London Chest Activity of Daily Living Scale
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London Chest Activity of Daily Living Scale

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Purpose

The London Chest Activity of Daily Living (LCADL) scale is a patient-reported questionnaire that assesses the level of dyspnea during daily activities including self-care, household activities (domestic), physical activity, and leisure activities.

Link to Instrument

Instrument Available in Appendix

Acronym LCADL

Area of Assessment

Activities of Daily Living

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Actual Cost

$0.00

CDE Status

Not a CDE as of 5/9/22

Populations

Cardiovascular Disease
Spinal Injuries
Pulmonary Diseases

Key Descriptions

  • Patient-reported outcome measure, which can be self-administered or administered as a patient interview
  • Contains 15 items grouped into four domains: self-care, household activities (domestic), physical, and leisure activities
  • Responses for each item range from 0-5, with 0 indicating “wouldn't do anyway”, 1-4 representing degree of breathlessness and 5 representing the greatest difficulty with performing ADL (someone else completes)
  • Responses to items 1-15 are added; the total score can range from 0 to 75 points, with higher scores indicating greater functional limitation
  • The score 0 can reduce the total LCADL raw score and overestimate functional status, so a LCADL % total score may be used
  • Item 16 refers to the client’s overall perception of how breathing impacts ADL performance which needs to be answered “A lot,” “A little,” or “Not at all.”

Number of Items

15 items

Self-Care (4 items), Domestic (6 items), Physical Activity (2 items), Leisure (3 items), Overall Breathing (1 item)

Equipment Required

  • Paper/pencil

Time to Administer

5-15 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Su Choe-Baek, MS, OTR/L, Lauren Raschen, MS, OTR/L, Brocha Stern, PhD, MOT, OTR/L at New York University

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living

Considerations

  • Gender and age may affect the activity engagement and performance in different domains
  • Home environment or living conditions can affect the outcome measures
  • Changes of social support or caregiver availability may influence the outcome.
  • Individual’s cultural background needs to be considered.

Pulmonary Diseases

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Standard Error of Measurement (SEM)

Chronic Obstructive Pulmonary Disorder (COPD): (Bisca et al., 2014; n = 40 (20 male, 20 female); mean (SD) age: 66 (7) years; moderate COPD (n = 13), severe COPD (n = 17), very severe COPD (n = 10); 3-month high-intensity exercise program performed; Brazilian sample)

  • SEM for LCADL total: 1.40
    • SEM for self-care domain: 0.32
    • SEM for domestic domain: 0.94
    • SEM for physical activity domain: 0.16
    • SEM for leisure domain: 0.21

Minimal Detectable Change (MDC)

COPD: (Bisca et al., 2014)

  • MDC for LCADL total: 3.88
    • MDC for self-care domain: 0.89
    • MDC for domestic domain: 2.60
    • MDC for physical activity domain: 0.44
    • MDC for leisure domain: 0.58

Minimally Clinically Important Difference (MCID)

COPD: (Almedia Gulart et al., 2020, n = 77 (47 male, 30 female); mean (SD) age = 64 (9) years; Brazilian sample)

  • MID range for LCADL total: - 2.13 to - 5.90; cut-off for MID of -3 points (AUC = 0.66; 51% sensitivity, 82% specificity)
  • MID range for LCDAL %total: - 1.79 to - 4.96; cut-off for MID of -4 points (AUC = 0.70; 56% sensitivity, 82% specificity)

Cut-Off Scores

Moderate to severe COPD: (Belo et al., 2019; Sample 1: n = 138 (71 male, 67 female); mean age (SD) for men = 68 (10); mean age (SD) for women = 65 (7); used to develop cut-off point / Sample 2: n = 70 (57% male, 43% female); mean age (SD) = 67 (7); used to test cutoff point validity; Brazilian sample)

  • The cut-off point of 37% was identified in Sample 1 (AUC = 0.70, sensitivity = 0.56 and specificity = 0.74)
  • Subjects in Sample 2 who scored ≥ 37% of LCADL obtained a higher BODE index classification (body mass index, airflow obstruction, dyspnea and exercise)

COPD: (Gulart et al., 2020; n = 61 (47 male, 14 female); mean age (SD) = 65.5 (8.76); age range = 40-80 years; COPD classification II (Moderate) - IV (Very Severe); Brazilian sample)

