Barthel Index

Abstract

The Barthel Index (BI) is a widely utilized, foundational ordinal scale designed to quantify an individual’s functional status and performance in ten core Activities of Daily Living (ADL). Developed initially by Mahoney and Barthel in 1965, this instrument assesses the degree of assistance required by a patient in areas of mobility and self-care.

It is a critical tool in clinical settings, particularly in rehabilitation, geriatric care, and chronic illness management, providing a reliable measure for tracking functional improvement over time, predicting long-term outcomes, and informing discharge planning. Subsequent revisions, notably the 15-item version formalized by Granger and colleagues in 1981, have enhanced its sensitivity and applicability across diverse patient populations, including those recovering from a stroke.

Keywords

Barthel Index, Activities of Daily Living, ADL, Functional assessment, Rehabilitation, Stroke, Mobility, Self-care, Outcome measure, Geriatrics

Authors

Mahoney, FI., Barthel, DW., Granger, CV.

Purpose

The primary purpose of the Barthel Index is to provide an objective, standardized measure of a patient’s level of functional independence. This assessment is crucial for determining the need for personal assistance and monitoring changes in functional status throughout the course of medical care or rehabilitation.

It helps clinicians quantify the severity of physical disability resulting from conditions such as spinal cord injury, traumatic brain injury, or stroke. The total score, typically ranging from 0 (completely dependent) to 100 (fully independent), is often used to predict the eventual functional outcome and the necessary level of ongoing care.

Construct

The core construct measured by the Barthel Index is Functional Independence in Activities of Daily Living (ADL). This construct encompasses two major domains: self-care activities and mobility functions.

Self-care items include feeding, dressing, grooming, and continence management. Mobility items involve transfers (e.g., bed to chair), ambulation, and stair climbing. The scale is structured to reflect the continuum of dependence, where higher scores indicate greater independence and less need for external assistance.

Validity

The Barthel Index demonstrates robust validity across various clinical populations. It exhibits strong criterion validity, showing high correlations with other measures of functional status and predicting key clinical outcomes, such as discharge disposition and long-term institutionalization risk.

Specifically, studies have confirmed its predictive validity in stroke rehabilitation. Research, such as that conducted by Shah, Vanclay, and Cooper (1989), focused on enhancing the sensitivity of the BI, confirming its utility in capturing subtle functional changes relevant to clinical epidemiology and recovery trajectories.

Reliability

The Barthel Index is consistently reported to have high levels of reliability. Studies have confirmed excellent inter-rater reliability, meaning different assessors arrive at similar scores when evaluating the same patient.

Furthermore, strong test-retest reliability ensures that the scale provides stable measurements over short periods, provided the patient’s clinical status remains unchanged. Collin et al. (1988) published a dedicated reliability study confirming the stability and consistency of the Barthel ADL Index in clinical practice.

Factor Analysis

While the Barthel Index is generally treated as a unidimensional measure reflecting overall functional ability, factor analysis studies have occasionally explored its structure. Most analyses support a strong primary factor representing global functional independence.

However, some research suggests a potential two-factor structure, separating mobility tasks from self-care tasks. Granger et al. (1989) investigated the relative merits of the total BI score versus subscores (e.g., a four-item subscore) in predicting patient outcomes, implicitly confirming that the total score remains the most robust predictor, despite the presence of distinct functional components.

Instrument

Test Type: Observer-rated functional performance scale / Clinical outcome measure

Format: Ordinal scale. The original 10-item version yields a score from 0 to 100. The modified 15-item version (Granger) typically uses a 0–15 point system per item, normalized for a total score.

Language Available: English (original) and numerous translations globally, due to its widespread adoption in international rehabilitation research and practice.

Population Group: Patients with physical disabilities, chronic diseases, or acute medical events requiring functional assessment and rehabilitation.

Age Group: Primarily adults and older adults (geriatric populations).

Population Details: Widely used in rehabilitation units for patients recovering from stroke, spinal cord injuries, hip fractures, and other neurological or musculoskeletal conditions.

Test Methodology: Assessment is typically conducted via direct observation of the patient performing tasks or through structured interview with the patient or a caregiver, focusing on performance during the preceding 24–48 hours.

Keywords

Assessment scale, Functional status, Independence, Geriatric assessment, Neurology, Physical therapy, Outcome measurement

Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: N/A

Permissions & Fee and Test Year

The Barthel Index is generally considered a public domain instrument for clinical and research use. The original concept was published in 1965 by Mahoney and Barthel. The widely adopted modification and standardization by Granger et al. were introduced around 1979–1981.

The original PDF detailing this instrument can be downloaded here: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf

Reference’s

• Mahoney, FI., Wood, OH., Barthel, DW. (1958). Rehabilitation of chronically ill patients: the influence of complications on the final goal. South Med J, 51:605–609.
• Mahoney, FI., Barthel, DW. (1965). Functional evaluation: the Barthel Index. Maryland State Med J,14:62.
• Granger, CV., Albrecht, GL., Hamilton, BB. (1979). Outcome of comprehensive medical rehabilitation: measurement by PULSES Profile and the Barthel Index. Arch Phys Med Rehabil, 60:145–154.
• Granger, CV. (1982). Health accounting functional assessment of the long-term patient. In: Kottke FJ, Stillwell GK, Lehmann JF, eds. Krusen’s handbook of physical medicine and rehabilitation. 3rd ed. Philadelphia: WB Saunders, 253–274.
• Collin, C., Wade, DT., Davies, S, et al. (1988). The Barthel ADL Index: a reliability study. Int Disabil Stud, 10:61–63.
• Shah, S., Vanclay, F., Cooper, B. (1989). Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol, 42:703–709.
• Granger, CV., Hamilton, BB., Gresham, GE., et al. (1989). The stroke rehabilitation outcome study: Part II. Relative merits of the total Barthel Index score and a four-item subscore in predicting patient outcomes. Arch Phys Med Rehabil, 70:100–103
• McDowell, Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires, Third Edition. OXFORD UNIVERSITY PRESS

Items of the Barthel Index

Original 10-Item Version (Mahoney & Barthel et al, 1965)

1. Feeding (if food needs to be cut up = help)
2. Moving from wheelchair to bed and return (includes sitting up in bed)
3. Personal toilet (wash face‚ comb hair‚ shave‚ clean teeth)
4. Getting on and off toilet (handling clothes‚ wipe‚ flush)
5. Bathing self
6. Walking on level surface (or if unable to walk‚ propel wheelchair) *score only if unable to walk
7. Ascend and descend stairs
8. Dressing (includes tying shoes‚ fastening fasteners)
9. Controlling bowels
10. Controlling bladder

Modified 15-Item Version (Granger et al, 1981)

1. Drink from cup/feed from dish
2. Dress upper body
3. Dress lower body
4. Don brace or prosthesis
5. Grooming
6. Wash or bathe
7. Bladder continence
8. Bowel continence
9. Care of perineum/clothing at toilet
10. Transfer‚ chair
11. Transfer‚ toilet
12. Transfer‚ tub or shower
13. Walk on level 50 yards or more
14. Up and down stairs for one flight or more
15. Wheelchair/50 yards—only if not walking