Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2014;95:2304-11

ORIGINAL ARTICLE

Examining the Function In Sitting Test for Validity,

Responsiveness, and Minimal Clinically Important
Difference in Inpatient Rehabilitation
Sharon L. Gorman, PT, DPTSc, GCS,a Cathy C. Harro, PT, MS, NCS,b
Christina Platko, PT, DPT,c Cara Greenwald, PT, DPTd
From the aDepartment of Physical Therapy, Samuel Merritt University, Oakland, CA; bPhysical Therapy Department, Grand Valley State
University, College of Health Professions, Grand Rapids, MI; cPhysical Therapy Department, Mary Free Bed Rehabilitation Hospital, Grand
Rapids, MI; and dPhysical Therapy Department, Alta Bates Summit Medical Center, Herrick Campus, Berkeley, CA.

Abstract
Objectives: 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).
Design: Prospective, nonblinded, reference-standard comparison study.
Setting: Four accredited inpatient rehabilitation units.
Participants: Population-based sample of adults (NZ125) with sitting balance dysfunction, excluding persons with spinal cord injury, significant
bracing/orthotics, and inability to perform testing safely.
Interventions: 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.
Results: The FIST demonstrated good to excellent concurrent validity with the BBS and FIM at admission and discharge (Spearman rZ.71e.85).
Significant improvement (P<.000; 95% confidence interval [CI], 10.73e15.41) 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, .66e.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).
Conclusions: 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.
Archives of Physical Medicine and Rehabilitation 2014;95:2304-11
2014 by the American Congress of Rehabilitation Medicine

Sitting balance is an important requisite for functional activities
and is frequently impaired after neurologic insult.1 Studies2-4
indicate that sitting balance is a substantial predictor of func-
tional recovery after stroke and brain injury. Sitting balance at
Presented using an interim data analysis (nZ51) to the World Congress of the International
Society for Physical and Rehabilitation Medicine, June 19, 2013, Beijing, China.
Disclosures: S.L.G. reports personal fees from the following: Acute Care SectioneAmerican
Physical Therapy Association; Northern California Geriatric Education Center, University of
California, San Francisco; Sutter Sacramento; Kaiser Permanente, Northern California; and
Rehabilitation Education Formula, outside the submitted work. The other authors have nothing to
disclose.
hospital admission is a strong predictor of standing balance and
functional recovery at discharge from inpatient rehabilitation
(IPR).1,5,6 Early sitting balance ability is also predictive of
walking outcomes 6 months poststroke.2 However, there are no
criterion assessments to specifically measure seated postural
control. Commonly used clinical balance tools incorporate limited
items specifically related to sitting balance or do not isolate sitting
balance abilities.7-11 The Trunk Impairment Scale,12 Sitting Bal-
ance Scale,13 Functional Reach Test,14,15 and Trunk Control
Test16,17 may only capture limited functional aspects and are not
validated in IPR. Common clinical practice for sitting balance

0003-9993/14/$36 - see front matter 2014 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2014.07.415

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Function in sitting test validity and responsiveness 2305