  • The cut-off point of 28% (LCADL %total score) had 83% sensitivity and 72% specificity (UAC = 0.80) to discriminate patients’ functional status according to anchor-based approach

Normative Data

COPD: (Almedia Gulart et al., 2020)

  • LCADL total score (pre-treatment) = 22.7 (10.7)
  • LCADL % total score (pre-treatment) = 35 (13)

 

Severe COPD: (Garrod et al., 2000; n = 60 (33 male, 27 female); median (IQR) age = 70 (50-82) years)

  • LCADL total mean (SD) = 37.0 (12.7)

 

Severe COPD: (Garrod et al., 2002; n = 59; median (IQR) age = 66 (38-84) year)

  • LCADL total mean (SD) = 39.5 (12.7)

 

Moderate to severe COPD: (Belo et al., 2019; Sample 1, n = 138)

  • LCADL total score median (IQR) for men = 17 (13 - 22)
  • LCADL total score median (IQR) for women = 24 (19 - 34)
  • LCADL % median (IQR) for men = 29 (24 – 37)
  • LCADL % total median (IQR) for women = 36 (26 - 47)

 

Severe COPD: (Kovelis et al., 2011; n = 22 (11 male, 11 female); mean (SD) age = 66 (7) years; Brazilian sample)

  • LCADL total median (IQR) pre-treatment = 53 (41-61)

 

Patients waiting for a lung transplantation: (Muller et at., 2013; n = 26 (10 male, 16 female); mean age = 48 (14) years; diagnoses included pulmonary fibrosis, COPD, cystic Fibrosis, bronchiectasis, and others; Brazilian sample)

  • Mean LCADL total % score was 36%
  • 16 patients scored a total LCADL above 50%

 

Refractory breathlessness due to advanced respiratory disease: (Reilly et al., 2016; n = 88 (51 male, 37 female); median (range) age = 68 (43-88) years; diagnoses included COPD, interstitial lung disease, and cancer)

 

Median (range)

Total Sample

46.5 (14 – 67)

COPD

49 (16 – 61)

Cancer

44 (16 – 61)

Interstitial Lung Disease

39 (14 – 59)

Carer available

49 (14 – 67)

Carer not available

42 (22 – 59)

Test/Retest Reliability

Severe COPD: (Garrod et al., 2002; n = 19); Test-retest reliability was assessed by the same therapist over a 4-week period.

  • Excellent test-retest intraclass correlation for Total LCADL score: ICC = 0.96
    • Adequate test-retest reliability for the self-care domain: ICC = 0.78
    • Adequate test-retest reliability for the domestic domain: ICC = 0.88
    • Adequate test-retest reliability for the physical domain: ICC = 0.89
    • Adequate test-retest reliability for the leisure domain: ICC = 0.78

Internal Consistency

Severe COPD: (Garrod et al., 2000)

  • Excellent: Cronbach’s alpha value of 0.98

 

Patients waiting for a lung transplantation: (Muller et at., 2013)

  • Excellent: Cronbach’s alpha for the LCADL Total score = 0.89
  • Adequate to Excellent: Cronbach’s alpha ranged for LCADL domains from 0.72 - 0.94
  •  

Refractory breathlessness due to advanced respiratory disease: (Reilly et at., 2016)

  • Excellent: Cronbach’s alpha for the LCADL Total score = 0.90

Criterion Validity (Predictive/Concurrent)

Severe COPD: (Garrod et al., 2000)

  • Excellent concurrent validity with St. George’s Respiratory Questionnaire (SGRQ) activity score (p = 0.70; P < 0.0001)
  • Adequate concurrent validity with SGRQ total score (p = .42; P = 0.001) and impact component (p = 0.48; P = 0.004)
  • Poor concurrent validity with SGRQ symptoms (p = 0.24; P = 0.007)
  • Adequate concurrent validity between Nottingham Extended Activity of Daily Living Questionnaire (EADL) score (p = -0.46; P = 0.0008)
  • Poor concurrent validity with Hospital Anxiety and Depression Score (HAD)  depression score (p = -0.25; P =0.06)
  • Poor concurrent validity with HAD anxiety score (p = 0.28; P = 0.03)
  • Adequate concurrent validity with Forced Vital Capacity (FVC) (p = - 0.38; P = 0.007)
  • Poor concurrent validity with Forced Expiratory Volume in one second (FEV1) (p = - 0.18; P = 0.18)
  • Adequate concurrent validity with Shuttle Walk Test (p = -0.58; P < 0.0001)

