Barthel Index (BI)

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Tool Description

  • one of the oldest developed measures of basic activities of daily living
  • originally developed to assess the severity of disability in personal care and mobility in stroke patients.
  • consists of 10 items:

1) Bathing
2) Grooming
3) Feeding
4) Dressing
5) Toilet use
6) Ascend/descend stairs
7) Bowel management
8) Bladder management
9) Bed/wheelchair transfer
10) Mobility (level surface)

Availability:

See the ‘How-to use’ page of this tool.

ICF Domain:

Activity – subcategory: Self-Care.

Number of Items:

10

Brief Instructions for Administration & Scoring

Administration:

  • Scores are obtained primarily from using direct observation
  • Self-report, or proxy responses (from family/friends) have been reported.
  • Scores based on performance in the past 48 hours are preferred.
  • Administration takes:
    • 20-30 minutes to complete by direct observation
    • 2-10 minutes to complete for self-report or proxy

In the original version, each item is scored in three steps. **A modified Barthel Index (MBI) with a five-step scoring system, developed by Shah et al. was found to achieve a greater sensitivity and improved reliability compared with the original version. It has been tested in the SCI population by Kucukdevici et al. 2000 – measurement properties are described below.

Equipment: None.

Scoring:

  • item scores are summed to give a total score ranging from 0 to 100 (0: fully dependent; 100: fully independent).

Interpretability

MCID: not established for the SCI population, but for a stroke sample (n= 43; mean (SD) age = 55.4 (14.6) yrs; Taiwanese adults post-stroke mean (SD) of 7.04 (64.1) days):

BI MCID = 1.85 points
Reference: Hsieh et al. 2007, “Establishing the minimal clinically important difference of the Barthel Index in stroke patients” Neurorehabil Neural Repair 21(3): 233-238

SEM: not established for the SCI population, but for a stroke sample (n=56, Taiwanese adults post-stroke mean of 1197.1 days):

BI SEM=1.45 points
Reference: Hsieh et al. 2007, “Establishing the minimal clinically important difference of the Barthel Index in stroke patients” Neurorehabil Neural Repair 21(3): 233-238

MDC: not established for the SCI population, but for a stroke sample (n=56, Taiwanese adults post-stroke mean of 1197.1 days):

BI MDC = 4.02 points
Reference: Hsieh et al. 2007, “Establishing the minimal clinically important difference of the Barthel Index in stroke patients” Neurorehabil Neural Repair 21(3): 233-238

  • Higher scores indicate a higher level of independence
  • Scores reflect the nursing burden and social acceptability of the activity.
  • Cut scores have been established for the stroke population and are not necessarily representative for the SCI population. Scores of 0-20 indicate total dependence; 21-60: severe dependence; 61-90: moderate dependence and 91-99: slight dependence.
  • Published data for the SCI population is available for comparison (see the Interpretability section of the Study Details sheet).

Languages:

The 10 item English version has been assessed for the SCI population.

Training Required:

No training is required, though clinical experience/practice is beneficial.

Clinical Considerations

  • The BI is one of the best-researched ADL tools and has been used with a number of patient populations. Use of adaptive aids is permitted with a score of ‘independent’.
  • The BI covers very basic functional abilities and while a score of 100 suggests independence, assistance may still be required with other higher order tasks such as cooking/cleaning and therefore other measures are needed to assess these areas.
  • Though the test items are deemed important to society, they may not reflect activities that are of importance to individuals with SCI.
  • There is minimum patient burden unless the entire test is scored by observation. Floor and ceiling effects makes the scale less useful for the SCI population.

Measurement Property Summary

Barthel Index

# of studies reporting psychometric properties: 2

Reliability:

No values were reported for the reliability of the Barthel Index for the SCI population.

Validity:

  • Correlation of the Barthel Index is adequate with:
    •  the Walking Index for Spinal Cord Injury (Spearman’s ρ=0.67)
    • the Rivermead Mobility Index (Spearman’s ρ=0.6)
    • the Spinal Cord Independence Measure (Spearman’s ρ=0.7)
    • the Functional Independence Measure (Spearman’s ρ=0.7).

[Morganti et al. 2005, Plantinga et al. 2006]

Responsiveness:

  • Total score effect size (ES) for all participants = 0.98 (items: 0.38 to 1.16)

[O’Connor et al. 2004]

Floor/ceiling effect:

  • Ceiling effects were detected at discharge for the Barthel Index score (24.1% of subjects had the highest score).

[O’Connor et al. 2004]

Modified Barthel Index

# of studies reporting psychometric properties: 1

Reliability:

  • Internal consistency of the Modified BI is excellent at admission (Cronbach’s α=0.88) and discharge (Cronbach’s α=0.90).
  • Inter-rater reliability for MBI items range from adequate to excellent (ICC= 0.50-0.78).
  • Inter-rater reliability for the total MBI scale is adequate (ICC=0.77)

[Kucukdeveci et al. 2000]

Validity:

  • Correlations between the MBI and ASIA (American Spinal Injury Association) motor scores were adequate at admission (r=0.55) and excellent at discharge (r=0.76).
  • Correlations were weaker between the MBI and ASIA sensory scores; adequate at both admission (r=0.43) and discharge (r=0.51).

[Kucukdeveci et al. 2000]

Responsiveness:

No values were reported for the responsiveness of the Modified Barthel Index for the SCI population.

Floor/ceiling effect:

No values were reported for the presence of floor/ceiling effects for the Modified Barthel Index for the SCI population.

Reviewer

Dr. William Miller, Christie Chan

Date Last Updated:

Feb 1, 2013

Download the measure

Download Worksheet:

Worksheet Document

Video

n/a

Scoring

A total score is calculated by summing the item scores.

Equipment Needed

Barthel Index:

Granger CV, Albrecht GL, Hamilton BB. Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index. Arch Phys Med Rehabil 1979;60:145-154.
http://www.ncbi.nlm.nih.gov/pubmed/157729

Kucukdeveci AA, Yavuzer G, Tennant A, Suldur N, Sonel B, Arasil T. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med 2000;32:87-92.
http://www.ncbi.nlm.nih.gov/pubmed/10853723

Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J 1965;14:61-65.
http://www.ncbi.nlm.nih.gov/pubmed/14258950

Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking index for spinal cord injury (WISCI): criterion validation. Spinal Cord, 2005; 43: 27-33.
http://www.ncbi.nlm.nih.gov/pubmed/15520841

O’Connor RJ, Cano SJ, Thompson AJ, Hobart JC. Exploring rating scale responsiveness: Does the total score reflect the sum of its parts?. Neurology, 2004; 62: 1842-44.
http://www-ncbi-nlm-nih-gov.ezproxy.library.ubc.ca/pubmed/15159490

Plantinga E, Tiesinga LJ, van der Schans CP, Middel B. The criterion-related validity of the Northwick Park Dependency Score as a generic nursing dependency instrument for different rehabilitation patient groups. Clin Rehabil, 2006; 20: 921-926.
http://www.ncbi.nlm.nih.gov/pubmed/17008343

Scivoletto G, Morganti B, Ditunno P, Ditunno JF, Molinari M. Effects on age on spinal cord lesion patients’ rehabilitation. Spinal Cord, 2003; 41: 457-464.
http://www.ncbi.nlm.nih.gov/pubmed/12883544