Barthel Index (BI)

Overview
 There is considerable psychometric data available for the BI (McDowell & Newell, 1996) and its various modified versions. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the original BI and the modified 10-item BI (MBI), the two most commonly used versions. We then selected to review articles from high impact journals, and from a variety of authors.

*Please note that the content in the original BI and MBI version of the BI is the same.  Only the scoring values were changed in the MBI version (scored 0, 1, 2 or 3 versus 0, 5 and 10 in the original version), and thus do not impact the clinimetric properties of the tool (Quinn, Langhorne and Stott, 2011).  The MBI yields a score ranging from 0 to 20, whereas the original BI yields a score of 0 to 100.  For the purposes of this module, the psychometric properties for both the BI and MBI will be presented together and will be referred to as either the BI or MBI. 

Floor and ceiling effect

Salbach et coll. (2001) examined the ceiling effects of the BI, Timed Up and Go (TUG), Berg Balance Scale (BBS), 10 meter walk test (10mWT) and 5 meter walk test (5mWT) in 50 patients with residual gait deficits after a first-time stroke.  The BI demonstrated the most significant ceiling effects at both 8 and 38 days post-stroke (28% and 56% respectively).

Dromerick, Edwards and Diringer (2003) examined the floor/ceiling effects of the BI, the Functional Independence Measure (FIM), the Modified Rankin Scale (MRS) and the International Stroke Trial Measure.  The four measures were administered to 95 patients with stroke on admission to and discharge from rehabilitation. The BI demonstrated adequate floor effects at admission (5%) and poor ceiling effects at discharge (27%), whereas the FIM demonstrated excellent floor and ceiling effects (0% for both); the MRS demonstrated adequate floor effects at admission (18%) and excellent ceiling effects at discharge (0%); and the International Stroke Trial Measure demonstrated poor floor effect at admission (100%) and excellent ceiling effect at discharge (0%).

Van der Putten, Hobart, Freeman and Thompson (1999) compared the floor/ceiling effects of the MBI to that of the Motor-FIM, cognitive-FIM and total FIM in 201 patients with multiple sclerosis and 82 patients with stroke undergoing inpatient neurorehabilitation. The MBI, and motor-FIM demonstrated adequate floor and ceiling effects for both patients with stroke and patients with multiple sclerosis (floor effects = 1.2% (BI, stroke), 1.2% (motor-FIM, stroke); and ceiling effects = 8.5% (BI, stroke) and 1.2% (motor-FIM, stroke).  The total-FIM showed no floor or ceiling effects for both patients with stroke and patients with MS (0% for all).  The Cognitive-FIM demonstrated poor ceiling effects in patients with multiple sclerosis (36%) and adequate ceiling effects in patients with stroke. 

Hsueh, Lin, Jeng and Hsieh (2002) compared the floor/ceiling effects of the FIM to that of the MBI and the 5-item BI (BI-5) in 118 patients with stroke undergoing treatment on an inpatient rehabilitation unit.  The MBI and the motor-FIM both exhibited adequate floor effects at admission and discharge (MBI 18.2% and 4.7%; motor-FIM 5.8% and 3.5% respectively) and excellent ceiling effects at admission and discharge (0% for all). The BI-5 exhibited poor floor effects at admission (46.6%) and adequate floor effects at discharge (13.6%), and excellent ceiling effects at admission and discharge.  The results of this study indicate that the MBI and motor-FIM have comparable floor/ceiling effects, with the motor-FIM performing slightly better with respect to floor effects (18.2% vs. 5.8%).

Reliability

Internal consistency:
Hobart and Thompson (2001) compared the psychometrics of the MBI, FIM and the 30-item FIM + Functional Assessment Measure (FIM+FAM) in 149 patients with various neurological disorders. All measures were found to be psychometrically similar measures of physical disability. The internal consistency of the MBI was excellent, with a Cronbach’s alpha of 0.94 (Cronbach’s alpha of the FIM ranged from 0.89-0.96).

Hsueh, Lin, Jeng and Hsieh (2002) compared the internal consistency of the FIM to that of the MBI and the 5-item BI (BI-5) in 118 patients with stroke undergoing treatment on an inpatient rehabilitation unit.  The MBI and FIM motor subscale both demonstrated excellent internal consistency (Cronbach’s alpha coefficient ≥ 0.84), whereas the BI-5 demonstrated adequate internal consistency (Cronbach’s alpha coefficient ≥ 0.71) at admission and discharge.

