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RehabMeasures Instrument

London Handicap Scale

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Purpose

Measures health status in patients with chronic, multiple, or progressive diseases, including evaluation of interventions deployed treatment

Link to Instrument

Instrument Details

Acronym LHS

Area of Assessment

Activities of Daily Living
Functional Mobility
Life Participation
Occupational Performance
Quality of Life
Social Relationships

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Multiple Sclerosis
  • Stroke Recovery

Key Descriptions

  • Scale generates a profile of handicaps on 6 different dimensions:
    1) Mobility
    2) Physical independence
    3) Occupation
    4) Social integration
    5) Orientation
    6) Economic self-sufficiency

    Each dimension has six levels, arranged in order of increasing disadvantage.
    Equal item weights result in roughly the same score as empirically derived weights (Jenkinson et al, 2000; Harwood and Ebrahim, 2000)
  • The 6 dimensions generate an overall handicap severity score.
  • Each dimension has 6 levels, arranged in order of increasing disadvantage:
    1) No disadvantage
    2) Minimal disadvantage
    3) Mild disadvantage
    4) Moderate disadvantage
    5) Severe disadvantage
    6) Most severe disadvantage
  • Equal item weights result in roughly the same score as empirically derived weights (Jenkinson et al., 2000; Harwood & Ebrahim, 2000).

Number of Items

6

Equipment Required

  • Depends on the scoring method employed (see Jenkinson et al, 2000):
  • Traditional scoring methods require a computer with software capable of statistical analysis.
  • A modified scoring version has also been used that requires no special equipment.

Time to Administer

5-10 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Reviewed by Isabel Garcia, COTA, MOTS, DOTS.

ICF Domain

Participation

Measurement Domain

Activities of Daily Living
General Health
Motor

Considerations

  • Use caution when assessing changes as part of a clinical assessment; the LHS is intended for between group comparisons.
  • Responses to self-report questions may differ depending upon whether older persons respond to what they actually do (performance) versus what they feel they are capable of doing (capable) (Dubuc et al., 2004).

Stroke

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Normative Data

Acute Stroke: (Hershkovitz et al., 2004; n = 207; mean age for men 71 (7) and women 69 (10) years; assessed 4 to 12 weeks post stroke)

Measure

Mean Admit(SD)

Mean Disch (SD)

LHS total

11.29 (5.53)

8.88 (5.53)

FIM

100.30 (10.58)

104.25 (10.23)

Nottingham Index

22.35 (12.22) 

32.18 (14.71)

Get Up and Go

27.8 (27.93) 

17.44 (19.28)

Acute Stroke: (Jenkinson et al., 2000, n = 323, mean age = 74 (11) years)

  • Mean score = 63.9 (SD 16.4, range 15.3–100)

Chronic Stroke: (Gall et al., 2009; n = 351; mean age = 75 (14) years; assessed 5 years post stroke)

  • Mean (SD) The London Handicap Scale (LHS); 73 (21), range; LHS range 16 – 100.

Test/Retest Reliability

Chronic Stroke: (Harwood et al., 1994; n = 89; mean age - 71; mailed survey 12 months post-stroke)

  • Excellent agreement between assessments (approximately 2 weeks apart; mean difference between assessments = 0.01; SD = 0.09)

  • Excellent correlation between assessments (= 0.91)

Internal Consistency

Acute Stroke: 

(Jenkinson et al., 2000; n = 323; mean age = 74 (11) years)

  • Excellent internal consistency (Cronbach’s alpha = 0.83)

(Chau et al., 2009; n = 188; mean age = 71.7 (10.2) years)

  • Excellent internal consistency (Cronbach's alpha = 0.80) at 12 months post stroke.

Criterion Validity (Predictive/Concurrent)

Chronic Stroke: Concurrent Validity (Harwood et al., 1994)

  • Adequate correlation with the Barthel Index (= 0.56)

  • Excellent correlation with the Nottingham Extended Activities for Daily Living total score (r = 0.69)

  • Excellent to Adequate correlation with the Nottingham Extended Activities for Daily Living (Subscales) - Mobility = 0.66), Kitchen (r = 0.52), Domestic (r = 0.62), Leisure (= 0.64)

  • Adequate correlation with the Nottingham Health Profile total score (r = -0.42)

  • Adequate  to poor correlation with the Nottingham Health Profile (subscales) - Physical mobility (r = -0.52), Energy (= -0.36), Pain (r = -0.31), Social isolation (= -0.30), Emotion (= -0.28), Sleep (r = -0.19)

  • Adequate correlation with the Geriatric Depression Scale (r = -0.42)

Acute Stroke: (Hershkovitz et al., 2004) Predictive Validity; LHS discharge and Admission Scores  

  • Adequate correlation with the FIM (= -0.522; p < 0.001)

  • Adequate correlation with the Nottingham Index (r = -0.458; p < 0.001)

  • Adequate correlation with the Timed Get Up and Go (r = 0.350; p = .002)

Construct Validity

Chronic Stroke: (Jenkinson et al., 2000)

Measure

LHS

Correlation Strength

Frenchay activities index

0.76*

Excellent

Barthel ADL index

0.73*

Excellent

HAD-anxiety

−0.33*

Adequate

HAD-depression

−0.56*

Adequate

*p < 0.0001

 

 

  • Excellent correlations with the Barthel at 3 months (r = 0.8) and 12 months (r = 0.7) post stroke (Strum et al, 2002).

