9/12/16

Applied Anatomy 1 HSc-51124

Seminar 2.1: Clinimetrics of Tests &
Measures in Physical Therapy Practice

Carlos Ladeira BScPT, MScPT,

EdD, FAAOMPT, MTC, OCS
Associate Professor

Objectives
Define & Describe Clinimetrics
Discuss why clinimetrics is important in
clinical practice.
Discuss what makes a good test/measure
Discuss the basic constructs of reliability and
validity
Compare the tenets of diagnostic validity:
sensitivity versus specificity.
Discuss the meaning of Minimum Detectable
Change (MDC)

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Clinimetrics: the science of clinical

measurements.
l It uses indexes (MDC) and scales to describe
or measure symptoms, physical signs and
other clinical phenomena (Gait, Disability).
l It has a set of rules that help clinicians
choose tests and measures to make clinical
decisions
Am I getting the results I should during
my examination?
l Accurate (no measurement error)

l Reliable (reproducible)

l Valid (measure what it is supposed to)

Good Decision is Based on Good Measures!

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Valid = True
Validity: each time a test/measure is performed
we must understand how the results of the test
compare with the truth. An instrument is valid if it
measures what it is supposed to measure.
For concurrent validity, the method is often
compared to a gold standard instrument.
l Manual radial pulse assessment is compared to EKG heart
monitor
l Manual Muscle Test is compared to Muscle Test with
Isokinetic Dynamometry
For diagnostic validity, the test is performed in subjects with
and without a confirmed diagnoses and the truth verified (see
diagnostic validity below).

Validity & Reliability

A valid instrument is always reliable (accuracy requires
consistency), but a reliable instrument may not be valid

Quantitatively, we can use numbers to say if a test has

good or bad reliability and validity
0.10 0.25 0.50 0.75 0.90

Very Poor Poor Acceptable Good Excellent

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Palpation Reliability & Validation Studies

Inter-rater reliability Palpation of PSIS on
iliac crest.
l .27 (poor). Cooperstein et al, 2016
Inter-rater reliability Muscle Trigger points
(symptomatic & asymptomatic tenderness)
l Location of tenderness .18 to .60 (poor to
moderate) depending on muscle (6 different
muscles in total). Bron et al 2007.
Validity of Palpation Trans Process (C1)
l Validation done with imaging test as gold standard.
l .57 to .90 (acceptable to excellent). Cooperstein et
al, 2015.

Diagnostic Validity

Sensitivity (SnNout) is the ability of the test to identify

correctly affected individuals. Proportion of persons testing
positive among affected individuals.
True positive rate: A / A + C
Specificity (SpPin) is the ability of the test to identify correctly
non-affected individuals. Proportion of person testing negative
among non affected individuals
True negative rate = D / D + B

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Sensitivity Calculation
Example: sensitivity of sharp-dull test to detect
sensory loss
Population 200 patients with diabetes, 100 patients
have sensory loss and 100 do not.
l 31 patients test positive from 100 patients with sensory
loss.
l Sensitivity: 31 / 31 + 69 = 0.31 (Sensitivity is poor <
0.5)
l Conclusion: Sharp-dull test only confirms the the
presence of sensory loss in 31% of
patients, it fails in 69% of all cases.

Specificity Calculation
Example continued: Sharp-dull for sensor loss
Population: 100 patients with diabetes and normal
sensation.
l 16 positive tests out of 100 patients normal sensation.

l Specificity: 84 / 84 + 16 = 0.84 (good specificity >

0.84).
l Sharp-dull test confirms the absence of sensory loss in
84% of all cases and only identifies sensory loss
incorrectly in 16% of all cases.
l Conclusion: The test is useful when
when positive, not when it is
negative.

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Diagnostic Validity
Example above
Diabetes 100 patients with 100 patients with
Sensory loss normal sensation
Positive Sharp-dull 31 patients 16 patients
test
Negative sharp-dull 69 patients 84 patients
test
The Test must be Positive for Negative for
sensitivity specificity
Use in the clinic Rule out Rule in

Calculation Sensitivity = Specificity = 84/

31/100 or .31 100 or .84

Measurement Error & Minimum Detectable

Change (MDC)
Standard error of measurement (SEM): amount of error
one consider measurement error
l SEM= Standard Deviation x (1- reliability [ICC]).

Minimum Detectable Change: the minimum amount of

change that is not considered measurement error.
l MDC90= Z-score (1.65, 90% CI) x SEM x 2

l MDC95= Z-score (1.96, 95% CI) x SEM x 2

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Example 2: Patient with Knee OA

Mr. JH, 55-year-old male.
Evaluation day
l R Knee flexion 900 & Extension -100 (PROM).

Two weeks after intervention

l R Knee flexion 1000 & Extension -50.

Patient progress
l Is the 100 gain considered real improvement for
flexion and -50 real gain for knee extension?

Stratford et al, Physiotherapy Canada, 2010

Intra-rater reliability for Knee ROM
74 patients with knee OA
Flexion Test-Retest reliability .84 (ICC)
Extension Test-Retest reliability .60 (ICC)
Standard Error (SEM)
Knee flexion: 4.10
Knee extension: 2.70
MDC 90
Knee flexion: 9.60
Extension: 6.30

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Discussion
Is the range improvement from our knee
patient real? Based on the MDC90 results
by Stratford (2010)?
Flexion went from 900 to 1000 = 100
The 100 knee flexion (> 9.60) was real
improvement
Extension went from -100 to -50
The -50 knee extension was measurement error
(< 6.30).

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Key Summary Points

Clinimetrics provides a frame for clinical
decision-making & judgment.
Good clinical-decision making is based on
accurate, reliable, and valid measures.
A diagnostic test or measurement have
little or no meaning without validity.
Meaningful test scores should exceed the
MDC90 of the tool or instrument utilized.

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