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1 Clinical Article The Korean Journal of Sports Medicine 2012;30(2): 경직형뇌성마비아동에서수중운동프로그램과지상운동프로그램이운동기능과균형에미치는영향비교 삼성서울병원재활의학과 1, 삼육대학교물리치료학과 2 강성훈 1 ㆍ배영현 1,2 Comparison between the Effect of Aquatic Exercise Program and Land Exercise Program in Spastic Cerebral Palsy on Motor Function and Balance Sung-Hoon Kang, PT, MS 1, Young-Hyeon Bae, PT, MS Derpatrment of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul, 2 Department of Physical Therapy, Sahmyook University, Seoul, Korea The purpose of this study was to evaluate the efficacy of a aquatic exercise program (AEP) compared with a land exercise program (LEP) in children with spastic cerebral palsy on motor function and balance. Thirty children with spastic cerebral palsy receiving edgewise treatment were randomly assigned to two groups, a AEP and a LEP. AEP and LEP were applied to two groups of children with spastic cerebral palsy for 30 minutes, three times a week for 8 weeks. Range of motion (ROM) of ankle dorsi flexion, Modified Ashworth Scale (MAS) while ankle dorsi flexed, Pediatric Berg s Balance Scale (PBS), and Gross Motor Function Measure (GMFM) were used for pre and post comparison. There were significant differences of ROM while ankle dorsi flexed, PBS and GMFM between pre and post treatment in all the two groups (p<0.05). But as a measure of MAS while ankle dorsi flexed did not show a significant differences. And the was significant difference in the amount of change of the ROM while ankle dorsi flexion between the two groups (p<0.05). The results would suggest that both of the exercise program are equally effective. Key Words: Aquatic exercise, Balance, Land exercise, Motor function, Spastic cerebral palsy 서 론 Received: July 10, 2012 Accepted: October 19, 2012 Correspondence: Young-Hyeon Bae Derpatrment of Physical and Rehabilitation Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul , Korea Tel: , Fax: baeyhhhh@naver.com CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 제왕절개등의분만과관련한의학기술의발달로정상분만하는경우가많아졌으나조산과초저체중아로출생하는뇌성마비고위험군의생존율이증가하고있다 1,2) 년간국내뇌성마비환아의유병률은소아 1,000명당 3.2명으로뇌성마비의유병률은낮아지지않고있다 2). 뇌성마비는미성숙된뇌의병변이나장애로인하여태아시또는생후첫 2년이내발생하는비진행성장애를말하며운동과자세조절능력을상실하는증상을지니고있다. 따라서 116 대한스포츠의학회지

