Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 49, No. 5S, October 15, 2003, pp S15–S27

DOI 10.1002/art.11415
© 2003, American College of Rheumatology
MEASURES OF FUNCTION

Measures of Adult General Functional

Status
The Barthel Index, Katz Index of Activities of Daily Living, Health Assessment
Questionnaire (HAQ), MACTAR Patient Preference Disability Questionnaire, and
Modified Health Assessment Questionnaire (MHAQ)

Patricia P. Katz for the Association of Rheumatology Health Professionals

Outcomes Measures Task Force

BARTHEL INDEX Number of items in scale. Ten in original and

General Description
Purpose. Measure functional independence and
need for assistance in mobility and self-care (1).
The Barthel Index was developed in a chronic
hospital setting; it has generally not been adopted
for use in community-based studies (2). Items were
chosen to reflect the level of nursing care required.
The item weightings are based on the level of
nursing care required and social acceptability (3).
modified English version; 15 in an expanded
version; 5 in short version. Other variants have
different numbers of items. Ten in Turkish; 13 in
Japanese.
Subscales. None.
Populations. Developmental/target.
Rehabilitation patients with stroke and other
neuromuscular or musculoskeletal disorders.

Content. Basic activities of daily living (e.g., Other uses. Oncologic disorders.
feeding, transfer, hygiene). Items are rated in terms
of whether individuals can perform activities WHO ICF Components. Impairment, Activity
independently, can perform with some assistance, limitation.
or are dependent.

Developer/contact information. Dorothea Administration

Barthel, PT, BA.
Versions. Original, modified 10-item version (4),
expanded 15-item version (5), and 5-item short
form (6) in English. Other variants are also
available. There is little consensus over which
should be considered the definitive version (3), but
the original and the 10-item and 15-item
modifications are the most commonly used. It has
been translated into Turkish and Japanese (self-
rated version).
Method. Data obtained from medical records,
direct observation, or by interview. Can also be
self-administered (7). One study suggests that the
scale can be administered reliably over the
telephone to subjects; data provided by proxy
respondents were slightly less reliable (8).
Training. Self-explanatory.
Time to administer/complete. Completion by
health professional takes ⬍5 minutes. Self-
administration takes ⬍10 minutes.

Patricia P. Katz, PhD: Arthritis Research Group, Univer-
sity of California, San Francisco.
Address correspondence to Patricia Katz, PhD: Arthritis
Research Group, University of California, San Francisco,
3333 California Street, Suite 270, San Francisco, CA 94143-
0920. E-mail: pkatz@itsa.ucsf.edu.
Submitted for publication July 30, 2003; accepted July 30,
2003.
Equipment needed. None.
Cost/availability. Original form available at
http://www.medal.org/adocs/docs_ch37/
doc_ch37.05.html#A37.05.03. Modified 10-item
version available at: http://www.medal.org/adocs/
docs_ch37/doc_ch37.05.html#A37.05.04.

