Development of the Web-Based Spanish Version of the Barthel Index in Patients with Multiple Sclerosis

BACKGROUND

The aims of this study were to develop a web-based Spanish form of the Barthel index (BI), to evaluate its psychometric properties and stability over time (test-retest), and to determine minimal detectable change (MDC) in patients with multiple sclerosis (MS).

METHODS

Participants answered the BI on two forms (web-based and face-to-face interview), 7-10 days apart. The internal consistency was evaluated using Cronbach's alpha, and intraclass correlation (ICC) and kappa (κ) coefficients were used to investigate the agreement between both forms.

RESULTS

143 participants were included. The Spanish web-based form of the BI showed excellent agreement between both forms for each item (κ = 0.86 (0.79 to 0.92), and for total score (κ = 0.87 (0.81 to 0.93); ICC = 0.99 (0.98 to 0.99). The internal consistency was good-excellent (Cronbach's alpha = 0.89 (0.86-0.91)). The stability over time was adequate, the agreement of each item was κ = 0.63 (0.52-0.74)), and for total score (ICC = 0.97), determining a MDC₉₅ of 12.09 points.

CONCLUSIONS

The Spanish web-based form of the BI is a valid and reliable tool to assess functionality and can be applied in both formats in patients with MS. A total score difference of more than 12 points was found to indicate a deterioration or improvement in the patient's functionality.

Reliability and validity of telephonic Barthel Index: an experience from multi-centric randomized control study

Telephonic Barthel Index (BI) assessment is less time-consuming and more feasible than a face-to-face interview. The aim of this study was to test the validity as well as reliability of the BI administered by telephone in comparison with face-to-face assessment in a multi-centric study. The study was conducted during the course of a randomized controlled trial in which 120 patients with subacute strokes from five teaching hospitals from different parts of India were recruited. Central telephonic follow-up and face-to-face assessment of BI and modified Rankin Scale (mRS) at 3 and 6 months were done by trained and certified blinded researchers. Kappa or weighted kappa (wK) was estimated. Sensitivity and specificity at various cutoff levels of telephonic BI were calculated. Concurrent validity of the telephonic BI was assessed by correlating it with the mRS and National Institutes of Health Stroke Scales (NIHSS) at 3 and 6 months. We observed high sensitivity and specificity at various cutoff levels of BI. Moderate to substantial agreement was observed between the two methods at 6 months wK 0.72 (95% CI 0.70-0.77). Item-wise and center-wise kappa also reflected substantial agreement. The study shows that telephonic assessment of activities of daily living with the BI in moderate to severely disabled stroke patients is valid and reliable compared to face-to-face assessment. Our study shows that telephonic assessment requires smaller sample size compared to face-to-face assessment of BI.

Measurement of function in older adults transitioning from hospital to home: an integrative review

Older adults often experience decline in functional status during the transition from hospital to home. In order to determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults. The purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments when investigating older adults transitioning from hospital to home, (2) examine the development and existing psychometric testing of the instruments, and (3) discuss gaps and implications for future research. The authors conducted an integrative review of forty research studies that assessed functional status in older adults transitioning from hospital to home. This review reveals important gaps in the functional status instruments' psychometric testing, including limited testing to support their validity and reliability when administered by self-report and limited evidence supporting their ability to detect change over time.

Outcomes for family carers of a nurse-delivered hospital discharge intervention for older people (the Further Enabling Care at Home Program): Single blind randomised controlled trial

BACKGROUND

Hospital discharge of older people receiving care at home offers a salient opportunity to identify and address their family caregivers' self-identified support needs.

OBJECTIVES

This study tested the hypothesis that the extent to which family caregivers of older people discharged home from hospital felt prepared to provide care at home would be positively influenced by their inclusion in the new Further Enabling Care at Home program.

DESIGN

This single-blind randomised controlled trial compared outcomes from usual care alone with those from usual care plus the new program. The program, delivered by a specially trained nurse over the telephone, included: support to facilitate understanding of the patient's discharge letter; caregiver support needs assessment; caregiver prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports.

SETTING AND PARTICIPANTS

Dyads were recruited from the medical assessment unit of a Western Australian metropolitan public hospital. Each dyad comprised a patient aged 70 years or older plus an English speaking family caregiver.

METHODS

The primary outcome was the caregiver's self-reported preparedness to provide care for the patient. Data collection time points were designated as: Time 1, within four days of discharge; Time 2, 15-21days after discharge; Time 3, six weeks after discharge. Other measures included caregivers' ratings of: their health, patients' symptoms and independence, caregiver strain, family well-being, caregiver stress, and positive appraisals of caregiving. Data were collected by telephone.

