Examining the Function In Sitting Test for Validity, Responsiveness, and Minimal Clinically Important Difference in Inpatient Rehabilitation

Published:August 23, 2014DOI:



      To determine the responsiveness of the Function In Sitting Test (FIST), compare scores at admission and discharge from inpatient rehabilitation (IPR) with other balance and function measures, and determine the minimal clinically important difference (MCID).


      Prospective, nonblinded, reference-standard comparison study.


      Four accredited inpatient rehabilitation units.


      Population-based sample of adults (N=125) with sitting balance dysfunction, excluding persons with spinal cord injury, significant bracing/orthotics, and inability to perform testing safely.


      Not applicable.

      Main Outcome Measures

      FIST, FIM, and Berg Balance Scale (BBS) at admission and discharge, and Global Rating of Change for function and balance at discharge.


      The FIST demonstrated good to excellent concurrent validity with the BBS and FIM at admission and discharge (Spearman ρ=.71–.85). Significant improvement (P<.000; 95% confidence interval [CI], 10.73–15.41) occurred in the FIST from admission (mean ± SD: 36.81±15.53) to discharge (mean ± SD: 49.88±6.90). The standard error of measurement for the FIST was 1.40, resulting in a minimal detectable change of 5.5 points. The receiver operator characteristic curve differentiated participants with meaningful balance changes (area under the curve, .78; P>.000; 95% CI, .66–.91), with a change in FIST score of ≥6.5 points designating the MCID. Findings support the strong responsiveness of the FIST during IPR as evidenced by the large effect size (.83), standardized response mean (1.04), and index of responsiveness (1.07).


      In this study, the FIST correlated well with balance and function measures (concurrent validity) and was responsive to change during IPR. A clinically meaningful change was indicated by an increase in score of ≥6.5 points.


      List of abbreviations:

      BBS (Berg Balance Scale), CI (confidence interval), ES (effect size), FIST (Function In Sitting Test), GRC (Global Rating of Change), IPR (inpatient rehabilitation), MCID (minimal clinically important difference), MDC (minimal detectable change), ROC (receiver operator characteristic), SRM (standardized response mean)
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        • Black K.
        • Zafonte R.
        • Millis S.
        • et al.
        Sitting balance following brain injury: does it predict outcome?.
        Brain Inj. 2000; 14: 141-152
        • Feigin L.
        • Sharon B.
        • Czaczkes B.
        • Rosin A.
        Sitting equilibrium 2 weeks after a stroke can predict the walking ability after 6 months.
        Gerontology. 1996; 42: 348-353
        • Agarwal V.
        • McRae P.M.
        • Bhardwaj A.
        • Teasell R.W.
        A model to aid in the prediction of discharge location for stroke rehabilitation patients.
        Arch Phys Med Rehabil. 2003; 84: 1703-1709
        • Wade D.T.
        • Skilbeck C.E.
        • Hewer R.L.
        • Wood V.A.
        Therapy after stroke: amounts, determinants and effects.
        Int Rehabil Med. 1984; 6: 105-110
        • Feld J.
        • Rabadi M.
        • Blau A.
        • Jordon B.
        Berg Balance Scale and outcome measures in acquired brain injury.
        Neurorehabil Neural Repair. 2001; 15: 239-244
        • Katz-Leurer M.
        • Fisher I.
        • Neeb M.
        • Schwartz I.
        • Carmeli E.
        Reliability and validity of the modified functional reach test at the sub-acute stage post-stroke.
        Disabil Rehabil. 2009; 31: 243-248
        • Gorman S.L.
        • Radtka S.
        • Melnick M.E.
        • Abrams G.M.
        • Byl N.N.
        Development and validation of the Function In Sitting Test in adults with acute stroke.
        J Neurol Phys Ther. 2010; 34: 150-160
        • Shumway-Cook A.
        • Woollacott M.H.
        Normal postural control. Motor control: theory and practical applications.
        3rd ed. Lippincott Williams & Wilkins, New York2007: 163-191
        • Amusat N.
        Assessment of sitting balance of patients with stroke undergoing inpatient rehabilitation.
        Physiother Theory Pract. 2009; 25: 138-144
        • Berg K.
        • Wood-Dauphinee S.
        • Williams J.I.
        The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke.
        Scand J Rehabil Med. 1995; 27: 27-36
        • Carr J.H.
        • Shepard R.B.
        • Nordholm L.
        • Lynne D.
        Investigation of a new motor assessment scale for stroke patients.
        Phys Ther. 1985; 65: 175-180
        • Verheyden G.
        • Nieuwboer A.
        • Merin J.
        • Preger R.
        • Kiekens C.
        • DeWeerdt W.
        The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke.
        Clin Rehabil. 2004; 18: 326-334
        • Medley A.
        • Thompson M.
        Development, reliability, and validity of the Sitting Balance Scale.
        Physiother Theory Pract. 2011; 27: 471-481
        • Lynch S.M.
        • Leahy P.
        • Barker S.P.
        Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury.
        Phys Ther. 1998; 78: 128-134
        • Newton R.A.
        Validity of the Multi-Directional Reach Test: a practical measure for limits of stability in older adults.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M248-M252
        • Collin C.
        • Wade D.
        Assessing motor impairment after stroke: a pilot reliability study.
        J Neurol Neurosurg Psychiatry. 1990; 53: 576-579
        • Duarte E.
        • Marco E.
        • Muniesa J.
        • et al.
        Trunk Control Test as a functional predictor in stroke patients.
        J Rehabil Med. 2002; 34: 267-272
        • Guccione A.A.
        • Scalzitti D.A.
        Examination of functional status and activity level.
        in: O'Sullivan S. Schmitz T.J. Fulk G.D. Physical rehabilitation. 6th ed. FA Davis, Philadelphia2014: 373-400
        • Gorman S.L.
        • Rivera M.
        • McCarthy L.
        Reliability of the Function In Sitting Test (FIST).
        Rehabil Res Pract. 2014; 2014: 593280
        • Mustille R.
        • Petersen H.
        • Abele J.
        • et al.
        A pilot study of the FIST as a functional outcomes measure in a neurological acute care population.
        J Acute Care Phys Ther. 2013; 4: 129-130
      1. Gorman S. Function In Sitting Test (FIST) web-based training. Available at: Accessed May 7, 2012.