assessment includes use of global ratings, a description of sitting

Table 1 Participant demographics
performance, or both, but there are reliability issues and a lack of
consensus using these qualitative assessments.18 The Function In Characteristics No. %
Sitting Test (FIST) was developed to provide an objective measure Medical diagnosis Stroke 80 64
of sitting balance.7 (nZ125) Cancer and/or tumor 12 9.6
The FIST, designed as a short test of sitting balance after acute resection
stroke, consists of 14 functional sitting tasks quantifying perfor- Traumatic brain injury 12 9.6
mance while addressing the complex interactions between Nontraumatic brain 5 4.0
postural control and function.7 The FIST demonstrates excellent injury
intra- and interrater reliability with minimal online training, can Deconditioning 2 1.6
be administered at the bedside or in the therapy gym, and Guillain-Barre syndrome 2 1.6
generally takes less than 10 minutes to administer and score.19-21 Hydrocephaly 2 1.6
The 14 FIST test items consist of static sitting balance (sitting Encephalitis 2 1.6
quietly, eyes closed, turning head, lifting foot), reactive nudges CIDP 2 1.6
(lateral, anterior, posterior), dynamic balance (pick up item from Arteriovenous 1 0.8
floor, forward reach, pick up item from behind, lateral reach), and malformation
seated scooting (lateral, anterior, posterior). The FIST bridges Multiple sclerosis 1 0.8
gaps between simple observations about sitting balance and bal- Parkinsons disease 1 0.8
ance measures more heavily weighted toward standing balance or Hemicolectomy 1 0.8
gait. By incorporating common functional movements, the FIST Medically complex 1 0.8
measures sitting at the activity level within the International with falls
Classification of Functioning, Disability and Health framework,22 Cardiac condition, not 1 0.8
something increasingly needed to plan treatment and assess specified
rehabilitation outcomes.23-25 Comorbidities, no. Cardiovascular system 180 38.9
Qualifying diagnoses for admission to IPR include diseases or reported by body Neurologic system 78 16.9
disorders of the central nervous system, such as stroke and trau- system involved Endocrine system 52 11.2
matic brain injury.26,27 Individuals with these commonly (nZ463)* Other (visual, 41 8.7
encountered diagnoses often have difficulty with sitting balance hemopoietic,
and are working on recovery of balance.15,28,29 Clinicians need an integumentary,
objective, reliable, and valid clinical measure to assess sitting hepatic)
balance abilities in IPR. The clinical outcome measure can then be Musculoskeletal system 40 8.6
used to design appropriate treatments and monitor balance out- Renal/genitourinary 28 6.0
comes during rehabilitation. Previous research supported the system
reliability of the FIST, as well as its construct, content, and con- Gastrointestinal system 26 5.6
current validity in adults with neurologic dysfunction in acute Pulmonary system 18 3.9
care.7,19 Research is needed to validate the FIST in IPR. Addi- TBI severity rating Mild 2 1.6
tionally, the ability of the FIST to detect change over time has not (nZ12)y Moderate 4 3.2
been examined. Therefore, the objectives of this study were (1) to Severe 6 4.8
evaluate concurrent validity by comparing FIST performance with Discharge disposition Home 32 25.6
other accepted measures of balance and function; (2) to examine (nZ125) Home with assist 61 48.8
the responsiveness of FIST scores during IPR; and (3) to estimate Skilled nursing facility 21 16.8
the minimal clinically important difference (MCID) in the FIST. Acute care 3 2.4
Assisted living/board 3 2.4
Methods and care
Subacute rehab 3 2.4
Design Transitional living 2 1.6
Cognitive, affective, Yes 36 30
A prospective, reference-standard comparison design was used.30 memory deficits No 84 70
Four accredited Commission on Accreditation of Rehabilitation impairing use of GRC
Facilities IPR centers in different regions of the United States scales (at discharge)
(nZ120)
List of abbreviations:
Abbreviations: CIDP, chronic inflammatory demyelinating poly-
BBS Berg Balance Scale neuropathy; TBI, traumatic brain injury.
CI confidence interval * Participants could have multiple comorbidities in the same body
ES effect size system.
FIST Function In Sitting Test y
TBI severity ratings based on initial Glasgow Coma Scale score:
GRC Global Rating of Change severe, 8; moderate, 9e12; mild, 13e15.
IPR inpatient rehabilitation
MCID minimal clinically important difference
MDC minimal detectable change
participated in this study with approval of their institutional re-
ROC receiver operator characteristic
view boards. Standardized methodological procedures were
SRM standardized response mean
applied across sites. The a priori power analysis showed that a

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2306 S.L. Gorman et al

sample size of 120 was necessary to detect an effect size of 0.5

with a beta level of 0.8 and an alpha level of .05.30,31

Therapist GRC-
Participants

2.21
0.86
(e3 to 3)

nZ121
Balance*

(0e3)
All patients admitted to 4 IPR programs were screened for eligi-
bility based on the following inclusion criteria: (1) 18 years of

NA
NA
age; (2) sitting balance deficit identified by a physical therapist;
and (3) the ability to understand English to participate in the
consent process. Exclusion criteria included the following: (1)
medical condition(s) preventing testing procedures such as
weight-bearing restrictions, or medical status precluding sitting/