2 강성훈외. 경직형뇌성마비아동에서수중운동프로그램과지상운동프로그램이운동기능과균형에미치는영향비교 적절한치료를받지못하면성장하면서운동기능의발달장애뿐만아니라비정상적인움직임패턴이심화되는양상을나타낸다. 그리고뇌성마비의발생률은높지않다고볼수도있으나그장애가환자의일생동안지속되는경우가대부분이므로발생률은높으나쉽게치료되는타질환보다오히려더심각하다고할수있다 3). 뇌성마비중에경직형은근육의과긴장 (hypertension), 저긴장 (hypotension) 으로인해근골격계의비정상적인협응형태를보이고 4), 이러한근육의불균형은다리와골반에서높은긴장도를만들뿐만아니라체간의불안정성을유발하여비정상적인자세 (abnomal posture) 를유발한다. 또한자세조절과체중부하에있어서도발달장애를일으켜제한된움직임을만들며앉고, 서고, 걷는데어려움을갖게된다. 따라서경직형뇌성마비아동에서관절가동범위및근긴장도, 운동기능등의평가가중요하다 5,6). 현재뇌성마비아동의운동기능과균형을회복시키기위해여러가지운동프로그램방법이개발되어이용되어지고있다. 이러한운동중재방법들은대부분지상운동이주종을이루고있으며, 대부분과도한병적반사와비정상적인동작을억제하는쪽으로초점이맞추어져있어기능적으로자세조절과보행형태를개선하는데상대적으로효과가떨어지는한계점을나타냈다 1). 최근국내에서신체의기능적운동조절과운동학습을위한운동중재방법으로써수중운동방법에대한관심이확대되고있는실정이다. 뇌성마비환자에서수중운동은신경근촉진과근력향상, 지구력향상, 관절가동범위증가, 근육이완, 근재교육, 균형감각과안정성의증진에효과적인것으로알려져있고 7), 수중운동이근력강화와경직을감소시키는데효과적일뿐만아니라, 심리적안정과새로운경험에대한흥미를유발시켜오랜시간운동에적극적으로참여할수있게한다 8). 그리고 33 o C 35 o C의물온도는근육의경직없이스트레칭, 마사지를통한근골격계이완의효과와통증감소, 순환개선, 과긴장성근육군에발생되는소비성대사를감소시켜움직임을개선한다 9). 또한, 수중운동은다양한물의유체역학적특성에의해지상에서움직일수없는움직임을충격이나부상없이수행할수있는장점을가지고있다 7). 기존의연구들중에는편마비환자들을대상으로지상운동과수중운동을실시한후근긴장도를비교한연구 10), 경직형뇌성마비아동들을대상으로수중운동을실시할때수온에따른근긴장도를측정한연구 11), 수중운동이뇌성마비아동의운동기능, 보행패턴과정적균형에미치는영향을알아본 연구 12-16), 그룹수중운동의효과연구 17) 가진행되었다. 그러나국내에서수중운동이확대되고있는데비해기존의지상운동과효과를비교검증한연구와수중운동과지상운동의복합운동프로그램의연구는미비한실정이다. 따라서, 본연구는병원, 특수학교, 복지관등다양한기관에서뇌성마비아동에서수중운동프로그램의활용이점점활성화되고있는점을고려하여, 경직형뇌성마비아동에서수중운동프로그램과지상운동프로그램이하지운동기능과균형에미치는영향을비교하여수중운동프로그램의효과를검증하고자하였다. 연구방법 1. 대상 서울 N 복지관에서치료를받는경직형뇌성마비아동중에레어의공식 (Lehr s formula) 에의해탈락률을고려하여대상자선정기준에적합한 36명을대상자를선정한후무작위로두군으로나누어수중운동군 18명, 지상운동군 18명을대상으로하였다. 대상자중탈락자를제외하여최종분석대상은수중운동군 15명, 지상운동군 15명이었다. 대상자선정기준은뇌성마비아동으로항경련제의투여나선택적후근절제술등의외과적수술을시행하지않는경우로연구자가지시하는내용을이해하고협조할수있을정도로의사소통이가능한아동, 아동과아동의부모가본연구의목적을이해하여연구에참여하는것을동의한대상으로하였다. 대상자의일반적특성과의학적특성은 Table 1과같다. Table 1. General and disease-related characteristics of subjects Value Aquatic exercise (n=15) Land exercise (n=15) X 2 /p Sex (male/female) 11/4 8/ Age (y) 8.40± ± Height (cm) ± ± Weight (kg) 24.06± ± Spastic type Hemiparesis Diparesis 6 6 Quadriparesis 4 5 GMFM type III IV 6 5 GMFM: Gross Motor Function Measure. 제 30 권제 2 호

3 SH Kang, et al. Effect of Aquatic Exercise Program and Land Exercise Program in Spastic Cerebral Palsy 성별은수중운동군에서남성 11명과여성 4명이었고지상운동군에서남성 8명과여성 7명이었다. 수중운동군과지상운동군의평균나이는각각 8.40±2.19세와 8.06±2.40세, 평균키는각각 ±13.04 cm와 ±19.43 cm, 평균몸무게는각각 24.06±8.43 kg과 25.40±11.56 kg을나타냈고마비의종류는수중운동군에서편마비형 5명, 양하지마비형 6명, 사지마비형 4명이었고지상운동군에서편마비형 4명, 양하지마비형 6명, 사지마비형 5명이었다. 그리고대동작기능의분류는수중운동군에서 III형 9명, IV형 6명이었고지상운동군에서 III형 10명, IV형 5명이었다. 2. 방법본연구에서는수중운동과지상운동을물리치료사각각 1명이실시하였으며, 각운동프로그램에대해교육을이수하고경력 5년이상의숙달된자로선정하였다. 각군에따라수중운동과지상운동을 8주간에걸쳐주 3회, 1일 30분간실시하였다. 8주간의중재후두군모두사전검사와동일한사후검사를받았다. 운동프로그램은선행연구를바탕으로구성하였으며, 운동은 8주에걸쳐주 3회씩연구자의감독하에수행되어졌다. 