114 年 國立成功大學職能治療研究所《職能治療文獻閱讀》

本題主要在測試考生對於職能治療研究文獻的理解能力，包含研究的臨床應用目標、統計方法的辨識以及結果的詮釋。

題組共用題幹：

• Study 1 摘要：
  • Authors, title and journal source: Loubani, K., Schreuer, N., & Kizony, R. (2022). Participation in Daily Activities Among Women 5 Years After Breast Cancer. American Journal of Occupational Therapy, 76, 7604205050.
  • Abstract:
    • Objective: To (1) compare women's participation during the breast cancer (BC) subacute phase (2 yr postdiagnosis) with the chronic (5 yr postdiagnosis) phase, (2) explore factors associated with participation in the chronic phase, and (3) describe strategies women use to overcome participation restrictions.
    • Design: Descriptive longitudinal study.
    • Setting: A community health service in Israel.
    • Participants: A convenience sample of 30 women (M age = 53.9 yr, SD = 8.3) diagnosed with BC (Stages 1–3).
    • Outcomes and Measures: Demographic and BC-related symptom questionnaires; an adapted version of the Activity Card Sort, used to assess retained activity levels (RALs) compared with prediagnosis activity levels in sociocultural, physical, and instrumental domains; the Canadian Occupational Performance Measure; and one open-ended qualitative question, "How were you able to retain your participation in daily activities despite the long-term effects of BC?"
    • Results: Significantly higher total RALs were found in most domains for women in the chronic (M = 0.93 RAL, SD = 0.27) compared with the subacute (M = 0.71, SD = 0.22) phase, t(29) = 4.72, p < .001. Almost half the women achieved clinically significant change in their meaningful activities. Lower levels of participation were significantly correlated with higher symptom severity. The qualitative findings indicated that coping strategies, such as positive thinking and changing priorities, helped in managing women's participation.

本題旨在測試考生對研究設計中常見術語的理解，特別是隨機對照試驗（RCT）中的關鍵元素，以及特定研究方法學上的考量。

題組共用題幹：

• Study 2 摘要：
  • Authors, title and journal source: Rangon, F., Marinho, I., Cuviena, C., de Moraes, R., de Jesus Guirro, R., & de Oliveira Guirro, E. (2024). Effects of the Anchor System on Postural Balance of Women Undergoing Breast Cancer Treatment: A Clinical, Randomized, Controlled, and Crossover Trial. Archives of Physical Medicine and Rehabilitation, 105: 258-267.
  • Abstract:
    • Objective: Investigate the effects of multisensory training with and without the anchor system on breast cancer survivors' postural balance and self-efficacy of falls.
    • Design: Clinical randomized, controlled, and crossover trial.
    • Setting: Teaching, Research, and Assistance Center in Mastectomized Rehabilitation.
    • Participants: Eighty breast cancer survivors homogeneously distributed in the groups of adults and elderly affected, or not, by lymphedema.
    • Interventions: Participants were randomized to multisensory training with and without the anchor system involving 3 sessions per week for 12 weeks. After the 4-week washout period, the remaining therapeutic intervention was applied.
    • Main Outcome Measures: The primary outcome was semi-static and dynamic balance as evaluated by baropodometry and Mini Balance Evaluation Systems Test, and the secondary outcome was self-efficacy of the fall episode as assessed by Falls Efficacy Scale - International in the pre-, post-immediate, and 4-week follow-up period.
    • Results: Both therapeutic interventions caused positive and significant effects on postural balance and self-efficacy of falls in the immediate period. The multisensory training with the anchor system induced significant functional retention in the short term, related to the clinical effect of small to moderate variation.
    • Conclusions: Multisensory training with the anchor system is convenient for postural balance and self-efficacy for falls, regardless of age and upper limb volume, for breast cancer survivors.

