[ evidence in practice ]

STEVEN J. KAMPER, PhD1

Fundamentals of Measurement:
Linking Evidence to Practice
Downloaded from www.jospt.org at University of Sydney on February 3, 2019. For personal use only. No other uses without permission.

J Orthop Sports Phys Ther 2019;49(2):114-115. doi:10.2519/jospt.2019.0701

M
easurement is fundamental to science, which means that tools are designed to direct a patient to-
physical therapists must engage with measurement if the ward a certain type of treatment, such as
profession wishes to call itself scientific. However, while it the STarT Back tool. Outcome measures
are designed to track the level or pres-
is simple enough to agree that measurement is a good idea,
ence of a symptom, function, or disease
there is more to measurement than meets the eye. marker, for example, the Patient-Specific
From the researcher’s point of view, tionnaire are also measures of disability Functional Scale. Some measures might
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the reason for measuring various demo-
graphic, personal, and clinical factors is
self-evident: scores on the measures an-
swer the research question. In the clinic,
physical therapists collect measurements
(often informally) from the beginning of
the clinical encounter, whether by asking
a question like, “What is bothering you
today?” or by observing the way the pa-
Journal of Orthopaedic & Sports Physical Therapy®
in people with shoulder pain (FIGURE).
Purpose
There are many reasons to measure
something, and any number of avail-
able measures. Screening measures are
designed to estimate how likely it is that
a healthy person will have a certain con-
dition in the future, and whether further
serve several purposes; for example, pain
intensity measured on a numeric rating
scale may form part of a diagnostic test,
inform likely prognosis, and be tracked
over time as an outcome measure.
Subjective and Objective Measures
A common mistake is to call measures
rated by the patient “subjective” and

tient gets out of a chair and walks. This
information guides further assessment
and management. Clinicians and re-
searchers both face similar issues when it
comes to interpreting the measures they
collect. To do this accurately, understand-
ing some basic concepts about measure-
ment is necessary.
Constructs and Measures
A construct is what you are interested in
measuring. A measure (sometimes called
a tool or an instrument) is how the con-
struct is measured. For example, you may
be interested in the construct of “disabil-
ity” in a patient with shoulder pain, and
choose to use the Disabilities of the Arm,
Shoulder and Hand questionnaire as the
investigations (eg, screening for cardio- those rated by an observer “objective.”
vascular risk) should be pursued. Diag- Subjectivity refers to the extent of per-
nostic measures (tests) are designed to sonal judgment involved in taking a mea-
determine whether someone does or does sure, and the personal judgment could be
not have a certain condition, an example on behalf of the patient or the observer;
being the Lachman test for anterior cru- for example, a physical therapist’s rating
ciate ligament rupture. Prognostic tools of the amount of swelling is also subjec-
are designed to help predict whether or tive. Further, it is better to consider mea-
when a patient will recover, such as the sures as more or less subjective—along
Örebro Musculoskeletal Pain Question- a hypothetical continuum—rather than
naire. Treatment-based classification wholly subjective or objective. Another
Construct Measure Score
Less disabled More disabled
Disabilities of the Arm, Shoulder and 0 20 40 60 80 100
Hand questionnaire
Shoulder
Shoulder Pain and Disability Index 0 20 40 60 80 100
disability

measure. There may be several different

Shoulder Disability Questionnaire 0 20 40 60 80 100
measures for the same construct; for ex-
ample, the Shoulder Pain and Disability
FIGURE. Constructs, measures, and scores.
Index and the Shoulder Disability Ques-

School of Public Health, University of Sydney, Camperdown, Australia; Centre for Pain, Health and Lifestyle, Australia. t Copyright ©2019 Journal of Orthopaedic & Sports Physical
1

Therapy®

114 | february 2019 | volume 49 | number 2 | journal of orthopaedic & sports physical therapy
 mistake is to automatically consider more
objective measures as being superior to
more subjective measures, based on the
assumption that objective measures are
more reliable and valid. Research has
shown that reliability and validity do not
depend on how objective or subjective
a measure is. Finally, it is important to
Downloaded from www.jospt.org at University of Sydney on February 3, 2019. For personal use only. No other uses without permission.
by the clinician. They may include
physical capacity measures like
strength or range of motion, move-
ment quality, or the ability to per-
form particular tasks. They may also
include observations such as the ex-
istence of scoliosis, muscle activation
levels, gait characteristics, and the re-
dance, work absence, insurance claim
data, and death.
Patient Relevance
Another aspect of interpreting measures
is determining patient relevance. This
involves judgment as to how important
the outcome construct is to your patient.

recognize that some constructs are inher-
ently subjective, such as a person’s pain
experience, and in such cases a more sub-
jective measure will be the most valid.
Methods of Measurement
There are many ways of collecting mea-
surements, and some of the most com-
mon types are listed below:
• Patient-reported measures. As the
name implies, these are ratings pro-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
sults of clinical tests. Note that many
of these measures assess not only
physical performance, but also the
motivation of the patient. Note that
these meausres also involve subjec-
tive judgment of the clinician.
• Scans, images, tests, and monitor-
ing devices. These may be used for
screening, diagnosis, or measurement
of constructs like habitual physical
activity. Even though these types of
For example, a study might conclude that
an intervention is effective because it im-
proves strength, but strength itself may
not matter too much to a patient unless
it translates to ability to perform impor-
tant tasks.
Conclusion
The options for measurement are limited
only by the imagination, but using poor or
inappropriate measures has critical con-

vided by the patient. This might
involve filling out a written question-
naire or answering questions verbally.
Patient-reported measures are com-
monly used to rate symptom sever-
ity, the impacts of a condition, or to
measure psychological constructs
like quality of life, depression, and
self-efficacy.
Journal of Orthopaedic & Sports Physical Therapy®
measures are typically toward the
more objective end of the spectrum,
their fit for purpose, reliability, and va-
lidity should not be automatically as-
sumed. For example, interpretation of
scans and images is highly subjective,
and findings may not have important
functional consequences.
• Administrative data. These are most
sequences for both clinical practice and
research. When reading research, it is im-
portant to check that the construct matches
the study question. From a clinical perspec-
tive, being able to clearly articulate why you
want to measure a certain construct is key.
Having decided on the appropriate con-
struct, you need to select the best measure.
This involves consideration of reliability

• Observer-rated measures. These commonly used in research, and in- and validity, which will be the subject of the
measures involve observations made clude metrics such as hospital atten- next Evidence in Practice article. t

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journal of orthopaedic & sports physical therapy | volume 49 | number 2 | february 2019 | 115