Original Paper
Cerebrovasc Dis 2006;22:231239
DOI: 10.1159/000094009
Activity Index A Complementary ADL
Scale to the Barthel Index in the Acute
Stage in Patients with Severe Stroke
Louise Martinsson a Staffan Eksborg b
a
Institution of Clinical Neurosciences, Karolinska Institutet and the Stroke Research Unit, Department of
Neurology, Karolinska University Hospital, and b Department of Woman and Child Health,
Childhood Cancer Research Unit, Karolinska Institutet and Karolinska Pharmacy, Stockholm, Sweden
Key Words
Cerebrovascular stroke
Activity Index
Barthel Index

Outcome measures
Floor effect
Ceiling effect
Abstract
Objective: It was the aim of this study to compare the Bar-
thel Index (BI) and the activities of daily living (ADL) compo-
nent of the Activity Index [AI(ADL)] regarding floor and ceil-
ing effects, responsiveness and the predictive value for
survival during the first week until 3 months after stroke on-
set. Patients and Methods: Basic ADL were assessed in 75
patients with ischaemic stroke. Results: There was a strong
concordance between BI and AI(ADL) scores at all time points
(Kendalls
b = 0.7878, p ! 0.0001 at baseline; Kendalls
b =
0.8901, p ! 0.0001 at 1 week; Kendalls
b = 0.9027, p ! 0.0001
at 3 months). BI had a significantly more pronounced floor
effect at baseline and at 1 week compared with AI(ADL) in
patients with severe stroke. Both scales had a substantial
ceiling effect at 3 months. At 1 week, the baseline BI score
was significantly higher in patients being alive as compared
with those who had died, while their AI(ADL) score did not
differ significantly. At 3 months, baseline BI and AI(ADL)
scores were significantly higher in patients being alive as
compared with those who had died. The predictive value of
being alive at 1 week and 3 months did not differ between
BI and AI(ADL). Conclusion: AI(ADL) is recommended to be
2006 S. Karger AG, Basel
10159770/06/02240231$23.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/ced
Received: December 8, 2005
Accepted: February 22, 2006
Published online: June 20, 2006
used in addition as a complement to BI in patients with se-
vere stroke since the floor effect with BI in the acute stage is
significantly more pronounced than with AI(ADL), thus ham-
pering the responsiveness. Copyright 2006 S. Karger AG, Basel
Introduction
Measures of outcome are important for both clinical
practice and research to objectively quantify efficacy of
treatment. A useful measure should show high reliability,
i.e. the degree to which a measure is free from random
error, and be valid, i.e. measure what it is supposed to
measure [1]. It should also be able to demonstrate respon-
siveness [2], including both longitudinal improvement
and deterioration, and should neither contain floor nor
ceiling effects.
Assessment of stroke treatment poses problems due to
the natural history of the illness. Change may continue
over time, and the rate and extent of change may vary
depending on initial stroke severity [3] and the domain
[4], i.e. the level of disease [5], which is being assessed [3,
6]. Thus, the choice of appropriate measurement for
stroke outcome should be based mainly on the timing of
assessment [7], the severity of the patients symptoms [3]
and the domain being assessed [6].
Dr. Staffan Eksborg
Karolinska Pharmacy
Karolinska University Hospital
SE171 76 Stockholm (Sweden)
Tel. +468 51 77 53 30, Fax +468 30 73 46, E-Mail staffan.eksborg@karolinska.se
 The Barthel Index (BI) [8] is the most commonly used
measure of activity (disability) in drug therapeutic trials
in patients with stroke [6] and in rehabilitation studies
after stroke [9]. BI has been recommended, together with
the Functional Independence Measure [10], as a measure
of activity [11] and has been proposed as the standard in-
dex for clinical as well as for research purposes [12]. The
reliability [1317] and validity [13, 14, 18, 19] of BI is well
established, but shortcomings with insensitivity to small
changes in functional status and severe floor and ceiling
effects have been observed [2022]. BI has a predictive
ability for functional skills [23], life satisfaction in general
[24] and the ability to live independently [25]. The Activ-
ity Index (AI) [26, 27] was developed to evaluate early sys-
tematic activation in daily nursing after stroke. AI con-
sists of three main parts: mental capacity, motor activity
and ADL. Studies on reliability and validity as well as the
predictive value of death of AI have been published
[26, 27].
The objective of the present study was to compare BI
and the ADL component of AI regarding floor and ceil-
ing effects (the fraction of patients with the lowest or
highest possible score, respectively, for each scale), the
responsiveness and the predictive value for survival dur-
ing the first week until 3 months after stroke onset.
Patients and Methods
Patients
Data for the present study were collected from two studies that
will be referred to as study A [28] and study B [29]. Totally, 75 pa-
tients with first as well as recurrent ischaemic stroke, admitted to
the Department of Neurology, Karolinska Hospital, Stockholm,
Sweden, were included. The diagnosis of stroke was based on the
medical history and clinical examination of the patient according
to the WHO criteria [30]. A CT scan was performed in all patients
to confirm the diagnosis. Informed consent was given by all pa-
tients or their relatives. The trials were approved by the local eth-
ical committee at Karolinska Hospital, Stockholm, Sweden, and
the Swedish Medical Products Agency. Complete descriptions of
the patients and methods are given elsewhere [28, 29]; a short
summary is given here.
Study A [28], performed between October 1998 and January
2001, was a double-blind, placebo-controlled, safety and efficacy
study of dexamphetamine (d-amph). Forty-five patients with se-
vere, moderate and mild paresis after cerebral ischaemia were in-

