The Barthel Index: Italian Translation, Adaptation and Validation
Galeoto G1*, Lauta A2, Palumbo A2, Castiglia SF3, Mollica R1, Santilli V1 and Sacchetti ML3
1Department of Anatomical Sciences, Histological, Forensic and of the Musculoskeletal System, Sapienza University of Rome, Italy
2Physical Therapist, Italy
3Department of Neurology and Psychiatry, Sapienza University of Rome, Italy
*Corresponding author: Galeoto G, Department of Anatomical Sciences, Histological, Forensic and of the Musculoskeletal System, Sapienza University of Rome, Italy, Tel: +393271431083, E-mail: email@example.com
Int J Neurol Neurother, IJNN-2-028, (Volume 2, Issue 1), Research Article; ISSN: 2378-3001
Received: February 27, 2015 | Accepted: June 17, 2015 | Published: June 19, 2015
Citation: Galeoto G, Lauta A, Palumbo A, Castiglia SF, Mollica R, et al. (2015) The Barthel Index: Italian Translation, Adaptation and Validation. Int J Neurol Neurother 2:028. 10.23937/2378-3001/2/1/1028
Copyright: © 2015 Galeoto G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The Barthel Index (BI) is widely used to measure disability also in Italy, although a validated and culturally adapted Italian version of BI has not been produced yet. This article describes the translation and cultural adaptation into Italian of the original 10-item version of BI, and reports the procedures for testing its validity and reliability.
The cultural adaptation and validation process was based on data from a cohort of disabled patients from two different Rehabilitation Centers in Rome, Italy.
Forward and backward translation method was adopted by qualified linguist and independent native English official translators. The scale obtained was reviewed by 20 experts in psychometric sciences. The Italian adapted version of the BI was then produced and validated. A total number of 180 patients were submitted to the adapted scale for testing its acceptability and internal consistency. The total time of compilation was 5 ± 2,6 minutes (range 3-10). Validation of the scale was performed by 7 trained professional therapists that submitted both the translated and the adapted versions to a group of 62 clinically stable patients (T-test=-2.051 p=0.05). The internal consistency by Cronbach's alpha resulted equal to 0.96. Test - retest intra - rater reliability was evaluated on 35 cases; at test-retest was ICC=0.983 (95%IC: 0.967-0.992).
This is the first study that reports translation, adaptation and validation of the BI in Italian language. It provides a new tool for professionals to measure functional disability when appraising Italian speaking disable patients in health and social care settings along the continuum of care.
Barthel index, Functional disability, Validation, Cultural adaptation, Italian
Independence in self-care activities is a common outcome measure to assess disability. Among all other instruments Barthel Index (BI) has been regarded as the best in terms of sensitivity, simplicity, communicability and ease of scoring [1-5].
The BI was first developed by Mahoney and Barthel in 1965 , and later modified by Collin et al.  and Shah et al. (1989) . The original 10-item form consists of 10 activities of daily living (ADL) including feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfers (bad to chair and back), mobility, and stairs climbing. Items are rated in terms of whether patients can perform the task independently, with assistance or are totally dependent (scored as 0, 5 or 10; 15 points per item for transfers and mobility). The total score is calculated by adding up the individual scores, and ranges from 0 (total dependence) to 100 (total independence). There is little consensus over which of the versions should be considered as definitive, but the original and the 10-item versions are the most commonly used .
As rehabilitation was integrated in the processes of care to disabling people in Italy, the need of objective measures of both disability and recovery was satisfied by developing "in house" versions of the BI. Some of them can be downloaded from the link in citing [10-15]. Even though none of the versions translated have been culturally adapted and validated, the BI is widely used in Italy to determine whether the disability criteria for access of patients to rehabilitation services are fulfilled, as well as to monitor patients' recovery [16,17].
Simple translation misses cultural peculiarities with consequent distortions of items' meaning. Cross-cultural validation and adaptation is necessary .
This article describes the translation and cultural adaptation into Italian of the original BI (Italian culturally adapted Barthel Index-IcaBI), and reports the procedures for testing its cross - cultural validity, test - retest reliability, internal consistency, validity and reliability. The structural validity, inter - rater reliability, sensitivity to disability changes, as well as items' quality, will be reported in a subsequent paper.
The study was divided into two stages. Firstly, the English version of the 10-item BI was translated into Italian and culturally adapted according to a team - approach procedure as described by the Census Bureau Guideline for the Translation of Data Collection Instrument . The translated BI was then tested for its validity and reliability properties in a prospective study.
