Surya Shah

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.

In Praise of the Biometric and Psychometric Qualities of the Barthel Index

Since the Barthel Index (BI) was first published nearly 30 years ago (Mahoney and BartheT, 1965) it has become a widely used, internationally acclaimed measure of physical ability and function. It is regarded as superior and more robust than any other activities of daily living (ADL) scale (Dombovy et al, 1986; Jongbloed, 1986) and there are more than 200 scientific articles acclaiming it as the tool to measure independent functioning to predict outcome, and to assess the efficiency and effectiveness of intervention and quality of life issues. The BI’s superiority as a measure of function is evident in many of the 85 journals and periodicals and the scientific published and unpublished reports which report rehabilitation related research (Davis and Findley, 1990). Recently, some authors have expressed concerns about the use of the BI in comprehensive rehabilitation (Ashburn et al, 1993; Rodgers et al, 1993; Simpson and Forster; 1993; Smith, 1993). I hope this article will help resolve any reservations readers may have about using the BI as a scientific measurement tool to record therapeutically meaningful and valid information about patient care and rehabilitation outcomes.

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).

Body Scheme Disorders following Stroke and Assessment in Occupational Therapy

Disorders of neural body scheme are common perceptual sequelae following hemiplegia. Such disorders affect performance of voluntary movements and quality of functional performance adversely. This article provides a comprehensive definition of body scheme and explains its development, maintenance and newel basis. It further explains the distortions of body scheme and classifies the syndromes following hemiplegia, with implications for occupational therapy. Based on published evidence, the article discusses the strengths and limitations of various body scheme measurements and concludes with recommendations that, first, further studies are required to establish the validity of existing body scheme assessments and, secondly, there is a need for a study comparing neurologically unimpaired adults with neurologically impaired adults to determine the impact of body scheme on functional performance.

A Comparison of Rehabilitation Outcome Measures for Traumatic Brain Injury

This study evaluates the appropriateness, responsiveness, and predictive ability of the Modified Barthel Index (MBI), the Disability Rating Scale (DRS), the Barry Rehabilitation In-patient Screening of Cognition (BRISC), and the Glasgow Coma Scale (GCS) for 78 patients with traumatic brain injury referred for in-patient rehabilitation. Appropriateness was evaluated by examining means, standard deviations, coefficients of variation, and ceiling and floor effects. Responsiveness was determined by examining paired t-test results for admission and discharge scores, and on the basis of an effect size calculation. Predictive power was evaluated by performing two stepwise regressions with length of rehabilitation and total length of hospital stay. The results suggest that although the DRS and GCS have some advantages, notably in low ceiling and floor effects, overall the MBI is the most effective measure, particularly for prediction, with a moderate coefficient of determination (r2 = 0.42) and no significant differences between predicted and real length of hospital stay.