Barthel Index
A 10-item activities of daily living scale that measures functional independence.
By Claire White
- Rated by a clinician, a nurse, a relative, or the person themselves; 2 to 5 minutes by report.
- 10 activities of daily living: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility, and stairs.
- Total 0 to 100 in the original and Shah versions; higher scores indicate greater independence.
- Free to use. No training required.
Psychometrics
Internal consistency of the two scorings, compared head to head in 258 first stroke patients admitted for inpatient rehabilitation (Shah et al., 1989). Higher is better.
What does the Barthel Index measure?
The Barthel Index scores ten personal activities of daily living: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, walking, and stairs. Each activity is rated for how much help the person needs, and the items are weighted rather than counted equally. In the original scoring most are worth 0, 5, or 10 points and transfers and walking are worth up to 15, so the total runs from 0 to 100 in steps of 5.
The scale is used in stroke rehabilitation to describe care needs and track functional change. Its scope is personal care and getting about. Instrumental activities such as cooking, housework, money, and medication sit outside it.
What does a Barthel Index score mean?
Higher means more independent. Shah and colleagues grouped the 0 to 100 total into five bands of dependence.
| Barthel total | Dependence |
|---|---|
| 0 to 20 | Total dependence |
| 21 to 60 | Severe dependence |
| 61 to 90 | Moderate dependence |
| 91 to 99 | Slight dependence |
| 100 | Independent in all ten activities |
Check which scoring a total came from before comparing it with another. Collin and Wade score the same ten activities out of 20, so a 16 there is not a 16 on this table. Shah keeps the 0 to 100 range but splits each activity into five levels, which detects smaller changes than the original two or three.
Two limits are worth stating. The index has a ceiling, so it separates people poorly once they are close to independent, and a Rasch analysis of hospitalised older medical patients found that neither the original nor the modified version measures a single dimension. The total is reference information for the care team, most useful when it is repeated.
How the Barthel Index is administered
- Administered by
- A clinician, or anyone who knows the person well. Asking an informed nurse or relative is as reliable as testing directly, and quicker.
- Time to administer
- 2 to 5 minutes by report. Up to 20 minutes by direct observation.
- Equipment
- A pencil and a copy of the checklist
- Cost
- Free to take here.
- Published by
- MAPI Research Trust
- Training required
- None. It is equally reliable in skilled and unskilled hands.
- Remote administration
- Can be completed by telephone
- Age range
- Adults and older adults
- Available languages
- Translations include Dutch, German, Turkish, Persian, French, and Chinese
Which conditions is the Barthel Index used for?
Related instruments
- Modified Rankin Scale (mRS)One grade for overall disability instead of ten separate activities
- NIH Stroke Scale (NIHSS)The neurological deficit itself, scored in the first hours
- Spinal Cord Independence Measure (SCIM III)The same idea rebuilt for spinal cord injury, adding respiration and sphincter management
- Oswestry Disability Index (ODI)A disability index built the same way for low back pain, scored as a percentage
Barthel Index questions, answered
How is the Barthel Index scored?
Ten activities of daily living, each weighted by how much it matters. In the original 1965 scoring most items are worth 0, 5, or 10 points, transfers and walking are worth up to 15, and the total runs from 0 to 100 in steps of 5. Two later scorings are also in use. Collin and Wade score the same ten activities out of 20. Shah keeps the 0 to 100 total but splits each activity into five levels rather than two or three, which picks up smaller changes. Check which version a score came from before comparing it with another.
What does a Barthel Index score of 60 mean?
On the Shah reading of the 0 to 100 total, 60 sits at the top of the severe dependence band, which runs from 21 to 60. One more point moves it into moderate dependence. That is a good illustration of why a single total is read alongside the pattern of items rather than on its own.
What is a normal Barthel Index score?
100, meaning independent in all ten activities. It does not mean the person needs no help at all. The index covers personal care and getting about. It says nothing about cooking, housework, managing money, or taking medication, so someone can score 100 and still not be able to live alone.
Who can complete the Barthel Index?
Anyone who knows how the person actually manages. The reliability study behind it compared self-report, an informed nurse who had worked one shift with the patient, and two skilled observers testing directly. All four methods agreed closely. Asking a nurse or a relative was as reliable as testing, and faster.
How long does the Barthel Index take?
2 to 5 minutes when it is completed from report. Up to 20 minutes when each activity is observed directly.
Is the Barthel Index free?
Yes. It is free to take here. No training or certification is needed. The Barthel Index and its official translations are distributed by the MAPI Research Trust, which is who to approach about administering it in your own practice.
Evidence, psychometrics and provenance
Published by Mahoney and Barthel in 1965. Collin and Wade proposed a 0 to 20 scoring in 1988 and published the reliability study alongside it, arguing the same year that the Barthel should be adopted as the standard measure of physical disability and that variations on it should be resisted. Shah, Vanclay and Cooper set out a more sensitive scoring in 1989.
- Agreement between methods
- Self-report, an informed nurse, and two independent testers agreed closely. A difference of 4 points out of 20 was taken to reflect a genuine change (Collin et al., 1988)
- Construct validity
- Confirmed in 976 acute stroke patients. The items form a hierarchical scale (Wade and Hewer, 1987)
- Known limitation
- Ceiling effects, and neither the original nor the modified version is unidimensional in hospitalised older medical patients (de Morton et al., 2008)
References
- 1.Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.
- 2.Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry. 1987;50(2):177-182.
- 3.Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10(2):61-63.
- 4.Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988;10(2):64-67.
- 5.Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989;42(8):703-709.
- 6.de Morton NA, Keating JL, Davidson M. Rasch analysis of the Barthel Index in the assessment of hospitalized older patients after admission for an acute medical condition. Arch Phys Med Rehabil. 2008;89(4):641-647.
- 7.Shirley Ryan AbilityLab. Rehabilitation Measures Database: Barthel Index.
- 8.StrokEngine. Barthel Index (BI).
This assessment uses a validated instrument and is reference information, not a diagnosis.