# data[].attributes.body
The Barthel Index can be administered in a variety of ways. The 10 skills can be rated using patient reports, reports of others including nurses or caregivers, or by direct observation. It can also be rated through clinical reasoning and common sense. For example, if a patient is not able to sit up in bed or transfer to a chair, it can be inferred that they cannot walk greater than 50 yards. Each item is scored as described on the sheet. For the items that have 2 options - independent or requires assistance - any assistance needed is included in the requires assistance section. This includes supervision and verbal prompts, as well as set up.

This is not a standardized administration. There are no time limits. The only materials needed are the scoring sheet and writing utensil. More materials may be needed if any portions are done by direct observation. This would require the needed furniture or supplies for that particular ADL. For example, bed, chair, grooming supplies, shower supplies, stairs, and toilet. The patient can use any aids needed for independence. For example, sock aid, shoe horn, etc.

# data[].attributes.body
Free to use.

Can be used to show any deficit within the categories, regardless of extent of assistance or reason

Allows for use of aids without impacting the score.

Relatively simple and fast to administer.

It has become widespread and a good standard in ADL performance. It is available in multiple languages. Newer assessments have used the Barthel Index as a standard for comparison.

# data[].attributes.body
The Barthel Index has a lot of supporting literature for reliability and validity. It is also used as a standard to compare other, newer assessments. It was originally created for patients with stroke and there is literature measuring validity and reliability in other areas as well.

# data[].attributes.body
The scoring is completed by totaling each component. It is a score out of 100 points. The lower the value indicates less independence. There are no official levels for categorizing scores in the original document. String et al. proposed two cut off scores to indicate a risk of a difficult discharge (2020). A score of 0-35 indicates a high risk, 35-70 indicates a medium risk, and above 70 indicates a low risk of difficult discharge (Strini et al., 2020).

# data[].attributes.body
I administered the Barthel Index on Nathan who was portraying someone following a neurological event or surgery. He scored a 65 out of 100. I demonstrated how the assessment can be completed in multiple ways or combinations involving reports and direct observation. This can also be done in collaboration with physical therapy for input on the mobility and stairs. In this particular instance I may check with them on the mobility and stairs. His score of 65 shows he is not independent and would have some areas to address. Areas would be functional mobility and transfers. Overall he is close to being above 70 which would indicate a lower risk of a difficult discharge. He is currently in the medium risk level.

# data[].attributes.body
Joe is a 55 year-old man. He is married and has two children. One is 15 and lives at home and one is in college. Joe's wife is a school teacher. Joe works for an insurance company and primarily works from home on the computer. Four days ago Joe had a CVA and was admitted to the hospital. He stayed for 3 days and he has moved to a sub-acute rehab hospital. Joe has left sided weakness and needs assistance with transfers and functional mobility. He is not independent with ADLs of dressing, grooming, eating, bathing, or toileting. The OT completed the Barthel Index as part of the evaluation. He scored 25 indicating a lower level of independence.

He continues to have deficits in left UE and LE weakness, ADL performance, and functional mobility. He is able to feed himself with setup and assistance to cut food. He is able to perform grooming tasks at the sink with setup, sit to stand with mod assist, transfer to chair with mod assist, and complete toileting tasks when assisted with toilet transfer and clothing management. He needs assistance with transfers, dressing, and bathing.

Goal:

Joe will perform bed to chair transfer using hemi walker with min A by 6/1/24.

Joe will complete upper and lower body dressing using dressing aids with mod A by 6/1/24.

Intervention:

Dressing intervention

Education on assistive devices (sock aid, dressing stick, reacher, and long handled shoe horn).

Education on alternative dressing techniques - one handed techniques.

Guided practice donning shirt, pants, socks, and shoes while providing graded assistance and verbal prompts.

# data[].attributes.body
The Barthel Index is a tool used to show the level of independence for a person to complete BADLs and functional mobility. It has scores for the following areas:

Feeding

Bathing

Grooming

Dressing

Bowels

Bladder

Toilet Use

Transfers

Mobility on Level Surfaces

Stairs

Each category has scores for being independent or those requiring assistance. The total score is out of 100 points. Lower total scores represent less independence. The assessment categories are very straight forward with either requiring assistance, being dependent or being independent. Some categories break down levels of assistance and it is clearly written out what proportion is expected for each score.

The assessment can be completed using best available evidence. This includes reports from patient, caregivers, or nurses; direct observation; and common sense. Direct testing is not a requirement. The assessment can be completed using a mix of reports and direct observation as well as clinical reasoning for ability (Mahoney, 1965).

Time: 2-20 minutes depending on how it is administered - reports versus direct observation.

Target Population:

Adults and older adults

The Barthel index can be used in acute care, skilled nursing, sub-acute facilities, and in-patient rehab. It may not be thorough enough to show small changes in dependence level so it may not always be appropriate in some settings or with some patients, especially at the extremes of high or low level functioning. It is most appropriate for those with neuromuscular or musculoskeletal chronic conditions (Marvin, nd). Some conditions include stroke, Parkinson's Disease, Multiple Sclerosis, arthritis, and generalized weakness in older adults.

The Barthel Index was developed in 1965 by Barthel and Mahoney to be used for adults with strokes. There are other variations including the Modified Barthel Index created in 1988 to make it more sensitive to detecting smaller changes (Marvin, nd). Although originally developed for use in patients with stroke, it has been shown to be valid for use with other diagnoses.