S15
S16
Scoring
Responses. Scale. Scale depends on the version
used. In the original version, functional status
descriptions are provided, and the rater selects the
appropriate description of functional ability for each
category. Items are weighted according to the level of
nursing care required. Weights range from 0–15. A
modified scoring system has been suggested by Shah
and colleagues (9) using a 5-level ordinal scale.
In the modified 10-item version, functional
categories may be scored from 0 to 1, 0 to 2, or 0 to
3, depending on the function. The 15-item version
uses a 4-point response scale, and the 5-item
version is scored 0 to 1, 0 to 2, or 0 to 3,
depending on the function.
Score range. Original version 0 –100. The score
range for individual items is Feeding 0 –10 (3
functional descriptions, unable, needs some help,
independent, score as 0, 5, or 10), Moving from
wheelchair to bed/return 0 –15, Personal hygiene
0 –5, Toileting 0 –10, Bathing 0 –5, Walking on
level surface 0 –15, Ascend/descend stairs 0 –10,
Dressing 0 –10, Controlling bowels 0 –10, and
Controlling bladder 0 –10. In the 10-item modified
version, the scores range from 0 to 20. The 15-item
version has scores ranging from 0 to 100, and the
5-item version scores range from 0 to 20.
Interpretation of scores. Higher scores reflect
greater independence. In the original version, a
patient who scores 100 is continent; independent
in feeding, dressing, getting in and out of bed, and
bathing; can walk at least one block; and can
ascend and descend stairs without help. Shah and
colleagues (9) note that a score of 0 –20 suggests
total dependence, 21– 60 severe dependence, 61–90
moderate dependence and 91–99 slight
dependence. In the 15-item version, a score of 60
is commonly considered to be the threshold score
for marked dependence (10).
Method of scoring. Arithmetic computation by
hand.
Time to score. Less than 5 minutes.
Training to score. Not reported.
Training to interpret. Not reported.
Norms available. No.
Psychometric Information
Reliability. In the original version, the interrater
reliability for each item via weighted kappa ranged
Katz et al
from 0.53 to 0.94 (11); the interrater reliability for
total score: intraclass correlation (ICC) ⫽ 0.94 (95%
confidence interval [95% CI] 0.91– 0.96) (11), and
the internal consistency via Cronbach’s alpha ⫽
0.87– 0.92 (9). In the 5-item version, the test-retest
reliability was 0.89 (12), interrater agreement was
0.99 (13), and Cronbach’s alpha 0.98 (13).
In the 5-item version, Cronbach’s alpha was
0.88 (6).
Validity. Original version criterion-related. A
comparison of self-report versus observed
performance in 126 patients ⱖ75 years old (14)
gave the follow figures, values shown are Kappa
(95% CI; % exact agreement) Eating 0.34 (0.19 –
0.49; 69.8), Dressing 0.33 (0.20 – 0.47; 56.1),
Hygiene 0.21 (0.06 – 0.37; 66.7), Bathing 0.34 (0.22–
0.47; 50.8), Control bladder 0.32 (0.17– 0.47; 65.9),
Control bowel 0.10 (0.00 – 0.26; 73.0), Transfer bed
0.36 (0.00 – 0.71; 80.2), Transfer toilet 0.40 (0.21–
0.58; 79.4), Walking 0.30 (0.15– 0.44; 59.5), Stairs
0.37 (0.36 – 0.38; 51.6).
Original version construct validity. Correlation
with Short Form-36 subscales is r ⫽ 0.22 (Role
Emotional subscale) to 0.81 (Physical Functioning
subscale) (15). Correlation with Nottingham Health
Profile subscales: r ⫽ 0.189 – 0.840 depending on
subscale (15). Correlation with Berg Balance Scale
and Fugl-Meyer: r ⱖ0.78 (11). Correlation with
PULSES: Pearson r ⫽ ⫺0.61 to ⫺0.80, depending
on point in time measurement was taken, (i.e.,
admission, discharge, and followup at 2 years
(scales are inverse to each other) (12).
Original version, predictive validity. Correlation
with Frenchay Activities Index at 180 days after
stroke: r ⱖ 0.59 (11).
Modified 10-item version validity. Wade and
Hewer showed high concurrent validity (r ⫽ 0.73–
0.77) with a measure of motor ability (16).
Predictive validity: Barthel scores were predictive
of 6-month mortality, hospital length of stay, and
progress following stroke (10,17,18).
The 15-item version validity. There were high
correlations (overall r ⫽ 0.91) between scores and
performance of tasks and role performance (5), and
high correlations with other measures of function
(e.g., with Katz Index of Activities of Daily Living,
r ⫽ 0.78; with PULSES profile, r ⫽ ⫺0.74 to ⫺0.90)
(10,13,19,20). Scores were predictive of return to
independent living after 6 months (21).
Adult General Function
The 5-item short form validity validity.
Concurrent validity correlation with original
version, r ⫽ 0.90 (6).
Sensitivity/responsiveness to change. Studies
have demonstrated that the Barthel Index can
demonstrate change with effect sizes equivalent to
the Functional Independence Measure (22). Among
patients in a geriatric day hospital, the Barthel
Index was not as sensitive as the London Handicap
Scale (23).
Comments and Critique
The many variants of the index may produce
confusion. Some authors have noted that
interpreting the middle scoring categories may be
difficulty (3,4). The Barthel Index is not designed
to detect low levels of disability. Individuals may
receive the highest score, and still require
assistance with other activities (3). There is
considerably more psychometric data available for
the Barthel Index than for many other activities of
daily living scales (3).
References
1. (Original) Mahoney FI, Barthel DW. Functional
evaluation: the Barthel Index. MD State Med J 1965;
14:61–5.
2. Spector WD. Functional disability scales. In: Spilker
B, editor. Quality of life and pharmacoeconomics in
clinical trials. 2nd edition. Philadelphia: Lippincott-
Raven; 1996. p. 133– 43.
3. McDowell I, Newell C. Measuring health: a guide to
rating scales and questionnaires. 2nd edition. New
York: Oxford University Press; 1996. p. 63–7.
4. Collin C, Wade DT, Davies S, Horne V. The Barthel
ADL Index: a reliability study. Int Disabil Stud 1988;
10:61–3.
5. Fortinsky RH, Granger CV, Seltzer GB. The use of
functional assessment in understanding home care
needs. Med Care 1981;19:489 –97.
6. Hobart JC, Thompson AJ. The five item Barthel
index. J Neurol Neurosurg Psychiatry 2001;71:225–
30.
7. McGinnis GE, Seward ML, DeJong G, Osberg JS.
Program evaluation of physical medicine and
rehabilitation departments using self-report Barthel.
Arch Phys Med Rehabil 1986;14:61–5.
8. Korner-Bitensky N, Wood-Dauphinee S. Barthel
Index information elicited over the telephone: is it
reliable? Am J Phys Med Rehabil 1995;74:9 –18.
9. Shah S, Vanclay F, Cooper B. Improving the
sensitivity of the Barthel Index for stroke
rehabilitation. J Clin Epidemiol 1989;42:703–9.
10. Granger CV, Sherwood CC, Greer DS. Functional
