四个脑卒中量表的信度与效度研究
摘要
目的研究脑卒中患者美国国立卫生院卒中量表(NIHSS)、Barthel指数(BI)、临床神经功能缺损评分、中国ADL量表四个量表的信度和效度。
对象与方法222例急性脑卒中患者分别由不同评定者于入院当天、入院第14天、发病后第90天对同一脑卒中患者进行NIHSS、BI、临床神经功能缺损评分、中国ADL评定量表的评定。重测信度、评定者间信度与不同评定方式间的信度用Kappa值表示，分半信度、内部一致性信度用Cronbachα值表示。临床神经功能缺损评分、中国ADL量表的同时效度以及NIHSS、临床神经功能缺损评分的预测效度采用Spearman相关分析。结构效度采用因子分析的方法，其中脑梗死患者根据OCSP分型评定三种不同梗死类型的NIHSS和临床神经功能缺损评分的结构效度。
结果中文版的NIHSS“面肌功能”、“共济失调”的信度评定中等，Cronbachα值为0.861；不同评定者间信度显示8项条目信度不佳；“面肌功能”的评定效度较低，除了“共济失调”的评定，没有特异性反映小脑、脑干功能的条目；其评定结果与卒中结局有很好的相关性(均P=0.000)。中文版的BI“移动”和“洗澡”的信度评定相对较低，其Cronbachα值为0.941；电话随访评估与直接评测的相关性很高；有两个公因子，反映运动功能和括约肌功能。神经功能缺损程度评分“步行能力”信度评定相对较低，Cronbachα值为0.886；不同评定者间信度显示4项条目信度不佳；其与NIHSS评定结果间呈正相关(均P=0.000)，不同OCSP分型患者神经功能缺损评分与NIHSS评分结果均相关(均P=0.000)且与卒中结局有很好的相关性(均P=0.000)。中国ADL量表的“一般家务”和“用钞、点钞”的信度评定相对较低，Cronbachα值为0.966；电话随访评估与直接评测的相关性很高；其与BI在卒中后急性期及恢复期均有很好的相关性(均P=0.000)；该量表有2个公因子，反映患者的运动功能和认知功能。
结论
1．中文版的NIHSS内部一致性信度较高，但不适于电话评定。其对卒中结局有预测效度，且偏重于颈内动脉系统障碍的评定，对椎—基底动脉系统障碍的评定相对较少，应增加小脑、脑干功能评定的条目和／或权重。
2．中文版的BI内部一致性信度很高，可能有条目重复或不必要，适于电话随访，其有很好的结构效度，反映运动功能和括约肌功能。
3．神经功能缺损程度评分内部一致性信度较高，但不适于电话评定。其与NIHSS有同时效度，对卒中结局有预测效度；对PACI患者的结构效度最好，可以用来评定椎—基底动脉系统的卒中但并不敏感。
4．中国ADL量表的内部一致性信度很高，适于电话随访，但可能有条目重复或不必要，部分条目定义含混，涉及内容不具体，建议将此类条目进一步修订。其与BI有同时效度，该量表有2个公因子，反映患者的运动功能和认知功能，对卒中患者的日常生活活动能力评定更加全面，推荐使用修订后的中国ADL量表。
Objective To study the reliability and validity of the four scalesin evaluating stroke patients, which include the National Institutes ofHealth stroke scale (NIHSS)、the Barthel index (BI)、the clinicalneurologic deficit scale (CNDS) and the Chinese scale of the activitiesof daily living (ADL).
Sudjects and Methods Totally 222 consecutive inpatients with acutestroke onset were included in the study. They were assessed when admitted,at the 14th and 90th day of hospitalization by different rators using theNIHSS, BI, CNDS and the Chinese ADL. Intrarater、interrater andtest-retest reliability were determined by using Kappa correlation. Thesplit-half reliability and internal consistency were evaluated usingCronbach's a coefficient. Concurrent validity of the CNDS and theChinese ADL, and the predictive validity of the NIHSS and the CNDS weredetermined by spearman rank correlation coefficients. Construct validitywas assessed by the factor analysis and the construct validity of theNIHSS and the CNDS was measured according to the classifications of theOxfordshire Community Stroke Project (OCSP) ischemic stroke subtypes inthe patients with cerebral infarction.
