CHAPTER 11: THE BARTHEL INDEX (BI)

Description

The Barthel Index (BI) is a standardized activities of daily living (ADLs) assessment designed to quantify level of occupational performance by observing how well a person performs basic ADLs. The BI is composed of 10 items related to a client’s ability to feed him- or herself, bathe, groom, dress, bowel and bladder management, toilet use, ability to transfer, mobility, and ability to use stairs. The BI uses a unique scoring algorithm where 2 items are evaluated with a 2-point scale (0 and 5 points), 6 items are evaluated with a 3-point scale (0, 5, or 10 points), and 2 items are evaluated with a 4-point scale (0, 5, 10, or 15 points). Scores can range from 0 to 100 with higher scores indicating better ADL performance. The assessment can be completed in 10 to 15 minutes where a score of 0 to 20 suggests total dependence, 21 to 60 severe dependence, 61 to 90 moderate dependence and 91 to 95 slight dependence (Shah, Vanclay, & Cooper, 1989).

Psychometrics

Original research by Mahoney and Barthel (1965) has shown an inter-rater reliability median of 0.96 with a range from 69% to 100% suggesting excellent agreement. The same study reported good instrument sensitivity evidenced by its ability to detect changes in ADLs in response to rehabilitation. A study of 5 physical therapist raters with 7 subjects found that inter-rater agreement was 0.80 and had a range of 0.70 to 0.88 (Loewen & Anderson, 1988). A systematic review and meta-analysis by Duffy, Gajree, Langhorne, Stott, and Quinn (2013) found two high quality studies displaying excellent inter-rater reliability of r = 0.93 at a 95% confidence interval. Another study of 22 subjects with 1 physiotherapist rater found that test-retest agreement ranged from r = 0.77 to perfect agreement for the 10 items of the BI (Green, Forster, & Young, 2001). A study by Hartigan and O’Mahony (2011) found a strong correlation between BI scores when rated by doctors and nurses (Spearman’s ρ = 0.70), whereas the correlation among only doctors was 0.74 and between only nurses it was 0.83. Finally, a study by Sarker, Rudd, Douiri, and Wolfe (2012) demonstrated good concurrent validity between the Frenchay Activities Index and Barthel Index at r = 0.80 among 238 subjects 3 months post-cerebrovascular accident.

Advantages

The BI is easy to administer, can be completed in 10 to 15 minutes, no special training is required, and it is simple to score. There is a good amount of research in support of its use in clinical practice and at one time was considered a gold standard of ADL assessment.

Disadvantages

The BI has been limited by inherent ceiling and floor effects in its scoring system. When ceiling/floor effects occur in data-gathering, there is a pooling of scores at either the upper or lower levels reported by the instrument. The modified version of the BI by Shah et al. (1989) was designed, in many respects, to address this problem.

Administration

The BI is an observational tool where the clinician observes the client performing specific basic ADLs thought critical for independence in which they are scored according to level of performance. Activities outlined on the assessment include feeding; moving from wheelchair to bed and returning, as well as sitting up in bed; the ability to wash face; comb hair; shave; clean teeth; getting on and off of a toilet including handling clothes, wiping, and flushing; bathing self; walking or propelling a wheelchair on a level surface; managing stairs; dressing, which includes tying shoes and fastening fasteners; and the ability to control bowels and bladder (Mahoney & Barthel, 1965). The cumulative score is calculated by summing each item scored. BI scores are multiples of 5 with a range of 0 to 15 and may vary for each item. Total scores have a range from 0 meaning the person is completely dependent, to 100 which suggests complete independence in basic ADLs, thus higher scores represent a higher degree of independence (Kwon, Hartzema, Duncan, & Lai, 2004).

Permissions

The BI can be accessed through the Mapi Research Trust education information dissemination website and can be used in clinical practice or publication if requested first. A user agreement for the measure is necessary if it is to be used for commercial or research purposes. Distribution fees may be requested according to the study design and context of use of the questionnaire. Furthermore, the Maryland State Medical Society holds the original copyright for the BI where it can be accessed through the Copyright Clearance Center at www.copyright.com. Search under “Maryland State Medical Journal,” the journal in which the index was initially published. If requested, it may be used (certain royalties may apply). More information can be found in the following original journal article:

Mahoney, F. I., & Barthel, D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 56-61.

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