status measures in a comprehensive stroke care
program. Arch Phys Med Rehabil 1977;58:555– 61.
11. Hsueh I-P, Lee M-M, Hsieh C-L. Psychometric
characteristics of the Barthel Activities of Daily
S17
Living Index in stroke patients. J Formos Med Assoc
2001;100:526 –32.
12. Granger CV, Albrecht GL, Hamilton BB. Outcome of
comprehensive medical rehabilitation: measurement
by PULSES Profile and the Barthel Index. Arch Phys
Med Rehabil 1979;60:145–54.
13. Shinar D, Gross CR, Bronstein KS, Licara-Gehr EE,
Eden DT, Cabrera AR, et al. Reliability of the
Activities of Daily Living Scale and its use in
telephone interview. Arch Phys Med Rehabil 1987;
68:723– 8.
14. Sinoff G, Ore L. The Barthel Activities of Daily
Living Index: self-reporting versus actual
performance in the old-old (ⱖ 75 years). J Am
Geriatr Soc 1997;45:832– 6.
15. Wilkinson PR, Wolfe CDA, Warburton FG, Rudd AG,
Howard RS, Ross-Russell RW, et al. Longer term
quality of life and outcome in stroke patients: is the
Barthel index alone an adequate measure of
outcome? Qual Health Care 1997;6:125–30.
16. Wade DT, Hewer RL. Functional abilities after
stroke: measurement, natural history and prognosis.
J Neurol Neurosurg Psychiatry 1987;50:177– 82.
17. Wylie CM. Gauging the response of stroke patients to
rehabilitation. J Am Geriatr Soc 1967;5:797– 805.
18. Granger CV, Greer DS, Liset E, Coulombe J, O’Brien
E. Measurement of outcomes of care for stroke
patients. Stroke 1975;6:34 – 41.
19. Granger CV. Outcome of comprehensive medical
rehabilitation: an analysis based upon the
impairment, disability, and handicap model. Int
Rehabil Med 1985;7:45–50.
20. Rockwood K, Stolee P, Fox RA. Use of goal
attainment scaling in measuring clinically important
change in the frail elderly. J Clin Epidemiol 1993;46:
1113– 8.
21. Granger CV, Hamilton BB, Gresham GE, Kramer AK.
The Stroke Rehabilitation Outcome Study: Part II.
Relative merits of the total Barthel Index Score and a
four-item subscore in predicting patient outcomes.
Arch Phys Med Rehabil 1989;70:100 –3.
22. Van der Putten JJMF, Hobart JC, Freeman JA,
Thompson AJ. Measuring change in disability after
inpatient rehabilitation: comparison of the
responsiveness of the Barthel Index and the
Functional Independence Measure. J Neurol
Neurosurg Psychiatry 1999;66:480 – 4.
23. Harwood RH, Ebrahim S. Measuring the outcomes of
day hospital attendance: a comparison of the Barthel
Index and London Handicap Scale. Clin Rehabil
2000;14:527–31.
KATZ INDEX OF INDEPENDENCE IN
ACTIVITIES OF DAILY LIVING, OR
INDEX OF ADL
General Description
Purpose. Measure independence in activities of
daily living (ADL).
S18
Content. Basic activities of daily living (bathing,
dressing, toileting, transfers, continence, and
feeding). Katz et al noted that the loss of functional
skills occurs in a specific order, with the most
complex being lost first (1). The initial scoring
method for this scale reflects this hierarchy of
function.
Developer/contact information. Sidney Katz,
MD.
Versions. Original.
Number of items in scale. There are 6, one for
each ADL. Some research has suggested that
continence should not be considered an ADL and
should not be included in the scale (2).
Subscales. None.
Populations. Developmental/target. Older adults
and individuals with chronic diseases.
Other uses. None.
WHO ICF Components. Impairment, Activity
limitation.
Administration
Method. Observation.
Training. Observer must be trained to administer
the scale.
Time to administer/complete. Not reported.
Equipment needed. None.
Cost/availability. Available at http://www.
medal.org/adocs/docs_ch37/doc_ch37.05.
html#A37.05.05.
Scoring
Responses. Scale. Each ADL is scored on a 3-
point scale of independence. The Katz Index of
ADL is a semi-Guttman scale, meaning that the
scale items are ordered in terms of difficulty. The
scoring reflects this, although some variation in the
hierarchy of difficulty is allowed. Katz et al (1)
reported that the function of 86% of persons
evaluated was consistent with the hierarchy. The
original scoring using the ADL hierarchy uses an
8-level ordinal scale where A ⫽ independence in
feeding, continence, transferring, going to toilet,
dressing and bathing; B ⫽ independent in all but
one of these functions; C ⫽ independent in all but
Katz et al
bathing and one additional function; D ⫽
independent in all but bathing, dressing and one
additional function; E ⫽ independent in all but
bathing, dressing, going to toilet, and one
additional function; F ⫽ independence in all but
bathing, dressing, going to toilet, transferring and
one additional function; G ⫽ dependent in all six
functions; Other ⫽ dependent in at least two
functions, but not classifiable as C, D, E, or F. Katz
and Akpom (3) later proposed a simplified scoring
system in which individuals are scored 0 – 6 ,
reflecting the number of ADLs in which they are
dependent.
Score range. Range is A–G, or 0 – 6.
Interpretation of scores. Scores reflect the
specific ADLs, or number of ADLs, in which an
individual is dependent. Higher (alphabetically or
numerically) scores reflect greater dependence.
Method of scoring. Independence in various
combinations of ADL determine ordinal rank on
alpha scale, or add the number of ADLs in which
the individual is dependent for the numeric scale.
Time to score. Less than 5 minutes.
Training to score. Not reported.
Training to interpret. Not reported.
Norms available. Not reported.
Psychometric Information
Reliability. The interrater reliability is 0.95 or
better after training (1,4). The coefficient of
reproducibility, (a measure of the internal
consistency of an ordered measure), is 0.96 – 0.99
(5).
Validity. Construct validity. Scores on the Katz
ADL Index are correlated with scores on the
Barthel index (r ⫽ 0.78 [6], kappa ⫽ 0.77 [7]).
Predictive validity. Correlation with mobility
dysfunction (0.50) and house confinement (0.39)
among older adult patients 2 years later (8).
Correlation between ADL dependency level and
mortality among nursing home residents (4). In a
comparison of outcome (home versus hospitalized/
deceased) at one month post stroke between
patients with grade A-B-C versus patients with
grade D-E-F-G using 2 different hospital samples
the following were found (9): positive predictive
value 94%, 96%; negative predictive value 92%,
Adult General Function
96%; sensitivity 83%, 94%, and specificity 97%,
97%.
In a comparison of outcome (survived versus
deceased) 1 month after stroke between patients
with grades A-B-C-D-E-F for survival versus
patients with grade G, the following were found
(9): positive predictive value 94%, 98%; negative
predictive value 68%, 62%; sensitivity 84%, 86%,