Therapist GRC-
standing activities; (2) severe cognitive/language deficits limiting

2.33
0.79
Function*
(e3 to 3)

nZ120
the participants ability to follow simple directions, as determined

(0e3)
by a speech-language pathologists evaluation; (3) diagnosis of

NA
NA
spinal cord injury; (4) use of cervical, thoracic, or lumbar bracing/
orthotics limiting neck or trunk mobility; and (5) use of knee-
ankle-foot orthoses for stabilization of the lower extremities. All

GRC-Balance*
participants or their legally authorized representatives voluntarily

2.42
0.85
(3 to 3)

nZ119
(0e3)
gave written and verbal informed consent.

Patient

NA
NA
Measures
Demographic and pertinent medical information was collected
from the patients medical records after informed consent and
study enrollment, including the admission diagnosis, comorbid

Patient GRC-
diagnoses, age, and sex. Calculation of length of stay was

2.62
0.75
(3 to 3)
Function*

nZ118
performed using the IPR admission and discharge dates.32

(0e3)
Primary outcome measures for this study included the FIST,
FIM,33 and Berg Balance Scale (BBS).10 Both the FIM and

NA
BBS are used in standard clinical practice in IPR and have been NA
found to be reliable and valid to assess function and balance in
FIM Motor (13e91)

the IPR population.1,5,34,35 Since there is no criterion standard

(e19 to 56)
measure for sitting balance, these 2 outcomes, both well-
30.73
12.96

58.20
17.01
27.76
12.77

(19e91)
supported reference measures, were selected to examine the
nZ124
nZ124

nZ125
(9e67)

association of the FIST with balance and function. Because the

FIST was designed as a functional test of sitting balance,
comparing it to both a surrogate measure of balance (BBS) and
function (FIM) was determined to best elucidate the relation-
ship of FIST to both of these constructs. The total FIM and
FIM Total (18e126)

motor FIM data were obtained, with each section scored by a

(e15 to 72)

professional specializing in the respective content area. Par-

50.18
16.90

84.64
21.79
34.84
15.17

(34e126)
(15e97)

ticipants had baseline measures collected during the first 5 days

nZ124

nZ125
nZ124
Distribution of FIST, BBS, FIM, and GRC scores

of IPR admission, and discharge measures collected within 3

days of discharge. Some participants who initially had language
issues, cognitive issues, or both on admission but otherwise
satisfied both inclusion and exclusion criteria were offered the
12.92
14.08

29.63
17.21
16.32
12.39

opportunity for late study enrollment once they could follow

BBS (0e56)

nZ125

nZ119
nZ119
(0e54)

(3e56)
(0e51)

simple commands.
The participants and their primary physical therapist
* Only measured at time of discharge.
NOTE. Values are mean
SD (range).

completed a Global Rating of Change (GRC) scale for both bal-

ance and function at the time of discharge.36-38 Two separate GRC
Abbreviation: NA, not applicable.

questions read: Since your admission to this IPR facility, has

36.50
15.69

13.07
12.81
(e1 to 56)
FIST (0e56)

49.88
6.9

there been any change in your OVERALL physical function/

(25e56)
nZ125

nZ117
nZ118
(0e56)

ability to balance yourself? Responses were scored on a 7-point

Likert scale: much worse, moderately worse, a little worse, no
change, a little better, moderately better, or much better.39 To
account for potential recall, judgment, and/or memory issues
confounding participant responses, both the primary physical
Admission

Discharge
Table 2

score

score
score
Change

therapist and participants completed the GRC ratings. Addition-

Scores

ally, the therapist indicated whether the participant had cognitive,

affective, or memory deficits, as determined by a speech-language

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Function in sitting test validity and responsiveness 2307

Fig 1 Changes in outcome measures from admission to discharge. *P<.000; **P<.001; ***P<.05. GRC of participant used if no potential
recall/judgment/memory issues; composite GRC (average of participant and therapist) if recall/judgment/memory issues present.

