of the activity)
• 2: Maximal assistance (patient performs 25-49%)
• 3: Moderate assistance (patient performs 50-74%)
• 4: Minimal assistance (patient performs 75-99%)
• 5: Supervision or setup only
• 6: Modified independence (uses equipment)
• 7: Complete independence

5. Glasgow Coma Scale (GCS)

• Initial and serial assessment of level of consciousness following traumatic brain injury (TBI)
• Assessment of consciousness level in any cause of altered mental status (stroke, metabolic encephalopathy, infection, overdose, post-cardiac arrest)
• Triage and severity grading: GCS 14-15 = mild head injury; GCS 9-13 = moderate; GCS 3-8 = severe
• Guiding intubation decisions (GCS ≤8 classically indicates airway protection need)
• Monitoring ICU patients for neurological deterioration or improvement
• Pre- and post-resuscitation neurological status documentation
• Grading subarachnoid hemorrhage severity (Hunt-Hess and WFNS scales incorporate GCS)
• Predicting neurological outcome: the motor score component is the best single predictor of neurological outcome in TBI - Bailey & Love's Surgery, p. 8446

• Drug-induced sedation or paralytic agents affect all three domains
• Severe orbital trauma prevents eye opening assessment
• Tracheostomy or intubation prevents verbal response (the "T" modifier is used)
• Severe facial trauma prevents verbal assessment

• Intubated patients cannot score verbal responses fully; document with the "1T" modifier
• Results are affected by alcohol, sedative medications, neuromuscular blocking agents, and metabolic disturbances (hypoglycemia, hyponatremia)
• The scale should be assessed post-resuscitation (stable airway, oxygenation, and hemodynamics) for valid trauma scoring
• In small children, the Pediatric GCS (modified criteria for developmental stage) should be used
• Individual domain scores (E, V, M) are more informative than the total alone and should always be reported separately
• A normal GCS does not exclude significant intracranial pathology (e.g., extradural hematoma with lucid interval)

• 1: No eye opening
• 2: Opens to pain (nail-bed or supraorbital pressure)
• 3: Opens to speech (not sleep-awakening; that scores 4)
• 4: Eyes open spontaneously

• 1: No verbal response
• 2: Incomprehensible sounds (moaning)
• 3: Inappropriate words (random speech, no conversation)
• 4: Confused (coherent but disoriented)
• 5: Oriented (knows name, place, date)

• 1: No motor response
• 2: Extension to pain (decerebrate posturing)
• 3: Abnormal flexion to pain (decorticate posturing)
• 4: Withdrawal from pain
• 5: Localizes pain
• 6: Obeys commands

FUNCTIONAL INDEPENDENCE SCALES

1. Barthel Index (BI)

• Assessing baseline functional independence in patients with neurological, orthopaedic, or general physical impairments
• Measuring functional outcomes after stroke, spinal cord injury, TBI, hip fracture, and other disabling conditions
• Monitoring rehabilitation progress over time
• Discharge planning and determination of care needs (home vs. facility)
• Benchmarking outcomes in clinical trials (used as a primary outcome in many stroke trials)
• Most appropriate for individuals with significant physical or cognitive impairments - Kaplan & Sadock's Psychiatry, p. 2633

• Significant ceiling effects in patients who are more functional - they may score 100 but still have meaningful deficits in instrumental ADLs (IADLs) or community function
• The scale scores basic ADL capacity and does not assess cognitive, communicative, or community function
• Point scoring is variable across items and emphasizes transfers, mobility, and toileting over other domains
• Scores obtained in clinical settings may not reflect performance in the patient's home environment
• Should be supplemented by the FIM, FAM, or community-function measures when a fuller picture is needed

1. Feeding (0, 5, or 10)
2. Bathing (0 or 5)
3. Grooming (0 or 5)
4. Dressing (0, 5, or 10)
5. Bowel movements (0, 5, or 10)
6. Bladder control (0, 5, or 10)
7. Toilet use (0, 5, or 10)
8. Transfers (bed to chair and back) (0, 5, 10, or 15)
9. Mobility on level surfaces (0, 5, 10, or 15)
10. Stair use (0, 5, or 10)

• 0-20: Total dependence
• 21-60: Severe dependence
• 61-90: Moderate dependence
• 91-99: Minimal dependence
• 100: Complete independence (for basic ADLs only)

2. Functional Independence Measure (FIM)

• Determining the level of functional dependence/independence in patients in inpatient rehabilitation settings
• Measuring rehabilitation outcomes in TBI, stroke, spinal cord injury, and other disabling conditions
• Tracking functional change over the course of an inpatient rehabilitation stay
• Calculating burden of care (more total assistance = higher burden)
• Predicting length of inpatient rehabilitation stay and discharge destination
• Research outcome measurement across rehabilitation populations

• The FIM rates observed performance, not capacity; it is less valid in inpatient settings with high levels of observation where the patient's actual everyday performance is seen rather than a standardized assessment
• Should not be used as the sole outcome measure for community-dwelling patients where IADLs and participation-level function are more relevant
• Patients in acute ICU phases with minimal ability to cooperate cannot be fully assessed on all 18 items

• Trained and certified raters are required for standardized administration; uncertified raters produce less reliable scores
• The FIM does not capture community or instrumental activities; the FAM must be added to address these domains
• Motor and cognitive subscores should be reported separately; the total score blends functionally distinct domains
• The scale has well-documented floor and ceiling effects at the extreme ends of function
• Environmental adaptations (equipment, home modifications) are not distinguished from true independence

• 7: Complete independence (timely, safely, no helper)
• 6: Modified independence (device used)
• 5: Supervision or setup only
• 4: Minimal assistance (patient performs ≥75%)
• 3: Moderate assistance (patient performs 50-74%)
• 2: Maximal assistance (patient performs 25-49%)
• 1: Total assistance (patient performs <25%)

3. Functional Assessment Measure (FAM)

• Supplementing the FIM to capture cognitive, behavioral, and community domains that the FIM alone does not address
• Comprehensive evaluation of individuals with TBI, stroke, or acquired brain injury in inpatient and transitional rehabilitation settings
• Measuring functional change over the course of inpatient rehabilitation when cognitive and community dimensions are clinically relevant
• Evaluating older adults in rehabilitation settings where cognitive and social function are important outcomes
• Research in brain injury rehabilitation where a more complete functional profile is required

• Should not be used independently from the FIM, as the FAM was designed as a supplement, not a standalone instrument
• Patients with severe communication impairment or profound cognitive impairment may be unable to be rated accurately on all 12 FAM items
• Not indicated when the primary concern is basic motor ADLs only (the FIM alone suffices in those cases)

• The FIM + FAM is a 30-item battery; administration is more time-intensive than the FIM alone and requires a trained rater
• Inter-rater reliability varies across FAM items; cognitive and behavioral items require experienced clinical judgment
• The FAM items use the same 7-point FIM scale, so rater certification for the FIM is a prerequisite
• Community and instrumental function items may be difficult to assess accurately in an inpatient or restricted clinical environment

• Community functioning: community access, car transfers, reading, writing, speech intelligibility, employability, orientation, attention, safety judgment, concentration
• Behavioral/emotional: emotional status, adjustment to limitations