Quinn, Langhorne and Stott (2011) conducted a literature review examining the internal consistency of the MBI in studies involving patients with stroke.  The internal consistency of the MBI was found to be excellent (Cronbach’s alpha ³ 0.80) across all reviewed studies, as detailed below. 

Shah and coll. (1989) examined the internal consistency of the MBI in 258 patients with stroke. The internal consistency was excellent (Cronbach’s alpha 0.90).

Leung and coll. (2007) examined the internal consistency of the Chinese version and the English version of the MBI and found internal consistency to be excellent for both measures (Cronbach’s alpha 0.93 and 0.92 respectively). 

Hseuh, Lee and Hsieh (2001) examined the internal consistency of the MBI in 121 Taiwanese patients with stroke at four time points (14, 30, 90 and 180 days post-stroke).  The internal consistency of the BI was excellent (Cronbach’s alpha 0.89-0.92).

Test-retest:
Green, Forster and Young (2001) examined the test-retest reliability of the MBI, Rivermead Mobility Indice (RMI), Nottingham extended Activities of Daily Living Scale (NEADL) and Frenchay Activities Indice (FAI) in 22 patients that were at least one year post-stroke.  The four measures were administered twice, with a one-week interval.  The MBI and RMI were found to have the strongest test-retest reliability with 75% and 85% agreement overall, respectively; however there was still considerable variability in kappa statistics (BI kappa =-0.09-0.81; RMI kappa =0.64-1.00).  The NEADL and FAI demonstrated greater variability and more error (NEADL kappa =0.14-0.89; FAI kappa =0.25-1.00).

Inter-rater:
Leung and coll. (2007) examined the inter-rater reliability of the Chinese and English versions of the MBI in 15 patients with stroke. The inter-rater reliability was found to be excellent for the Chinese version (kappa = 0.81-1.00) and adequate to excellent for the English version (kappa =0.63-0.85), as calculated using kappa statistics.

Duffy, Gajree, Langhorne, Stott and Quinn (2013) conducted a systematic review examining the inter-rater reliability of the BI and MBI in patients with stroke.  In a systematic review and meta-analysis, 10 studies were included that involved assessors of differing backgrounds and experience.  The BI was found to have excellent inter-rater reliability in eight of the ten studies and adequate inter-rater reliability in two of the ten studies, as calculated using intraclass correlation (ICC), kappa statistics or weighted kappa statistics (ICC ranging from 0.94 to 0.96; kappa ranging from 0.62 to 0.90; weighted kappa ranging from 0.70 to 0.99).  The results from five of the 10 studies are included below; the remaining 5 studies could not be reviewed for the purposes of this module as they were not available in English. 

Loewen and Anderson (1988) examined the inter-rater and intra-rater reliability of the BI in seven patients with stroke.  Inter-rater reliability and intra-rater reliability were excellent (ICC=0.96 and 0.99 respectively).  

Wolfe, Taub, Woodrow and Burney (1991) compared the inter-rater and intra-rater reliability of the BI with the Rankin Scale.  Inter-rater reliability was excellent for both the BI and Rankin Scale (kw=0.88 to 0.98 and 0.75 to 0.95 respectively). Intra-rater reliability was excellent for both the BI and Rankin Scale (kw=0.98 and 0.95 respectively). 

Hseuh, Lee and Hsieh (2001) examined the inter-rater reliability of the BI in Taiwanese patients with stroke, at four time points (14, 30, 90 and 180 days post-stroke).  The inter-rater reliability between items of the BI was adequate (weighted kappa = 0.53) to excellent (weighted kappa =0.94).  The inter-rater reliability for the total score was excellent (ICC=0.94).

Oveisgharan and coll. (2006) examined inter-rater reliability of a Persian translated version of the BI; inter-rater reliability was excellent (weighted kappa =0.99).

Cincura and coll. (2008) examined the inter-rater reliability of the National Institutes of Health Stroke Scale, Modified Rankin Scale and the BI in Brazilian patients with stroke.  Inter-rater reliability was found to be adequate (kappa =0.70).