매회운동시간은전체 30분으로구성하였으며수중운동군은수중회전조절프로그램 (Halliwick rotation program) 을바탕으로구성된운동프로그램을 30분간실시하였고지상운동군은신경발달치료를바탕으로구성된운동프로그램을 30분간실시하였다 18,19). 주차별로목적에따라점진적으로강도와빈도를증가시켰으며, 모든운동은치료사의지도및감독하에실시하였다. 또한훈련을시작하기전에물리치료사가운동프로그램에대한교육을실시하고운동시개인별신체상태나체력수준, 운동에대한이해를고려하여운동의강도와횟수를점차늘려시행하였다. 1) 수중운동프로그램수중운동프로그램은 32 o C의수온에서 Lambeck와 Stanat 18) 가제시한수중회전조절프로그램으로 Halliwick 10 point program을바탕으로구성된운동프로그램이다 (Table 2). Halliwick 10 point program은수중에서자세조절을위한정신- 감각-운동학습단계 (psycho-sensory-motor learning sequence) 로서유체역학과더불어, 정신적적응과이탈 (mental adju stment and disengaement), 균형조절과이탈 (balance control and disengagement), 운동과이탈 (movement and disengagement) 의 3단계로크게구성된다. 정신적적응은환자가수중이라는 Table 2. Halliwick 10 point program The 10 point program Mental adjustment The three learning stage Mental adjustment and disengaement Balance control and Sagittal rotation control Transversal rotation control disengagement Longitudinal rotation control Combined rotation control Upthrust (mental inversion) Balance in stillness Turbulent gliding Simple progression Basic Halliwick movement (s) Movement and disengagement 새로운환경에적응하고정신적으로완전하게독립할수있도록치료하는동안에계속정신조절과이탈이번갈아가면서이루어져한다. 균형조절은수중에서자세유지를하기위한수중운동조절로각신체축에대한회전력을조절하여균형을유지해야한다. 수중에서회전조절이이루어지면스스로물에뜨게되며정신적적응도이루어진다. 마지막단계인운동에는억제와촉진단계가있다. 억제단계에서는스스로물에뜨는능력을획득한후가만히물에떠있는상태에서균형을이루어야하고와류에의해균형이무너지지않도록해야한다. 촉진단계에서는보다큰움직임으로유영을하는단계로수중에서자유로운움직임이완성되는단계이다 18). 2) 지상운동프로그램 지상운동프로그램은 Bobath 19) 가제안한신경발달치료원리에기초하여대상아동의현재기능수준에따라개별화된운동프로그램중재계획을설정하였다 (Table 3). 중재목표는몸통늘리기, 앉은자세에서일어나기, 균형감각조절, 다리분리운동프로그램을적용하는동안치료사의핸들링으로자세조절, 분리된움직임, 균형감각의향상등을촉진하였다 19). 3) 측정방법 연구대상자들에게운동프로그램을적용하기전에일반적특성을조사하였고평가는물리치료사 2명이담당하였으며, 평가를담당한물리치료사는치료를실시하지않았다. 평가에앞서발목관절의배측굴곡관절가동범위및근긴장도, 아동균형척도, 대동작기능측정에대하여검사자 2명이각측정도구에관해내용을숙지하고측정에필요한세부내용은동질성확보를위하여조정하였다. 평가를위한도구는발목관절의배측굴곡관절가동범위및 118 대한스포츠의학회지

4 강성훈외. 경직형뇌성마비아동에서수중운동프로그램과지상운동프로그램이운동기능과균형에미치는영향비교 Table 3. Land exercise program Land exercise program Objective Warming up (10 min) Treatment (50 min) Cooling down (10 min) Normalising postural tone, selectively movement Objective retraning balance reaction in sitting and standing Re-educating functional walk in Mat activities (side sitting, long sitting, rolling) Mat activities (Kneel-standing, Half-kneel-standing, standing up from half kneeling) Important activities for the trunk and lower limbs in lying activities in sitting Activities in standing with weight on the hemiplegic leg Activities during which the weightis on alternate legs Practical ways to facilitate walking Self-inhibition of associated reactions Protective step to regain balance Going up and down stairs Mat activities (side sitting, long sitting, rolling) 근긴장도, 아동균형척도, 대동작기능로나누어평가하였고, 모든평가는실험전과후에시행하였다. 