1173

The Frenchay Activities Index

Assessment of Functional Status in Stroke Patients
J. Schuling, MD; R. de Haan, MS; M. Limburg, MD, PhD; and K.H. Groenier, MS

Background and Purpose: Assessment of functional status in stroke patients is of major importance in
both clinical practice and outcome studies. The Frenchay Activities Index has been developed specifically
for measuring disability and handicap in stroke patients. The purpose of the study was to evaluate the
metric properties of this instrument and to obtain normal values in a group of unselected elderly subjects.
Methods: The Frenchay Activities Index was tested in a group of stroke patients and a group of
unselected subjects aged 65 or older. The functional status of the stroke patients was measured 26 weeks
after stroke. Their prestroke status was registered retrospectively. Reliability and validity of the
instrument were assessed.
Results: The mean scores in the prestroke, poststroke, and control group demonstrated differences in
functional status. The reliability of unweighted scores (range of Cronbach's et-coefficients, 0.78 to 0.87)
was sufficient. The construct validity was supported by meaningful correlations between the Frenchay
Activities Index and scores on the Barthel Index and Sickness Impact Profile. Principal-components
analysis indicated that the Frenchay Activities Index showed two traits: instrumental disability and some
aspects of handicap. The reliability of the instrument could be improved by deleting two items and by
creating two subscale scores: domestic and outdoors activities.
Conclusions: The Frenchay Activities Index is a useful stroke-specific instrument to assess functional
status. Completion of the questionnaire is easy and takes only a few minutes. Currently, the instrument
is suitable for use in patient care and cross-sectional, descriptive studies. (Stroke 1993;24:1173-1177)
KEY WORDS * activities of daily living * cerebrovascular disorders * stroke assessment

N o doubt the most important outcome of illness is
survival. However, a wide range of possibilities
lies between death and complete recovery. To
assess these outcomes, the concept of functional status has
been introduced. Functional status refers to the ability of
people to look after themselves and to perform certain
roles and tasks.'2 The number of instruments that have
been developed to answer questions such as "Which
activities of daily living can a patient perform?" and "To
what degree is the patient dependent on the help of
others?" is impressive. Some of these instruments are not
developed for a specific target population and may be
suitable for use in many patient populations (generic
measures); other instruments are more sensitive to func-
tional issues particularly relevant to a specific population
of patients (disease-specific measures).3-5
Assessing the patients' disabilities and handicaps is of
great importance in cerebrovascular research and pa-
tient care. Disability refers to the consequence of
neurological impairments in terms of the patient's func-
tional performance. Handicaps are concerned with the
Received September 30, 1992; final revision received February
19, 1993; accepted March 18, 1993.
From the Department of General Practice, University of Gron-
ingen (J.S., K.H.G.), and the Departments of Neurology (R. de H.,
M.L.) and Clinical Epidemiology and Biostatistics (R. de H.),
Academic Medical Center, University of Amsterdam, the
Netherlands.
Correspondence to Department of General Practice, University
of Groningen, A Deusinglaan 4, 9713 AW Groningen, the Neth-
erlands (Dr Schuling).
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social disadvantages resulting from impairments and
disabilities.6 Assessment of these outcomes allows one
to adapt treatment and circumstances to the patient's
needs, to enhance supportive care, and to evaluate the
efficacy of therapeutic interventions.7-9 Most activities
of daily living (ADL) scales, however, do not refer to the
patient's ability to perform complex activities such as
housekeeping, recreation, hobbies, and social interac-
tion.10-12 Because these so-called instrumental disabili-
ties (IADL) may affect the quality of life considerably,
they should be given due attention.
Before setting goals for rehabilitation, one should
obtain accurate information on the premorbid life-style
of stroke patients; furthermore, to evaluate treatment
programs, poststroke changes in activities should be
recorded at specific time intervals so that a therapeutic
strategy can be chosen and adjusted when necessary.
However, in a busy office practice instruments to mea-
sure the patient's functional activities routinely should
be concise and easy to understand.
Holbrook and Skilbeck13 constructed an instrument
that appears to meet these demands: the Frenchay
Activities Index (FAI). This instrument measures activ-
ities that reflect a higher level of independence and
social survival.13-1' Considering the simplicity of this
instrument and its potential value in stroke rehabilita-
tion studies, the FAI may prove to be appropriate to
measure functional outcome in stroke patients.16 Stud-
ies concerning its reliability and validity, however, are
rare. The purpose of this study is (1) to examine the
metric properties of the FAI in prestroke, poststroke,
1174 Stroke Vol 24, No 8 August 1993