pathologists evaluation, that may have interfered with the par-
ticipants ability to complete the GRC questions.
To ensure accurate data collection and standardization across
the study sites, all physical therapists collecting data, approxi-
mately 20 across 4 sites, completed inservice training conducted
by the research team before enrollment of participants, success-
fully completed their yearly FIM certification, and had prior
clinical experience administering the BBS. Therapists completed a
web-based training in FIST administration and scoring,21 followed
by a 1-hour inservice. This partially standardized approach most
closely resembles a realistic training methodology common in
clinical settings.30
Data analysis
All completed participant data sheets were de-identified before
being sent for data management and analysis using IBM SPSS
Statistics, version 22 (2013).a Descriptive statistics were analyzed
for participant demographics, length of stay, and the 3 outcome
measures. To examine the concurrent validity of the FIST with
reference measures, Spearman rank correlation coefficients were
calculated between the FIST, BBS, and FIM scores.30,31
Nonparametric correlational tests were selected because of the
ordinal nature of the data. Paired t tests were analyzed to examine
whether there were any significant differences in the 3 outcome
measures from admission to discharge. Significance for all sta-
tistical tests used was set at an alpha level of .05, with a 95%
confidence interval (CI).
GRC ratings were used to assess whether there was a
meaningful change in balance, function, or both during IPR. The
ratings of both therapists and participants were collected
because of concern about the ability of those participants with
cognitive deficits, as determined by a speech-language pathol-
ogists evaluation, to validly assess change. To determine
whether there was a significant difference in GRC ratings of
balance and function between the participants and therapists
ratings in the subgroup with potential confounding cognitive
status, Wilcoxon signed-rank test were analyzed. If a significant
difference was found, a composite GRC rating for participants
who were identified with cognitive deficits was calculated by
averaging the therapists and participants ratings. This more
conservative method preserved the participants perspective,
while tempering it with the therapists views on their
improvement in light of their potentially confounding cognitive
status. In the subgroup without cognitive impairment, the par-
ticipants ratings were used to preserve the intent of the GRC
methodology at ascertaining the participants perspective on
recovery. Meaningful improvement was defined as a GRC score