모든평가는연구자에의해직접시행되었으며, 연구대상자는평가하기전평가에대한자세한설명을듣고충분한휴식으로피로감이없는상태에서소음이나외부로부터의방해를받지않는독립된공간에서평가를받도록하였다. 평가도중어지럼증이나중한피로감이있을때는즉시평가를중지하도록하였으며평가자와평가보조자는연구대상자의상태를계속모니터링을하였다. (1) 발목관절의배측굴곡관절가동범위 : 발목관절의배측굴곡관절가동범위측정은바로누운자세에서베개를사용하여슬관절을 20 o 굴곡시킨후발목관절이침대밖으로나오게한다. 외과의중앙을축으로하고고정자는축과비골두의연장선에위치하고이동자는전족부외측연에위치하여배측굴곡시에나타나는관절각을측정하였다 11). (2) 발목관절의배측굴곡근긴장도 : 근긴장도의측정도구로보정한 Modified Ashworth Scale (MAS) 를사용하였으며, 측정은실험대상자의양말을제거하고침상에앉은자세에서족관절의배측굴곡및저측굴곡운동을수동으로 5 8회시행한후긴장도를 MAS 등급에의해측정한다 20). (3) 균형능력 : 균형능력측정은아동균형척도 (Pediatric Berg s Balance Scale, PBS) 를사용하였다. Berg 균형척도를수정하여뇌병변질환과발달장애로인한경도또는중증도의운동장애를가진아동에게적용할수있는균형검사도구인 PBS를개발하였고, 이측정도구는전체 14항목으로구성되어있으며아동이그항목에대해정확히이해하도록하여구두로설명하거나, 시범을보여주거나, 연습기회를제공한다. 각각의항목에서독립적인수행정도에따라 0점에서 4점까지 5점척도로측정한다. 한글로번역한아동균형척도의측정자간신뢰도는 0.97로높은신뢰도를보였고본연구에서도 0.95로 높은신뢰도를보였다 21). (4) 대동작기능 : 대동작기능 (Gross Motor Function Measure, GMFM) 은시간경과에따른뇌성마비아동의대동작기능의변화를측정하기위해개발된도구이며 5개의기능적영역 ( 눕기와뒤집기, 앉기, 네발기기와무릎서기, 서기, 걷기 / 달리기 / 도약하기 ) 에서전체 88개항목으로이루어져있으며, 점수부여는 4점척도를적용한다. 0점은전혀수행못하는경우, 1점은그과제를 10% 미만수행한경우, 2점은과제의수행정도가 % 미만인경우, 3점은완전히수행한경우에부여된다. 한글로번역한대동작기능의측정자간신뢰도는 0.94로높은신뢰도를보였고본연구에서도 0.93으로높은신뢰도를보였다 22). 3. 통계처리연구의모든통계적분석은 SPSS ver (IBM, Armonk, NY, USA) 을이용하였다. 모든자료는 Shapiro-Wilk 검정방법을통해검정을실시하였다. 각집단내프로그램실시전ㆍ후차이비교분석은대응표본 t검정 (paired t-test) 을이용하였으며, 프로그램실시에따른집단과시기간의상호작용및집단간차이에대한주효과검정은이원반복측정분산분석 (2-way analysis of variance repeated measure) 을이용하였다. 집단간변화량의차이를비교하기위하여독립표본 t검정 (independent t-test) 을실시하였다. 모든통계적유의수준은 0.05 이하로하였다. 결과 1. 중재에따른전과후변화비교수중운동군과지상운동군의실험전측정항목의점수는 제 30 권제 2 호

5 SH Kang, et al. Effect of Aquatic Exercise Program and Land Exercise Program in Spastic Cerebral Palsy Table 4. Change of measurement fators between before and after Variable Group Before After t F Dorsi flexion of ankle ROM Aquatic exercise (n=15) -6.00± ± * Land exercise (n=15) -3.67± ± * MAS Aquatic exercise (n=15) 1.80± ± Land exercise (n=15) 1.67± ± PBS Aquatic exercise (n=15) 14.27± ± * Land exercise (n=15) 14.73± ± * GMFM Aquatic exercise (n=15) 56.52± ± * Land exercise (n=15) 58.26± ± * Values are presented as mean±standard deviation. ROM: Range of Motion, MAS: Modified Ashworth Scale, PBS: Pediatric Berg s Balance Scale, GMFM: Gross Motor Function Measure. *Paired t-test, p<0.05; Two-way analysis of variance repeated measure, p<0.01. 