Original Article

http://mjiri.iums.ac.ir
Medical Journal of the Islamic Republic of Iran (MJIRI)
Med J Islam RepubIran. 2017(3 June);31.30. https://doi.org/10.18869/mjiri.31.30

Clinical assessment of activities of daily living in acute

stroke: Validation of the Persian version of Katz Index
Akram Azad1*, Tayyebe Mohammadinezhad1, Ghorban Taghizadeh1, Laleh Lajevardi1

Received: 11 Feb 2016 Published: 3 June 2017

Abstract
Background: Katz Index is a well-known index for assessing basic activities of daily living. The aim was to determine validity and
reliability of the Katz Index in Iranian patients with acute stroke.
Methods: Eighty-seven patients (56 male, 31 female) with acute stroke (1-30 days post-stroke) participated in this psychometric
properties study. Interval time for retest was 14 days. All participants were Iranian with Persian as native language, had no other major
diseases (e.g. cancer, Alzheimer) and no psychiatric disorder. Cognitive mental score of all participants was above 18 (according to
Mini-Mental State Examination). If they had another stroke during the following-up period, they were excluded from the study. Intraclass
Correlation Coefficient (ICC), Standard Error of Measurement (SEM) and Minimum Detectable Change (MDC) were calculated to
investigate the reliability of the KI. Criterion validity of the KI was assessed by Spearman’s Correlation Coefficient (ρ). Moreover,
Confirmatory Factor Analysis (CFA) and Exploratory Factor Analysis (EFA) were performed to investigate the construct validity of the
KI.
Results: Inter-rater and intra-rater reliability of Persian Katz Index were reasonable (ICC2,1=0.93, ICC2,1=0.83; respectively). Internal
consistency of this index was high (cronbach’s alpha=0.79). The high to excellent correlation was found between Katz Index and the
motion (ρ=0.88), self-care (ρ=0.98), and total scores (ρ=0.92) of Barthel Index. Factor analysis of the Persian Katz Index indicated two
factors including motion (bathing, toileting, and transferring) and self-care (dressing, bowel & bladder control, and feeding).
Conclusion: The results of this study suggest that Persian version of Katz Index in patients with acute stroke can be considered as an
acceptable clinical instrument in practice and research.

Keywords: Validation, Katz Index, Acute stroke

Copyright© Iran University of Medical Sciences

Cite this article as: Azad A, Mohammadinezhad T, Taghizadeh Gh, Lajevardi L. Clinical assessment of activities of daily living in acute stroke:
Validation of the Persian version of Katz Index. Med J Islam Repub Iran. 2017(3 June 2017);31:30.
https://doi.org/10.18869/mjiri.31.30

Introduction
Stroke is the adults’ most common condition leading to achieving independence in daily life are named as ADL (4).
sensory-motor defects and disability in activities of daily It describes the patient’s current status in self-care activities
living (ADL) (1). The main focus of health measures is and also is a predictor of the treatment process and out-
ADL (2) and it is related to subjective well-being feeling or comes (5). In recent decades, various tools have been de-
quality of life in patients with stroke (1). Indeed, promotion veloped for functional ability assessment (4,6). The Katz
of ADL independence during rehabilitation is valuable for Index (KI) and Barthel Index (BI) are two primary tests in
a better quality of life in stroke patients (3). the assessment of ADL performance. Katz et al. in 1959
Individuals’ activities aimed at protecting themselves and
______________________________
Corresponding author: Dr Akram Azad, [email protected], [email protected]
↑What is “already known” in this topic:
1.Department of Occupational Therapy, School of Rehabilitation Sciences, Iran Univer- Katz index (KI) is a valid and reliable measure for assessing
sity of Medical Sciences, Tehran, Iran. basic activities of daily living in elderly and patients with cancer.
Moreover, the predictive validity of KI regarding length of hos-
pital stay, discharge to own home or death within one month af-
ter stroke has been investigated.