and nonstroke patient samples; (2) to compare the TABLE 1. Score Distributions of Frenchay Activities Index in
functional activities of stroke patients with those of an Percentages and Mean Sum Scores and Variances of
unselected group of elderly subjects in the community; Absolute Values
and (3) to provide normal values of the FAI. Group
Control Prestroke Poststroke
Subjects and Methods FAI scores (n=216) (n=92) (n=96)
The FAI comprises 15 items, each concerning an 15-20 4.6 6.5 21.9
activity that requires some decision making and orga-
nizing on the part of the patient at home as well as 21-25 3.3 9.8 18.7
outside the home (see also "Appendix"). The instru- 26-30 6.0 12.0 11.5
ment depends on the patient's own report or on the 31-35 11.6 16.3 14.6
report of relatives. Data can be collected either by 36-40 14.3 20.6 13.5
means of an interview or a mailed questionnaire. The 41-45 22.2 19.6 8.3
FAI consists of a single summary score (with a range of 46-50 24.1 11.9 8.4
15 to 60 points) as well as three subscale scores: 51-55 13.0 3.3 3.1
domestic, leisure/work, and outdoors.
We translated the FAI and tested it in a stroke group 56-60 0.9 0 0
in a direct interview and in a control group of elderly
people as a mailed questionnaire. In the stroke group Mean 40.86 35.90 30.19
the prestroke functional status was measured retrospec- 95% CI 39.6-42.1 34-37.8 28-32.4
tively (A); the present status was measured at 26 weeks SD 9.37 9.21 10.90
poststroke (B). FAI, Frenchay Activities Index; CI, confidence interval.
To measure prestroke functional status retrospec-
tively, during the first 9 months of 1990, general practi-
tioners in the northern region of the Netherlands re- strokes) would have a low FAI score. In addition, to
ported all new patients with a stroke (first ever as well as demonstrate discriminant validity, we would expect the
recurring) to the research team.17 Patients were inter- FAI scores to be unrelated to Sickness Impact Profile
viewed at fixed intervals up to 6 months after stroke. At items focusing on emotional behavior (eg, "I laugh or
the end of the first week patients were visited by a cry suddenly," "I act irritably and impatiently with
member of the research team to confirm the diagnosis. myself'), alertness (eg, "I react slowly to things that are
The patients' prestroke functional status was assessed said or done," "I do not finish things I start"), and
by means of the FAI. No intervention took place; with eating. Finally, the construct validity of the FAI was
the exception of patients living in a nursing home or evaluated by way of principal-components analysis. This
having a stroke during a hospital admission, all stroke procedure, based on the relations between the scale
patients were included. To measure present functional items, identifies a limited set of underlying dimensions
status, at 26 weeks after stroke the interviewer com- (or factors) of a scale.
pleted the Barthel ADL Index, the FAI, and the The differences between mean sum scores of the
Sickness Impact Profile. For the control group, all three groups were analyzed with 95% confidence inter-
patients (aged 65 years or older) registered on the vals (CIs). The reported correlations were calculated
practice list of four general practitioners in the city of with Pearson's correlation coefficients.
Groningen who were living at home received the FAI by
mail; since virtually every Dutch citizen is registered in Results
the practice of a general practitioner, these patients At the end of the study period, data on 185 stroke
form a representative sample of elderly people living patients were reported. At the end of the 6 months'
independently in an urban area in the Netherlands. follow-up, 63 (34%) patients had died; a complete data
We evaluated the homogeneity and validity of the set could not be obtained in all of the remaining 122
FAI. Homogeneity (or internal consistency) was as- patients because of the severity of their clinical condi-
sessed by the Cronbach's a-coefficient.18 An a-coeffi- tion. An FAI score at 26 weeks after stroke was
cient greater than .80 is considered sufficient. If a scale obtained for 96 patients, and 92 patients also completed
or subscale merely intends to measure on group level, a the prestroke FAI. The mean age of the group was 74
more liberal standard (coefficient greater than .60) will years (median+SD, 76+10.4; range, 41 to 92 years);
be applied. To assess convergence and discriminant 41% were male. Time needed to complete the FAI
validity, the FAI was correlated with the Barthel Index questionnaire was less than 5 minutes. Communication
and the Sickness Impact Profile.19 We assumed that, for difficulties did not impede the completion of the FAI in
the FAI to be valid, the scale scores had to correlate any case.
significantly with the disability scores of the Barthel The FAI was mailed to 332 nonstroke control pa-
Index and the subscales of the Sickness Impact Profile tients. We received 216 (65%) questionnaires that were
measuring ambulation, mobility, body care/movement, correctly answered. The mean age of the respondents
and home management. We also expected a substantial was 74 years (median+SD, 74+6.0; range, 65 to 91
correlation between the FAI and the subscales of the years); 36% were male.
Sickness Impact Profile measuring the amount of rest Table 1 reports the distribution of the scores and the
needed, social interaction, and time spent on recreation. means and SDs of the total scores. The mean total score
Furthermore, we supposed that patients having dysfunc- in the control group made clear that in an unselected
tional scores on the Sickness Impact Profile's subscale group of elderly subjects, impairment of functional
of communication (and thus generally having larger status was quite common. The impact of the stroke
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 Schuling et al Frenchay Activities Index 1175

