NeuroRehabilitation 30 (2012) 315322 315

DOI 10.3233/NRE-2012-0761
IOS Press

Relationship between the modified Rankin

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

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

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

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

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

ISSN 1053-8135/12/$27.50 2012 IOS Press and the authors. All rights reserved
316 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index
The Barthel Index (BI) [2] and the modified Rankin
Scale (mRS) [3] show good clinimetrical properties for
measuring disability in stroke patients [47] and are
the most prevalent functional outcome scales in stroke
trials [1]. The BI is a 10-item scale used to investigate
patients capacities in activity of daily living (presence
or absence of fecal incontinence; presence or absence
of urinary incontinence; help needed with grooming,
toilet use, feeding, transfers, walking, dressing, climb-
ing stairs, bathing). In Collin and Wades BI (scored
020), 0 corresponds to complete dependence, while
20 is equivalent to total independence [2]. The 0 to 20
scale version has been shown to be reliable and concur-
rently valid when compared with the motor part of the
Functional Independence Measure and the mRS [8].
The mRS should be considered as a global disability
scale [9], whereby one grade is capable of describing
patients status (0 = No symptoms at all. 1 = No sig-
nificant disability despite symptoms; able to carry out
all usual duties and activities. 2 = Slight disability; un-
able to carry out all previous activities, but able to look
after own affairs without assistance. 3 = Moderate dis-
ability; requiring some help, but able to walk without
assistance. 4 = Moderately severe disability; unable
to walk without assistance and unable to attend to own
bodily needs without assistance. 5 = Severe disability;
bedridden, incontinent and requiring constant nursing
care and attention. 6 = Dead). Patients with mRS  2
are by definition independent [10].
Comparison of simultaneously collected BI and mRS
scores helps prove validity of both scores. It has been
argued, however, that the BI is more reliable and less
subjective than the mRS [1,7]. In addition, discrepan-
cies between the BI scores and mRS grades have been
observed. Changes in activity and lifestyle after stroke
measured by the mRS do not always match the basic
activities of daily living measured by the BI [11]. The
reasons for the inconsistencies between mRS grades
and the BI scores are not clear. It has been argued that
the timing for test presentation after stroke may not
be appropriate for the outcome measure selected. An-
other possibility lies in the fact that BI measures basic
domestic activities, whereas mRS describes the grade
of independence with respect to global extradomestic
activities, with particular emphasis on the necessity of
continuous assistance by the caregiver.
The aim of our study is to investigate the relationship
between the BI and the mRS at multiple time points
after stroke. The BI, which is a widely used instrument
for longitudinal follow-up post-stroke, was used as ref-
erence to determine the effect of time on the sensitivity
of the mRS in differentiating functional recovery.
2. Methods
2.1. Design
In the present study, we applied intensive repeated
measurements in relationship with timing after stroke,
clinical stability and the real possibility to quantify
functional status.
The diagnosis of ischemic stroke was defined as an
infarction of central nervous system tissue [12]. Also
patients with spontaneous, nontraumatic intracerebral
hemorrhage (ICH) were included in the study.
The study included one hundred and twenty three pa-
tients with lesions located in a cerebral hemisphere who
were admitted to the Stroke Unit of Siena University
Hospital during a period of 14 months. Measurements
started within 48 hours after stroke. For this study, they
were reassessed on day 10 and month 3; final outcome
was assessed at 6 months. All motor and functional
measurements were performed by 2 physiotherapists
working at the Stroke Unit. Clinical evaluations were
performed by the clinicians of the Stroke team.
Patients recruited received usual rehabilitation care
according to the SPREAD VI Edition [13]. Rehabili-
tation Intervention (RI) started at 3 days post-stroke in
Stroke Unit Area. After the discharge from the Stroke
Unit, patients followed a Rehabilitation Program (RP)
ad hoc based on physiotherapy, speech therapy, er-
gotherapy in intensive rehabilitation structures, or out-
patients intensive or non-intensive rehabilitation struc-