(1) "randomized", "controlled", and "crossover" 的定義：

• Randomized (隨機)： 指研究參與者在進入不同研究組別（例如實驗組與對照組）時，是透過隨機化的方法來分配的。這意味著每個參與者都有相等或可預測的機率被分配到任一組。
  • 目的： 隨機化是為了確保研究開始時，各組之間在已知和未知的干擾因素（如年齡、疾病嚴重度、共病情況等）上達到均衡，從而減少選擇偏差（selection bias）。

本題主要在檢測考生對研究文獻摘要的解讀能力，特別是研究動機、臨床應用價值，以及對研究限制的批判性思考。

題組共用題幹：

• Study 3 摘要：
  • Authors, title and journal source: Ergen, H. I., Kudin, R., & McGee, C. W. (2024). Interrater reliability and precision of a novel hand strength assessment and treatment device: The GripAble. American Journal of Occupational Therapy, 78, 7805205140.
  • Abstract:
    • Objective: To establish the (1) interrater reliability and (2) precision of the GripAble among three raters with different expertise in occupational therapy when testing healthy participants, and to (3) evaluate the relative reliabilities of different approaches to estimating grip strength (i.e., one trial, mean of two trials, and the mean of three trials).
    • Design: Measurement study.
    • Setting: Minnesota Translational Musculoskeletal and Occupational Performance Research Lab, University of Minnesota, Minneapolis.
    • Participants: Thirty volunteers, age ≥18 yr, without any hand problems.
    • Outcomes and Measures: Using GripAble, three occupational therapy raters with varied experience measured the maximal grip strength of the dominant and nondominant hands of all participants. Using the mean of three trials when testing grip strength with GripAble adds precision.
    • Results: GripAble has excellent interrater reliability (i.e., intraclass correlation coefficient > .75) and acceptable precision (minimal detectable change < 15%) among healthy adults.
    • Conclusions and Relevance: GripAble allows occupational therapy practitioners with different experiences to assess grip strength in healthy hands quickly, precisely, and with excellent reliability. Additional research is needed on its psychometrics in clinical populations and capacities in remote monitoring and exergaming.

(1) 研究動機 (study motivation) 與臨床顯著性 (clinical significance)：

本題主要在測試考生對研究方法學中「次級資料分析」的理解，以及其優缺點的判斷。

題組共用題幹：

• Study 4 摘要：
  • Authors, title and journal source: Chang Rhim, H., Ward, R., Travison, T., Latham, N., & Bean, J. (2024). Defining Clinically Meaningful Cut Points for Leg Power Impairment Using Physical Performance in Older Adults: A Secondary Analysis from Boston RISE. Archives of Physical Medicine and Rehabilitation; 105:690-695.
  • Abstract:
    • Objective: To identify clinically meaningful thresholds of leg power impairment identified by the stair climb power test (SCPT).
    • Design: Cross-sectional analysis using the baseline data from an observational cohort study.
    • Setting: The Boston Rehabilitative Impairment Study of the Elderly.
    • Participants: Community-dwelling older adults (N=413).
    • Outcomes and Measures: SCPT and the Short Physical Performance Battery (SPPB).
    • Results: Using the receiver operating characteristic curves and Youden's J statistics, the optimal threshold for the SCPT associated with mobility limitation as defined by an SPPB score ≤9 was 3.07 Watts/kg for men with a sensitivity of 74%, a specificity of 73% and, an area under the curve (AUC) value of 0.78. For women, the optimal threshold was 2.59 Watts/kg with a sensitivity of 83%, a specificity of 69%, and an AUC value of 0.81. The classification and regression tree sensitivity analysis demonstrated similar thresholds, 2.88 Watts/kg and 2.53 Watts/kg for men and women, respectively.

本題旨在測試考生對證據等級（Levels of Evidence）概念的理解，以及如何根據研究設計來判斷其證據等級。證據等級是評估研究品質和可靠性的重要指標。

題組共用題幹：

• Study 1 摘要： Descriptive longitudinal study.
• Study 2 摘要： Clinical randomized, controlled, and crossover trial.
• Study 3 摘要： Measurement study.
• Study 4 摘要： Cross-sectional analysis using the baseline data from an observational cohort study.

證據等級 (Levels of Evidence) 的一般排序 (由高至低)：

• Level I： 系統性回顧（Systematic reviews）或統合分析（Meta-analyses） of randomized controlled trials (RCTs)。
• Level II： 隨機對照試驗（Randomized controlled trials, RCTs）。
• Level III： 非隨機對照試驗（Non-randomized controlled trials）或對照組研究（Controlled trials without randomization）。
• Level IV： 世代研究（Cohort studies）或病例對照研究（Case-control studies）。
• Level V： 橫斷面研究（Cross-sectional studies）、描述性研究（Descriptive studies）、或測量研究（Measurement studies）。
• Level VI： 個案報告（Case reports）、臨床經驗（Expert opinion）、或權威意見（Anecdotal evidence）。