TABLE 2. Reliability Coefficients Indicating Homogeneity of TABLE 3. Convergent-Discriminant Validity as Shown by

Frenchay Activities Index Pearson's Correlation Coefficients (26 Weeks After Stroke)
Group FAI n*
Control Prestroke Poststroke Barthel Index 0.66 94
(n=216) (n=92) (n=96) Subscales of the Sickness Impact Profilet
Mean interitem correlation 0.23 0.18 0.29 Home management -0.73 77
a Total scale 0.83 0.78 0.87 Body care and movement -0.70 86
Domestic domain (items 1-5) Mobility -0.68 81
Mean interitem correlation 0.49 0.47 0.59 Ambulation -0.56 69
a Subscale 0.82 0.82 0.88 Recreation/pastimes -0.47 77
Leisure/work domain (items 7, 9, 11, 13, 15) Communication -0.42 89
Mean interitem correlation 0.22 0.21 0.22 Eating -0.42 88
a Subscale 0.63 0.58 0.61 Rest/sleep -0.42 89
a If item 15 deleted 0.69 0.61 0.65 Social interaction -0.39 78
Outdoors domain (items 6, 8, 10, 12, 14) Emotional behavior -0.15 88
Mean interitem correlation 0.29 0.20 0.29 Alertness behavior -0.14 86
a Subscale 0.67 0.55 0.66 FAI, Frenchay Activities Index.
a If item 14 deleted 0.72 0.66 0.73 *The number of subjects varies because only those were in-
volved who did not have missing values on the respective subscales.
tBecause higher scores on the Sickness Impact Profile indicate
more dysfunction, the correlations are negative. The subscale
appeared to be substantial. In comparison with both "work" and the item "sexual function" on the subscale "social
prestroke functioning and reference scores, there was a interaction" were not included in the analysis because of too many
substantial shift of the scores to the lower end of the missing values.
scale (95% CI of the difference of the mean scores
between poststroke and prestroke functioning, 4.03 to (body care, mobility, and ambulation). Discriminant
7.41; 95% CI between poststroke group and reference validity was supported by low correlations between the
group, 8.29 to 13.1). The prestroke FAI scores were FAI and the subscales of emotional and alertness
lower than the scores of the reference group (95% CI of behavior.
the difference, 2.68 to 7.24). Table 4 reports the results of a principal-components
Table 2 presents the reliability coefficients for both analysis that showed that most of the score variance
the total FAI and its three subscales: domestic, leisure/ could be attributed to two factors, which explained 52%
work, and outdoors. The data indicated that the FAI of the total variance in the stroke group. The first factor
was a homogeneous scale. The Cronbach's a-coeffi- was closely related to the domestic activities as mea-
cients met the standards set previously. The data of the sured by items 1, 2, 3, and 4. Much weight was assigned
retrospective prestroke measurement, however, were
less convincing. The leisure/work and outdoors domains TABLE 4. Principal-Components Analysis: Rotated* Loadings
included two weak items: 14 (reading books) and 15 for Two-Factor Solution (Poststroke Group, n=96)
(gainful work). Removal of these items had a positive Loadingst Loadings
effect on the reliability of the subscales. Item factor 1 factor 2 Communalityt
In the above analyses the unweighted scale scores 1. Preparing meals 0.87 0.06 0.76
were used. The same analyses, based on the weighted
2. Washing up 0.75 0.25 0.63
scores as suggested by Wade et al,14,15 did not improve
the scale's reliability. Moreover, it had a rather negative 3. Washing clothes 0.89 0.03 0.79
effect (Cronbach's of the weighted scores; poststroke
a
4. Light housework 0.86 0.07 0.75
group, a=.83; prestroke group, a=.70; control group, 10. Driving/bus travel 0.23 0.73 0.59
a=.77). The suggested weights were based on expected 11. Outings/car rides 0.10 0.70 0.50
differences in sex. Separate analyses in our samples, 12. Gardening 0.04 0.79 0.62
however, did not show differences of mean total scores 13. House/car maintenance -0.02 0.86 0.73
between men and women (95% CI of difference of the 7. Social outings 0.29 0.58 0.41