Table 1. Demographic and medical history, baseline characteristics of the present stroke, and baseline scores
for all patients, patients classified as TACI and patients classified as LACI/PACI

Characteristic All patients Patients classified Patients classified as

(n = 75) as TACI (n = 47) LACI/PACI (n = 28)

Age, years
Median 74 77 69
Interquartile range 6479 6781 6077
Sex, female/male 38/37 24/23 14/14
Affected side of the body, left/right 30/44a 20/26a 9/19
Alert 38 (50.7) 14 (29.8) 25 (89.3)
Previous stroke 20 (26.7) 10 (21.3) 5 (17.9)
Urinary incontinence 55 (73.3) 40 (85.1) 10 (35.7)
OCSP classification
TACI 47 (62.7)
PACI 21 (28.0) 21 (75.0)
LACI 7 (9.3) 7 (25.0)
BI
Median 15b 10c 47.5d
Interquartile range 050 040 2075
AI(ADL) score
Median 17e 13e 28
Interquartile range 1226 1019 1931.5

Figures in parentheses are percentages.

TACI = Total anterior circulation infarcts; LACI/PACI = lacunar infarcts/partial anterior circulation in-
farcts.
a
Only cognitive problems at baseline (no side affected) in 1 patient; b n = 59; c n = 31; d n = 26; e n = 74.

232 Cerebrovasc Dis 2006;22:231239 Martinsson /Eksborg

cluded within 72 h after onset of stroke symptoms and randomized
to three different doses of d-amph (total 30 patients) or placebo (15
patients) for 5 consecutive days. Data from assessments with BI and
AI at baseline (n = 45), 1 week (n = 42) and 3 months (n = 34) were
extracted for use in the present analysis. Study B [29], performed
between February 1997 and December 2000, was a single-blind
study of efficacy of physiotherapy in combination with d-amph.
Thirty patients with severe hemiparesis and an impaired level of
consciousness after cerebral ischaemia were included within 96 h
after onset of symptoms and were randomized to d-amph and in-
tensive or standard physiotherapy for 5 consecutive days. Data
from assessments with BI and AI at baseline (n = 14 and 30, respec-
tively), 1 week (n = 11 and 28, respectively) and 3 months (n = 8 and
21, respectively) were extracted for use in the present analysis.
One physiotherapist performed all assessments at all time
points in study A. In study B, 2 other physiotherapists assessed
the patients. The assessments were based on the observed activity
of the patient in both studies.
Demographic and medical history, baseline characteristics of
the present stroke and baseline scores are shown in table 1.

The Barthel Index

The BI includes 10 items: feeding, personal hygiene, bathing,
dressing, toilet, bladder control, bowel control, chair/bed transfer,
ambulation and stair climbing. In the present study, the original
version of BI [8] was used. Items are of different value, with 2 items
rated on a 2-point scale of 0 and 5, 6 items rated on a 3-point scale
of 0, 5 and 10, and 2 items rated on a 4-point scale of 0, 5, 10 and
15. Consequently, the scale ranges from 0 to 100. For all items,
higher scores are associated with a greater degree of indepen-
dence. However, a score of 100 does not mean that the individual
is able to live alone or perform instrumental ADL (such as cook-
ing and house cleaning).

The Activity Index

The AI(ADL) function part includes 6 items: ambulation, per-
sonal hygiene, dressing, feeding, emptying/function of bladder
and bowels, rated on a 4-point scale of 1, 3, 4 and 6 [26, 27]. The
sum of scores ranges between 6 and 36. For all items, higher scores
are associated with a greater degree of independence. However, a
score of 36 does not mean that the individual is able to live alone
or perform instrumental ADL.

