中風病人標準化評估工具在職能治療實習生之學習成效

Learning Effectiveness of Using Two Standardized Assessment Tools for Stroke Patients in Occupational Therapy Students

10.6145/jme.200606_10(2).0006

謝妤葳(Yu-Wei Hsieh)；薛漪平(I-Ping Hsueh)；羅彬心(Pin-Hsin Lo)；簡啟文(Chi-Wen Chien)；謝清麟(Ching-Lin Hsieh)

職能治療 ； 學習成效 ； 標準化評估 ； occupational therapy ； learning effectiveness ； standardized assessment

Journal of Medical Education

10卷2期（2006 / 06 / 01）

135 - 144

繁體中文

目的：職能治療實習生(Occupational Therapy Student, OTS)學習使用標準化評估工具是職能治療臨床教育的重點之一，但其學習成效甚少被驗證。本研究目的為檢驗OTS使用二種中風病人標準化評估工具：Stroke Rehabilitation Assessment of Movement(STREAM)之上、下肢動作次量表及Postural Assessment Scale for Stroke patients(PASS)之學習成效。方法：選取接受職能治療之住院中風病人為施測對象，由2位熟悉STREAM及PASS量表之職能治療師(Occupational Therapist Registered, OTR)，每次隨機安排2位OTS先後施測同一位中風病人。1位OTR亦同時評分，做為標準分數。OTS在STREAM上、下肢動作次量表及PASS量表之主要學習成效指標有二：（一）量表總分施測者間信度之組內相關係數值(intraclass correlation coefficient, ICC)及（二）不同施測者間測量誤差之最小真實差異值(smallest real difference, SRD)；另以「個別項目之施測者間信度」為次要學習成效指標。結果：共施測14位中風患者。由主要學習成效指標顯示：總分之施測者間信度ICC值皆有良好的一致性(≥0.94)；SRD值顯示PASS量表之測量誤差較小（PASS量表之SRD約為總分之10%，STREAM上、下肢動作次量表之SRD約為總分之20%）。此外，次要學習成效指標顯示：STREAM上、下肢動作次量表及PASS量表總共32個項目中，其中22項具備良好或佳的施測者間信度，9項具備中等施測者間信度，1項之施測者間信度差。結論：本研究結果顯示：OTS在STREAM上、下肢動作次量表及PASS量表之學習成效尚屬良好，但仍有改善之空間，其中PASS量表學習成效優於STREAM上、下肢動作次量表。未來職能治療臨床教學應特別加強STREAM上、下肢動作次量表以及10個具備「中等或差的施測者間信度」項目之標準化教學與練習，以提昇學習成效與評量之精確度。

Objective: Learning how to use the standardized assessment tools is an important part of the clinical education of Occupational Therapy Student (OTS). However, the learning effectiveness has been rarely examined. The purpose of this study was to examine the learning effectiveness of two standardized assessment tools for stroke patients (two subscales of the Stroke Rehabilitation Assessment of Movement [STREAM] and the Postural Assessment Scale for Stroke patients [PASS]) in OTS. Method: Stroke inpatients receiving occupational therapy were recruited. Occupational Therapist Registered (OTR) randomly assigned two OTS to assess the same stroke patient using the STREAM and the PASS individually. An OTR also rated the patients at the same time to render the standard scores. Two major indicators of the learning effectiveness of the STREAM and the PASS were (1) the intraclass correlation coefficient (ICC) to examine the inter-rater agreement of the total score and (2) the smallest real difference (SRD) to examine the measurement errors. In addition, the inter-rater reliability of individual items served as the secondary indicator. Results: A total of 14 stroke patients were recruited in this study. The ICCs of the total score were larger than 0.94, indicating there were good agreements between pairs of raters. In addition, the SRDs of the two subscales of the STREAM were about 20% of the total scores, and the SRDs of the PASS were nearly 10%. In addition, 22 out of the total 32 items showed excellent or good agreement, 9 out of the total 32 items showed moderate agreement, and 1 item showed poor agreement. Conclusion: Learning effectiveness of the OTS of the STREAM and the PASS was satisfactory, but it still has the potential to be improved. In clinical education, the standardized criteria and the practice of the two subscales of the STREAM and the 10 items of the STREAM and the PASS with moderate and poor agreement should be emphasized especially to improve learning effectiveness and precision of assessment.

