EDITORIAL
Reliability
Clinical measurements lie at the core of our prac-
tice. We use them constantly to aid in diagnosis,
assess severity of impairment, monitor response to
treatment, and ultimately guide our clinical deci-
sions. Crucial as our measurements are, they must be
accurate. As the one and only Erle Peacock, MO,
pointed out some years ago in this journal, "The
greatest advance in hand therapy in the last few
decades and certainly one of the greatest contribu-
tions to the care of patients has been the introduction
of the science of measurement." 1
And at the very heart of the concept of accuracy is
the concept of reliability. Webster defines reliability
as, "suitable or fit to be relied on, or dependable."
This is how we all understand it in the context of
everyday life. In our clinical settings, we need a con-
cept of reliability with a slightly different spin to it,
like that offered by Portney and Watkins in their
research textbook Foundations of Clinical Research:
"Reliability can be conceptualized as reproducibility
or dependability, and is the extent to which a meas-
ure is consistent and free from error." 2 When applied
to a clinical measurement, it becomes an important
indicator of the accuracy of that measurement.
Despite the obvious fact that outcomes deserve our
attention,* we cannot forget about the important ele-
ments that contribute to function, such as ROM. I can
think of no area of our practice where accuracy is more
critical than in measuring joint motion. Small changes
in motion trigger our clinical decisions to alter plans of
treatment in the management of joint stiffness, for
example. Such decisions require us to have confidence
in the accuracy of our measures.
To comply with Peacock's description of our prac-
tice being based on science, we cannot casually
assume that our methods-and in this case I am
referring to goniometry-are accurate. We need doc-
umented evidence. In this issue, we are offered four
reliability studies that contribute to that body of evi-
dence, three of which are goniometric investigations.
As a general statement, reliability is expressed sta-
tistically in the form of a correlation coefficient of
some sort. In lay terms, this means a mathematical
representation that indicates how closely a measure
comes to being duplicated when the measurement is
'Because of the increasing importance of outcomes as indicators of
the efficacy of hand therapy practice, this year's Special Issue of the
Journal (April-June 2001) will be dedicated to Outcomes and guest
edited by Joy c. MacDermid, BScPT, PhD.
repeated. A perfect correlation would be an exact rep-
etition of the same score both times the measure is
taken. In most formulas used to express this correla-
tion, such a perfect correlation would be 1.0. The clos-
er to 1.0 a correlation is, the more reliable and hence
the more accurate the measure. For example, a 0.95
correlation is far better than a 0.50 correlation. There
are no absolute values, or cut-off points, assigned to
correlation scores to render them excellent, good, fair,
or poor. It is more a matter of a gradient of scores,
where the higher the better, and the lower the poorer.
Another question that needs to be asked in any reli-
ability situation is whether we are talking about the
same person taking the measure more than once or
about different people taking the measure on different
occasions. Clearly, both these situations may arise clin-
ically. If it is always the same person taking the meas-
ure, then this is intra rater or intratester reliability, in con-
trast to interrater or intertester reliability, when we are
comparing measures taken by different people.
Many practitioners (myself included) are outspo-
ken advocates of avoiding, whenever possible, the
sharing of responsibility for repeated measures with
our colleagues. We strongly recommend that one
person alone follow the patient and take all meas-
ures. One reason for this argument is that, typically,
intrarater reliability is greater than interrater reliabil-
ity. Therefore, if accuracy is the legitimate concern
that Peacock suggests, we should opt for the more
reliable method. This is especially true if we are
going to make clinical decisions based on these meas-
ures. Given that bias, I am usually more interested in
the intrarater reliability value.
I hope to see many more such manuscripts, so that
in future issues of the JHT we can continue to docu-
ment the accuracy of our methods.
References
1. Peacock EE Jr. Frontiers in wound healing research that may
affect the work of hand therapists. J Hand Ther. 1989;2:221-2.
2. Portney LG, Watkins M. Foundations of Clinical Research. 2nd
ed. Upper Saddle River, NJ: Prentice Hall, 2000.
Correspondence to Kenneth R. Flowers, PT, CHT, Editor, Journal
of Hand Therapy, 270 Danell Road, Radnor, PA 19087; e-mail: <ken.
flowers@prodigy.net>.
January-March 200 I