RESULTS

Complete data sets were obtained from 62 intervention group caregivers and 79 controls. Groups were equivalent at baseline. Needs prioritised most often by caregivers were: to know whom to contact and what to expect in the future and to access practical help at home. Support guidance included how to: access help, information, and resources; develop crisis plans; obtain referrals and services; and organise legal requirements. Compared to controls, preparedness to care improved in the intervention group from Time 1 to Time 2 (effect size=0.52; p=0.006) and from Time 1 to Time 3 (effect size=0.43; p=0.019). These improvements corresponded to a change of approximately 2 points on the Preparedness for Caregiving instrument. Small but significant positive impacts were also observed in other outcomes, including caregiver strain.

CONCLUSIONS

These unequivocal findings provide a basis for considering the Furthering Enabling Care at Home program's implementation in this and other similar settings. Further testing is required to determine the generalisability of results.

An investigation of commonly prescribed stretches of the ankle plantarflexors in people with Multiple Sclerosis

BACKGROUND

Stretches are often prescribed to manage increased limb stiffness in people with Multiple Sclerosis. This study determined the ankle plantarflexor torque magnitude that people with Multiple Sclerosis can apply during four commonly prescribed stretches and determined the relationship between the applied torque and functional ability.

METHODS

People with Multiple Sclerosis (N=27) were compared to healthy control participants (n=15). Four stretches were investigated; stretching in step standing; using a step; pulling the ankle into dorsiflexion and standing in a frame. Joint position and forces were measured using 3D motion analysis and torque transducers. Baseline ankle strength and stiffness was measured using motor driven ankle perturbations.

FINDINGS

People with Multiple Sclerosis (N=27) had higher stretch reflex amplitudes and lower strength compared to the control group (n=15). People with Multiple Sclerosis achieved less lengthening of the plantarflexor muscle-tendon complex when stretching but similar ankle torques compared to controls. While stretching people with Multiple Sclerosis showed greater muscle activation in the ankle plantarflexors. Stretches in weight bearing positions produced higher plantarflexor torques. People with Multiple Sclerosis with lower functional ability preferred the more supported stretches (ankle pull and standing frame).

INTERPRETATION

Stretches in weight bearing positions achieve higher ankle torques but this is in part due to increased postural activity in people with Multiple Sclerosis. Functional ability may limit stretch effectiveness.

The Canadian survey of health, lifestyle and ageing with multiple sclerosis: methodology and initial results

OBJECTIVE

People with multiple sclerosis (MS) are living longer so strategies to enhance long-term health are garnering more interest. We aimed to create a profile of ageing with MS in Canada by recruiting 1250 (5% of the Canadian population above 55 years with MS) participants and focusing data collection on health and lifestyle factors, disability, participation and quality of life to determine factors associated with healthy ageing.

DESIGN

National multicentre postal survey.

SETTING

Recruitment from Canadian MS clinics, MS Society of Canada chapters and newspaper advertisements.

PARTICIPANTS

People aged 55 years or older with MS symptoms more than 20 years.

OUTCOME MEASURES

Validated outcome measures and custom-designed questions examining MS disease characteristics, living situation, disability, comorbid conditions, fatigue, health behaviours, mental health, social support, impact of MS and others.

RESULTS

Of the 921 surveys, 743 were returned (80.7% response rate). Participants (mean age 64.6±6.2 years) reported living with MS symptoms for an average of 32.9±9.5 years and 28.6% were either wheelchair users or bedridden. There was only 5.4% missing data and 709 respondents provided optional qualitative information. According to data derived from the 2012 Canadian Community Health Survey of Canadians above 55 years of age, older people with MS from this survey sample are about eight times less likely to be employed full-time. Older people with MS were less likely to engage in regular physical activity (26.7%) compared with typical older Canadians (45.2%). However, they were more likely to abstain from alcohol and smoking.

CONCLUSIONS

Despite barriers to participation, we were able to recruit and gather detailed responses (with good data quality) from a large proportion of older Canadians with MS. The data suggest that this sample of older people with MS is less likely to be employed, are less active and more disabled than other older Canadians.

Validity and Reliability of the Barthel Index Administered by Telephone

Background and Purpose—

We aimed to evaluate validity and reliability of the Barthel Index administered telephonically compared with face-to-face assessment in clinically stable patients with stroke.

Methods—

One hundred thirty-one patients were interviewed twice by 2 registered nurses with identical training. Half of the patients were randomized to receive the telephone interview followed by the face-to-face interview and half the contrary. The sequence of interviewers was randomized.

Results—

The median value of the Barthel Index score was 30 (first to third interquartile range, 15 to 80) by telephone and 35 (15 to 75) by face-to-face ( P =0.29). The weighted κ was 0.90 (95% CI, 0.85 to 0.94); κ values ranged from 0.70 (0.58 to 0.82) for bowel control to 0.91 (0.83 to 0.99) for bathing.

