Vol. 17 •Issue 21 • Page 8
The (Original) Barthel Index of ADLs
The Barthel Index is one of the most widely used rating scales for the measurement of activity limitations in patients with neuromuscular and musculoskeletal conditions in an inpatient rehabilitation setting. It has been used with rehabilitation patients to predict length of stay and to indicate the amount of nursing care needed.
The Barthel is a 10-item ordinal scale that measures functional independence in the domains of personal care and mobility. Specifically, it measures self-care, sphincter management, transfers and locomotion.1
Reliability and Validity
Historically, the Barthel has been shown to have fair to moderate reliability. Shah reported alpha internal consistency coefficients of 0.87 to 0.92 (admission and discharge) for the original scoring system.2 Wartski and Green retested 41 patients after a three-week delay and found that for 35 patients, test-retest scores fell within 10 points.
Concordance among the four rating methods was 0.93 (no major disagreement for 60 percent of patients, disagreement on 1 rating for 28 percent, 12 percent had more discrepancies) in a study examining agreement based on four different ways of administering the Barthel (self-report, nurse clinical observation, administration by a nurse and testing by a physical therapist).3
Self-report accorded least well with the other methods; agreement was lowest for items on transfers, feeding, dressing, grooming and toileting.4 Roy et al. found an inter-rater correlation of 0.99 and with patient self-report, 0.88.5
Sherwood et al. reported high Cronbach's reliability's (ranging from .95 to .96) for three samples of hospital patients proposing that the test is consistent internally as a measure of self-care activities.6 More recently, the Barthel was found to be reliable in assessing patients post-stroke (Cronbach's range .84 to .85).7-9
Validity was found to be between 0.73 and 0.77 when compared with an index of motor ability for 976 stroke patients.10 Factor analysis identified two factors that approximate the mobility and personal-care groupings. The Barthel Index correlated well with clinical judgment and was shown to predict mortality and ability to be discharged to a less restrictive environment.11
Administration and Scoring
Clinically, the Barthel can be administered via interview, by observation of the patient's performance in a specific setting, or by asking the patient to demonstrate an activity.
The Barthel includes 10 personal activities: feeding, personal toileting, bathing, dressing and undressing, getting on and off a toilet, controlling bladder, controlling bowel, moving from wheelchair to bed and returning, walking on level surface (or propelling a wheelchair if unable to walk) and ascending and descending stairs.
The response categories of disability in an activity were defined and rated in scale steps (0, 5), (0, 5, 10), (0, 5, 10, 15) dependent on the item.
The original Index is a three-item ordinal rating scale completed by a therapist or other observer in 2-5 minutes. Each item is rated in terms of whether the patient can perform the task independently, with some assistance, or is dependent on help based on observation (0=unable, 1=needs help, 2=independent).
An overall score is formed by adding scores on each rating. Scores range from 0 to 100, in steps of 5, with higher scores indicating greater independence. Items are weighted and include instructions for assessing the time it takes a subject to perform a task as a dimension of ability.
Scoring of the Barthel is done through assignment of different values to different activities. Individuals are scored on 10/15 activities which are summed to give a score of 0 (totally dependent) to 100 (fully independent). The scores are designed to reflect the amount of time and assistance a patient requires. However, the scoring method is inconsistent in that changes by a given number of points do not reflect equivalent changes in disability across different activities.
Several authors have proposed guidelines for interpreting Barthel scores. Shah et al. suggested that scores of 0-20 indicate "total" dependency, 21-60 indicate "severe" dependency, 61-90 indicate "moderate" dependency, and 91-99 indicates "slight" dependency.2 Most studies apply the 60/61 cutting point, with the stipulation that the Barthel Index should not be used alone for predicting outcomes.
Modifications to the Barthel Index include a variation of the 10-item version by Collin and Wade,4,10 that reordered the original 10 items, clarified the rating instructions, and modified the scores for each item based on a three point scoring system with a total score range from 0 to 20.