tures. Patients were under the RP till functional ability
could be improved.
The procedures were approved by the review body of
the University Hospital and conformed with the Decla-
ration of Helsinki.
2.2. Subjects
Subjects were recruited according to the following
inclusion criteria: (1) First-ever stroke in 1 hemisphere
and no previous functional alteration (BI = 20; mRS =
0); (2) mono-paresis or -plegia or hemi-paresis or -
plegia within 48 hours after stroke; (3) administration
of recombinant tissue plasminogen activator without
full recovery within 48 hours or conventional therapy
for secondary stroke prevention; (4) aged 18 years or
older. Critical subjects with no functional recovery
prognosis at 48 hours were not eligible. Type and loca-
lization of stroke were determined by neurologists and
radiologists using Head CT and/or Head MRI.
Nineteen subjects were excluded because dead or not
available, and twelve because of brainstem lesions. In
conclusion 92 patients were eligible to be studied.
 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index
Table 1
Patients characteristics and timing of clinical measurements
Patients characteristics and timing of clinical measurements
No.
Gender female/male
Mean (SD) age, years
Hemisphere of stroke, left/right
Stroke, ischemic/hemorragic
Diabetic yes/no
Fibrinolysis treatment yes/no
NIHSS, median (IR) 48 hours, 10 days
MI, median (IR) 48 hours, 10 days
TCT, median (IR) 10 days
BI, median (IR): 10 days, 3, 6 months
mRS, median (IR): 10 days, 3, 6 months
2.3. Outcome variables
The BI (020) was used to determine the function-
al status and what the patients was capable of. The
mRS was used to determine the grade of dependency
of each patient and the need of help and supervision by
another person. Scales were assessed at 10 days, 3 and
6 months after stroke.
2.4. Independent variables
The following clinical measurements were made by
clinicians and physiotherapists during daily clinical and
rehabilitation activities in the Stroke Unit Area. For
this study, stroke severity was assessed by the National
Institutes of Health Stroke Scale (NIHSS) at 10 days
after stroke [14]. Motor function was evaluated with
the Motricity Index (MI) at 10 days [15], and trunk
performance was assessed with the Trunk Control Scale
(TCS) at 10 days [15].
2.5. Subject characteristics in Stroke Unit Area
Table 1 describes baseline characteristics and clinical
measurements of patients.
2.6. Data analysis
We studied the relationship between the scores of
BI and the grades of mRS at 10 days, 3 and 6 months
after stroke in all patients for whom both scores were
available. Boxplots were made to show the distribution
of BI scores within each mRS grade at multiple time
points. We also studied the relationship between two
aggregation of mRS grades (mRS = 02, mRS = 3
5) [10] and BI scores at the same time periods after
stroke.
317
Total
92
49/43
69 (12,5)
33/59
74/18
27/65
14/78
6 (8) 4 (6,25)
69 (30,5) 80 (57,87)
87 (63,25)
9 (11,25) 16 (11,25) 18 (10,25)
4 (1) 3 (3) 2 (3)
2.7. Statistics
The BI and the mRS are ordinal scales. We there-
fore used a non-parametric test (KruskalWallis test) to
investigate whether BI median scores significantly dif-
fered amongst the different grades of mRS at 10 days,
3 and 6 months. If the comparison amongst the grades
of mRS showed a significant difference, Dunns multi-
ple comparison test was performed to compensate for
multiple comparisons. Mann and Whitney non- para-
metric test was used to compare median differences in
BI scores between classes 02 vs 35 of mRS grades.
The results are presented as median values and the cor-
responding interquartile range (IQR). For all tests, the
level of significance was set to p < 0.05.
3. Results
The frequency distribution of BI scores for each mRS
grade at 10 days, 3 and 6 months is shown in Figs 1A,
1B and 1C. There was a significant difference (p <
0.0001) in the distribution of BI median scores amongst
the grades of mRS at all times (Kruskall-Wallis: 61.83
at 10 days, 83.62 at 3 months and 85.37 at 6 months).
Post-hoc test at 10 days: 0 vs 5 (p < 0.01), 1 vs 4 (p <
0.001), 1 vs 5 (p < 0.001), 2 vs 5 (p < 0.001), 3 vs 5
(p < 0.001) and 4 vs 5 (p < 0.01).
Post-hoc test at 3 months: 0 vs 4 (p < 0.001), 0 vs
5 (p < 0.001), 1 vs 4 (p < 0.001), 1 vs 5 (p < 0.001),
2 vs 4 (p < 0.01), 2 vs 5 (p < 0.001) and 3 vs 5 (p <
0.05)
Post-hoc test at 6 months: 0 vs 3 (p < 0.05), 0 vs 4
(p < 0.001), 0 vs 5 (p < 0.001), 1 vs 3 (p < 0.05), 1
vs 4 (p < 0.001), 1 vs 5 (p < 0.001), 2 vs 4 (p < 0.01)
and 2 vs 5 (0.001).
We used the criterion that patients with mRS  2 are
by definition independent, and patients with mRS > 2
318 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index

