Barthel Index (BI)

This summary includes information on the original Barthel Index (0-100), the
Modified Barthel Index (0-100) and the Barthel Index (Collin scoring, 0-20). All
include 10 test items. Other modifications, including a 5-item and 15-item extended
Barthel Index have also been reported, and are summarised in Finch et al., (2002).

Developers: The original Barthel Index was developed in the USA by Florence
Mahoney and Dorothea Barthel (1965). The Modified Barthel Index was developed in
Australia by Surya Shah, Frank Vanclay and Betty Cooper (1989). A third version
was developed in England by Collin and colleagues (1988).

Access: A printable copy of the original Barthel Index, with guidelines for
administration and scoring, is available through The Stroke Center at
http://www.strokecenter.org/trials/scales/barthel.pdf . The original version is also
available via the Centre for Evidence Based Physiotherapy in the Netherlands at
http://www.cebp.nl/?NODE=77&SUBNODE=1125. The Barthel Index (20 point
scoring) is available in Part 1 of the National HACC Functional Assessment
Instrument through the University of Wollongong, available at
http://www.uow.edu.au/commerce/chsd/Tools/AssessForm_HACC_final.pdf

Cost: Free to download the instructions, scoring criteria and score sheets.

Copyright: Health practitioners may download, copy and use the Barthel Index for
non-commercial purposes and without modification from the websites previously
mentioned.

Description: The original Barthel Index was developed to measure activities of daily
living. The 10 subtest items include (1) feeding, (2) moving from wheelchair to bed
and return, (3) personal grooming, (4) getting on/off the toilet, (5) bathing, (6)
walking or propelling a wheelchair , (7) stair climbing, (8) dressing and undressing,
(9) bowel and (10) bladder continence.. Each subtest item on the original Barthel
Index is rated 0, 5 or 10 (or 15 for two of the test items). Maximum total score is 100.

The Modified Barthel Index includes the same 10 subtest items, scored on a 5-point
ordinal scale which varies from item to item (eg 0, 1, 3, 4, or 5 for personal hygiene;
0, 3, 8, 12 or 15 for ambulation). This scale was developed to enhance the sensitivity
of the original scale. The Modified Barthel Index scores the degree of independence
of a client from any assistance (regardless of how minor, and for what purpose the
assistance is provided). Maximum total score is 100.

The 20-point Barthel Index includes the same 10 subtest items with variable sub-
scores between 0 and 3. For example, bathing can be rated 0 (dependent) or 1
(independent), while transferring can be rated 0 (unable, no sitting balance), 1 (major
help one or two people, physical contact), 2 (major help, verbal or physical), or 3
(independent). Maximum total score is 20.

Administration: The Barthel Index is completed through observation by a health

professional or trained interviewer. Rating is completed after direct observation of

Barthel summary prepared by Occupational Therapy Program, University of Western Sydney

Funded by the Motor Accidents Authority of NSW, February 2006
performance, or using information from records. Time taken to complete the
assessment will depend on the setting (inpatient or community) but may take between
20 - 60 minutes.

Research has been conducted using ratings subsequent to telephone interview

(Korner-Bitensky et al., 1995), a postal version (Gompertz, et al., 1994) and ratings
performed through self-report or proxy respondent (cited in Law, et al., 2001 and
Finch et al., 2002). Scores can be reliably obtained over the telephone by lay-persons
and health professionals from clients with milder disabilities but less reliably from
those with moderate or severe disability.

Scoring and Interpretation: The original Barthel Index uses weighted scoring, with
subtest scores ranging from 0 to 15 with increments of 5. A total score of 100
represents the highest level of independence although a perfect score does not
necessarily mean that a person is able to perform instrumental activities of daily
living. The total score is not as meaningful as the breakdown into individual subtest
scores, since these indicate where limitations exist.

The Modified Barthel Index and 20-point Barthel Index also use weighted scoring.

Population Groups: Adults (not necessarily older people) with neuromuscular or

musculo-skeletal disorders. Groups that have been tested with this measure include
stroke, spinal cord injuries, neurologic conditions (e.g multiple sclerosis), burns,
cardiac problems, rheumatoid arthritis, amputations and the aged.

Languages: English

References:

Carroll, D. G. (Ed.). (1965). Functional evaluation. The Barthel Index. Annual

meeting, Baltimore City Medical Society, Rehabilitation Section, February, 61-65

Collin, C. Wade, D.T. Davies, S., & Horne, V. (1988). The Barthel ADL Index: A
reliability study. International Disability Studies, 10(2), 61-63.

Dittmar, S, Gresham, G.E., (1997). Functional assessment and outcome measures for
the rehabilitation health professional (pp.112-113). Gaithersburg Maryland:
Aspen Publishers.

Finch, E., Brooks, D., Stratford, P.W., & Mayo, E.N. (2002). Reintegration to normal
living (RNL) index. In: Physical rehabilitation outcome measures (2nd ed., pp.201
- 203). Ontario: Lippincott, Williams & Wilkins.

Formiga, F., Mascaro, J., & Pujol, R. (2005). Inter-rater reliability of the Barthel
Index. Age and Ageing, 34, 655-657.

