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J Korean Soc Phys Med, 2017; 12(4): 139-146 http://dx.doi.org/10.13066/kspm.2017.12.4.139 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 한글화된균형평가도구들의신뢰도와타당도분석 장호영 이정훈 1 이석민 2 삼육대학교물리치료학과일반대학원, 1 연세대학교작업치료학과, 2 삼육대학교물리치료학과 The Analysis on the Reliability and Validity of Korean-Version Balance Assessment Tools Ho-Young Jang, PT Jeong-Hoon Lee, OT 1 Suk-Min Lee 2 Dept. of Physical Therapy, The Graduate School, Sahmyook University 1 Dept. of Occupational Therapy, The Graduate School, Yonsei University 2 Dept. of Physical Therapy, College of Health and Welfare, Sahmyook University Received: November 1, 2017 / Revised: November 1, 2017 / Accepted: November 3, 2017 c 2017 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to systematically analyze the reliability and validity of the Korean-version of the balance assessment tools. METHODS: Two reviewers of this study independently evaluated the titles of articles and abstracts of studies published until December 2016 through electronic databases (RISS, NDSL, KISS, DBpia) using the keywords Balance or posture or postural control or postural stability, Test or assessment or measurement or outcome measure or assessment tool or measurement tool, Korean version, Reliability and Validity. Regarding the questions considered suitable for the purpose of this study, consensus was reached after reading the full text. Selecting journals Corresponding Author : leesm@syu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. suitable for the purpose of the study, they were analyzed as data. RESULTS: The reviewers selected nine papers suitable for the purpose of this study, and Korean-version of the balance assessment tools, included the Berg Balance Scale (BBS), Activities-specific Balance Confidence (ABC) scale, Postural Assessment Scale for Stroke (PASS), Motor Assessment Scale (MAS), Trunk Impairment Scale (TIS), Falls Efficacy Scale (FES), Tinetti-Balance scale, Fullerton Advanced Balance (FAB) scale, and Function In Sitting Test (FIST). Our study showed that the reliability and validity of the Korean-version of the balance assessment tools were high. CONCLUSION: The Korean-version of the balance assessment tools with high reliability and validity would enable physical therapists to make a more accurate evaluation of balance. Key Words: Assessment, Balance, Reliability, Tool, Validity

140 J Korean Soc Phys Med Vol. 12, No. 4 Ⅰ. 서론균형은지지면내에서체중심을유지하는능력 (Shumway-Cook과 Woollacott, 2007) 혹은넘어지지않고특정상태를유지 (maintaining), 성취 (achieving), 회복 (restoring) 하는인체의능력으로운동계, 감각계그리고물리적특성 (physical properties) 에영향받는다고하였다 (Pollock 등, 2000). 이런균형은일상생활을수행하고사회참여에있어서가장기본적으로요구되는신체활동능력이다 (Mayo 등, 2002). 뇌졸중, 외상성뇌손상, 척수손상, 뇌성마비, 파킨슨병등다양한신경계손상환자뿐만아니라관절염, 소아마비같은근골격계손상과당뇨와같은내과적질환그리고노인에게서균형장애를보인다 (Tyson 등, 2006; Basford 등, 2003; Sturnieks 등, 2004; Sturnieks 등, 2008). 물리치료는이런균형장애를개선하여신체능력을증진시키기위한방법으로 neurophysiological approaches (Bobath), moving platform, biofeedback, repetitive taskspecific training, virtual reality training과 pressure sense perception training 그리고진동을이용한몸통근력운동등의중재를사용한다 (Langhorne 등, 2009; Lee, 2013; Kim 등, 2015; Cho 등, 2017). 