차이가없었으며, 전과후의변화는다음과같다. 집단과시기간의상호작용효과는관절가동범위 (p<0.01) 에서만유의하게나타났다. 수중운동군에서실험전과후발목관절의배측굴곡관절가동범위는 o ±3.87 o 에서 5.60 o ±4.66 o 로, 아동균형척도는 14.27±10.69에서 18.27±11.52로, 대동작기능은 56.52±16.87에서 62.90±19.07로모두유의하게증가하였고 (p<0.05) 발목관절의배측굴곡근긴장도는 1.80±0.41에서 1.40±0.51로감소하였으나유의한차이를보이지않았다. 지상운동군에서실험전과후발목관절의배측굴곡관절가동범위는 o ±4.80 o 에서 2.67 o ±4.63 o 로, 아동균형척도는 14.73±7.08 에서 17.93±6.47로, 대동작기능은 58.26±17.64에서 64.24± 17.16로모두유의하게증가하였고 (p<0.05) 발목관절의배측굴곡근긴장도는 1.67±0.49에서 1.27±0.46로감소하였으나유의한차이를보이지않았다 (Table 4). 2. 두군간에실험전과후변화량차이비교수중운동군과지상운동군간에실험전과후의변화량비교는다음과같다. 수중운동군과지상운동군간에실험전과후변화량을비교해보면발목관절의배측굴곡관절가동범위는수중운동군 o ±5.45 o 와지상운동군 6.34 o ±6.82 o 으로두군간에유의한차이를보였다 (p<0.05). 그러나발목관절의배측굴곡긴장도는수중운동군 0.40±0.79과지상운동군 0.39 ±0.83, 아동균형척도는수중운동군 4.00±14.76과지상운동군 3.21± 11.32, 대동작기능은수중운동군 6.37±27.41, 지상운동군 5.98± 28.97로두군간에유의한차이를보이지않았다 (Table 5). 고찰물과같이점성이있는액체를통하여물체를움직이는 Table 5. Comparison of between experimental and control Variable Aquatic exercise After-before Land exercise Dorsi flexion of ankle ROM 11.61± ± * MAS 0.40± ± PBS 4.00± ± GMFM 6.37± ± Values are presented as mean±standard deviation. ROM: Range of Motion, MAS: Modified Ashworth Scale, PBS: Pediatric Berg s Balance Scale, GMFM: Gross Motor Function Measure. *Independent t-test, p<0.05. 것이점성이상대적으로적은공기를통해서움직이는것보다더많은체성감각입력 (somatosensory input) 을만들어낸다고했다 23). 또한, 움직임에대한저항이피부의팽창혹은신장을야기시키는데이것은기계적수용기 (mechano receptor) 들을빠르게적응시키는자극을유발시키고고유수용성감각 (pro prioception) 에기여한다고하였으며, 물의부력, 저항등의효과로인해신체전반부위에고유수용기에대한자극이저하된기능을향상시킬수있다고주장하였다 24). 이러한장점을통해수중에서는개방역학적운동 (open kinetic chain exercise) 과폐쇄역학적운동 (close kinetic chain exercise) 을지상에서보다쉽게적용할수있으며, 머리의회전조절을통해다양한자세를유지할수있다 25). 본연구의결과를보면발목관절의배측굴곡관절가동범위에서는치료전ㆍ후두군모두에서통계학적유의한차이가나타났고두군간에는수중운동프로그램군이발목관절의배측굴곡관절가동범위에유의하게더많은증가를보였다. t 120 대한스포츠의학회지

6 강성훈외. 경직형뇌성마비아동에서수중운동프로그램과지상운동프로그램이운동기능과균형에미치는영향비교 그리고발목관절의배측굴곡근긴장도는치료전ㆍ후두군모두에서감소하였지만유의한차이가없었다. 뇌졸중환자에게관절가동범위운동을매트와수중에서적용한결과, 수중에서관절가동범위가더크게증가하였고 10), 뇌성마비아동에게물의온도에달리하여수중운동프로그램을적용하였을때근긴장도에변화가모두유의하게나타났다 11). 그러나본연구에서는근긴장도평가를위해근전도를사용한선행연구와달리 6단계로구분되는 MAS로측정하여근긴장도의전ㆍ후변화값이크게차이를보이지않았기때문에유의한결과를보이지못한것으로생각된다. 경직성편마비와양하지마비아동에서동일연령의정상아동에비해정적선자세, 동적앉은자세의균형조절능력이감소된소견을보여경직형뇌성마비아동의정적선자세와동적앉은자세균형조절능력의향상을위한집중적인훈련이필요하다고제시하였다 13). 본연구에서는아동균형척도에서는수중운동군과지상운동군모두실험전ㆍ후에유의하게향상된것으로나타났지만두군간에는유의한차이를보이지않았다. 경직형뇌성마비아동에게 12주간수중운동을실시한후균형이유의하게증가하였고 26), 같은대상으로 48주간수중운동적용시균형이유의하게증가하였다 27). 그리고경직형뇌성마비아동에서신경발달치료를바탕으로체간안정화운동을포함한지상운동은앉은자세의균형, 일상생활동작, 아동균형척도점수가향상되었다고하였다 28). 본연구에서수중운동과지상운동간에균형능력에서유의한차이는보이지않았으나두군모두치료적용후균형능력의향상을볼수있었다. 