title: Ensuring inter-tester reliability of voluntary muscle and monofilament sensory testing in the INFIR Cohort Study.
abstract: OBJECTIVE
  To assess the reliability of monofilament (MF) and voluntary muscle strength (VMT) testing carried out by nine physiotherapy staff recruited for the ILEP Nerve Function Impairment & Reaction (INFIR) Cohort Study in India.
  
  
  METHODS
  A multiple pair inter-tester reliability study was carried out in Uttar Pradesh, India. Newly trained testers were paired up with an experienced physiotherapist, whose assessment served as the gold standard. Each pair completed a series of assessments. All testers had undertaken a week of specific VMT and MF training, followed by a month of practice in the hospital setting. Reliability was assessed by calculating weighted Kappa (Kw) statistics, which may be interpreted as the chance-corrected proportion of agreement between testers.
  
  
  RESULTS
  Eight newly-trained physiotherapists and one physiotechnician took part in the study. In the early stages of the study some areas of weak agreement were identified and correct assessment technique was reviewed, particularly for the eye. Good to very good reliability (Kw 0.62 to 0.99) was found for all sensory tests and most muscle strength tests. The only lower Kw scores (0-48 to 0-59, suggesting only moderate reliability) were for the VMT of muscles supplied by the median nerve in one of the study's two field centres. Even in this case, testers never varied by more than one grade, but calculation of Kw was negatively influenced by a lack of variation among the subjects. In addition, testers never varied by more than one grade from the gold standard.
  
  
  CONCLUSIONS
  Even though all testers were professionally trained and received additional specific training and practice in MF and VMT testing, discrepancies in technique required an early review and correction. This fact highlights the need for careful training and formal reliability testing. This should extend to referral centres where staff are involved in assessing the symptoms of reaction and monitoring response to treatment. Reliability testing provides the opportunity to address important discrepancies in technique that may persist even in the presence of protocols and qualified and trained staff. It is therefore a valuable tool as part of a training procedure for situations, where patients may be assessed by different testers. Overall, our results were deemed good enough to proceed with the INFIR study, using VMT and MF testing as a baseline against which to compare more sophisticated methods of nerve function testing.
authors.affiliation: The Leprosy Mission Trust India, CNI Bhavan, 11 Pandit Pant Marg, New Delhi, India.
authors.forename: Anne E
authors.initials: AE
authors.lastname: Roberts
authors.forename: Peter G
authors.initials: PG
authors.lastname: Nicholls
authors.forename: Pranava
authors.initials: P
authors.lastname: Maddali
authors.forename: Wim H
authors.initials: WH
authors.lastname: Van Brakel
mesh_terms: D015331:Cohort Studies; D006801:Humans; D007194:India; D007918:Leprosy / Q000150:complications*; D018482:Muscle, Skeletal / Q000294:innervation*; D009460:Neurologic Examination / Q000379:methods*; D015588:Observer Variation; D010523:Peripheral Nervous System Diseases / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012684:Sensory Thresholds