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RehabMeasures Instrument

Lower Extremity Functional Scale

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Purpose

The test can be used to evaluate the impairment of a patient with lower extremity musculoskeletal condition or disorders. Can be used clinically to measure the patients’ initial function, ongoing progress, and outcome as well as to set functional goals.

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Instrument Details

Acronym LEFS

Area of Assessment

Activities of Daily Living
Balance – Non-vestibular
Coordination
Functional Mobility
Life Participation
Occupational Performance
Quality of Life
Range of Motion
Strength

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Stroke Recovery

Key Descriptions

  • Questionnaire containing 20 questions about a person’s ability to perform everyday tasks.
  • Scoring scale 0-80.
  • All 20 items are scored with a maximum score 4 for each item.
  • The columns on the scale are summed to obtain a final score.
  • Patients are provided with 20-item instrument on paper and instructed to indicate their current level of difficulty with each activity.

Number of Items

20

Time to Administer

5 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jonathan Weinhold, SPT; Bradley Basch, SPT; Laura Good, SPT; Susan Kokot, SPT; Dylan Elliott, SPT; Devin DeGreif, CSCS, SPT; Ramiro Garrido, SPT, MHS; Bradley Matthews, SPT; Kelsey Nix, SPT; Brittany Boehnke, SPT; Danielle Overcash, SPT, and Rebecca Schuck, SPT in July 21, 2013

Body Part

Lower Extremity

ICF Domain

Activity

Measurement Domain

Motor

Professional Association Recommendation

TKA/THA due to OA:

(Stratford et al, 2010)

  • The general recommendation is to utilize a combination of self-report and performance measures incorporating essential and diverse functional activities to better encapsulate the change over time post arthroplasty

 

Stroke:

(Verheijde et al, 2013)

  • In rehabilitation of patients with subacute stroke the LEFS is shown to be a clinically efficient outcome measure

Considerations

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Joint Pain and Fractures

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Standard Error of Measurement (SEM)

ACL Reconstruction:

(Alcock et al, 2012; n = 25 participants after ACL surgery, with 10 women, in the test-retest reliability sample)

  • SEM = 3.7 points

 

Various Lower Extremity Injuries:

(Binkley et al, 1999; n = 107 patients with hip, thigh, knee, leg, ankle and foot injuries)

  • SEM = 3.9 points

 

Total Knee Anthroplasty and Total Hip Anthroplasty (TKA and THA):

(Stratford et al, 2000; n = 40 patients with TKA; n = 33 patients with THA)

  • SEM = 3.7 points

 

Orthopaedic Rehab Ward:

(Young et al, 2009; n = 91 subjects with a primary complaint of neck pain and with or without concomitant upper extremity symptoms)

  • SEM = 4 points

Minimal Detectable Change (MDC)

ACL Reconstruction:

(Alcock et al, 2012; n = 45 total participants after ACL surgery; 28 men, mean age = 29.4 years; 17 women, mean age = 29 years)

  • MDC = 8.7 points

 

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • MDC = 9 points

 

Hip Impairment:

(Wang et al, 2009; n = 8714 people who had hip impairments)

  • MDC = 7 points or 11.3%

 

TKA and THA:

(Stratford et al, 2000)

  • MDC = 9 points

Minimally Clinically Important Difference (MCID)

ACL Reconstruction:

(Alcock et al, 2012)

  • MCID = 9 points

 

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • MCID = 9 points

 

Hip Impairment:

(Wang et al, 2009)

  • MCID = 6 points or 11.3%

 

TKA and THA:

(Stratford et al, 2000)

  • MCID = 9 points

Normative Data

ACL Reconstruction:

(Alcock et al, 2012)

  • LEFS scores can be used to predict functional recovery after surgery with rapid improvements 7 to 8 weeks post with slower improvements after. Improvement adheres to bone and soft tissue healing as well as a regain of muscle inhibition secondary to decreased swelling and pain. An example of such a prediction would be at 16 weeks where the predicted LEFS score is 63 out of 80. It is speculated that further treatment could overcome any remaining deficits

Test/Retest Reliability

ACL Reconstruction:

(Alcock et al, 2012)

  • The mean (SD) LEFS scores for the test and retest assessments were 50.6 (11.6) and 51.0 (12.5)

 

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • Excellent test-retest reliability for the entire sample (= 0.86; 95% lower limit CI = 0.80), and for the subset of patients with more chronic conditions (= 0.94; 95% lower limit CI = 0.89)

 

Total Knee Arthoplasty (TKA):

(Kennedy et al, 2008)

  • Excellent test-retest reliability (intraclass correlation coefficient, type 2,1) for the LEFS derived from a sample of patients following arthroplasty (r = 0.85)

 

TKA and THA:

(Stratford et al, 2009)

  • Excellent test-retest reliability (r = 0.85)

 

TKA/THA due to OA:

(Stratford et al, 2010)

  • Excellent test-retest reliability for entire sample (= 0.86), and more chronic conditions (r = 0.94)

 

Self Report/Performance Measures:

(Stratford et al, 2003; n = 93 total patients who are awaiting or received TKA or THA, mean age = 63.2 (11.3), 46 females and 47 males)

  • Excellent test-retest reliability in sample-dependent range (r = 0.85 to 0.94)

Interrater/Intrarater Reliability

ACL Reconstruction:

(Alcock et al, 2012)

  • Excellent interrater reliability (ICC = .90)

 

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • Excellent interrater reliability (r = 0.84)

 

TKA/THA due to OA:

(Stratford et al, 2010)

  • Excellent interrater reliability (r = 0.84)

 

Internal Consistency

Ankle Fractures:

(Lin et al, 2009; n = 306 participants with ankle fracture were recruited within 7 days of cast removal)

  • Excellent reliability coefficient at baseline (alpha = 0.92)
  • Excellent reliability coefficient at short-term follow up (alpha = 0.94)
  • Excellent reliability coefficient at long-term follow up (alpha = 0.90)

 

Hip impairments:

(Hart et al, 2005)

  • Excellent reliability coefficient (alpha = 0.96)

Criterion Validity (Predictive/Concurrent)

THA:

(Domzalski et al, 2010; n = 128 high functioning hip anthroplasty patients)

  • The ASAP (Activity Scale for Arthroplasty Patients) demonstrated strong concurrent validity with the LEFS with both identified factors (activity, running and running related environments): The Pearson product correlation (concurrent validity) between the summated LEFS score was 0.77 (P < .01) for the activities factor of the ASAP and 0.31 (P < .01) for the running and running- related environment aspect of the ASAP

 

Ankle Fractures:

(Lin et al, 2009)

  • Concurrent validity of the Lower Extremity Functional Scale was excellent compared with the Olerud Mo- lander Ankle Score at the short- and medium-term follow-ups (r = 0.80 and 0.87, respectively). The correlation with walking speed and stepping rate on stairs was moderate at the short-term follow-up (r = 0.61 and 0.63, respectively) but poor at the medium-term follow-up (r = 0.24 and 0.39, respectively)

Construct Validity

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • Excellent correlations between the LEFS scores and the SF-36 physical function subscale and physical component summary scores (r = 0.80; 95% lower limit CI=.73) and (r = 0.64; 95% lower limit CI = 0.54)
  • Poor correlation between the LEFS scores and the SF-36 mental component summary scores (= 0.30; 95% lower limit CI = 0.14)

 

THA:

(Domzalski et al, 2010)

  • Excellent correlation between the ASAP AUC and LEFS AUC (r = 0.769 and r = 0.723)

 

Ankle Fractures:

(Lin et al, 2009)

  • To assess construct validity, the variance in activity limitation explained by the Lower Extremity Functional Scale was analyzed using principal components analysis of the residuals generated by the Rasch analysis using WINSTEPS software. High construct validity of the Lower Extremity Functional Scale was demonstrated using Rasch analysis. At all time points, the scale explained a high variance in activity limitation. All items of the scale had a positive correlation with the overall scale

Self Report/Performance Measures:

(Stratford et al, 2003; n = 93 patients with osteoarthritis in hip or knee; mean age = 63.2 (11.3))

  • Composite performance score based on time, pain, and exertion: 0.44 (composite timed score) to 0.59 (pooled domain and activity score) when correlating the LEFS with single and multiple activity domain scores.