→What this article adds:

This study, investigated the reliability and validity of KI in acute
stroke patients and showed that Persian version of Katz Index in
patients with acute stroke can be considered as an acceptable
clinical instrument in practice and research.
Validation of Persian version of Katz Index in acute stroke

developed KI based on theories of human development, ac- Methods

tivities, and anthropologic hierarchies. It is an important Participants
and useful tool in the prediction of fall incidences and com- In this methodological research, eighty-seven patients
plications, mortality/ morbidity, length of hospital stay and (56 male, 31 female) by mean age of 61 yrs. (range: 40-80
discharge, necessity of health services and institutionaliza- yrs.) were recruited from neurological clinics and rehabili-
tion, and functional status of non-institutionalized commu- tation centers of Iran University of Medical Sciences by the
nity-dwelling in post-stroke patients (2,6,7). The reliability simple non-probability method. Inclusion criteria were:
of KI has been well documented. Also, it has an adequate passing maximum one month from the last stroke (based on
and acceptable validity in assessing basic ADL especially physician's diagnosis) (15), being Iranian with Persian as
in patients hospitalized for the first time (2). In addition, it native language, not having other major diseases (e.g. can-
is adopted in clinical decision making and health status im- cer, Alzheimer and dementia) or no known psychiatric dis-
provement (4). Although, BI is frequently used as a prog- order (based on physician's diagnosis), not having cognitive
nosis indicator in hospital and long-term care units, KI ap- impairment (i.e. obtaining a score equal or higher than 18
plications mostly include detecting subtle changes in health on Mini-Mental State Examination) (16). Patients were ex-
status and functional deterioration in severe diseases in cluded from the study if they had another stroke during the
long term as well as assessing the social adaptation of pa- follow-up period or did not wish to continue participating
tients with different diseases (e.g. older adults, stroke, po- in the study. All patients/ primary caregiver signed written
liomyelitis, rheumatoid arthritis and hip fracture). In addi- informed consent to participate in this study. Two experi-
tion, it is adaptable to most clinical conditions especially enced occupational therapists performed the test through
chronic ones with high incidence such as cardiovascular observation and face-to-face interviews with patients or pri-
diseases (2,4,6). KI is simple, inexpensive and reliable in mary caregivers. The time interval between test and retest
practice and clinic (4,8). This Index creates a common lan- was 14 days (1,8). The study protocol was approved by the
guage about changes of patients function between all ther- Ethics Committee of Iranian University of Medical Sci-
apist and clinicians involved in overall care and discharge ences.
planning (9,10). Validation of KI has been investigated in
several studies (2,4,8). Eloah et al. (2015) surveyed the val- Translation of KI
idation of KI in two groups including patients with and The International Quality Of Life Assessment method
without cognitive impairment and reported the mean (17) was used to translate and adapt this questionnaire from
cronbach's alpha (α) of 0.96 for the first group and 0.97 for the original English version to Persian language version.
the second group (11). In 2013, investigation of KI in Greek First of all, permission license for KI translation was taken
individuals with cancer showed excellent reliability from “Oxford University Press” (License Number
(cronbach's α was 0.88) and satisfactory validity (12). Nas- 2975190407921). Forward translation from the original
ser and Doumit (2009) studied the validity and reliability of English version to Persian was done by two native Persian
Arabic version of KI in elderly older than 60 years and re- speaker, independently. Then, the primary Persian form of
ported the cronbach's α of 0.9 for the first three subscales KI was provided by translators and researchers. The back-
(i.e. bathing, dressing and going to the toilet) and 0.65 for ward translation from Persian to English was done by two
second three subscales (i.e. mobility, continence and feed- native English language translators, separately. Finally, this
ing) (13). Spanish version of KI in old people showed ex- questionnaire was checked by the expert committee includ-
cellent reliability (2). Reijneveld et al. (2006) assessed the ing translators and authors, and the final version of this in-
reliability and validity of Turkish KI in Turkey, Moroccan strument was provided.
and Dutch elderly and showed good internal consistencies
for each group (cronbach's α: 0.84-0.94) and reasonable cri- Measurements
terion validity (14). Katz Index (KI): This Index has two versions: original
KI has been originally developed for evaluating the basic version with seven items and modified new version with six
ADL in elderly (7). Alizadeh-Khoei et al. (2013) translated items (18). The new version (used in this study) contains
this index in Persian language and validated it in Iranian six basic functional tasks: bathing, dressing, toileting,
elderly population with cancer (8). This study has found transferring, bowel & bladder control, and feeding (7). KI
that the KI is a reliable and valid instrument for evaluating as a Guttman-type scale presents items in a hierarchy of se-
basic ADL in patients with cancer. However, considering verity or difficulty of performing each task. Scoring of each
the different underlying pathologies in patients with stroke item of this instrument includes independence [1] and de-
compared to those with cancer, the results of Alizadeh- pendence [0]. Independence is defined as performing these
Khoei et al. study cannot be directly applied to patients with tasks without supervision, guidance or personal assistance
stroke. Moreover, investigating the validity and reliability while dependence is defined as doing the tasks with super-
of this frequently used index in stroke patients allows com- vision, guidance or personal assistance. Total KI score is in
parison of the results with other pathologies and studies. the range of 0 to 6 which score of 6 represents an independ-
Therefore, the purpose of the present study was to examine ent patient and 0 indicates a very dependent one (10,19).
inter and intra-rater and internal consistency reliability, cri- Completing this test lasts less than 5 minutes (2,14).
teria and construct validity of the Persian version of KI in Barthel Index (BI): This Index has satisfactory psycho-
patients with acute stroke. metric properties in stroke patients (20). It evaluates de-

