J Korean Soc Phys Ther Vol.26, No.4, August 2014 The Journal of Korean Society of Physical Therapy plssn elssn X Original articles 승

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1 J Korean Soc Phys Ther Vol.26, No.4, August 2014 The Journal of Korean Society of Physical Therapy plssn elssn X Original articles 승마운동이뇌성마비아동의정적균형에미치는영향 최현진 1, 남기원 2 1 순천평화병원재활센터, 2 동신대학교보건과학대학물리치료학과 The Effect of Horseback Riding Simulator on Static Balance of Cerebral Palsy Hyun-Jin Choi 1, Ki-Won Nam 2 1 Department of Physical Therapy, Pyungwha hospital, 2 Department of Physical Therapy, College of Health Science, Dong-shin University Purpose: The purpose of this study is to examine the effects of using a horseback riding simulation on static balance in children with cerebral palsy. Methods: This study was conducted with 30 children with cerebral palsy at levels Ι IV in the Gross Motor Function Classification System (GMFCS), who were randomly divided into a control group and a hippotherapy group. Both the control group and the experimental group received NDT for 30 minutes per session, four times per week, for ten weeks, while the experimental group also received hippotherapy, 15 minutes per session, four times per week, for ten weeks, after the neurodevelopmental treatment (NDT). The horseback riding simulators JOBA (JEU7805, Panasonic, 일본 ) used in this study simulated actual horse movements; static balance was measured in each group before the exercise and five weeks and ten weeks after the beginning of the exercise using a pedoscan system (Diers Pedo, Germany). Results: The intergroup effects on static balance were tested, and the results showed no significant differences (p<0.05). Conclusion: The horseback riding simulation exercise was shown to be effective for the static balance of children with cerebral palsy. Therefore, additional studies should be conducted with more children with CP divided according to type. Key Words: Cerebral Palsy, Horseback riding simulator, Balance Ⅰ. 서론 균형을위한자세조절은공간에서몸의위치를조절하는 능력으로안정화를취하는것이다. 1-3 안정성은기저면내에서 정적, 동적으로활동하는동안 COM (center of body mass) 을 유지하는것이다. 4-6 Received Jul 15, 2014 Revised Aug 11, 2014 Accepted Aug 12, 2014 Corresponding author Ki-Won Nam, nkw1212@hanmail.net Copylight c 2014 The Korea Society of Physical Therapy This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License ( creativecommons.org/license/by-nc/3.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. 안정적인자세를유지하기위해서는기능적인활동동안, 감각시스템과중추신경계, 근골격계사이의복잡한상호작용이필요하다. 1,4,7 뇌성마비아동은체간의근긴장도가낮아안정적인자세조절과운동이어려워지고특정방향으로의운동성이떨어져균형능력이부족해진다. 8,9 또한고관절굴곡근의과긴장으로길항근인복부근과대둔근에서저긴장이나타나고, 장요근의단축은전방경사를유발한다. 10 그결과아동들이대칭성의결여와정중위로모아지는경험의부족으로신체분절에서균형감각을보상하는움직임으로나타난다. 11 따라서아동의가능한정상적인균형자세를위하여아동의근위부즉체간과골반의대칭성을개선하는데최우선순위로두어야할것이다. 12 또한뇌성마비아동에게일 269