 

Severe COPD: (Garrod et al., 2002)

  • Poor concurrent validity between change in LADL score and change in  Shuttle Walk Test (SWT) (p = -0.28; P = 0.03)
  • Adequate concurrent validity between change in LADL score and  change in Chronic Respiratory Disease Questionnaire (CRDQ) score (p = -0.37; P = 0.004)

Construct Validity

Severe COPD: (Garrod et al., 2000; n = 60)

  • The LCADL total mean (SD) score [37.0 (12.7)] was over twice as high as score in 20 patients with no history of respiratory disease[17.5 (3.51)]

 

Patients waiting for a lung transplantation: (Muller et at., 2013)

  • Significant association of total score (%) with the six-minute walk distance:  B = -0.079, p = 0.002
  • Significant association of total score (%) with the six-minute walk work: B = -0.348, p = 0.002

 

Refractory breathlessness due to advanced respiratory disease: (Reilly et at., 2016)

  • Moderate convergent validity between the LCADL Total score and subcategories of Chronic Respiratory Questionnaire (CRQ): r = - 0.40 (Health-related quality of life), r = - 0.56 (Dyspnea), r = - 0.31 (fatigue)
  • Moderate convergent validity between the LCADL Total score and Palliative care Outcome Scale - symptoms (POS-s): r = 0.40
  • Weak convergent validity between the LCADL Total score and Numerical Rating Scale (NRS): r = 0.24 - 0.25 and CRQ Mastery
  • Weak convergent validity between the LCADL Total score and CRQ mastery: r = - 0.30
  • Weak convergent validity between the LCADL Total score and Hospital Anxiety and Depression (HAD): r = - 0.29 (depression) and r = 0.08 (anxiety)
  • Divergent validity in between the LCADL Total score and pulmonary function measures with r < 0.2

Content Validity

Items of LCADL were generated through interviews with patients with moderate to severe COPD and patients with very severe COPD. It was further developed by item reduction process considering appropriateness of the activity (i.e. ‘wouldn't do anyway or do not get breathless’), demographic variables (i.e. gender and age), association with general health, and poor test-retest reliability. Domains developed through a principal component analysis. (Garrod et al., 2000).

Moderate to severe COPD: (Belo et al., 2019)

  • Gender potentially causes bias to the assessment of functional status by the LCADL, especially in the domestic domain, with overestimation of men’s status compared to women
  • Sample 1 (n = 138)
    • Median (IQR) for LCADL domestic for men = 4 (2-7)
    • Median (IQR) for LCADL domestic for women = 10 (7-15)
  • Sample 2 (n = 70)
    • Median (range) for LCADL domestic ≥ 37% cutoff point, men = 7 (2-11)
    • Median (range) for LCADL domestic ≥ 37% cutoff point, women = 16 (12-19)

Floor/Ceiling Effects

Patients waiting for a lung transplantation: (Muller et at., 2013)

  • No floor or ceiling effect

 

Refractory breathlessness due to advanced respiratory disease: (Reilly et at., 2016)

  • No floor or ceiling effect for the LCADL total score. The LCADL domestic domain demonstrated a ceiling effect, with 23% of respondents achieving the highest possible score.

Responsiveness

Severe COPD: (Garrod et al., 2002; n = 59)

  • Mean difference pre- & post-pulmonary rehabilitation (6 weeks minimum) in LCADL total = - 5.91 
  • All domains except the domestic component had a statistically significant reduction in dyspnea after pulmonary rehabilitation.

 

Severe COPD: (Kovelis et al., 2011)

  • Significant improvements in LCADL total score and self-care, domestic, and leisure domains after a 12-week training program. The overall effect size around or above 0.50 suggests a moderate change.