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2 Med J Islam Repub Iran. 2017 (3 June); 31:30.
 A. Azad, et al.

pendence/ independence of functional ability 10 items in- Results

cluding bowels, bladder, toilet use, bathing, dressing, Descriptive Statistics: No case was omitted from the
grooming, feeding (as self-care items); and transfer (bed to analyses due to the missing data. The mean age of partici-
chair and back), mobility, stair up and down (as motion pants was 61 (SD=12.46) years. The score of Mini-Mental
items). Four point increments are used in scoring Status Examination was 18 to 26 (mean±SD=20.9±2.84).
[0,5,10,15], with total score between 0 (dependent bed-rid- Minimum and maximum numbers of medications per day
den state), and 100 (fully independent in physical function- were 1 and 5; respectively. Seventy-five participants
ing). Scores of self-care items and motion items, as well as (86.2%) took their medications in the morning. Table 1 il-
total sore of BI, were used in this survey. It takes approxi- lustrates the detailed participants’ descriptive data. The
mately 5-10 minutes to be completed (2,8). Validation of mean (SD) total score of KI for motion, self-care and, total
this tool has been studied in Iranian people (20). scores of BI were 3.66 (1.99), 29.12 (14.23), 41.9. (17.26),
and 67.87 (29.74), respectively. The result of Kolmogorov-
Procedure Smirnov showed that total scores of KI and BI have no nor-
To investigate the inter-rater reliability of the KI, all sam- mal distribution (p<0.001).
ples were assessed by two experienced raters in one session Reliability: Inter-rater reliability for total score of KI
(21). To determine the intra-rater reliability of the KI, all items indicated excellent reliability (ICC2,1=0.93, p<0.001,
subjects in the first assessment were evaluated in the second 95%CI: 0.89-0.95). The SEM, SEM%, MDC, and MDC%
assessment (i.e. 14 days later) by one experiencedrater. Re- values were 0.51, 13.8%, 1.42, and 38.2%; respectively. In-
sults of first assessment of the first rater were used to ex- tra-rater reliability of total items indicated excellent relia-
amine the internal consistency reliability, criterion and con- bility (ICC2.1=0.83, p<0.001, 95%CI: 0.70-0.90). The
struct validity. In order to examine the criterion and con- SEM, SEM%, MDC, and MDC% values were 0.79, 20.3%,
struct validity of the KI, BI and factor analysis was used; 2.19, and 56.3%; respectively.
respectively. Internal consistency of the total score in Persian KI was
good (cronbach’s α=0.79). The range of cronbach's α with
Statistical Analysis deletions of each item was 0.77 to 0.85. Correlation be-
Normal distribution of data was tested by Kolmogorov- tween each item of Persian KI and its total score was 0.48-
Smirnov test. Inter-rater reliability and intra-rater reliability 0.88 (Table 2). The ceiling and floor effects of Persian KI
for total item of KI were calculated by Intraclass Correla- were 28.74% and 5.75%; respectively.
tion Coefficients (ICC2,1) (22). The ICC value≥0.8 and be- Validity: Criterion validity was calculated by evaluating
tween 0.6-0.8 indicates excellent and moderate reliability; the correlation between Persian KI and BI. An excellent
respectively (23). Standard Error of Measurement (SEM), correlation (ρ=0.92, p<0.001) was found. Also, there were
SEM%, Minimum Detectable Change (MDC) and MDC%
were calculated for both of inter-rater & intra-rater reliabil- Table 1.Characteristics of study participants
ity with the following formula: SEM=SD and Variable Number %
Gender
MDC=SEM √2 1.96 (24). Internal consistency was Male 56 64.4
assessed using cronbach's α coefficient (α). The minimum Female 31 35.6
acceptable value for α was 0.7 (23). Ceiling and floor ef- Education level
fects are described as the number of patients obtaining the Under diploma 60 69
Diploma 19 21.8
highest and lowest possible scores on the used test; respec- Collage 8 9.2
tively. Ceiling/ floor effects less than 15% are generally Family status
considered acceptable (25,26). Criterion validity was as- Single 7 8
sessed by measuring the correlation between Persian KI Married 67 77
Widow/divorce 13 15
scores and BI (Self-care/ Motion) using Spearman’s Corre- Living arrangement
lation Coefficient (ρ). Spearman values between 0.90-1.00 Alone 7 8
indicate excellent correlation (21). Confirmatory Factor With spouse/relative 80 92
Analysis (CFA) and Exploratory Factor Analysis (EFA) High risk factors
Hypertension (from 87 subjects) 44 50.6
with Varimax rotation were conducted to investigate the Cholesterol (from 87 subjects) 22 25.3
construct validity of the Persian KI version (23). In order to Diabetes (from 87 subjects) 21 24.1
investigate the goodness-of-fit of the model with the given Smoking (from 87 subjects) 12 13.8
dataset, several model fit indices and their criteria were Poly pharmacy≥4 (from 87 subjects) 78 89.7
Use assistive devise
used including Goodness-of-Fit Index (GFI), Adjusted Yes 35 40.2
Goodness-of-Fit Index (AGFI), Normed Fit Index (NFI), No 52 59.8
Tucker-Lewis Index (TLI), Comparative Fit Index (CFI), Rehab service
and Root Mean Square Error of Approximation (RMSEA). Yes 37 42.5
No 50 57.5
EFA and CFA were conducted with SPSS for Windows Number of stroke
(version 13.0) and AMOS (version 24.0); respectively. The 1 67 77.1
level of statistical significance were considered at P- 2 18 20.7
value<0.005. 3 1 1.1
>3 1 1.1