Conclusions—

Telephone assessment of stroke disability with the Barthel Index is reliable in comparison to direct face-to-face assessment.

Applying cognitive debriefing to pre-test patient-reported outcomes in older people with multiple sclerosis

PURPOSE

The aim of this study was to reduce respondent burden and decrease data errors in patient-reported outcomes (PROs) intended for a postal survey measuring health and lifestyle factors that may affect quality of life in older people with multiple sclerosis (MS).

METHODS

Participants (n = 18) were recruited from a database of outpatient visits. Using the qualitative diagnostic method, cognitive debriefing, participants completed five standardized questionnaires; Frenchay Activities Index, Barthel Index, Simple Lifestyle Indicator Questionnaire, EuroQoL EQ-5D and Personal Resources Questionnaire 2000. PRO item issues and respondent behaviors such as skipping items were recorded. Data collection was an iterative process whereby difficulties experienced by 2-3 subjects were used to modify the survey for following respondents until data saturation was reached.

RESULTS

Most respondents had serious difficulties with at least one PRO item. Response errors fell into three main categories: (1) respondents did not read instructions and completed the item incorrectly, (2) respondents did not understand the question and required examples to clarify and (3) respondents felt that the pre-determined response options did not apply to them. PRO reformatting, minor modifications to item wording and addition of item examples improved precision and reduced respondent burden.

CONCLUSION

Our findings support the notion that methods such as cognitive debriefing help improve precision of self-reported measures in a special population such as ours.

Issues for selection of outcome measures in stroke rehabilitation: ICF activity

PURPOSE

To evaluate the psychometric and administrative properties of outcome measures in the WHO International Classification of Functioning, Disability and Health (ICF) Activity category used in stroke rehabilitation research and reported in the published literature.

METHOD

Critical review and synthesis of measurement properties for nine commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.

RESULTS

The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. There was evidence to suggest that the measures were responsive to change as well as being valid and reliable tools. The best available instruments were associated with the assessment of activities of daily living, balance (static and dynamic), functional independence, and functional mobility.

CONCLUSIONS

Given the diversity that exists among available measures, the reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved functional activity in stroke rehabilitation. However, there appears to be good consensus regarding the most important indicators of successful rehabilitation outcome, especially in the case of functional mobility.

Changing needs of Chinese family caregivers of stroke survivors

AIM

To examine the changing needs of Chinese family caregivers before and after stroke survivors' discharge from hospital.

BACKGROUND

Stroke ranks third as the most common cause of death in Hong Kong and is the leading cause of adult disability. Community care has been adopted as the major source of care for older people in Hong Kong and this has impacted on family caregivers.

DESIGN AND METHODS

This is a descriptive-correlational design using a within-subjects design. The needs of 40 Chinese family caregivers who met the inclusion criteria were assessed before discharge and two weeks later using the Carer Assessment Scale, Cost of Care Index and one open-ended question. Modified Barthel Index measured the functional ability of stroke survivors.

RESULTS

Family caregivers are able to anticipate most of their needs and to make provision to meet the basic practical needs before discharge. Although needs changed after discharge the four most important needs persisted. These were associated with emotional and psychological problems and financial difficulties. Discharge destinations made no difference to the total scores obtained using the above scales.

CONCLUSIONS

This study provides information about need at a time of transition in an under-researched population of Chinese caregivers. Assessment of need is important with Chinese family carers in order to identify focused interventions in a population, i.e. reluctant to make their needs known to professional services. More research about caregiving problems for Chinese family caregivers at the transition from hospital to community is required.

RELEVANCE TO CLINICAL PRACTICE

Ongoing need assessment by nurses who are in regular contact with caregivers in hospital and community will enable appropriate interventions such as providing education and emotional support both before and after discharge to be offered to Chinese communities.

Association of physical functioning with same-hospital readmission after stroke

OBJECTIVE

Readmission after hospitalization for stroke is an important outcome. We sought to document the frequency of same-hospital readmission and to determine the relative value of physical functioning as a predictor of the outcome.

DESIGN

Consenting patients (n = 228) who were admitted for ischemic stroke were characterized according to demographics, stroke severity, and self-reported prestroke and postadmission physical functioning. The hospital's administrative database was used to track readmissions during the year after index hospitalization.

RESULTS

Same-hospital readmissions were experienced by 37.3% of the patients. The readmissions usually occurred within 100 days of discharge. The most common readmission diagnosis was stroke (14.1%). Lower prestroke and postadmission physical functioning (as reflected by dichotomous Barthel index scores) were weak but significant predictors of readmission (r = -0.165 and -0.268, respectively). Regression analysis showed that once postadmission physical functioning was accounted for, neither prestroke functioning nor any other measured variable added to the explanation of same-hospital readmission.