2 최현진, 남기원 : 승마운동이뇌성마비아동의정적균형에미치는영향 상생활의기능향상과보행능력을향상시키기위하여좌우하지의체중이동을통한균형적인서기자세유지가필수적이며, 정적인기립균형과보행과의긴밀함을설명하고있다. 13 말의보행은정상적인사람의보행역학과유사한정확하고반복적인운동패턴을제공하고, 14,15 뇌성마비아동에게정상적인균형반응자극을통하여바로서는경험을제공하며, 균형잡힌움직임을제공한다. 16 말의보행의장점을가진승마시뮬레이션운동은느리고리듬감있는움직임은뻣뻣한비정상적인과긴장을감소시키고, 이완을촉진하며, 동시에양측의대칭적인 (bilateral symmetry) 자세반응을향상시키고, 저긴장근육의긴장도를증가시킨다. 또한골반과몸통조절을향상시켜보행과운동기능에도움을준다. 17,18 따라서본연구는승마시뮬레이션운동을통해뇌성마비아동에게정적균형의영향을알아보고자한다. Ⅱ. 연구방법 1. 연구대상본연구는 C시에소재한재활병원에서경련성뇌성마비아동으로진단받은 6 15세아동 30명으로구성되었다. 대동작기능분류체계 (Gross Motor Function Classification System; GMFCS) 19 단계에서 Ι Ⅳ 단계인뇌성마비아동을대상으로하였으며, 독립보행이나보조보행이가능하고, 보행기를잡고서있을수있는아동을대상으로하였다. 모든뇌성마비아동과보호자는실험에참가하기전연구목적과연구방법에대한충분한설명을듣고자발적인동의서를작성하였다. 대상자의일반적특징은다음과같다 (Table 1). 동의정적균형에미치는영향을알아보고, 승마시뮬레이션적용유무에따른군간차이를비교하고자시행하였다. 대조군과실험군은모두신경발달물리치료를 1일 30분, 주 4회 10주간받았으며, 실험군은신경발달물리치료후승마치료를 1일 15분주 4회 10주간추가적으로실시하였다. 본연구에서사용한승마기구는실제말의움직임을유사하게모방할수있는파나소닉사의승마기구 (JOBA, EU7805, Panasonic) 를사용하였다. 선정된대상자 30명은무작위로선정하여대조군과실험군으로나누었다. 모든대상자의치료는물리치료경력 5년차이상의신경발달물리치료과정을이수한치료사가실시하였다. 2) 실험도구승마기구인 JOBA 는살아있는말의움직임처럼 3차원적인운동 ( 전-후, 좌-우, 상-하 ) 을체험할수있으며, 다양한움직임을경험할수있도록설계되어있다. 본연구에서는 JOBA simulator에내장되어있는프로그램에따라 side-to-side, waist, hips 등아동들의특성에적합하게 15분동안실시하였다. 아동스스로자세를조절할수있도록하였으며, 아동이안장에앉았을때허리를정확하게세우기위해경추에긴장감을유지하도록하였다. 또한안장에앉았을때상지를이용하여손잡이를반드시잡고승마기구를타도록하였다. 승마시뮬레이션치료는안전을위하여물리치료사 1명과보호자 1명이아동을보조하여운동을실시하였다. 운동의난이도는각각의적응력및운동강도를감안하여시트가움직이는속도를점차적으로늘려나갔다. 최대속도레벨은 4 까지설정하였다 (Figure 1). 2. 실험방법 1) 실험설계 본연구는승마시뮬레이션을이용한승마운동이뇌성마비아 Table 1. General characteristic of subjects. Experimental group(n=15) Control group (n=15) Sex(male/female) 11a/4 10/5 Age(years) 8.80 ± 3.14b 9.27 ± 3.81 Height( cm ) ± ± Weight( kg ) ± ± 9.67 GMFCS 1.67 ± ± 1.10 a : Frequency b : Mean±standard deviation Figure 1. Horseback riding simulator 270

Hyun-Jin Choi and Ki-Won Nam : The Effect of Horseback Riding Simulator on Static Balance of Cerebral Palsy 3) 정적균형측정 (Pedoscan) 균형을측정하기위해 Pedoscan (Pedoscan, DIERS, 독일 ) 을사용하였다.

3 Hyun-Jin Choi and Ki-Won Nam : The Effect of Horseback Riding Simulator on Static Balance of Cerebral Palsy 3) 정적균형측정 (Pedoscan) 균형을측정하기위해 Pedoscan (Pedoscan, DIERS, 독일 ) 을사용하였다. Pedoscan은정적기립시양발에가해지는압력을측정하기위한도구로압력센서의너비는 50 cm이며, 4,096개의센서로구성되어있다. 좌우체중과전후체중을각영역을 1/4영역으로나누어좌-우측전-후측족저압을측정하는이유는발바닥압력과관련정보를하나로합쳐진수치로얻기보다는세분화되어각영역별압력분포의특성을분석하기위함이다. 20 Pedoscan은 DICAM 프로그램을이용하여발바닥영역을구분한후센서별로압력지수를색상으로표현하거나, 수치와막대그래프로각영역을분석하였다. 본연구에서는양발을측정장비위로바로선상태에서움직임을최소화하여시선을바로보고 30초동안움직임없이서도록하여측정하였으며, 21 균형측정을위하여대상자의체중을측정한후프로그램에입력하고양발을측정장비위로바로선상태에서체중분포좌-우 (%), 전-후 (%) 를측정하였다 (Figure 2). 운동기간에따른좌우 (left-right) 정적균형능력에대한군-내효과검정결과, 군과기간의상호작용효과는유의한차이를나타내지못하였으나 (p>0.05), 군-간효과검정결과유의한차이를나타내었다 (p<0.05)(table 2). 운동기간에따른전-후 (Anterior-Posterior) 의정적균형능력에대한군-내효과검정결과, 군과기간의상호작용효과는유의한차이를나타내지못하였으며 (p>0.05), 군-간효과검정결과유의한차이를나타내지못하였다 (p>0.05) (Table 3). Table 2. The comparison of left-right among groups Period: p>0.01 Period ⅹ Group : p>0.01 Group: p<0.05 Table 3. The comparison of Anterior Posterior among groups Figure 2. Pedoscan measurement position 4). 자료분석본연구에서측정된정적균형검사의모든자료값은 SPSS (ver for window) 통계프로그램을이용하여분석하였다. 각각의자료는 Kolmogorov-Smirnov(K-S) 적합도검정 (Goodness-of-Fit Test) 을이용하여정규성검정을실시하였다. 기간에따른각군의유의성검정과군간비교를위한유의성검정은이요인반복측정분산분석 (two-way repeated ANOVA) 을실시하였다. 통계학적유의성검정을위한유의수준은 α=0.05로하였다. Ⅲ. 결과 Period: p>0.01 Period ⅹ Group : p>0.01 Group: p>0.05 Ⅳ. 고찰 본연구에서, 정적인균형능력을알아보기위하여 Pedoscan 을이용하여, 좌우와전후의체중분포를비교한결과, 좌우의 체중분포에서군간효과검정결과정적인균형능력의유의 한향상을확인하였다. Mackinnon 22 등과정진화 15 등은승 마운동후앉아있는자세에서뇌성마비아동을대상으로힘 271