and specificity 86%, 96%.
Sensitivity/responsiveness to change. This scale
has a significant floor effect, in that it is relatively
insensitive to variations at low levels of disability
(10).
Comments and Critique
The Katz Index of ADL is very widely used, in
a wide variety of populations (10), although
relatively little has been published on its reliability
and validity. The Katz ADL scale is sensitive to
environment; that is, different scores may be
obtained for individuals in different settings or
with different environmental modifications (11).
References
1. (Original) Katz S, Ford AB, Moskowitz RW, Jackson
BA, Jaffe MW: The Index of ADL: a standardized
measure of biological and psychosocial function.
JAMA 1963;185:914 –9.
2. Jagger C, Clarke M, Davies RA. The elderly at home:
indices of disability. J Epidemiol Community Health
1986;40:139 – 42.
3. Katz S, Akpom CA. A measure of primary
sociobiological functions. Internat J Health Serv
1976;6:493–507.
4. Spector WD, Takada HA. Characteristics of nursing
homes that affect resident outcomes. J Aging Health
1991;3:427–54.
5. Brorsson B, Asberg KH. Katz Index of Independence
in ADL: reliability and validity in short term care.
Scand J Rehabil Med 1984;16:125–32.
6. Rockwood K, Stolee P, Fox RA. Use of goal
attainment scaling in measuring clinically important
change in the frail elderly. J Clin Epidemiol 1993;46:
1113– 8.
7. Gresham GE, Phillips TF, Labi MLC. ADL status in
stroke: relative merits of three standard indices. Arch
Phys Med Rehabil 1980;61:355– 8.
8. Katz S, Downs TD, Cash HR, Grotz RC. Progress in
development of the Index of ADL. Gerontologist
1970;10:20 –30.
9. Asberg KH, Nydevik I. Early prognosis of stroke
outcome by means of Katz Index of Activities of
Daily Living. Scand J Rehab Med 1991;23:187–91.
10. McDowell I, Newell C. Measuring health: a guide to
rating scales and questionnaires. 2nd edition. New
York: Oxford University Press; 1996. p. 63–7.
11. Spector WD. Functional disability scales. In: Spilker
B, editor. Quality of life and pharmacoeconomics in
S19
clinical trials. 2nd edition. Philadelphia: Lippincott-
Raven; 1996. p. 133– 43.
HEALTH ASSESSMENT
QUESTIONNAIRE (HAQ)
General Description
Purpose. Although the original (“full”) HAQ
covers 5 dimensions of health outcomes, the
version most commonly used includes only the
Disability Index, the Visual Analog Pain (VAS)
Pain Scale, and the VAS Patient Global
Assessment. This review will focus only on the
Disability Index.
The HAQ Disability Index measures difficulty
in performing activities of daily living. It is the
most widely used functional measure in
rheumatology. The HAQ was specifically
developed for use among adults with arthritis, but
it has since been used in a wide range of
populations (1).
Content. Questions assessing difficulty over the
past week in 20 specific functions, grouped into 8
categories: dressing and grooming, arising, eating,
walking, personal hygiene, reaching, gripping, and
other activities.
Developer/contact information. James F. Fries,
MD, Division of Immunology and Rheumatology
Stanford University Medical Center, 1000 Welch
Road, Suite 203, Palo Alto, CA 94304-1808.
Versions. Many adaptations and/or translations
are available including English (US, Canada,
Australia), Belgian Flemish and French, Canadian
French, Chinese (Cantonese, Hong Kong), Danish,
French, German, Spanish (US, Spain, many Central
and South American countries), Swedish, and
Turkish. (For complete listing, see Bruce and Fries
[reference 2], p. 172.)
Number of items in scale. There are 20 items
covering 8 categories. In addition, questions are
asked about personal assistance or assistive aids or
devices needed to perform the 20 functions.
Subscales. Dressing and grooming (2 items, dress
yourself, including tying shoelaces and doing
buttons, shampoo your hair); Arising (2 items,
stand up straight from an armless straight chair, get
in and out of bed); Eating (3 items, cut your meat,
lift a full cup or glass to your mouth, open a new
milk carton); Walking (2 items, walk outdoors on
flat ground, climb up 5 steps); Personal hygiene (3
items, wash and dry your entire body, take a tub
bath, get on and off the toilet); Reaching (2 items,
S20
reach and get down a 5-pound object from just
above your head, bend down to pick up clothing
from the floor); Gripping (3 items, open car doors,
open jars that have been previously opened, turn
faucets on and off); Other activities (3 items, run
errands and shop, get in and out of a car, do
chores such as vacuuming or yardwork).
Populations. Developmental/target. Individuals
with rheumatoid arthritis and osteoarthritis.
Other uses. Modifications have been made for
other rheumatologic and non-rheumatologic
conditions.
WHO ICF Components. Activity limitation.
Administration
Method. Interviewer (in person or by telephone)
or self-administered.
Training. None required.
Time to administer/complete. Less than 10
minutes.
Equipment needed. None.
Cost/availability. Contact the author.
Scoring
Responses. Scale. Each item is rated from 0 to 3,
with 0 ⫽ no difficulty, 1 ⫽ some difficulty, 2 ⫽
much difficulty, 3 ⫽ unable to do.
Score range. The highest score within a category
is used as the category score. Dependence on
physical assistance or equipment automatically
raises the category score to 2. The HAQ score is
calculated as the mean of the 8 category scores.
Scores range from 0 to 3, in increments of 0.125. If
fewer than 6 category scores are present, the
overall score is not calculated.
Interpretation of scores. Higher scores reflect
more limitation.
Method of scoring. Hand scored. Alternate
methods of scoring have been developed—for
example, scoring without taking use of assistance
or aids into account (3) or using the mean category
score instead of the highest score (4)— but these
scoring methods have not gained wide use. Wolfe
(5) suggests that even if alternative scoring
methods are used, the traditional score should also
Katz et al
be calculated in order to compare with published
data.
Time to score. Less than 2 minutes.
Training to score. None.
Training to interpret. Not reported.
Norms available. Not reported.
Psychometric Information
Reliability. Test-retest correlations have ranged
from 0.87 to 0.99 (2,6). In alternate forms, i.e.,
interviewer versus self-administered forms of the
instrument (1), the Spearman rank correlation was
Dressing 0.60, Arising 0.82, Eating 0.85, Walking
0.83, Hygiene 0.56, Reach 0.80, Grip 0.64, and
Index 0.88.
Validity. Criterion validity. Fries et al (1)
compared an interviewer-administered HAQ to
observed performance and found an overall
correlation of 0.88, with component scores ranging