CONCLUSION

The importance of physical functioning goes beyond rehabilitation. It is a potentially modifiable variable with implications for readmission.

Ratings of physical function obtained by interview are legitimate for patients hospitalized after stroke

This study was conducted to examine the legitimacy of Barthel Index (BI) scores and subset of Functional Independence Measure (FIM) scores obtained by interview from patients hospitalized after stroke. This study included 82 patients with stroke. Interviews by a trained study coordinator were conducted to obtain BI and FIM subset (transfer, locomotion, feeding) scores from patients or a knowledgeable proxy. In addition, therapists' observational FIM scores on subset items recorded in the medical record were retrieved. The reliability, responsiveness, and validity of the BI and FIM subset were examined using Cronbach's alpha, effect size calculations, Wilcoxon tests, Spearman (r(S)) correlations, and regression analysis. Statistical analysis indicated that the post-stroke interview BI (.952) and FIM subset (.939) scores had excellent internal consistency. Large effect sizes and Wilcoxon test results between the prestroke and poststroke interview scores for the BI and FIM subset (z, -3.739 to -6.168) indicated that these 2 instruments were responsive to changes in patients' physical function status that accompanied stroke. Excellent correlations were found between BI and FIM interview scores poststroke (r(s), .913 to .971). The FIM subset interview scores and therapists' scores showed correlations that were moderate to good (r(s), .508 to .754). Length of stay correlated significantly with both the interview BI score (r(s), -.604) and the interview FIM subset score (r(s), -.583). Length of stay was correlated also with the National Institutes of Health Stroke Scale scores (r(s), .484). The regression analysis depicted the BI interview scores as the best predictor of the length of stay. Results provide support for the use of functional scores obtained by interview from hospitalized stroke patients. Both the BI and the FIM subset examined in this study are legitimate for this purpose.

Comparison of postal version of the Frenchay Activities Index with interviewer-administered version for use in people with stroke

OBJECTIVE

To assess the agreement between postal and interviewer-administered versions of the Frenchay Activities Index (FAI) and to assess the criterion validity of the postal version, using interviewer administration as a gold standard.

DESIGN

Comparison of responses to FAI administered by post and then by interview (median delay 10 days).

SUBJECTS

Forty-eight Oxfordshire residents admitted to hospital with acute stroke between 1 August 1994 and 31 January 1995 and discharged alive within six months of their stroke.

RESULTS

The limits of agreement of the total FAI score are from -5.4 to 7.2. The kappa statistic for each of the 15 individual items that make up the FAI ranged from 0.35 to 1. For nine items, agreement was moderate or fair, and for six items, agreement was good or very good. The mean difference between the overall scores was 0.9 (95% confidence interval: -0.1 to 1.9). The correlation between the overall scores was 0.94 (Spearman's rank correlation coefficient).

CONCLUSION

The postal version of the FAI is a satisfactory alternative to direct administration, but poor agreement in scores for individual patients emphasizes that the two approaches should not be used sequentially to monitor individual patients.

Test-retest and inter-method reliability of the self-rating Barthel Index

OBJECTIVE

To develop a self-rating Barthel Index questionnaire (SB) for assessing stroke patients living at home, the test-retest reliability of SB versions 1 and 2 and the inter-method reliability of SB version 3 were examined.

DESIGN

Case series.

SETTING

Clinics of the Department of Rehabilitation Medicine at the University Hospital and two affiliated hospitals.

PATIENTS

Thirty-one, 140 and 65 chronic stroke patients living at home, being seen for regular follow-up, and having no severe aphasia for SB versions 1, 2 and 3, respectively.

MAIN OUTCOME MEASURE

Kappa coefficients of items in SB versions 1 and 2 for test-retest reliability, intra-class correlation coefficients of the self-care index, mobility index and total score, kappa coefficients of items and Friedman's two-way ANOVAs of ranking in SB version 3 among the self-ratings, family ratings and occupational therapist (OT) ratings; a regression analysis of age, gender, duration, time for filling in the SB, OT ratings, Mini-Mental State score and aphasia.

RESULTS

Kappa coefficients in SB version 2 were higher than those in version 1. Intra-class correlation coefficients in SB version 3 among the three ratings were good, and kappa coefficients in each item were also good or excellent. By Friedman's two-way ANOVA, all the items except walking up/down stairs had no significant difference in ranking. Regression analysis revealed that OT ratings and time for filling in the SB affected the absolute difference of scores between the self-ratings and OT ratings.

CONCLUSIONS

SB version 3 is sufficiently reliable for practical use.