4 최현진, 남기원 : 승마운동이뇌성마비아동의정적균형에미치는영향 판을이용한자세동요측정연구에서좌우동요거리, 총동요거리와좌우동요속도, 총동요속도에서통계적으로유의가차이가있어서본연구와일치하였다. 정적기립시균형유지를위한신경근반응을바탕으로한다양한연구들중 Winter 등 23,24 은양발을좌우로벌리고기립자세에서의좌 -우균형조절에는고관절부위의움직임전략이사용되는데이것은고관절의전인 (protraction) 과후인 (retraction) 움직임을이용하여좌우다리의체중부하정도를조절하는것이다. 본연구에서도승마시뮬레이션운동을통하여골반의내측외측움직임의증가로골반에대한보상움직임이줄어들고, 하지내전근의긴장도가감소하여, 좌우의균형능력이증가되었다고생각한다전-후 (Anterior-Posterior) 의체중분포를비교한정적균형에서 Quint와 Toomey 25 는승마기구를이용한승마시뮬레이션치료에서정적인자세가향상되는것을알수있었고, Kuczynski와 Slonka 26 는승마시뮬레이션치료를사용하여 3개월치료후에전-후 (Anterior-Posterior) 의안정성이증가되었다고하였다. 그러나본연구에서는 Ferdjallah 등 27,28 의연구에서처럼뇌성마비아동들의균형감소는중추신경계의손상으로자세조절의불균형이인체역학적으로근육의동원순서가변화였기때문이며, 주동근과길항근의협력수축이감소하여전-후균형조절을유지하는발목관절의저굴 / 배굴전략이감소하였기때문이다. 또한보조도구를이용하여움직임을유지하는뇌성마비아동들이발목관절의경직과선택적움직임조절의장애로전-후균형조절을위해고관절부위의움직임이나체간회전전략의보상움직임이많이감소하였기때문이다. 승마시뮬레이션운동은뇌성마비아동의정적균형에효과적임을알수있었다. 따라서뇌성마비아동을대상으로비교적쉽게접근할수있는승마기구를이용한승마시뮬레이션운동을물리치료적사용을제고할수있는기회가될것으로생각되며, 청소년뇌성마비아동에게신체의변형방지를위하여추천하고자한다. 본연구의제한점으로개인의특성을충분히고려하지못하여전체집단을같은강도로실시하였던점과외부치료를온전히통제하지못한점이다. 추후연구에는타입별로세분화된운동과외부치료를통제하는연구가필요할것으로생각된다. 참고문헌 1. Shumway-Cook A, Woollacott MH. Motor control: Translating research into clinical practice. Baltimore, Lippincott/Williams and Wilkins. 2007; KIM JH. Relationship Between Gait symmetry and Functional Balance, Walking Performance in Subjects with Stroke. J Kor Soc Phys Ther. 2014;26(1): Duarte M, Freitas SMSF. Revision of posturography based on force plate for balance evaluation. BJPT. 2010;14(3): Corrêa JC, Corrêa FI, Franco RC et al. Corporal oscillation during static biped posture in children with cerebral palsy. Electromyogr Clin Neurophysiol, 2007;47(3): Pollock AS, Durward BR, Rowe PJ. What is balance? Clinl Rehabil. 2000;14(4): Massion J. Movement, posture and equilibrium: interaction and coordination. Prog Neurobiol, 1998;38(1): Woollacott MH, Shumway-Cook A. Postural dysfunction during standing and walking in children with cerebral palsy: What are the underlying problems and what the new therapies might improve balance? Neural Plasticity. 2005;12(2-3): Oh JL. The Effects of Trunk Muscle Strength Training on Sitting Balance of Children with Spastic Cerebral palsy. Daegu University. Dissertation of Master s Degree Choi JH, Lee HS, Chang JS. Changes of postural sway and muscle activation while standing Upright and performing a dual task. J Kor Soc Phys Ther. 2011;23(5): Bobath K. A neurological basis for the treatment of cerebral palsy. 2nd ed, Clinics in Developmental medicine No. 75. Mac Keith Press. 1980; Kim JH. Effects of functional trunk strengthening program for Children with Spastic Cerebral Palsy. Daegu University. Dissertation of Master s Degree Levitt S. Treatment of cerebral palsy and motor delay. Archives of Disease in Childhood. 1983;58(3); Dettmann MA, Linder MT, Sepic SB. Relationship among walking performance, postural stability, and functional assessments of the hemiplegic patient. Am J Phys Med, 1987;66(2): Choi HJ, Kim KJ, Nam KW. The Effects of a Horseback Riding Simulation Exercise on the Spinal Alignment of Children with Cerebral palsy. J Kor Soc Phys Ther, 2014;26(3): Jung JH, YU JH. The Effects of Hippotherapy over 8 Weeks on Trunk Proprioception, Stability and posture in Cerebral palsy patients. J Kor Soc Phys Ther. 2010;22(5): MacPhail HEA, Edwards J, Golding J et al. Trunk postural reactions in children with and without cerebral palsy during therapeutic horseback riding. Pediatric Physical Therapy. 1998;10(4): McGibbon NH, Andrade CK, Widener G et al. Effect of an equine movement therapy program on gait, energy by expenditure, and 272

