Reframing hands-on musculoskeletal assessment as a measurement instrument rather than a technique debate: a theoretical framework applying COSMIN to HODA-A

BACKGROUND: Hands-on assessment remains central to musculoskeletal practice across physiotherapy and related professions. However, its scientific status has been questioned because reliability and diagnostic accuracy studies have produced inconsistent findings, often without prior construct definition, content validity assessment, or examiner calibration. The palpation literature illustrates this problem, with mixed findings that appear to vary according to the construct under investigation. PURPOSE: This theoretical paper proposes Hands-On Data Acquisition and Analysis (HODA-A) as a framework for conceptualizing hands-on musculoskeletal examination and assessment as a clinician-reported outcome measurement process, rather than as isolated manual techniques. METHODS: Although the same measurement principles apply to other clinical tests, hands-on assessment poses challenges as tactile-perceptual data streams and target constructs are often less defined. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN), although frequently associated with patient-reported outcome measures, is applicable to clinician-reported outcome measures when adapted to the construct and context being evaluated. RESULTS: Drawing on COSMIN principles, this paper argues that evaluation of hands-on musculoskeletal assessment requires an explicit sequence: construct definition, content validity, examiner calibration, reliability and measurement error testing, construct validity or hypothesis testing, responsiveness, and interpretability. Because the construct is the clinician-generated judgment itself, HODA-A has no single gold standard; validity is therefore addressed through hypothesis testing, with criterion validity confined to subconstructs for which a justified reference standard exists. CONCLUSION: HODA-A does not claim premature validity but establishes a foundation for validation research by defining hands-on assessment as a structured clinician-reported measurement process warranting scrutiny comparable to other outcome measurement instruments.