 

Validity

Content:
No studies have examined the content validity of the BI in patients with stroke.

Criterion:
Concurrent:
Hsueh, Lin, Jeng and Hsieh (2002) examined the concurrent validity of MBI and the 5-item BI (BI-5) with the motor subscale of the FIM in patients with stroke, using Spearman correlation coefficient.  The three measures were administered to 118 patients with stroke at admission to and discharge from an inpatient rehabilitation unit. Concurrent validity of the MBI and the FIM motor subscale was excellent at admission and discharge (r=0.92 and 0.94 respectively), whereas the 5-item BI demonstrated adequate to excellent concurrent validity with the FIM motor subscale at admission and discharge (r=0.74 and 0.92 respectively).

Predictive:
Hseuh, Lee and Hsieh (2001) examined the predictive validity of the MBI in 121 patients with stroke by comparison with the Frenchay Activities Indice (FAI), using Pearson product-moment correlation coefficient.  The MBI was administered at 14, 30, 90 and 180 days post-stroke and the FAI was administered at 180 days post-stroke.  The MBI scores at 14, 30 and 90 days post-stroke demonstrated adequate correlation with FAI scores at 180 days post-stroke, (r=0.59, 0.66. 0.63 respectively).  Results of this study found the MBI to be an adequate predictor of instrumental ADL performance at six months following stroke onset. 

Patel, Coshall, Lawrence, Rudd and Wolfe (2001) examined the ability of the MBI and Frenchay Activity Indice (FAI) to predict whether a patient with post-stroke urinary incontinence would regain continence.  The study involved 207 patients with stroke with new onset urinary incontinence in the acute phase of recovery.  Univariate analysis and multiple regression analysis were used to determine predictive validity.  The MBI and the FAI were administered on approximately day seven post-stroke to allow for medical stabilization and at 3-months post-stroke.  Patients scoring 15 to 18 (out of 20) on the MBI on day seven were found more likely to regain continence as compared with those scoring less than 15 (Odds ratio=21.8, 95% CI=5.95 – 79.7). At 3 months, patients with incontinence were found to have greater disability as measured by the MBI (P<0.001) and FAI (P=0.002) and greater rates of institutionalization (P<0.001).

Sze, Wong, Leung and Woo (2001) investigated the predictors of falls in patients with stroke, using a study sample of 677 patients admitted to an inpatient rehabilitation stroke unit.  Initial assessments, including the MBI, were completed on admission (three to seven days following stroke onset).  For the purposes of their study, MBI scores were stratified as: ≥15 mild disability, 6-14 moderate to severe disability, and ≤5 very severe disability. Patients with moderate to severe disability (MBI scores 6-14) were found to have an increase risk for falls (odds ration 2.59, 95%CI=1.24-5.42, r=0.0114). Dysphagia was also found to put patients at an increased risk for falls (odds ratio 1.81; 95% CI, 1.03–3.17, r=.0382).

Tilling and coll. (2001) examined the ability of the MBI to predict functional recovery following stroke. The MBI was administered to 299 patients with stroke at baseline, 2, 4, 6, and 12 months following stroke; recovery trajectories were then plotted using the MBI scores in an effort to establish a prediction model based on the found normal patterns of recovery. Performance of the prediction model was validated using an additional group of 710 patients with stroke. Initial MBI scores, when considered along with individual patient characteristics (such as age, sex and pre-stroke disability), were found to be predictive of future MBI scores up to 1-year following stroke. The predictive validity was found to be even stronger when the patient’s actual observed recovery was taken into consideration and the predictions of future MBI scores were adjusted accordingly. Scoring <1 point below the predicted score on the MBI was found to be predictive of death before the next assessment time point (65% sensitivity, 79% specificity). The results of this study suggest that this model can aid in establishing initial recovery predictions, developing rehabilitation goals and monitoring recovery in patients with stroke.

Chang, Tseng, Weng, Lin, Liou and Tan (2002) examined the predictors of acute care hospital length of stay in 330 patients with first-ever acute stroke. Univariate analysis and multiple regression analysis were used to determine predictive validity. MBI scores at admission (r=0.042), along with National Institute of Health Stroke Scale (NIHSS) scores at admission (r=0.001), the quadratic term of initial NIHSS score (r=0.001), small-vessel occlusion stroke (r<0.001), gender (male) (r=0.004) and smoking (r=0.043) were found to be the most significant predictors of hospital length of stay. A one-point decrease in score on the MBI (indicating a decline in function) corresponded to an increase in length of stay by approximately one day.

