NEUROTHERAPY NEUROTHERAPY 2018;22(3):11-18 뇌성마비에게두려움을증가시켜비정상적인근긴장도와조절되지않는반사의출현을야기하고변형, 통증등뇌성마비의상태를악화시킬수있는위험이있다. 5),6),12) 슬링운동은근력강화와균형능력향상에탁월한중재방법이지만뇌

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1 NEUROTHERAPY 대한신경치료학회지제22권이은주제3호 보바스개념에기초한슬링운동이양하지뇌성마비균형에미치는영향 : 단일사례연구 이은주경성대학교이과대학물리치료학과 The Effects of Sling Exercise Based with Bobath Concept on the Balance of Spastic Diplegia Cerebral Palsy: Case Report Eun-Ju Lee Dept. of Physical Therapy, College of Health Science, Kyungsung University Purpose This study is to investigate the effect of sling exercise on the balance capacity of spastic diplegia cerebral palsy patient based on Bobath concept. Methods A single subject experiment was designed targeting an 8-year old child with the rigid bilateral cerebral palsy. The static balance test used the 30 second Rombug test of BT4, and the dynamic balance test used the timed up and go test. Results In the 30-second Rombug test of BT4, the child had a smaller median outcome than baseline and withdrawal period. In the TUG test, the walking speed in the intervention period was improved comparing to the baseline and withdrawal period. Conclusion The sling exercise based on the Bobath concept has been proved that it is an effective intervention to improve the static and dynamic balance capacity of patients with rigid bilateral cerebral palsy. Key words Spastic diplegia, Sling exercise, Muscle strengthening, Bobath concept, Balance Corresponding author Eun ju Lee (nkdreamju@ks.ac.kr) Received date 12 September 2018 Revised date 08 October 2018 Accepted date 10 October 2018 I. 서론 뇌성마비는발달중인뇌손상으로인한감각 운동장애증후군으로비정상적인근긴장도가나타나고근위부근육은동시수축이유발되지않아올바른자세유지가어렵다. 1) 특히경직성양하지뇌성마비는서기와보행시과도한골반전방경사, 고관절굴곡구축, 요추전만, 두부전방자세등비정상적인신체정렬과신체의무게중심이전방으로쏠리게되는현상이나타나는데, 2) 이런신체정렬은큰볼기근의근활성모멘트팔을감소시키고넙다리곧은근의길이와장력관계에서불충분을야기해항중력신전근들의근력을약화시킨다. 3) 또한신체가전방으로넘어지는것을막기위해후방에위치한넙다리뒤근과장딴지근은과활성화되어경직이증가되며근길이는단축되고균형능력은더욱떨어진다. 4) 균형이란일상생활활동의기능적인수행에있어매우중요한요소로신체의중력중심이체중지지기저면내에유지하며중력에대항하여서도넘어지지않게조절하는능력이다. 5) 균형은자세를 유지할때신체가움직이지않게하는정적균형과움직이는동안평형을유지하는동적균형으로나누어지는데신체의중심을기저면내에유지하고다시돌아오도록하기위해서는반드시근활성과근력생산이요구된다. 6) 균형능력향상을위해서정적상태에서의운동과동적상태에서의운동을하는데동적상태에서의운동이근활성을더욱일으키어균형감각과자세유지능력을증가시킨다고하였다. 7-8) 즉, 고정된지면과같은환경보다는치료용공위나슬링과같은상태에서운동을수행하는것이대뇌의운동기관에자극을주고고유수용기를자극하여균형감각과균형유지능력을극대화한다는것이다. 9) 슬링운동은매달려있는줄을통한다양한축변화를이용하여관절의가동성과신장, 근지구력증가및이완, 체간안정화의효과를얻어낼수있어근육강화운동에효과적인치료방법으로능동적으로환자가치료에참여할수있는중재방법이다. 10) 뇌성마비에게도슬링운동을적용하였을때체간근육활동이증진되어체간을안정화시켰다하였다. 11) 그러나근력강화운동시발생할수있는과도한노력과흔들리는줄로인한불안정한지면을제공할수밖에없는슬링운동은 보바스개념에기초한슬링운동이양하지뇌성마비균형에미치는영향 : 단일사례연구 11