from 0.47 (arising) to 0.88 (walking). Daltroy et al
(7) also found a high correlation (-0.72) between
HAQ scores and a physical capacity measure.
Construct validity. Numerous studies have
shown significant correlations of HAQ scores with
clinical (e.g., joint count, grip strength) and
laboratory (e.g., erythrocyte sedimentation rate
[ESR]) measures, and other measures of function
(e.g., Arthritis Impact Measurement Scales [AIMS],
WOMAC) (2,6,8).
Predictive. HAQ scores are among the best
predictors of long-term outcomes, including work
disability, economic loss, and joint surgery, among
people with rheumatoid arthritis (9). HAQ scores
have been found to be better predictors of
mortality than other patient self-report measures,
laboratory, radiographic, or physical examination
data (10).
Sensitivity/responsiveness to change. Liang et al
(11) found that the HAQ was less responsive to
change within subjects before and after hip or knee
surgery than the Sickness Impact Profile (SIP),
AIMS, and the Index of Well-Being (IWB).
However, Hawley and Wolfe (12) showed that the
HAQ may be more sensitive to detecting change
than traditional measures of disease activity and
disease-related impairments (e.g., ESR, grip
strength). Ziebland et al (13) reported that the
modified HAQ (MHAQ) was more responsive to
Adult General Function
change than pre-post differences in HAQ. They
attributed this to the MHAQ’s use of “transition”
questions. On the other hand, Stucki et al (14)
found that changes in clinical and laboratory
parameters were associated with improved,
unchanged, or worse HAQ scores, but this
association was not noted for the MHAQ. Wolfe (5)
also found the HAQ better at detecting treatment
change than the MHAQ. HAQ may also be more
sensitive to detecting change in the middle of the
scale rather than at the ends of the scale (15).
Comments and Critique
The HAQ is probably the most widely used
instrument in rheumatology. Available evidence
indicates high reliability and validity. However,
the HAQ may be less responsive to change than
other instruments, especially among individuals
with very low or very high levels of disability.
References
1. (Original) Fries JF, Spitz P, Kraines RG, Holman HR.
Measurement of patient outcome in arthritis.
Arthritis Rheum 1980;23:137– 45.
2. Bruce B, Fries JF. The Stanford Health Assessment
Questionnaire: a review of its history, issues,
progress, and documentation. J Rheumatol 2003;30:
167–78.
3. Van der Heide A, Jacobs JWG, van Albada-Kuipers
GA, Kraaimaat FW, Geenan R, Bijlsma JWJ. Self
report functional disability scores and the use of
devices: two distinct aspects of physical function in
rheumatoid arthritis. Ann Rheum Dis 1993;52:497–
502.
4. Tomlin GS, Holm MG, Rogers JC, Kwoh CK.
Comparison of standard and alternate Health
Assessment Questionnaire scoring procedures for
documenting functional outcomes in patients with
rheumatoid arthritis. J Rheumatol 1996;23:1524 –30.
5. Wolfe F. Which HAQ is best? A comparison of the
HAQ, MHAQ and RA-HAQ, a Difficult 8-Item HAQ
(DHAQ), and a Rescored 20 Item HAQ (HAQ20):
analyses in 2,491 rheumatoid arthritis patients
following leflunomide initiation. J Rheumatol 2001;
28:982–9.
6. McDowell I, Newell C. Measuring health: a guide to
rating scales and questionnaires. 2nd edition. New
York: Oxford University Press; 1996. p.106 –15.
7. Daltroy LH, Larson MG, Eaton HM, Phillips CB,
Liang MH. Discrepancies between self-reported and
observed physical function in the elderly: the
influence of response shift and other factors. Soc Sci
Med 1999;48:1549 – 61.
8. Ramey DR, Fries JF, Singh G. The Health Assessment
Questionnaire 1995: status and review. In Spilker B,
editor. Quality of life and pharmacoeconomics in
clinical trials, 2nd edition. Philadelphia: Lippincott-
Raven; 1996, p. 227–37.
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9. Wolfe F. A reappraisal of HAQ disability in
rheumatoid arthritis. Arthritis Rheum 2000; 43:2751–
61.
10. Wolfe F, Michaud K, Gefeller O, Choi HK. Predicting
mortality in patients with rheumatoid arthritis.
Arthritis Rheum 2003;48:1530 – 42.
11. Liang MH, Larson MG, Cullen KE, Schwartz JA.
Comparative measurement efficiency and sensitivity
of five health status instruments for arthritis
research. Arthritis Rheum 1985;28:542–7.
12. Hawley DJ, Wolfe F. Sensitivity to change of the
Health Assessment Questionnaire (HAQ) and other
clinical and health status measures in rheumatoid
arthritis: results of short-term clinical trials and
observational studies versus long-term observational
studies. Arthritis Care Res 1992;5:130 – 6.
13. Ziebland S, Fitzpatrick R, Jenkinson C, Mowat A,
Mowat A. Comparison of two approaches to
measuring change in health status in rheumatoid
arthritis: the Health Assessment Questionnaire
(HAQ) and modified HAQ. Ann Rheum Dis 1992;51:
1202–5.
14. Stucki G, Stucki S, Bruhlmann P, Michel BA. Ceiling
effects of the Health Assessment Questionnaire and
its modified version in some ambulatory rheumatoid
patients. Ann Rheum Dis 1995;54:461–5.
15. Daltroy LH. Common problems in using, modifying,
and reporting on classic measurement instruments.
Arthritis Care Res 1997;10:441–7.
MACTAR PATIENT PREFERENCE
DISABILITY QUESTIONNAIRE
General Description
Purpose. To assess disability in patients with
rheumatoid arthritis (RA), focusing only on those
activities affected by RA and judged to be
important to the patient.
Content. Patients identify the 5 specific activities
in which they would most like to have
improvement. Questions are provided for baseline
and followup assessments. Followup assessments
focus on changes in ability to perform the activities
identified at baseline. The scale is scored by
assessing changes in the ability to perform these
activities from baseline to followup.
Developer/contact information. Peter Tugwell,
MD and colleagues, Center for Global Health
Institute of Population Health, 1 Stewart St, Rm
312, Ottawa, ON K1N 6L5, Canada. E-mail:
elacasse@uottawa.ca.
Versions. Original.
Number of items in scale. The baseline
interview includes 5 questions intended to elicit
activities that have been affected by arthritis.
S22
Additional questions are used to query the
patient’s priorities for improvement. The number
of additional questions depends on how many
activities are ranked for priority; 5 is the usual
number. The followup interview assesses changes
in each of the priority activities.
Subscales. None.
Populations. Developmental/target. Individuals
with rheumatic conditions.
Other uses. None.
WHO ICF Components. Activity limitation,
Participation restriction.
Administration
Method. Interviewer-administered.
Training. Interviewers need to be trained to
