Title of measure:

Barthel Index of Activities of Daily Living (ADLs)

This summary was last revised 3 December 2010.

Brief overview:
The Barthel Index of Activities of Daily Living (ADLs), first developed in 1965 (1)
and later modified by Granger et al.(2), measures functional disability by quantifying
patient performance in 10 activities of daily life. These activities can be grouped
according to self-care (feeding, grooming, bathing, dressing, bowel and bladder care,
and toilet use) and mobility (ambulation, transfers, and stair climbing). 5-point
increments are used in scoring, with a maximal score of 100 indicating that a patient
is fully independent in physical functioning, and a lowest score of 0 representing a
totally dependent bed-ridden state. A five-item short form of the Barthel Index is also
available (3). The test takes approximately 5 minutes to complete and should be used
as a record of what a patient does, not of what a patient can do. Direct testing of the
patient is not needed, as information can be derived from friends/relatives and nurses;
although, the best available evidence should be used in evaluating the patient’s
performance.

Validated:
Originally designed by Mahoney and Barthel for use in scoring improvement during
rehabilitation of patients with chronic neuromuscular or musculoskeletal disorders,
the Barthel index has also been validated in the setting of primary brain tumors and
brain metastases (4-7) and is considered easy to use, reliable and sensitive to change.

Psychometric properties:
The Barthel Index has been reported to have excellent reliability and validity and
adequate responsiveness to change, in measuring neurologic physical disability.
Hobart et al. compared psychometric properties of the Barthel Index with newer and
lengthier scales, the Functional Independence Measure (FIM) and the Functional
Independence Measure + Functional Assessment Measure (FIM+FAM), in patients
undergoing rehabilitation. All three rating scales demonstrated equivalent reliability
and validity in measuring physical disability, and were similarly responsive to
change. This study suggested that the newer and more extensive rating scales of FIM
and FIM+FAM offered few advantages over the more practical and economical
Barthel Index (8). Similar results were observed in studies of patients with multiple
sclerosis and stroke (9, 10).

However, the Barthel Index is limited by inherent ceiling and floor effects, potentially
limiting its responsiveness to change in the chronic setting. Schepers et al. compared
the Barthel Index with the FIM and other functional health status measures in stroke
patients admitted for inpatient rehabilitation. They compared floor/ceiling effects and
responsiveness, quantified by effect sizes, between three time points: rehabilitation
admission, six months post-stroke (subacute phase) and between six and 12 months
post-stroke (chronic phase). Though the Barthel Index demonstrated a large effect
size in the subacute phase, a smaller effect size was observed in the chronic phase.
This was attributed to the interference of the ceiling effect with the assessment of
responsiveness in the chronic phase (11). In addition, the Barthel Index is based on
an ordinal rather than interval scale. With ordinal scales, the overall score is obtained
by adding up arbitrary numerical values assigned to a subject’s ratings on a series of
items. This limits the scale’s ability to quantify the exact amount of change between
measurements. Van Hartingsveld et al. examined Barthel Index scores on 559 stroke
patients using a Rasch probability model that weighted scores based upon “patient
ability” and “item difficulty.” In doing so, they observed an improvement in the
psychometric properties and clinical interpretation of the Barthel Index (12).

The psychometric properties of the five-item short form of the Barthel Index have
also been studied prospectively in patients admitted with a stroke by Hsueh et al. In
comparison to the Barthel Index and the FIM, they observed limitations in the 5-item
short form in patients with severe disability due to a notable floor effect. Otherwise,
psychometric properties were similar (9).

The psychometric properties of the Barthel Index have also been tested in brain tumor
patients. In patients with high-grade gliomas, Brazil et al. demonstrated that a
verbally administered Barthel Index was sensitive to change, correlated with other
measures of functional impairment including the Karnofsky performance score
(KPS), and prognosticated for survival (5). In the setting of brain metastases, Herman
et al. demonstrated the feasibility of administering the Barthel Index, along with other
neurocognitive tests, in patients with brain metastases.

Normative data:
Normative data do not exist for the Barthel Index.

Clinically significant changes:

Clinically significant changes can be determined by calculating effect sizes between
baseline and subsequent total scores. Though many effect size calculations exist, a
commonly used calculation divides the mean absolute change score by the standard
deviation of the baseline scores (13). The interpretation of the magnitude of the
effect size is then based on Cohen’s rule-of-thumb, in which an effect size of 0.2-0.5
represents a small effect, 0.5-0.8 represents a moderate effect, and 0.8 or greater
represents a large effect (14).

