Australian Occupational Therapy Journal (1996) 43, 22-29

Inter-rater r e l i a b i l i t y o f t h e o r i g i n a l a n d
m o d i f i e d B a r t h e l Index, a n d a c o m p a r i s o n w i t h
t h e Functional Independence Measure

Janet Fricke and Carolyn A. Unsworth

School of Occupational Therapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia

The Barthel Index (BI), the Modified Barthel Index ( M B I ) and the Functional Independence Measure (FIM) are
all widely used by occupational therapists as assessment tools f o r clinical decision-making and outcome
measurement. All of these tools have demonstrated validity and the BI and the FIM have demonstrated inter-rater
reliability. The M B I has been modified to increase sensitivity; however, there have been no publications on the
inter-rater reliability of this tool following the changes. The purpose of this research was to examine the inter-rater
reliability of two versions of the Barthel Index, and draw some comparisons between this assessment tool and the
FIM. Twenty-five patients with neurological and orthopaedic conditions were assessed by three occupational
therapists using the three tools. The method of analysis selected was percentage agreement and intraclass
correlation coefficient. The results indicated that both the original and modified versions of the Barthel Index
possess good inter-rater reliability. As all three tools have demonstrated adequate reliability and validity, it is
suggested that clinicians select the most sensitive tool that best meets their clinical needs, and use this assessment
tool in its standardized format.

K E Y W 0 R D S activities of daily living, functional assessment, Functional Independence Measure, modified

Barthel Index, original Barthel Index.

INTRODUCTION and limitations of each tool must be carefully considered.

The selection of functional assessment tools for use in
rehabilitation and geriatric care facilities is a widely
debated issue. Such tools are being used not only to
inform clinical discussions such as patient treatment and
discharge plans but to monitor programme outcomes.
Choosing a tool is a time-consuming process because no
functional assessment measure will perfectly meet the cir-
cumstances of every client or hospital, and the advantages
It is essential that the selected tool has demonstrated
validity, reliability and sensitivity (Eakin, 1989; Fricke,
1993; Law, 1987).
In 1995 the Department of Health and Community
Services, Australia, recommended that a non-standardized
version of the Barthel Index (BI) should be adopted for
rehabilitation programmes. This version of the Barthel
index appeared to be ‘cobbled together’ from the original
Barthel Index (OBI; Mahoney & Barthel, 1965) and ver-

