Derick Wade

The Barthel ADL Index: a reliability study*

The Barthel Index is a valid measure of disability. In this study we investigated the reliability of four different methods of obtaining the score in 25 patients: self-report, asking a trained nurse who had worked with the patient for at least one shift, and separate testing by two skilled observers within 72 hours of admission. Analysis of total (summed) scores revealed a close correlation between all four methods: a difference of 4/20 points was likely to reflect a genuine difference. In individual items, most disagreement was minor and involved the definition of middle grades. Asking an informed nurse or relative was as reliable as testing, and is quicker.

The Barthel ADL Index: A standard measure of physical disability?

There is no agreed single measure of physical disability for use either clinically or in research. It is argued that acceptance of a single standard measure of activities of daily living (ADL) might increase awareness of disability, improve clinical management of disabled patients, and might even increase acceptance of published research. The Barthel ADL Index is proposed as the standard index for clinical and research purposes. Its validity, reliability, sensitivity, and utility are discussed. The Barthel Index is as good as any other single simple index, and should be adopted as the standard against which future indices are compared. The temptation to use variations on the standard Barthel Index should be resisted.

Emotion-related learning in patients with social and emotional changes associated with frontal lobe damage.

A group of patients with damage to the ventral part of the frontal lobes was severely impaired relative to a group of patients without damage in this area (the non-ventral group) in the reversal and in the extinction of simple visual discrimination tests. In these tests they continued to make responses to a previously rewarded stimulus. Patients often reported verbally that the contingencies had changed, but were unable to alter their behaviour appropriately. These impairments occurred independently of IQ or verbal memory impairments. The perseverative touching of a previously rewarded stimulus is consistent with work with non-human primates showing impaired reversal and extinction after orbitofrontal lesions. Performance on these reversal and extinction tests was highly correlated with scores obtained on a behaviour questionnaire, which reflected the degree of disinhibited and socially inappropriate behaviour exhibited by patients. It is suggested that a difficulty in modifying responses, especially when followed by negative consequences, as manifested in these simple laboratory tests, may contribute to the inappropriate behaviour shown in daily life by patients with frontal lobe damage.

Functional abilities after stroke: measurement, natural history and prognosis.

Actual functional performance of 976 acute stroke patients was assessed using the Barthel index: the data were analysed to determine the frequency of disability after stroke, the validity of the Barthel index, and the recovery seen. At 6 months, over 45% of survivors were functionally independent. Validity of the Barthel index was confirmed: it related as expected with motor loss and factor analysis showed a single major factor. The items of the Barthel index form an hierarchical scale. There was some recovery between 3 weeks and 6 months in almost all patients: the major prognostic factors were urinary incontinence, functional ability, sitting balance and age.

Face and voice expression identification in patients with emotional and behavioural changes following ventral frontal lobe damage

Impairments in the identification of facial and vocal emotional expression were demonstrated in a group of patients with ventral frontal lobe damage who had socially inappropriate behaviour. The expression identification impairments could occur independently of perceptual impairments in facial recognition, voice discrimination, or environmental sound recognition. The face and voice expression problems did not necessarily occur together in the same patients, providing an indication of separate processing. Poor performance on both expression tests was correlated with the degree of alteration of emotional experience reported by the patients. There was also a strong positive correlation between the degree of altered emotional experience and the severity of the behavioural problems (e.g. disinhibition) found in these patients. A comparison group of patients with brain damage outside the ventral frontal lobe region, without these behavioural problems, was unimpaired on the face expression identification test, was significantly less impaired at vocal expression identification and reported little subjective emotional change. The expression identification deficits in ventral frontal patients may contribute to the abnormal behaviour seen after frontal lesions, and have implications for rehabilitation.

The Rivermead Mobility Index: A further development of the Rivermead Motor Assessment

This paper reports on a development of the Rivermead Motor Assessment Gross Function scale, the Rivermead Mobility Index (RMI), a new measure of mobility disability which concentrates on body mobility. An early development included a second scale concentrating on elective mobility, but the results showed this to be unreliable. The RMI comprises a series of 14 questions and one direct observation, and covers a range of activities from turning over in bed to running. Its inter-observer reliability was tested on two groups of patients (n = 23 and 20 respectively) and it is reliable to a limit of 2 points (out of 15). Its validity as a measure of mobility after head injury and stroke was tested by concurrent measurement of mobility using gait speed and endurance, and by standing balance. The RMI does form a scale. It is short, simple, and clinically relevant, and can be used in hospital or at home.

Assessing motor impairment after stroke: a pilot reliability study.

Two short tests of motor function, the Motricity Index (MI) and the Trunk Control Test (TCT), were assessed at regular intervals after stroke and compared with a detailed physiotherapy test, the Rivermead Motor Assessment (RMA). The MI and TCT were valid and reliable tests which were usually quicker to perform than the RMA. The TCT was of predictive value when related to eventual walking ability. All three tests appeared to be of equal sensitivity in detecting change.

Recovery after stroke

One hundred and sixty-two patients were referred to a rehabilitation unit after an acute stroke. The patterns of recovery of overall functional ability, arm function, walking and speech in 92 of 101 survivors have been analysed. In all modalities the majority of recovery occurs within 3 months; although improvement is seen thereafter it does not reach statistical significance. Possible reasons for the apparent lack of late recovery are discussed.

Arm function after stroke: measurement and recovery over the first three months.

Four short, simple measures of arm function, suitable for use with patients recovering from acute stroke, are described. These tests are: the Frenchay Arm Test, the Nine Hole Peg Test, finger tapping rate and grip strength. Good interobserver and test-retest reliability was demonstrated for all tests, and the Frenchay Arm Test was shown to be valid. Normal values for all tests were established on 63 controls. It was found that the limited sensitivity of the Frenchay Arm Test could be improved using the Nine Hole Peg Test and grip strength. Recovery of arm function has been studied in a sample of 56 patients seen regularly over the first 3 months after their stroke, using these standard measures. The results demonstrated a wide variation in recovery curves between patients. The use of the Nine Hole Peg Test enabled further recovery to be detected after patients achieved a top score on the Frenchay Arm Test. Failure to recover measureable grip strength before 24 days was associated with absence of useful arm function at three months. Measurement of finger tapping rate was not useful.

Mobility after stroke: Reliability of measures of impairment and disability

This paper investigates the reliability of six measures of impairment and disability related to mobility after stroke: the Rivermead Motor Assessment (RMA, gross function subsection); gait speed (over 5 and 10 m); the motricity index (leg scores only); functional ambulation categories; sitting to standing (by observation); and mobility categories. Twenty-five patients who had suffered a stroke 2-6 years earlier leaving them with mobility disability were seen as part of a home-based physiotherapy trial. Assessments were made by three people on three occasions over 5 weeks. All six measures were reliable in statistical terms. A variation in gait speed of up to 25% and a difference of 3 points in the RMA were the actual limits of reliability.