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Barthel Index

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Purpose

The BI assesses the ability of an individual with a neuromuscular or musculoskeletal disorder to care for him/herself.

Link to Instrument

Instrument Details

Acronym BI

Area of Assessment

Activities of Daily Living
Functional Mobility
Gait

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Contact information and permission to use:

MAPI Research Trust, Lyon, France:

E-mail: PROinformation@mapi-trust.org
Internet: www.mapi-trust.org
Information on Barthel Index: http://www.mapi-trust.org/services/questionnairelicensing/catalog-questionnaires/212-barthelindex

Diagnosis/Conditions

  • Brain Injury
  • Stroke Recovery

Key Descriptions

  • 10 ADL/mobility activities including:
    1) Feeding
    2) Bathing
    3) Grooming
    4) Dressing
    5) Bowel control
    6) Bladder control
    7) Toileting
    8) Chair transfer
    9) Ambulation
    10) Stair climbing
  • Items are rated based on the amount of assistance required to complete each activity.

Number of Items

10

Time to Administer

20 minutes

Self-Report: 2-5 minutes
Direct Observation: 20 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitaton Measures Team in 2010; Updated by Kelly Askins, SPT and Holly Ford, SPT with stroke and elderly populations in 2011; Updated with references for the TBI population by Tammie Keller, PT, DPT, MS and the TBI EDGE task force of the Neurology Section of the APTA in 2012.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled

Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

R

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

NR

LS

LS

LS

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

No

Yes

Not reported

Considerations

There are several possible scoring techniques for the BI. The method of obtaining the information does not appear to be important, but allowance needs to be made for confused patients if self-reporting is used. (Collin et al, 1988) The BI, FIM, FIM+FAM have similar measurement properties for activities of daily living and functional mobility (Hobart JC, 2001) “The results of this study would support considering the use of scales other than the Barthel Index when describing disability following traumatic head injury.” It looks at the physical aspect almost exclusively and does not consider the psychological (McPherson et al., 1997). This measure has demonstrated good responsiveness and adequate floor and ceiling effects in more acutely involved individuals. May be less effective in a chronic or highly mobile patient population. “In 1983, the 18-item Functional Independence Measure (FIM)5 was developed because the BI was considered too restricted and poorly responsive “.(Hobart, 2001)

Barthel Index translations:
hinese: http://rehabsociety.org.hk/e/customize/images/pdf/中文版Barthel%20Index%20評級標準.pdf
Danish: http://fysio.dk/fafo/Maleredskaber/Maleredskaber-alfabetisk/Barthel-Indeks-/
French: http://www.cofemer.fr/UserFiles/File/Barthel2.pdf
German: http://www.praxis-wiesbaden.de/icd10-gm-diagnosen/zusatz-barthelindex.php
Italian: http://www.iss.it/binary/publ/cont/08-39%20web.1233562284.pdf
Korean: http://webcache.googleusercontent.com/searchq=cache:uZfd1yxOtQoJ:cfile206.uf.daum.net/attach/112  
These translations, and links to them, are subject to theTerms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

 

Brain Injury

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Standard Error of Measurement (SEM)

Brain injury: (Liu, 2004; n=175 with n=101 with vascular brain injury, n=49 with traumatic brain injury, n=27 with other brain injuries; median age=45, inpatient rehabilitation; length of stay=95 days).

 

Admission

Median (IQR)

Mean (SD)

Discharge

Median (IQR)

Mean (SD)

Barthel Index

11 (6,11)

10.7 (6.2)

15 (12, 19)

14.1 (5.6)

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Brain injury: (Liu, 2004; n=175 with n=101 with vascular brain injury, n=49 with traumatic brain injury, n=27 with other brain injuries; median age=45, inpatient rehabilitation; length of stay=95 days).

  • Adequate predictive validity: The admission score on the Barthel was predictive of the discharge score. The lower the admission score, the greater the change with rehabilitation. (Rho=-0.42)

Responsiveness

Brain injury: (Liu, 2004; n=175 with n=101 with vascular brain injury, n=49 with traumatic brain injury, n=27 with other brain injuries; median age=45, inpatient rehabilitation; length of stay=95 days).

