Barthel Index

Original Editor - Gayatri Jadav Upadhyay

Top Contributors - Stacy Schiurring, Kim Jackson, Jess Bell, Lucinda hampton, Gayatri Jadav Upadhyay, Lauren Lopez, George Prudden, Areeba Raja, WikiSysop and Shaimaa Eldib  

Introduction

The Barthel Index for Activities of Daily Living is an ordinal scale which measures a person's ability to complete activities of daily living (ADL). Published in 1965, the original Index was created to measure disability in patients whose rehabilitation impairments affect the use of their limbs to complete activities of daily living, it has since undergone two modifications. All three versions are used today in both clinical practice and for research purposes.

Multidisciplinary Team Member Spotlight: Occupational Therapist

An occupation therapist is a member of the rehabilitation multidisciplinary team, whose focus is on improving an individual's ability to participate in their ADL's. The American Occupational Therapy Association describes an occupational therapist's role as to use of "everyday life activities (occupations) to promote health, well-being, and your ability to participate in the important activities in your life. This includes any meaningful activity that a person wants to accomplish, including taking care of yourself and your family, working, volunteering, going to school, among many others."

Occupational therapy does not exist in all parts of the world, currently there are 100 member countries and 7 regional members of the World Federation of Occupational Therapists. Depending on your country/region of practice, other rehabilitation professionals must therefore be responsible for assessing and providing interventions of a patient's ability to complete ADL's. It is important for all members of the rehabilitation team, from therapy to nursing to medical doctors, be prepared to assess this vital component of a patient's life and ability to live independently.

For example, in the United States, a physical therapist can set goals to improve a patient's "ability to perform actions, tasks, or activities related to self-care and domestic, education, work, community, social, and civic life integration or reintegration with and without human assistance, devices, or equipment.". Nursing staff are often the first members of the MDT to assess a patient's functional decline during hospitalisation, therefore routine ADL screening is of utmost importance on all hospitalised patients, whether or not they are receiving skilled therapy care.

Optional Reading: To learn more about the role physiotherapists can play in the assessment and treatment of ADL's, please read this article.

Barthel Index Overview

The Barthel Index assesses 10 common ADL's and basic mobility:

1. Feeding
2. Bathing
3. Grooming
4. Dressing
5. Bowel
6. Bladder
7. Toilet use
8. Transfers bed-to-chair-and-back
9. Mobility on level surfaces
10. Stair negotiation

Formal training is not required to perform any version of the Barthel Index, rather the examiner just needs to be familiar with the 10-functional skills to be assessed and the scoring system used.  Shah et al recommends examiners attend a one-hour clinical demonstration and review of the modified Barthel Index to show competency.

The Index can be performed by any member of the multidisciplinary team but is typically completed by clinical staff such as: nursing, occupational therapy, or physical therapy over a 24-48 hour period.

Typically the assessment takes only minutes to complete and can be a part of a rehabilitation evaluation.

• The Index measures the degree of assistance required by an individual on 10 items of mobility and self care ADL's
• Time taken and physical assistance required to perform each item are used in determining the assigned value of each item
• The 10 items are scored with a number of points, then a final score is calculated by summing the points awarded to each functional skill.  This allows this examiner to measure a patient’s functional disability by quantifying their performance. 
• Scores can be assigned either via direct assessment or observation, or from reliable interviews from the patient, family, or staff.  Research also suggests that the examiner’s “common sense” and clinical experience can be used to assign scores. 
• The higer the score, the more independent the patient is in completing the measured ADL’s.  Higher scores also indicate the patient is more likely to return home, with varying degrees of assistance, following hospital discharge. 
• The lower the score, the more dependent the patient is with ADL completion and the more skilled care will be required at discharge.

Intended Population

It is highly recommended for assessment with stroke, parkinson’s disease, brain injury, cancer, COVID-19, patients admitted to the intensive care unit, and with older persons.  The Index has also shown portability and has been successfully used in 16 major diagnostic conditions with fair to moderate reliability and validity.

Guidelines when completing for the Barthel Index include:

1. Assess and record what a patient actually does, not what you believe they can do
2. Allow the patient to complete the functional skills with as much independence as possible, avoid providing physical or verbal assistance as patient safety allows
3. The use of assistive devices or aides is allowed and can be scored as independent
4. If the patient requires supervision, even for safety, they cannot be scored as independent
5. The best level of data collection, direct testing and/or observation, should be utilized.  However the examiner can also ask the patient, a family member, or other staff for information if needed.  
6. The Barthel Index is not meant to be used as a standalone assessment to predict functional outcomes but rather to be part of a complement of assessments to create a full picture of a patient’s ability and rehabilitation potenital
7. The examiner should also make note of the amount of time and assistance a patient requires for each of the 10-functional skills

There are currently two modifications of the 10-item Original Barthel Index: The Collin and Shah version. All the three versions of the Index assess the same 10 ADL and mobility tasks.. All three versions of the Barthel Index are freely available online. 