Janet Fricke BAppSc(OccTher1; Lecturer. Carolyn A. Unsworth PhD, OTR; Senior Lecturer.
Correspondence: Janet Fricke, School of Occupational Therapy, Faculty of Health Sciences, La Trobe University, Locked Bag 12, Carlton South, Vic.
3053, Australia. Email: J.Fricke@latrobe.edu.au
Accepted for publication January 1997.
Inter-rater Reliability of ADL Assessments
sions of the BI by Granger, Albrecht and Hamilton (1979),
and Fortinsky, Granger and Seltzer (1981). Thus previ-
ously established reliability was no longer valid.
The occupational therapists at North-west Hospital’s
Greenvale campus (a 92-bed aged care and rehabilitation
hospital) were concerned that the proposed tool was not a
standardized version of the BI (Mahoney & Barthel,
1965), and that the three-point scale it used lacked sensi-
tivity to change in patient status. North-west Hospital is a
multi-campus hospital specializing in aged care. It was
proposed that the more sensitive Modified Barthel Index
(MBI; Shah, Vanclay & Cooper, 1989) should be used in
preference to the recommended tool. However, no litera-
ture could be found on the inter-rater reliability of the
MBI. In addition, the North-west Hospital group currently
uses (and will continue to use) the Functional Indepen-
dence Measure (FIMSM; Granger, Cotter, Hamilton,
Fiedler & Hens, 1990).
Review of B a r t h e l Index l i t e r a t u r e
The BI, in its various versions, is one of the most fre-
quently cited activities of daily living (ADL) assessments.
In recent occupational therapy literature the strengths and
weaknesses of the BI have become topical issues (Eakin,
1993; Murdock, 1992a, 1992b; Shah & Cooper, 1993a,
1993b). Despite concerns over possible limitations associ-
ated with some versions, the BI is frequently used in Aus-
tralia and has been widely adopted for clinical
decision-making and as a measure of outcome for general
use with elderly patients. This tool is recommended for
use by the Aged Care Assessment Teams in Victoria (But-
ler, Fricke, & Humphries, 1993).
The OBI was developed by Dorothea Barthel to moni-
tor orthopaedic patients’ progress in selfcare and mobility
skill during inpatient rehabilitation (Mahoney & Barthel,
1965). The activities that were evaluated included feeding,
wheelchairlbed transfer, personal toilet (personal care),
toilet transfer, bathing, walking, stair climbing, dressing,
and bladder and bowel control. The OBI uses a 3-point
scale where raters assign scores of 0,5,10 or 15 to items on
the assessment (Appendix 1). The scores are often
summed to give a maximum score of 100. The assessment
incorporates a weighting system giving extra emphasis to
mobility and continence: the two areas that appear to be
most important for accommodation placements. Gresham,
Phillips and Labi (1980) suggest that the OBI ‘reflects the
23
pragmatism and long clinical experience of its designers in
its frankly preferential weighting of mobility and conti-
nence above other variables’ (p. 358).
Studies of various versions of the BI have stated that it
is a valid and relatively reliable tool but not very sensitive
to change (Collin, Wade, Davies & Horne, 1988; Granger,
Dewis, Peters, Sherwood & Barrett, 1979; Gresham,
Phillips & Labi, 1980; Kidd et al., 1995; Wade & Collin,
1988). The measurement of clinical change is crucial to the
assessment of outcome, benefit and cost effectiveness,
thus requiring a sensitive tool (Kidd et al., 1995; Wellwood,
Dennis & Warlow, 1995). Shah ef al. (1989) revised the
OBI to increase its sensitivity to change or small improve-
ments, stating that ‘greater sensitivity of the BI is required
in scoring those individuals who require assistance of
some nature to perform the tasks’ (p. 704). The new tool,
the MBI (Shah ef al., 1989), was used in a research project
on initial and discharge assessments of 258 patients who
had experienced their first stroke. While the activities
being assessed were not changed, the scoring system was
modified to be more sensitive by including coding for help
required: from 1 (unable) to 5 (independent) (Appendix
2). The score for each category reflected the original
weighting. The MBI included detailed operational defini-
tions, with research demonstrating it to have good internal
consistency (Shah ef al., 1989).
The lack of sensitivity of the original BI suggests that
the changes to the MBI were worthwhile. However, these
changes, while making the MBI more sensitive, may have
altered the inter-rater reliability of the tool. A major prob-
lem, therefore, was the lack of research demonstrating the
inter-rater reliability of the MBI (Di Fabio, 1990; Eakin,
1993). Kidd et al. (1995) asserted that for a measurement
tool to be effective it requires ‘reliability: that the mea-
surement is repeatable and reproducible when measured
by single and different observers’ (p. 12). Inter-rater relia-
bility is imperative in clinical fields where therapists make
judgements on patients’ functional status. These judge-
ments determine treatment protocols and accommodation
placement, in addition to being used as a measure of ther-
apy outcome. It is therefore essential that acceptable relia-
bility of the MBI scoring is regularly attained.
The study reported in this article was based on
methodologies from several other related studies about
inter-rater reliability of functional assessment scales.
Collin et al. (1988) undertook a reliability study of the
original BI that investigated four different methods of
24
obtaining the score with 25 patients. In one section of the
study, scores taken by a trained nurse and an occupational
therapist, who tested the patient within 72 hours of
admission, were compared. Kidd et al. (1995) also used 25
patients in their study on the reliability of the FIM and the
BI. Cole (1989) studied the inter-rater reliability of the
Crichton Geriatric Behavioural Rating Scale, by having
two raters interview each of the carers of 47 subjects with
dementia. The method and analyses (namely percentage
agreement and intraclass correlation coefficient, ICC)
selected for Cole’s study were also successfully adopted in
research examining the inter-rater reliability of the per-
sonal care section of the FIM (Fricke, Unsworth & Wor-
rell, 1993).
Study aims
The aims of the current study, and rationale to support
these, were as follows.
(1) To examine the spread of scores for the OBI, MBI
and brief FIM using frequency data. The purpose of this
aim was to provide a description of scores that are gener-
ated when therapists rate the same patient using three dif-
ferent assessment tools.
(2) To determine the individual item reliability of the
OBI and MBI. When examining the inter-rater reliability
of a tool, it is also important to consider the reliability of
individual scale items. This is particularly important when
considering that more sensitive scales (with greater range
of score options) often consequently have reduced
reliability.
(3) To determine the inter-rater reliability of the OBI
and MBI. No published studies reporting the inter-rater
reliability of the MBI have been identified, hence research
of this nature is required. In addition, a further inter-rater
reliability study of the OBI served as a comparison point
in the present study, and may offer further supportive
information about the psychometric properties of this
tool.
(4) To examine patterns of score shift between the
OBI and MBI. The purpose of this aim was to examine if
the three therapists were consistent in any scoring shift
when scoring patients on both the OBI and the MBI.
(5) To correlate the MBI, OBI and brief FIM to look
at the relationship between scores on these three assess-
ments. Given that the OBI is considered a gold standard,
it is important to determine if, and how well, the MBI and
J. Fricke and C. A. Unsworth
brief FIM correlate with this tool. The brief FIM was
included in this analysis because of its current use and per-
ceived value by the occupational therapists at North-west
Hospital.
METHODS
Twenty-five consecutively admitted patients who were
referred to the occupational therapy programme were
included in this study. The age range of patients was 52-87
years, with 50% being over 77 years, and a mean age of
75.4 years. Seventeen of the patients were diagnosed with
a lower limb orthopaedic condition and eight were neuro-
logical patients or patients who had had a stroke. The sex
distribution was 12 males and 13 females. Informed con-
sent was obtained from each of the 25 patients. Each of
the patients were identified by number to maintain confi-
dentiality. Three occupational therapists, who had more
than 12 months clinical experience, conducted initial
assessments of the patients and obtained MBI, OBI and
FIM scores.
Instruments
The assessment tools used in this study were the OBI
(Mahoney & Barthel, 1965), the MBI (Shah et al., 1989),
and a brief FIM (Granger et al., 1990). These tools have all
been recommended for multidiagnostic groups (Granger
et al., 1990; Mahoney & Barthel, 1965; Shah et al., 1989).
The brief FIM used in this study consisted of summing the
totals from the FIM subsections of ‘selfcare’, ‘sphincter
control’, ‘mobility’ and ‘locomotion’. The developers of
FIM suggest that this is a legitimate practice, and the FIM
score is rated out of 91. The use of the brief FIM suited the
purposes of this study, given that the OBI and MBI are
compared with the FIM and yet do not contain items on
‘communication’ or ‘social cognition’.
Procedure
The three occupational therapists who were members of
the rehabilitation team were trained for approximately 2
hours in the use of the MBI and the OBI by the investiga-
tors. Training consisted of reviewing the operational defin-
Inter-rater Reliability of ADL Assessments 25
I