Results In the Chinese version of NIHSS, the items of "facialmuscle function" and "ataxia" have modest reliability and the internalconsistency is good as demonstrated by the score ofCronbach'sα(0.861).Eight items do not show good reliability in various assessments. The itemof "facial muscle function" has low validity. There dos not exist a specific item to evaluate the function of cerebellum and brain stem exceptthe item of "ataxia". The scores of NIHSS have a high correlation withstroke outcome (both P=0.000). In the Chinese version of BI, the itemsof "transfer" and "bathing" have low reliability and the internalconsistency is perfect as demonstrated by the high Cronbach' s score(0.941). Telephone assessment in the BI exhibits a high correlation withdirect evaluation. Factor analysis in the BI reveal two factors, whichreflect functions of motor, bowel and bladder in stroke patients. Inthe SCND, the item of "walking" has low reliability and the internalconsistency is good as reflected by the score of Cronbach'sα(0.886).Four items do not show good reliability in various assessments, whichis highly correlated with the NIHSS (both P= 0.000) in both total andsubtypes of stroke patients according to OCSP classification byconcurrent validity analysis. There is ahigh correlation between thescores of the SCND and stroke outcome (both P=0.000). In the ChineseADL, the items of "household duties" and "paying cash, cash counting"have low reliability and the internal consistency is extraordinarily highreflected by high Cronbach'sαscore (0.966). There is a highcorrelation between telephone assessment and direct evaluation.Concurrent validity analysis of the scale demonstrates a high correlationwith the BI in both acute and convalescence stage after stroke, factoranalysis displays two factors in the scale, reflecting the motor andcognition functions of stroke patients.
Conclusions
1. The Chinese version of NIHSS has a good internal consistency, butis not suitable for telephone assessment. It is consistently predictive of stroke outcome, focusing more on the evaluation of disorders of arteriacarotis interna than those of vertebrobasilar artery. Addition of theitems and/or weight to assess the function of cerebellum and brain stemis necessary.
2. The internal consistency of the Chinese version of BI is extremelyhigh, indicating redundancy of some items or unnecessary items. It issuitable for telephone assessment. Two factors are demonstrated by factoranalysis, reflecting the motor function and bowel and bladder functionof stroke patients.
3. The SCND has good internal consistency, but it is not suitablefor telephone interview. There is concurrent validity between the scaleand the NIHSS and could predict stroke outcome. Factor analysis of theSCND displays the best construct validity in the patients with partialanterior circulation infarction (PACI), and could be used to evaluatethe focus of vertebrobasilar artery despite its insensitivity.
4. The Chinese ADL has an extremely high internal consistency,suggesting that some might be redundant or unnecessary., It is suitablefor telephone evaluation. Due to ambiguity, confusion andnon-specificity of some items, further revision is suggested. Concurrentvalidity exists between the scale and the BI. Factor analysis of theChinese ADL reveals two factors, which reflect the motor function andcognition function of stroke patients. It can thoroughly evaluate theactivities of daily living, therefore, the Chinese scale of theactivities of daily living is recommended for use after revision.