이는두운동모두경직형뇌성마비아동들의균형능력향상에효과를보이지만어떤방법이더효과적인지는알수없었다. 경직성하지마비아동에서근력강화운동을바탕으로구성된지상운동적용전ㆍ후대동작기능의점수가향상되었다 29). 그리고체간근력강화훈련을기반으로한수중운동뇌성마비아동의앉은자세, 하지근긴장도와대동작기능점수에서유의하게증가하였으며 30), 본연구에서도지상운동뿐만아니라수중운동모두뇌성마비아동의대동작기능향상에도움이되는것으로나타났지만두군간에는유의한차이를보이지않았으며, 본연구는각항목의점수를비교한것이아니라총점을비교한한계점이있었다. 따라서, 본연구는경직형뇌성마비아동에서수중운동과지상운동이운동기능과균형의향상에동등한효과를보이는것을확인할수있었다. 앞으로수중운동의효과를과학적으로검증하기위하여다양한운동프로그램과의비교연구, 객관적인변수를이용한연구와복합적구성된운동프로그램의연구가필요할것으로보인다. 참고문헌 1. Kim MK. Quantitative analysis and classification of the subtalar joint in standing and walking of children with cerebral palsy [dissertation]. Seoul [KR]: Sahmyook University; Brown JE, O'Hare NJ. Review of the different methods for assessing standing balance. Physiotherapy 2001;87: Winters TF Jr, Gage JR, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am 1987;69: Jones ET, Knapp DR. Assessment and management of the lower extremity in cerebral palsy. Orthop Clin North Am 1987;18: Gudjondottir B, Mercer VS. Hip and spine children with cerebral palsy: Muscularskeletal development and clinical implication. Pediatr Phys Ther 1997;9: Song BH. The effect of an exercise using elastic thera-band strengthening trunk muscles on the static sitting posture for children with CP. Korean J Spec Educ 2003;10: Kim TY, Kim KY, Lambeck J. Hydrotherapy in rheumatoid arthritis. J Korean Soc Phys Ther 2000;12: Hutzler Y, Chacham A, Bergman U, Szeinberg A. Effects of a movement and swimming program on vital capacity and water orientation skills of children with cerebral palsy. Dev Med Child Neurol 1998;40: Bates A, Hanson N. Aquatic exercise therapy. Philadelphia; Saunders: Chon SC, Yoon SI, Oh DW, Shim JH, Lee GW, Ahn CS. The effect of submerged relaxation exercise on muscle tone in persons with hemiparesis. J Korean Acad Univ Trained Phys Therapists 2006;13: Seo SK. Quantitative evaluation of muscle tonus by pool temperature during the aquatic therapy [dissertation]. Seoul [KR]: Dongshin Universtity; Kim MJ. Effects on the gross motor skills of the children with hemiplegia by aquatic rehabilitation exercise [dissertation]. Changwon [KR]: Changwon National University; Chung BK. The effect of aquatic rehabilitation exercise in interventions on gait pattern in pediatric with spastic cerebral palsy. J Phys Growth Motor Dev 2008;16; Chung BK. The effects of 16 weeks aquatic rehabilitation exercise on gross motor function in pediatric with cerebral 제 30 권제 2 호