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Med J Islam Repub Iran. 2017 (3 June); 31:30. 3
Validation of Persian version of Katz Index in acute stroke

Table 2. Factor analysis and internal consistency of Persian Katz Index in stroke
Items Mean (SD) Factor Loading Community Cronbach’s α Correlation
Factor 1 Factor 2 If item deleted Item to total
Bathing 0.39 (0.49) 0.80 -0.07 0.68 0.78 0.81
Dressing 0.45 (0.50) 0.43 0.45 0.54 0.81 0.73
Toileting 0.52 (0.50) 0.95 -0.02 0.88 0.77 0.88
Transferring 0.56 (0.50) 0.97 0.10 0.87 0.77 0.84
Bowel & Bladder Control 0.87 (0.33) -0.16 0.95 0.81 0.85 0.48
Feeding 0.86 (0.35) 0.29 0.55 0.51 0.82 0.62
Total 3.66 (1.99) 0.84 1
Eigen value 3.27 1.03

Fig. 1. Results of Confirmatory Factor Analysis of the Persian Katz Index for stroke
(BBC: Bowel & Bladder Control; SC: Self-Care; GFI: Goodness-of-Fit Index; AGFI: Adjusted Goodness-of-Fit Index; NFI: Normed Fit Index,
TLI: Tucker-Lewis Index; CFI: Comparative Fit Index; RMSEA: Root Mean Square Error of Approximation)