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2308 S.L. Gorman et al

minimized to identify the FIST change score cutoff for partici-

Table 3 Responsiveness of measures
pants with meaningful GRC improvement (2) to determine the
Measures ES SRM MCID in the FIST score.
All participants
FIST (nZ118) 0.83 1.04 Results
BBS (nZ119) 1.16 1.34
FIM motor (nZ124) 2.06 2.15 This study enrolled 125 participants over a 23-month period, with
FIM total (nZ124) 2.14 2.27 complete data collected on 118 participants. Two participants
Positive meaningful improvement were discharged to acute care (1 died, 1 discharged to skilled
in function (composite nursing), while 5 participants had an unexpected discharge
GRC2, nZ104) resulting in incomplete discharge data. Only 2 participants were
FIST 0.86 0.99 enrolled under the late enrollment protocol. Table 1 summarizes
BBS 1.27 1.44 the participants demographics. Overall, participants had an
FIM motor 2.27 2.55 average age
SD of 60
16.63 years (range, 18e94y), and 56%
FIM total 2.18 2.72 (nZ70) of the participants were men. Admitting diagnoses were
Positive meaningful improvement diverse, with 64% of participants recovering from stroke and 10%
in balance (composite with traumatic brain injury, half of whom were classified as se-
GRC2, nZ97) vere based on evaluation with the Glasgow Coma Scale at the
FIST 0.90 1.06 time of acute care admission.44 Participants had complex medical
BBS 1.28 1.58 histories, as evidenced by their comorbidities, with more than one
FIM motor 2.21 2.89 third of the comorbidities representing cardiovascular problems.
FIM total 2.32 3.03 The average
SD length of stay in IPR was 26
16.33 days, with
a large range (3e118d). The distribution of participants scores on
NOTE. The standard for large ES and SRM is 0.8; all ESs and SRMs the studys outcome measures at IPR admission and discharge are
exceeded the standards for large estimates of change.31
found in table 2.
Spearman rank correlation coefficients revealed that at admis-
sion, the FIST showed excellent concurrent validity with the BBS
2, corresponding to moderately better or much better. An (rZ.851, P<.000), and moderate to good validity with the FIM
independent t test was analyzed to examine whether there was a motor (rZ.712, P<.000) and FIM total scores (rZ.749, P<.000).45
difference in the mean FIST change score between those par- Similar correlations were found at discharge between the FIST and
ticipants with meaningful improvement (2) and those without BBS (rZ.801, P<.000), FIM motor (rZ.786, P<.000), and FIM
meaningful improvement (<2). total score (rZ.769, P<.000), supporting the concurrent validity of
Distribution-based methods were used to examine the the FIST with balance and functional measures.
responsiveness of the FIST during IPR. Effect size (ES) and A statistically significant difference was found in GRC balance
standardized response mean (SRM) were calculated (using this (P<.005) and function (P<.000) scores between participants and
studys reliability results) for the FIST and the reference mea- the therapists ratings (see table 2). Therefore, for participants
sures.40 ES and SRM were also calculated for those participants with cognitive deficits potentially affecting GRC ratings (nZ36),
who reported meaningful changes in balance (GRC2). Addi- composite GRC ratings were calculated, whereas for those par-
tionally, the index of responsiveness for the FIST was calculated ticipants without cognitive deficits potentially interfering with
applying Guyatts method,41 using the mean FIST score of par- GRC ratings (nZ84), the participants ratings were used in data
ticipants who had positive meaningful balance improvement and analysis. Table 2 summarizes GRC scores for balance and func-
the SD of FIST scores for those who did not have meaningful tion. GRC ratings revealed that 81.5% of the participants had
balance improvement. meaningful improvement in balance, 88.9% had meaningful
Mathematical distribution methods were applied to determine improvement in function, and no participants reported getting
the standard error of measurement of the FIST, and using a 95% worse in either balance or function. A statistically significant
CI, the minimal detectable change (MDC) for FIST scores.42 difference was found (2-tailed, PZ.048; 95% CI, .054e12.10) in
Because of a lack of a clear standard in the literature for deter- the mean
SD FIST change scores between those with mean-
mining floor and ceiling effects, for this study the MDC was used ingful balance improvement (14.32
13.51) and those with no
to analyze potential floor or ceiling effects of the FIST at admis- balance improvement (8.19
8.00).
sion and discharge. FIST scores classified in the ceiling range fell There was significant improvement found (P<.000) in all 3
within the maximal total FIST score minus MDC (56 points  outcome measures from admission to discharge, reflecting a
MDC). FIST scores classified in the floor range fell within the measurable change in balance and function during IPR (fig 1).
minimum FIST score plus the MDC (0 MDC). Fifteen percent Specific to this studys purpose, there was a significant improve-
of the study sample was used as the cutoff score for positive floor ment in FIST scores from admission to discharge (P<.000; 95%
or ceiling effects of the target test.43 CI, 10.73e15.41), with a mean
SD change of 13.07
12.81
A receiver operator characteristic (ROC) curve was used to points out of a possible 56 points.
examine whether there was a clinically meaningful difference in Strong responsiveness of the FIST during IPR was evident as
the FIST change score in participants with meaningful GRC both the calculated ES (.83) and SRM (1.04) reflected large esti-
changes (GRC2) and those without meaningful changes mates of change based on reported thresholds.31,46-48 The ES and
(GRC<2) over the course of IPR. If a significant difference was SRM for the BBS and FIM also reflected large estimates of
found, by using the ROC curve characteristics of FIST change change. The ES and SRM for participants who reported a mean-
scores, sensitivity was maximized and 1 minus specificity was ingful change in balance (GRC2) were .90 and 1.06,