2 NEUROTHERAPY NEUROTHERAPY 2018;22(3):11-18 뇌성마비에게두려움을증가시켜비정상적인근긴장도와조절되지않는반사의출현을야기하고변형, 통증등뇌성마비의상태를악화시킬수있는위험이있다. 5),6),12) 슬링운동은근력강화와균형능력향상에탁월한중재방법이지만뇌성마비적용에는위험성이있어슬링운동을뇌성마비에게적용할때는세심한주의가필요하다. 즉, 슬링운동으로인해발생될수있는문제점을최소한으로낮추며동시에슬링운동의긍정적인효과를가져올수있도록뇌성마비의임상적특징을완전히이해하고접근하여야한다. 보바스개념은중추신경계손상으로인한제한된일상생활능력을가진뇌성마비나뇌졸중환자등을위한평가, 치료, 관리를위한문제해결식치료접근방법으로비정상적인근긴장도와움직임은억제하고정상동작은촉진하는것을목적으로한다. 13) 슬링운동을보바스개념에기초하여시행하면근력운동의양과강도는뇌성마비특성과능력에맞게조절하며뇌성마비의비정상적인근긴장도는억제시킬수있어뇌성마비에게더욱안전하고효과적인중재방법이될수있을것이다. 이에본연구는보바스치료개념을기초로한슬링운동을경직성양하지뇌성마비에게시행하여슬링운동이뇌성마비의정적 동적균형능력에미치는영향을알아보고자한다. Ⅱ. 연구방법 1. 연구대상본연구대상은만 8세의경직형하지뇌성마비아동이다. 아동은재태연령 27주, 출생체중 1.06kg으로태어났고출생후 1분아프가점수는 3점, 5분아프가점수는 5점, 뇌출혈 4 단계, 뇌실주위백질연화증, 수두증등의진단과뇌실복강션트 (ventriculo-peritoneal shunt, V-P shunt) 시술을받았었다. 일상생활에서사물을조작하는아동의손기능은손기능분류체계 (Manual ability classification system; MACS) 2 단계로대부분의사물을조작할수는있으나속도는떨어지며서투르다. 운동기능은대근육운동분류시스템 (Gross motor function classification system, GMFCS) 2단계로실내나바닥이평평한실외에서는단거리이동이가능하지만제한적이다. 아동은소아의식척도 (Rancho Los Amigos) 8단계에해당되어시각이나청각에문제가없고자유롭게의사소통이가능하며근긴장도는대부분의하지관절전가동범위에서저항이느껴지는애쉬워스경직척도 (Modified Ashworth scale, MAS) 2단계에속한다. 아동의자세특징은서기에서과도한골반전방경사, 고관절굴곡, 무릎과신전, 발목저측굴곡이나타나고몸의무게중심은체중지지면전방으로쏠리 며과도한요추의전만이나타난다. 보행시에는한쪽다리지지기에체간을바로세우는정위반응이나타나지못하고체중지지쪽으로체간이과도하게측굴되는양상을보인다. 2. 실험방법 1) 연구절차본연구는단일피험자실험설계를사용하였으며기초선-중재- 유지-중재단계로수행되었다. 연구기간은총 10주기간이었고기초선과유지기간은각각 2주, 중재기간은각각 3주로배정하였다. 전연구기간내내보바스기본과정과심화과정을이수한물리치료 15년경력의물리치료사가뇌성마비아동에게기초선과유지기에는전통적인매트와테이블에서근력운동을실시하였고중재기에는슬링운동도구 (red cord, Norway) 를이용하여근력운동을실시하였다. 평가는기초선 2주후, 중재 3주후, 유지 2주후, 중재 3주후총 4번실시하였다. 본연구에서아동과보호자는연구에관한충분한설명을들은후자발적으로동의하여연구에참여하였다. 2) 슬링운동중재본연구에서사용된슬링운동은선행연구와문헌을보바스치료관점에서수정보완하여아동의특성과능력에맞추어주의깊게적용하였다 ) 중재프로그램은주 3회, 1시간씩, 총 18회실시하였으며준비운동, 본운동, 정리운동으로구성하였다 (Table 1). 중재시에는발가락꾸부림, 주먹을꽉지는원위부고정상태, 신체를분절적으로움직이기어려움, 비대칭적인자세, 입술과혀가뒤로당겨짐등의 2차적인보상경직이나타나지않는범위내의강도로만운동을실시하였으며중재중간아동이피로를호소하거나보상경직이나타나면즉시중재를중단하고휴식을취하게하였다. 3) 측정방법 (1) 전문균형평가및훈련시스템정적균형능력을알아보기위하여전문균형평가및훈련시스템 (BT4-Hur Lab, Finland) 의롬버그테스트 (Romberg test) 30초를사용하였다. 측정은맨발상태와보조기를착용한상태에서각각 2회측정하여더좋은값을채택하였다. 눈을뜨고균형능력을측정할때에는벽면에표시된한점을응시하도록시선의위치를통제하였고측정사이에는 5분간의휴식시간을두었다. 정적균형능력에사용한결과값으로는압력중심점이움직인범위로수치가클수록균형능력이저하됨을의미하는 C90 area(mm 2 ) 와압력중심점이움직인거리로수치가클수록균형능력이저하됨을의미하는 Trace length(mm), 일정한측정시간동안에움직인 Trace length(mm) 를측정시간으로나눈값으로수치가클수록자 12 The Effects of Sling Exercise Based with Bobath Concept on the Balance of Spastic Diplegia Cerebral Palsy: Case Report