1. Beckcrman H,Rocbroeck ME,Lankhorst GJ(2001).Smallest real difference, a link between reproducibility and responsiveness.Qual Life Res,10,571-578.
2. Benaim C,Perennou DA,Villy J(1999).Validation of a standardized assessment of postural control in stroke patients: the Postural Assessment Scale for Stroke Patients (PASS).Stroke,30,1862-1868.
3. Brouwer S,Reneman MF,Dijkstra PU(2003).Test-retest reliability of the Isernhagen Work Systems Functional Capacity Evaluation in patients with chronic low back pain.J Occup Rehabil,13,207-218.
4. Bushnell CD,Johnston DC,Goldstein LB(2001).Retrospective assessment of initial stroke severity: comparison of the NIH Stroke Scale and the Canadian Neurological Scale.Stroke,32,565-660.
5. Daley K,Mayo N,Danys I(1997).The Stroke Rehabilitation Assessment of Movement (STREAM): refining and validating the content.Physiother Can.
6. Daley K,Mayo N,Wood-Dauphinee S(1999).Reliability of scores on the Stroke Rehabilitation Assessment of Movement (STREAM) measure.Phys Ther,79,8-19.
7. Dettmann MA,Linder MT,Sepic SB(1987).Relationships among walking performance, postural stability, and functional assessments of the hemiplegic patient.Am J Phys Med,66,77-90.
8. Flansbjer UB,Hoimback AM,Downham D(2005).What change in isokinetic knee muscle strength can be detected in men and women with hemiparesis after stroke?.Clin Rehabil,19,514-522.
9. Flansbjer UB,Holmback AM,Downham D(2005).Reliability of gait performance tests in men and women with hemiparesis after stroke.J Rehabil Med,37,75-82.
10. Hendricks HT,van Limbeek J,Geurts AC(2002).Motor recovery after stroke: e systematic review of the literature.Arch Phys Med Rehabil,83,1629-1637.
11. Holm MB(2000).The 2000 Eleanor Clarke Slagle Lecture. Our mandate for the new millennium: evidence-based practice.Am J Occup Ther,54,575-585.
12. Horak FB,Esselman P,Anderson ME(1984).The effects of movement velocity, mass displaced, and task certainty on associated postural adjustments made by normal and hemiplegic individuals.J Neurol Neurosurg Psychiatry,47,1020-1028.
13. Kelly-Hayes M,Robertson JT,Broderick JP(1998).The American Heart Association Stroke Outcome Classification.Stroke,29,1274-1280.
14. Mao HF,Hsueh IP,Tang PF(2002).Analysis and comparison of the psychometric properties of three balance measures for stroke patients.Stroke,33,1022-1027.
15. Shrout PE,Fleiss JL(1979).Intraclass correlations: uses in assessing rater reliability.Psychol Bull,86,420-428.
16. Sim J,Wright CC(2005).The kappa statistic in reliability studies: use, interpretation, and sample size requirements.Phys Ther,85,257-268.
17. van der Lee JH,Wagenaar RC,Lankhorst GJ(1999).Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial.Stroke,30,2369-2375.
18. Wang CE,Hsieh CL,Dai MB(2002).Inter-rater reliability and validity of the Stroke Rehabilitation Assessment of Movement (STREAM) instrument.J Rehahil Med,34,20-24.
19. Wang CH,Hsueh IP,Sheu CF(2005).Discriminative, predictive, and evaluative properties of a hunk control measure in patients with stroke.Phys Ther,85,887-894.
20. 楊培銘(2004)。實證醫學與健康照護。台灣醫學，8，862-864。