对象与方法222例急性脑卒中患者分别由不同评定者于入院当天、入院第14天、发病后第90天对同一脑卒中患者进行NIHSS、BI、临床神经功能缺损评分、中国ADL评定量表的评定。重测信度、评定者间信度与不同评定方式间的信度用Kappa值表示，分半信度、内部一致性信度用Cronbachα值表示。临床神经功能缺损评分、中国ADL量表的同时效度以及NIHSS、临床神经功能缺损评分的预测效度采用Spearman相关分析。结构效度采用因子分析的方法，其中脑梗死患者根据OCSP分型评定三种不同梗死类型的NIHSS和临床神经功能缺损评分的结构效度。
结果中文版的NIHSS“面肌功能”、“共济失调”的信度评定中等，Cronbachα值为0.861；不同评定者间信度显示8项条目信度不佳；“面肌功能”的评定效度较低，除了“共济失调”的评定，没有特异性反映小脑、脑干功能的条目；其评定结果与卒中结局有很好的相关性(均P=0.000)。中文版的BI“移动”和“洗澡”的信度评定相对较低，其Cronbachα值为0.941；电话随访评估与直接评测的相关性很高；有两个公因子，反映运动功能和括约肌功能。神经功能缺损程度评分“步行能力”信度评定相对较低，Cronbachα值为0.886；不同评定者间信度显示4项条目信度不佳；其与NIHSS评定结果间呈正相关(均P=0.000)，不同OCSP分型患者神经功能缺损评分与NIHSS评分结果均相关(均P=0.000)且与卒中结局有很好的相关性(均P=0.000)。中国ADL量表的“一般家务”和“用钞、点钞”的信度评定相对较低，Cronbachα值为0.966；电话随访评估与直接评测的相关性很高；其与BI在卒中后急性期及恢复期均有很好的相关性(均P=0.000)；该量表有2个公因子，反映患者的运动功能和认知功能。
结论
1．中文版的NIHSS内部一致性信度较高，但不适于电话评定。其对卒中结局有预测效度，且偏重于颈内动脉系统障碍的评定，对椎—基底动脉系统障碍的评定相对较少，应增加小脑、脑干功能评定的条目和／或权重。
2．中文版的BI内部一致性信度很高，可能有条目重复或不必要，适于电话随访，其有很好的结构效度，反映运动功能和括约肌功能。
3．神经功能缺损程度评分内部一致性信度较高，但不适于电话评定。其与NIHSS有同时效度，对卒中结局有预测效度；对PACI患者的结构效度最好，可以用来评定椎—基底动脉系统的卒中但并不敏感。
4．中国ADL量表的内部一致性信度很高，适于电话随访，但可能有条目重复或不必要，部分条目定义含混，涉及内容不具体，建议将此类条目进一步修订。其与BI有同时效度，该量表有2个公因子，反映患者的运动功能和认知功能，对卒中患者的日常生活活动能力评定更加全面，推荐使用修订后的中国ADL量表。
Objective To study the reliability and validity of the four scalesin evaluating stroke patients, which include the National Institutes ofHealth stroke scale (NIHSS)、the Barthel index (BI)、the clinicalneurologic deficit scale (CNDS) and the Chinese scale of the activitiesof daily living (ADL).
Sudjects and Methods Totally 222 consecutive inpatients with acutestroke onset were included in the study. They were assessed when admitted,at the 14th and 90th day of hospitalization by different rators using theNIHSS, BI, CNDS and the Chinese ADL. Intrarater、interrater andtest-retest reliability were determined by using Kappa correlation. Thesplit-half reliability and internal consistency were evaluated usingCronbach's a coefficient. Concurrent validity of the CNDS and theChinese ADL, and the predictive validity of the NIHSS and the CNDS weredetermined by spearman rank correlation coefficients. Construct validitywas assessed by the factor analysis and the construct validity of theNIHSS and the CNDS was measured according to the classifications of theOxfordshire Community Stroke Project (OCSP) ischemic stroke subtypes inthe patients with cerebral infarction.
Results In the Chinese version of NIHSS, the items of "facialmuscle function" and "ataxia" have modest reliability and the internalconsistency is good as demonstrated by the score ofCronbach'sα(0.861).Eight items do not show good reliability in various assessments. The itemof "facial muscle function" has low validity. There dos not exist a specific item to evaluate the function of cerebellum and brain stem exceptthe item of "ataxia". The scores of NIHSS have a high correlation withstroke outcome (both P=0.000). In the Chinese version of BI, the itemsof "transfer" and "bathing" have low reliability and the internalconsistency is perfect as demonstrated by the high Cronbach' s score(0.941). Telephone assessment in the BI exhibits a high correlation withdirect evaluation. Factor analysis in the BI reveal two factors, whichreflect functions of motor, bowel and bladder in stroke patients. Inthe SCND, the item of "walking" has low reliability and the internalconsistency is good as reflected by the score of Cronbach'sα(0.886).Four items do not show good reliability in various assessments, whichis highly correlated with the NIHSS (both P= 0.000) in both total andsubtypes of stroke patients according to OCSP classification byconcurrent validity analysis. There is ahigh correlation between thescores of the SCND and stroke outcome (both P=0.000). In the ChineseADL, the items of "household duties" and "paying cash, cash counting"have low reliability and the internal consistency is extraordinarily highreflected by high Cronbach'sαscore (0.966). There is a highcorrelation between telephone assessment and direct evaluation.Concurrent validity analysis of the scale demonstrates a high correlationwith the BI in both acute and convalescence stage after stroke, factoranalysis displays two factors in the scale, reflecting the motor andcognition functions of stroke patients.