LCADL

Effect Size

Standardized Response Mean

Standard Error of Measurement

Self-care

0.60

0.75

0.40

Domestic

0.26

0.73

0.50

Physical Activity

0.43

0.40

0.24

Leisure

0.61

0.81

0.21

Total

0.45

0.91

1.03

 

 

COPD: (Bisca et al., 2014)

  • Statistically significant improvements in the LCADL total score and self-care, domestic, and leisure domains after a 3-month high-intensity training intervention (effect size of 3.45 for the total score)

COPD: (Almedia Gulart et al., 2020; n = 77)

  • Mean (SD) change from pre- and post- LCADL total = 2.7 (6.4) with p = 0.004 after 24 sessions of a supervised physiotherapy training program
  • Mean (SD) change from pre- and post- LCADL % total = 4 (8) with p = 0.001 after 24 sessions of a supervised physiotherapy training program

Cardiovascular Disease

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Normative Data

Heart failure: (Carvalho et al., 2010; n = 47 (57% males, 43% females); mean age (SD) = 50 (9) years; mean left ventricle ejection fraction (SD) = 29% (9); New York Association (NYHA) functional class I (No limitation) - III (Symptoms of heart failure with minimal exertion); Brazilian sample)

LCADL

Total Sample

NYHA I

NYHA II

NYHA III

 

M (SD)

M (SD)

M (SD)

M (SD)

Total Score

35.9 (21.9)

12 (14)

43 (14)

51 (13)

Physical

7.3 (3.0)

3 (2)

9 (1)

9 (1)

Domestic

15.7 (9.7)

5 (7)

19 (6)

22 (6)

Leisure

5.2 (4.4)

1 (3)

6 (4)

8 (3)

Self-Care

8.0 (6.2)

2 (3)

10 (5)

12 (5)

Test/Retest Reliability

Heart failure: (Carvalho et al., 2010; 1-week apart administration)

  • Excellent LCADL total score: Cronbach’s alpha = 0.99; ri = 0.98
    • Excellent self-care domain: Cronbach’s alpha = 0.97; ri = 0.95
    • Excellent domestic domain: Cronbach’s alpha = 0.99; ri = 0.97
    • Excellent physical domain: Cronbach’s alpha = 0.96; ri = 0.91
    • Excellent leisure domain: Cronbach’s alpha = 0.98; ri = 0.96

Criterion Validity (Predictive/Concurrent)

Heart failure: (Carvalho et al., 2010)

  • Excellent correlation of LCADL total score with the Minnesota Living with Heart Failure Questionnaire (MLHFQ) total: r = 0.88; p < 0.0001
  • Excellent correlation of LCADL total score with the MLHFQ physical: r = 0.82; p < 0.0001
  • Excellent correlation with exercise capacity (peak VO2): r = - 0.75; p < 0.0001
  • Excellent correlation with CPX (cardiopulmonary exercise test): r = - 0.71; p < 0.0001
  • Adequate correlation between LCADL total score and NYHA functional class: r = 0.68, p < 0.0001
    • Adequate correlation between self-care score with NYHA functional class: r = 0.65, p < 0.0001
    • Adequate correlation between domestic score with NYHA functional class: r = 0.69, p < 0.0001
    • Adequate correlation between physical score with NYHA functional class: r = 0.67, p < 0.0001
    • Adequate correlation between leisure score with NYHA functional class: r = 0.60, p < 0.0001

Spinal Injuries

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Standard Error of Measurement (SEM)

Spinal cord injury: (Sobreira et al., 2021; n = 60 (36 male, 24 female) at baseline; mean age (SD) = 54.5 (15.9) years, level of injury: cervical (n = 31), thoracic (n = 19), lumbar (n = 10); average rehabilitation program (SD): 7.3 (1.7) weeks; Portuguese sample)

  • SEM for LCADL, total points = 0.6
    • SEM for self-care domain = 2.7
    • SEM for domestic domain = 0.4
    • SEM for physical domain = 1.1
    • SEM for leisure domain= 1.6 

Minimal Detectable Change (MDC)

Spinal cord injury: (Sobreira et al., 2021)

  • MDC for LCADL, points = 1.6
    • MDC for self-care domain = 7.5
    • MDC for domestic domain = 1.2
    • MDC for physical domain = 3.2
    • MDC for leisure domain = 4.5 

Minimally Clinically Important Difference (MCID)

Spinal cord injury: (Sobreira  et al., 2021)

  • MCID estimates for LCADL total = 1.4
  • MCID estimates for domains: self-care = 4.1; domestic = 0.8; physical = 1.8; leisure = 2.5
  • MCID estimates were obtained only by distribution-based methods because LCADL showed non-significant correlations with the Global Rating of Change (GRC).