administer the interview.
Time to administer/complete. Time is 10 –15
minutes (1,2).
Equipment needed. None.
Cost/availability. Available in original reference
(1). Copy available at the Arthritis Care & Research
Web site at http://www.interscience.wiley.com/
jpages/0004-3591:1/suppmat/index.html.
Scoring
Responses. Scale. Based on responses to follow-
up interview: (“Have you noticed any change in
your ability to ___.” [If yes], “Has your ability to
___ improved or become worse?”) Worse ⫽ -1; no
change ⫽ 0; better ⫽ 1.
Score range. A summary score can be created by
weighting each change score according to its
priority ranking, with the highest ranked activity’s
change score multiplied by 5, and the lowest
ranked multiplied by 1. The formula is ⌺([6 – rank]
⫻ change score).
Interpretation of scores. Scores are interpreted
to represent change for each individual over time.
If the summary score is used, higher positive
scores reflect improvement; negative scores reflect
worsening.
Method of scoring. Hand-scored.
Time to score. Not reported.
Katz et al
Training to score. Not reported.
Training to interpret. Not reported.
Norms available. Not reported.
Psychometric Information
Reliability. Interrater reliability: ICC ⫽ 0.78 (3).
Validity. In assessing concurrent validity,
Tugwell et al (4) noted significant correlations of
MACTAR scores with other end-points: McMaster
Health Index Questionnaire, Physical subscale
0.53, Physician’s global assessment r ⫽ 0.52, Lee
Functional Index r ⫽ 0.50, Joint pain/tenderness
count r ⫽ ⫺0.38, Grip strength r ⫽ 0.33.
Verhoeven et al (2) examined the correlation of
MACTAR scores (using the weighted summary
scores) with other functional and outcome
measures. HAQ r ⫽ ⫺0.66, AIMS mobility scale r
⫽ 0.52, Grip strength r ⫽ 0.43, Patient’s global
assessment r ⫽ ⫺0.57.
Sensitivity/responsiveness to change. The
MACTAR has generally been found to be highly
responsive to change (2– 4). Tugwell et al (4)
attribute the high degree of responsiveness to the
use of “transition” questions (“have you noticed a
change in your ability to . . .”?) rather than pre-post
changes in “single-state” questions, and to the
tailoring of items to patients. Wright and Young (3)
noted that, although the MACTAR was a highly
responsive scale, its use of a “transition” question
may reduce variability and elevate the score, and
limiting individuals to 5 items (activities) may
exaggerate improvement because problems not
listed do not change.
Comments and Critique
The unique aspect of the MACTAR is its focus
on patient preferences. Tugwell and others (1,2,4,5)
have noted that standard functional status
questions often do not include activities that are
important to patients, and that the activities that
are included in standard functional status
measures are often not considered to be important
by patients.
Limitations of the MACTAR include its
unique method of calculating change and a lack of
knowledge of the reliability and stability of patient
preferences during a stable functional period (6).
The latter issue may be particularly relevant to
longer-term followup i.e., activities selected at
baseline may become less important as the pattern
of disability changes (2). Some authors have noted
that evaluating each patient according to different
Adult General Function
critieria (e.g., different activities) may also be
problematic (7); the developers of the scale argued
that using different items to assess functional
change was no more problematic than a situation
in which individuals may obtain the same overall
score on a standard functional status instrument by
exhibiting problems with different activities (1).
Verhoeven et al (2) noted that the scoring
system was complex and required amendments.
Although the MACTAR is a valid and highly
responsive instrument, the complexity of
administration and scoring may limit the feasibility
of its use for clinical trials or other aggregrate
situations (2). Its strength may be in monitoring
change in function for individual patients over
relatively short periods of time.
References
1. (Original) Tugwell P, Bombardier C, Buchanan W,
Goldsmith CH, Grace E, Hanna B.The MACTAR
Patient Preference Disability Questionnaire: an
individualized functional priority approach for
assessing improvement in clinical trials in
rheumatoid arthritis. J Rheumatol 1987;14:446 –51.
2. Verhoeven AC, Boers M, van der Linden S. Validity
of the MACTAR Questionnaire as a functional index
in a rheumatoid arthritis clinical trial. J Rheumatol
2000;27:2801–9.
3. Wright JG, Young NL. A comparison of different
indices of responsiveness. J Clin Epidemiol 1997;50:
239 – 46.
4. Tugwell P, Bombardier C, Buchanan WW, Goldsmith
C, Grace E, Bennett KJ, et al. Methotrexate in
rheumatoid arthritis: impact on quality of life
assessed by traditonal standard-item and
individualized patient preference health status
questionnaires. Arch Intern Med 1990;150:59 – 62.
5. Hewlett S, Smith AP, Kirwan JR. Values for function
in rheumatoid arthritis: patients, professionals, and
public. Ann Rheum Dis 2001;60:928 –33.
6. Bell MJ, Bombardier C, Tugwell P. Measurement of
functional status, quality of life, and utility in
rheumatoid arthritis. Arthritis Rheum 1990;33:591–
601.
7. Karlson EW, Katz JN, Liang MH. Chronic rheumatic
disorders. In: Spilker B, editor. Quality of life and
pharmacoeconomics in clinical trials. 2nd edition.
Philadelphia: Lippincott-Raven; 1996. p. 1029 –37.
MODIFIED HEALTH ASSESSMENT
QUESTIONNAIRE (MHAQ)
General Description
Purpose. The MHAQ is a modification of the
Health Assessment Questionnaire (HAQ).
Content. The number of specific activities
queried is reduced from 20 to 8 (one item is used
S23
from each of the 8 categories covered in the HAQ).
The MHAQ has subscales that assess degree of
difficulty, satisfaction with function, change in
function over the past 6 months, and perceived
need for help with each activity, although the
degree of difficulty items are the most commonly
used.
Developer/contact information. Theodore
Pincus, MD, Division of Rheumatology, Vanderbilt
University, 203 Oxford House, Box 5, Nashville,
TN 37232-4500. E-mail: t.pincus@vanderbilt.edu.
Versions. Original.
Number of items in scale. There are 8 items
(dressing, arising, eating, walking, hygiene,
reaching, gripping, getting in and out of car)
repeated in each of 4 subscales.
Subscales. Difficulty, satisfaction, change in
function, need for help.
Populations. Developmental/target. Individuals
with rheumatic conditions.
Other uses. None.
WHO ICF Components. Activity limitation.
Administration
Method. Self-report.
Training. Not reported.
Time to administer/complete. Less than 5
minutes.
