Betty Cooper

Improving the sensitivity of the Barthel Index for stroke rehabilitation

The Barthel Index is considered to be the best of the ADL measurement scales. However, there are some scales that are more sensitive to small changes in functional independence than the Barthel Index. The sensitivity of the Barthel Index can be improved by expanding the number of categories used to record improvement in each ADL function. Suggested changes to the scoring of the Barthel Index, and guidelines for determining the level of independence are presented. These modifications and guidelines were applied in the assessment of 258 first stroke patients referred for inpatient comprehensive rehabilitation in Brisbane, Australia during 1984 calendar year. The modified scoring of the Barthel Index achieved greater sensitivity and improved reliability than the original version, without causing additional difficulty or affecting the implementation time. The internal consistency reliability coefficient for the modified scoring of the Barthel Index was 0.90, compared to 0.87 for the original scoring.

Efficiency, effectiveness, and duration of stroke rehabilitation.

This prospective multicenter study identifies the variables significant in the prediction of rehabilitation efficiency, achievement of rehabilitation potential and duration of rehabilitation stay in 258 persons with a first stroke admitted to comprehensive inpatient rehabilitation in Brisbane, Australia, during 1984. All three dependent variables were poorly predicted, with only 17% of the variance in rehabilitation efficiency, only 30% of the variance in achievement of rehabilitation potential, and only 22% of the variance in duration of rehabilitation stay explained. Unlike other reports, we considered most of the major medical (side of paralysis, stroke etiology, site of the lesion, arterial distribution affected, etc.), rehabilitative (initial Barthel Index score, interval from stroke onset to acute-care hospital admission, interval from hospital admission to rehabilitation commencement, neurologic measures, etc.), and demographic (age, years of education, occupation, ethnicity, etc.) variables. The high proportion of unexplained variance is likely to be due to nonmedical factors influencing the selection of patients for rehabilitation.

Predicting discharge status at commencement of stroke rehabilitation.

We discuss the functional ability of all 258 surviving patients with first stroke referred for inpatient comprehensive rehabilitation in Brisbane, Australia, during 1984 and derive an equation to predict the discharge Barthel Index score from characteristics assessed at admission to comprehensive rehabilitation. A boundary condition limiting improvement for patients with high admission Barthel Index scores and the lesser improvement observed for low-scoring patients indicate that the relation between initial and discharge Barthel Index scores is nonlinear. A quadratic equation including initial Barthel Index score and six other independent variables selected by stepwise regression analysis explained 61% of the variance in discharge Barthel Index scores.

The Barthel Index and ADL Evaluation in Stroke Rehabilitation in Australia, Japan, the UK and the USA.

At present many of the activities of daily living indices used in Australia lack essential characteristics of an index yielding desirable results. This study argues that the Barthel Index as modified by Shah, Vanclay and Cooper (1989a) is robust and has the required biometric and psychometric qualities. It presents evidence in support of the use of the Barthel Index as a preferred measure of the activities of daily living function to report therapeutically meaningful and valid information of patient care and stroke rehabilitation outcomes in Australia. It also presents the functional performance on the modified Barthel Index and the outcome of all 258 first stroke patients admitted for inpatient rehabilitation in Brisbane, Australia. Using the Barthel Index as a measure of activities of daily living functions, the study then compares the performances and outcomes of stroke patients between Australia, Japan, the United Kingdom and the United States of America.

Stroke rehabilitation: Australian patient profile and functional outcome.

A prospective, multi-institutional, population based study identified 1274 non-surgical stroke admissions to all hospitals in a major Australian city during 1984. The demographic and diagnostic profile and the nature of functional recovery of all 258 first stroke survivors who were referred for inpatient rehabilitation are presented. The median duration of rehabilitation stay was 49 days. The mean functional independence score, as measured on a modified Barthel Index at admission was 44, compared with 78 on discharge, a mean improvement of 34. Stair climbing had the lowest mean value on admission (12), while bowel control had the lowest residual deficit on discharge (95). The stroke study group was representative of the unimpaired aged population in all respects except ethnicity, where differences are attributed to age. The variables identified as significant are; side and severity of paralysis, age and sex, marital status and ethnicity. Stroke rehabilitation outcome was not influenced by etiology, site of lesion, arterial distribution, occupation or education.

Commentary on ‘A Critical Evaluation of the Barthel Index’

The Barthel Index is the most extensively researched scale and is considered superior to and more robust than any other ADL scale. The Barthel scores can gauge the need for care and help to report therapeutically meaningful and valid information of patient outcomes. Rehabilitation workers can feel confident in advocating the use of the Bl, as modified by Shah et al in 1989, as the preferred measure of ADL.

Documentation for Measuring Stroke Rehabilitation Outcomes

Stroke is the third commonest cause of hospital admission in Australia. Approximately 71% of patients with an acute stroke are likely to be admitted to public and private hospitals. With no advanced clinical information system in place in Australia, it is difficult to determine who is likely to benefit, what type of inpatient care is efficient and effective in providing maximum potential to the stroke patients. This paper highlights some of the problems encountered with the current medical records, in conducting a prospective, multi-institutional, population based stroke rehabilitation outcome study in Brisbane. The paper also discusses how these deficiencies affect health professionals such as occupational therapists, and how one can work with the medical record administrators of today as key resource people in health information management. To illustrate this, a pro forma rectifying some of the current deficiencies in the medical records is provided as a guide. (AMRJ, 1991, 21(3), 88–95).

Investigation of the Transient Ischemia Workload and its Incidence: Implications for Occupational Therapy Research

With limited effectiveness of medical and surgical intervention following stroke, the focus has shifted to preventing stroke and the most important warning sign of an impending stroke, the Transient Ischemic Attack (TIA) or the “mini stroke.” We found that the incidence of hospital admissions for the TIA patients in a population of slightly more than 1 million (660,598 people 25 years and older) was 1.18 per 1,000 men, or a total of 386 men, and 0.73 per 1,000 women, or a total of 258 women. The overall admission rate was 0.95 per 1,000 people 25 and older. For those hospitalized, the mean age was 67.9 years for men, and 71.3 years for women. Our epidemiological study of hospital admissions and the cases reported and managed by the general medical practitioners in the community showed the crude incidence rate of 2.89 per 1,000 people 25 years and older, while the adjustment for the world standardized population rate yielded a value of 1.26 per 1,000, or 44% of the crude rate that was actually observed. There appeared to be a marked disparity between the reported female and male cases of TIA. The research discussion focuses on two equally important thrusts: 1) development of strategies to reduce identified risk factors for stroke, and 2) establishment of a premorbid patient profile by occupational therapists that will have widespread implications for identifying changes for the potential prevention and treatment of stroke.

Stroke rehabilitation – who benefits? A comparison of medical wards and rehabilitation units

This prospective, multicentre, population study, of all first-stroke survivors in one year referred for in-patient rehabilitation, compares the efficiency and effectiveness of functional recovery following ad hoc and routine rehabilitation of general medical wards with intensive and comprehensive rehabilitation of mixed disability geriatric/rehabilitation units. After controlling for potential confounding variables, no significant differences were recorded in terms of Barthel discharge function scores, effectiveness or efficiency of rehabilitation. Conventional rehabilitation in general medical wards of acute hospitals was 35% more efficient than comprehensive rehabilitation in geriatric/rehabilitation units (1.08 vs. 0.70, P < 0.001), this being due to unnecessarily long rehabilitation stays (44 vs. 70 days, P < 0.000). Contrary to other studies, geriatric/rehabilitation units did not significantly increase the discharge scores, did not accelerate the process of rehabilitation, and did not decrease the demand for extended-care beds.