효과적인치료를위해서는환자에대한정확한균형평가가우선되어야한다. 평가는균형문제의원인을밝혀내고, 치료계획을수립하며, 결과측정에사용된다. 또한환자와보호자교육에필요한정보를제공하고이를통해신뢰를얻게한다. 뿐만아니라재활전문가들사이에정보공유를위한자료가되며, 근거중심물리치료에중요한부분이다 (Horak, 1997; APTA, 2001). Tyson과 Connell (2009) 은신경계손상환자의신뢰도와타당도있는균형평가도구들로 sitting balance section of the Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Brunel Balance Assessment (BBA), Standing Balance Scale, Trunk Impairment Scale (TIS), Sandin and Smith, balance section of the Fugl-Meyer motor assessment (FM-B) 등의다양한평가방법을추천하고 있다 (Tyson과 Connell, 2009). 그러나이런평가도구들은대부분다른나라에서만들어진평가도구들로언어적, 문화적차이로인해그리고물리치료사의균형평가에대한인식과실태조사에서낮은인식과실태를보이고있어 (Jang 등, 2017) 국내물리치료사들이균형평가를위해임상에적용하는데어려움이있다. 한글화된 Berg Balance Scale, Trunk Impairment Scale, Motor Assessment Scale의제시는이런문제를해결하고효과적으로균형평가를수행하게한다 (Jung 등, 2006; Seo 등, 2008; Cha 등, 2013). 현재많은한글화된균형평가도구들이신뢰도와타당도를검증하여제시되고있으나이에대한체계적인분석이이루어지지않았다. 이에본연구의목적은한글화된균형평가도구들의신뢰도와타당도를체계적으로분석하고제시하여임상에서물리치료사들이정확한평가를위해활용하고자한다. 아울러균형평가도구의임상가이드라인을위한기초자료로도활용될수있을것이다. Ⅱ. 연구방법 1. 연구절차문헌검색을통한체계적고찰로 electronic databases 는 RISS, NDSL과 KISS 그리고 DBpia를이용해 2016년 12월까지출간된문헌을검색하였으며, 검색 key word Balance or posture or postural control or postural stability, Test or assessment or measurement or outcome measure or assessment tool or measurement tool, Korean version, Reliability 그리고 Validity 를영어로 2명의리뷰어 (Jang HY과 Lee JH) 가독립적으로검색하였다. 2명의리뷰어는각각문헌의제목과초록을검토한후확인된자료중연구에적당하다고판단된문헌은전체문헌 (Full text) 을읽었다. 리뷰어들은선정된자료를연구방법과결과로분류하였고서로합의하에결정하였다 (Fig. 1).

한글화된균형평가도구들의신뢰도와타당도분석 141 Two reviewers entered the search keywords in electronic databases (RISS, NDSL, KISS, DBpia) to check 237 titles and 34 abstracts of publications published to December 2016. After checking each title and abstract, the reviewers read the full texts of appropriate articles (14 publications). Two reviewers checked the contents of the literature (14 publications) and classified them according to study methods and results. Full-text articles excluded, (5 publications) Reason to exclude publications Modified Balance assessment (2) Functional performance test (2) Pediatric balance scale (1) Two reviewers finally agreed on nine publications most relevant to the purpose of our study. Fig. 1. Process of the study Ⅲ. 연구결과리뷰어들은본연구에목적에맞는 9개문헌에자료를채택했으며, 한글화된균형평가도구들로는 Berg 균형척도 (Berg Balance Scale, BBS), 활동특이성균형자신감척도 (Activities-specific Balance Confidence, ABC scale), 뇌졸중의자세평가척도 (Postural Assessment Scale for Stroke, PASS), Motor Assessment Scale (MAS), Trunk Impairment Scale (TIS), 낙상효능척도 (Falls Efficacy Scale, FES), 티네티균형척도 (Tinetti-Balance Scale), 플러턴어드밴스드균형척도 (Fullerton Advanced Balance Scale, FAB scale), 기능적앉기검사 (Function In Sitting Test, FIST) 가있었으며, 각각의신뢰도와타당도를알아보았다. 1. Berg 균형척도 (Berg Balance Scale, BBS) 한글화된 Berg 균형척도의신뢰도는일차검사로 18례의환자에게서시행된 Berg 균형척도가기록된비디오영상을보고 9명의측정자는각기독립적으로 평가하고점수화하였으며, 이차검사는 10일후일차검사와같은방식으로시행되었다. 측정자간신뢰도는일차검사에서.97을보였고, 이차검사에서도.97로서측정자간의높은일치도를보였다. 측정자내신뢰도는재활의학과의사군은.95를보였고, 물리치료사군은.97이였다(Jung 등, 2006). 2. 활동특이성균형자신감척도 (Activities-specific Balance Confidence, ABC scale) 한글화된활동특이성균형자신감척도는 90명의노인을대상으로분석하였고, 4주후같은도구에대한재측정에응한 26명을대상으로검사-재검사신뢰도를구하였다. 그결과는.82로틍계적으로의미가있는상관관계를보여재검사에의해서도유사한결과를보임을알수있다. 타당도조사에서한글화된활동특이성균형자신감척도와낙상효능척도는통계적으로유의한차이를보여내용타당도가입증되었다 (Jang 등, 2003).