3 이은주 Table 1. Intervention program Exercise Type Exercise Goal Exercise Contents Precaution Break Time Warm -up Flexibility Exercise & Normal Posture alignment Pelvic posterior tilting Eccentric contraction of rectus femoris In the supine position, the lumbar vertebrae are pressed to the floor and the navel is pulled up to the head. In the Ely test Position, the hip joint that has bending build-up is pressed to the floor. Preventing the compensatory dorsiflexion on the distal part of upper limbs, arms are stretched and fixed beside ears, and the navel is pulled up to the head to induce the rear inclination of pelvis. The head should be in the chin-tuck position. A symmetrical position should be maintained. Exercise Strengthening abdominal and pelvic muscles in sling exercise Supine position Prone position Rectilinear exercise of lower limbs is repeated in the positions of rear pelvic inclination and 90 degree flexion position of hip joint In the position eliminating the gravity of lower limbs, the child is let observe lower limbs and experience various movements. In the position of Prone on elbow, the pelvis is lifted to maintain the trunk in a straight line, and then the anal sphincter tightening exercise and abdominal drawing exercise are executed. The exercise should be within the strength not to induce distal fixation as the secondary compensation stiffness. The intervention should be stopped when the fatigue appears and the break should be given. 1min. between exercises Vibratory stimulation In each position, the activation of core stabilization muscle is induced by providing vibratory stimulation in various strengths and speeds. Warm -down Relaxation and fatigue recover Sitting position Breathing exercise, Stretching Vibratory stimulation 세및균형조절능력이떨어져낙상의위험이높다는것을의미하는 Sway average velocity(mm/s) 를사용하였다. (2) 일어서서걷기검사일어서서걷기검사 (Timed up and go test, TUG) 는신체장애가있거나없는아동들의기본적인운동성과균형을빠르게평가할수있는검사도구이다. TUG 검사는팔걸이가있는의자에서앉아 시작 이라는신호에따라의자에서일어나 서 3m 지점까지걸어간후방향을전환하여되돌아와서의자에앉기까지의시간을측정하는방법으로자세조절의선행적또는예측적측면을알수있다. TUG를완수하는데걸리는평균시간은 5-9세의아동들이 5.1±0.08초이다. 측정은초시계를사용하였고, 2회측정하여더좋은값을측정값으로하였다. 본검사의측정자내신뢰도는 r=0.99, 측정자간신뢰도는 r=0.98이다 16). 보바스개념에기초한슬링운동이양하지뇌성마비균형에미치는영향 : 단일사례연구 13

