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      The Barthel index-dyspnea: a new two-dimensional dyspnea scale

      1 , 2 , 3

      International Journal of Chronic Obstructive Pulmonary Disease

      Dove Medical Press

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          Dear editor Clinical evaluation tools have been widely used in assessing the baseline status, treatment response, and prognosis for patients with chronic respiratory diseases and mostly for patients with chronic obstructive pulmonary disease (COPD).1 By factor analysis, multiple domains of disease entities involve dyspnea, psychological status, health-related quality of life, and sensation or perception of dyspnea,2 wherein dyspnea is commonly evaluated by dyspnea scales such as Medical Research Council (MRC), Baseline Dyspnea Index, Oxygen-Cost Diagram, St George Respiratory Questionnaire activity domain, and Chronic Respiratory Disease Questionnaire dyspnea domain (CRQ-dyspnea).2 These scales describe the subjects’ capability to perform at various levels of motor activity or functional status influenced or even limited by dyspnea. Indeed, exercise capacity is quantified; however, dyspnea is not. In our experience, the exertional dyspnea scales had better correlations with exercise performances (|r|=0.29–0.65) than dyspnea sensation intensity (|r|=0.06–0.55) and better correlation with walking (|r|=0.5–0.65) than peak exercise (|r|=0.29–0.39). Recently, Vitacca et al addressed daily activities and dyspnea sensation intensity simultaneously in exertional dyspnea scale.3 They have successfully developed a new dyspnea scale by integrating ten daily life activities of Barthel index and five categories of dyspnea sensation intensity.3 The new scale was reported to be reliable, sensitive, and adequate as a tool for measuring the level of dyspnea while performing daily life activities and the responsiveness after treatment. The new dyspnea scale is two-dimensional and conceptually agrees with multidimensional dyspnea profile.4 There are some similarities between the Barthel index-dyspnea and the CRQ-dyspnea,5 which was not discussed in Vitacca’s report. The CRQ-dyspnea encompasses five items regarding exertional dyspnea part that the subject experienced during the last 2 weeks. The five items regarding activities of 26 listed activities in which the patient experiences dyspnea during day-to-day activities were selected by the research subjects as they considered these were the most important activities. The subject indicated the degree of dyspnea from grade 1 (extremely short of breath) to grade 7 (not at all short of breath) he or she had had. The five activity items were selected by the subjects’ own volition, thereby being their most important activities but varying from one subject to another. In contrast, the ten daily activities of Barthel index are listed as a format, thereby probably some selected items not being their important activities but being more consistent in the subjects’ daily activities during follow-up. Barthel index-dyspnea and CRQ-dyspnea scales simultaneously use categories to describe dyspnea sensation intensity, although the categories are different. In Vitacca’s report, Barthel index-dyspnea has strong concurrent validity with 6-minute walk test and MRC. Since 6-minute walk test and MRC are a submaximum exercise test and exercise capacity oriented scale, respectively, comparison of the utility of Barthel index-dyspnea scale with CRQ-dyspnea scale or with other quality of life questionnaires is enthusiastically anticipated in the future study. Additionally, the exercise intensity of daily activity of Barthel index is very mild-to-mild. This might be hard to extrapolate Barthel index-dyspnea scale to the subjects who have mild severity in chronic respiratory diseases as only 8.1% of study population were mild COPD in their study. Finally, magnitude of uncertainty was not quantified in Vitacca’s report. Providing the confidence interval of correlation coefficient would be helpful for the readers.

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          Reliability and validity of the multidimensional dyspnea profile.

          Most measures of dyspnea assess a single aspect (intensity or distress) of the symptom. We developed the Multidimensional Dyspnea Profile (MDP) to measure qualities and intensities of the sensory dimension and components of the affective dimension. The MDP is not indexed to a particular activity and can be applied at rest, during exertion, or during clinical care. We report on the development and testing of the MDP in patients with a variety of acute and chronic cardiopulmonary conditions. One hundred fifty-one adults admitted to the ED with breathing symptoms completed the MDP three times in the ED, twice at least 1 h apart (T1, T2), and near discharge from the ED (T3). Measures were repeated in 68 patients twice in a follow-up session 4 to 6 weeks later (T4-T5). The ED sample was 56% men with a mean age of 53 ± 15 years; the follow-up sample was similar. Factor analysis resulted in a two-factor solution with a total explained variance of 63%, 74%, and 72% at T1, T2, and T3, respectively. One domain related to primary sensory qualities and immediate unpleasantness, and the second encompassed emotional response. For the two domains, Cronbach α ranged from 0.82 to 0.95, and the intraclass correlation coefficient ranged from 0.91 to 0.98. Repeated-measures analysis was significant for change (T1, T3, T4), showing responsiveness to change in MDP domains with treatment (F([2,66]) = 19.67, P > .001). These analyses support the reliability, validity, and responsiveness to clinical change of the MDP with two domains in an acute care and follow-up setting.
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            Development of a Barthel Index based on dyspnea for patients with respiratory diseases

            Background As Barthel Index (BI) quantifies motor impairment but not breathlessness, the use of only this index could underestimate disability in chronic respiratory disease (CRD). To our knowledge, no study evaluates both motor and respiratory disability in CRD during activities of daily living (ADLs) simultaneously and with a unique tool. The objective of this study was to propose for patients with CRD an additional tool for dyspnea assessment during ADLs based on BI items named Barthel Index dyspnea. Methods Comprehensibility, reliability, internal consistency, validity, responsiveness, and ability to differentiate between disease groups were assessed on 219 subjects through an observational study performed in an in-hospital rehabilitation setting. Results Good comprehensibility, high reliability (interrater intraclass correlation coefficient was 0.93 [95% confidence interval 0.892–0.964] and test–retest intraclass correlation coefficient was 0.99 [95% confidence interval 0.983–0.994]), good internal consistency (Cronbach’s alpha 0.89), strong concurrent validity with 6 minute walking distance (Pearson r=−0.538, P<0.001) and Medical Research Council (Spearman r S=0.70, P<0.001), good responsiveness after rehabilitation (P<0.001), and good appropriateness of the index were found evidencing patients with different dyspnea severity. Divergent validity showed weak correlation (Pearson r=−0.38) comparing Barthel Index dyspnea and BI. Conclusion The BI based on dyspnea perception proved to be reliable, sensitive, and adequate as a tool for measuring the level of dyspnea perceived in performing basic daily living activities. A unique instrument simultaneously administered may provide a global assessment of disability during ADLs incorporating both motor and respiratory aspects.

              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
              03 August 2016
              : 11
              : 1843-1844
              [1 ]Division of Pulmonary Medicine, Department of Internal Medicine
              [2 ]Department of Critical Care Medicine, Chung Shan Medical University Hospital
              [3 ]School of Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
              Author notes
              Correspondence: Ming-Lung Chuang, Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, No 110, Section 1, Chien-Kuo North Road, South District, Taichung 40201, Taiwan, Republic of China, Tel +886 4 2473 9595 ext 34718, Fax +886 4 2473 9220, Email yuan1007@
              © 2016 Chuang. 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.


              Respiratory medicine


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