Hsieh and coll. (2007) investigated the minimal clinically important difference (MCID) of the modified 10-item BI in a two-part study involving patients with sub-acute to chronic stroke.  In the initial part of the study, 43 patients with sub-acute stroke that demonstrated potential for improvement with regard to activities of daily living (ADL) were selected for a 4-week intensive occupational therapy program.  The MBI and a 15-point Likert-type scale assessing the patients’ perceived global ratings of their ADL function were administered at baseline and at discharge (with a mean interval between assessment and discharge of 25 days).  The estimated MCID was 1.85.  The second part of the study involved assessing the repeatability of scores in 56 patients with chronic stroke who were thought to have stable ADL function.  The estimated MCID was 1.45.  Results indicate that an improvement in total score by 1.85 points or more (on the 0 to 20 scoring scale) indicate a meaningful change beyond measurement error, and thus a change in score less than 1.85 points may be subject to measurement error.
Note: The MCID estimated in this study is applicable only for improvement in function, not deterioration.

Construct:
Wilkinson and coll. (1997) investigated the construct validity of the MBI as a standard long-term outcome measure of patients with stroke. The Hospital Anxiety and Depression Scale (HADS), London Handicap Scale (LHS), Frenchay Activities Indice (FAI), SF36, Nottingham Health Profile (NHP) and the Life Satisfaction Indice (LSI) were administered alongside the MBI in a long-term study involving 106 patients with first-ever stroke (patients were followed for a mean interval of 4.9 years). Rank Correlation Coefficients were excellent between the MBI and SF36 Physical Functioning dimension (r=0.81), NHP Energy (r=0.605) and Physical Mobility (r=0.840) dimensions, LHS (r=0.726) and FAI (r=0.826). Rank Correlation Coefficients were adequate between the MBI and the SF36 Social Functioning (r=0.481), Role: Physical (r=0.415), Mental Health (r=0.332), Vitality (r=0.500), Bodily Pain (r=0.356) and General Health (r=0.438) dimensions, HADS (r=-0.563), and LSI (r=0.361). Poor correlations were found between the MBI and the SF36 Role: Emotional dimension (r=0.217) and NHP Sleep dimension (r=0.189). The results of this study suggest that the MBI should be administered alongside other measures that assess the psychosocial dimensions of health status as the MBI fails to sufficiently assess these aspects.

Convergent/Discriminant:
Hseuh, Lee and Hsieh (2001) examined the convergent validity of the MBI, Berg Balance Scale (BBS) and the Fugl-Meyer Motor Assessment (FMA) in 121 patients with stroke, using Pearson product-moment correlation coefficient .   The three measures were administered at 14, 30, 90 and 180 post-stroke.  The total MBI score had excellent correlation with the FMA and BBS scores at all four time points (MBI and FMA r=0.8, 0.81, 0.78, 0.8; MBI and BBS r =0.89, 0.94, 0.9, 0.91 respectively).

Known Groups:
No studies have examined the known groups validity of the BI in patients with stroke.

Responsiveness

Wood-Dauphinee, Williams and Shapior (1990) compared the responsiveness of the BI to the Fugl-Meyer Assessment (FMA) in 167 patients with stroke. Patients were assessed at admission to hospital and at 5-weeks post-stroke. The correlation between mean change in FMA Upper and Lower Extremity Motor subscores and total Barthel Indice scores was adequate (r = 0.57), as calculated using Pearson correlation coefficients. The FMA and BI were both found to have small effect sizes (ES = 0.24 and 0.42 respectively) from admission to 5-weeks post stroke. The results of this study suggest that both measures have poor responsiveness with the BI being more sensitive to detecting change that the FMA.

Salbach and coll. (2001) examined the responsiveness of the BI, Timed Up and Go (TUG), Berg Balance Scale (BBS), 10 meter walk test (10mWT) and 5 meter walk test (5mWT) in 50 patients with residualgait deficits after a first-time stroke. The BI, BBS 5mWT and 10mWT demonstrated large effect sizes and the TUG demonstrated a moderate effect size, between 8 days and 38 days post-stroke, as calculated using standardized response means (SRM = 0.99, 1.04, 1.22, 0.92 and 0.73 respectively). 

