Barthel Index

What is a Barthel Index?

The Barthel Index (BI) is a widely used outcome measure that assesses a person's ability to perform activities of daily living (ADLs). Developed by Mahoney and Barthel (1965), it was initially created to measure functional and physical disability in stroke patients. However, its usefulness has extended to a broader range of conditions, including:

• Musculoskeletal disorders
• Brain injury
• Mental disorders
• Multiple sclerosis
• Hospital discharge planning
• Nursing home care
• Stroke and post-stroke care

The BI, a widely used functional outcomes measure, is a ranked scale with ten items, each focusing on a specific ADL. These include:

• Eating
• Bathing
• Grooming
• Dressing
• Bowel control
• Bladder control
• Toilet use
• Transfer (moving between sitting and standing)
• Mobility (on level surfaces)
• Stair climbing

Each item is scored based on the level of assistance a person requires to complete the task. Scores range from 0 (completely dependent) to 10 (completely independent). The total score (maximum score of 100) or the outcome measures reflect the patient's overall functional independence in daily living.

The core concept behind the Barthel Index is functional independence. This refers to a person's ability to manage daily tasks without assistance. The Barthel Index measures a patient's progress in functional recovery, which is regaining independence after an illness or injury.

Considerations in using the Barthel Index

While the Barthel Index is a valuable tool, it's essential to consider the following aspects:

• Psychometric properties: The BI has good internal consistency (Cronbach's alpha) and inter-rater reliability, but its validity for specific diseases may require further investigation.
• Ceiling and floor effects: The BI may not be sensitive to small changes in function for patients with very high or very low scores (ceiling and floor effects, respectively).
• Modified versions alongside similar measures: The Barthel Index alone may not capture some populations' full range of functional abilities. Modified versions, like the Modified Barthel Index (MBI, a different resource) address these limitations. Other measures, like the Functional Independence Measure (FIM), Modified Rankin Scale, and the Berg Balance Scale, can be used to conduct a more comprehensive examination and monitor functional outcomes.

It is important to remember that the Barthel Index does not assess instrumental activities of daily living (IADLs), which are more complex tasks like managing finances or using transportation. For a more comprehensive assessment, the BI can be used with other functional evaluation tools, such as the FIM (Functional Independence Measure) or the MDS (Minimum Data Set).

While the Barthel Index has its limitations, it remains a valuable tool for healthcare professionals working with patients who require rehabilitation following a (chronic) stroke, brain injury, or other conditions that impact independent living.

How to use the Barthel Index

The Barthel ADL Index is a helpful tool to assess a person's physical function and ability to manage daily activities without assistance. It can even be used as a self-report measure, but the interpretation and clinical decisions still have to be made by a specialist. The following are the steps on how you can maximize this resource:

Step 1: Understand the purpose and components

The Barthel Index is widely used to measure disability and assess functional independence in ADLs. It consists of 10 items: personal hygiene, bathing, feeding, toilet use, dressing, bowel control, bladder control, transfers, mobility on level surfaces, and stair climbing.

Step 2: Prepare for assessment

Gather the necessary materials, such as the BI scoring form, pen or pencil, and assistive devices the patient typically uses. Ensure a quiet and comfortable environment for the assessment. Introduce the purpose of the assessment to the patient and obtain their consent for the direct observation process.

Step 3: Conduct the assessment

Observe the patient performing each ADL task or rely on self-report or caregiver input if direct testing is impossible. It's also important to note the activities that the patient can accomplish while carrying aid to assist them. When scoring each item, this ordinal scale typically ranges from 0 to 10, with some items having a maximum score of 15. The scoring criteria should be followed accurately to ensure consistency in assessment.

Step 4: Calculate the total score

Add up each item's scores to obtain the total BI score. The maximum score is 100, indicating complete functional independence. Lower scores indicate varying degrees of dependence.

Step 5: Interpret and document the results

Interpret the total BI composite score based on established guidelines, typically:

• 0-20: Total dependence
• 21-60: Severe dependence
• 61-90: Moderate dependence
• 91-99: Slight dependence
• 100: Complete independence

Document the results in the patient's medical record, including the total scores range, individual item scores, and any relevant observations or comments. Use the BI score and other clinical assessments to guide care planning, discharge planning, and treatment decisions, especially in stroke recovery.

Remember, the BI is a standardized tool, and proper training is recommended to ensure consistent and accurate administration and scoring (Quinn et al., 2011).

Scoring and interpretation

The Barthel Index is a widely used assessment tool that measures an individual's level of independence in performing ADLs. The scoring system is designed to evaluate the patient's functional abilities objectively.

The BI consists of 10 items, each scored on a scale ranging from 0 to either 10 or 15 points, depending on the specific task. The scoring criteria for each item are as follows:

1. Feeding: 0 (unable), 5 (needs help), 10 (independent)
2. Bathing: 0 (dependent), 5 (independent)
3. Grooming: 0 (needs to help with personal care), 5 (independent)
4. Dressing: 0 (dependent), 5 (needs help), 10 (independent)
5. Bowel control: 0 (incontinent), 5 (occasional accident), 10 (continent)
6. Bladder control: 0 (incontinent), 5 (occasional accident), 10 (continent)
7. Toilet use: 0 (dependent), 5 (needs some help), 10 (independent)
8. Transfers (bed to chair and back): 0 (unable, no sitting balance), 5 (major help), 10 (minor help), 15 (independent)
9. Mobility (on level surfaces): 0 (immobile), 5 (wheelchair independent), 10 (walks with the help of one person), 15 (independent)
10. Stairs: 0 (unable), 5 (needs help), 10 (independent)

The total BI score is calculated by summing the individual item scores, with a maximum possible score of 100, indicating complete independence in ADLs.

When would you typically use a Barthel Index?

The Barthel Index is a great choice when it comes to understanding a patient's ability to manage ADLs. Here are some common scenarios where the BI becomes a crucial and valuable tool:

Assessing stroke recovery

Initially designed for stroke patients, the BI provides a clear picture of functional independence after a stroke. This helps guide therapy plans and track progress in regaining daily living skills.

Evaluating functional decline

The BI can be used for people with various conditions that might affect their ability to perform ADLs. This includes brain injuries, musculoskeletal disorders, or multiple sclerosis.

Planning hospital discharge

Knowing a patient's functional independence level helps determine if they require additional physical assistance at home or in a rehabilitation facility after discharge.

Monitoring progress in rehabilitation

The BI's simple scoring system allows for regular assessments, making tracking a patient's progress easy and adjusting rehabilitation strategies as needed.

What are the benefits of using the Barthel Index?

The Barthel Index may benefit patients and therapists by helping them gauge the capabilities of patients admitted to rehabilitation units or facilities.

Results can be discussed with the patient. If the patient can still improve, discussing results might help inspire them to improve and hopefully become fully independent with some, ideally all, of their ADLs.

The data produced by the Barthel Index is a valid measure that helps the patient visualize and understand the areas in their life where function has been reduced. Having access to this kind of information allows people to more accurately focus their time and effort on areas requiring improvement, hopefully leading to their maximum benefit and positive changes during the treatment process. 

References

Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61–65.

Quinn, T. J., Langhorne, P., & Stott, D. J. (2011). Barthel Index for stroke trials: development, properties, and application. Stroke, 42(4), 1146–1151. https://doi.org/10.1161/STROKEAHA.110.598540