4 NEUROTHERAPY NEUROTHERAPY 2018;22(3):11-18 Table 2. Comparison of Static balance Type of foot Visual condition Baseline Intervention Withdrawal Intervention Trace length (Unit: mm) C90 area (Unit: mm 2 ) Velocity (Unit: mm/s) AFO Barefoot AFO Barefoot AFO Barefoot Open Close Open Close Open Close Open Close Open Close Open Close AFO: ankle foot orthoses (3) 분석방법정적균형능력을알아보기위한 BT4-HUR Balnce System (Finland) 의 Romberg 30초검사결과는각기간별추세를표로제시하였다 (Table 2). 동적균형능력을알아보기위한 TUG 검사결과는마이크로소프트오피스 Excel 2010과파워포인트를사용하여각기간별추세를그래프로나타내었다 (Figure 2). Figure 1. Intervention program Figure 2. Comparison of dynamic balance 14 The Effects of Sling Exercise Based with Bobath Concept on the Balance of Spastic Diplegia Cerebral Palsy: Case Report

5 이은주 Ⅲ. 결과 1. 정적균형능력의변화 보조기착용유무, 시각정보의각각변수들이정적균형능력과관계가있음을알수있다. 맨발보다보조기를착용했을때, 시각정보를제공하지않았을때보다는제공하였을때 Trace length 는짧아지며, C90 area 가좁아지고, Velocity 는감소하여속도가느려짐을알수있었고, 중재가끝난후 Trace length, C90 area, Velocity 의모든값이중재가없었던기초선과유지기에비해감소함으로써슬링운동중재가정적균형에긍정적인영향을미침을알수있었다. 또한, 1차중재후슬링운동을중단한 2주간의유지기에도 Trace length, C90 area, Velocity 값이기초선과비교하였을때감소함으로써슬링운동으로인한균형능력향상이중재가끝난일정시점까지도지속되고있음을확인할수있었다. 2. 동적균형능력의변화 TUG 검사결과는단하지보조기착용시 31.18초, 27.25초, 30.27초, 24.65초맨발 33.38초, 30.43초, 30.65초, 25.69초로아동은기초선과유지기에비해중재기에둘다수행속도가단축되어동적균형능력이향상되었음을알수있었다. 또한 1차중재후유지기에도기초선에비해서수행속도가감소됨으로써 1차중재의효과가일정시점까지지속되고있음을확인할수있었다. Ⅳ. 고찰 뇌성마비의모든주요근육은건강한또래집단에비해약하며운동능력이제한적인뇌성마비일수록근력은더약해진다고하였다. 17) 본연구에서는슬링운동을이용하여체간안정성과관계된근력강화운동을뇌성마비에게시행하였고그결과, 정적 동적균형능력이향상되었음을확인할수있었다. 체간안정화근육들은허리, 골반, 복부의 20여개의근육들로이루어며, 18) 척추를선택적이고분절적으로조절하여팔 다리동작을자유롭게하고신체의중력중심이체중지지기저면내에서유지하게하여사람의자세유지와기능적움직임수행에있어매우중요한역할을한다. 19) 뇌성마비에관한자세안정성에대한선행연구들을살펴보면등척성근력강화운동이나탄성밴드를이용한체간근력강화운동이뇌성마비의대동작운동기능, 근력, 보행속도, 균형능력을향상시켰다고하였는데 20-22) 이는슬링을이용한체간안정화근력강화운동이뇌성마비의정적 동적균형능력을향상시켰던본연구의결과와도일치된다. 김용순 (2000) 은뇌성마비에게누운자세에서일어나기, 다리들고버티기, 무릎을가슴까지구부리기, 쪼그렸다일어서기등의체간근력강화운동을시행하였으나서기와앉기자세에서는큰변화가없었다고하여본연구의결과와상반된다. 23) 이는위연구의체간근력강화운동프로그램이고정된지면에서실시하는정적안정상태에서의운동이었고본연구에서는슬링운동이근활성에더욱효과적인동적안정상태에서의운동이었기때문에서기와걷기같은균형능력에효과적이었을것이라고사료된다 ) 체간의안정성과고관절신전근강화를위하여적용되는교각 (bridging) 운동경우에도슬링을이용하여실시했을때가지면에서실시했을때보다체간의안정성에중요한역할을하는척추심부근의근활성도와고유수용성감각을더증가되었다고하였다. 7) 이는슬링의불안정한지지면이근활성도를더욱증가시키며근육의안정성과균형능력에영향을주기때문이라하였다. 23),26) 슬링을이용한체간안정화운동이뇌성마비족저압에미치는영향에관한연구에서는뇌성마비의정적족저압과동적족저압에슬링운동이긍정적인영향을미쳤고운동능력과균형능력도더욱향상시켰다고보고하였다. 6),27) 본연구의대상자인뇌성마비아동은서있는자세에서앞쪽복부근육은정상보다약하고느슨해져있고고관절굴곡근과등쪽체간근육들은상대적으로긴장하고짧아져골반전방경사증가와과도한요추만곡이관찰되었는데이러한부적절한자세와정렬에서는올바른근력운동이이루어지기어렵다. 28) 근력강화운동은뇌성마비의경직을증가시키지않는다는연구도있지만, 29) 잘못된자세에서과도한노력으로행하는근력강화운동은뇌손상환자에게경직을증가하게하고근육과관절이구축되게하며운동기능을저하시킬수있는위험요인으로인식되고있다. 