 

Change Median (IQR); Mean (SD)

Z-score; p -value

Barthel Index

+3 (+1, +5) ;+3.5 (3.4)

-10.2; P <0.000

Non-Specific Patient Population

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Interrater/Intrarater Reliability

Neurologic Rehab Patients:

  • Excellent : (Rollnik et al., 2011; n=273) Inter-rater reliability was r=0.849 (p<0.001). The findings suggest that the Early rehabilitation Barthel Index (ERBI) is a reliable and valid scale to assess early neurological rehabilitation patients (Modified version of BI)

Internal Consistency

Neurologic Rehabilitation: (Hobart, 2001; n=149; female= 81; mean age= 46.2 (14.8) ; stroke n=45, head injury n=9, ms n=64, other n=34)

  • Excellent internal consistency alpha = 0.94

Construct Validity

Neurologic Rehabilitation: (Hobart, 2001; n=149; female= 81; mean age= 46.2 (14.8) ; stroke n=45, head injury n=9, ms n=64, other n=34)

  • Excellent correlation for between the disability FIM motor and FIM + FAM motor and 10 item BI (r = 0.84) for all 3

Content Validity

  • The bladder item for the Barthel Index had fit residuals greater than 2, indicating the likely measurement of another construct (Morton et al, 2008)

  • Multiple items indicated item redundancy and observed proportions deviated significantly from the Rasch model (Morton et al, 2008)

Responsiveness

Neurological rehab patients : (Houlden, 2006; n=259 vascular brain injury due to single cerebral infarction (n = 75), spontaneous intracerebral haemorrhage (n = 34) and subarachnoid haemorrhage (n = 43), and 107 patients who had sustained traumatic brain injury, setting= regional neurologic rehabilitation unit)

  • Highly responsive to detecting changes:
    • In all patient groups there was a significant improvement (Wilcoxon's rank sum, P<0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic 3.95)Barthel Index (effect size: vascular 0.65, traumatic 0.55)

Older Adults and Geriatric Care

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Interrater/Intrarater Reliability

Elderly: (Richards et al, 1998; n = 94; mean age = 78.4 years)

  • Fair to Good interrater reliability depending on the activity assessed.

Floor/Ceiling Effects

Elderly: (Morton,  et al. 2008)

  • The range of person abilities exceeded the range of item difficulty at both ends of the scale

  • The original Barthel Index had a ceiling effect at hospital admission and hospital discharge

Stroke

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Standard Error of Measurement (SEM)

Chronic Stroke: (Hsieh et al, 2007; n = 56; mean time post-stroke = 1197.1 (1281.8) days; mean age = 59.4 (14.6) years; Taiwanese sample)

  • SEM = 1.45 points

Minimal Detectable Change (MDC)

Chronic Stroke: (Hsieh et al, 2007)

  • MDC = 4.02 points

Minimally Clinically Important Difference (MCID)

Acute Stroke: (Hsieh et al, 2007; n = 43; mean age = 55.4 (14.6) years; mean time since stroke 7.04 (64.1) days; Taiwanese sample)

  • MCID = 1.85 points

Cut-Off Scores

Acute Stroke: (Uyttenboogaar et al, 2005; n = 1034; mean age = 69.1 (12.8) years; Median BI score = 80 (IQR = 40 to 100); assessed 12 weeks post stroke)

  • Cutoff scores that indicate a favorable outcome:

    • > 95 (sensitivity 85.6%; specificity 91.7%)

    • > 90 (sensitivity 90.7%; specificity 88.1%)

    • > 75 (sensitivity 95.7%; specificity, 88.5%)

Normative Data

Acute Stroke: (Hsueh et al, 2002; n = 118, mean age = 67.5 (10.9) years; mean number of days in rehab = 26; Taiwanese sample)

Normative Data:

 

BI

 

BI-5  (Modified version)

 
 

Admission

Discharge

Admission

Discharge

Median

5

10

1

4

Inter-quartile range

1.5 - 8

6 - 13

0 - 1

1 - 5

Chronic Stroke: (Lin et al, 2010; n = 45, mean age = 60.0 (12.6) years; mean time since stroke = 9 months; outpatient therapy by a trained physiotherapist at 1 week, 2 months, and 5 months of out patient rehab; Taiwanese sample)

Normative Data:

 