142 J Korean Soc Phys Med Vol. 12, No. 4 3. 뇌졸중의자세평가척도 (Postural Assessment Scale for Stroke, PASS) 43명의뇌졸중환자를대상으로한글화된뇌졸중의자세평가척도의신뢰도와타당도를분석하였다. 측정자간신뢰도는.97로높은신뢰도를보였다. PASS 는 BBS, TCT, FM-B (r=.65-.96, p<.01) 와유의한양의상관관계를보여자세조절의기능적인향상이있을수록균형능력은증가하는것을알수있었다 (An과 Lee, 2009). 4. Motor Assessment Scale (MAS) 한글화된 MAS는측정자간신뢰도를알아보기위해무작위로 20명의비디오파일을빔프로젝트를사용하여, 23명의물리치료사가각자독립적으로평가하였다. 측정자내신뢰도를평가하기위해무작위로 9명의환자를 3주간격으로 7명의물리치료사가 2번의평가를시행하였다. 측정자간신뢰도는.99이상으로매우높은신뢰도를나타내었다. 측정자내신뢰도는 1번항목 (ICC=.75) 과 3번항목 (ICC=.79) 에서보통의신뢰도를보였고, 다른항목에서는모두높은신뢰도를나타내었다 (ICC=.87~.99)(Cha 등, 2013). 5. Trunk Impairment Scale (TIS) 한글화된 TIS는 25명의뇌졸중환자를대상으로두명의측정자에의해측정자간신뢰도와측정자내신뢰도가평가되었다. 그결과측정자간신뢰도 ICC=.95, 검사-재검사일치도 ICC=.97으로높은신뢰도를보였다 (Seo 등, 2008). 6. 낙상효능척도 (Falls Efficacy Scale, FES) 한글화된낙상효능척도의검사-재검사신뢰도결과는.97였다. 한글화된낙상효능척도의총점과다른평가도구와의상관관계를분석한결과 GDS (r=.41), BBS (r=.45), TUG (r=.54) 및 MBI (r=-.47) 와중간정도의상관관계가있는것으로나타나만족할만한신뢰도와타당도가입증되었다 (An 등, 2012). 7. 티네티균형척도 (Tinetti-Balance Scale) 한글화된티네티균형척도의측정자간신뢰도는.91으로높은신뢰도를보였다. 한글화된티네티균형척도의총점과다른평가도구와의상관관계를분석한결과 10m 보행속도검사 (r=-.74), 마비측 OLST (r=-.72), 비마비측 OLST (r=-.76), STS (r=-.73) 와는음의상관관계가있었고, FM-상지운동기능 (r=.64), 하지운동기능 (r=.76) 과는양의상관관계가있어만족할만한동시타당도가있음을확인할수있었다 (Lee 등, 2013). 8. 플러턴어드밴스드균형척도 (Fullerton Advanced Balance Scale, FAB scale) 한글화된플러턴어드밴스드균형척도의검사- 재검사신뢰도는.99로높은신뢰도를보였고, Berg 균형척도와의동시타당도는 r=.89로높은상관관계를보였다 (Kim, 2016). 9. 기능적앉기검사 (Function In Sitting Test, FIST) 한글화된기능적앉기검사의측정자간신뢰도는.99로매우높았고, 동시타당도역시 TCT (r=.85), PASS (r=.82), MBI (r=.81) 로매우높은양의상관관계가있는것으로확인되었다 (An과 Lee, 2016). 본연구를통해한글화된균형평가도구들의신뢰도와타당도는높은것으로조사되었다 (Table 1). 측정자간신뢰도는 Berg 균형척도 (.97), 뇌졸중의자세평가척도 (.97), MAS (.99), 티네티균형척도 (.91), 기능적앉기검사 (.99) 가높았으며, 측정자내신뢰도는 Berg 균형척도 (.95~.97), TIS (.95) 높았다. 동시타당도조사에서는플러턴어드밴스드균형척도 (r=.89) 그리고기능적앉기검사 (r=.81~.85) 가높았다. Ⅳ. 고찰 많은평가도구들이대부분다른나라에서만들어진평가도구들로언어적, 문화적차이로인해그리고물리치료사의균형평가에대한인식과실태조사에서낮은인식과실태를보이고있어 (Jang 등, 2017) 국내물리치료사들이균형평가를위해평가도구를임상에적용하는데어려움이있다. 현재많은한글화된균형

