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NINDS CDE Notice of Copyright
Barthel Index
Barthel Index
| Availability |
The Maryland State Medical Society holds the copyright for the Barthel Index. It may be used freely for non-commercial purposes with the primary reference cited: [Mahoney FI, Barthel D. Functional evaluation: the Barthel Index. Maryland State Med J. 1965;14:56-61. Used with permission.]
Permission is required to modify the Barthel Index or to use it for commercial purposes. Shorter version of the form is available for use. Multiple language translations available - validation studies in English only. Please contact MAPI Research Trust to sign a translation agreement and to obtain Linguistic Validation Guidelines.
Contact information and permission to use:
MAPI Research Trust, Lyon, France:
E-mail:
Internet:
Information on Barthel Index:
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| Classification |
NeuroRehab Supplemental - Highly Recommended:
Recommendations for Use: Indicated for studies requiring a measure of Activities of Daily Living. Advocacy for its use cannot be generalized to conditions for which it has not been validated.
Supplemental: Multiple Sclerosis (MS), Myotonic Muscular Dystrophy (DM), Neuromuscular Disease (NMD), Stroke and Amyotrophic Lateral Sclerosis (ALS), Friedreich's Ataxia (FA)
Exploratory: Congenital Muscular Dystrophy (CMD), and Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)
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| Short Description of Instrument |
The Barthel Index (BI) or Barthel ADL index is a scale used to measure performance in basic activities of daily living (ADL). It uses ten variables describing ADL and mobility. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital.
Purpose: Assesses the ability of an individual with a neuromuscular or musculoskeletal disorder to care for him/herself.
Administration: The examination requires 5-10 minutes to complete.
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| Comments/Special Instructions |
The BI was originally developed as an ADL assessment for long-term patients in hospital with neuromuscular or musculoskeletal disorders (Mahoney and Barthel 1965). It is one of the most widely used generic disability measures, and has been used extensively in MS. A five-item short form of the Barthel Index is also available (Hobart et al., 2001). It should be used as a record of what a patient does, not of what a patient can do.
NeuroRehab Specific: The Barthel Index is a direct measure of activities of daily living.
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| Scoring and Psychometric Properties |
Scoring: A patient scoring 100 is continent, feeds himself, dresses himself, gets up out of bed and chairs, bathes himself, walks at least a block, and can ascend and descend stairs. This does not mean that he is able to live alone: he may not be able to cook, keep house, and meet the public, but he is able to get along without attendant care. A score of 0 is given in all of the above activities when the patient cannot meet the criteria as defined above.
According to Sinoff and Ore, scoring on the BI can be interpreted as follows:
Psychometric Properties: A number of studies support the validity, reliability and responsiveness of the BI in MS. Ceiling and floor effects potentially limits its responsiveness to change in the community and long term settings. A sizable number of studies support the high reproducibility of the BI, Cronbach's reliability ranging from 0.84-0.96. Responsiveness is similar to that of the FIM. The BI is highly correlated with the FIM (Prodinger et al., 2017).
The BI is considered a reliable disability scale for stroke patients.
A meta-analysis by Duffy et al. (2013) found the BI to have excellent inter-rater reliability (κw, 0.93; 95% confidence interval, 0.90-0.96 random effects modeling) for standard administration after stroke.
However, the scale suffers from 'ceiling effects' and therefore does not differentiate disability well among patients with higher levels of functioning. The BI also has 'floor effects' and is not useful in the setting of acute stroke because it typically cannot be used to measure initial stroke severity.
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| Rationale/Justification |
Strengths: The advantage of the BI is its simplicity. It is useful in evaluating a patient's state of independence before treatment, his progress as he undergoes treatment, and his status when he reaches maximum benefit. It can easily be understood by all who work with a patient and can accurately and quickly be scored by anyone who adheres to the definitions of items. A potential advantage of the Barthel Index is that it can be administered by patient self-report, patient interview including by telephone, or by report of a proxy able to provide reliable information (e.g., spouse, family member, or caregiver). However, there are few data confirming the equivalence of these data collection methods.
A shorter version of the form is available for use; the modified 20-point version of the BI introduced by Collin and colleagues in 1988. The modified 20-point BI is easier and quicker to administer than the 100-point BI. English and other translations are available.
Weaknesses: There are currently no published instructions on the use of the BI to assess initial stroke disability. Pre- morbid BI is reasonable to assess on presentation, but there is a lack of data to identify how to use it to assess initial stroke presentation. Raters using this at admission or discharge should develop a standard methodology and scoring instructions for use in hospital settings.