Stroke Prognosis
The Oxfordshire Community Stroke Project (OCSP) classifi-
cation [31, 32] is used in prognostication of survival and depen-
dence and can be considered as an indicator of stroke severity.
Patients are classified as belonging to one of four groups: (1) total
anterior circulation infarcts (TACI), (2) partial anterior circula-
tion infarcts (PACI), (3) lacunar infarcts (LACI), and (4) poste- Fig. 1. Concordance between the BI score and the AI(ADL) score
rior circulation infarcts. In the present study, TACI is defined as at baseline (a), 1 week (b) and 3 months (c).
severe stroke and PACI/LACI as moderate/mild stroke. No pos-
terior circulation infarct patients were included.

Statistics
Non-parametric statistical procedures were used throughout
the present study. Concordance between the two scales was estab-
lished by Kendalls
b [33]. The differences in baseline scores be-
tween patients who died during the study period and patients
alive were evaluated by the Mann-Whitney U test. Floor effects
were quantified by the percentage of subjects with the minimum
possible score and ceiling effects by the percentage of subjects
with the maximum possible score. Dichotomized data (floor ef-
fect/no floor effect, ceiling effect/no ceiling effect) from two in-
dependent samples were compared by Fishers exact test. Ninety-

Activity Index A Complementary Cerebrovasc Dis 2006;22:231239 233

Stroke ADL Scale to the Barthel Index
 Table 2. Floor and ceiling effects for BI and AI(ADL) scores at baseline, 1 week and 3 months

BI AI(ADL) score p values

n proportion n proportion

Floor effect
Baseline 17/59 28.9 (17.842.0) 4/74 5.4 (1.513.3) 0.0003
1 week 12/53 29.3 (17.943.0) 5/70 7.7 (3.115.5) 0.0177
3 months 0/41 0 (0.07.0) 0/55 0 (0.05.3)
Ceiling effect
Baseline 0/59 0 (0.05.0) 2/74 2.7(0.39.4) 0.5026
1 week 7/53 13.2 (5.525.3) 12/70 17.1 (9.228.0) 0.6209
3 months 19/41 46.3 (30.662.6) 22/55 40.0 (27.054.1) 0.6769

Figures in parentheses are 95% CI.

five percent confidence intervals (95% CI) were calculated for
proportions. Sensitivity, specificity and prediction were calculat-
ed as given in Taube and Malmquist [34]. The analyses were per-
formed on scores from patients being alive at each assessment
point. Two-sided p values were calculated. Analyses were carried
out with GraphPad InStat version 3.05 and GraphPad StatMate
version 1.01 (GraphPad Software Inc., San Diego, Calif., USA) and
JMP version 4.02 (SAS Institute Inc., Cary, N.C., USA).
Results
There was a strong concordance between BI and
AI(ADL) scores at baseline (Kendalls
b = 0.7878, p !
0.0001), 1 week (Kendalls
b = 0.8901, p ! 0.0001) and 3
months (Kendalls
b = 0.9027, p ! 0.0001) (fig. 1ac).
The number of patients with a minimum score (floor
effect) and a maximum score (ceiling effect) are shown in
table 2. BI had a significantly more pronounced floor ef-
fect than AI(ADL) at baseline and at 1 week (p = 0.0003
and p = 0.0177, respectively) (fig. 1a, b). Differences in
floor and ceiling effects at the other time points were not
significant.
The baseline floor effect was observed only in patients
classified as TACI, in 17/33 patients assessed with BI
(51.5%; 95% CI 33.669.2) and in 4/46 patients assessed
with AI(ADL) (8.7%; 95% CI 2.420.8; p ! 0.0001) (fig. 2a,
b). At 1 week, the floor effect was mainly observed in
TACI patients, in 11/27 patients assessed with BI (40.7%;
95% CI 22.461.2) and in 4/42 patients assessed with
AI(ADL) (9.5%; 95% CI 2.722.6; p = 0.0057) (fig. 2c, d).
A floor effect was also observed in 1 patient classified
as PACI. No floor effects were observed at 3 months
(fig. 2e, f).
The responsiveness of the BI and AI(ADL) is ham-
pered by the floor and ceiling effects as illustrated in fig-
ure 3ad.
The baseline BI score was significantly higher in pa-
tients being alive at 1 week as compared with patients
who had died (p = 0.0152), while their baseline AI(ADL)
score did not differ statistically (p = 0.1401) (fig. 4a, b).
Baseline BI and AI(ADL) scores were significantly higher
in patients being alive at 3 months as compared with pa-
tients who had died (p = 0.0068 and p = 0.0019, respec-
tively) (fig. 4c, d).
The highest predictive value of being alive at 1 week
was 1.56 for a BI baseline score exceeding 10 (sensitivity
0.76; specificity 0.80) and 1.58 for an AI(ADL) baseline
score exceeding 15 (sensitivity 0.58; specificity 1.00)
(fig. 4a, b). The highest predictive value of being alive at
3 months was 1.34 for a BI baseline score exceeding 10
(sensitivity 0.81; specificity 0.53) and 1.40 for an AI(ADL)
baseline score exceeding 15 (sensitivity 0.65; specificity
0.75) (fig. 4c, d).
Discussion
Overall, there was a strong concordance between BI
and AI(ADL) scores, despite the fact that BI had a sig-
nificantly more pronounced floor effect than AI(ADL) in
the acute stage in patients with severe stroke. Substantial
floor and ceiling effects, i.e. more than 20% of the data
[35], were observed with both scales. Patients with high-
er BI and AI(ADL) baseline scores were more likely to
survive than patients with lower scores in accordance
with previous findings [36] (fig. 4), but the predictive val-