Community Dwelling: Chronic-Stroke: (Kutlay et al., 2010)

Measure

LHS

Correlation Strength

WHO Disability Assessment Scale II - WHODAS-II

0.92

Excellent

FIM – Motor Scale

0.79

Excellent

FIM – Cognitive Scale

0.68

Excellent

Community Dwelling: Chronic-Stroke: (Cardol et al., 2001); 5 Diagnostic Groups – Respectively, neuromuscular disease, stroke, spinal cord injury (SCI), rheumatoid arthritis, or fibromyalgia; Discriminant Validity

  • Correlations between all domains of the IPAQ and the domains “economic self-sufficiency” and “orientation” (LHS) were poor (range, r= -.01 to -.29), demonstrating discriminant validity.

Content Validity

The LHS is based on the ICIDH classification of Disablement developed by the World Health Organization (WHO).

Face Validity

Goonetilleke (1995) reports acceptable face validity.

Responsiveness

Acute Stroke: (Harwood & Ebrahim, 2000; n = 76; re-tested on 37; mean age = 83 years; day hospital patients)

The LHS was more sensitive in measuring day hospital outcomes than the Barthel Index

Multiple Sclerosis

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Responsiveness

Adequate responsiveness for inpatient rehabilitation for multiple sclerosis (Freeman et al., 1997).

Joint Pain and Fractures

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Responsiveness

Adequate responsiveness for the scale after hip and knee replacement (Harwood & Ebrahim, 1995)

Older Adults and Geriatric Care

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Criterion Validity (Predictive/Concurrent)

Community Dwelling Adults: (Dubuc et al., 2004) Concurrent Validity

  • Excellent correlation between the LHS and the Late-Life Function and Disability Instrument's (LLFDI) disability limitation (r = 0.66; p < 0.0001)

  • Adequate correlation between the LHS and and Disability frequency (r = 0.47, p < 0.001) scores.

Floor/Ceiling Effects

Community Dwelling Adults: (Dubuc at al., 2004)

  • Poor ceiling effects were observed for the LHS (31%).

Responsiveness

Medically Ill Elderly: (Shah et al., 2000; 6–8 months follow-up)

  • Only the LHS scores (p = 0.024) independently predicted mortality*

*Association between low LHS scores and mortality is consistent with previous reports.

Pediatric Disorders

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Normative Data

Very Preterm Birth and/or Very Low Birth Weight – Transition into Adulthood: (Lunenburg et al., 2013; assessed at 19 years and 28 years of age, n = 314 for participants age 19; n=957 for participants age 28).

Measure

Mean Outcome (SD)

#MI Outcome (SD)

Health Utilities Index 3

(Multi Attribute Utility)

19y = 0.89 (0.16)

28y = 0.88 (0.16)

19y = 0.83 (0.22)

28y = 0.85 (0.20)

London Handicap Scale (Utility)

19y = 96.5 (8.3)

28y = 95.9 (8.0)

19y = 93.9 (12.4)

28y = 94.6 (9.8)

# MI: After multiple imputation.

Responsiveness

Young Adults with Disabilities: (Van Dommelen et al., 2014).

  • Higher catch-up growth in head circumference (HC) was associated with less disabilities in young adulthood according to the LHS.

Alzheimer's Disease and Progressive Dementia

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Normative Data

Dementia – Parkinsonism Severity: (Coelho et al., 2015; n = 50; mean age = 74.1 (7.0) years; mean duration of disease = 17.94 (6.3) years).

  • Mean (SD) The London Handicap Scale (LHS); 0.33 (0.15).

Criterion Validity (Predictive/Concurrent)

Dementia – Parkinsonism Severity: (Coelho et al., 2015) Predictive Validity; Total LHS Scores

  • Adequate correlation with the Unified Parkinson’s Disease Rating Scale (UPDRS) part I (r = −0.57; p < 0.000)

  • Adequate correlation with the Hoehn & Yahr (H&Y) stage in ‘off’ (r = −0.47; p = 0.001)

Floor/Ceiling Effects

Dementia – Parkinsonism Severity: (Coelho et al., 2014)

  • The scores had a normal distribution and no obvious ceiling or floor effects.

Non-Specific Patient Population

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Cut-Off Scores

  • Maximum score = 1.00 (sum of all “no disadvantage” value is 0.544 + 0.456; indicating normal function)

  • Minimum score = 0.00 (sum of all “most severe disadvantage” value is -0.456 which when added to 0.456; indicating total disability)

Content Validity

The LHS is based on the international classification of impairments, disabilities and handicaps (ICIDH) developed by the World Health Organization (WHO).