 

TKA:

(Stratford et al, 2004; n = 102 patients with hip or knee osteoarthritis undergoing total joint replacement within 16 days or over 20 days after the first postoperative assessment)

 

 

WOMAC Pain

WOMAC Physical Function

Preoperative

0.64

0.85

Postoperative follow up 1

0.59

0.76

Postoperative follow up 2

0.58

0.78

Floor/Ceiling Effects

Various Lower Extremity Injuries:

(Binkley et al, 1999)

  • Excellent no ceiling or floor effect associated with the LEFS in this patient population

 

THA:

(Domzalski et al, 2010)

  • Adequate when for every item, at least 88% of the participants selected either “no difficulty” or “a little bit of difficulty,” suggesting ceiling effects of the LEFS for this population. In many of the younger, more active patients this instrument failed to measure progressive patient report of improvements at 6 months to 1 year and beyond

 

Ankle Fractures:

(Lin et al, 2009)

  • Excellent no participant scored the lowest possible score at baseline or follow up, indicating no floor effect
  • Adequate the LEFS did not have a ceiling effect at short term follow up, but was close at medium-term follow up (14% scored the highest possible score, close to the 15% cut off)

Responsiveness

Ankle Fractures:

(Lin et al, 2009)

  • The LEFS was responsive in the short-term, but it is still uncertain whether it is in the medium term. Responsiveness in the medium term warrants further validation. Although the mean area under the ROC curve showed that the Lower Extremity Functional Scale had high external responsiveness, the 95% confidence interval included values below 0.70, suggesting uncertainty.

 

Measure

Short - term follow-up (Baseline - 4 wk)

Medium - term follow up (Baseline - 24 wk)

 

Internal Responsiveness

 

Effect Size

1.92 (Large change)

3.33 (Large change)

Standardized Response Mean

1.91

2.95

 

External Responsiveness

 

Guyatt Responsiveness Ratio

1.99

1.74

Area Under the ROC Curve

0.79 (95% CI = 0.70 - 0.88)

0.84 (95% CI = 0.57 - 1.10)

 

TKA:

(Stratford et al, 2004)

  • Standardized Response Mean: Preoperative to first postoperative interval: -0.68 (n = 102). First postoperative to second postoperative interval: 1.62 (n = 102)
  • Moderate effect size (first postoperative follow up = 0.73)
  • Large effect size (second postoperative follow up = 1.76)

Osteoarthritis

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Standard Error of Measurement (SEM)

Hip Osteoarthritis (OA):

(Pua et al, 2009; n = 100 adults with symptomatic hip OA)

  • SEM = 5.3 points

 

Orthopaedic Rehab Ward:

(Young et al, 2009; n = 91 subjects with a primary complaint of neck pain and with or without concomitant upper extremity symptoms)

  • SEM = 4 points

Minimal Detectable Change (MDC)

Lower Extremity Osteoarthritis:

(Kennedy et al, 2007)

  • MDC = 9 points

 

Hip Osteoarthritis:

(Pua et al, 2009)

  • MDC = 9.9 points

Test/Retest Reliability

Hip Osteoarthritis:

(Pua et al, 2009)

  • Excellent test-retest reliability (r = 0.86)

Interrater/Intrarater Reliability

Hip Osteoarthritis:

(Pua et al, 2009)

  • Excellent interrater reliability (r = 0.84)

Internal Consistency

Hip Osteoarthritis:

(Pua et al, 2009)

  • Excellent reliability coefficient (alpha = 0.92)

Construct Validity

Hip Osteoarthritis:

(Pua et al, 2009)

  • Pearson coefficients and one way analysis of variance, compared with SF-36, showed to be more sensitive to change

Stroke

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Test/Retest Reliability

Stroke:

(Verheijde et al, 2013; n = 43 individuals receiving neurorehabilitation for lower extremity dysfunction after stroke; age range = 32 to 95 years; mean age = 70) Excellent test-retest reliability (ICC = 0.96)

