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Rehabilitation
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Use of the Barthel Index and the Functional Independence Measure during early inpatient
rehabilitation after single incident brain injury
Henry Houlden, Mark Edwards, Jane McNeil and Richard Greenwood
Clin Rehabil 2006 20: 153
DOI: 10.1191/0269215506cr917oa
The online version of this article can be found at:
http://cre.sagepub.com/content/20/2/153
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Received 3rd July 2004; returned for revisions 13th January 2005; revised manuscript accepted 12th June 2005.
10. I 191/0269215506cr9l7oa
Introduction
Nearly 80% of health care costs in the US are
incurred through treatment of patients with chronic
conditions.' The use of death as an outcome is
therefore not a good indicator of the success or
failure of many clinical interventions. Thus the
description and evaluation of most clinical interventions, and their evidence-based provision, is
dependent on the development and use of valid
and reliable measures of function and quality of
life. The instrument chosen to evaluate or represent
an intervention must be able to capture the range of
disablement in the population studied (appropriateness), and detect clinically significant change in
the outcome measured (responsiveness). These
properties enable valid measurement of case-mix
pretreatment and subsequently the effectiveness of
treatment.
After severe single incident brain injury in
younger people, early specialist multidisciplinary
inpatient rehabilitation in the first 12 months is an
essential part of the series of services needed to
optimize outcome.2'3 Overall, programmes aim to
reduce impairment and increase functional independence and social participation for the patient,
and minimize distress in the patient and carer.
Measurement of change in all these areas is
necessary for the comprehensive evaluation of
rehabilitation. Soon after the injury there is
usually particular focus on change in functional
independence in the patient at the level of
personal and domestic activities of daily living.
In contrast, later programmes emphasize increased social participation. The Barthel Index
and/or the Functional Independence Measure
(FIM) are observer-rated generic measures of
activity (disability) which are widely used to score
change in function.
The 10-item Barthel Index was published in
1965 as a simple index of functional independence, particularly in personal and domestic
activities of daily living.4 The Barthel Index
was subsequently considered too simple and
unresponsive, and the FIM followed in 1986. It
comprises 18 items including five cognitive items;
each has a 7-point response option rather than
the 2- to 4-point response options in the Barthel
Index. Multiple studies have demonstrated the
reliability and validity of the Barthel Index and
injury.
Methods
Setting
The Regional Neurological Rehabilitation Unit
at the Homerton Hospital is a 24-bed unit that
provides intensive, multidisciplinary, goal-orientated, individualized inpatient rehabilitation for
younger patients early after single incident neurological damage, largely (95%) after brain injury.'6
Traumatic brain injury accounts for about 40% of
all admissions, and vascular brain injury due either
to cerebral infarction, subarachnoid and intracerebral haemorrhage, for about 45%.
Study samples
Consecutive patients discharged from the unit
between 1 January 1995 and 24 December 2001
with a diagnosis of cerebral infarction, intracerebral or subarachnoid haemorrhage, or traumatic
brain injury were included in the study. Patients
who were discharged from the unit after an
admission of less than one week without discharge
scores being assessed were excluded from the study.
17
The FIM is an 18-item instrument also measuring functional independence in personal activities
of daily living (13 items) but includes measures of
communication and social cognition (five items).
There are three FIM scores, generated by summing
item scores: a total score (FIM total: 18 items), a
physical score (FIM physical: 13 items), and a
cognitive score (FIM cognitive: five items).
Procedure
The Barthel Index and FIM were rated simultaneously by a multidisciplinary team comprising a
nurse, physiotherapist, occupational therapist,
speech and language therapist, and clinical psychologist, within 10 days of admission to the
Regional Neurological Rehabilitation Unit and
within two weeks of discharge in all patients.
Statistical analyses
Appropriateness
Appropriateness examines whether the range of Results
problems in a study sample is effectively gauged by
a measuring instrument or scoring system. The Sample
Table 1 presents the characteristics of the 152
greater the variability which can be detected in
score range the more sensitive the measure is in patients with vascular (focal) brain injury and the
discriminating between subjects. The central ten- 107 patients with traumatic (diffuse) brain injury
Table 1 Characteristics of brain injured patients
Disease group
Male
58
60
26
62
87
48
48
50
45
38
(10.4)
(11.3)
(8.7)
(9.9)
(13.4)
LOS (days)
to A (days)
Age (years)
23-66
23-66
24-62
25-59
15-64
Mean (SD)
151.0
137.2
181.5
142.0
135.8
(222.3)
(221.0)
(249.3)
(185.2)
(115.1)
Range
Mean (SD)
Range
28-1951
39-1951
28-1720
36-1154
35-955
112.8 (64.5)
99 (42.6)
121.0 (55.1)
132.3 (101.1)
120 (70.7)
7-600
7-263
18-308
35-600
13-321
were
Appropriateness
Table 2 shows Barthel Index and FIM score
distributions for patients on admission to the
Regional Neurological Rehabilitation Unit. For
both disease groups, scores on the Barthel Index
and the FIM spanned the entire score range. The
admission scores had a mean near the scale
midpoint, and small floor and ceiling effects. The
floor and ceiling effects for the Barthel Index
(5.2-11.3%) were greater than those for the FIM
scores (0-6.5%).
Responsiveness
Table 3 shows change scores and effect sizes for
the Barthel Index and FIM scores in patients
grouped for vascular and traumatic brain injury
and the three vascular brain injury subgroups.
Figure 1 is a scatterplot of the change score of the
Barthel Index plotted against the FIM and shows a
good (R2 = 0.733) correlation between the two
measures. Change scores for all scales in all disease
groups were positive, indicating less disablement
Discussion
Table 2 Barthel Index and FIM scores on admission: sample range, mean, floor and ceiling effects
Scale range
9.0 (6.0)
9.97 (7.2)
Floor effect
Ceiling effect
N %)
N (%)
13 (8.4)
12 (11.3)
8 (5.2)
10 (9.3)
152
107
0-20
0-20
152
107
5-34
5-32
19.0 (8.6)
17.3 (7.4)
8 (5.2)
7 (6.5)
0 (0)
0 (0)
152
107
13-91
13-91
50.9 (23.6)
53.6 (28.7)
5 (3.2)
7 (6.5)
4 (2.6)
6 (5.6)
152
107
18-125
18-125
69.8 (29.2)
70.8 (33.7)
2 (1.3)
5 (4.7)
0 (0)
0 (0)
0
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40
60
80
populations.
There are limitations to this study. First, the
appropriateness of the measures may not generalize to other patient populations and in some
clinical settings there will be greater floor and
ceiling effects. This has been reported in a group of
patients recruited within a mean of nine days after
stroke,'3 but comparable data to ours has been
seen in different stroke populations recruited early7
and later post stroke,8 and patients with multiple
sclerosis.' Second, calculation of the effect sizes
should ideally use non-parametric analysis, given
that the Barthel Index and FIM are ordinal
measures but parametric analysis is well established in the literature in calculating effect sizes in
this context and enables comparison with other
studies.'5 Lastly, our patient group was not ran-
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