mean scores in the poststroke group, -8.24 to .80;
9. Pursuing hobby 0.23 0.50 0.31
prestroke group, -2.97 to 4.93; and control group,
-5.25 to .49). Neither did men and women in the three 5. Heavy housework 0.51 0.63 0.66
samples differ on the mean subscale scores (the nine 6. Local shopping 0.54 0.58 0.62
95% CIs are available on request). Furthermore, a-co- 8. Walking outdoors 0.46 0.39 0.36
efficients did not indicate that men or women scored 14. Reading books 0.24 0.15 0.08
with more reliability. 15. Gainful work -0.06 -0.03 0.00
Support for the construct validity of the instrument is
shown in Table 3. As expected, there was a substantial *Rotation is a statistical procedure to facilitate the identification
of the underlying dimensions.
convergent relation between the total scores of the FAI tLoadings represent the correlation coefficients between factors
and the disability scores of the Barthel Index. This was and items.
also true for the subscales of the Sickness Impact Profile 4:Communality indicates the proportion of variance of each item
measuring household activities and physical functioning explained by both factors.
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1176 Stroke Vol 24, No 8 August 1993
to the second factor by items 10, 11, 12, and 13. The
items that reflect a social component (7 and 9) were also
moderately related to this factor. Items 5, 6, and, to a
lesser extent, 8 were loading onto both factors. The
score variances of items 14 and 15 could not be ex-
plained by the two factors. In the unselected group this
same analysis produced even more definite results:
items 1 to 4 loaded onto factor 1; items 6 to 13 onto
factor 2; item 5 loaded onto both factors; and an
absence of communality of items 14 and 15. According
to the above results, the reliability of the FAI could be
further improved by introducing two subscales: (1) the
original domestic subscale as presented in Table 2 and
(2) an outdoor subscale containing items 6 to 13 (stroke
group, a=.82).
Discussion
The FAI proved to be a homogeneous scale that
showed substantial validity. The instrument had the
ability to distinguish between stroke patients' present
and prestroke functioning and the functional status of
unselected elderly. It appeared to have no ceiling effect.
The FAI could be completed within a few minutes by
means of a direct interview and as a mailed question-
naire, which enhances its value for researchers.
The FAI measured, for the greater part, two con-
cepts: (1) instrumental disabilities: indoor (items 1 to 5)
and outdoor (items 6, 8, and 10 to 13) physical activities
and (2) some elements of the handicap concept (items 7
and 9).
We recommend deleting two clinimetrically weak
items: "gainful work" and "reading books." Although,
in general, the ability to work is an important indicator
of handicap, this item is of little informative value in
stroke research. Because stroke is a disease of the
elderly, most patients are already retired at stroke
onset. Because the scores on the item "reading books"
were low in the three samples and hardly changed
between prestroke and poststroke measurement, this
item has little discriminative value as well.
The weighting of scores is not necessary. Preferably a
sum score is calculated by simply adding the ordinal
values of the 13 items. If one wants to distinguish
between domestic and outdoor activities, one can also
calculate two summated subscale scores.
Although the 65% response rate in our control group
is not perfect, it is quite acceptable for a mailed
questionnaire survey.20 The nonresponders did not dif-
fer from the total group with regard to the distribution
of the characteristics sex and age, but they probably
were more disabled than the responders. The missing
data in the prestroke group were due to the fact that
some patients were not able or preferred not to be
interviewed completely because of the severity of their
