Barthel Index

Original Editor - Gayatri Jadav Upadhyay

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

Introduction

The Barthel Index for Activities of Daily Living (ADL's) is an ordinal scale which measures a person's ability to complete activities of daily living (ADL). The Barthel Index was first published in 1965, it has since undergone two modifications.  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.

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. 
• 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.

There are currently two modifications of the 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.

Intended Population

Patients with stroke, patients with other neuromuscular or musculoskeletal disorders, oncology patients.

Method of Use

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

Time to administer- Self report: 2-5 minutes; Direct observation: 20 minutes, Times may vary depending on clients tolerance and abilities. The MBI/BI is simple to administer. Requires training if administered by direct observation. It has been developed in many forms that can be administered in many situations and can be used for longitudinal assessment.

The Barthel Index Items and Scoring

The index measures a person's performance in ten areas of functioning:

1. Feeding
2. Bathing
3. Grooming
4. Dressing
5. Bowel control
6. Bladder control
7. Toilet use
8. Transfers (e.g., from bed to chair and back)
9. Mobility (on level surfaces)
10. Stairs

Each area is given a score based on the individual's ability to perform the task independently. The maximum score one can receive is 100, indicating that the individual can perform all of the assessed functions independently. The minimum score is 0, indicating full dependence.

The below video gives a great overview of the test.

Versions

Modified 10-item version (MBI); 5-item short form; The expanded 15-item version; The extended BI (EBI); The 3-item BI; Self-rating BI (SB); Early Rehabilitation Barthel Index (ERI)Level of measurements are limited to either complete independence or needing assistance. Each performance item is scored on an ordinal scale with a specified number of points assigned to each level or ranking.

Reliability and Limitations

The Barthel Index scale demonstrates good reliability and sensitivity to change in ADL ability.  It is highly recommended for assessment with stroke, parkinson’s disease, brain injury, 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.

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.

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.  For example, if a patient is to return home their bed to chair transfer should be assessed using a flat bed surface of the same height as their bed at home and into a chair similar to their own chair, rather than using a hospital bed with an elevated head and bed rails.

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 utilization of other outcome measures.

The MBI and BI are reliable tests to administer.

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.

Responsiveness

Ability to detect change in patients is poor in highly functional individuals, a ceiling effect being noted.

Resources

• Barthel Index of Activities of Daily Living
• The use of Barthel Index and its psychometric properties are summarised here.