The 10-item version of BI was adopted . Permission for translation, adaptation, and validation was received from The Maryland State Medical Society. The procedure of translation included three steps. Firstly two native English official translators independently translated into Italian both the original BI and definitions of the performance criteria (forward translation). One translator had a technical background and the other had a medical background and he was the judge of translation. Secondly, 2 bilingual persons, blind to the original English version and independently one the other, back - translated the scales into English. These two new English versions were translated into Italian by two independent health-care professionals with a certificated knowledge of English language, and blind to the original version (backward translation). Scoring of questions were the same as for the original BI. All translators had a consensus meeting to consolidate the final translated BI.
In order to adapt the translated index to Italian culture, it was reviewed by a panel of 20 experts in psychometric sciences, pertaining to different medical disciplines. The experts could comment on items' translation by writing observations on a form. The judge of translation reviewed and approved this final culturally adapted version that was then tested for validity and reliability (Appendix 1).
Patients and validation procedures
The validation process was based on data from a cohort of 180 patients hospitalized in two different Rehabilitation Centers providing care for internal medicine, neurological and orthopedic disorders in Rome, Italy. The cross-cultural validity of the scale was performed on 62 and test-retest reliability on 35 out of the 180 patients enrolled in the study.
All cases admitted to the outpatient Rehabilitation Centers of Israelite Hospital and San Giovanni Battista Hospital- Order of Malta between May 2014 and November 2014 were screened for inclusion in the study, irrespective of the illness they were affected. The study was approved by the Ethics Committee of participating hospitals.
All patients were informed about the study and their interest in taking part in it was recorded; those who entered the study gave their consent before inclusion. Post-comatose patients were excluded, as well as cases aged<18 years old, affected by spinal cord injuries, cognitive impairment or psychiatric illnesses , and if they did not consent to enter the study.
The scale was administered voluntarily by 6 physical therapists (PT) and 1 occupational therapist (OT). Assessments were made by observing patients' performance directly at bedside. Before starting evaluations, all therapists were trained on the administration of the scale.
All statistical analyses were performed with Statistical Package of Social Sciences (SPSS) version 18.0 for Windows. The description of the variables was carried out using frequency tables, means and standard deviations (SD). Data were analyzed with IBM-SPSS statistical software version 20.0.
Pre- test (cross-cultural validity)
According to Perneger et al. Small samples (5-15 participants) that are common in pre-tests of questionnaires may fail to uncover even common problems. A default sample size of 30 participants is recommended . To evaluate the cross-cultural validity of the scale, alternatively the translated and the culturally adapted scale were administered to 62 out of the 180 patients enrolled. In order to avoid bias, the same patient was tested two times by the same professional. A time interval between the repeated administrations should be short enough to ensure that clinical change had not occurred. A time period of 4-6 has been considered appropriated . The time interval of 4 days between the two administrations was considered to be appropriate for the current population. T Paired two - sample T - test was performed to reveal possible mistakes, mis-understandings or changes as respect to the original meanings of each item of the scale. The significance was set for p<0.05.
Test-retest intra-rater reliability: For assessment of test-retest reliability, each patient was evaluated twice by the same professional (Table3). The sample size was calculated according to McMillan et al.  and to Lam et al. . A cut-off value of 60, and a sensitivity of 97.2% was established. Basing on a disability prevalence rate of 28% and a 2.8% False Negative Rate, a sample of 35 subjects was calculated. The time interval for test-retest studies needs to be sufficiently short to support the assumption that the patients remain stable, and sufficiently long to prevent recall. A time interval of 6 days was considered to be appropriate for the current population. In order to measure test-retest reliability, Intraclass Correlation Coefficient (ICC) was calculated. From the 2 assessments to each patient, one of them was chosen randomly and those answers were used for calculation of validity and internal consistency. The scale was considered as stable at the test-retest for ICC >0.70. Two-way random ICC for absolute agreement was adopted to evaluate intra-rater reliability [24,25].
Internal Consistency: The sample size for internal consistency was calculated by considering 10 patients for each item . The Italian culturally adapted BI was administered to the 180 patients that consent to enter the study, by the same 7 therapists that performed the cross-cultural validation and the test-retest reliability.
Chronbach's alpha was used for Internal Consistency. In order to assess the interrelatedness among the items and the homogeneity of the scale, Pearson's correlation coefficient and Chronbach's α were calculated with a value of >0.70 being considered acceptable for both tests .
Acceptability of the scale has been evaluated by clocking time of administrations on the same sample of 180 patients included in the Internal Consistency evaluation.
After forward and backward translation and after a consensus meeting, the translated scale was formed (Appendix 2).
The experts agreed on that the sentence "categorie intermedie implicano che il paziente fornisce più del 50% dello sforzo" was misleading, and asked for its deleting from definitions of the performance criteria; the phrasing of some of the items were also re-formulated. Furthermore, modifications were made to individual items with reference to the experts' opinions (Appendix 3).
A total of 210 patients were initially assessed for their inclusion in the study. Of these, 18 (8.6%) patients did not fulfill the inclusion criteria, and 12 (5.7%) did not consent to enter the study. A total number of 180 patients were administered the Italian culturally adapted BI. Their mean age was73.6 ± 14 years (range: 21-101). 91 patients were females (51%), aged 73.9 ± 14.2 years (range 21-101); 89 were males (49%), aged 70.9 ± 13.8 years (range 22-93). At the time of evaluation, patients were hospitalized meanly since 9.1 ± 12.2 days before (Figure 1).
Figure 1: Time from hospitalization (days) View Figure 1
Pre-test (cross-cultural validity)
Cross-cultural validity was evaluated on 62 patients out of the 180 that entered the study (mean age 75.8 ± 12.9 years, 32 males, 30 females, mean time of hospitalization before administration 3.4 ± 3.7 days) (Table 1). The mean total score of first translation was 74.11; the mean total score of adapted version was 74.44. The total scores were not influenced by age (χ2=241.2 p=0.6), gender (χ2=19.0 p=0.4) and pathology (χ2=95.4 p=0.8). Paired two - sample T - test revealed no significant differences between the results of the two administrations (t=2.05; mean difference=0.3; p=0.05).
Test-retest and intra-rater reliability: Thirty-five out of the 180 included patients were submitted to test-retest and intra-rater reliability procedures (mean age 75.6 ± 12.0 years, 20 males, 15 females, mean time of hospitalization before administration 3.5 ± 3.7 days) (Table 1). The test-retest reliability of each item is reported in Table 2. As to the intra-rater reliability, ICC between the different administrations over time was 0.983 (95%IC: 0.967 - 0.992). The total scores were not influenced by age (χ2=311.5 p=0.4), gender (χ2=16.3 p=0.3) and pathology (χ2=27.8 p=0.48).
Table 1: Test-retest reliability of the single items View Table 1
Table 2: Demographic characteristics and hospitalization ward of patients submitted to each test View Table 2
Internal consistency: The internal consistency was calculated on all the 180 included cases. Both Pearson and Spearman Tests (Appendix 4) revealed a strong correlation between each item and the whole scale (Ρ>0.7 p<0.01). Crombach's α was 0.94 (p<0.001). Demographic data and clinical characteristics of included cases are reported in Table 2.The distribution of cases among operators is reported in Table 3. The total scores were not influenced by age (χ2=893.9 p=0.1), gender (χ2=16.39p=0.3) and pathology (χ2=2110.7 p=0.9).
Table 3: Distribution of subjects among evaluators View Table 3
The total time of compilation was 5 ± 2.58 minutes (range 3-10). No multiple answers and no mis-understandings were found.
The aim of this study was to translate the original 10 items BI into Italian, to culturally adapt it for Italian disabled people, and to validate it. Translation and linguistic adaptation was performed applying internationally recognized methods , and under the supervision of a panel of experts that ensured the maintenance of the original meaning of the items.
In order to describe the differences between the translated and the culturally adapted version, comparison were made by a t-test analysis. The differences in total scores were not significant, indicating that the two scale might be indifferently adopted. In accordance with ISPOR Task Force for Translation and Cultural Adaptation we propose the adoption of the version culturally adapted .
Test-retest intra-rater reliability has been calculated for IcaBI, and resulted equal to 0.983; ICC's value ≥0,70 is considered optimal to establish the degree to which repeated measurements are free from measurement error. The most important index of test reliability is the alpha coefficient . Nunnally  has implicated that if a new questionnaire is going to be used, its alpha coefficient should be at least 0.7. The IcaBI internal consistency was equal to 0.94. The high IcaBI reliability indicates that scores of patients remain stable after repeated measurement, as in the original version. The high level of interrelatedness among the items represents the cross - cultural validity of the adapted scale that reflects adequately the performances of the original English version .
The BI was firstly developed as a simple index of independence, useful to evaluate functional disability in any disabled patient and in scoring improvement in rehabilitation . Examples of BI validity as ADL indicator are available in literature [37,38]. The original BI has been shown to have a Chronbach's alpha of 0.87 . The Dutch translated version of the BI has been reported to have a Chronbach's alpha of 0.87 . The Turkish have validated BI for rehabilitation patients, reporting an internal consistency of 0.88 ,whereas the Japanese validated the scale for older people living at home, and reported a Chronbach's alpha equal to 0.93 . Most of those studies have been performed on stroke cases. They reported an Internal consistency nearly at 0.93, the Chinese at 0.92 , the Brazilian at 0.967 .
As shown in Appendix, all items of the BI have a corrected item-item correlation coefficient of more than 0.5. So all items have acceptable item total correlation and, hence, the IcaBI fulfills the first criterion of item analysis. Based on the literature review which was done for this project, item analysis has not been determined for the Barthel Index yet. Item analysis of IcaBI should be addressed in future research.
Disability at the time of admission to a rehabilitation hospital is a major predictor both of discharge disability [41-43] and of return home [41,42,44]. It has been estimated that more than 3 million people suffered functional impairment in Italy in 2013 . With such a burden, it is of great importance to apply evidence-based, validated and comprehensive instruments able to quantify disability and document whether patients fulfill the criteria of access to rehabilitation centers. The BI is used in most of the Italian Regional Health Systems to determine discharge placement of patients, the burden of care, the efficiency and effectiveness of rehabilitation intervention. Unfortunately, only one Italian study that evaluated the validity and reliability of the BI administered by telephone compared with face-to-face was recently published, and no data on translation of the scale and adaptation processes to Italian culturally are available in literature .
This study has some limits. The reliability of ADL assessment may not be generalizable to assessments by other care staff or to self-rated interviews because only OTs and PTs were involved in this study. Furthermore, the IcaBI is not applicable to post-comatose patients and to cases affected by spinal cord injuries, cognitive impairment or psychiatric illnesses, cause those cases were excluded from our series.
Among several ways to confirm the cross - cultural validity of IcaBI, only test - retest, intra - rater reliability, and internal consistency were compared to the original version of the BI. Factorial analysis, inter-rater reliability and responsiveness will be verified in following research.
The FIM is the only scale that that is applicable to disable patients regardless the illness they are affected. Unfortunately, although usually administered in Italian language, psychometric properties of the Italian version have not been verified yet. Future studies are needed to evaluate the concurrent validity of IcaBI as respect to FIM.
The Italian culturally adapted BI as a whole has demonstrated to be valid, reliable, acceptable, easy to understand and rapidly administrable.
This work provides a new tool for professionals to measure functional impairment when appraising Italian speaking disable patients in health and social care settings along the continuum of care. Further studies involving other healthcare workers are needed to evaluate generalizability of our data.
Shah S, Cooper B (1993) Commentary on 'A Critical Evaluation of the Barthel Index'. The British Journal of Occupational Therapy 56: 70-72.
Granger CV, Dewis LS, Peters NC, Sherwood CC, Barrett JE (1979). Stroke rehabilitation: analysis of repeated Barthel index measures. Arch Phys Med Rehabil 60: 14-17.
Wade DT, Skilbeck CE, Hewer RL (1983) Predicting Barthel ADL score at 6 months after an acute stroke. Arch Phys Med Rehabil 64: 24-28.
Bentur N, Eldar R (1993) Quality of rehabilitation care in two inpatient geriatric settings. Qual Assur Health Care 5: 237-242.
Campbell SE, Seymour DG, Primrose WR, et al. (2005) A multi-centre European study of factors affecting the discharge destination of older people admitted to hospital: analysis of in-hospital data from the ACMEplus project. Age Ageing 34: 467-475.
Mahoney FI, Barthel DW (1965) Functional evaluation: The barthel index. Md State Med J 14: 61-65.
Collin C, Wade DT, Davies S, Horne V (1988) The Barthel ADL Index: a reliability study. Int Disabil Stud 10: 61-63.
Shah S, Vanclay F, Cooper B (1989) Predicting discharge status at commencement of stroke rehabilitation. Stroke 20: 766-769.
Wade DT, Collin C (1988) The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 10: 64-67.
Wild D, Grove A, Martin M, Eremenco S, McElroy S, et al. (2005) Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: report of the ISPOR Task Force for Translation and Cultural Adaptation. Value Health 8: 94-104.
Shah S, Vanclay F, Cooper B (1989) Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol 42: 703-709.
Heuschmann PU, Kolominsky-Rabas PL, Nolte CH, Hünermund G, Ruf Hu et al. (2005) The reliability of the german version of the barthel-index and the development of a postal and telephone version for the application on stroke patients. Fortschr Neurol Psychiatr 73: 74-82.
Perneger TV, Courvoisier DS, Hudelson PM, Gayet-Ageron A (2015) Sample size for pre-tests of questionnaires. Qual Life Res 24: 147-51.
McMillan GP, Hanson TE (2014) Sample size requirements for establishing clinical test-retest standards. Ear Hear 35: 283-286.
Lam SC, Lee DT, Yu DS (2014) Establishing CUTOFF values for the Simplified Barthel Index in elderly adults in residential care homes. J Am Geriatr Soc 62: 575-577.
Hallgren KA (2012) Computing Inter-Rater Reliability for Observational Data: An Overview and Tutorial. Tutor Quant Methods Psychol 8: 23-34.
Weir JP (2005) Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. J Strength Cond Res 19: 231-240.
Nunnally JC, Bernstein IH (1994) Psychometric theory, 3rd edition. McGraw-Hill, New York.
Valasek T, Varga PP, Szövérfi Z, Bozsodi A, Klemencsics I et al. (2015) Validation of the Hungarian version of the Roland-Morris disability questionnaire. Disabil Rehabil 37: 86-90.
Kline P (2000) Test construction: factor analytic and item analytic methods; in Kline P: Handbook of Psychological Testing, Edition 2. Routledge, 161-181.
Nunnally JC (1978) Psychometric Theory. McGraw-Hill, New York.
Terwee CB, Bot SD, de Boer MR, van der Windt Da, Knol DL, et al. (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60: 34-42.
Kucukdeveci AA, Yavuzer G, Tennant A, Suldur N, Sonel B, et al. (2000) Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med 32: 87-92.
Oveisgharan S, Shirani S, Ghorbani A, Soltanzade A, Baghaei A, et al. (2006) Barthel index in a Middle-East country: translation, validity and reliability. Cerebrovasc Dis 22: 350-354.
Leung SO, Chan CC, Shah S (2007) Development of a Chinese version of the Modified Barthel Index-- validity and reliability. Clin Rehabil 21: 912-922.
Cincura C, Pontes-Neto OM, Neville IS, Mendes HF, Menezes DF, et al. (2009) Validation of the National Institutes of Health Stroke Scale, Modified Rankin Scale and Barthel Index in Brazil: The Role of Cultural Adaptation and Structured Interviewing. Cerebrovascular Diseases 27: 119-122.
Post MW, van Asbeck FW, van Dijk AJ, Schrijvers AJ (1995) [Dutch interview version of the Barthel Index evaluated in patients with spinal cord injuries]. Ned Tijdschr Geneeskd 139: 1376-1380.
Ohura T, Higashi T, Ishizaki T, Nakayama T (2014) Assessment of the validity and internal consistency of a performance evaluation tool based on the Japanese version of the modified barthel index for elderly people living at home. J Phys Ther Sci 26: 1971-1974.
Morley D, Selai C, Thompson A (2012) The self-report Barthel Index: preliminary validation in people with Parkinson's disease. Eur J Neurol 19: 927-929.
Quinn TJ, Langhorne P, Stott DJ (2011) Barthel index for stroke trials: development, properties, and application. Stroke 42: 1146-1151
Shah S, Vanclay F, Cooper B (1989) Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol 42: 703-709.
Cincura C, Pontes-Neto OM, Neville IS, Mendes HF, Menezes DF et al. (2009) Validation of the National Institutes of Health Stroke Scale, modified Rankin Scale and Barthel Index in Brazil: the role of cultural adaptation and structured interviewing. Cerebrovasc Dis 27: 119-122.
Ween JE, Alexander MP, D'Esposito M, Roberts M (1996) Factors predictive of stroke outcome in a rehabilitation setting. Neurology 47: 388-392.
Alexander MP (1994) Stroke rehabilitation outcome. A potential use of predictive variables to establish levels of care. Stroke 25: 128-134.
Inouye M, Kishi K, Ikeda Y, Takada M, Katoh J et al. (2000) Prediction of functional outcome after stroke rehabilitation. Am J Phys Med Rehabil 79: 513-518.
Stein J, Bettger JP, Sicklick A, Hedeman R, Magdon-Ismail Zet al. (2015) Use of a standardized assessment to predict rehabilitation care after acute stroke. Arch Phys Med Rehabil 96: 210-217.
Della Pietra GL, Savio K, Oddone E, Reggiani M, Monaco F et al. (2011) Validity and Reliability of the Barthel Index Administered by Telephone. Stroke 42: 2077-2079.