clinical condition. However, because prestroke and
poststroke groups comprise the same patients, our
conclusion, that the FAI can discriminate between
prestroke and poststroke functional status, is not af-
fected by the missing data.
Of the great number of measuring instruments, we
would like to discuss three instruments that could be
considered as alternatives to the FAI. The Rankin scale,
a five-grade modified handicap scale and by far the
oldest scale, is suitable for epidemiological purposes.
However, it probably lacks sensitivity to change over a
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period of time (responsiveness) and would be less useful
for monitoring progress or measuring detailed out-
come.21-23 The Functional Independence Measure is a
comprehensive scale that includes ADL items, including
a wide range of items concerning social behavior, com-
munication, and cognitive impairment.24 This aggrega-
tion of neurological impairments and aspects of disabil-
ities is conceptually confusing and masks the clinical
meaning of total scores. Reliability is established for use
with four-level responses but not for seven-level re-
sponses. The score weights are arbitrary, so that differ-
ent disabilities cannot be compared.25 The Lawton scale
is a Guttman scale of items concerning physical self-
maintenance and IADL. Its metric properties are well
documented.2627 While the former section resembles
the Barthel ADL Index, the content of the latter shows
great similarity to the FAI. In our opinion, only this
instrument provides a real alternative for the FAI. We
chose the FAI because initially this instrument was
developed specifically for stroke patients and because,
compared with ADL scales, there is a need for supple-
mentary data concerning the validity and reliability of
IADL instruments.
Like most disability scales, the FAI refers to a typical
middle-class, western way of life, which limits its appli-
cability to this kind of society. The usefulness of the
instrument in patients with cognitive impairment or
with aphasia needs further research, specifically with
regard to the possibility of completion by relatives or
friends.
Although our data did support relevant clinimetric
qualities of the FAI, future studies to assess the stability
of the ratings (eg, interobserver reliability) and its ability
to detect important health changes over a period of time
(responsiveness) are necessary. Some support for re-
sponsiveness to within-patient changes over a period of
time has been demonstrated in long-term follow-up.16
Currently, the FAI is suitable for use in both patient care
and cross-sectional, descriptive outcome studies. In these
latter studies, age-matched control groups should be
viewed as an essential component of outcome research.
Such a control group allows one to distinguish between
disability and handicap effects related to the disease and
those attributable to the aging process per se. As we have
demonstrated, these normal values were not exchange-
able with retrospective measurements of prestroke func-
tioning. This was probably the result of increased preex-
isting morbidity in these patients and lower reliability of
retrospective measuring.
Appendix
The Frenchay Activities Index15
Item Code
In the last 3 months
1. Preparing main meals 1 =never
2. Washing up 2= < 1 time per week
3=1-2 times per week
4=most days
3. Washing clothes 1=never
4. Light housework 2=1-2 times in 3 months
5. Heavy housework 3=3-12 times in 3 months
6. Local shopping 4 ..t 1 time per week
=
 Schuling et al Frenchay Activities Index 1177

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 The Frenchay Activities Index. Assessment of functional status in stroke patients.
J Schuling, R de Haan, M Limburg and K H Groenier

Stroke. 1993;24:1173-1177
doi: 10.1161/01.STR.24.8.1173
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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