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

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

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

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

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

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

At 6 months (Table 2B), four more patients moved
from group 35 to group 02.
Table 2C shows the groupings at 3 months and at
6 months. A few patients in grade 3 shifted to grade 2.
Patients who were already in a mRS grade  2 shifted
to a better grade.
4. Discussion
Ideally, a scale should measure and detect changes
across the range of possible functional outcomes. Our
study shows that the mRS can furnish a global descrip-
tion of the patients functional status, providing that it
is administered at least 3 months after stroke. Leav-
ing 0 grade aside, as it represents complete recovery
and absence of stroke after-effects, BI score distribu-
tion amongst mRS grades overlapped at 10 days. Sig-
nificant differences were evident between grade 5 and
grades 1,2,3 and 4 allowing for no functional discrim-
ination. This indicates that, immediately after stroke,
the mRS should be interpreted with caution. The dif-
ference between grade 1 and grade 4 may convey a
gross distinction between no disability vs severe dis-
ability. The only significant difference between adja-
cent grades was that between 4 and 5. At this early stage,
the mRS is helpful to distinguish between patients who
need or need not continuous assistance. At 3 months,
there was no overlap in the median frequency distribu-
tion. It was possible to better discriminate the patients
functional global status using the mRS, as supported
by the increased number of significant differences be-
tween grades. Specifically, the difference between 1,2
vs 4,5 suggests that at 3 months the mRS is capable
of distinguishing patients with slight disability who are
independent vs patients with marked disability who are
not independent. The difference between grade 3 and
5 is indicative of some functional improvement after
3 months, as compared to 10 days. At 6 months, there
was no overlap in the frequency distribution between
grade 2 and 3, with further improved discrimination
(grade 1vs3). This allowed to dichotomize total mRS,
making a cut-off between grades 02 and grades 35
which functionally corresponds to the state of indepen-
dence and dependence, respectively [10]. This was fur-
ther supported by the frequency distribution and sta-
tistical comparison of the two groups data at different
time periods, suggesting that the longer the time from
stroke, the more meaningful becomes the description
of the patients functional status by the mRS.
The greatest recovery from neurological deficits due
to stroke occurs during the first 3 months after the onset
of symptoms, and this is considered the optimal time for
rehabilitation [16]. Indeed, patients transitions within
mRS grades at different time periods show that already
at 3 months 27% of patients shifted from a dependent
state to an independent one. At 6 months, a further 4%
made the same transition. The largest transition to an
independent functional status occurred from grade 4;
no such transition occurred from grade 5. It remains
to be explained why grade 3 presented with an equal
number of patients at different time periods. Grade 3
describes patients with moderate disability; requiring
some help, but able to walk without assistance. Un-
aided walking is strictly influenced by the setting (do-
mestic/extradomestic context), by the patients fear of
322 D. Cioncoloni et al. / Relationship between the modified Rankin Scale and the Barthel Index
falling, and by the kind of caregiver assistance [17].
This may give origin to some overestimation. However,
assuming independence of walking, the most important
disability factor is arm dysfunction [18]. This limits
the transition to a grade of independence. Therefore,
patients who improve in their ambulatory capacity, but
not in their arm function transit from grade 4 to grade 3.
In conclusion, the mRS can furnish a global descrip-
tion of the patients functional status, providing that
it is administered at least 3 months after stroke. The
maximal discriminatory capacity of mRS appears to be
reached at six months post-stroke. Before this time, the
mRS does not differentiate functionally independent
patients from dependent ones, optimally.
Acknowledgements
We wish to thank all the patients who participated in
the study, Drs. Marotta, DAndrea and Lo Giudice for
helping with data collection, and the nurse staff of the
Stroke Unit of Siena University Hospital.
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