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      The Barthel index-dyspnea a tool for respiratory rehabilitation: reply to the letter by Chuang [Letter of clarification]

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          Dear editor We read the remarkable letter by Chuang.1 We thank him for his valid suggestions on our paper. Interestingly, he focused on the two dimensions of the Barthel index-dyspnea (BI-d), which was exactly our goal. As rehabilitators, our goal is to provide patients with physical therapy depending on their health status and to improve their respiratory function. We need to verify and demonstrate the efficacy and the outcomes of respiratory rehabilitation, supported by physical therapy. For these reasons, we need an assessment device that measures respiratory improvement during daily motor activities that should be monitored. The modified Barthel index2 is a well-consolidated and widely used instrument to assess the performance of a person in a predetermined and fixed set of activities of daily living (ADLs). By proposing BI-d,3 we aimed to develop a scale to measure how dyspnea precludes or reduces the same ADLs, with the ultimate goal of globally assessing the effectiveness of rehabilitation. Hence, an assessment method that measures the impact of dyspnea on activities monitored by a rehabilitation program is of utmost importance for rehabilitators. Large part of Chuang’s letter is based on the Chronic Respiratory Questionnaire-dyspnea (CRQ-d). The CRQ-d is a health-related quality of life (health status) questionnaire, with a dyspnea “domain”.4 However, for our purposes, the CRQ-d is too individualized as each subject selects five activity items – “the most important” – out of 26 listed activities. Therefore, each subject may choose different items from other subjects in the same study group. Due to this significant methodology, CRQ was standardized recently into a version that contains a total of only five items with a dyspnea domain, all of which have to be responded.5 Conversely, the modified Barthel index2 includes a predetermined and fixed set of ADLs. This allows better comparison between subjects or group of subjects, before and after a treatment, a significant criterion in rehabilitation, and a specific field for which we mainly developed the scale. Moreover, CRQ-d is dyspnea centered, whereas BI-d is activity centered. This first paper on BI-d validation is auspicious. The metric qualities are good and the variability is acceptable, with 95% confidence intervals of correlation coefficient of BI-d versus 6-minute walking test being −0.609 and −0.352, respectively. As pointed out in our paper, additional studies in respiratory rehabilitation programs are required to further assess the applicability of the scale in a broadest context. Mild COPD patients are among those populations who are potential candidates of BI-d. Dr Chuang showed accurately that only 8.1% of our study population had mild COPD. This is obvious as COPD is largely underestimated, and patients usually consult a specialist only when they are diagnosed with GOLD 26 stage disease.7–9 Table 1 and Figure 1 show a few outcomes of four subjects based on the four GOLD stages. They also show that the less obstructed the patient, the lower the BI-d was. Conversely, the more obstructed the patient, the higher the BI-d was. After pulmonary rehabilitation, the BI-d improved in all patients. The best results were observed in GOLD 4 stage as they received a more intensive health care and rehabilitation program. On the other hand, the smallest limitation was assessed at the baseline, and the smallest differences in outcome were observed in subjects at GOLD 1 stage. Conclusion In conclusion, we consider it appropriate to uphold all items of both the modified Barthel index score (because they collect important information from a physical rehabilitation point of view) and of the Barthel dyspnea index (because they allow the estimate of the outcome of a specifically tailored respiratory rehabilitation program).

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          Improving the sensitivity of the Barthel Index for stroke rehabilitation.

          The Barthel Index is considered to be the best of the ADL measurement scales. However, there are some scales that are more sensitive to small changes in functional independence than the Barthel Index. The sensitivity of the Barthel Index can be improved by expanding the number of categories used to record improvement in each ADL function. Suggested changes to the scoring of the Barthel Index, and guidelines for determining the level of independence are presented. These modifications and guidelines were applied in the assessment of 258 first stroke patients referred for inpatient comprehensive rehabilitation in Brisbane, Australia during 1984 calendar year. The modified scoring of the Barthel Index achieved greater sensitivity and improved reliability than the original version, without causing additional difficulty or affecting the implementation time. The internal consistency reliability coefficient for the modified scoring of the Barthel Index was 0.90, compared to 0.87 for the original scoring.
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            The chronic bronchitis phenotype in chronic obstructive pulmonary disease: features and implications.

            Chronic obstructive pulmonary disease (COPD) is a major public health problem that is projected to rank fifth worldwide in terms of disease burden and third in terms of mortality. Chronic bronchitis is associated with multiple clinical consequences, including hastening lung function decline, increasing risk of exacerbations, reducing health-related quality of life, and possibly raising all-cause mortality. Recent data suggest greater elucidation on the risk factors, radiologic characteristics, and treatment regimens. Our goal was to review the literature on chronic bronchitis that has been published in the past few years.
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              A comparison of the original chronic respiratory questionnaire with a standardized version.

              The chronic respiratory questionnaire (CRQ), a widely used measure of health-related quality of life (HRQL) in patients with chronic airflow limitation, includes an individualized dyspnea domain (patients identify five important activities, and report the degree of dyspnea on a 7-point scale). Because the individualized domain is unwieldy in multicenter clinical trials, we developed a standardized version and tested its discriminative and evaluative properties. We enrolled 51 patients who completed the standardized and individualized CRQ before starting a respiratory rehabilitation program, and again 3 months later. We calculated both cross-sectional and longitudinal correlations between the two versions and a number of other HRQL instruments, and tested the relative ability of the individualized and standardized versions of the CRQ to detect improvement with rehabilitation. The results of the individualized questions suggested greater dysfunction (lower scores) than did the standardized questions both at baseline (3.18 vs 3.92, p < 0.001) and follow-up (4.62 vs 4.84, p = 0.051). The standardized dyspnea domain showed superior discriminative validity. While both techniques detected important, statistically significant improvement with rehabilitation (individualized domain mean change, 1.44; 95% confidence interval [CI], 1.11 to 1.77 [p < 0.001]; standardized domain mean change, 0.92; 95% CI, 0.61 to 1.24 [p < 0.01]), the difference in effect was substantial and statistically significant (mean difference, 0.52; 95% CI, 0.22 to 0.82; p = 0.001). The two versions showed comparable longitudinal validity. A standardized version of the CRQ dyspnea domain improves the cross-sectional validity, maintains longitudinal validity, but reduces the responsiveness. By increasing sample size, investigators can use the more efficient standardized version of the CRQ without compromising validity.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                08 March 2017
                : 12
                : 813-815
                [1 ]Respiratory Division, ICS MAUGERI SPA SB, Institute of Cassano Murge (BA) IRCCS, Italy
                [2 ]Respiratory Rehabilitation Division, ICS MAUGERI SPA SB, Institute of Lumezzane (BS) IRCCS, Italy
                [3 ]Scientific Direction, ICS MAUGERI SPA SB, Institute of Pavia, IRCCS, Italy
                [4 ]Respiratory Rehabilitation Division, ICS MAUGERI SPA SB, Institute of Tradate (VA) IRCCS, Italy
                [5 ]Respiratory Diseases Unit, University of Insubria, Varese
                [6 ]Psychology Unit, ICS MAUGERI SPA SB, Institute of Tradate (VA) IRCCS, Italy
                Author notes
                Correspondence: Mauro Carone, Via per Mercadante km 2, 70010 Cassano delle Murge (BA), Italy, Email mauro.carone@
                © 2017 Carone et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.


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