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Clinical

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
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Clinical Rehabilitation 2006; 20: 153-159

Use of the Barthel Index and the Functional


Independence Measure during early inpatient
rehabilitation after single incident brain in jury
Henry Houlden, Mark Edwards, Jane McNeil and Richard Greenwood Regional Neurological Rehabilitation Unit,
Homerton Hospital, London, UK

Received 3rd July 2004; returned for revisions 13th January 2005; revised manuscript accepted 12th June 2005.

Objective: To compare the appropriateness and responsiveness of the Barthel Index


and the Functional Independence Measure (FIM) during early inpatient rehabilitation
after single incident brain injury.
Design: Cohort study.
Setting: A regional neurological rehabilitation unit.
Patients: Two hundred and fifty-nine consecutive patients undergoing inpatient
comprehensive neurological rehabilitation following a vascular brain injury due to
single cerebral infarction (n = 75), spontaneous intracerebral haemorrhage (n = 34)
and subarachnoid haemorrhage (n = 43), and 107 patients who had sustained
traumatic brain injury.
Measurements: Admission and discharge FIM total, physical and cognitive scores
and the Barthel Index were recorded. Appropriateness and responsiveness in the
study samples were determined by examining score distributions and floor and
ceiling effects, and by an effect size calculation respectively. Non-parametric
statistical analysis was used to calculate the significance of the change in scores.
Results: In all patient groups there was a significant improvement (Wilcoxon's rank
sum, P < 0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic
3.95) and FIM (mean change score: vascular 17.3, traumatic 17.4) scores during
rehabilitation, and similar effect sizes were found for the Barthel Index (effect size:
vascular 0.65, traumatic 0.55) and FIM total (effect size: vascular 0.59, traumatic
0.48) and physical scores in all patient groups. In each patient group the cognitive
component of the FIM had the smallest effect size (0.35-0.43).
Conclusions: All measures were appropriate for younger (less than 65 years of age)
patients undergoing early inpatient rehabilitation after single incident vascular or
traumatic brain injury. The Barthel Index and the total and physical FIM scores
showed similar responsiveness, whilst the cognitive FIM score was least responsive.
These findings suggest that none of the FIM scores have any advantage over the
Barthel Index in evaluating change in these circumstances.

Address for correspondence: Richard Greenwood, Regional


Neurological Rehabilitation Unit, Homerton Hospital, Homerion Row, Hackney, London E9 6SR, UK.
email: Richard.Greenwood@homerton.nhs.uk
(o 2006 Edward Arnold (Publishers) Ltd

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10. I 191/0269215506cr9l7oa

154 H Houlden et al.

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

FIM scales during inpatient rehabilitation, the


Barthel Index particularly after stroke6-8 and the
FIM after head injury9'0 and stroke." Even a
five-item Barthel Index has been shown to be
useful indicator of disability change,7 but it has
been suggested that the Barthel Index may mask
responsiveness at high levels of functioning'2"'3
and this has also been suggested for the motor
component of the FIM.14 The insensitivity of the
Barthel Index compared with the FIM has been
argued but seldom tested empirically. Dromerick
et al. 13 found the FIM more responsive to
change than the Barthel Index in patients undergoing early (mean admission of nine days after
stroke) inpatient rehabilitation for stroke but
other studies have found the FIM was no more
responsive than the Barthel Index when tested in
patients with multiple sclerosis'5 and early and
late poststroke rehabilitation.7'8 Ours is the first
study to compare the appropriateness and responsiveness of the Barthel Index and FIM in
patients undergoing early inpatient rehabilitation
after focal and diffuse single incident brain

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.

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Barthel Index and FIM in early inpatient rehabilitation 155


Measures
The Barthel Index is a 10-item instrument
measuring functional independence in personal
activities of daily living. The Barthel Index is
quick and easy to complete. The scoring instructions used for the Barthel Index in the Regional
Neurological Rehabilitation Unit have been modified to make the contribution which cognitive
problems make to functional dependency more
explicit.

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

dency of a group is indicated by the mean score


and this should be as close as possible to the
midpoint of the scale range. Floor effects indicate
what percentage of the group score the minimum
possible score and ceiling effects the number
scoring the maximum score. Floor and ceiling
effects, which reduce the ability to discriminate
between subjects and indicate a likely lack of
variability in the scoring system used, exceeding
20% are considered to be significant.'8
Responsiveness
This is defined as the ability of a measure to
detect clinically important change and was determined using an effect size calculation (mean
change score divided by SD of admission scores).'9
The size of the effect indicates how much change
has occurred over time: the greater the effect size
the greater the responsiveness of the measure. By
relating change scores to the standard deviation of
the study sample, effect sizes standardize raw
change scores which allows comparisons between
different instruments or samples. As these data
produced by the measuring instruments are not
normally distributed, to determine the statistical
significance of the change scores we used Wilcoxon's rank sum test. This is a non-parametric
statistical analysis where no assumptions about
the nature of the distribution of data are made.

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

Mean (SD) Range


Vascular brain injury
152
75
Infarct
Subarachnoid haemorrhage 43
Intracerebral haemorrhage 34
107
Traumatic brain injury

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

to A, injury to Regional Neurological Rehabilitation Unit admission; LOS, length of stay.

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156 H Houlden et al.

studied. Most patients with traumatic brain injury


male (traumatic brain injury 87% vs. vascular
brain injury 58%) and were significantly younger
(traumatic brain injury mean = 37.5 years vs.
vascular brain injury 47.7 years, P < 0.001) than
patients with vascular brain injury. Resource use,
measured by injury to Regional Neurological
Rehabilitation Unit admission time and length of
stay, was similar in all groups of patients analysed.

