Original articleComparison of the responsiveness of the Barthel Index and the Motor Component of the Functional Independence Measure in stroke: The impact of using different methods for measuring responsiveness
Introduction
Stroke is a major cause of mortality and morbidity in the United States, particularly among persons over 55 years of age. Acute stroke occurs in over 700,000 individuals each year, with over 80% of these persons likely to survive, many with residual neurologic difficulties. About 4,400,000 stroke survivors are alive today 1, 2, 3, 4. As acute care for stroke continues to improve, the number of individuals surviving stroke with residual deficits is likely to increase over the next decade.
Older adults strongly value the ability to be independent in activities of daily living, and stroke survivors are usually deprived of this ability. The neurologic impairments resulting from stroke disable the patient in varying degrees with respect to performing the essential of everyday life—basic activities of daily living (ADL). Furthermore, individuals are also limited in their ability relative to instrumental activities of daily living that represent the fundamental skills necessary to live independently in the community 5, 6.
One major objective of stroke rehabilitation as well as a major focus of ongoing research on stroke recovery is increasing independence of stroke survivors in ADL. Furthermore, assessment of ADL outcomes in individuals who survive stroke is necessary for appropriate clinical management and evaluation of outcomes for quality management of rehabilitation services and for research. The Agency for Health Care Policy and Research Post-Stroke Rehabilitation panel recommended that clinicians use well-validated, standardized instruments to ensure reliable documentation progress over time in levels of disability and functional independence [7]. Two instruments recommended by the panel for assessing disability/activities of daily living are the Barthel Index (BI) and the Motor Component of the Functional Independence Measure (FIM® Instrument). Both instruments have been demonstrated to be valid and reliable measures of functional outcomes in stroke patients 8, 9, 10, 11.
Frequently, when the FIM® Instrument and BI are applied in clinical settings, longitudinal measures are obtained on the same subjects over time to assess patterns of recovery in achieving independence in ADL. Although reliability and validity are sufficient to ensure usefulness of instruments for defining cross-sectional differences among persons, Kirshner and Guyatt and Guyatt et al. 12, 13 suggest that another property, responsiveness, is essential for instruments designed to measure longitudinal change over time. Responsiveness is defined as the ability of an instrument to detect clinically important changes over time, even if those changes are small 12, 13. Although health outcomes generally agree on the need to measure responsiveness, no general consensus has been reached on the best way to measure responsiveness, and multiple measures have been proposed 14, 15, 16, 17, 18, 19. Also, although the reliability and validity of the FIM® Instrument and BI are well established, less information is available on the responsiveness of these instruments. 8, 11.
The objectives of this study are to assess the responsiveness of the BI and FIM® Instrument for evaluating recovery from stroke over the 1- to 3-month poststroke period, and to assess the impact of different methods for assessing responsiveness on instrument comparison. The data for the study were collected as a part of the Kansas City Stroke study, an epidemiologic study of a cohort of stroke survivors, who lived in the community and were independent in activities of daily living prior to their stroke.
Section snippets
Participants
The participants in this study are 459 individuals who sustained an eligible stroke and were recruited for the Kansas City Stroke Study. Case ascertainment for the Kansas City Stroke Study started in August of 1995 and ended in September of 1999. The eligible study participants were recruited from any of 12 participating hospitals in the Greater Kansas City area. Eligible stroke patients were identified by (1) a review of daily admission records; (2) referrals from physicians, clinical nurse
Results
Comparison of responsiveness to change was based on a subset of 372 of the 459 subjects from the Kansas City Stroke Study Cohort. These subjects had FIM® Instrument and BI scores at both 1 and 3 months and either improved or remained constant in Rankin score over that time frame. Of the 87 subjects excluded from these analyses, 56 were excluded because they had missing values for the MRS at both months 1 and 3 (19), at month 1 only (1), or month 3 only (36); 26 were excluded because they
Discussion
Reliable measurement tools are needed to help researchers assess new stroke treatments and clinicians to evaluate patterns of stroke recovery in the treatment setting. Guyatt has argued that scales that are used in an evaluative sense to measure progress of patients over time must also exhibit a property that he called responsiveness or sensitivity to change. A number of articles have addressed the general issue of responsiveness or sensitivity to change 1, 27, 28, 29, 30, 31, yet no consensus
Acknowledgements
This study was funded by the Department of Veterans Affairs Rehabilitation Research and Development and the University of Kansas Claude D. Pepper Older Americans Independence Center funded by the National Institute of Health (P60 AG 14635-02). Participating facilities in the Kansas City area included: Baptist Medical Center, Department of Veteran Affairs Medical Centers in Kansas City and Leavenworth, Liberty Hospital, Medical Center of Independence, Mid-American Rehabilitation Hospital,
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