234 Cerebrovasc Dis 2006;22:231239 Martinsson /Eksborg

 BI AI (ADL)
100 36

80 30

60 24

40 18

20 12

0 6
a b

100 36

80 30

60 24

40 18

20 12

0 6
c d

100 36

80 30

60 24

40 18

20 12

0 6
e f

Fig. 2. Score distribution of basic ADL in patients classified as TACI (U), PACI (S) and LACI (+) with BI and
AI(ADL) at baseline (a, b), 1 week (c, d) and 3 months (e, f). Horizontal lines indicate median values.

ue, comparable for the two scales, was too low to be of
clinical importance.
In the present study, the ADL part of AI was exclu-
sively compared with BI, a measurement of basic ADL.
The other parts of the AI measure contain items measur-
ing body function (impairment) and activity (disability).
Mixing different domains (levels of disease) can make
interpretation of the results difficult [37].
The patients included in the present study had more
severe strokes than the general stroke population, which
could be expected considering the inclusion criteria in
study B [29]. Almost 51% of the patients had an impaired

Activity Index A Complementary Cerebrovasc Dis 2006;22:231239 235

Stroke ADL Scale to the Barthel Index
 100 30

20

Change in AI (ADL)
50
Change in BI

10

0
0

10

50 20

a 0 25 50 75 100 b 6 12 18 24 30 36

100 30

20

Change in AI (ADL)
50
Change in BI

10

0
0

10

50 20

c 0 25 50 75 100 d 6 12 18 24 30 36
Baseline BI Baseline AI (ADL)

Fig. 3. Floor and ceiling effects limit changes in scores with BI and AI(ADL) at 1 week (a, b) and 3 months (c,
d), as demonstrated by solid and dotted lines, respectively. Baseline scores are plotted against changes in scores,
i.e. the difference between the baseline score and the score at follow-up, at 1 week and 3 months, respectively.

level of consciousness at baseline as compared with only
15% in the OCSP study [31] and 42% in the Rochester
study [38]. Seventy-three percent of the patients were uri-
nary incontinent as compared with 3366% reported in
other studies [39], and 63% were classified as TACI com-
pared with 17% in the OCSP study [31]. An impaired lev-
el of consciousness and urinary incontinence are impor-
tant indicators of the severity of stroke [39], and patients
classified as TACI indeed have a bad survival and func-
tional prognosis [32]. Still, patients with mild/moderate
strokes were included as well, and conclusions about the
clinimetric properties investigated in the present study
can also be drawn in these groups of patients.
In the present study, 60 out of 75 patients received d-
amph (30 out of 45 patients in study A and 30 out of 30
patients in study B). The placebo-treated patients in study
A did not differ in basic ADL during the course of the
study [28]. In contrast, the motor recovery rate was sig-
nificantly higher in d-amph-treated patients during the
treatment period [28]. These results are further support-
ed in a systematic Cochrane review [40]. Thus, it seems
unlikely that the d-amph administration affected the re-
sults in the present study.
The ability to measure clinically meaningful change
over time, i.e. responsiveness [2], is an essential clinimet-
ric property of measures of outcome. However, there is no
consensus on the appropriate strategy to quantify re-
sponsiveness [20]. Generally, parametric statistical meth-
ods are used for evaluation of responsiveness despite the
fact that outcome measures are usually ordinal [41], and
thus, should be analysed with non-parametric statistics
only. Evaluation of responsiveness by visual inspection of
plots of change in the disability score versus the baseline
score is suggested in the present study (fig. 3ad). There