itions and specific guidelines related to each assessment, Table 1. Summary of averaged kappa scores for original
and practice using each tool with a written case study. Barthel Index (OBI) and the modified Barthel Index (MBl)
Each rater was issued with operational definitions pub- items for three raters
lished in the original articles (Mahoney & Barthel, 1965;
Item OBI MBI
Shah et al., 1989) and with specific guidelines for the two
versions of the BI modified from Collin and Wade (1988; Personal hygiendtoilet 0.61 0.68
Appendix 3). They were all credentialled FIM administra- Bathing self not calculable 0.66
tors. Two of the occupational therapists observed an ADL Feeding 0.85 0.88
assessment being undertaken by the third occupational Getting on/off toilet 0.67 0.61
therapist. Some data, such as continence, was obtained by Stair climbing insufficient data insufficient data
questioning the patient or nursing staff. The FIM score Dressing 0.57 0.52
from the rehabilitation team was recorded for each Bowel control 0.81 I 0.67
patient. The two occupational therapists observing and the Bladder control 0.75 0.60
therapist administering the assessments scored the activi- Am bulation 0.67 0.68
ties undertaken using the MBI and the OBI. The therapist Wheelchair (only if ambulation
administering the assessment changed according to who is 0) insufficient data insufficient data
had been assigned to assess the patient’s showering ability. Wheelchair or chair to
Scoring was completed independently by each rater. Score bed transfers 0.66 0.53
sheets were colour coded to indicate which therapist was
scoring. At the conclusion of the data collection phase, the
three occupational therapists completed a questionnaire bility. These are important questions because, often,
to obtain information on their perception of the advan- greater scale sensitivity is achieved with a corresponding
tages and disadvantages of the three assessments, includ- decrease in inter-rater reliability. Initially, the individual
ing operational definitions, scale sensitivity, ease of use reliability of each of the items on the OBI and MBI was
and clinical utility. established. Following convention, this was achieved using
the kappa coefficient. The results are summarized in Table
1. The reliability of four items could not be assessed due to
RESULTS
lack of variability in the scoring, or missing scores (e.g.
Spread of scores f o r t h e OBI, MBI and only wheelchair or ambulation is scored). All other items
brief F I M were found to possess moderate to good reliability, with
the kappa scores ranging from 0.52 on the MBI for dress-
Frequency distributions of scores generated by the three ing to 0.88 for feeding.
therapists using the OBI and MBI for 25 patients were
constructed. A frequency distribution was also generated The i n t e r - r a t e r r e l i a b i l i t y of t h e OBI and
for the brief FIM. The results indicated that, while FIM MBI scales
and MBI assessments produce a range of scores, scores on
the OBI are clustered and have a more limited range. Inter-rater reliability of each therapist’s scores using the
OBI was calculated using the ICC (type 2,l; Shrout &
Individual i t e m reliability of the OBI and Fleiss, 1979). Scores generated from both the OBI and the
MBI MBI were treated parametrically as argued in Unsworth,
Thomas and Greenwood (1995). The ICC for the OBI was
Given the above finding, that the MBI produces a better
spread of scores, we examined then whether the MBI and found to be 0.957. Inter-rater reliability of each therapist’s
the OBI possess adequate item and scale inter-rater relia- scores using the MBI was then calculated using the same
bility. These are important questions because, often, method. The ICC for MBI was also found to be very good
greater scale sensitivity is achieved with a corresponding at ICC (type 2 , l ) = 0.979.
26
P a t t e r n s of score shift b e t w e e n t h e OBI
and t h e MBI
The data were also examined to determine if the thera-
pists were consistent in any scoring shift when moving
from the OBI to the MBI, for the 25 patients. For exam-
ple, for the item ‘feeding’, a patient who needs assistance
scores a 5 (with help) on the OBI. However, on the MBI
the therapists could score a patient who needs assistance
as a 2 (attempts task but unsafe), a 5 (moderate help
required), or an 8 (minimal help required). This led the
researchers to question if patient 1 was scored as a 5 on
the OBI by all therapists, did they consistently rate the
patient as a 2, 5 or 8 on the MBI? The findings for ‘feed-
ing’ indicate that the raters used both 5 and 8 for patients
who had been rated as 5 on the OBI, and did so consis-
tently: of 13 patients originally rated as 5 by all three ther-
apists, eight were subsequently given a rating of 8 on the
MBI and five patients were consistently left with an MBI
rating of 5. Thus, the raters appeared to be making use of
the expanded scale, and did so consistently. Visual inspec-
tion of the data for all 10 items revealed that this was the
case for six items. The six items were: feeding, transfers,
grooming, bathing, toileting and ambulation. It was not
possible to see this trend in the scoring for dressing, conti-
nence of bowels, continence of bladder or stair climbing,
due to lack of variability in the data or lack of data (e.g.
very few patients used a wheelchair).
Correlations b e t w e e n t h e M B I , OBI a n d
F I M subsections
The Pearson product-moment correlation coefficient