Conclusions
1. The Chinese version of NIHSS has a good internal consistency, butis not suitable for telephone assessment. It is consistently predictive of stroke outcome, focusing more on the evaluation of disorders of arteriacarotis interna than those of vertebrobasilar artery. Addition of theitems and/or weight to assess the function of cerebellum and brain stemis necessary.
2. The internal consistency of the Chinese version of BI is extremelyhigh, indicating redundancy of some items or unnecessary items. It issuitable for telephone assessment. Two factors are demonstrated by factoranalysis, reflecting the motor function and bowel and bladder functionof stroke patients.
3. The SCND has good internal consistency, but it is not suitablefor telephone interview. There is concurrent validity between the scaleand the NIHSS and could predict stroke outcome. Factor analysis of theSCND displays the best construct validity in the patients with partialanterior circulation infarction (PACI), and could be used to evaluatethe focus of vertebrobasilar artery despite its insensitivity.
4. The Chinese ADL has an extremely high internal consistency,suggesting that some might be redundant or unnecessary., It is suitablefor telephone evaluation. Due to ambiguity, confusion andnon-specificity of some items, further revision is suggested. Concurrentvalidity exists between the scale and the BI. Factor analysis of theChinese ADL reveals two factors, which reflect the motor function andcognition function of stroke patients. It can thoroughly evaluate theactivities of daily living, therefore, the Chinese scale of theactivities of daily living is recommended for use after revision.
引文
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6. Hantson L, DeWeerdt W, DeKeyser J, et al. The european stroke Scale. Stroke, 1994, 25: 2215-2219.
7. Brott TG, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: aclinical examination scale. Stroke, 1989,20: 864-870.
8. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J,1965,14: 61-65.
9．中华神经科学会．脑卒中患者临床神经功能缺损程度评分标准(1995)(全国第四届脑血管病学术会议通过)．中华神经科杂志，1996，29：381-383．
10．陶寿熙，刘文耀，银占魁．一种简易型偏瘫运动功能评价法的应用．中国康复，1992，7：155—158．
11. Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry, 1988,51:1373-1380.
12. Feinstein AR. An additional basic science for clinical medicine, Ⅰ: the constraining fundamental paradigms. Ann Intern Med, 1983,99:393-397.
13. Feinstein AR. An additional basic science for clinical medicine, Ⅲ: the challenges of comparison and measurement. Ann Intern Med, 1983,99:705-712.
14. Feinstein AR. An additional basic science for clinical medicine, Ⅳ: the development of clinimetrics. Ann Intern Med, 1983,99:843-848.
15. Asplund K. Clinimetrics in stroke research. Stroke.1987,18:528-530.
16. Posner KL, Sampson PD, Caplan RA, Ward RJ, Cheney FW. Measuring interrater reliability among multiple raters: an example of methods for nominal data. Stat Med, 1990,9:l103-1115.
17. Cyr L, Francis K. Measures of clinical agreement for nominal and categorical data: the kappa coefficient. Comput Biol Med, 1992,22:239-246.
18. Lyden PD, Lau GT. A critical appraisal of stroke evaluation and rating scales. Stroke, 1991,22:1345-1352.
19. Mittl RL, Broderic M, Carpenter JP, et al. Blinded-reader comparison of magnetic resonance angiography and duplex ultrasonography for carotid artery bifurcation stenosis. Stroke, 1994,25:4-10.
20. Alexandrov AV, Bladin CF, Maggisano R, Norris JW. Measuring carotid stenosis: time for a reappraisal. Stroke, 1993,24:1292-1296.
21. Lyden PD, Lu M, Levine SR, Brott TG, Broderick J, NINDS rtPA Stroke Study Group. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke ,2001,32: 1310-1317.