5 Hyun-Jin Choi and Ki-Won Nam : The Effect of Horseback Riding Simulator on Static Balance of Cerebral Palsy motor function in children with spastic cerebral palsy: A pilot study. Dev Med Child Neurol. 1998;40(11): Kang HG, Chang SY. The Effects of Robo-horseback Riding Exercise on Trunk Muscle Activity Ratios in Patients with Low Back pain. J Kor Soc Phys Ther. 2012;24(6): Jung JW, Ko JY. Development of the chest Wall in Children with Cerebral Palsy according to GMFCS Levels. J Kor Soc Phys Ther. 2013;25(5): KIM YJ, JI JG, KIM JT. The 20-year-old women's shoes steps according to the type of comparative study on the low pressure zones. J Kor of sports Bio, 2004;14(3): Gong WT, Cho GY, Han JM. The Analysis of Static Foot Pressure on Functional Leg Length Inequality. J of the Kor Data Anal Soci. 2009;11(3): Mackinnon JR, Noh S, Lariviere J et al. A study of therapeutic effects of horseback riding for children with cerebral palsy. Physical & Occupational Therapy in Pediatrics. 1995;15(1): Winter DA. Biomechanics of normal and pathological gait: implicate for understanding human locomotor control. J. Motor Behavior. 1993;21(4): Lim JH, Park JS. Cho WS. The Effect of Mechanical Horseback- Riding Training Velocity on Vestibular Functions and Static Postural Balance in Healthy Adults. J Kor Soc Phys Ther. 2013;25(5): Quint C. & Toomey M. Powered saddle and pelvic mobility : an investigation into the effects on pelvic mobility of children with cerebral palsy of a powered saddle which imitates the movements of a walking horse. Physiotherapy. 1998;84;(8) Kuczynski M, Slonka K. Influence of artificial saddle riding on postural stability in children with cerebral palsy. Gait Posture. 1999;10(2): Ferdjallah M, harris GF, Smith P et al. Analysis of postural control synergies during quiet standing in healthy children and children with cerebral palsy. Clin Biomech (Bristol, Avon), 2002 ;17(3): Choi HJ, Nam KW. The Effect of Weight-support Treadmill Training on the Balance and Activity of Daily Living of Children with Spastic Diplegia. J kor soc phys Ther. 2012;24(6):

012임수진

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