Gomertz, P., Pund, P., & Ebrahim, S. (1994). A postal version of the Barthel Index.
Rehabilitation, 8(30), 233-239.

Barthel summary prepared by Occupational Therapy Program, University of Western Sydney

Funded by the Motor Accidents Authority of NSW, February 2006
Hill, K., Denisenko, S., Miller, K., Clements, T., & Batchelor, F. (2005) 3rd edition.
clinical outcome measurement in adult neurological physiotherapy. Australian
Physiotherapy Association National Neurology Group. Victoria.

Korner-Bitensky, N., & Wood-Dauphine, S. (1995). Barthel Index information

elicited over the telephone. Is it reliable ? American Journal of Physical Medicine,
74, 9-18.

Laake, K., Laake, P., Hylen Ranhoff, A., Sveen, U., Wyller, T.B., Bautz-Holter, E.
(1995). The Barthel ADL Index: factor structure depends on the category of
patient. Age and Ageing, 24 (5), 393-8.

Law, M., Baum, C., Dunn, W. (2001). Measuring occupational performance:

supporting best practice in occupational therapy. Thorofare, NJ: Slack Inc.

Law, M., King, G., Russell, M., Stewart, D., Hurley, P. & Bosch E. (2005). All about
outcomes: An educational program to help you understand, evaluate and choose
adult outcome measures. [CD-ROM]. Thorofare NJ: Slack Incorporated.

Mahoney, F.I., & Barthel, D.W.(1965). Functional evaluation: The Barthel Index. A
simple index of independence useful in scoring improvement in the rehabilitation
of the chronically ill. Maryland State Medical Journal, 14, 61-65.

Murdock, C. (1992). A critical evaluation of the Barthel Index. Part 1. British Journal
of Occupational Therapy, 55(3), 109-111

Murdock, C. (1992), A critical evaluation of the Barthel Index. Part 2. British Journal
of Occupational Therapy, 55(3), 153-156

Sainsbury, A., Seebass, G., Bansal, A., & Young, J.B. (2005). Reliability of the
Barthel Index when used with older people. Age and Ageing, 34, 228-232.

Shah S., & Cooper, B., (1993). Commentary on “A critical evaluation of the Barthel
Index”. British Journal of Occupational Therapy, 56(2), 70-72.

Shah, S., Vanclay, F., Cooper, B. (1989). Improving the sensitivity of the Barthel
Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42(8), 703-709.

Wade, D.T., & Collin, C (1988). The Barthel ADL Index: A standard measure of
physical disability? International Disability Studies, 10(2), 61-67.

Wellwood, I., Dennis, M.S., & Warlow, C.P. (1995). A comparison of the Barthel
Index and the OPCS Disability instrument used to measure outcome after acute
stroke. Age and Ageing, 24 (1), 54-58.

Wyller, B., Sveen, U., & Bautz-Holter, E. (1995). The Barthel ADL Index one year
after stroke: comparison between relatives and occupational therapists scores. Age
and Ageing, 24 (5), 398-402.

Barthel summary prepared by Occupational Therapy Program, University of Western Sydney

Funded by the Motor Accidents Authority of NSW, February 2006
ICF Levels:

Level Addressed by Measure Yes No

Body Function/ Structure √

Activity √

Participation √

Psychometric Properties:

Published Data Available for the Barthel Modified Post

Measure Barthel Telephone
Interview
Version
Validity 13
Face √1,11 √11
Content √1,2, 6,10
Criterion √2,5,6,10,11 √11 √12
Construct √1,2,5,6,7,10,11 √11

Reliability # 13
Test – retest √ 2,6,10,11 √5,11 √ 8,12
Intra – rater √ 1,6,10
Inter – rater √ 1, 2, 4, √11 √ 2.8,12
6,8,10,11,14

Other information available

Responsiveness to √ 1,2,4,7,10,11,13 √ 4 ,11
change √ 4,11
Standardised * √ 1, 3,6,9,10

Clinically important √1
change
Clinical utility √1, 6,9,11,13 √11 √12

* There is no published manual for purchase the Barthel or Modified Barthel. The
measure, tasks, operational definitions and detailed scoring instructions are included
in Mahoney et al (1965) and Shah et al (1989).
# There are uncertainties regarding the Barthel’s reliability when used with older
people and with multiple diagnoses (Sainsbury et al., 2005; Wyller et al., 1995).

1. Data summarised in Law et al 2001

2. Data summarised in Finch et al 2002

Barthel summary prepared by Occupational Therapy Program, University of Western Sydney

Funded by the Motor Accidents Authority of NSW, February 2006
3. Mahoney et al (1965)
4. Shah et al (1989)
5. Data summarised in Hill et al (2005)
6. Data summarised in Law et al (2005)
7. Wellwood et al (1995)
8. Sainsbury et al (2005)
9. Murdock , C (1992) Part 1.
10. Murdock, C (1992) Part 2
11. Shah, S and Cooper, B (1993)
12. Korner-Bitensky et al (1995)
13. Data summarised in Dittmar et al (1997)
14. Formiga et al (2005)

Barthel summary prepared by Occupational Therapy Program, University of Western Sydney

Funded by the Motor Accidents Authority of NSW, February 2006