Modified Barthel Index for Activities of Daily Living

About the Barthel Index versions

The Barthel Index for activities of daily living was first published in 1965 by Barthel and Mahoney in the Maryland State Medical Journal. The scale and its subsequent modification are meant to be used in the assessment of patient performance (or degree of assistance required) with respect to self-care, sphincter management, transfers and locomotion.

Originally, the index was designed to be used in scoring improvement during rehabilitation of patients with chronic neuromuscular or musculoskeletal disorder and continues to be used so but has also been validated in studies on patient populations with: primary brain tumors and brain metastases (4-7).

Concerns about the Barthel Index mostly revolve around its interpretability as there are several versions of the index and scorings available.

Collin et al. introduced a modification of the index where each domain was scored in 1-point increments with scores ranging from 0 to 20, under the argument that the original scoring system gave a disproportionate impression of accuracy. Collin et al. also reordered the 10 items and clarified the instruction.

Shah et al. retained the original 10 items but proposed five-point rating scales for each item to improve sensitivity to detecting change.

The original Barthel Index scale and the modified versions have been used for in-patient rehabilitation assessments, as a means of monitoring functional changes, mostly in populations recovering after stroke.

All the three versions of the index consist of 10 items (each scored with a number of points) that relate to activities of daily living (ADLs) where the final score is calculated by summing the points awarded to each item.

The 10 items assessed relate to:

■ Help needed with feeding;

■ Help needed with bathing;

■ Help needed with grooming;

■ Help needed with dressing;

■ Presence or absence of fecal incontinence;

■ Presence or absence of urinary incontinence;

■ Help needed with transfers;

■ Help needed with walking;

■ Help needed with climbing stairs.

To eliminate the tendency for the patient to overestimate their own abilities, it is best for the Barthel Index to be administered by clinical staff. The evidence required to evaluate the patient’s performance (the record of what the patient does, not of what they can do) can be derived from relatives, friends, nurses).

It is important to establish the patient’s degree of independence from any help, whether of verbal or physical nature, of, usually, longer periods of time, as opposed to the preceding 24-48 hours, but please note that the Barthel Index should not be used standalone for predicting outcomes in stroke patients. The assessment should also account for the amount of time and assistance a patient requires for each of the items.

Result interpretation

The Barthel Index scale versions all measure functional disability in 10 ADLs by quantifying patient performance. The highest scores indicate full independence in physical functioning whilst the lowest scores (closer to 0) indicate a bed-ridden state.

With higher scores, the functional outcomes after stroke or other conditions suggest that the patient is more likely to be able to live at home, independently, with varying degrees of help and care, following discharge from hospital.

The Collin et al. 1988 Interpretation: 0 indicates complete dependency and 20 indicates functional independence.

The Shah et al. 1989 Interpretation:

■ 91–99 Slight dependency

■ 61–90 Moderate dependency

■ 21–60 Severe dependency

■ 0–20 Total dependency

Reliability and limitations of the Barthel Index scale versions

The original Barthel Index scale is considered easy to use, with good reliability and sensitivity to change, mainly in predicting the functional outcomes related to stroke. The Index has shown portability and has been successfully used in 16 major diagnostic conditions with satisfactory (fair to moderate) reliability and validity.

The index is not meant to be used in isolation to predict functional outcomes and should be combined with findings from other parts of clinical examination and functional assessment of the patient.

Shah reported alpha internal consistency coefficients of 0.87 to 0.92 (admission and discharge). Self-report accorded least well with the other methods; agreement was lowest for items on transfers, feeding, dressing, grooming and toileting. Roy et al. found an inter-rater correlation of 0.99 and with patient self-report, 0.88.

Validity was found to be between 0.73 and 0.77 when compared with an index of motor ability for 976 stroke patients.

It is also considered that the scale is somewhat restricted in the sense that some improvements may not become apparent, enough to be quantified on scale, as the patient may still be in the position to require some degree of physical assistance to perform a task.

All the versions of the index are limited in the sense that they do not account for situational factors (i.e. adaptations to the environment, ramps etc), so there is the argument that the test should be administered in an environment that best simulates the one to which the patient would return upon discharge, to prevent falsely lower or higher scores.

Also, some patients may score close to 100, thus indicating full independence in the 10 tested ADLs but still require some assistance with other ADLs, not included in the index.

References

Original references

Collin, C., et al. The Barthel ADL Index: a reliability study. International disability studies 10.2 (1988): 61-63.

Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989; 42(8):703-9.

Other references

Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14:56-61.

Sinoff G, Ore L. The Barthel activities of daily living index: self-reporting versus actual performance in the old-old (> or = 75 years). J Am Geriatr Soc. 1997; 45(7):832-6.

Granger CV, Dewis LS, Peters NC, Sherwood CC, Barrett JE. Stroke rehabilitation: analysis of repeated Barthel index measures. Arch Phys Med Rehabil. 1979; 60(1):14-7.

Lam, Simon C.; Lee, Diana T. F.; Yu, Doris S. F. Establishing CUTOFF Values for the Simplified Barthel Index in Elderly Adults in Residential Care Homes. Journal of the American Geriatrics Society. 2014; 62 (3): 575–577.