(Pearson’s r ) was used to examine the relationships
between the scores on the three tools given by each thera-
pist. For this analysis, data from only four of the six FIM
subsections was used. The FIM subsections ‘social cogni-
Table 2. Correlations between the Original Barthel Index
(OBI), the Modified Barthel Index (MBI) and the brief
Functional Independence Measure (FIM)
Correlation Therapist A Therapist B Therapist C
MBI and OBI 0.90 0.96 0.93
MBI and FIM 0.91 0.89 0.90
OBI and FIM 0.86 0.87 0.90
I. Fricke and C.A. Unsworth
tion’ and ‘communication’ were removed from the analy-
ses because the OBI and the MBI do not contain these
items. Results shown in Table 2 indicate that results on the
three assessments are highly correlated, with coefficients
ranging from 0.86 to 0.96.
DISCUSSION
Spread o f scores f o r t h e OBI, t h e M B I
and t h e b r i e f F I M
As already suggested, the frequency distributions for the
OBI, the MBI and the brief FIM indicated that both the
MBI and the FIM can give a more ‘sensitive’ or precise
indication of a patient’s status, due to the greater range of
possible total scores. It becomes clear from this simple
analysis that we can tell more about the patient’s ADL
performance using the totals from the brief FIM and the
MBI, than using the OBI.
Individual i t e m r e l i a b i l i t y of t h e OBI and
the MBI
All items were found to possess moderate to good reliabil-
ity. The items that were found to be under 0.60 for the
MBI were ‘dressing’, ‘wheelchair or chair to bed transfers’
and ‘bladder control’. The only item on the OBI with reli-
ability of 0.60 or less was ‘dressing’. It is possible that the
operational definitions for these items require revision to
reduce any ambiguity. In other versions of the BI (Fortin-
sky et al., 1981; Granger, Albrecht & Hamilton, 1979) and
in the FIM, ‘dressing’ has been divided into upper body
dressing and lower body dressing. This could overcome
the reliability problem and also provide a more sensitive
score.
The i n t e r - r a t e r r e l i a b i l i t y of t h e OBI and
t h e MBI
The ICC figure for both the OBI and the MBI were very
high, suggesting that the tools possess excellent inter-rater
reliability. It was expected that scores on the MBI may
have been lower than the OBI, simply as a function of the
greater choice of scores available. However, this was not
the case. The three therapists who participated in this
study were diligent in their attention to detail on both
Inter-rater Reliability of ADL Assessments
scales. It is also possible that having worked together for
some time, these therapists have calibrated their style of
rating. While the OBI has long since established inter-
rater reliability, further studies of the MBI are required
using multiple facilities and therapists.
P a t t e r n s of s c o r e shift b e t w e e n t h e OBI
and t h e MBI
The consistent patterns of score shift when rating patients
on the OBI and the MBI for several of the scale items pro-
vides further evidence of the reliability and increased sen-
sitivity of the MBI. Although data plots have not been
provided for visual inspection, these trends are of signifi-
cance. They indicated that, in the main, scores from the
OBI seemed to be ‘reliably’ or ‘consistently’ divided into
two or three of the MBI categories.
Correlations b e t w e e n t h e MBI, t h e OBI
and t h e F I M subsections
Results for the three assessments were found to be highly
correlated for each of the three therapists. Although an
expected result, this is reassuring as it ihdicates the stabil-
ity of the tools, and the fact that these three assessments
all seem to be measuring a patient’s level of functional
independence.
Clinicians’ c o m m e n t s
The three therapists involved in the study were also asked
several questions relating to their perceptions of the tools.
They found it helpful to have all three scales ranked from
most independent to most dependent. We suggest that the
MBI operational definitions should be reversed to become
5-1, or independent to dependent. The raters should pro-
vide the patient with every possible opportunity to com-
plete a task, rather than assist the patient too soon. While
the therapists reported that the OBI was much easier to
score than the MBI, they felt that the OBI did not always
reflect the incremental nature of patient improvement
made in rehabilitation. They also found it frustrating that
patients were not rewarded with some score points on the
OBI for partially completing tasks (e.g. bathing and
grooming/personal toilet). There were two other areas of
confusion with the operational definitions of the MBI.
The first occurred with the term ‘on and off toilet’, being
27
misleading as it also included perineal hygiene. ‘Cleaning
self’ is also included in ‘bowels’ and ‘on and off toilet’.
Secondly in ‘on and off toilet’ in the MBI, ‘washing hands’
is mentioned in level 3 but nowhere else. Overall, the ther-
apists felt that the FIM was the easiest tool to use, and
score, because of the availability of clear guidelines and
the mandatory need for training. Although they felt that
training to use any functional assessment tool was
required to ensure reliable data, the clinicians felt that
training was particularly important with the FIM.
Study l i m i t a t i o n s
A limitation of this study was the modest sample size.
While studies of a similar nature that evaluate inter-rater
reliability also use samples of approximately 25 patients
(Cole, 1989; Collin et al., 1988; Kidd et al., 1995), future