22. Schlegel D, Kolb SJ, Luciano JM, et al. Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke, 2003, 34: 134-137.
23. Schlegel DJ, Tanne D, Demchuk AM, Levine SR, Kasner SE, Multicenter rt-PA Stroke Survey Group. Prediction of hospital disposition after thrombolysis for acute ischemic stroke using the National Institutes of Health Stroke Scale. Arch Neurol, 2004, 61: 1061-1064.
24. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health stroke scale: extension to non-neurologists in the context of a clinical trial. Stroke, 1997, 28: 307-310.
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39．王新，王拥军，颜振瀛，等．脑卒中患者临床神经功能缺损评分标准的信度和效度研究．卒中与神经疾病，1999，6：118—120．
2. Chopra P, Couper J, Herrman H. The assessment of disability in patients with psychotic disorders: an application of the ICIDH-2. Aust N Z J Psychiatry, 2002, 36:127-132.
3. Stuki G, Cieza A, Ewert T, et al. Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice. Disabil Rehabil, 2002,24:281-282.
4. Rimmer JH. Use of the ICF. in identifying factors that impact participation in physical activity/rehabilitation among people with disabilities. Disabil Rehabil, 2006,28:1087-1095.
5. Bamford J. Clinical examination in diagnosis and subclassification of stroke. Lancet, 1992,339:400-402.
6. Hantson L, DeWeerdt W, DeKeyser J, et al. The european stroke Scale. Stroke, 1994, 25: 2215-2219.
7. Brott TG, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: aclinical examination scale. Stroke, 1989,20: 864-870.
8. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J,1965,14: 61-65.
9．中华神经科学会．脑卒中患者临床神经功能缺损程度评分标准(1995)(全国第四届脑血管病学术会议通过)．中华神经科杂志，1996，29：381-383．
10．陶寿熙，刘文耀，银占魁．一种简易型偏瘫运动功能评价法的应用．中国康复，1992，7：155—158．
11. Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry, 1988,51:1373-1380.
12. Feinstein AR. An additional basic science for clinical medicine, Ⅰ: the constraining fundamental paradigms. Ann Intern Med, 1983,99:393-397.
13. Feinstein AR. An additional basic science for clinical medicine, Ⅲ: the challenges of comparison and measurement. Ann Intern Med, 1983,99:705-712.
14. Feinstein AR. An additional basic science for clinical medicine, Ⅳ: the development of clinimetrics. Ann Intern Med, 1983,99:843-848.
15. Asplund K. Clinimetrics in stroke research. Stroke.1987,18:528-530.
16. Posner KL, Sampson PD, Caplan RA, Ward RJ, Cheney FW. Measuring interrater reliability among multiple raters: an example of methods for nominal data. Stat Med, 1990,9:l103-1115.
17. Cyr L, Francis K. Measures of clinical agreement for nominal and categorical data: the kappa coefficient. Comput Biol Med, 1992,22:239-246.
18. Lyden PD, Lau GT. A critical appraisal of stroke evaluation and rating scales. Stroke, 1991,22:1345-1352.
19. Mittl RL, Broderic M, Carpenter JP, et al. Blinded-reader comparison of magnetic resonance angiography and duplex ultrasonography for carotid artery bifurcation stenosis. Stroke, 1994,25:4-10.
20. Alexandrov AV, Bladin CF, Maggisano R, Norris JW. Measuring carotid stenosis: time for a reappraisal. Stroke, 1993,24:1292-1296.
21. Lyden PD, Lu M, Levine SR, Brott TG, Broderick J, NINDS rtPA Stroke Study Group. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke ,2001,32: 1310-1317.
22. Schlegel D, Kolb SJ, Luciano JM, et al. Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke, 2003, 34: 134-137.
23. Schlegel DJ, Tanne D, Demchuk AM, Levine SR, Kasner SE, Multicenter rt-PA Stroke Survey Group. Prediction of hospital disposition after thrombolysis for acute ischemic stroke using the National Institutes of Health Stroke Scale. Arch Neurol, 2004, 61: 1061-1064.
24. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health stroke scale: extension to non-neurologists in the context of a clinical trial. Stroke, 1997, 28: 307-310.
25. Meyer BC, Hemmen TM, Jackson CM, et al. Modified National Institutes of Health stroke scale for use in stroke clinical trials: prospective reliability and validity. Stroke, 2002, 33: 1261-1266.
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