an excellent (ρ=0.93) and high (ρ=0.88) correlations be- reliability for total items indicated excellent reliability.
tween the Persian KI with self-care and motion scores of Similarly, Alizadeh-Khoei et al. (8), Mystakidou & Tsilika
BI; respectively. (12), and Alvarez et al. (27) reported excellent intra-rater
Value of the “Kaiser-Meyer-Olkin” measure of sampling reliability with correlation coefficients range of 0.83 to
adequacy used to verify the data set suitability for factor 0.94. A possible explanation for this result might be that the
analysis was 0.713. The “Bartlett’s Test of Sphericity” KI is a large scale measure and it is unlikely that patients
value was significant (‫א‬2=277.63, p<0.001). Two compo- score on this measure change markedly in 14 days interval
nents (Motion: bathing, toileting, transferring; and Self- for a retest (32). Values of the MDC% in total scores of
care: dressing, bowel & bladder control, feeding) were ex- Persian KI for the intra-rater after two weeks and inter-rater
tracted based on Eigen values greater than one (Table 2). were 56.3% and 38.2%; respectively. This implies that for
These components explained 71.65% of the total variance. clinical users, 56.3% and 38.2% or higher change of KI
Two-factor model from the results of this study for CFA is score for intra-rater and inter-rater, indicates that real im-
depicted in Figure 1. The model fit indices were: GFI=0.97, provement has occurred.
AGFI=0.91, NFI=0.76, TLI=0.90, CFI=0.95 and Internal consistency of all items of Persian KI was ac-
RMSEA=0.04. ceptable. Similarly, Alizadeh-Khoei et al. (8) and Mystaki-
dou & Tsilika (12) reported an acceptable internal con-
Discussion sistency in patients with cancer. Other studies such as
The present study assessed the psychometric properties Rodgers & Miller (33) (cronbach’s α=0.89), Sonn (34) (α
of the Persian KI in Iranian patients with acute stroke. Re- range=0.84-0.9), and Spector et al. (35) (α range=0.73-
sults indicated that the Persian KI has excellent reliability 0.78) also stated acceptable internal consistency in all items
and acceptable validity in assessing basic ADL in patients of KI in elderly.
with acute stroke. Results of correlation between each item and total Per-
Reliability: Inter-rater reliability for total score indicated sian KI score indicated a statistically significant associa-
excellent reliability. Similarly, Alvarez et al. (27), Spector tion, but only item 5 (bowel & bladder control) had a rela-
& Takada (28), Hulter Asberg & Sonn (29), and Katz et al. tively low correlation with the total score. The same find-
(10) reported excellent inter-rater reliability. Also, EK et al. ings were observed by Mystakidou & Tsilika (12), Spector
(30) stated moderate to good inter-observer reliability et al. (35) and Spector & Fleischman (36), suggested rea-
(Kappa=0.56), but Brosson & Asberg (31) reported low in- sons for this finding include: shame, fear of mortality, re-
ter-rater reliability. Possible explanation for different re- ceiving another medication or operation, the belief that
sults compared to the results of the current study could be there is no effective remedy, reduction of self-esteem, self-
the different methods used for training the raters. Katz et al. neglect, and feeling of social incompetence (6,37).
(10) explained that the inter-rater reliability was greater af- Validity: Criterion validity was assessed by the associa-
ter tool training in the scoring of each item. Another possi- tion of the Persian KI and motion, self-care and total score
ble reason for this result may be cultural differences such of BI; asignificant correlation was found. Results demon-
as the concepts of shame and religious beliefs. Intra-rater strated that higher Katz scores were associated with better

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4 Med J Islam Repub Iran. 2017 (3 June); 31:30.
 A. Azad, et al.