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

on discharge than admission. The scores all


changed significantly between admission and discharge (P < 0.0001), the FIM cognitive score less
than the Barthel Index and FIM total and physical
scores.

After traumatic brain injury and vascular brain


injury the effect size was similar for the Barthel
Index and the FIM total and physical scores and
smallest for the FIM cognitive scores, indicating
that the FIM cognitive score was the least responsive for each disease group.

Discussion

This study compares the appropriateness and


responsiveness of the Barthel Index and FIM
during early inpatient rehabilitation in younger
patients after focal and diffuse single incident brain
injury. Soon after vascular brain injury, physical impairment is usually the main determinant
of functional independence,20 particularly in a
younger age group when the picture is not complicated by dementing comorbidities. After traumatic brain injury, cognitive and behavioural
impairments impact on independence, particularly
later after injury when in the community,21 but
early after injury, mobility status is an equally good
predictor of length of stay in both groups. 2 It is
reasonable therefore to expect that measures recording mobility, sphincter function and self-care
such as the Barthel Index and FIM physical scale

Table 2 Barthel Index and FIM scores on admission: sample range, mean, floor and ceiling effects
Scale range

Sample range Admission score


Mean (SD)

Barthel Index (0-20)


Vascular
Traumatic
FIM cog (5-35)
Vascular
Traumatic
FIM phys (13-91)
Vascular
Traumatic
FIM total (18-126)
Vascular
Traumatic

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)

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Barthel Index and FIM in early inpatient rehabilitation 157


Table 3 Comparison of Barthel Index and FIM change
scores and effect sizes in all groups

would be appropriate to use during early inpatient


rehabilitation in both patient groups.
Our results showed that all measures were
Disease groups
Change score
Effect sizea
Mean SD
appropriate to the study group with good score
variability and low percentages of floor and ceiling
All vascular
effects. Although the floor and ceiling effects for
Barthel Index
3.9 (3.4)
0.65
the Barthel Index were greater than those for the
FIM cog
3.1 (4.37)
0.36
13.9 (12.1)
FIM phys
0.59
FIM scores, between 5.2 and 11.3% compared to
FIM total
17.3 (15.1)
0.59
0-6.5%, they were well below the recommended
Infarct
upper limit of 20%.18,19 The Barthel Index, which
Barthel Index
4.0 (3.0)
0.79
has no specific cognitive items, was equally approFIM cog
0.38
3.3 (4.15)
priate in both the vascular brain injury and
FIM phys
13.8 (10.5)
0.69
traumatic brain injury groups. This is likely to be
FIM total
17.5 (13.4)
0.72
because the patients were sufficiently dependent
ICH
after injury to require inpatient rehabilitation,
Barthel Index
0.52
3.4 (3.5)
FIM cog
3.0 (4.2)
0.35
rather than because of the modification to the
14.2 (11.8)
FIM phys
0.57
scoring instructions for the version of the Barthel
17.1 (14.7)
FIM total
0.54
Index used in the study. Even floor and ceiling
SAH
effects
for the Barthel Index were small, in contrast
Barthel Index
0.64
4.26 (4.0)
to
the
ceiling effect of over 60% for patients
FIM cog
3.1 (4.9)
0.40
assessed in the community after traumatic brain
14.3 (14.8)
FIM phys
0.53
FIM total
17.3 (18.1)
0.53
injury.23 In addition, the Barthel Index and FIM
total and physical scales were found to have a
Traumatic
0.55
Barthel Index
3.95 (3.4)
similar responsiveness in all patient groups. The
3.2 (4.4)
FiM cog
0.43
cognitive
component of the FIM was slightly less
14.0 (12.1)
FIM phys
0.48
responsive,
producing a smaller change score
FIM total
17.4 (15.0)
0.52
significance and effect size when compared to the
aEffect size is the change score/standard deviation of admis- Barthel Index and FIM physical scores, and other
studies have seen a similar effect.'5 The limited
sion score.
ICH, intracerebral haemorrhage; SAH, subarachnoid haemor- usefulness of this measure may be related to
rhage.
factors other than the non-responsiveness of the
scale, for example the faster physical recovery but
slower cognitive improvement in these patient
vata
a

0
a
a

Q)

10

C13 CID 0
co 03

M "OOD
a 0 0 a..
a a=m
aa
CID m m
m
a

C(-V

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0 a
0

a 0 cm
a
a

0
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04)
-1in

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-20

20

40

60

80

FIM Total - Change Score

Figure 1 Scatterplot showing the traumatic and vascular


brain injury combined change score for the Barthel Index
plotted against the change score for the FIM total. An R2
correlation of 0.733 is seen between the two measures.

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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158 H Houlden et al.

domly selected, test-retest was not examined,


there is the disadvantage of simultaneous scoring
of the two measures, and data was obtained from a
single rehabilitation unit.
These findings are contrary to the intention
behind the development of the FIM, to be 'more
sensitive to change' than the Barthel Index,5 and
challenge subsequent assumptions that, for example, the Barthel Index 'is relatively insensitive to
change' as well as having 'marked floor and ceiling
effects'.24 The FIM appears to have no advantages
over the Barthel Index in evaluating functional
change during early inpatient rehabilitation after
single incident brain injury. The Barthel Index is
quicker and simpler to score, and can be scored
independently by any health care professional and
even by self-report questionnaire.25 By contrast,
the FIM should be rated by a multidisciplinary
team, trained in its use, after a period of up to 72 h
of patient observation. It is therefore difficult to
avoid the conclusion that in these inpatient groups,
early post injury, the Barthel Index remains the
functional assessment measure of choice.

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