For self-care items the group mean FIM scores on admission ranged from 3.57 to 4.96 and at the time of discharge varied between 5.64 and 6.50. The low scores for dressing of the lower body, toileting and bathing reflect difficulty not only with ambulation but also with reaching and postural balance, continuing problems which lead to lower discharge FIM scores for these items. Nevertheless, the change in group mean FIM score from admission to discharge is statistically significant for each of the self-care items.
For bowel and bladder management the group mean FIM scores on admission (4.79 and 5.07) are indicative of the need for supervision, help to set up equipment or incidental help with placement of clothes. Again, the group mean FIM score on discharge shows a statistically significant increase.
On admission, group mean FIM scores are lowest for bath transfer (3.64) followed by toilet transfer (3.86) and bed–chair transfer (3.93) as physical help, with lifting, from the attendant was required. The lower group mean discharge FIM score for bathing (5.64) is owing to the need for supervision or help to set up the necessary equipment despite statistically significant increase in FIM scores across the board for all transfers.
As expected, the lowest group mean FIM score on admission is for stairs (1.79) as patients are unable to manage stairs without assistance of two persons and also requiring assistance for ambulation (3.75). Gratifyingly, by the end of inpatient rehabilitation the scores have improved to 4.79 and 6.07 respectively although the need for contact guarding or steadying to go up and down 12 to 14 stairs remains.
The group mean FIM scores for items of communication and social cognition varied between 6.14 for problem solving to 6.58 for expression on admission and between 6.68 for problem solving to 6.93 for memory at the time of discharge. The increase was statistically significant for all items except comprehension and expression.
FIM scores in ventilated versus not-ventilated patients
Those who were ventilated in the acute phase of the illness had lower total FIM scores and Cognitive FIM subscale scores on admission than those who were not ventilated (U = 35.0, P = 0.041;U = 21.5, P = 0.005 respectively). Ventilated patients also had lower motor FIM subscale score on admission than those who were not but the difference was not significant (U = 44.5, P = 0.124).
At discharge the difference between the two groups for Total FIM score, Cognitive FIM subscore and Motor FIM subscore was not significant (U = 70.0, P = 0.852;U = 53.0, P = 0.215;U = 72.5, P = 0.957 respectively).
Length of stay in ventilated versus not-ventilated patients
Ventilated patients had longer inpatient rehabilitation but the difference was not statistically significant.
Length of stay and FIM score
There was a significant correlation between length of stay in the rehabilitation unit and Total FIM scores on admission and discharge. Patients with longer length of stay had lower admission Total FIM scores and discharge Total FIM scores (r s = – 0.678, P < 0.001; and r s = – 0.581, P = 0.001 respectively).
Antecedent infection/inoculation and FIM score
There were no significant differences between patients who had antecedent infection/inoculation and those who had none on admission or discharge FIM scores
There were no significant correlations with length of time between onset and disease nadir and Total FIM score, Cognitive FIM subscore or Motor FIM subscore either on admission or discharge from the unit.
The results show a significant improvement in all areas of function, as measured on the FIM between admission to and discharge from the rehabilitation unit (Total FIM, Cognitive FIM subscore and Motor FIM subscores being Z = – 4.62, P < 0.001; Z = – 3.75, P < 0.001; Z = – 4.54, P < 0.001 respectively).
Analysis of motor FIM subscore domains showed an especially significant improvement in function over mobility, self-care and sphincter domains (Mobility items score P < 0.001; self-care items score Z = – 4.29, P < 0.001; Sphincter items score Z = – 3.60, P < 0.001).
Quantification of function has become a basic tool in everyday rehabilitation work, inpatient selection before admission and in monitoring progress during treatment.
Unfortunately, textbooks and review articles concentrate on motor impairments, clinical features, complications and treatment modalities in GBS. In an acute rehabilitation setting FIM is one of the most widely used instruments for determining patients’ rehabilitation relevant clinical status (Fiedler et al., 1996). Several studies have demonstrated the interrater reliability of the FIM (Hamilton et al., 1994).
Meythaler et al. (1997) have looked at prognostic factors such as anaemia, dysautonomia, peripheral nerve function, disease nadir and ventilator support and their relationship to acute care length of stay, rehabilitation length of stay, FIM Rasch converted scores and cost of acute care and inpatient rehabilitation, while we have focused on inpatient rehabilitation length of stay because of the obvious implication it has on bed occupancy in these days of bed crisis.