Hsueh, Lin, Jeng, and Hsieh (2002) compared the responsiveness of the BI, 5-item short form BI (BI-5) and motor-FIM in 118 patients with stroke undergoing treatment on an inpatient rehabilitation unit. The BI, BI-5 and motor-FIM all exhibited high responsiveness, as calculated using standardized response mean (SRM) (BI=1.2; 5-BI=1.2; motor-FIM=1.3) indicating significant sensitivity for detecting change.

Wallace, Duncan, and Lai (2002) compared the responsiveness of the BI to that of the motor-FIM for recovery following stroke. Change was measured using the Modified Rankin Scale. The BI and motor-FIM were administered to 372 patients with stroke at one and three months following stroke. The BI and motor-FIM were both found to have small effect sizes (ES = 0.31 and 0.28 respectively), indicating similar responsiveness between the measures.

Van der Putten, Hobart, Freeman and Thompson (1999) compared the responsiveness of the MBI to that of the motor and cognitive components of the FIM and the FIM total score in 201 patients with multiple sclerosis and 82 patients with stroke undergoing inpatient neuro-rehabilitation. The MBI and the total-FIM and motor-FIM all demonstrated large effect sizes for patients with stroke (ES = 0.95, 82, 91 respectively) and the cognitive-FIM demonstrated an adequate effect size (ES = 0.61). Change in scores for all scales in both disease groups were positive, indicating less disability on discharge than admission. Effect sizes on the MBI were similar to those of the FIM in both patient groups.

Hsueh, Lee and Hsieh (2001) examined the responsiveness of the MBI in 121 patients with stroke. The MBI was administered at 14, 30, 90 and 180 post-stroke. Standardized effect size scores were calculated for the intervals between 14-30 days, 30-90 days, 90-180 days and 14-180 days.  The MBI demonstrated moderate to large effect sizes for all intervals, except for the 90-180 days post-stroke interval (ES = 0.56, 0.53, 0.11 and 1.27 respectively). The largest effect size was 14-180 days post-stroke, indicating that the MBI is most sensitive to detecting change in ADL function over longer periods of time.

Dromerick, Edwards, and Diringer (2003) examined responsiveness of the MBI and the FIM in a sample of 95 patients with stroke on admission to and discharge from a stroke rehabilitation service. The Modified Rankin Scale and the International Stroke Trial Measure were used to measure disability. The FIM was found to be more responsive to change from admission to discharge than the MBI, as calculated using the standardized response mean (SRM) (SRM= 2.18 vs. 1.72). The MBI detected change in 71/95 subjects but demonstrated ceiling effects with 27% of subjects scoring >95. The results of this study found the FIM to be the most sensitive of the four measures, detecting change in 91/ 95 patients, including change in 18 patients in whom the MBI detected no change.

Schepers, Ketelaar, Visser-Meily, Dekker and Lindeman (2006) investigated the responsiveness of the MBI, FIM, Frenchay Activities Indice (FAI), and Stroke Adapted Sickness Impact Profile 30 (SA-SIP30). The four measures were administered to 163 patients with stroke at admission to inpatient rehabilitation and at 6-months and 1-year post stroke. The MBI and the FIM total and motor scores were found to have a large effect sizes at 6-months post stroke (ES 0.98, 0.84 and 0.89 respectively) and a moderate effect size at 1-year post stroke (ES = 0.52, 0.47 and 0.51 respectively). The FIM cognitive score was found to have a moderate effect size at both 6-months and 1-year post stroke (ES = 0.47 at both time points). The SASIP30 and FAI demonstrated moderate effect sizes at 1-year post stoke (ES = 0.63 and 0.59 respectively). Results of this study indicate that the MBI and FIM (total and motor) are most apt to detect change in the subacute phase.
Note: The effect sizes for the SIP30 and FAI were not calculated at 6-months post stroke due to insufficient data. The FAI was only administered to patients who resided at home during the time of testing as the measure pertains to function relating daily housekeeping and activities typically performed outside of the rehabilitation or hospital environment. 

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