Measuring handicap: the London Handicap Scale, a new outcome measure for chronic disease

Factors associated with strain in co-resident spouses of patients following stroke

OBJECTIVE

To identify the factors associated with carer strain following stroke.

DESIGN

Co-resident spouses of stroke patients were sent questionnaire measures of their perceptions of strain, stress, mood, handicap, adjustment, social support, life satisfaction and personality, and patient's mood and independence in activities of daily living.

SETTING

Stroke spouses were identified from the stroke register at City Hospital, Nottingham.

RESULTS

In a sample of 222 carers, 37% had significant strain. Strain was highly correlated with negative affectivity on the Positive and Negative Affectivity Scale, carer mood on the General Health Questionnaire-12 (GHQ-12) and carer's perceptions of patient's independence in activities of daily living on the Extended Activities of Daily Living Scale (EADL). Logistic regression analysis of 96 of these carers supported the correlations and showed three factors, carer GHQ-12, patient EADL and negative affectivity, were independently associated with carer strain.

CONCLUSION

The relationship between these factors and strain needs to be tested prospectively. Early identification of carers who may be at risk of strain later on will enable services to be targeted at prevention rather than cure.

Measuring psychosocial recovery after traumatic brain injury: psychometric properties of a new scale

OBJECTIVES

To determine the psychometric properties of the Sydney Psychosocial Reintegration Scale (SPRS), an instrument developed to quantify disability and handicap in persons with traumatic brain injury (TBI).

DESIGN

Descriptive correlational study.

SETTING

Brain Injury Rehabilitation Unit and Brain Injury Outpatient Clinic.

PARTICIPANTS

Two samples, a "subacute" group (n = 20) and a "long-term" group (n = 40), were studied to examine responsiveness (subacute group), reliability, and validity (long-term group) of the SPRS.

MAIN OUTCOME MEASURE

The SPRS is a 12-item questionnaire measuring three domains of everyday living commonly disrupted after severe TBI: occupational activities, interpersonal relationships, and independent living skills.

PROCEDURE

Patients in the subacute group were rated with the SPRS by a clinician at admission to the rehabilitation unit and again three months later or at discharge from the unit (whichever occurred first). For individuals from the long-term group attending the outpatient clinic, a close relative was interviewed with the SPRS and other validating measures. The SPRS was readministered one month later.

RESULTS

Internal consistency of the SPRS was high (alpha coefficient = .90), as was agreement between raters and stability over a one-month period (r(i) = .95 and .90, respectively). Reliability and stability coefficients for the three domains of the scale were also high, ranging from.86 to.94 for reliability and.77 to.93 for stability. Preliminary evidence for construct validity was established with a number of standard instruments, with evidence of both convergent and discriminant construct validity from the Sickness Impact Profile (SIP). The SPRS was sensitive to group differences on the Glasgow Outcome Scale (GOS) and to changes occurring during the period of active recovery.

CONCLUSIONS

The results suggest that the SPRS has sound psychometric properties, being a reliable, stable, sensitive, and valid instrument. It is potentially useful in both clinical and research settings.

A multidimensional assessment of multiple sclerosis: relationships between disability domains

OBJECTIVE

To test the feasibility of a multidimensional assessment based on both task-related and self-evaluation questionnaire scores in patients with multiple sclerosis (MS); ii) to correlate the results from selective measures with the severity of illness in terms of the Expanded Disability Status Scale (EDSS) score; iii) to assess the relationships between different domains of MS-related disability and handicap.

PATIENTS AND METHODS

Eighty-three MS patients (M/F 31/52; age 43.26 +/- 10.9 years, range 21-72) underwent a standard clinical evaluation of motor abilities (by means of the Rivermead Mobility index, Timed Walking Test, Nine Hole Peg test and Hauser Ambulation Index) and cognitive performances (using Digit Symbol, Buschke-Fuld selective remind test, "FAS"-Word Fluency, Wisconsin Card Sorting test and Block design test). The Beck Depression inventory, MS Specific Fatigue Scale, Functional Assessment of MS and London Handicap Scale were applied to evaluate mood, fatigue, quality of life and handicap, respectively. Minimal Record of Disability measures - MRD (i.e. EDSS, Inability Status Scale and Environmental Status Scale) were also applied to test the criterion validity of the selected disability and handicap scales. The Kruskal-Wallis H-test for independent samples tested differences between subgroups with an increasing EDSS score (<3.5, 3.5-6.0, >6.0). The covariance and redundancy of measures included in the multidimensional assessment were evaluated through Factor Analysis. The Multiple Regression Analysis was used to detect the relative impact of either motor or cognitive disabilities and depression on handicap and quality of life.