Criterion Validity (Predictive/Concurrent)

Stroke:

(Verheijde et al, 2013)

  • Adequate to Excellent correlation between the LEFS and the Short Form 36 Function Scale, Berg Balance Scale, Six Minute Walk Test, Five Meter Walk Test, Timed Up and Go Test, and the LAS of function (r = 0.40 - 0.71)

Responsiveness

Stroke:

(Verheijde et al, 2013)

  • From baseline to studies end increased 1.2 standard deviations

Chronic Pain

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Standard Error of Measurement (SEM)

Orthopaedic Rehab Ward:

(Young et al, 2009; n = 91 subjects with a primary complaint of neck pain and with or without concomitant upper extremity symptoms)

  • SEM = 4 points

Test/Retest Reliability

Orthopaedic Rehab Ward:

(Young et al, 2009)

  • Excellent test-retest reliability (ICC = 0.88)

Responsiveness

Orthopaedic Rehab Ward:

(Yeung et al, 2009)

  • The SRM of the LEFS from admission to discharge was 1.76 on patients rated as improved

Bibliography

Alcock, G. K., Werstine, M. S., et al. (2012). "Longitudinal changes in the lower extremity functional scale after anterior cruciate ligament reconstructive surgery." Clin J Sport Med 22(3): 234-239. Find it on PubMed

Binkley, J. M., Stratford, P. W., et al. (1999). "The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network." Phys Ther 79(4): 371-383. Find it on PubMed

Domzalski, T., Cook, C., et al. (2010). "Activity scale for arthroplasty patients after total hip arthroplasty." J Arthroplasty 25(1): 152-157. Find it on PubMed

Hart, D. L., Mioduski, J. E., et al. (2005). "Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments." Journal of clinical epidemiology 58(6): 629-638.

Kennedy, D. M., Stratford, P. W., et al. (2008). "Assessing recovery and establishing prognosis following total knee arthroplasty." Phys Ther 88(1): 22-32. Find it on PubMed

Lin, C. W., Moseley, A. M., et al. (2009). "The lower extremity functional scale has good clinimetric properties in people with ankle fracture." Phys Ther 89(6): 580-588. Find it on PubMed

Pua, Y. H., Cowan, S. M., et al. (2009). "The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale." J Clin Epidemiol 62(10): 1103-1111. Find it on PubMed

Stratford, P. W., Binkley, J. M., et al. (2000). "Feature Articles-Validation of the LEFS on patients with total joint arthroplasty." Physiotherapy Canada 52(2): 97-105.

Stratford, P. W., Kennedy, D., et al. (2003). "The relationship between self-report and performance-related measures: questioning the content validity of timed tests." Arthritis Rheum 49(4): 535-540. Find it on PubMed

Stratford, P. W., Kennedy, D. M., et al. (2004). "Condition-specific Western Ontario McMaster Osteoarthritis Index was not superior to region-specific Lower Extremity Functional Scale at detecting change." J Clin Epidemiol 57(10): 1025-1032. Find it on PubMed

Stratford, P. W., Kennedy, D. M., et al. (2009). "New study design evaluated the validity of measures to assess change after hip or knee arthroplasty." J Clin Epidemiol 62(3): 347-352. Find it on PubMed

Stratford, P. W., Kennedy, D. M., et al. (2010). "Quantifying self-report measures' overestimation of mobility scores postarthroplasty." Phys Ther 90(9): 1288-1296. Find it on PubMed

Verheijde, J. L., White, F., et al. (2013). "Reliability, Validity, and Sensitivity to Change of the Lower Extremity Functional Scale in Individuals Affected by Stroke." PM R. Find it on PubMed

Wang, Y. C., Hart, D. L., et al. (2009). "Clinical interpretation of a lower-extremity functional scale-derived computerized adaptive test." Phys Ther 89(9): 957-968. Find it on PubMed

Yeung, T. S., Wessel, J., et al. (2009). "Reliability, validity, and responsiveness of the lower extremity functional scale for inpatients of an orthopaedic rehabilitation ward." J Orthop Sports Phys Ther 39(6): 468-477. Find it on PubMed

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