236 Cerebrovasc Dis 2006;22:231239 Martinsson /Eksborg

 100 36

80 30

Baseline AI (ADL)
Baseline BI

60 24

40 18

20 12

0 6
a b

100 36

80 30

Baseline AI (ADL)
Baseline BI

60 24

40 18

20 12

0 6
c d

Fig. 4. Baseline scores for BI and AI(ADL) in patients who died (U) and those alive (S) at 1 week (a, b) and 3
months (c, d). Horizontal lines indicate median values.

are clear difficulties in detecting deterioration in activity
(disability) during the first week after stroke onset due to
floor effects with BI (fig. 3a; table 2). Improvements 3
months after stroke onset are also difficult to detect due
to ceiling effects both with BI (fig. 3c) and AI(ADL)
(fig. 3d). Patients showing the worst possible score at
baseline with both scales are all classified as TACI (fig. 2a,
b), but there is a significantly larger proportion of TACI
patients having a floor effect with BI compared with
AI(ADL). BI has been reported to better differentiate lim-
itations in activity in lower than in higher degree of activ-
ity limitations, but still, BI does not very well discrimi-
nate activity limitations in patients with pronounced lim-
itations [42]. The results from the present study are of a
similar nature, with BI showing substantial floor effects
in the acute stage in patients with severe stroke. The re-
sponsiveness of BI in the context of research has been
questioned [12]. This assumption is strengthened by the
results in the present study, with AI(ADL) being more
responsive to change than BI in patients with severe
stroke during the first week after stroke onset.
To facilitate comparisons between studies, simplify in-
terpretation of results and make meta-analysis easier and
more powerful, it would be desirable that the same mea-
surement of outcome could be used for the same type of
measurement in all studies. Presently, there is no consen-
sus on the level of outcome, i.e. body functions and struc-
ture, activity or participation; there is neither consensus
concerning the method of measurement of outcome. The
best agreement on which measurement of outcome is to
be used seems to be in the domain of activity [43, 44]
which can be assessed with measures of both basic and
instrumental ADL. Basic ADL is more frequently assessed
in research studies compared with instrumental ADL, de-

Activity Index A Complementary Cerebrovasc Dis 2006;22:231239 237

Stroke ADL Scale to the Barthel Index
spite the weaknesses [44]. Presently, the alternatives to BI
[8] as a measure of basic ADL are very limited. Besides BI,
Functional Independence Measure [10] is the recom-
mended choice of activity [11] and is commonly used, es-
pecially in North America. However, it has the same lim-
itations as BI, but in addition, it takes longer to administer
and requires training and certification [42]. Attempts to
measure indicators of domains other than body structure
and function (impairment) and activity (disability) as a
whole seem unlikely to succeed either in theory or prac-
tice [43]. Thus, BI will probably not be replaced as an im-
portant measure of stroke outcome in the near future.
Many drug trials are started in a very early stage, i.e.
within 6 h of thrombolysis [45] and a median time to
treatment of 12 h with neuroprotectants [46]. The ability
to detect changes, especially deterioration in patients
with severe stroke, to elucidate negative drug effects is of
high importance.
The responsiveness of an instrument may be related to
the timing of the measurement of rehabilitation [20]. The
advantage of AI(ADL) observed in the present study, with
less pronounced ceiling effects in the acute stage in pa-
tients with severe stroke, indicates that the well-known
BI might be complemented albeit not replaced with the
AI(ADL) scale until a new, more responsive measure of
outcome of activity is available. Thus AI(ADL) can be
used as a complement to BI in the acute stage, since
AI(ADL) is more responsive than BI.
In conclusion, substantial floor and ceiling effects
were observed with both AI(ADL) and BI scales, but the
floor effect with BI in the acute stage is significantly more
pronounced than with AI(ADL), hampering the respon-
siveness. Thus AI(ADL) is recommended to be used in
addition as a complement to BI in patients with severe
stroke.
Acknowledgements
This study would not have been possible without the dedicated
cooperation of the patients and their families, Anita Hansson-
Tyrn, research assistant at the Stroke Research Unit, Malin Ns-
sn and Marie Kierkegaard, physiotherapists at the Department
of Neurology, all Karolinska Hospital, Stockholm, Sweden.
The trial was supported by grants from the Federation of
County Councils (main sponsor), the Vrdal Foundation, the
Family Janne Elgqvist foundation, the Swedish Association of
Neurologically Disabled, the ke Wiberg Foundation, Karolins-
ka Institutet, and the Swedish Stroke Association.

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