한글화된균형평가도구들의신뢰도와타당도분석 143 Table 1. The Reliability and Validity of Korean-Version Balance assessment Tools Assessment tool Author (Year) Method Reliability and Validity BBS Jung et al. (2006) 18 stroke patients 9 physical therapy Inter-rater reliability.97 Intra-rater reliability.95~.97 ABC scale Jang et al. (2015) 90 elderly adults Test-retest reliability.82 PASS An and Lee (2009) 43 stroke patients Inter-rater reliability.97 Correlation with BBS, TCT, and FM-B (r=.65-.96) MAS Cha et al. (2013) 23 stroke patients 23 physical therapy Inter-rater reliability.99 Intra-rater reliability.75~.99 TIS 25 stroke patients Intra-rater reliability.95 Seo et al. (2008) Test-retest consistency.97 FES An et al. (2012) 73 stroke patients Test-retest reliability.97 Tinetti-balance scale Lee et al. (2013) 38 stroke patients Inter-rater reliability.91 FAB scale Kim (2016) 97 elderly adults Test-retest reliability.99 concurrent validity of BBS (r=.89) 43 stroke patients Inter-rater reliability.99 FIST An and Lee (2016) Concurrent validity of TCT (r=.85), PASS (r=.82), MBI (r=.81) BBS: Berg Balance Scale, ABC scale: Activities-specific Balance Confidence scale PASS: Postural Assessment Scale for Stroke, MAS: Motor Assessment Scale TIS: Trunk Impairment Scale, FES: Falls Efficacy Scale FAB scale: Fullerton Advanced Balance Scale, FIST: Function In Sitting Test 평가도구들이신뢰도와타당도를검증하여제시되고있으나이에대한체계적인분석이이루어지지않았다. 이에본연구의목적은한글화된균형평가도구들의신뢰도와타당도를체계적으로분석하고제시하여임상에서물리치료사들이정확한평가를위해활용하고자한다. 한글화된균형평가도구들의제작은먼저타국가의평가도구를한국어로번역하고, 그것을다시역번역하여이후원문과역번역본간의언어의구조적유상성과의미전달의유사성을평가하여최종감수를거쳐번역을완성하는과정을거친다. Berg 균형척도는 14개항목으로구성된서열척도로노인의균형능력을평가하기위해개발되었으며, 뇌졸중환자의균형능력평가에도신뢰도와타당도가인정되고있다 (Jung 등, 2006). 활동특이성균형자신감척도는낙상효능척도와같이 Bandura의이론을바탕으로만들어졌으나, 낙상효능척도와대조적으 로집안에서의활동뿐만아니라, 집밖의외부활동에대해서도광범위하게측정되어노인들중기능수준이중간이상으로높은대상자들의평가에특히유용하다고주장되었다 (Jang 등, 2003). 뇌졸중의자세평가척도는 Fugl- Meyer균형척도항목을수정보안하여뇌졸중환자의균형측정뿐만아니라뇌졸중환자의자세조절수행능력을평가하기위해만들었다 (An과 Lee, 2009). MAS는뇌졸중환자의기능적과제수행능력을평가하기위한평가지이다. MAS는뇌졸중환자의잔여운동기능을평가하여시너지패턴보다오히려기능적과제의수행능력을평가하기때문에널리유용하게사용되고있으며현재까지높은신뢰도와타당도를보이고있다 (Cha 등, 2013). TIS는 3가지항목으로최소 0점에서 23점으로정적앉은자세균형항목 (7점), 동적앉은자세균형항목 (10점), 협응평가항목 (6점) 으로구성되어있다. 해외에서 TIS는뇌졸중, 다발성경화증, 파킨슨씨병과같은다양한신경학