RESULTS

The multimodal assessment took 70 min on average to be performed, being well accepted by patients. Motor abilities worsened as the EDSS score rose, unlike cognitive performances which proved to be similarly impaired at different severity levels. Measures of fatigue and depression were not related to EDSS values. The chosen measures were assigned by Factor Analysis to 4 domains corresponding to motor performance, executive performance, cognitive abilities and quality of life, respectively. Regression analysis showed how handicap and depression independently affect quality of life. While the handicap score is mostly influenced by motor ability, as measured by the Rivermead Mobility Index, the depression score grows independently of any physical or cognitive disability and seems to be related to fatigue self-assessment scores.

CONCLUSIONS

A multidimensional approach to MS patient assessment allows a more detailed and sensitive evaluation of their disability profile and perceived difficulties, leading to a care programme tailored to the patient's needs.

Measuring handicap in multiple sclerosis

Handicap, shortly to be renamed participation, is a well defined though somewhat neglected entity which addresses an important aspect of the impact disease has on the individual. It is particularly relevant in Multiple Sclerosis (MS) which has such a major impact on issues such as employment, relationships, transport and social integration. Few validated measuring tools exist, and the generic London Handicap Scale is probably the best currently available but is only appropriate for group comparison. Handicap should be monitored in MS and is particularly appropriate in the evaluation of rehabilitation strategies.

Rehabilitation needs of community stroke patients

PURPOSE

The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided.

METHOD

Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed.

RESULTS

Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27% with severe mobility problems and 47% with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occurred in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided.

CONCLUSION

There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.

Measuring progress and outcome in community rehabilitation after brain injury with a new assessment instrument--the BICRO-39 scales. Brain Injury Community Rehabilitation Outcome

OBJECTIVE

Construction and validation of a new instrument, the Brain Injury Community Rehabilitation Outcome scales, to assess problems experienced by brain-injured patients living in the community.

DESIGN

Seventy-six items describing aspects of personal and social functioning were generated. Two hundred thirty-five patients and/or their carers (separately) rated the items on 6-point scales, and patients retrospectively rated their functioning before injury. Seven scales were derived from factor analysis; one was included a priori. Thirty-nine items with high factor loadings were retained. Test-retest reliability, interrater reliability, and construct validity were examined in subsamples.

SETTING

Patients were recruited from four centers: two community-based teams, a day-patient clinic, and an outpatient clinic.

PATIENTS

Of the patients, 127 had traumatic brain injury, 72 had cerebrovascular accidents, 15 had multiple sclerosis, and 21 had acquired brain injury of other origins. Mean time since brain injury was 2.6 years; mean age was 43 years; 164 were men and 71 were women.

RESULTS

All scales showed good test-retest reliability, and agreement between patient and carer ratings was moderate to high. They showed predicted moderate correlations with other relevant scales. Postinjury scores differed significantly from preinjury scores, and 6 of the 8 scales showed change over a period of recovery/rehabilitation.

CONCLUSIONS

The scales appear reliable and easy to complete. They may have utility as quantitative measures of outcome for clinical and treatment evaluations.

Reliability of stroke patients' reports on rehabilitation services received

OBJECTIVE

To compare stroke patients' reports with service providers' reports on the rehabilitation services patients receive.

SETTING

Community, predominantly urban.

SUBJECTS

Ninety-three stroke patients who had not been admitted to hospital.

METHOD

Between August 1994 and August 1996, 54 general practitioner practices in Nottingham (population 344 200) were requested to notify the Nottingham Community Stroke Project of all cases of stroke. Patients were visited one month after stroke and asked to report on whether they had received any hospital, social, community or voluntary services. Some departments were contacted and asked if the patients were known to them and whether they had been seen.

RESULTS

Patients reported having little contact with hospital or social services. Comparison of patients' reports with that of the appropriate service department showed poor agreement for community care assistants (kappa = 0.18), fair agreement for social workers (kappa = 0.59), speech therapy (kappa = 0.48), hospital outpatient appointments (kappa = 0.55) and admissions to hospital (kappa = 0.48) and good agreement for social services occupational therapists (kappa = 0.64).

CONCLUSION

Stroke patients' and service providers' reports on rehabilitation services may not always agree. Care should be taken when interpreting information on service provision.

Stroke services in general practice--are they satisfactory?

BACKGROUND

The contribution of general practice and primary care teams to stroke care has received surprisingly little attention despite research evidence on the importance of coordinated care.

AIM

To determine general practitioners' (GPs') and their patients' satisfaction with hospital and community services for stroke patients in Grampian Region, Scotland.

METHOD

A questionnaire survey of 138 stroke patients and their GPs was carried out six weeks after each patient was discharged home between June 1995 and January 1996. Outcomes measured were GP and patient satisfaction with services, Barthel Index, Hospital Anxiety and Depression scores, London Handicap Score, and Homsat and Hospsat scores (satisfaction with stroke services).

RESULTS

Response rates of 95% (131) for GPs and 91% (125) for patients were obtained. GPs and patients were generally satisfied with services. Stroke patients were more likely to have had contact with their GP than with any other service. Adverse comments from GPs focused on problems with hospital discharge letters. At six weeks, patients received an average of 2.5 community services and 1.5 hospital services, but there was wide variation across disability groups.