The Original Barthel Index

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).
• The final score is x 5 to get a number on a 100 point score.
• Proposed guidelines for interpreting Barthel scores are 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.

The Collin Modified Barthel Index

The Collin Modified Barthel Index changed the scoring system to 1-point increments with the total score ranging from 0 to 20 to correct for a “disproportionate impression of accuracy.”

The Shah Modified Barthel Index

The Shah Modified Barthel Index is scored 0-100 like the original Barthel Index, also changed the scoring scale to a five-point rating scale to improve reliability and sensitivity for detecting change.

Comparing Versions of the Barthel Index

• The modified versions can detect more subtle changes in ADL ability than the original version
• Patients making more substantial improvements in their ADL ability, either the original or modified versions of the Barthel Index have been shown to be equally responsive
• The modified versions are also recommended for research purposes to capture the most detailed data
• Research supports the use of the original Barthel Index as a measure and indicator of a person’s expected hospital length of stay, in-patient mortality, and discharge destination

Other Available Versions

The following are further adaptations of the Original Barthel Index with differing numbers of assessment tasks, not all are freely available.

• 5-item short form
• The Expanded 15-item Version
• The Extended Barthel Index
• The 3-item Barthel Index
• Self-rating Barthel Index
• Early Rehabilitation Barthel Index

Special Topic: Why Assess ADL's?

Assessing a person's ability to perform and complete ADL's gives insight into their overall functional status and likely discharge disposition.

• When patient's present with low scores on clinical assessment tools, such as the Barthel Index, they are more likely to be dependent on caregivers and/or assistive devices.
• Poor ability to complete ADL's may also lead to unsafe living conditions and a decreased quality of life.
• ADL ability is also a predictor of admission to skilled facilities such as nursing homes, need for home care/assistance in the home, and hospitalisation.
• Research shows that hospitalisation for an acute or chronic condition can influence an individual's ability to maintain independent living
• As the demographics of countries age, chronic illnesses progress which can result in expected physical decline and related loss of ability to independently perform ADL's.
• ADL outcome measures can also search as a means to assess the effectiveness of a rehabilitation treatment programme.

Reliability and Limitations

The Barthel Index scale demonstrates good reliability and sensitivity to change in ADL ability.  The Index has also shown portability and has been successfully used in 16 major diagnostic conditions with fair to moderate reliability and validity.

The original version and the Collin Modified version can be considered somewhat restricted in the sense that some ADL improvements may not be quantified in the scoring, such as when the patient may still require some degree of physical assistance to perform a task.

Five studies of the MBI reported excellent internal consistency: one study of the MBI reported excellent test-retest reliability; one study of the MBI and 4 studies of BI reported excellent inter-rater reliability; and 1 study of the BI reported adequate inter-rater reliability.

As a predictive tool the the MBI predicted instrumental ADL performance at 6-months post-stroke: likelihood a patient will regain continence following stroke; risk for falls in patients with stroke; functional recovery following stroke; and acute care hospital length following stroke.

All the versions of the Index are limited in that they do not account for situational or environmental factors such as ramps, stair railings, bed adjustments, etc.  Research suggests that the assessment can be administered in environments that best simulate the patient’s ideal discharge environment.  This would prevent falsely lowering or raising scores. 

It is also important to mention that there are other ADL’s which are essential for safe and proper discharges which are not assessed on any version of the Barthel Index.  This is where the experience and clinical insight of the rehabilitation professional is paramount in designing a personalized therapy plan of care and utilisation of other outcome measures.

Complimentary Clinical Assessment Tools

The Barthel Index should not serve as a stand alone assessment tool. It is commonly utilised along side other assessment tools, especially in the assessment of patients with neurological diagnoses such as CVA or Parkinson's disease. Such complimentary tools can include:

• The Modified Rankin Scale
• The Functional Independence Measure (FIM) Scale
• The pictorial-based Longshi Scale

Resources

Clinical Resources

• Original Barthel Index (PDF)
• Modified Barthel Indexes (app)
• Barthel Index overview by StrokeEngine