        • Steiner W.A.
        • Ryser L.
        • Huber E.
        • Uebelhart D.
        • Aeschlimann A.
        • Stucki G.
        Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine.
        Phys Ther. 2002; 82: 1098-1107
        • Potter K.
        • Fulk G.
        • Salem Y.
        • Sullivan J.
        Outcome measures in neurological physical therapy practice: part I. Making sound decisions.
        J Neurol Phys Ther. 2011; 35: 57-64
        • Sullivan J.
        • Andrews A.
        • Lanzino D.
        • Peron A.
        • Potter K.
        Outcome measures in neurological physical therapy practice: part II. A patient-centered process.
        J Neurol Phys Ther. 2011; 35: 65-74
        • Fulk G.
        • Field-Fote E.
        Measures of evidence in evidence-based practice.
        J Neurol Phys Ther. 2011; 35: 55-56
      2. Centers for Medicare and Medicaid Services (CSM). Inpatient rehabilitation facility prospective payment system. Memo on inpatient rehabilitation facility PPS and the 75% rule. Available at: Accessed March 10, 2011.

      3. MedPac. Chapter 9. Inpatient rehabilitation facility services: assessing payment adequacy and updating payments. Available at: Accessed May 31, 2012.

        • Tinetti M.E.
        Performance-oriented assessment of mobility problems in elderly patients.
        J Am Geriatr Soc. 1986; 34: 119-126
        • Verheyden G.
        • Nieuwboer A.
        • De Weerdt W.
        Clinical tools to measure trunk performance after stroke: a systematic review of the literature.
        Clin Rehabil. 2007; 21: 387-394
        • Carter R.E.
        • Lubinsky J.
        • Domholdt E.
        Methodological research. Rehabilitation research: principles and applications.
        4th ed. Saunders, St. Louis2011: 245-253
        • Portney L.G.
        • Watkins M.P.
        Statistical measures of validity. Foundations of clinical research: applications to practice.
        3rd ed. Pearson Prentice Hall, Upper Saddle River2009
      4. Time and Date AS. Date duration calculator: days between two dates. Available at: Accessed July 9, 2012.