CONCLUSIONS

Levels of satisfaction were high, but the wide range and variation in services used by patients emphasized the complexity of the primary care of stroke patients; the need for coordination, review and effective links with hospital; and the key role of the GP.

Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome?

OBJECTIVES

To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke.

DESIGN

Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index.

SETTING

South east London.

SUBJECTS

People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years.

INTERVENTIONS

Observational study.

MAIN OUTCOME MEASURES

Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures.

RESULTS

One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826.

CONCLUSIONS

The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains.

Determinants of handicap 1 and 3 years after a stroke

A total of 361 consecutive admissions to hospital with acute stroke were followed up to examine the determinants of handicap 1 year and 2-3 years later. Handicap was measured using the London Handicap Scale, and data were collected on initial stroke severity, disability, mood and sociodemographic variables. Ninety-five of 170 survivors returned handicap questionnaires at 1 year, 102 of 149 survivors at 2-3 years, and 58 on both occasions. Mean handicap score decreased slightly between 1 and 2-3 years (45-48 on a 0-100 scale, 95% confidence interval for difference -1 to +7, p = 0.09). At both 1 and 2-3 years handicap was associated with pre-stroke disability, 1-year score disability, initial stroke severity and mood. Age and sex were associated at 1 year but not at 2-3 years. In multivariate analyses disability, stroke severity and mood were independently associated with handicap. None of the variables examined predicted change in handicap score. The study demonstrates the overriding importance of stroke severity (impairment) and disability in determining handicap. In comparison, social variables were less important.

Can we achieve accountability for long-term outcomes?

OBJECTIVE

To explore options for the development of a set of indicators to assess the long-term outcomes achieved by all people with a given disabling condition in a given population.

DATA SOURCES

The review draws on empirical studies of predictive indicators, theoretical literature on long-term recovery processes, and literature from administrative science on the use of indicators in accountability systems.

STUDY SELECTION

Studies were selected that explicitly sought to relate short-term and long-term outcomes or that explored the mediating factors in the relationship between impairment, disability, and handicap.

DATA EXTRACTION

The focus of the review is on (1) empirical evidence of the relationship between short- and long-term outcomes, particularly in causal claims, and (2) theoretical analyses of the factors that mediate this relationship.

DATA SYNTHESIS

Evidence is presented that certain outcome states can be considered thresholds that make the outcome usable and, hence, sustainable or that create the opportunity for further improvement. Such thresholds could meet the construct validity criteria necessary for measures that are to be used as indicators in an accountability system. The interaction between psychological and physical factors in setting thresholds means that both objective and subjective indicators are required in an indicator system.

CONCLUSIONS

It may well be possible to develop a parsimonious set of population-based outcome indicators for people with disabilities. The key safeguards required are construct validity and the involvement of people with disabilities in both the development and use of the indicators.

Outcomes-based research in neurorehabilitation: the need for multidisciplinary team involvement

There is a need for the evaluation of neurorehabilitation to reflect the integrated multidisciplinary input which is fundamental to the intervention process. The importance of multidisciplinary involvement in achieving this is discussed with particular reference to multiple sclerosis, which exemplifies the many problems inherent in chronic neurological disease that must be addressed in the evaluation of the rehabilitation programme. Some of the current difficulties of research in this specialty are raised, and suggestions made for the future.

Rehabilitation medicine

The nature of rehabilitation medicine is outlined in terms of its objectives, its methods, the patient groups which it seeks to help and its relationships to other specialties. Some major advances of recent years are discussed, such as the development of the impairment/disability/handicap framework. With particular emphasis upon neurological rehabilitation, the breadth of the specialty is then illustrated with examples of current preoccupations. These include recovery patterns of the damaged nervous system, testing the efficacy of existing therapies, applying new treatment techniques and developing quantitative measures of disability and handicap. Looking to the future, some key areas are identified where further advances might be sought.

Clinical and public health perspectives and applications of health-related quality of life measurement

Health-related quality of life (HRQL) measures have been developed from the utilitarian ethical perspective of public health medicine which may be contrasted with individual-centered indicators; these emphasise the unique experience of a patient. The impairment-disability-handicap framework provides a more complete description of disease consequences and health outcomes than a generic HRQL indicator. The assessment of reliability and validity of HRQL indicators is often carried out inappropriately: population repeatability is measured when an indicator will be used to examine changes in individuals; between observer variation may be large compared with variation between populations. Content and construct validity are usually measured but the more important predictive validity is neglected. Effect sizes of HRQL indicators are likely to be inflated by use of between subject estimates of variance but the more appropriate within subject variance is seldom reported. HRQL indicators are of very limited value for many clinical and public health tasks: monitoring health of individuals and populations; evaluating the effects of health and social policy; allocating resources; evaluating the effects of treatment. Alternative methods of assessment derived from the impairment-disability-handicap conceptual framework are preferable.