Equipment needed. None.
Cost/availability. Available in original reference
(1).
Scoring
Responses. Scale. For Difficulty (“Are you able
to . . .?”). the scale is 0 ⫽ Without any difficulty,
1 ⫽ With some difficulty, 2 ⫽ With much
difficulty, 3 ⫽ Unable to do. Any positive response
regarding help or assistive devices raises the score
to 2. For Satisfaction (“How satisfied are you with
your ability to . . .?”), 0 ⫽ Satisfied and 1 ⫽
Dissatisfied ⫽ 1. Change in difficulty (“Compared
to 6 months ago, how difficult is it NOW (this
week) to . . . ?”) 0 ⫽ Less difficult now, 1 ⫽ No
change, and 2 ⫽ More difficult now. Need for help
S24
(“Do you need help to . . .?”), 0 ⫽ Do not need
help ⫽ 0, and 1 ⫽ Need help.
Score range. Scale scores are the mean of the
scores on the 8 items within the scale. Difficulty
0 –3; Satisfaction 0 –1; Change in function 0 –2;
Need for help 0 –1.
Interpretation of scores. Higher scores on all
scales are more negative (i.e., reflect more
difficulty, less satisfaction, function more difficult
now than previously, and need for more help).
Method of scoring. Arithmetic calculation by hand.
Time to score. Less than 5 minutes.
Training to score. Not reported.
Training to interpret. Not reported.
Norms available. Not reported.
Psychometric Information
Reliability. For the Difficulty scale, the test-
retest reliability at one month ⫽ 0.91 (1).
Validity. Concurrent validity for the Difficulty
scale. Concurrent validity showed the following
correlation with HAQ subscale scores (1): Dressing
0.75, Arising 0.71, Eating 0.75, Walking 0.74,
Hygiene 0.79, Reaching 0.82, Gripping 0.76, and
In/Out Car 0.84. Blalock and colleagues (2) also
examined the equivalency of the HAQ with the
MHAQ, and found that although the scores were
highly correlated, the MHAQ scores were
consistently and significantly lower (indicated
better function) than the HAQ score. In every
category, HAQ items chosen for the MHAQ had a
lower mean than the MHAQ-excluded items.
Construct validity for the Difficulty Scale.
Although Pincus et al (3) reported significant
correlations of MHAQ scores with clinical (e.g.,
joint count, radiographic measures) and laboratory
(e.g., ESR) measures, Stucki et al (4) found that
MHAQ scores were not correlated with changes in
laboratory or clinical measures. Arvidson et al (5)
reported that MHAQ scores were not correlated
with radiographic evidence of joint damage; but
were correlated with performance measures (e.g.,
walk test, grip strength).
Construct validity for Dissatisfaction With
Function scale. Scores were incrementally greater
(more dissatisfied) as difficulty in function
increased (1).
Katz et al
Sensitivity/responsiveness to change. Difficulty
scale. Blalock and colleagues (2) suggest that the
MHAQ is relatively insensitive to low levels of
disability, and, because of its restricted range and
skewed distribution, should be used with caution
when the intent is to assess functional change.
Stucki and colleagues (4) and Wolfe (6) also noted
clustering of scores at the low end of the scale
(Stucki at scores ⬍0.3; Wolfe at scores ⱕ 1.0).
Change in Difficulty scale. Ziebland and
colleagues (7) found that the MHAQ change in
difficulty scale was more sensitive to changes in
clinical variables (i.e., correlated more highly with
variables such as grip strength, pain, morning
stiffness, and ESR) than a pre-post difference in the
traditional HAQ score.
Comments and Critique
The majority of psychometric analysis of the
MHAQ has focused on the difficulty subscale, and
has generally found that it appears to be less
psychometrically sound than the HAQ. Blalock
and colleagues (2) noted that scores on the MHAQ
were consistently lower than those on the HAQ.
Mean differences on the overall difficulty score
were 0.67 lower using HAQ score calculated with
adjustment for help and/or assistive devices, and
0.52 lower using HAQ scores without such
adjustments. The MHAQ does not make
adjustments for use of help or assistive devices.
Blalock also noted that while HAQ scores were
normally distributed across the scale’s full possible
range (0 – 3), MHAQ scores were not normally
distributed and ranged only from 0 to 1.75. Similar
findings were also noted by Stucki et al (4) and by
Wolfe (6). There are conflicting reports about
correlations between MHAQ scores and clinical
and laboratory variables. Wolfe concluded that the
advantages in length of the MHAQ over the HAQ
were offset by loss of sensitivity and
responsiveness to change (6).
On the other hand, there is some evidence
that the change in difficulty scale may be more
sensitive to changes in clinical variables than a
pre-post change score calculated from the HAQ.
This finding is consistent with findings of high
responsiveness using the MACTAR’s “transition”
questions.
References
1. (Original) Pincus T, Summey JA, Soraci SA, Wallston
KA, Hummon NP. Assessment of patient satisfaction
in activities of daily living using a modified Stanford
Health Assessment Questionnaire. Arthritis Rheum
1983;26:1346 –53.
Adult General Function
2. Blalock SJ, Sauter SVH, DeVellis RF. The Modified
Health Assessment Questionnaire difficulty scale: a
health status measure revisited. Arthritis Care Res
1990;3:182– 8.
3. Pincus T, Callahan LF, Brooks RH, Fuchs HA, Olsen
NJ, Kaye JJ. Self-report questionnaire scores in
rheumatoid arthritis compared with traditional
physical, radiographic, and laboratory measures. Ann
Intern Med 1989;110:259 – 66.
4. Stucki G, Stucki S, Bruhlmann P, Michel BA:.Ceiling
effects of the Health Assessment Questionnaire and
its modified version in some ambulatory rheumatoid
arthritis patients. Ann Rheum Dis 1995;54:461–5.
5. Arvidson NG, Larsson A, Larsen A. Simple function
tests, but not the modified HAQ, correlate with
radiological joint damage in rheumatoid arthritis.
Scand J Rheumatol 2002;31:146 –50.
6. Wolfe F. Which HAQ is best? A comparison of the
HAQ, MHAQ and RA-HAQ, a Difficult 8 Item HAQ
(DHAQ), and a Rescored 20 Item HAQ (HAQ20):
S25
analyses in 2491 rheumatoid arthritis patients
following leflunomide initiation. J Rheumatol 2001;
28:982–9.
7. Ziebland S, Fitzpatrick R, Jenkinson C, Mowat A,
Mowat A. Comparison of two approaches to
measuring change in health status in rheumatoid
arthritis: the Health Assessment Questionnaire (HAQ)
and modified HAQ. Ann Rheum Dis 1992;51:1202–5.
Acknowledgments
Members of the Association of Rheumatology
Health Professionals Outcomes Measures Task
Force are Patricia P. Katz, PhD, (Chairman), Karen
W. Hayes, PT, PhD, John E. Hewett, PhD, Carol
Oatis, PT, PhD, Janet L. Poole, PhD, OTR/L,
Elizabeth A. Schlenk, PhD, RN, Christina H.
Stenström, PhD, RPT and Janalee Taylor, MSN,
RN.
 S26