Normative Data

Spinal cord injury: (Sobreira et al., 2021)

  • Mean (SD) LCADL total score at baseline: 6.1 (2.9)

Responsiveness

Spinal cord injury: (Sobreira et al., 2021)

  • Non-significant mean (SD) change in total  score of LCADL after an interdisciplinary inpatient intervention up to 9 weeks: -0.4 (1.6), effect size = -0.17

Bibliography

Almedia Gulart, A.  de Araujo, C., Munari, A. B., Schneider, B. F., Dal Lago, P., & Mayer, A. F. (2020). Minimal important difference for London Chest Activity of Daily Living scale in patients with chronic obstructive pulmonary disease. Physiotherapy, 107, 28–35. https://doi.org/10.1016/j.physio.2019.08.007

Belo, L. F., Rodrigues, A., Paes, T., Machado, F., Schneider, L. P., Vicentin, A. P., Probst, V. S., Pitta, F., & Hernandes, N. A. (2019). Functional status of patients with COPD assessed by London Chest Activity of Daily Living Scale: Gender association and validity of a cutoff point. Lung, 197(4), 509–516. https://doi.org/10.1007/s00408-019-00235-2

Bisca, G. W., Proença, M., Salomão, A., Hernandes, N. A., & Pitta, F. (2014). Minimal detectable change of the London chest activity of daily living scale in patients with COPD. Journal of Cardiopulmonary Rehabilitation and Prevention, 34(3), 213–216. https://doi.org/10.1097/HCR.0000000000000047

Carvalho, V. O., Garrod, R., Bocchi, E. A., Pitta, F., & Guimarães, G. V. (2010). Validation of the London Chest Activity of Daily Living scale in patients with heart failure. Journal of Rehabilitation Medicine, 42(8), 715–718. https://doi.org/10.2340/16501977-0578

Garrod, R., Bestall, J. C., Paul, E. A., Wedzicha, J. A., & Jones, P. W. (2000). Development and validation of a standardized measure of activity of daily living in patients with severe COPD: The London Chest Activity of Daily Living Scale (LCADL). Respiratory Medicine, 94(6), 589–596. https://doi.org/10.1053/rmed.2000.0786

Garrod, R., Paul, E. A., & Wedzicha, J. A. (2002). An evaluation of the reliability and sensitivity of the London Chest Activity of Daily Living Scale (LCADL). Respiratory Medicine, 96(9), 725–730. https://doi.org/10.1053/rmed.2002.1338

Gulart, A. A., Munari, A. B., Klein, S. R., Venâncio, R. S., Alexandre, H. F., & Mayer, A. F. (2020). The London Chest Activity of Daily Living scale cut-off point to discriminate functional status in patients with chronic obstructive pulmonary disease. Brazilian Journal of Physical Therapy, 24(3), 264–272. https://doi.org/10.1016/j.bjpt.2019.03.002

Kovelis, D., Zabatiero, J., Oldemberg, N., Colange, A. L., Barzon, D., Nascimento, C. H. S. C., Probst, V. S., & Pitta, F. (2011). Responsiveness of three instruments to assess self-reported functional status in patients with COPD. Journal of Chronic Obstructive Pulmonary Disease, 8(5), 334–339. https://doi.org/10.3109/15412555.2011.594463

Muller, J. P., Gonçalves, P. A., Fontoura, F. F., Mattiello, R., & Florian, J. (2013). Applicability of the London Chest Activity of Daily Living scale in patients on the waiting list for lung transplantation. Jornal Brasileiro De Pneumologia, 39(1), 92–97. https://doi.org/10.1590/s1806-37132013000100013

Reilly, C. C., Bausewein, C., Garrod, R., Jolley, C. J., Moxham, J., & Higginson, I. J. (2017). Breathlessness during daily activity: The psychometric properties of the London Chest Activity of Daily Living Scale in patients with advanced disease and refractory breathlessness. Palliative Medicine, 31(9), 868-875. https://doi.org/10.1177/0269216316680314

Sobreira, M., Almeida, M.P., Gomes, A., Lucas, M., Oliveira A., & Marques, A. (2021). Minimal clinically important differences for measures of pain, lung function, fatigue, and functionality in spinal cord injury. Physical Therapy & Rehabilitation Journal, 101, 1-11. https://doi:org/10.1093/ptj/pzaa210

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