NeuroRehab Specific:
Strengths: The Barthel Index is a direct measure of activities of daily living.
Weaknesses: It does not measure an individual's capacity or what activities of daily living they are capable of performing. Advocacy for its use cannot be generalized to conditions for which it has not been validated. Several important ADL tasks are not included in this measure: medication; sleep; personal care device management, e.g., insulin shots, hearing aids. The Barthel Index may manifest ceiling or floor effects and may not be appropriate for measuring individuals outside their range of assessment.
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| References |
Key Reference:
Mahoney FI, Barthel D. Functional evaluation: the Barthel Index. Maryland State Med J. 1965;14:56-61.
Additional References:
Collin C, Wade DT, Davies S et al. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10:61-63.
D'Olhaberriague L, Litvan I, Mitsias P, Mansbach HH. A reappraisal of reliability and validity studies in stroke. Stroke. 1996;27:2331-2336.
Duffy L, Gajree S, Langhorne P, Stott DJ, Quinn TJ. Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: systematic review and meta-analysis. Stroke. 2013 Feb;44(2):462-8.
Gayà-Barroso A, González-Moreno J, Rodríguez A, Ripoll-Vera T, Losada-López I, Gili M, Paneque M, Cisneros-Barroso E. Establishing Occupational Therapy Needs: A Semi-Structured Interview with Hereditary Transthyretin Amyloidosis Patients. Int J Environ Res Public Health. 2022 Sep 17;19(18):11721.
Granger CV, Dewis LS, Peters NC, Sherwood CC, Barrett JE. Stroke rehabilitation: analysis of repeated Barthel index measures. Arch Phys Med Rehabil. 1979;60(1):14-17.
Gupta, A. (2008) Barthel Index. In Measurement Scales Used in Elderly Care (pp. 42-49). Radcliffe Publishing Ltd.
Hobart JC, Lamping DL, Freeman JA, Greenwood RJ, McLellan DL, Thompson A. Evidence-based measurement: which disability scale for neurological rehabilitation? Neurology. 2001;57:639-644.
Hobart JC, Thompson AJ. The five item Barthel index. J Neurol Neurosurg Psychiatry 2001;71:225-230.
Karasu AU, Karataş L, Yıldız Y, Günendi Z. Natural Course of Muscular Strength, Physical Performance, and Musculoskeletal Symptoms in Hospitalized Patients With COVID-19. Arch Phys Med Rehabil. 2023 Jan;104(1):18-26. doi: 10.1016/j.apmr.2022.09.001.
Masuccio FG, Tipa V, Invernizzi M, Solaro C. Guillain-Barré Syndrome Related and Unrelated to COVID-19: Clinical Follow-Up in the COVID-19 Era. Phys Ther. 2022 Jun 3;102(6):pzac049.
McGivney GP, Haughton V, Strandt JA, Eichholz JE, Lubar DM. A comparison of computer-assisted tomography and data-gathering modalities in prosthodontics. Int J Oral Maxillofac Implants. 1986 Summer;1(1):55-68.
Prodinger B, O'Connor RJ, Stucki G, Tennant A. Establishing score equivalence of the Functional Independence Measure motor scale and the Barthel Index, utilising the International Classification of Functioning, Disability and Health and Rasch measurement theory. J Rehabil Med. 2017 May 16;49(5):416-422.
Quinn TJ, Langhorne P, Stott DJ. Barthel index for stroke trials: development, properties, and application. Stroke. 2011 Apr;42(4):1146-51.
Shah N, Shrivastava M, Kumar S, Nagi RS. Supervised, individualised exercise reduces fatigue and improves strength and quality of life more than unsupervised home exercise in people with chronic Guillain-Barré syndrome: a randomised trial. J Physiother. 2022 Apr;68(2):123-129.
Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index in stroke rehabilitation. J Clin Epidemiol. 1989;42:703-709.
Sinoff G, Ore L. The Barthel Activities of Daily Living Index: self-reporting versus actual performance in the old-old (> 75 years). J Am Geriatr Soc. 1997;45:832-36.
Tani T, Imai S, Fushimi K. Increasing daily duration of rehabilitation for inpatients with sporadic inclusion body myositis may contribute to improvement in activities of daily living: A nationwide database cohort study. J Rehabil Med. 2023 Apr 19;55:jrm00386.
Document last updated October 2024
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