144 J Korean Soc Phys Med Vol. 12, No. 4 적인질환을가지고있는환자들의평가에서높은신뢰도와타당도를보고하였다 (Seo 등, 2008). Tinetti와 Richman (1990) 는낙상없이다양한일상생활동작을수행하는동안의만족도를평가하는도구인낙상효능척도를개발하였다. 총 10개문항으로다차원적으로구성되어있어사정도구로써의이용가치가높다. 한글화된낙상효능척도의검사-재검사신뢰도평가를위해치료사와환자의 1:1 대면하에초기평가를실시한후 72시간내에재평가를실시하였다. 그리고객관적인다른평가도구들과비교하여도구의타당도를알아보기위해한국판노인우울증척도 (Geriatric Depression Scale-Korean version, GDS), Berg 균형척도, 일어나걸어가기검사 (Timed Up & Go test), 수정된바델지수 (Modified Barthel Index, MBI) 가시행되었다. 검사-재검사신뢰도결과는.97였다(An 등, 2012). 노인의낙상위험도를결정하고균형및운동성의정도를평가할수있는도구로티네티균형 / 보행척도가개발되었다. 2~3점척도로구성되어있으며, 균형검사는 16점, 보행검사는 12점으로총 28점이만점이다. 뇌졸중환자 38명을대상으로 2명의물리치료사가측정자간신뢰도를측정했으며, 티네티균형척도의타당도를조사하기위해 2~3일에걸쳐 10m 보행속도검사, 마비측 비마비측외발서기검사, 앉고일어서기검사, Fugl Myer (Upper/Lower Extremity) 순으로검사를시행하였다 (Lee 등, 2013). 플러턴어드밴스드균형척도은 Berg 균형척도를이용한연구에서드러난높은균형능력을가진노인그룹에서의천정효과 (ceiling effect) 뿐만아니라전정계와시각계등과같은균형에영향을미치는다양한감각체계에대한평가항목이포함되지않은문제점을보완하기위해개발된수행능력기반균형평가도구이다. 10개항목으로구성되어있으며, 각항목은 0~4점서열척도로구성되어있다. 한글화된플러턴어드밴스드균형척도은노인 97명을대상으로검사-재검사신뢰도를위해대상자 97명중무작위로 64명을선정하여 3일후에재평가를실시하였다. 동시타당도를알아보기위해한글화된 Berg균형척도와비교하였다 (Kim, 2016). 기능적앉기검사는뇌졸중환자들의자세조절과균형과의 관련성을고려하여국제기능 장애 건강분류 (International Classification of Function, Disability and Health, ICF) 에기반한 14개의기능적이고양적인앉기균형을평가할수있도록고안되었다. 기능적앉기검사는침상에서앉기균형능력에현저히제한이있는뇌졸중환자들에게도평가를할수있다. 한글화된기능적앉기검사는 43명의만성뇌졸중환자를대상으로 2명의물리치료사가측정자간신뢰도를평가했고, 동시타당도를알아보기위하여 Trunk Control Test (TCT), PASS와 MBI를이용했다 (An과 Lee, 2016). 측정자간신뢰도는 Berg 균형척도 (.97), 뇌졸중의자세평가척도 (.97), MAS (.99), 티네티균형척도 (.91), 기능적앉기검사 (.99) 가높았으며, 측정자내신뢰도는 Berg 균형척도 (.95~.97), TIS (.95) 높았다. 동시타당도조사에서는플러턴어드밴스드균형척도 (r=.89) 그리고기능적앉기검사 (r=.81~.85) 가높았다. 본연구를통해한글화된균형평가도구들의신뢰도와타당도는높은것으로나타났다. 본연구의제한점은체계적인문헌고찰을통해자료를수집하였으나 electronic databases로 RISS, NDSL과 KISS 그리고 DBpia만을사용했으며, 2016년 12월이후출간된문헌과등재되지않은문헌이나회색문헌은검색하지못하였다. 아울러기능적동작수행을통한평가방법인 Sit to stand test (Cho 등, 2013), Step test (Lee 등, 2017) 와같은기능적동작수행을통한평가방법과수정된 PASS (Lee 등, 2014), 수정된 TIS (An과 Park, 2015) 같은수정된평가도구그리고아동균형평가도구 (PBS)(Ko 등, 2008) 는배제하였다. Ⅴ. 결론본연구는체계적인문헌고찰을통해한글화된균형평가도구들을확인하고, 그신뢰도와타당도를분석하였다. 그결과한글화된평가도구들은높은신뢰도와타당도를갖고있었다. 높은신뢰도와타당도를갖는한글화된균형평가도구들은임상에서치료사들이균형능력을평가하는데유용하게사용될수있을것이다.

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