motion and good mobility. In other words, it showed that Conclusion

KI could be a good criteria measure in predicting mobility In conclusion, the Persian version of KI is a reliable and
problem of stroke patients. Also, the results demonstrated valid clinical instrument for assessing the ADL among Ira-
higher total KI score was correlated with independence in nian acute stroke patients.
self-care activities. Similarly, Harting et al. (38), Wade &
Hewer (39), and Gresham et al. (40) have reported a high Acknowledgements
correlation between KI and BI. We would like to appreciate all patients and their families
The criteria of the various model fit indices were consid- for their co-operation. The authors are also grateful to Dr.
ered to discuss the model fit of CFA. It has been proposed Anita Emrani, Ph.D. for the kind assistance and insightful
that RMSEA values less than 0.05 are good, values between comments in English language editing of this article.
0.05 and 0.08 are acceptable, values between 0.08 and 0.1
are marginal, and values greater than 0.1 are poor (41). Conflict of Interests
Therefore, the RMSEA value of 0.04 in this study shows a The authors declare that they have no competing inter-
good fit. The GFI as well as AGFI value of 0.9 or over in- ests.
dicates a good fit. So, the GFI value of 0.97 and AGFI value
of 0.91 in this sample indicates a good fit of the model (42).
References
Also, CFI value of 0.95 shows a good fit (43). NFI and TLI 1. Hsueh IP, Wang CH, Liou TH, Lin CH, Hsieh CL. Test-retest reliabil-
should be equal or over 0.9 for a good fit (43), but in this ity and validity of the comprehensive activities of daily living measure
study, the NFI is little below the criteria. Based on these in patients with stroke. J Rehabil Med. 2012;44(8):637-41.
indices, this sample has a good fit to the 2-factor model. 2. Cabanero-Martınez MJ, Cabrero-Garcıa J, Richart-Matinez M,
Munoz-Mendoza CL. The Spanish versions of the Barthel Index (BI)
The factor analysis of Persian KI in stroke patients depicted and the Katz Index (KI) of activities of daily living (ADL): A structured
two major factors, including Motion (bathing, toileting, review. Arch Gerontol Geriatr. 2009;49(1):e77-e84.
transferring) and Self-care (dressing, bowel & bladder con- 3. Fawcus R. Stroke rehabilitation: A collaborative approach. UK: Black-
trol, feeding). Also, a strong correlation was observed be- well Science Ltd; 2008.pp.80-8.
4. Hartigan I. A comparative review of the Katz ADL and the Barthel
tween the items and the two extracted components. Simi- Index in assessing the activities of daily living of older people. Intern J
larly, Alizadeh-Khoei et al. (8) found two factors in elderly Older People Nurs. 2007;2(3):204-12.
subjects with cancer. Since culture significantly affects 5. Indsay P, Bayley M, Hellings C, Hill M, Woodbury E, Phillips S. Ca-
daily activities of living through its important role in shap- nadian best practice recommendations for stroke care. Canada Med As-
soc J. 2008;179(12):S1-25.
ing our behavior, cultural norms and values (44), the similar 6. Cohen ME, Marino RJ. The tools of disability outcomes research func-
extracted factor in the current study and the study of Aliza- tional status measures. Arch Phys Med Rehabil. 2000;81(12):S21-9.
deh-Khoei et al. may be explained by the fact that both stud- 7. Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of
ies were conducted in Iranian subjects. Mystakidou & the Index of ADL. Gerontologist. 1970;10(1):20-30.
8. Alizadeh-Khoei M, Akbar ME, Sharifi F, Fakharzadeh H, Larijani B.