Bibliography

Ackerley, S. J., Gordon, H. J., et al. (2009). "Assessment of quality of life and participation within an outpatient rehabilitation setting." Disabil Rehabil 31(11): 906-913. Find it on PubMed

Cardol, M., Haan, R. J., Jong, B. A., Bos, G. A., & Groot, I. J. (2001, March 23). Psychometric properties of the impact on Participation and Autonomy Questionnaire. Archives of Physical Medicine and Rehabilitation, 82(2), 210-216. doi:10.1053/apmr.2001.18218

Chau, J. P., Thompson, D. R., Twinn, S., Chang, A. M., & Woo, J. (2009, September 07). Determinants of participation restriction among community dwelling stroke survivors: A path analysis. BMC Neurology BMC Neurol, 9(1). doi:10.1186/1471-2377-9-49

Coelho, M., Marti, M. J., Sampaio, C., Ferreira, J. J., Valldeoriola, F., Rosa, M. M. and Tolosa, E. (2015), Dementia and severity of parkinsonism determines the handicap of patients in late-stage Parkinson's disease: the Barcelona−Lisbon cohort. Eur J Neurol, 22: 305–312. doi:10.1111/ene.12567

Dubuc, N., Haley, S. M., Pengsheng, N., Kooyoomjian, J. T., & Jette, A. M. (2004). Function and disability in late life: comparison of the Late-Life Function and Disability Instrument to the Short-Form-36 and the London Handicap Scale. Disability & Rehabilitation, 26(6), 362-370.

Freeman, J. A., Langdon, D. W., et al. (1997). "The impact of inpatient rehabilitation on progressive multiple sclerosis." Ann Neurol 42(2): 236-244. Find it on PubMed

Gall, Seana L., Helen M. Dewey, Jonathan W. Sturm, Richard A. L. Macdonell, and Amanda G. Thrift. 2009. Handicap 5 years after stroke in the northeast melbourne stroke incidence study. Cerebrovascular Diseases 27, (2) (02): 123-30.

Goonetilleke, A. (1995). "Validity of the London handicap scale." J Neurol Neurosurg Psychiatry 58(1): 125-126. Find it on PubMed

Harwood, R. and Ebrahim, S. (1995). "Manual of the London handicap scale."

Harwood, R. H. and Ebrahim, S. (2000). "Measuring the outcomes of day hospital attendance: a comparison of the Barthel Index and London Handicap Scale." Clin Rehabil 14(5): 527-531. Find it on PubMed

Harwood, R. H., Gompertz, P., et al. (1994). "Handicap one year after a stroke: validity of a new scale." J Neurol Neurosurg Psychiatry 57(7): 825-829. Find it on PubMed

Hershkovitz, A., Beloosesky, Y., et al. (2004). "Is a day hospital rehabilitation programme associated with reduction of handicap in stroke patients?" Clin Rehabil 18(3): 261-266. Find it on PubMed

Jenkinson, C., Mant, J., et al. (2000). "The London handicap scale: a re-evaluation of its validity using standard scoring and simple summation." J Neurol Neurosurg Psychiatry 68(3): 365-367. Find it on PubMed

Kutlay, Sehim, Ayse Küçükdeveci A., Burcu Yanik, Atilla Elhan, Derya Öztuna, and Alan Tennant. 2011. The interval scaling properties of the london handicap scale: An example from the adaptation of the scale for use in turkey. Clinical rehabilitation 25, (3) (03): 248-55.

Lunenburg, A. V., Pal, S. M., Dommelen, P. V., Karin M Van Der Pal – De Bruin, Gravenhorst, J. B., & Verrips, G. H. (2013, March 26). Changes in quality of life into adulthood after very preterm birth and/or very low birth weight in the Netherlands. Health and Quality of Life Outcomes Health Qual Life Outcomes, 11(1), 51. https://doi.org/10.1186/1477-7525-11-51

Shah, A., Hoxey, K., & Mayadunne, V. (2000, September 29). Some predictors of mortality in acutely medically ill elderly inpatients. International Journal of Geriatric Psychiatry, 15(6), 493-499. doi:10.1002/1099-1166(200006)15:63.0.co;2-e

Sturm, J. W., Dewey, H. M., et al. (2002). "Handicap after stroke: how does it relate to disability, perception of recovery, and stroke subtype?: the north North East Melbourne Stroke Incidence Study (NEMESIS)." Stroke 33(3): 762-768. Find it on PubMed

Van Dommelen P., Sylvia Van Der Pal M., Bennebroek Gravenhorst J, Walther FJ, Wit JM, and Van Der Pal De Bruin, Karin , M. (2014). The effect of early catch-up growth on health and well-being in young adults. Annals of Nutrition & Metabolism 65, (2-3) (11): 220-6.

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