      5. Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM Instrument), version 5.1. State University of New York at Buffalo, Buffalo1997
        • Tyson S.F.
        • DeSouza L.H.
        Reliability and validity of functional balance tests post stroke.
        Clin Rehabil. 2004; 18: 916-923
        • Blum L.
        • Korner-Bitensky N.
        Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review.
        Phys Ther. 2008; 88: 559-566
        • Beaton D.
        • Boers M.
        • Wells G.
        Many faces of the minimal clinically important difference (MCID): a literature review and directions for future research.
        Curr Opin Rheumatol. 2002; 14: 109-114
        • Juniper E.
        • Guyatt G.
        • Willan A.
        • Griffith L.
        Determining a minimal important change in a disease-specific quality of life questionnaire.
        J Clin Epidemiol. 1994; 47: 81-87
        • Doyle C.
        • Crump M.
        • Pintilie M.
        • Oza A.M.
        Does palliative chemotherapy palliate? Evaluation of expectations, outcomes, and costs in women receiving chemotherapy for advanced ovarian cancer.
        J Clin Oncol. 2001; 19: 1266-1274
        • Kamper S.
        • Maher C.
        • Mackay G.
        Global Rating of Change Scales: a review of strengths and weaknesses and considerations for design.
        J Man Manip Ther. 2009; 17: 163-170
        • Jewell D.V.
        Unraveling statistical mysteries. In: Jewell DV, editor. Guide to evidence-based physical therapist practice.
        2nd ed. Jones and Bartlett, Sudbury2011 (p. 181-219)
        • Guyatt G.
        • Walter S.
        • Norman G.
        Measuring change over time: assessing the usefulness of evaluative instruments.
        J Chronic Dis. 1987; 40: 171-178
        • Kovacs F.
        • Abraira V.
        • Royuela A.
        • et al.
        Minimum detectable and minimal clinically important changes for pain in patients with nonspecific neck pain.
        BMC Musculoskelet Disord. 2008; 9: 43
        • Terwee C.
        • Bot S.
        • deBoer M.
        • et al.
        Quality criteria were proposed for measurement properties of health status questionnaires.
        J Clin Epidemiol. 2007; 60: 34-42
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale.
        Lancet. 1974; 2: 81-84
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research: applications to practice.
        3rd ed. Pearson Prentice Hall, Upper Saddle River2008
        • Husted J.A.
        • Cook R.J.
        • Farewell V.T.
        • Gladman D.D.
        Methods for assessing responsiveness: a critical review and recommendations.
        J Clin Epidemiol. 2000; 53: 459-468
        • Beninato M.
        • Portney L.G.
        Applying concepts of responsiveness to patient management in neurologic physical therapy.
        J Neurol Phys Ther. 2011; 35: 75-81
        • Jewell D.V.
        Appraising evidence about diagnostic tests and clinical measures. Guide to evidence-based physical therapist practice.
        2nd ed. Jones and Bartlett, Sudbury2011: 223-254
      6. Rehabilitation measures database. Statistics review. Available at: Accessed August 6, 2013.

        • Campo M.
        • Shiyko M.
        • Lichtman S.
        Sensitivity and specificity: a review of related statistics and controversies in the context of physical therapist education.
        J Phys Ther Educ. 2010; 24: 69-78
        • Stevenson T.
        Detecting change in patients with stroke using the Berg Balance Scale.
        Aust J Physiother. 2001; 47: 29-38
        • Mao H.F.
        • Hsueh I.P.
        • Tang P.F.
        • Sheu C.F.
        • Hsieh C.L.
        Analysis and comparison of the psychometric properties of three balance measures for stroke patients.
        Stroke. 2002; 33: 1022-1027
        • Wood-Dauphinee S.
        • Berg K.
        • Bravo G.
        • Williams J.I.
        The Balance Scale: responsiveness to clinically meaningful changes.
        Can J Rehabil. 1997; 10: 35-50
        • Chou C.
        • Chien C.
        • Hsueh I.
        • Sheu C.
        • Wang C.
        • Hsieh C.
        Developing a short form of the Berg Balance Scale for people with stroke.
        Phys Ther. 2006; 86: 195-204
        • Schmitt J.
        • Abbott J.
        Patient global ratings of change did not adequately reflect change over time: a clinical cohort study.
        Phys Ther. 2014; 94: 534-542
        • Cook C.
        Clinimetrics corner: the minimal clinically important change score (MCID): a necessary pretense.
        J Man Manip Ther. 2008; 16: E82-E83