Scaling the Barthel: a 10-point hierarchical version of the activities of daily living index for use with stroke patients

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Abstract
In summed indices of ADL, such as the widely used Barthel Index, scores may not form a truly ordinal scale since patients with different patterns of disability can achieve the same total score. This problem could be overcome if activities could be shown to have a consistent hierarchy of difficulty. We therefore examined the hierarchical properties of the Barthel Index in a large group of stroke patients, using Guttman-scaling analysis. We also examined a simplified 10-point version of the Barthel, as well as the 10-point Nottingham scale which was designed as a hierarchical ADL scale for stroke patients. The items of the full 20-point Barthel Index did not form a consistent hierarchical scale, but when each activity was graded simply as 'pass or fail', thus forming a 10-point scale, the criteria of Guttman-scaling were satisfied. This simplification of the Barthel Index produced an ordinal scale without significant loss in information content. The hierarchical properties of the Nottingham scale were also confirmed, but its prognostic value appeared to be slightly lower than that of the Barthel. The 10-point hierarchical version of the Barthel Index should be useful in large epidemiological or audit studies, where complete information is hard to obtain, but it is probably too crude to be useful in managing individual patients. We emphasize that our results apply only to stroke and that the hierarchy of ADL might be different for other conditions.

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