7 SH Kang, et al. Effect of Aquatic Exercise Program and Land Exercise Program in Spastic Cerebral Palsy palsy. J Korean Soc Leisure Sport 2004;8: Choi CN. The effect of aquatic rehabilitation exercise program on static balance in cerebral palsy. Seongjijaehwaryeongu 2009;18: Kim SH, Ko YH, Yoon YB. Effect of aquatic exercise on body composition, fitness and pulmonary function of spasticity cerebral palsy. J Korea Contents Assoc 2005;5: Ballaz L, Plamondon S, Lemay M. Group aquatic training improves gait efficiency in adolescents with cerebral palsy. Disabil Rehabil 2011;33: Lambeck J, Stanat FC. The Halliwick concept. J Aquatic Phys Ther 2000;8: Bobath K. A neurophysiological basic for the treatment of cerebral palsy. 2nd ed. Philadelphia: JB Lippincot; Allison SC, Abraham LD. Sensitivity of qualitative and quantitative spasticity measures to clinical treatment with cryotherapy. Int J Rehabil Res 2001;24: Ko MS, Lee NH, Lee JA, Jeon HS. Inter-examiner reliability of the Korean version of the pediatric balance scale. J Korean Acad Univ Trained Phys Therapists 2008;15: Yi CH, Hwang SG, Choi HS. Inter-rater reliability of the gross motor function measure. J Korean Acad Univ Trained Phys Therapists 1995;2: Geigle PR, Cheek WL, Gould ML, Hunt HC III, Shafiq B. Aquatic physical therapy for balance: the interaction of somatosensory and hydrodynamic principles. J Aquatic Phys Ther 1997;5: Bandy WD, Sanders B. Therapeutic exercise: techniques for intervention. Philadelphia: Lippincott Williams & Wilkins; Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther 2007;87: Chung JK, Lim SJ. The Effect of aquatic exercise on physical fitness of children with cerebral palsy. J Spec Educ: Theory Pract 2002;3: Lim JH. The effect of auatic rehabilitation exercise on children with cerebral palsy patients in terms of body composition, physical fitness and breathing capacity. Seongjijaehwaryeongu 2007;15: Hwang YB. The effect of stabilization exercise in children with spastic diplegia [dissertation]. Busan [KR]: Catholic University of Busan; Ko MS. The effects of strength training on motor function and activity daily living with cerebral palsy. Seongjijaehwaryeongu 2005;13: Lee JH. The effects of strengthening trunk muscles using water exercises on sitting posture and muscle tone in lower extremities for the children with cerebral palsy [dissertation]. Seoul [KR]: Dankook University; 대한스포츠의학회지

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar