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NeuroRehabilitation 30 (2012) 315322 315

DOI 10.3233/NRE-2012-0761
IOS Press

Relationship between the modified Rankin


Scale and the Barthel Index in the process of
functional recovery after stroke
D. Cioncolonia,b , P. Piuc , R. Tassid , M. Acampad, F. Guiderid , S. Taddeia, S. Biellia , G. Martinid and
R. Mazzocchioe,
a
U.O.P. Professioni della Riabilitazione, Azienda Ospedaliera Universitaria Senese, Siena, Italy
b
Scuola di Dottorato in Scienze Cognitive, Universita degli Studi di Siena, Siena, Italy
c
Scuola di Dottorato in Scienze Neurologiche Applicate, Sezione di Neuroscienze, Universita degli Studi di Siena,
Siena, Italy
d
Stroke Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
e
S.C. Neurologia e Neurofisiologia Clinica, Azienda Ospedaliera Universitaria Senese, Siena, Italy

Abstract. Objective: The modified Rankin Scale (mRS) and the Barthel Index (BI) are the most common clinimetrical instruments
for measuring disability after stroke. This study investigated the relationship between the BI and the mRS at multiple time points
after stroke. The BI, which is a widely used instrument for longitudinal follow-up post-stroke, was used as reference to determine
the effect of time on the sensitivity of the mRS in differentiating functional recovery.
Methods: Ninety-two patients with first stroke and hemispheric brain lesion were evaluated using the BI and mRS at 10 days,
3 and 6 months. The KruskalWallis test was applied to examine median differences in BI among the mRS levels at 10 days,
3 and 6 months with Dunns correction for multigroup comparison. The Mann and Whitney test was used to compare median
differences in BI scores between two aggregations of mRS grades (mRS = 02, mRS = 35) at the same time periods after
stroke.
Results: BI score distribution amongst mRS grades overlapped at 10 days, differentiating only between extreme grades (no
disability vs severe disability). At 3 months, independent patients with slight disability could be distinguished from dependent
patients with marked disability. At 6 months, grade 2 and 3 overlapped no more, differentiating independence (class 02) from
dependence (class 35). The largest transition to an independent functional status occurred from grade 4, at 3 months.
Conclusion: Maximum sensitivity of mRS in differentiating functional recovery is reached at six months post-stroke.

Keywords: Stroke, Barthel Index, modified Rankin Scale, rehabilitation, physiotherapy, functional recovery, prognosis

1. Introduction challenged to reliably predict at an early post-stroke


stage, the degree of disability the patient will ultimately
The ultimate goals for many stroke patients is to experience in order to facilitate optimal stroke rehabil-
achieve a level of functional independence necessary itation and appropriate discharge planning as well as
implementation of resources. Still, a gap remains be-
for returning home and to integrate as fully as possi-
tween prognostic research and rehabilitation practice.
ble into community life. For this reason, clinicians are
A critical issue is the quality of clinical measurements
(clinimetrical properties), i.e. the appropriate use of
Corresponding
measures to determine functional outcome in stroke re-
author: Dr. R. Mazzocchio, S.C. Neurologia e
Neurofisiologia Clinica, Azienda Ospedaliera Universitaria Senese,
habilitation. If assessment scales are not clinimetrical-
Viale Bracci, I-53100 Siena, Italy. Tel.: +39 0577 233409; Fax: +39 ly fit for purpose, the risk is to produce meaningless
0577 40327; E-mail: mazzocchio@unisi.it. data [1].

ISSN 1053-8135/12/$27.50 2012 IOS Press and the authors. All rights reserved
316 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index

The Barthel Index (BI) [2] and the modified Rankin 2. Methods
Scale (mRS) [3] show good clinimetrical properties for
measuring disability in stroke patients [47] and are 2.1. Design
the most prevalent functional outcome scales in stroke
trials [1]. The BI is a 10-item scale used to investigate In the present study, we applied intensive repeated
patients capacities in activity of daily living (presence measurements in relationship with timing after stroke,
or absence of fecal incontinence; presence or absence clinical stability and the real possibility to quantify
of urinary incontinence; help needed with grooming, functional status.
toilet use, feeding, transfers, walking, dressing, climb- The diagnosis of ischemic stroke was defined as an
ing stairs, bathing). In Collin and Wades BI (scored infarction of central nervous system tissue [12]. Also
020), 0 corresponds to complete dependence, while patients with spontaneous, nontraumatic intracerebral
20 is equivalent to total independence [2]. The 0 to 20 hemorrhage (ICH) were included in the study.
scale version has been shown to be reliable and concur- The study included one hundred and twenty three pa-
rently valid when compared with the motor part of the tients with lesions located in a cerebral hemisphere who
Functional Independence Measure and the mRS [8]. were admitted to the Stroke Unit of Siena University
The mRS should be considered as a global disability Hospital during a period of 14 months. Measurements
scale [9], whereby one grade is capable of describing started within 48 hours after stroke. For this study, they
were reassessed on day 10 and month 3; final outcome
patients status (0 = No symptoms at all. 1 = No sig-
was assessed at 6 months. All motor and functional
nificant disability despite symptoms; able to carry out
measurements were performed by 2 physiotherapists
all usual duties and activities. 2 = Slight disability; un-
working at the Stroke Unit. Clinical evaluations were
able to carry out all previous activities, but able to look
performed by the clinicians of the Stroke team.
after own affairs without assistance. 3 = Moderate dis-
Patients recruited received usual rehabilitation care
ability; requiring some help, but able to walk without
according to the SPREAD VI Edition [13]. Rehabili-
assistance. 4 = Moderately severe disability; unable
tation Intervention (RI) started at 3 days post-stroke in
to walk without assistance and unable to attend to own
Stroke Unit Area. After the discharge from the Stroke
bodily needs without assistance. 5 = Severe disability;
Unit, patients followed a Rehabilitation Program (RP)
bedridden, incontinent and requiring constant nursing
ad hoc based on physiotherapy, speech therapy, er-
care and attention. 6 = Dead). Patients with mRS  2
gotherapy in intensive rehabilitation structures, or out-
are by definition independent [10].
patients intensive or non-intensive rehabilitation struc-
Comparison of simultaneously collected BI and mRS
tures. Patients were under the RP till functional ability
scores helps prove validity of both scores. It has been
could be improved.
argued, however, that the BI is more reliable and less
The procedures were approved by the review body of
subjective than the mRS [1,7]. In addition, discrepan-
the University Hospital and conformed with the Decla-
cies between the BI scores and mRS grades have been
ration of Helsinki.
observed. Changes in activity and lifestyle after stroke
measured by the mRS do not always match the basic 2.2. Subjects
activities of daily living measured by the BI [11]. The
reasons for the inconsistencies between mRS grades Subjects were recruited according to the following
and the BI scores are not clear. It has been argued that inclusion criteria: (1) First-ever stroke in 1 hemisphere
the timing for test presentation after stroke may not and no previous functional alteration (BI = 20; mRS =
be appropriate for the outcome measure selected. An- 0); (2) mono-paresis or -plegia or hemi-paresis or -
other possibility lies in the fact that BI measures basic plegia within 48 hours after stroke; (3) administration
domestic activities, whereas mRS describes the grade of recombinant tissue plasminogen activator without
of independence with respect to global extradomestic full recovery within 48 hours or conventional therapy
activities, with particular emphasis on the necessity of for secondary stroke prevention; (4) aged 18 years or
continuous assistance by the caregiver. older. Critical subjects with no functional recovery
The aim of our study is to investigate the relationship prognosis at 48 hours were not eligible. Type and loca-
between the BI and the mRS at multiple time points lization of stroke were determined by neurologists and
after stroke. The BI, which is a widely used instrument radiologists using Head CT and/or Head MRI.
for longitudinal follow-up post-stroke, was used as ref- Nineteen subjects were excluded because dead or not
erence to determine the effect of time on the sensitivity available, and twelve because of brainstem lesions. In
of the mRS in differentiating functional recovery. conclusion 92 patients were eligible to be studied.
D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index 317

Table 1
Patients characteristics and timing of clinical measurements
Patients characteristics and timing of clinical measurements Total
No. 92
Gender female/male 49/43
Mean (SD) age, years 69 (12,5)
Hemisphere of stroke, left/right 33/59
Stroke, ischemic/hemorragic 74/18
Diabetic yes/no 27/65
Fibrinolysis treatment yes/no 14/78
NIHSS, median (IR) 48 hours, 10 days 6 (8) 4 (6,25)
MI, median (IR) 48 hours, 10 days 69 (30,5) 80 (57,87)
TCT, median (IR) 10 days 87 (63,25)
BI, median (IR): 10 days, 3, 6 months 9 (11,25) 16 (11,25) 18 (10,25)
mRS, median (IR): 10 days, 3, 6 months 4 (1) 3 (3) 2 (3)

2.3. Outcome variables 2.7. Statistics

The BI (020) was used to determine the function- The BI and the mRS are ordinal scales. We there-
al status and what the patients was capable of. The fore used a non-parametric test (KruskalWallis test) to
mRS was used to determine the grade of dependency investigate whether BI median scores significantly dif-
of each patient and the need of help and supervision by fered amongst the different grades of mRS at 10 days,
another person. Scales were assessed at 10 days, 3 and 3 and 6 months. If the comparison amongst the grades
6 months after stroke. of mRS showed a significant difference, Dunns multi-
ple comparison test was performed to compensate for
2.4. Independent variables multiple comparisons. Mann and Whitney non- para-
metric test was used to compare median differences in
The following clinical measurements were made by BI scores between classes 02 vs 35 of mRS grades.
clinicians and physiotherapists during daily clinical and The results are presented as median values and the cor-
rehabilitation activities in the Stroke Unit Area. For responding interquartile range (IQR). For all tests, the
this study, stroke severity was assessed by the National level of significance was set to p < 0.05.
Institutes of Health Stroke Scale (NIHSS) at 10 days
after stroke [14]. Motor function was evaluated with
3. Results
the Motricity Index (MI) at 10 days [15], and trunk
performance was assessed with the Trunk Control Scale
The frequency distribution of BI scores for each mRS
(TCS) at 10 days [15].
grade at 10 days, 3 and 6 months is shown in Figs 1A,
1B and 1C. There was a significant difference (p <
2.5. Subject characteristics in Stroke Unit Area 0.0001) in the distribution of BI median scores amongst
the grades of mRS at all times (Kruskall-Wallis: 61.83
Table 1 describes baseline characteristics and clinical at 10 days, 83.62 at 3 months and 85.37 at 6 months).
measurements of patients. Post-hoc test at 10 days: 0 vs 5 (p < 0.01), 1 vs 4 (p <
0.001), 1 vs 5 (p < 0.001), 2 vs 5 (p < 0.001), 3 vs 5
2.6. Data analysis (p < 0.001) and 4 vs 5 (p < 0.01).
Post-hoc test at 3 months: 0 vs 4 (p < 0.001), 0 vs
We studied the relationship between the scores of 5 (p < 0.001), 1 vs 4 (p < 0.001), 1 vs 5 (p < 0.001),
BI and the grades of mRS at 10 days, 3 and 6 months 2 vs 4 (p < 0.01), 2 vs 5 (p < 0.001) and 3 vs 5 (p <
after stroke in all patients for whom both scores were 0.05)
available. Boxplots were made to show the distribution Post-hoc test at 6 months: 0 vs 3 (p < 0.05), 0 vs 4
of BI scores within each mRS grade at multiple time (p < 0.001), 0 vs 5 (p < 0.001), 1 vs 3 (p < 0.05), 1
points. We also studied the relationship between two vs 4 (p < 0.001), 1 vs 5 (p < 0.001), 2 vs 4 (p < 0.01)
aggregation of mRS grades (mRS = 02, mRS = 3 and 2 vs 5 (0.001).
5) [10] and BI scores at the same time periods after We used the criterion that patients with mRS  2 are
stroke. by definition independent, and patients with mRS > 2
318 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index

Fig. 1. A: Frequency distribution of BI for each mRS level at 10 days. The figure shows the Box-and-Whiskers plot of the BI observed within
each mRS grade at 10 days post stroke. BI score distribution amongst mRS grades overlapped at 10 days. Significant differences were evident
between grade 5 and grades 1,2,3 and 4 allowing for no functional discrimination. B: Frequency distribution of BI for each mRS level at 3 months.
The figure shows the Box-and-Whiskers plot of the BI observed within each mRS grade at 3 months post stroke. There was no overlap in the
median frequency distribution. It was possible to better discriminate the patients functional global status using the mRS, as supported by the
increased number of significant differences between grades. C: Frequency distribution of BI for each mRS level at 6 months. The figure shows
the Box-and-Whiskers plot of the BI observed within each mRS grade at 6 months post stroke. There was no overlap in the frequency distribution
between grade 2 and 3, with further improved discrimination (grade 1vs 3).
D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index 319

Fig. 2. A: Frequency distribution of BI for the two mRS classes at 10 days. There was a significant difference in the BI median score (p <
0.0001). The whiskers of the two classes considerably overlapped at 10 days. B: Frequency distribution of BI for the two mRS classes at 3
months. There was a significant difference in the BI median score (p < 0.0001). The whiskers of the two classes overlapped at 3 months. C:
Frequency distribution of BI for the two mRS classes at 6 months. There was a significant difference in the BI median score (p < 0.0001). The
whiskers of the two classes did not overlap at 6 months.
320 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index

Table 2A
Patients shift during recovery period from 10 days to 3 months. Each entry in the table
contains the frequency of the joint occurrences of the mRS grades at the time 10 days
(rows) and at time 3 months (columns). Hence, in each row there is, for each grade of
mRS at 10 days, the distribution of the patients who (eventually) shifted to other classes
at 3 months.

Table 2B
Patients shift during recovery period from 10 days to 6 months. Each entry in the table
contains the frequency of the joint occurrences of the mRS grades at the time 10 days
(rows) and at time 6 months (columns). Hence, in each row there is, for each grade of
mRS at 10 days, the distribution of the patients who (eventually) shifted to other classes
at 6 months.

dependent [10], to aggregate our data in two classes the tables, the frequencies corresponding to the aggre-
according to whether they fell into a mRS 02 or a mRS gated mRS grades (02 and 35) are also shown. The
35. The distribution of the two classes in relation main diagonal of the matrix of transition contains the
to BI scores at 10 days, 3 and 6 months is shown in number of patients who still remained into the same
Figs 2A, 2B and 2C. There was a significant difference grade of mRS within the time periods compared. Thus,
in the BI median score (p < 0.0001) at all the evaluation at each row of the table, the values at the right of the
timings. The whiskers of the two classes considerably main diagonal indicate the shifts towards lower grades
overlapped at 10 days and 3 months, but not at 6 months.
of mRS, whilst on the left of the main diagonal there are
The Tables 2A, 2B, 2C explain the matrices of tran-
sition, i.e. the number of patients who shifted from one the frequencies of the shifts towards the upper grades.
mRS grade to another. This matrix can be converted Table 2A shows patients mRS grade at 10 days and
to a Markov transition matrix by dividing each column at 3 months. At 10 days, 20.6% of patients were in
by the total at the bottom of the column. This normal- the group 02, while 79% were in group 35. After
izes each column so that it sums to one, and each value 3 months, about 48% of patients were in group 02 and
represents the probability that a selected initial class 52% in group 35. Grade 4 patients contributed most
will make the transition to the selected final class. In to the shift from group 35 to group 02 after 3 months.
D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index 321

Table 2C
Patients shift during recovery period from 3 months to 6 months. Each entry in the table
contains the frequency of the joint occurrences of the mRS grades at the time 3 months
(rows) and at time 6 months (columns). Hence, in each row there is for each grade of
mRS at 3 months the distribution of the patients who (eventually) shifted to other classes
at 6months.

At 6 months (Table 2B), four more patients moved vs 4,5 suggests that at 3 months the mRS is capable
from group 35 to group 02. of distinguishing patients with slight disability who are
Table 2C shows the groupings at 3 months and at independent vs patients with marked disability who are
6 months. A few patients in grade 3 shifted to grade 2. not independent. The difference between grade 3 and
Patients who were already in a mRS grade  2 shifted 5 is indicative of some functional improvement after
to a better grade. 3 months, as compared to 10 days. At 6 months, there
was no overlap in the frequency distribution between
grade 2 and 3, with further improved discrimination
4. Discussion (grade 1vs3). This allowed to dichotomize total mRS,
making a cut-off between grades 02 and grades 35
Ideally, a scale should measure and detect changes which functionally corresponds to the state of indepen-
across the range of possible functional outcomes. Our dence and dependence, respectively [10]. This was fur-
study shows that the mRS can furnish a global descrip- ther supported by the frequency distribution and sta-
tion of the patients functional status, providing that it tistical comparison of the two groups data at different
is administered at least 3 months after stroke. Leav- time periods, suggesting that the longer the time from
ing 0 grade aside, as it represents complete recovery stroke, the more meaningful becomes the description
and absence of stroke after-effects, BI score distribu- of the patients functional status by the mRS.
tion amongst mRS grades overlapped at 10 days. Sig- The greatest recovery from neurological deficits due
nificant differences were evident between grade 5 and to stroke occurs during the first 3 months after the onset
grades 1,2,3 and 4 allowing for no functional discrim- of symptoms, and this is considered the optimal time for
ination. This indicates that, immediately after stroke, rehabilitation [16]. Indeed, patients transitions within
the mRS should be interpreted with caution. The dif- mRS grades at different time periods show that already
ference between grade 1 and grade 4 may convey a at 3 months 27% of patients shifted from a dependent
gross distinction between no disability vs severe dis- state to an independent one. At 6 months, a further 4%
ability. The only significant difference between adja- made the same transition. The largest transition to an
cent grades was that between 4 and 5. At this early stage, independent functional status occurred from grade 4;
the mRS is helpful to distinguish between patients who no such transition occurred from grade 5. It remains
need or need not continuous assistance. At 3 months, to be explained why grade 3 presented with an equal
there was no overlap in the median frequency distribu- number of patients at different time periods. Grade 3
tion. It was possible to better discriminate the patients describes patients with moderate disability; requiring
functional global status using the mRS, as supported some help, but able to walk without assistance. Un-
by the increased number of significant differences be- aided walking is strictly influenced by the setting (do-
tween grades. Specifically, the difference between 1,2 mestic/extradomestic context), by the patients fear of
322 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index

falling, and by the kind of caregiver assistance [17]. Van Zuylen P, Clinimetric evaluation of the Barthel Index,
This may give origin to some overestimation. However, a measure of limitation in daily activities, Ned Tijdschr Ge-
neeskd 137(18) (1993), 917-921.
assuming independence of walking, the most important [6] Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van
disability factor is arm dysfunction [18]. This limits Gijn, Interobserver agreement for the assessment of handicap
the transition to a grade of independence. Therefore, in stroke patients, Stroke 19(5) (1988), 604-607.
patients who improve in their ambulatory capacity, but [7] Wolfe CD, Taub NA, Woodrow EJ, Burney PG, Assessment
of scales of disability and handicap for stroke patients, Stroke
not in their arm function transit from grade 4 to grade 3. 22(10) (1991), 1242-1244.
In conclusion, the mRS can furnish a global descrip- [8] Kwon S, Hartzema A, Duncan P, Min-Lai S, Disability mea-
tion of the patients functional status, providing that sures in stroke: relationship among the Barthel Index, the
it is administered at least 3 months after stroke. The Functional Independence Measure, and the Modified Rankin
Scale. Stroke 35 (2004), 918-923.
maximal discriminatory capacity of mRS appears to be [9] De Hann R, Limburg M, Schuling J, Broeshart J, Aaronson
reached at six months post-stroke. Before this time, the N, The clinical meaning of Rankin handicap grades after
mRS does not differentiate functionally independent stroke, Stroke 26(11) (1995), 2027-2030.
[10] Rankin J, cerebral vascular accidents in patients over the age
patients from dependent ones, optimally.
of 60.II. Prognosis, Scott Med J2(5) (1957), 200-215.
[11] Uyttenboogaart M, Luijckx GJ, Vroomen PC, Stewart RE, De
Keyser J, Measuring disability in stroke: relationship between
Acknowledgements the modified Rankin Scale and the Barthel Index, J Neurol 254
(2007), 1113-1117.
[12] Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi
We wish to thank all the patients who participated in S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC,
the study, Drs. Marotta, DAndrea and Lo Giudice for Kidwell CS, Lutsep HL, Miller E, Sacco RL, Definition of
helping with data collection, and the nurse staff of the transient ischemic attack, Stroke 40 (2009), 2276-2293.
[13] Spread VI edizione. Ictus Cerebrale: linee guida italiane di
Stroke Unit of Siena University Hospital. prevenzione e trattamento. Pubblicazioni Catel Division-Pie-
rrel Research Italy SpA, Milano 2010.
[14] Brott T, Adams HP, et al., Measurement of acute cerebral
References infarciction: a clinical examination scale, Stroke 20(7) (1987),
864-870.
[15] Demeurisse G, Demol O, Robaye E. Motor evaluation in vas-
[1] Queen TJ, Dawson J, Walters MR, Lees KR, Reliability of cular hemiplegia, Eur Neurol 19 (1980), 382-389.
the Modified Rankin Scale: a Systematic Review, Stroke 40 [16] Van Peppen RP, Kwakkel G, Wood-Dauphinee S, Hendriks HJ,
(2009), 3393-3395. Van der Wees PJ, Dekker J, The impact of physical therapy on
[2] Collin C, Wade DT, Davis S, Horne V, The Barthel ADL Index: functional outcomes after stroke: whats the evidence? Clin
a reliability Study, International disability Study 10(2) (1988),
Rehabil 18(8) (2004), 833-862.
61-63. [17] Schmid A, Duncan PW, Studenski S, Min Lai S, Richards L,
[3] Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van Perera S, Wu SSm, Improvements in speed-based gait classi-
Gijn J. Interobserver agreement for the assessment of handicap fication are meaningful, Stroke 38 (2007) 2096-2100.
in stroke patients, Stroke 19(5) (1988), 604-607. [18] Plats T, Winter T, Muller N, Pinkowski C, Eickhof C, Mauritz
[4] DOlhaberriague L, Litvan I, Mitsias P, Mansbach HH, A KH, Arm ability training for stroke and traumatic brain injury
reappraisal of reliability and validity studies in stroke, stroke patients with mild arm paresis: a single-blind, randomised,
27(12) (1996), 2331-2336. controlled trial, Archives of Physical Medicine & Rehabilita-
[5] De Haan R, Limburg M, Schuling J, Broeshart J, Jankers L,
tion 82 (2001), 961-968.
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