# data[].attributes.body
The Barthel Index is well documented and studied. The more recent research tends to research the Barthel Index in a variety of settings or with different sub-sets of patients. There are also studies of its use in other countries or in other languages (Marvin, nd).

Two studies were completed to determine the validity of the use in ICU patients and oncology patients (dos Santos Barros et al., 2022; dos Reis et al., 2022). It was found to be an effective tool for use in patients in both settings. The Barthel Index was originally designed to be used with patients with a CVA but it has expanded to other neurolomuscular and musculoskeletal disorders. Based on these studies, it has also been validated to be used in ICU patients and oncology patients.

A study done in China used the Barthel Index as a comparison and way to validate the Longshi Assessment (Xiong et al, 2023). The Barthel Index has become a standard in the assessment of ADLs and is used to validate other assessments. The longshi assessment was used by non-medical assessors to assess over 14000 patients from a variety of educational, regional, and economic backgrounds (Xiong et al., 2023). This was compared to results from the Barthel Index administered by healthcare professionals. The results showed a positive correlation. This is an example of how the Barthel Index has become a very stable assessment that others can use as a comparison to establish validity.

A study was completed to determine the use of the Barthel Index to predict outcomes such as length of stay, rehospitalization, cardiac morbidity, and mortality (Bahrmann et al., 2019). The study consisted of 307 patients older than 68 who came to the emergency department. It was found that the score on the Barthel correlated with and could be used as a tool to predict length of stay, mortality risk, cardiovascular mortality risk, and risk of rehospitalization (Bahrmann et al., 2019). This further depicts the Barthel Index as a useful tool for practitioners.

# data[].attributes.body
Does not always show improvements made through reduction in required assistance. It has an all or nothing approach. For example, it may not distinguish between minimum assistance and moderate assistance and show those improvements made between those.

Ceiling Effect can be seen where it is harder to detect changes in those who have a very high functional level. (Salbach et al., 2001).

It can rely on reports from patient, family, or caregivers so reports may not always be accurate. Direct observation is also important.

# data[].attributes.body
An observational study was completed with 122 patients getting discharged from an intensive care unit (dos Reis et al., 2022). This showed good internal consistency and inter-rater reliability.

Internal Consistency: 0.81

Inter-rater: .98 (90% CI, 0.97-0.98; P<.001

A literature review compiled data for the Barthel Index and found that it typically rates as 0.80 to 0.93 (good to excellent) for internal consistency and test-retest is generally good although it is not always included in the measurements (Quinn et al., 2011).

# data[].attributes.body
The Barthel Index is a valid test for ADLs in a variety of population groups. It has shown to be so valid that it is often used as a comparison for other assessments. The literature is expanding to show that it is valid in populations other than patients with stroke.

A study was completed with 220 patients with cancer and was shown to be valid (dos Santos Barros et al., 2022).

There were adequate correlations between the KPS (0.766) and the EORTC-QLQ-C15-PAL (0.698) (dos Santos Barros et al., 2022).

In the study by dos Reis, et al described in the reliability section, there was a correlation between the Functional Status Score-ICU and the Barthel Index (0.88) (2022).

# data[].attributes.body
Bahrmann, A., Benner, L., Christ, M., Bertsch, T., Sieber, C. C., Katus, H., & Bahrmann, P. (2019). The Charlson Comorbidity and Barthel Index predict length of hospital stay, mortality, cardiovascular mortality and rehospitalization in unselected older patients admitted to the emergency department. Aging Clinical & Experimental Research, 31(9), 1233–1242. https://doi.org/10.1007/s40520-018-1067-x

dos Reis, N. F., Figueiredo, F. C. X. S., Biscaro, R. R. M., Lunardelli, E. B., & Maurici, R. (2022). Psychometric Properties of the Barthel Index Used at Intensive Care Unit Discharge. American Journal of Critical Care, 31(1), 65–72. https://doi.org/10.4037/ajcc2022732

dos Santos Barros, V., Bassi-Dibai, D., Guedes, C. L. R., Morais, D. N., Coutinho, S. M., de Oliveira Simões, G., Mendes, L. P., da Cunha Leal, P., & Dibai-Filho, A. V. (2022). Barthel Index is a valid and reliable tool to measure the functional independence of cancer patients in palliative care. BMC palliative care, 21(1), 124. https://doi.org/10.1186/s12904-022-01017-z

Mahoney FI, Barthel D. “Functional evaluation: the Barthel Index.” Maryland State Med Journal 1965;14:56-61

Marvin, A. K. (n.d.). Barthel index (BI). Strokengine. https://strokengine.ca/en/assessments/barthel-index-bi/#References

Salbach, N., Mayo, N., Higgins, J., Ahmed, S., Finch, L., & Richards, C. (2001). Responsiveness and predictability of gait speed and other disability measures in acute stroke. Archives of Physical Medicine and Rehabilitation, 82,(9), 1204-1212.

Strini, V., Piazzetta, N., Gallo, A., & Schiavolin, R. (2020). Barthel Index: creation and validation of two cut-offs using the BRASS Index. Acta bio-medica : Atenei Parmensis, 91(2-S), 19–26. https://doi.org/10.23750/abm.v91i2-S.9226

Xiong, F., Liu, X., Zhou, M., Wang, C., Liu, Q., Li, J., & Wang, Y. (2023). Validation of the Longshi scale in assessment of function in patients from different economic, educational and regional backgrounds in China. Clinical Rehabilitation, 37(11), 1552–1558. https://doi.org/10.1177/02692155231174689