1 week

2 months

5 months

Median score

18

19

19

1st to 3rd quartile

16 - 20

17 - 20

17 - 20

Chronic Stroke: (Lin et al, 2009)

Assessment of upper extremity function after stroke

 

14 days

30 days

90 days

180 days

Mean Age

64.3

63.9

64.0

64.0

BI Score

9.1

13.8

16.8

16.6

Interrater/Intrarater Reliability

Acute Stroke: (Hsueh et al, 2001; n = 121; assessed at 14, 30, 90 and 180 days)

  • Adequate to Excellent item level agreement among raters (kappa value range, 0.53-0.94)
  • Excellent total score agreement (ICC = 0.94)

Internal Consistency

Acute stroke: (Hsueh et al, 2001)

  • Excellent internal consistency (alpha = 0.89 to 0.90)

 

Acute Stroke: (Hsueh et al, 2002)

 

Barthel Index:

  • Excellent internal consistency at admission (alpha = 0.84)
  • Excellent internal consistency at discharge (alpha = 0.85)

BI-5 (a modified 5-item version):

  • Excellent internal consistency at admission (alpha = 0.71)
  • Excellent internal consistency at discharge (alpha = 0.73)

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Hsueh et al, 2002)

 

  • Excellent correlation between the FIM motor and 10 item BI at both admission and discharge (r > 0.92)
  • Excellent agreement between the FIM motor and 10 item BI at both admission and discharge (ICC >0.83)

Acute Stroke: (Wade and Hewer, 1987; n = 976; age not reported; assessed within 7 days of onset)

  • Excellent concurrent validity Between the modified BI and measure of motor ability using the Motricity Index (r = 0.73 to 0.77)

Floor/Ceiling Effects

Acute Stroke: (Duncan et al, 1997; n = 304; mean age = 62.89 (13.17) years; time since stroke not specified)

  • BI not sensitive to change among mild stroke/transient ischemic attack patients scoring at least 100 points.

Acute Stroke: (Hsueh et al, 2001)

BI
 
BI -5 (Modified version)
 

Admission %

Discharge %

Admission %

Discharge %

Floor

18.2

4.7

46.6

13.6
Ceiling

0

0

0

0

Mild Stroke:  (Duncan et al, 1997)

  • The Barthel Index, which has a ceiling effect and which captures only physical domains of health status, is not adequate for assessing the full impact of stroke-related disability

Responsiveness

Acute Stroke: (Hsueh et al, 2002):
Responsiveness (Standardised Response Mean)

  • The B1 and BI-5 are highly responsive in detecting changes:
  • BI (Original Measure) = 1.2
  • Bi-5 (Modified version) = 1.2

Acute Stroke: (Salbach et al, 2001; n = 53; mean age = 68 (13) years)

  • The 5MWT (at a comfortable pace) at 5 weeks post-stroke was more responsive than the Berg Balance Scale or the Barthel Index
  • All three measures were found to be responsive to change

Acute Stroke: (Tilling et all, 2001)

Acute Stroke: (Duncan et al, 1997; n = 304; mean age = 62.89 (13.17) years; time since stroke not specified):

  • BI not sensitive to change among mild stroke/transient ischemic attack patients scoring at least 100 points (maximal score is 100 points).
  • “Patients who score 100 on the Barthel Index have widely varying scores on the physical function subscale of the MOS-36; for example, fewer than 20% scored the maximum possible value on this subscale. Thus, if the Barthel Index is the only stroke outcome measure used, a decline in many domains of health status will be missed. The Barthel Index will also be ineffective in detecting the psychosocial dimensions of impaired function.”