studies using larger patient numbers should be conducted.
A further limitation of this study is the possibility that
raters may have been influenced by observing each other
administer the assessment, and thus alter their own prac-
tice as a consequence. All inter-rater reliability studies
potentially suffer this limitation. In addition, it is assumed
that the results of this study can be generalized to other
clinical facilities. However, further research is required to
confirm the external validity of this study’s findings.
CONCLUSION
This study has indicated that the OBI and the MBI both
possess high inter-rater reliability when clinicians spend a
short training period familiarizing themselves with the
scoring protocols. The findings of this and other research
presented in the introduction suggests that since the OBI,
the MBI and the FIM all appear to possess sound psycho-
metric properties, choice of tool remains a matter of per-
sonal preference. However, as the FIM and the MBI are
more sensitive tools and have acceptable inter-rater relia-
bility, they may be of more value in showing change over
time and demonstrating more precise scores for ADL
tasks. Factors that will continue to guide this choice
include the range of items that are covered in the tool,
clinical utility and time taken to administer the assess-
ment. Clinicians must be aware of the importance of using
a standardized version of the OBI, the MBI or the FIM
28
(as opposed to a composite version), and should always
indicate which version is being used.
ACKNOWLEDGEMENTS
The authors wish to thank the occupational therapists,
Colin Steel, Sally Dyte and Monique Baxter at the Green-
vale Campus of North-west Hospital, for participating in
the research. Their enthusiasm and dedication to the pro-
ject ensured its success. We also wish to thank the School's
Senior Research Assistant, Diane Worrell, for skilled data
management.
REFERENCES
Butler, A., Fricke, J., & Humphries, S. (1993). Standard
assessment instruments suitable for use by ACATs and
HACC Agencies. Lincoln Papers in Gerontology, 21,
1-74.
Cole, M. (1989). Inter-rater reliability of the Crichton
Behaviour Rating Scale. A g e and Ageing, 18,57-60.
Collin, C., Wade, D. T., Davies, S., & Horne, V. (1988).
The Barthel ADL Index: A reliability study. Inter-
national Disability Studies, 10 (2), 6143.
Di Fabio, R. P. (1990). Reliability and validity of func-
tional assessment in patients with stroke. Journal of
Neurological Rehabilitation, 4,145-152.
Eakin, P. (1989). Problems with assessments of activities of
daily living. British Journal of Occupational Therapy,
52,50-53.
Eakin, P. (1993). The Barthel Index: Confidence limits.
British Journal of Occupational Therapy, 56,184-185.
Fortinsky, R., Granger, C., & Seltzer, G. (1981). The use of
functional assessment in understanding home care
needs. Medical Care, 19,489-497.
Fricke, J. (1993). Measuring outcomes in rehabilitation: A
review. British Journal of Occupational Therapy, 56,
217-221.
Fricke, J., Unsworth, C., & Worrell, D. (1993). The relia-
bility of the Functional Independence Measure with
occupational therapists. The Australian Occupational
Therapy Journal, 40,7-15.
Granger, C., Albrecht, G., & Hamilton,'B. (1979). Out-
come of comprehensive medical rehabilitation: Mea-
surement by PULSES profile and the Barthel Index.
I. Fricke and C. A. Unsworth
Archives of Physical Medicine and Rehabilitation, 60,
145-154.
Granger, C . V., Cotter, A. C., Hamilton, B. B., Fiedler,
R. C., & Hens, M. M. (1990). Functional assessment
scales: A study of persons with multiple sclerosis.
Archives of Physical Medicine and Rehabilitation, 71,
870-875.
Granger, C., Dewis, L., Peters, N., Sherwood, C., & Bar-
rett, J. (1979). Stroke rehabilitation: Analysis of
repeated Barthel Index measures. Archives of Physical
Medicine and Rehabilitation, 60,14-17.
Gresham, G., Phillips, T., & Labi, M. (1980). ADL status
in stroke: Relative merits of three standard indexes.
Archives of Physical Medicine and Rehabilitation, 61,
355-358.
Kidd, D., Stewart, G., Baldry, J., Johnson, J., Rossiter, D.,
Petruckevitch, A,, & Thompson, A. (1995). The Func-
tional Independence Measure: A comparative validity
and reliability study. Disability and Rehabilitation, 17,
10-14.
Law, M. (1987). Measurement in occupational therapy:
Scientific criteria for evaluation. Canadian Journal of
Occupational Therapy, 54,133-138.
Mahoney, F., & Barthel, D. (1965). Functional evaluation:
The Barthel Index. Maryland State Medical Journal, 14,
6143.
Murdock, C. (1992a). A critical evaluation of the Barthel
Index part 1. British Journal of Occupational Therapy,
55,109-111.
Murdock, C. (1992b). A critical evaluation of the Barthel
Index part 2. British Journal of Occupational Therapy,
55,153-156.
Shah, S., & Cooper, B. (1993a). Commentary on 'a critical
evaluation of the Barthel Index'. British Journal of
Occupational Therapy, 56,70-72.
Shah, S., & Cooper, B. (1993b). Issues in the choice of
activities of daily living assessment. The Australian
Occupational Therapy Journal, 40,77-82.
Shah, S., Vanclay, F., & Cooper, B. (1989). Improving the
sensitivity of the Barthel Index for stroke rehabilita-
tion. Journal of Clinical Epidemiology, 42,703-709.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations:
Uses in assessing rater reliability. Psychological
Bulletin, 86,420-428.
Unsworth, C. A., Thomas, S. A., & Greenwood, K. (1995).
Rehabilitation team decisions concerning discharge
Inter-rater Reliability of ADL Assessments 29