30) 즉, 비대칭적인자세에서과도한노력을동반한잘못된근력운동은발가락꾸부림, 주먹꽉짐, 혀뒤로당김등뇌성마비의비정상적인근긴장도를증가시키고자세변형및통증을초래하는위험이된다. 31) 이에본연구에서는슬링에서대칭적이고바른자세정렬로정확한근력강화운동을시행하기위한준비운동으로안정적인지면의바로누운자세에서배꼽을복벽안쪽으로당기며동시에증가된요추만곡척추를바닥에붙이며골반후방경사를유도하는수정된복부드로잉-인기법을시행하였다. 32) 이운동은정상보다길어져있는앞쪽체간근육은구심성수축으로강화시키고, 짧아져있는뒤쪽체간근육은원심성으로수축시켜뇌성마비아동의자세를대칭적이게한다 (Figure 1). 또한엘라이테스트 (Ely test) 자세를취한엎드린상태에서증가된고관절굴곡부위를능동적으로바닥에닿도록하여고관절굴곡근은원심성수축으로근육의길이를늘이며강화하고큰볼기근은구심성수축으로강화시켜중심부의올 보바스개념에기초한슬링운동이양하지뇌성마비균형에미치는영향 : 단일사례연구 15

6 NEUROTHERAPY NEUROTHERAPY 2018;22(3):11-18 바른자세정렬을더욱촉진하였다 (Figure 1). 이와같은척추와골반의올바른자세정렬은본운동시척추심부근의동시수축과보다정확한고유수용성감각정보를받아들일수있게하여뇌성마비의자세긴장도와안정성을개선하고균형능력을향상시킬수있게한다. 19) 척추심부근은신체의갑작스러운동요나예상하지못한척추의하중에반응하는데, 33) 척추심부근이위치한요 천추분절의압박력을높이고체간을고정하는데는진동이도움된다고하였다. 34) 진동이있는훈련과진동이없는훈련을비교한연구에서진동을사용하였을때가체간의근활성도가더높게나타났다고하였고, 35) 지속적이고약한주파수로적용되는수동적진동자극은근지구력을향상시킨다고하였다 ) 이에본연구에서도슬링운동을시행할때수동적인진동자극도함께주었는데그결과정적균형능력과동적균형능력이향상되어진동자극이척추안정화근육의근활성도와지구력향상에긍정적인영향을미쳤을것으로사료된다. 뇌성마비는근긴장도는증가되어있어도근력은약화되어있어지상에서의정확한항중력동작과활동경험이부족하다. 본연구의대상인뇌성마비아동도항중력서기자세에사용되는큰볼기근과넙다리네갈래근등의하지의근육들이도수근력검사 2등급이하로중력에대항하는동작이나타나지않았다. 뇌성마비에게는중력을제거한상태에서 6),10) 운동을할수있는수중치료를실시하기도하는데, 38-39) 슬링운동도지상에서중력을제거한상태로운동을할수있는장점이있다. 40) 이에중력을제거한상태에서실시한본연구의슬링운동은뇌성마비아동에게항중력방향으로동작을쉽게경험할수있게하고반복적인연습도가능하게하여뇌성마비의체간안정화근력을빠르게강화시킬수있는중재방법이라할수있었다. 본연구의결과를볼때본연구에서보바스개념에기초한슬링운동은양하지뇌성마비의정적균형능력향상과동적균형능력향상에효과적이고효율적인중재방법임을알수이었다. 그러나본연구가단일사례를대상으로한연구결과라모든뇌성마비에게일반화시키기에는제한이있다. 따라서추후다양하고많은뇌성마비환자를대상으로하는연구가더필요할것으로사료된다. References 1. Bickley C, Linton J, Sullivan E et al. Comparison of Simultaneous Static Standing Balance Data on a Pressure Mat and Force Plate in Typical Children and in Children with Cerebral Palsy. Gait Posture Couillandre A, Maton B, Brenière Y. Voluntary toe-walking gait initiation: electromyographical and biomechanical aspects. Experimental brain research 2002;147(3): Neumann DA. Kinesiology of the musculoskeletal system-e-book: foundations for rehabilitation. : Elsevier Health Sciences; Park ES, Park CI, Lee HJ et al. The effect of electrical stimulation on the trunk control in young children with spastic diplegic cerebral palsy. J Korean Med Sci 2001;16(3): Eun NR, Chang WN, Song BK. Effects of Trunk Control on Sitting Posture and Standing Balance - by Adults Bobath Concept. J Korean Soc Neur Ther. 2015;19(3): Yeom JN, Lim CG. Change of static and dynamic foot pressure after trunk stabilization exercises in children with spastic diplegic cerebral palsy. J