Tsilika (12), Spector & Fleischman (36), and Kempen & Translation and validation of the activities of daily living scale with
Surrmeijer (45) reported one factor, while Cumming et al. Iranian elderly cancer patients treated in an oncology unit. Asian Pacific
(46) and Fitzgerlad et al. (47) have reported three factors. J Cancer Prevention (APJCP). 2013;14(5):2731-7.
The KI factors found in this study is consistent with the 9. Wallace M, Shelkey M. Katz Index of independence in activity of daily
living. Assisted Living Consult. 2008;108(4):21-2.
conceptual framework of this measure that assesses motion 10. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies
and self-care of activity daily living. of illness in the aged: The Index of ADL: A standardized measure of
The result of this study indicated that the KI have a ceil- biological and psychosocial functions. J Am Med Assoc.
ing effect in the assessment of ADL in acute stroke patients. 1963;185(12):914-9.
11. Eloah R, Alencar M. Validity of the Katz Index to assess activities of
Ceiling effect means that some patients obtain the highest daily living by informants in neuropath logical studies. Rev Esc Enferm
score with the used test (25,48). If the test items are not USP. 2015;49(6):944-50.
challenging enough for some individuals due to inappropri- 12. Mystakidou K, Tsilika E, Parpa E, Mitropoulou E, Galanos A,
ate item selection or a limited number of difficult items, Gouliamos A. Activities of daily living in Greek cancer patients treated
in a palliative care unit. Support Care Cancer. 2013;21(1):97-105.
ceiling effects will occur (25,49,50). Since most of the 13. Nasser R, Doumit J. Validity and reliability of the Arabic version of
participants in this study have the ability to walk inde- activities of daily living. BMC Geriatr. 2009;9:11.
pendently, with or without assistive devices, therefore the 14. Reijneveld AC, Spijker J, Dijkshoorn H. Katz’ ADL Index assessed
items of KI may be not challenging enough for these pa- functional performance of Turkish, Moroccan and Dutch elderly. J Clin
Epidemiol. 2007;60(4):382-8. .
tients. Another possible explanation for this result may be 15. Bouffioulx E, Amould C, Vandevelde L, Thonnard JL. Change in
the small number of items in KI (51). satisfaction with activities and participation between acute, post-acute,
A number of limitations need to be noted regarding the and chronic stroke phases: A responsiveness study of the SATIS-stroke
present study. The convenience sampling method may limit questionnaire. J Rehabil Med. 2010;42(10):944-8.
16. Schmid AA, Rittman M. Consequences of post stroke falls: Activity
the generalization of the results of this study. Given the limitation, increased dependence, and the development of fear of fall-
ceiling effect of the KI, as observed in this study, further ing. AJOT. 2009;63(3):310-16.
studies to investigate the ceiling effect of KI in patients 17. Aaronson NK, Acquadre C, Alonso J, Apolone G, Bucquet D, Bull-
with stroke is warranted. Moreover, the type of stroke was inger M, et al. International quality of life assessment (IQOLA) project.
Quality Life Res. 1992;1:349-51.
not considered in the current study which is recommended 18. Westergren A, Karlsson S, Andersson P, Ohlsson O, Hallberg IR.
to be addressed in future investigations. Eating difficulties, need for assisted eating, nutritional status and pres-
sure ulcers in patients admitted for stroke. J Clin Nurs. 2001;10(2):257-
69.
19. Patricia P. Measures of adult general functional status. Arthritis Care
http://mjiri.iums.ac.ir
Med J Islam Repub Iran. 2017 (3 June); 31:30. 5
Validation of Persian version of Katz Index in acute stroke