housing for stroke patients. Archives of Physical Medi-
cine and Rehabilitation, 76,331-340.
Wade, D . T., & Collin, C. (1988). The Barthel A D L Index:
A standard measure of physical disability? Znter-
national Disability Studies, 10,64-67.
Wellwood, I. D., Dennis, M. S., Warlow, C . F! (1995). A
comparison of the Barthel Index and the OPCS Dis-
ability Instrument used to measure the outcome of
stroke. Age and Ageing, 24,54-57.

Appendix 1. Scoring system for the original Barthel Index Appendix 2. Scoring system for the modified Barthel Index
(Mahoney & Barthel, 1965) (Shah eta/., 1989)
Activity Dependent With help Independent Items/ 1 Unable 2 Attempts 3 Moderate 4 Minimal 5 Fully
activity to perform task but help help indepen-
Feeding 0 5 10
task unsafe required required dent
Bathing self 0 0 5
Dressing 0 5 10 Feeding 0 2 5 8 10
Grooming/personal toilet 0 0 5 Bathing self 0 1 3 4 5
Getting on and off toilet 0 5 10 Dressing 0 2 5 8 10
Controlling bowels 0 5 10 Grooming/personal
Controlling bladder 0 5 10 hygiene 0 1 3 4 5
Moving from wheelchair to bed Toilet 0 2 5 8 10
and return 0 5-10 15 Bowel control 0 2 5 8 10
Walking on level surface 0 10 15 Bladder control 0 2 5 8 10
(or propelling wheel chair if Chair/bed transfers 0 3 8 12 15
unable to walk*) O* O* 5* Ambulation 0 3 8 12 15
Ascend and descend stairs 0 5 10 Wheelchair (only if
Total score 100 ambulation is 0) 0 1 3 4 5
Stair climbing 0 2 5 8 10
* Score only if unable to walk.
Total score 100