Website or how to register to use:

Go to www.copyright.com to get permission to use the Barthel Index, copyrighted to
the Maryland State Medical Society. Search under “Maryland State Medical
Journal,” the journal in which the index was initially published (1). Through this
website, a request for academic license can be made. A representative from the
Maryland State Medical Society should respond to you within a few days. If no
response is received, consider contacting the Society directly at www.medchi.org.
The permission information should be given to RTOG headquarters for each RTOG
QOL study.
 List any fees for usage:
Currently, there are no fees for use of the academic not-for-profit use of the Barthel
Index. A fee may be charged if a pharmaceutical company is sponsoring the trial.

Languages available:
The Barthel Index has been translated into Spanish(15) and Persian (16).

Instructions for CRAs and or credentialing for administration:

There is no credentialing needed for administration of the Barthel Index. The Barthel
Index can be completed by the patient without assistance. Direct testing of the patient
is not needed, as information can be derived from friends/relatives and nurses (17);
although, the best available evidence should be used in evaluating the patient’s
performance. Self-report by telephone has also been found reliable (18).

Time required to complete the instrument:

The majority of patients complete the questionnaire within 5-10 minutes without
assistance and 2-5 minutes with assistance.

Quality assurance for administration (if needed):

Each protocol has instructions for the CRA’s.

Scoring of instrument:
The Barthel Index consists of 10 items assessing the ability to achieve certain
activities without assistance. It evaluates the ability of feeding, moving from
wheelchair to bed and returning, doing personal toilet, getting on and off toilet,
bathing self, walking on level surface, ascending and descending stairs, dressing,
controlling bowels and controlling bladder. Scoring ranges from 0 (completely
dependent) to 100 (completely independent) with intervals of 5 points.

References:

1. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State
Med J 1965;14:61-65.
2. Granger CV, Dewis LS, Peters NC, et al. Stroke rehabilitation: analysis of
repeated Barthel index measures. Arch Phys Med Rehabil 1979;60:14-17.
3. Hobart JC, Thompson AJ. The five item Barthel index. J Neurol Neurosurg
Psychiatry 2001;71:225-230.
4. Jalali R, Dutta D, Kamble R, et al. Prospective assessment of activities of daily
living using modified Barthel's Index in children and young adults with low-grade
gliomas treated with stereotactic conformal radiotherapy. J Neurooncol
2008;90:321-328.
5. Brazil L, Thomas R, Laing R, et al. Verbally administered Barthel Index as
functional assessment in brain tumour patients. J Neurooncol 1997;34:187-192.
6. Grant R, Slattery J, Gregor A, et al. Recording neurological impairment in clinical
trials of glioma. J Neurooncol 1994;19:37-49.
7. Herman MA, Tremont-Lukats I, Meyers CA, et al. Neurocognitive and functional
assessment of patients with brain metastases: a pilot study. Am J Clin Oncol
2003;26:273-279.
8. Hobart JC, Lamping DL, Freeman JA, et al. Evidence-based measurement: which
disability scale for neurologic rehabilitation? Neurology 2001;57:639-644.
9. Hsueh IP, Lin JH, Jeng JS, et al. Comparison of the psychometric characteristics
of the functional independence measure, 5 item Barthel index, and 10 item
Barthel index in patients with stroke. J Neurol Neurosurg Psychiatry
2002;73:188-190.
10. van der Putten JJ, Hobart JC, Freeman JA, et al. Measuring change in disability
after inpatient rehabilitation: comparison of the responsiveness of the Barthel
index and the Functional Independence Measure. J Neurol Neurosurg Psychiatry
1999;66:480-484.
11. Schepers VP, Ketelaar M, Visser-Meily JM, et al. Responsiveness of functional
health status measures frequently used in stroke research. Disabil Rehabil
2006;28:1035-1040.
12. van Hartingsveld F, Lucas C, Kwakkel G, et al. Improved interpretation of stroke
trial results using empirical Barthel item weights. Stroke 2006;37:162-166.
13. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in
health status. Med Care 1989;27:S178-189.
14. Cohen J. Statistical power analysis for the behavioral sciences. Rev. ed. New
York: Academic Press; 1977.
15. Baztan JJ, Perez J, Alarcon T, et al. Indice de Barthel: instrumento valido para la
valoracion functional de pacientes con enfermedad cerebrovascular. Rev Esp
Geriatr Gerontol 1993;28:32-40.
16. Oveisgharan S, Shirani S, Ghorbani A, et al. Barthel index in a Middle-East
country: translation, validity and reliability. Cerebrovasc Dis 2006;22:350-354.
17. Collin C, Wade DT, Davies S, et al. The Barthel ADL Index: a reliability study.
Int Disabil Stud 1988;10:61-63.
18. Shinar D, Gross CR, Bronstein KS, et al. Reliability of the activities of daily
living scale and its use in telephone interview. Arch Phys Med Rehabil
1987;68:723-728.