Res. 2003;49:15-27. 46. Cumming SM, Neff JA, Ban H. Functional impairment as a predictor
20. Oveisgharan S, Shirani S, Ghorbani A, Soltanzade A, Baghaei A, of depressive symptomatology: The role of race, religiosity and social
Hosseni S, et al. Barthel Index in a Middle-East country: Translation, support. Health Soc Work. 2003;28(1):23-32.
validity and reliability. Cerebrovasc Dis. 2006;22(5-6):350-4. 47. Fitzgerlad JF, Smith DM, Martin DK, Freedman JA, Wolinsky FD.
21. Domholdt E. Rehabilitation research: Principles and applications. 3rd Replication of the multidimensionality of activities of daily living. J
ed. Philadelphia: Saunders; 2005.pp.274-6. Gerontol. 1993;48(1):S28-31.
22. Shrout PE, Fleiss JL. Intraclass Correlations: Uses in Assessing Rater 48. Trewee CB, Bot SD, de Boer MR, van der Windt DA, Dekker J,
Reliability. Psychol Bull. 1979;86(2):420-8. Bouter LM, et al. Quality criteria were proposed fof measurement prop-
23. Hsueh I, Lee M, Hsieh, C. Psychometric characteristics of the erties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-
Barthel: Activities of daily living Index in stroke patients. J Formo Med 42.
Assoc. 2001;100(8):526-32. 49. MCHorney CA, Tarlor AR. Individual-patient monitoring in clinical
24. Chou CY, Chien CW, Hsueh IP, Sheu CF, Wang CH, Hsieh CL. De- practice: Are available health status surveys adequate? Qual Life Res.
veloping a short from of the Berg Balance Scale for people with stroke. 1995;4(4):293-307.
J Phys Ther. 2006;86(2):195-204. 50. Lai SM, Perea S, Duncan PW, Bode R. Physical and social function-
25. Hamilton DF, Giesinger IM, MacDonald DJ, Simpson AH, Howie ing after stroke: Comparison of the stroke impact scale and short form-
CR, Giesinger K. Responsiveness and ceiling effects of the forgotten 36. Stroke. 2003;34(2):488-93.
joint score-12 following total his arthroplasty. Bone Joint Res. 51. Zhaeentan S, Legeby M, Ahlstrom S, Stark A, Salomonsson B. A
2016;5(3):87-91. validation of the Swedish version of the WORC index in the assessment
26. Justicia-Grande AS, Pardo-Seco J, Cebey-Lopez M, Vilanovar-Tril- of patients treated by surgery for subacromial disease including rotator
lol, Gomez-Carballa A, Rivero-Calle I, et al. Development and valida- cuff syndrome. BMC Muscuskeletal Disorders. 2016;17:165-73.
tion of a new clinical scale for infant with acute respivatory infection:
The ReSVinet Scale. PLOS. ONE. 2016:1-15. DOI:10-1371.
27. Alvarez M, Alaiz AT, Bru E, Cabaneros JJ, Calzon M, Cosio I, et al.
Capacidad funcional de pacientes mayores de 65 anos, segunel Indice
de Katz. Fiabilidad delmetodo. Aten. Primaria. 1992;10:812-16. (Ab-
stract in English).
28. Spector WD, Takada HA. Characteristics of nursing homes that resi-
dent outcome. J Aging Health. 1991;3(4):427-54.
29. Hulter-Asberg K, Sonn U. The cumulative structure of personal and
instrumental ADL. Scand J Rehabil Med 1989;21(4):171-7.
30. Ek AC, Unosson M, Larsson J, Ganowiak W. Inter-rater variability
in subjective nutritional assessment of elderly patients. Scand J Caring
Sci. 1996;10(3):163-8.
31. Brorsson B, Asberg, KH. Katz Index of independence in ADL. Reli-
ability and validity in short-term care. Scand J Rehabil Med.
1984;16(3):125-32.
32. Salavati M, Mazaheri M, Negahban H, Ebrahimi I, Jafari AH,
Kazemnjad A, et al. Effect of dual-tasking on postural control in sub-
jects with nonspecific low back pain. Spine. 2009;34(13):1415-21.
33. Rodger W, Miller B. A Comparative analysis of ADL questions in
survey of older people. J Gerontol B. 1997;52B(Special Issue):21-36.
34. Sonn U. Longitudinal studies of dependence in daily life activities
among elderly persons. Scand J Rehabil Med Suppl. 1996;34:1-35.
35. Spector WD, Katz S., Murphy JB., Fulton JP. The hierarchical rela-
tionship between activities of daily living and instrumental activities of
daily living. J Chronic Dis. 1987;40(6):481-9.
36. Spector WD, Fleischman JA. Combining activities of daily living
with instrumental activities of daily living to measure functional disa-
bility. J Gerontol. 1998;53(1):S46-57.
37. Wilson MM. Urinary incontinence: A treatise on gender, sexuality
and culture. Clin Geriatric Med. 2004;20(3):565-70.
38. Harting MT, Engle VF. Geraney MJ. Accuracy of nurse aides' func-
tional health assessment of nursing home residents. J Gerontol.
1997;52A(3):M142-8.
39. Wade D, Hewer R. Motor loss and swallowing difficulty after stroke:
Frequency, recovery and prognosis. Acta Neurol Scand.
1987;76(10):50-4.
40. Gersham GE, Phillips TF, Labi ML. ADL statues in stroke: Relative
merits of three standard indexes. Arch Phy Med Rehabil.
1980;61(8):355-8.
41. Fabrigar LR, MacCallum RC, Wegener DT, Strahan EJ. Evaluating
the use of exploratory factor analysis in psychological research. Psy-
chological Methods. 1999;4(3):272-99.
42. Mulaik SA, James LR, Van Alstine J, Bennett N, Lind S, Stilwell CD.
Evaluation of goodness-of-fit indices for structural equation models.
Psychological Bulletin. 1989;105(3):430-45.
43. Bentler PM. Comparative fit indexes in structural models. Psycho-
logical Bulletin. 1990;107(2):238-46.
44. Arik G, Varan HD, Yavuz BB, Karabulut E, Kara O, Kilic MK, Ki-
zilarslanoglu MC, et al. Validation of Katz Index of independence in
activities of daily living in Turkish older adults. Arch Gerontol Geriatr.
2015;61(3):344-50.
45. Kempen GI, Surrmeijer TP. The development of a hierarchical poly-
chotomous ADL-IADL scale for non-institutionalized elders. J Geron-
tol. 1990;30(4):497-502.

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