Appendix 3. Rules for using the modified and original Barthel Index for this research
It is recommended that the guidelines modified from Collin and Wade (1988) be used for any version of the Barthel adopted. They follow the general
thrust of the original article by Mahoney and Barthel (1965) and are well set out, logical and easy to interpret. They can be summarized as:
Use as a record of what a patient does, NOT as a record of what a patient could do.
The main aim is to establish degree of independence from any help physical or verbal, however, minor and for whatever reason.
The need for supervision renders the patient NOT independent.
Usually the performance over the preceding 24-72 h is important, but occasionally longer periods will be relevant.
Unconscious patients should score ‘0’ throughout, even if not yet incontinent.
Middle categories imply that patient supplies over 50% of the effort.
Use of devices to be independent is allowed.
If patient is using a wheelchair on admission, but is likely to be discharged with a walking aid, assess both methods of ambulation at admission.
Set up for feeding and dressing is not included in the rating; a patient can still score 5 if clothes are laid out or food placed on a tray or table.
Antiembolic stockings are not assessed as part of dressing.
Ambulation is assessed by observation and/or physiotherapy consultation or notes. Walking device is to be within reach of patient.
Stairs: the ability to go up and down three steps.
Bowel and bladder continence can be assessed from the nursing notes and/or observation.
If patient refuses to undertake an activity, score 0 and indicate refusal on score sheet.
In bladder assessment, an external device refers to condom drainage.