Kor Phys Ther 2014;26(4): Lehman GJ, Hoda W, Oliver S. Trunk muscle activity during bridging exercises on and off a swissball. Chiropractic & osteopathy 2005;13(1): Taube W, Gruber M, Beck S et al. Cortical and spinal adaptations induced by balance training: correlation between stance stability and corticospinal activation. Acta Physiologica 2007;189(4): O'sullivan PB, Phyty GDM, Twomey LT et al. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22(24): Kim SY, Kwon JH. Lumbar stabilization exercises using the sling system. The Journal of Korean Academy of Orthopedic Manual Physical Therapy. 2001;7(2): Lee MS, Choi JD. The Effects of Task Oriented Training with Suspension Device on Trunk Stability and Gross Motor Function of Children with Spastic Diplegia Cerebral Palsy. J Korean Soc Phys Med, 2013; 8(4): Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young people with cerebral palsy. Dev Med Child Neurol. 2003;45(10): Chang WN, Kim JH, Hwang BY. Effect of Trunk Facilitation based on the Bobath Concept on Trunk Alignment and Weight Distribution in Patients with Stroke. J Korean Soc Neur Ther. 2017;21(3): Song GB, Heo JY. The effects of bridge exercise with abdominal drawing-in on balance in patients with stroke. 16 The Effects of Sling Exercise Based with Bobath Concept on the Balance of Spastic Diplegia Cerebral Palsy: Case Report

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8 NEUROTHERAPY NEUROTHERAPY 2018;22(3):11-18 on Motor Function and Balance in Children with Spastic Cerebral Palsy. Journal of Special Education & Rehabilitation Science 2015;54(1): Gong WT. Effects of bridge exercises with a sling and vibrations on abdominal muscle thickness in healthy adults. Journal of back and musculoskeletal rehabilitation 2015;28(4): Broeks JG, Lankhorst GJ, Rumping K, et al. The long-term outcome of arm function after stroke: Results of a follow-up study. Disabil Rehabil. 1999;21(8): The Effects of Sling Exercise Based with Bobath Concept on the Balance of Spastic Diplegia Cerebral Palsy: Case Report

80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization

80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization 1) 스위스볼을적용한교각자세변화에따른체간의근활성도비교 The Comparison of Trunk Muscles Activity During Bridging Stabilization Exercises on Swiss Ball According to Change of Position Sun-tae Son, Min-hye Kim, Hee-jin Kim, Ji-hye