Barthel Index

Original Editor - Gayatri Jadav Upadhyay

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

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 research.

Multidisciplinary Team Member Spotlight: Occupational Therapist

An occupational therapist is a member of the rehabilitation multidisciplinary team. Their focus is on improving an individual's ability to participate in ADLs. The American Occupational Therapy Association describes an occupational therapist's role as using "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 seven 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 focused on a patient's ability to complete ADLs. All rehabilitation team members, from therapy to nursing to medical doctors, should 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." In a hospital setting, 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 for all hospitalised patients, whether or not they are receiving skilled therapy care.

Optional Reading: To learn more about the role physiotherapists can play in assessing and treating ADLs, please read this article.

Barthel Index Overview

The Barthel Index assesses ten common ADLs, including 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 ten functional skills being 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.

Any member of the multidisciplinary team can perform the Barthel Index, but it is typically completed by clinical staff such as nurses, occupational therapists, or physiotherapist over a 24-48 hour period.

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

• The Barthel Index measures the degree of assistance required by an individual on ten mobility and self-care ADL items
• The time taken and physical assistance required to perform each item are used to determine the assigned value of each item
• The ten items are scored with a number of points, and then a final score is calculated by summing the points awarded to each functional skill. This allows the examiner to measure a patient’s functional disability by quantifying their performance. 
• Scores can be assigned either via direct assessment / observation or from reliable interviews with the patient, family, or staff. Research also suggests that the examiner’s “common sense” and clinical experience can be used to assign scores. 
• The higher the score, the more independent the patient is in completing the measured ADLs. 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

While the Barthel Index is used in many populations, its use is highly recommended in the assessment of individuals with stroke, Parkinson’s, brain injury, cancer, COVID-19, patients admitted to the intensive care unit, and with older persons. 

Guidelines when completing 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, and 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 (e.g. for safety) they cannot be scored as independent.
5. The best level of data collection, direct testing and/or observation, should be utilised. 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 stand-alone 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 potential.
7. The examiner should also record the amount of time and assistance a patient requires for each of the ten functional skills.

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

The Original Barthel Index

The original Index was designed as a three-item ordinal rating scale. It can be completed by members of the MDT, including a rehabilitation therapist or other observer, in around 2-5 minutes.

• Each item is scored based on whether or not the individual can perform a task or activity independently, with assistance or if they are fully dependent. The scoring is as follows: 0 = unable, 1 = needs assistance/help, 2 = independent.
• The for the ten items are summed and x 5 to get a total score out of 100.
• Proposed guidelines for interpreting Barthel scores are as follows:
  • scores of 0-20 indicate “total” dependency
  • scores of 21-60 indicate “severe” dependency
  • scores of 61-90 indicate “moderate” dependency
  • scores of 91-99 indicate “slight” dependency
  • most studies use a score of 60/61 (moderate dependency) as a 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. It 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
• For 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 list includes 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 ADLs?

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

• When patients 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 ADLs 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, the 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 ADLs.
• ADL outcome measures can also provide a way to assess the effectiveness of a rehabilitation treatment programme.

Reliability and Limitations

The Barthel Index scale demonstrates good reliability and sensitivity to changes in ADL ability. It has portability and has been used for 16 diagnostic conditions with fair to moderate reliability and validity. However, the original version and the Collin Modified version can be considered "somewhat restricted" as some ADL improvements may not be quantified in the scoring, such as when a patient still requires some degree of physical assistance to perform an activity or task.

Study results on the Barthel Index and modified versions are as follows:

• Five studies on the modified Barthel Index found that it had excellent internal consistency
• One study looking at the modified Barthel Index reported excellent test-retest reliability
• One study on the modified Barthel Index and four on the Barthel Index studies found excellent inter-rater reliability
• One study on the Barthel Index found that it had adequate inter-rater reliability

It has been found that the modified Barthel Index can predict "instrumental ADL performance at 6-months post-stroke", including:

• the likelihood an individual will achieve continence after a stroke
• falls risk in individuals after stroke
• functional recovery after stroke
• length of stay in acute care after a 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 ADLs 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 personalised 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 alongside other assessment tools, especially in the assessment of patients with neurological diagnoses such as stroke or Parkinson's. 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
• Modified Barthel Indexes (app)
• Barthel Index overview by StrokeEngine