Summary Table of Adult Functional Status Measures*

Psychometric properties
Method of Time for Primary scale Validated
Measure/scale Content No. of items Response format administration administration outputs populations Reliability Validity Responsiveness

Barthel Index Functional Original: 10 Unable, needs help, Observer, from Observer: Less Overall score of Rehabilitation patients Excellent Excellent Moderate
independence and Modifications: independent (with medical than 5 dependence in with stroke and
need for assistance 5, 10, 15 some variation) records or minutes ADL other
in self-care/basic interview (in- Self: Less than neuromuscular or
activities of daily person or 10 minutes musculo-skeletal
living telephone), disorders
self-
administered
Katz Index of Independence in 6 3-point scale of Observer scored Not reported Overall score of Older adults and Little work Predictive Unknown
ADL ADL independence dependence in individuals with validity
ADL. Scored chronic diseases is
from A–G, or excellent
from 0–6
Health Difficulty in 20 items 0–3; 0 ⫽ no difficulty, Interviewer or Less than 10 Overall score Individuals with Excellent Excellent Moderate
Assessment performing (activities) 1 ⫽ some difficulty, self- minutes from 0–3 (mean rheumatoid arthritis
Questionnaire activities of daily over 8 2 ⫽ much difficulty, administered of category and osteoarthritis.
(HAQ) living categories, 3 ⫽ unable to do scores) Also used in other
plus rheumatic and non-
queries rheumatic
about use conditions
of help or
aids
MACTAR Disability, focusing Baseline: 5 At followup: Worse, Interviewer Less than 10 Summary score of Individuals with Acceptable Excellent Excellent
Patient only on activities questions no change, better minutes changes in arthritis, rheumatic
Preference judged to be to elicit priority conditions
Disability important by the activities. activities
Questionnaire patient Additional
items to
rank
priority.
Number
can vary,
usually 5.
Followup:
assesses
changes in
each
priority
activity
Modified Health Degree of difficulty, 8 items Difficulty (0–3) Interviewer or Less than 10 Scores for Individuals with Difficulty: Difficulty: Difficulty:
Assessment satisfaction with (activities) 0 ⫽ no difficulty, self- minutes difficulty, rheumatoid arthritis Excellent Moderate Moderate
Questionnaire function, changes within 1 ⫽ some difficulty, administered satisfaction,
(MHAQ) in function over each 2 ⫽ much difficulty, change in
past 6 months, subscale. 3 ⫽ unable to do. difficulty, need
and need for help Items are a Satisfaction (0–1) for help.
in activities of subset of 0 ⫽ dissatisfied, Difficulty score
daily living HAQ items. 1 ⫽ satisfied. most
Change in difficulty, commonly
(0–2), 0 ⫽ less reported.
difficult now,
1 ⫽ no change,
2 ⫽ more difficult
now
Need for help (0–1)
0 ⫽ do not need
help, 1 ⫽ need
help.

* ADL ⫽ activities of daily living.

Katz et al
Adult General Function S27

Content of Adult Functional Status Measures*

Barthel Katz HAQ MHAQ

Impairments
Continence ⫹ ⫹
Basic ADL-Mobility
Bed Activities ⫹ ⫹
Standing ⫹ ⫹
Transfers ⫹ ⫹ ⫹
Ambulation ⫹ ⫹ ⫹
Inclines/Stairs ⫹ ⫹
Basic ADL-Personal Care
Bathing ⫹ ⫹ ⫹ ⫹
Toileting ⫹ ⫹ ⫹
Grooming ⫹ ⫹
Dressing ⫹ ⫹ ⫹ ⫹
Feeding ⫹ ⫹ ⫹ ⫹
Hand Functions ⫹ ⫹
Instrumental ADL
Home chores ⫹

* ⫹ ⫽ has item(s) related to this activity or concept. Content of

MACTAR is dependent on patient-identified activities.
For another comparative presentation of the content of functional
status measures, see Stewart AL, Painter PL. Issues in measuring
physical functioning and disability in arthritis patients. Arthritis
Care Res 1997;10:395– 405. HAQ ⫽ Health Assessment Question-
naire; MHAQ ⫽ Modified Health Assessment Questionnaire; ADL ⫽
activities of daily living.