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Measuring clinically relevant outcomes

Updated: May 17, 2023

An easy - and free - way for therapists to assess clinical progress is to use an analogue scale.

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This can be a numeric scale such as the one developed in 1932 by Rensis Likert (1) to measure attitudes. Typically a 5- or 7-point ordinal scale, respondents rate the degree to which they agree or disagree with a statement. It is essentially a rating scale, usually presented as a score between 1 - 5 or 1 - 10, where the person selects the number to reflect the perceived quality of a product or service.

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Likert scales have been adapted for use across multiple health settings and are frequently used in lymphoedema research to track self-reported-symptoms (SRS) such as pain, perceived size, pins and needles or tingling, bursting sensations, limb temperature, ROM, or other commonly experienced symptoms.

Quality of life (QOL) and functional surveys also frequently employ a ranking system to elicit mobility and social impacts, with options such as none, mild, moderate, sever or most severe for the participant to choose from.

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Visual analogue scales may also be used to assess SRS and QOL and consist of a printed or digitally represented line between extreme scores of none and worst. The participant marks the line, or moves a slider to where they feel they sit between those end points. Other forms of visual scales such as a row of emojis can be useful in conveying levels of pain, and there are many versions in common use.

🙂 😐 😔 😯 😫 😝

All measures are subject to bias, but here are a few tips to reduce bias when using Likert and other rating scales.

Ask clear questions.

You may choose to have a standardised set of symptoms that you ask every client. Validated survey tools such as the LymQOL are great for lymphoedema clients, have formed the questions for you. they are free to use as long as you maintain the copyright statements on all printed material. Download the LymQOL Arm and LymQOL leg. Most other conditions will have a similar tool for tracking commonly experienced symptoms, or there are more generic surveys such as the Short Form 36 health Survey.

Or, you may choose to create a unique set of questions for each client according to their main concerns. The Measure Yourself Medial Outcomes Profile (MYMOP®) is a validated tool using this approach and is available for a small annual license fee. See my previous post on this clinically useful tool.

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Present the question in exactly the same way each time.

Digital web forms and printed pages are the best way to be consistent with the questions. Avoid offering more than minimal clarification on any question. If they have to ask what the question means you probably need to rethink how you are phrasing it. Practice asking the questions on friends and family to see what feels comfortable for you and make sure your questions can be easily understood.

If your person cannot read or record their own answers, then take care to ask the question in the same way each time. It may be better to use visual scales rather then numeric ones for these and other groups such as those experiencing dyslexia, or who do not speak the language used in the survey tool.

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Avoid the temptation to prompt, let people find their own answers. Be patient and reassure them there are no right or wrong answers, just an honest assessment of how they feel.

Don't offer previous scores during the survey. People will often ask what score they gave last time as they naturally want to compare how they feel now to their previous score. But this may bias the new score, so wait until after they have scored the question before you reveal any historical information.

These easy to use, numerical and visual scales can be a great way to track your progress over time, and they offer excellent discussion points to engage the client in home-care aspects of their treatment. Historical trends will appear over time, and as well as being motivating, can be used to identify and avoid future risks such as seasonal swelling or infection.

The seduction of the high-tech measuring devices is in their ability to accurately measure small changes in a single parameter. But I'd argue that knowing about a few extra mls here or there is not as clinically useful as knowing how your client is going in term of mobility, pain, QOL, and any of the myriad aspects of the life that are impacted by lymphoedema. Simple, easy to use tools to track SRS, QOL and ADLs are far more useful for this.

1. Likert, Rensis (1932). "A Technique for the Measurement of Attitudes". Archives of Psychology. 140: 1–55.


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