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Function in sitting test validity and responsiveness
respectively, which reflected an even higher change estimate than
the total sample (table 3). The index of responsiveness of the FIST
was 1.27, which is considered a large change.41
The standard error of measurement of the FIST was calcu-
lated at 1.40, and using a 95% CI, the MDC of the FIST is 5.50
(out of 56 points).41 At admission, 5 participants scores (4%)
fell within the floor range (0e5 points), and no participants
scores fell within the ceiling range (51e56 points) on the FIST.
At discharge, no participants scores fell within the floor range,
and 30 participants scores (29%) fell within the ceiling range
on the FIST. With the use of 15% of the study population as a
cutoff for positive floor or ceiling effects,49 no floor effect was
noted at admission, and a ceiling effect (29%) was noted at
discharge for the FIST. Conversely for the BBS, the same pro-
cedure found 51.2% with a floor effect on admission, and 11.1%
had a ceiling effect on discharge.
The ROC curve was calculated using the FIST change score
during IPR (fig 2). Because of the ceiling effect, calculation of an
ROC curve required removing participants whose discharge FIST
score placed them within the MDC of highest score on the FIST
(nZ30). The ROC curve differentiated participants with mean-
ingful changes in balance (GRC2) from those without mean-
ingful balance changes (area under the curve, .78; P>.000; 95%
CI, .66e.91).45 The ROC curve was used to maximize the sensi-
tivity at .93 and minimize 1 minus specificity at .53 (table 4),
corresponding to a change in FIST score of >6.5 points (out of
56), which can be considered to be the MCID for the FIST in the
IPR setting.50
Discussion
The results from this current study provide evidence supporting
the concurrent validity and responsiveness of the FIST in a
Fig 2 ROC curve for change in FIST score for participants with
meaningful change in balance over the course of IPR. Area under the
curve, .78; P<.000; 95% CI, .66e.91.
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2309
diverse, representative sample of persons undergoing IPR. These
findings expand on the initial validation study7 of the FIST in the
acute care setting. This study establishes an MDC of the FIST of
6 points, with an MCID of 7 points (out of a possible 56 points
total on the FIST). This studys findings provide evidence of
excellent concurrent validity of the FIST with the BBS, and good
concurrent validity with the FIM, which helps to validate the FIST
as an activity-based measure of balance. The stronger correlation
between the FIST and BBS may reflect that the FIST is more
directly related to balance abilities. Although the FIST in-
corporates functional tasks in sitting, which are foundational for
skill performance in sitting, the FIST demonstrated only a mod-
erate to good relationship with the more global functional skills
measured in the FIM. These findings, however, support previous
literature1,17 indicating that sitting balance impairments do
significantly contribute to the FIM score at IPR discharge.
The demographic profile of this studys sample, derived from 4
IPR centers in varied regions in the United States, is representative
of patients commonly admitted to IPR regarding age, sex, admis-
sion diagnoses, and level of complexity based on comorbidities.
While this sample covered a broad length of stay range, the mean
length of stay (26d) is twice the average length of stay in IPR in the
United States (13d), which may be explained by the lower-
functioning status of this studys population.27 Findings in this
study support the applicability of the FIST as a sensitive outcome
measure in IPR. The FIST may not be appropriate in patients un-
able/unwilling to follow test directions, or if test requirements are
contraindicated by a patients medical status. In clinical practice,
however, the FIST could be added when the patient is able to follow
directions or safely perform the test procedures, or both. Overall,
the FIST is a valid functional performance measure of sitting bal-
ance that is objective, quick to administer (<10min), and has
standardized online training available.21
The FIST demonstrated responsiveness to change over the
course of IPR, indicated by significant changes in participants
scores from admission to discharge and evidenced by a large ES
and SRM. Consistent with previous research on the BBS, our
findings support concurrent validity of the FIST with the FIM, and
demonstrated similarly high ES and comparable MDC values as the
BBS.51-54 Because the FIST uses everyday functional tasks to
comprise the test items, it may be a useful measure to bridge be-
tween balance impairments and activity limitations in sitting. This
feature may make the FIST more efficient for clinical use, espe-
cially for lower-functioning patients, because it captures both as-
pects of patient performance in 1 test. Clinicians should note that
the FIST did not demonstrate a floor effect at IPR admission in this