根據各研究設計進行判斷：

1. Study 2：Clinical randomized, controlled, and crossover trial.

   • 這是一個臨床隨機對照試驗（RCT），且是交叉設計。RCT 是評估介入效果的黃金標準，因此證據等級最高。
   • 證據等級：Level II

2. Study 4：Cross-sectional analysis using the baseline data from an observational cohort study.

   • 雖然其數據來源是觀察性世代研究（observational cohort study），但此研究本身進行的是「橫斷面分析」（Cross-sectional analysis）。橫斷面研究僅在特定時間點捕捉數據，無法建立因果關係，因此證據等級較低。
   • 證據等級：Level V

3. Study 1：Descriptive longitudinal study.

   • 這是一個描述性縱向研究。縱向研究（longitudinal study）比橫斷面研究（cross-sectional study）能觀察變化的趨勢，但若缺乏對照組或隨機化，則其證據等級通常低於 RCT。描述性研究主要在描述現象，若無對照組，則無法確立因果關係。

本題旨在測試考生對不同研究設計類型（橫斷面與縱向）的辨識能力，以及對研究摘要中描述的設計的理解。

題組共用題幹：

• Study 1 摘要： Design: Descriptive longitudinal study.
• Study 2 摘要： Design: Clinical randomized, controlled, and crossover trial. (此為介入性研究，其時間軸上會包含多個時間點的測量，具備縱向特性)
• Study 3 摘要： Design: Measurement study. (這類研究通常在特定時間點進行測量，或是在短時間內完成，不一定具備顯著的縱向特性，但也可視為單一時點的測量)
• Study 4 摘要： Design: Cross-sectional analysis using the baseline data from an observational cohort study.

(1) 橫斷型 (cross-sectional) 研究設計：

橫斷面研究是指在單一時點或短時間內，對一個群體進行數據收集和分析，以了解該群體在該特定時間點的特徵或關係。

• Study 4： 摘要明確指出 "Cross-sectional analysis using the baseline data from an observational cohort study"。

本題旨在綜合應用前面所學的知識，包含研究設計、研究動機、臨床應用，以及證據等級等概念，來回答一個與職能治療研究實務情境相關的問題。考生需要將所學知識融會貫通，並應用於一個假設性的研究情境。

題組共用題幹：

• Study 1 摘要： Descriptive longitudinal study.
• Study 2 摘要： Clinical randomized, controlled, and crossover trial.
• Study 3 摘要： Measurement study.
• Study 4 摘要： Cross-sectional analysis using the baseline data from an observational cohort study.

研究情境：
一位職能治療所的碩士生，研究方向是「開發一套新式的兒童本體覺評估工具」。

(1) 最直接相關可參考的研究：

開發一個「新式的評估工具」的研究，其核心目標是驗證這個新工具的測量特性，例如其準確性、可靠性、敏感度等。在前面四個研究中，Study 3 是最直接相關的。

• Study 3 (Measurement study): 其研究目標是「建立一個新型手部力量評估與治療裝置的組間信度與精確度」。這與本題情境「開發一套新式的兒童本體覺評估工具」的研究目的高度一致，都是在驗證一個新開發的測量工具。

其他研究的相關性：

• Study 1 (Descriptive longitudinal study) 和 Study 2 (RCT) 雖然可能涉及對兒童本體覺功能在不同時間點的評估，但其主要目標不是開發工具本身，而是評估介入效果或描述現象。
• Study 4 (Cross-sectional analysis) 雖然使用了現有的測量工具（SCPT, SPPB）來分析數據，但其目標是定義閾值，而非開發新工具。

【答案】Study 3。

(2) 此類新評估工具或新方法開發之研究初期將著重於何種研究類型之實施？

新評估工具的開發初期，最關鍵的是要確保工具本身是「可用」且「可信」的。因此，初期研究會著重於驗證工具的測量特性 (psychometric properties)。這通常會採用：

• 測量研究 (Measurement study)： 如 Study 3 所示。研究者需要確保工具的：
  • 信度 (Reliability)： 包括組內信度（intra-rater reliability，同一評估者在不同時間測量同一對象的結果是否一致）和組間信度（inter-rater reliability，不同評估者對同一對象的測量結果是否一致）。