Functional assessment of SCI patients by FIM: yes or no?

We read the article by Yasar et al.¹ with interest and concern. They used the functional independence measure (FIM) score as an outcome measure to investigate the effect of FES (functional electrical stimulation) cycling on late functional improvement in spinal cord injury (SCI). The FIM is an 18-item ordinal scale including assessment of motor and cognitive items.² The FIM was developed to assess the disability in patients with stroke and their requirements for burden of care. This instrument has already been used in the assessment of disability of SCI;³ however, at the moment, some outcome measures could be used that are more valid, reliable and responsive for SCI. Cognitive items of FIM have low internal consistency and are not sensitive to change in SCI.⁴ Therefore, it may be better to ignore the cognitive subscale portion in SCI subjects. Moreover, FIM scores are influenced by ceiling and floor effects for differing lesion levels (an effect whereby the instrument cannot detect changes in response on a value higher/lower than some ceiling/floor).⁵ Also, on the basis of some studies, FIM is not sufficiently a reflection of functional recovery.⁴ On the other hand, it has been showed that the spinal cord independence measure (SCIM III) is the most reliable, valid and sensitive measure of global disability that exists for SCI.^{5, 6} Accordingly, the use of SCIM as the primary outcome measure to assess functional recovery is recommended instead of FIM.