Bibliography

Collin, C., Wade, D. T., et al. (1988). "The Barthel ADL Index: a reliability study." International Disability Studies 10(2): 61-63. Find it on PubMed

de Morton, N. A., Keating, J. L., et al. (2008). "Rasch analysis of the barthel index in the assessment of hospitalized older patients after admission for an acute medical condition." Archives of Physical Medicine and Rehabilitation 89(4): 641-647. Find it on PubMed

Duncan, P. W., Samsa, G. P., et al. (1997). "Health status of individuals with mild stroke." Stroke 28(4): 740-745. Find it on PubMed

Ellul, J., Watkins, C., et al. (1998). "Estimating total Barthel scores from just three items: the European Stroke Database 'minimum dataset' for assessing functional status at discharge from hospital." Age and Ageing 27(2): 115-122. Find it on PubMed

Granger, C. V., Albrecht, G. L., et al. (1979). "Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index." Archives of Physical Medicine and Rehabilitation 60(4): 145-154. Find it on PubMed

Grauwmeijer, E., Heijenbrok-Kal, M. H., et al. (2012). "A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury." Arch Phys Med Rehabil 93(6): 993-999. Find it on PubMed

Gupta, A. and Taly, A. B. (2012). "Functional outcome following rehabilitation in chronic severe traumatic brain injury patients: A prospective study." Ann Indian Acad Neurol 15(2): 120-124. Find it on PubMed

Hobart, J. C. and Thompson, A. J. (2001). "The five item Barthel index." Journal of Neurology, Neurosurgery and Psychiatry 71(2): 225-230. Find it on PubMed

Hofstad, H., Naess, H., et al. (2012). "Early supported discharge after stroke in Bergen (ESD Stroke Bergen): a randomized controlled trial comparing rehabilitation in a day unit or in the patients' homes with conventional treatment." Int J Stroke. Find it on PubMed

Houlden, H., Edwards, M., et al. (2006). "Use of the Barthel Index and the Functional Independence Measure during early inpatient rehabilitation after single incident brain injury." Clinical rehabilitation 20(2): 153-159.

Hsieh, Y. W., Wang, C. H., et al. (2007). "Establishing the minimal clinically important difference of the Barthel Index in stroke patients." Neurorehabil Neural Repair 21(3): 233-238. Find it on PubMed

Hsueh, I. P., Lee, M. M., et al. (2001). "Psychometric characteristics of the Barthel activities of daily living index in stroke patients." J Formos Med Assoc 100(8): 526-532. Find it on PubMed

Hsueh, I. P., Lin, J. H., et al. (2002). "Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke." Journal of Neurology, Neurosurgery and Psychiatry 73(2): 188-190. Find it on PubMed

Lin, J. H., Hsu, M. J., et al. (2010). "Psychometric comparisons of 3 functional ambulation measures for patients with stroke." Stroke 41(9): 2021-2025. Find it on PubMed

Lin, J. H., Hsu, M. J., et al. (2009). "Psychometric comparisons of 4 measures for assessing upper-extremity function in people with stroke." Physical Therapy 89(8): 840-850. Find it on PubMed

Liu, C., McNeil, J. E., et al. (2004). "Rehabilitation outcomes after brain injury: disability measures or goal achievement?" Clin Rehabil 18(4): 398-404. Find it on PubMed

McPherson, K. and Pentland, B. (1997). "Disability in patients following traumatic brain injury-which measure?" International Journal of Rehabilitation Research 20(1): 1-10.

Richards, S. H., Peters, T. J., et al. (2000). "Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse?" Clinical Rehabilitation 14(1): 72-78. Find it on PubMed

Rollnik, J. D. (2011). "The Early Rehabilitation Barthel Index (ERBI)." Rehabilitation (Stuttg) 50(6): 408-411. Find it on PubMed

Salbach, N. M., Mayo, N. E., et al. (2001). "Responsiveness and predictability of gait speed and other disability measures in acute stroke." Archives of Physical Medicine and Rehabilitation 82(9): 1204-1212. Find it on PubMed

Tilling, K., Sterne, J. A., et al. (2001). "A new method for predicting recovery after stroke." Stroke 32(12): 2867-2873. Find it on PubMed

Uyttenboogaart, M., Stewart, R. E., et al. (2005). "Optimizing cutoff scores for the Barthel index and the modified Rankin scale for defining outcome in acute stroke trials." Stroke 36(9): 1984-1987. Find it on PubMed

van Hartingsveld, F., Lucas, C., et al. (2006). "Improved interpretation of stroke trial results using empirical Barthel item weights." Stroke 37(1): 162-166. Find it on PubMed

Wade, D. T. and Hewer, R. L. (1987). "Functional abilities after stroke: measurement, natural history and prognosis." Journal of Neurology, Neurosurgery and Psychiatry 50(2): 177-182. Find it on PubMed

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