In agreement with Meythaler et al., we found no correlation between disease nadir and inpatient rehabilitation stay. We also found that patients requiring ventilation had lower motor and cognitive FIM subscale score on admission to inpatient rehabilitation but by the time of discharge the difference was not statistically significant.
However, unlike them, we found that although ventilated patients had longer inpatient rehabilitation, this difference was not statistically significant. Some of the discrepancy might be owing to the fact that their patients had both acute care and inpatient rehabilitation in the same centre, implying seamless care, while our cohort had their acute care in the neurology ward of another tertiary care hospital before transfer to us.
Additionally, unlike them we have concentrated on the most finely grained individual FIM item score along with scores of the ADL and mobility domains of the motor subscale of FIM as well as cognitive subscale of FIM and their correlation to length of inpatient rehabilitation, as it is more reflective of the evolving functional profile during rehabilitation
As expected, activities in the mobility subscale, being dependent on the use of legs, were most severely affected. Not surprisingly, activities of self-care domain, which depend more on the use of arms, were also considerably affected, as were transfers, which depended on the use of both arms and legs.
The improvement in the physical functioning had an indirect effect on the cognitive items with the most pronounced result seen in social interaction
Change over time was related to degree of disability on admission. As expected, change over time was smallest on the cognitive items but the results still showed a significant improvement. While there has been no statistically significant correlation between factors such as prodromal symptoms, disease nadir, ventilation and outcome, FIM as an instrument is sufficiently sensitive in detecting disability and change over time during the rehabilitation of GBS patients. Moreover, not only Total FIM score but also Cognitive FIM subscore and Motor FIM subscore as well as mobility, self-care and sphincter domains of Motor FIM subscore reflect this in GBS patients in a rehabilitation setting.
1. Asbury, A.K. and Cornblath, D.R. ( 1990). Assessment of current diagnostic criteria for Guillain Barré syndrome
. Annals of Neurology 27 ( Suppl.):521–524.
2. Fiedler, R.G., Granger, C.V. and Ottenbacher, R.J. ( 1996). The uniform data system for medical rehabilitation
: report of first admissions for 1994. American Journal of Physical Medicine and Rehabilitation
3. Hamilton, B.B., Laughlin, J.A., Fiedler, R.C. and Granger, C.V. ( 1994). Interrater reliability of the 7 level Functional Independence Measure
(FIM). Scandinavian Journal of Rehabilitation
4. Meythaler, J.M., Devivo, M.J. and Braswell, W.C. ( 1997). Rehabilitation
outcomes of patients who have developed Guillain Barré syndrome
. American Journal of Physical Medicine and Rehabilitation
76 ( 5):411–419.
5. Molenaar, D.S., de Haan, R. and Vermeulen, M. ( 1995). Impairment, disability
or handicap in peripheral neuropathy: analysis of the use of outcome measures in clinical trials in patients with peripheral neuropathies. Journal of Neurology, Neurosurgery, and Psychiatry 59 ( 2):165–169.
6. Raphael, J.C., Masson, C., Morice, V., Bronel, D. and Goulon, M. ( 1984). Le syndrome de Guillain Barré: étude retrospective de 233 observations. Sem Hop Pares 60:2543–2546.
7. Ropper, A.H. ( 1992). The Guillain Barré Syndrome
. New England Journal of Medicine 326:1130–1136.
8. Stineman, M.G., Jette, A., Fiedler, R. and Granger, C. ( 1997). Impairment Specific Dimensions within the Functional Independence Measure
. Archives of Physical Medicine and Rehabilitation
9. Winer, J.B., Hughes, R.A.C. and Osmond, C. ( 1988). A prospective study of acute idiopathic neuropathy: clinical features and their prognostic value. Journal of Neurology, Neurosurgery, and Psychiatry 51:605–612.
10. Zelig, G., Ohry, A., Shemesh, Y., Bar-on, Z., Blumen, M. and Brooks, M.E. ( 1988). The rehabilitation
of patients with severe Guillain Barré syndrome
. Paraplegia 26 ( 4):250–254.
Keywords:© 2001 Lippincott Williams & Wilkins, Inc.
cognitive; disability; Functional Independence Measure; Guillain Barré syndrome; motor; rehabilitation