study, supporting its sensitivity as a sitting balance measure that
may be uniquely suited to lower-functioning persons. Since other
balance tests focus predominantly on balance during static and
dynamic standing activities, these tests have problems with floor
effects in lower-functioning patients52-54 as was evident in this
studys cohort (51.2% floor effect on BBS). Of note, although the
FIST demonstrated a ceiling effect in this studys sample at
discharge, this result was not unexpected given that the FIST spe-
cifically focuses on the somewhat narrow construct of sitting bal-
ance. Additionally, there are many other reliable and valid balance
measures that represent higher-level balance skills (eg, standing,
gait) that may be added to a patients test battery as the patient
approaches the ceiling of the FIST. The FIST may potentially fill a
gap in balance testing, especially regarding sitting balance abilities,
and provide clinicians with a sensitive measure of balance recovery
until such a time that standing balance tests are more suitable.
2310
Table 4 Coordinates of the ROC curve
Positive Meaningful
Change in Balance
(GRC2) if FIST Change
Greater Than or Equal to: Sensitivity 1  Specificity
.0 1.00 1.00
2.0 1.00 0.947
3.5 1.00 0.789
4.5 0.985 0.737
5.5 0.956 0.632
6.5* 0.926 0.526
7.5 0.868 0.421
8.5 0.765 0.421
* Point where sensitivity is maximized and 1  specificity is mini-
mized, corresponding to change in FIST of >6.5 points (out of 56).
Study limitations
Recruitment procedures and exclusion criteria may have initially
eliminated potential participants with more severe deficits, espe-
cially due to impaired cognition. While a late entry protocol was
instituted to account for this, only 2 participants were enrolled under
this adaptation. Similarly, the exclusion criteria limited participation
for some patients who otherwise may have been appropriate for the
FIST but were excluded because of the other outcome measures
used in this study. For example, persons with orthotic bracing or
weight-bearing status restrictions were excluded because both the
BBS and the FIM require standing and stepping, whereas the FIST
might be safely administered to these individuals. These issues with
exclusion criteria limited the sampling frame, which may have
affected the sample distribution and generalizability.
Many studies39,46,55,56 have used the GRC for participants
self-rating of change; however, there may be limitations with the
use of the GRC in IPR. Participants with stroke or brain injury
may have an impaired ability to rate changes secondary to
cognitive, memory, or deficit awareness issues. This study
attempted to address this potential problem by using a composite
rating of both the therapists and the participants GRC ratings
when cognitive, affective, or memory problems were deemed to
affect the participants ratings. Other methods to rate meaningful
changes in patients, especially those with neurologic dysfunction,
are needed.
Similar studies investigating the psychometric properties of the
FIST in different practice settings (eg, critical care, long-term
acute care) are needed, as these results may not be generalizable to
those populations. Further study comparing the FIST with
impairment-based balance tests, such as the Trunk Impairment
Scale, would help clinicians better understand the application of
the FIST in both clinical and research uses.12,29 Further research
investigating the predictive validity of the FIST with regards to
discharge disposition and fall risk is also recommended.
Conclusions
This study provides strong evidence supporting the concurrent
validity and responsiveness of the FIST in a diverse sample of IPR
participants. Significant and meaningful improvement in FIST
scores were found from admission to discharge in this studys
cohort. The FIST is recommended to measure change in sitting
balance function for patients undergoing IPR and may be
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S.L. Gorman et al
especially effective in lower-functioning patients because of a lack
of a floor effect. A FIST change score of 6 points exceeds the
MDC and is indicative of true change, whereas a change of 7
points exceeds the MCID, reflecting clinically meaningful change
in sitting balance abilities.
Supplier
a. IBM Corp, 1 New Orchard Rd, Armonk, NY 10504-1722.
Keywords
Outcome assessment (health care); Postural balance;
Psychometrics; Rehabilitation
Corresponding author
Sharon L. Gorman, PT, DPTSc, GCS, FNAP, Samuel Merritt
University, Department of Physical Therapy, 450 30th St, Ste
3734, Oakland, CA 94609. E-mail address: sgorman@
samuelmerritt.edu.
Acknowledgments
We thank Stephanie Dickerson, PT (participation in clinical trial);
Matthew Miller, PT, DPT, NCS (participation in clinical trial);
Kathleen Campbell, PT, DPT (critical review and development of
study proposal); Erica Lorie, PT, MS, NCS (critical review of
study proposal); and Leslie Wolf, PT, DPT (participation in clin-
ical trial).
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