using the barthel index in occupational therapy

Using the Barthel Index or Modified Barthel Index in Occupational Therapy

Are you an occupational therapist or OT student wondering if you should use the Barthel Index or Modified Barthel Index with your adult rehab patients? If you’re thinking about using either one of these self-care assessments but you aren’t sure if they are right for you, we’ve got you covered with the basics of each!

As occupational therapists, we are always hearing about a variety of outcome measures we can use with our patients. It can be challenging to know which ones are reliable, free, and relevant for our patient population.

The Barthel Index and Modified Barthel Index are both great free outcome measures appropriate for a wide patient population. We’ll elaborate:

What is the Barthel Index?

The Barthel Index (available here) is an outcome measure used to score performance in activities of daily living and mobility.

The 10 items to score are: feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation, and stair climbing.

Each item is either scored as 10 (independent), 5 (needs help,) or 0 (dependent).

It is very helpful in portraying the amount of assistance a patient needs. The higher the number, the more independent your patient is. The BI was developed by Mahoney and Barthel.

  • Time to score: less than 5 minutes
  • No training is required to administer
  • Test-retest reliability is good-excellent.
  • It is easily understood by the whole multidisciplinary team
  • It is recommended that you re-administer it every 10 treatment days, or every 30 calendar days. (whichever one comes first)

This website conveniently scores the BI for you, and provides you with the total score. 

What is the Modified Barthel Index?

The Modified Barthel Index (available here) uses the same 10 items as the Barthel Index, but a 5-level ordinal scale is used: 1=unable to perform task, 2=attempts task but unsafe, 3=moderate help required, 4=minimal help required, 5=fully independent.

This version of the Barthel Index was modified by Collin, Wade, and Davies.

Time to score: less than 5 minutes

Interpreting the Barthel Index and Modified Barthel Index:

Add the scores for each item and use the following score ranges to interpret them:

  • 0-20: total dependency
  • 21-60: severe dependency
  • 61-90: moderate dependency
  • 91-99: slight dependency
  • 100: independence

Prediction:

  • 0-40: Unlikely to go home and are dependent in ADLs and mobility
  • 60=Pivotal score at which patients transition from being dependent to assisted independence
  • 60-80: If they are living alone, they are likely to require community services to help them cope
  • >85: They are likely to be discharged to community living. They are independent in transfers and can walk or use a wheelchair independently.

Which Index should I use?

Now comes the tough choice of deciding whether to use the Barthel Index or the Modified Barthel Index. Both are great outcome measures, with research proving that they are effective tools to assess.

If your patient is making significant improvement in his ADLs then both indices are equal in their responsiveness.

However, according to a study published in 2022, the Modified Barthel Index is better at picking up the subtle changes in a patient’s ADL performance (2). If you had to choose just one, we would therefore recommend the use of the Modified Barthel Index, as it is more sensitive to changes in your patient’s functional abilities within ADLs.

Who can I use these assessments with?

  • Patients with strokes
  • Patients with neuromuscular or musculoskeletal conditions
  • Oncology patients
  • Older adults
  • Essentially any adult with a decline in ADL performance

Guidelines for using the Barthel Indices:

Each index must be scored based on what the patient is currently managing to do, not what a patient could do.

If a patient requires supervision, it renders them as not independent in the ADL task.

Use of assistive devices to be independent is allowed.

Using observation to score the test is superior to obtaining information from nurses or the patient’s friends or family.

Ideally, you are scoring using the patient’s performance from the preceding 24-48 hours, but longer than that can still be relevant.

The index aims to identify the level of independence from any help (physical or verbal).

Middle categories imply that the patient is contributing more than 50% of the effort.

What does research say about the Barthel Index?

The Barthel Index can even yield information on prognosis. Research done in 2021 determined that the BI was strongly associated with length of stay in-hospital, discharge destination and in hospital mortality.

Patients with severe dependence (as determined by the Barthel Index) were found to have higher in-hospital mortality and length of stay in hospital.

Helpful videos of the Barthel Index

The following are a small collection of videos to help you get comfortable with administering these assessments:

If you’re interested in observing an occupational therapist administer the Barthel Index, then you can watch this quick video. She has a lovely interaction with the patient while simultaneously asking pertinent questions needed to score the BI. 

If you would like to watch a video with further explanation on interpreting the BI, be sure to check out this video. 

Here is a video of an OT administering the BI using skills of observation and not just scoring based on what the patient self reports. 

Lastly, this video shows a health care practitioner administering the Modified Barthel Index using skills of observation in the different ADLs. 

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The Barthel and Modified Barthel Index are both excellent outcome measures that can be used with a variety of your patients. Both have had extensive research done on them, making them both reliable and valid tools for assessment and even prediction.

They are quick to administer and do not require any training, and can be used for a wide variety of conditions in adults. Overall, these are great self-care outcome measures for occupational therapists to use in their practice.

References

Ocagli. H, Cella. N, Stivanello. L , Degan. M , Canova. C. ‘The Barthel index as an indicator of hospital outcomes: A retrospective cross-sectional study with healthcare data from older people’, Journal of Advanced Nursing, vol. 77, no. 44, 2020.

Wang. Y, Chang.P , Chen. Y, Lee.Y , Huang. S , Chen. M, Hsieh. C. ‘Comparison of responsiveness of the Barthel Index and modified Barthel Index in patients with stroke.’ Disability and Rehabilitation.

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3 comments

  • Christin Allen May 17, 2023   Reply →

    This was unbelievably helpful! I’m transitioning out of phys/dis settings and starting in an emerging OT practice role in a behavioral health manage care organization. All the relevant OT tools are expected to be gathered by me because I’m “the expert” about my field amongst the interdisciplinary team. I didn’t realized until taking this role that I’ve only been using tools that were predetermined for me by other OTs in the settings I was working in.

  • Sabrina October 30, 2023   Reply →

    Is the Modified Barthel Index considered a “standardized assessment/test ?” If so… can you please provide data that confirms this? I truly appreciate your time. Thank you.

    • Sarah Stromsdorfer, OTR/L October 31, 2023   Reply →

      Yes, according to the chapter Evaluation of Function, Activity, and Participation in Science Direct “the Barthel index was one of the earliest standardized functional assessments.” The paper goes on to discuss how using the FIM in addition can be helpful, so it’s a good chapter to check out.

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