Generally speaking, a score of 14 indicates some disability, usually compatible with the level of support found in the home, a score of 10 is compatible with discharge home, provided there is maximum support and a caretaker in attendance.4
Shah et al. retained the original 10 items but proposed five-point rating scales for each item to improve sensitivity to detecting change.12 With so many modifications of the original index (5 and 15 item versions exist), determining what items should be included and how to score them is somewhat confusing and challenging.
While the Barthel is widely and easy to use, there are some concerns regarding its interpretability. As mentioned previously, there is no definitive scoring system. Moreover, the scale is restricted in that sometimes improvements may not be apparent because the patient may still need supervision (if not physical assistance) to perform a task.1 Thus, while a score of 100 indicates independence in all 10 areas, assistance may still be required with some IADLs, which are not included in the index.
The Barthel is also limited in that it does not evaluate other "life skills" and situational factors. If your patient requires environmental modifications such as ramps, wider than standard doorways or grab bars in the tub or toilet, the Barthel should be administered in such an environment that simulates the one to which the patient would return. If this does not occur, the patients score will be lower.1
Overall, the Barthel is easily administered and a generally acceptable measure of functional ability in persons with neuromuscular and musculoskeletal conditions. There is one caveat-the factor structure (in other words, the relatedness of the items in one subgroup to one another) did not hold up when administered to a mixed population of geriatric, hip fracture, cancer and dementia patients.14
Interestingly, when the Barthel was administered to geriatric patients, Ranhoff and Laake found that geriatric patients tended to overestimate their own abilities.15 This suggests, potentially, that the Barthel be administered by clinical staff.
In conclusion, given the variability in the scoring system of the Barthel, the results should not be used in isolation. The interpretation of the scores and conclusions drawn should be carefully combined with findings from other parts of the clinical examination. As always, a comprehensive evaluation is recommended for the assessment of safety and abilities in our patient populations.
References available at http://physical-therapy.advanceweb.com/Article/References-for-Geriatric-Function-Sept-25-2006.aspx
Dr. Lewis is a physical therapist in private practice and president of Premier Physical Therapy of Washington, DC. She lectures exclusively for GREAT Seminars and Books, Inc. Dr. Lewis is also the author of numerous textbooks. Her Website address is www.greatseminarsandbooks.com. Dr. Shaw is an assistant professor in the physical therapy program at the University of South Florida dedicated to the area of geriatric rehabilitation. She lectures exclusively for GREAT Seminars and Books in the area of geriatric function.
Barthel Index of Activities of Daily Living 12
2 continent (for preceding week)
1 occasional accident (once a week or less)
0 any worse grade of incontinence (or needs enemas for continence)
2 continent (for preceding week), or able to manage any device (e.g., catheter and bag) without help.
1 occasional accident (once a day or less), or catheterized and needs help with device.
0 any worse grade of incontinence.
FEEDING, food placed within reach by others:
2 able to cut up food, spread butter etc. without help
1 needs some help cutting or spreading
0 needs to be fed.
1 independent washing face, combing hair, shaving, and cleaning teeth (when implements are provided)
0 needs help.
2 independent putting on clothes, incl. fastening buttons, zips etc. (Clothes may be adapted).
1 needs some help, but can do at least half.
0 needs more help than this
TRANSFER, bed to chair and back:
3 needs no help
2 needs minor help, verbal or physica1: Can transfer with one person easily, or needs supervision.
1 needs major help: two people or one strong/trained person, but can sit unaided.
0 cannot sit; needs skilled lift by two people (or hoist)
2 able to get on and off toilet or commode, undress and dress sufficiently, and wipe self without physical or verbal help.
1 needs some help, can wipe self and do some of the rest with minimal help only.
0 needs more help than this.
MOBILITY around house or ward, indoors:
3 may use aid (stick or frame etc. but not wheelchair).
2 needs help of one person, verbal or physical, including help standing up.
1 independent in wheelchair, incl. able to negotiate doors and corners unaided.
0 needs more help than this.
2 independent up and down, and can carry any necessary walking aid
1 needs help, verbal or physical or help carrying aid
1 able to get in and out of bath or shower, wash self without help (may use any aids)