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1 Case Report 운동과학, 2015 년, 제24권제2 호. Exercise Science, 2015, Vol.24, No.2. pissn eissn 경직성뇌성마비로인한하지단마비환아의일단계다수준수술후치료적운동의효과 안근옥 1) 1), 김아람, 이호성 1)* 1) 단국대학교대학원운동의과학과 Keun-Ok An, Ah-Ram Kim, Ho-Seong Lee (2015). Effects of Therapeutic Exercise on Muscle Function following Single-Event Multilevel Surgery in Children with Spastic Lower Limb Monoplegic Cerebral Palsy. Exercise Science, 24(2): PURPOSE: To determine effects of therapeutic exercise on improving muscle strength and balance in children with spastic lower limb monoplegic cerebral palsy (CP) after single-event multilevel surgery (SEMLS). METHODS: A 7-year-old child with CP after SEMLS of left distal hamstring lengthening, achiles tendon lengthening, and tibialis posterior transfer was enrolled in the study, and presented, crouch gait to the left lower limb due to CP. A therapeutic exercise program was implemented for 8 weeks with a duration of 40 min/d and a frequency of 3 d/week, and the program consisted of ankle joint mobilization, balance exercise, walking up and down stairs, single leg heel raise, and single leg jump. Exercises were performed progressively to an individualized maximum number of repetitions in order to maximize improvements in motor learning and function. Bilateral measurements of calf circumference, ankle joint range of motion (ROM), and one leg standing test (OLS) were taken before and after 8 weeks of therapeutic exercise. RESULTS: Calf circumference on the affected side increased from cm to cm with, the ratio of affected side to unaffected side that improved from 94.07% to 95.75%. Ankle dorsiflexion ROM with the knee flexed on the affected side increased from to with the improved, ratio from 75.00% to 98.30%. Similarly, ankle dorsiflexion ROM with knee extended increased from to with the increased, ratio from 70.18% to 93.19%. OLS with eyes open on the affected side increased from 1.46 sec to sec with the substantially increased, ratio from 7.68% to 57.87%. OLS with eye closed of the affected side was increased from 0.73 sec to 1.60 sec, and ratio of affected side to unaffected side was improved from 8.96% to 18.54%. CONCLUSIONS: These results suggest that therapeutic exercise decreases contraction and improve muscle strength and balance in children with spastic lower limb monoplegic cerebral palsy after SEMLS. Key words: spastic cerebral palsy, monoplegia, SEMLS, therapeutic exercise 주요어 : 경직성뇌성마비, 단마비, SEMLS, 치료적운동 Ⅰ. 서론 뇌성마비(cerebral palsy; CP) 는중추신경계의결손혹은손상에의해야기되는자세및움직임의비진행성장애로 [28], 출생전, 출생중및출생후의여러가지원인에의해유발된다[65]. CP는아동기의가장흔한운동장애로서미국의유병률은출산 1000명당약 3.6 명이며 [72], 국내의경우에는출산 1000명당 2.6 명으로나타난다고하였다 [48]. 또한 CP는뇌병변의위치에따라경직성, 저긴장성, 무정위형, 근긴장성및운동실조성으로분류할수있으며 [28], 그중에서도경직성뇌성마비(spastic cerebral palsy; SCP) 는전체뇌성마비환아의 70~80% 를차지한다 [28]. 또한 SCP 는운동결핍부위, 발생빈도및특징에따라양마비, 편마비, 사지마비, 단마비및삼지마비로분류할수있으며 [65], 양마비는주로양하지에나타나는운동장애로경직성뇌성마비의 30-40% 에서발견되며사시의위험성이높고학습능력, 집중력및의사소통의장애가흔히나타난다고하였다 [33]. 편마비는편측상하지에나타나는운동장애로경직성뇌성마비의 20-30% 를차지하며시야결손, 경도인식장애, 의사소통장애및부분발작의위험성이크다 [51]. 또한사지뿐만아니라체간및구강근육의운동장애를동반하는사지마비는경직성뇌성마비의 10-15% 에서나타나며간질, 정신지체, 난청및시각장애의위험성이높고의사소통및자제능력의장애가흔히나타난다 [57]. 교신저자: 이호성, hoseh28@dankook.ac.kr Tel: , Fax: Received 3 Feb. 2015, Revised 6 Apr. 2015, Accepted 11 May. 2015

2 운동과학, 2015 년, 제24권제2 호, 아울러단마비및삼지마비는하나의지절또는세지절의운동장애가나타나며, 경직성뇌성마비중에서가장드물게나타난다고하였다 [28,63]. SCP 에관한선행연구는많이보고되어있다. 선행연구에따르면, SCP 는경직(spasticity), 구축(contracture), 협응력의감소, 균형능력의장애및근력약화와같은신경발달학적장애를보이며 [19,30], 그중에서도근력약화는뇌성마비환아에게주된문제로간주되고있다 [10,14,15,54,68]. Ross & Engsberg [54] 는같은연령대의아이들과비교하여뇌성마비환아의하지근력은평균 40~60% 정도로약화되어있다고보고하였으며, Zonta et al [73] 에따르면뇌성마비환아는건측(unaffect side) 과비교하여환측(affected side) 의하지근력이평균 85% 정도라고보고하였다. 따라서이러한하지의근력약화는보행및일상생활능력의장애를발생시킨다고추측하였다 [68]. 특히, 까치발보행(Crouch gait) 은입각기중에과도한슬관절굴곡이특징적으로나타나는뇌성마비환아에게가장흔한보행장애로족관절배측굴곡근약화, 비복근구축, 균형장애, 족부의부정렬및근력약화가원인으로발생하며 [17], 관절통증 [25], 뼈의기형 [22] 및보행의제한 [26,45] 을야기한다고하였다. 이에뇌성마비환아의보행장애의관리및개선을위하여물리치료 [67], 보조기 [2], 석고고정 [36] 및보톨리늄독소 (botulinum toxin type A) 주사 [38] 가사용되고있지만, 이러한비수술적관리에도불구하고경직성뇌성마비환아대부분은근육의구축및골기형이악화되며보행과앉는기능의유지를위한수술적치료가필요하다고하였다 [55]. 한편, 뇌성마비환아에게서정형외과적수술은수년에걸쳐여러번수술하는방법인다단계수술을사용하였으나, 최근에는일회수술로모든기형의치료, 보행능력의향상과더불어반복적인수술및재활기간을최소화하기위한목적으로개발된일단계다수준수술(single-event multilevel surgery; SEMLS) 이가장흔히사용되고있다 [59]. SEMLS 는일회의정형외과적수술에서다양한수술적중재들을결합하여적용하는방법으로 [6], 여러선행연구에서경직성뇌성마비환아의보행능력향상에효과적이라고보고하였다 [20,21,58]. SEMLS는 Norlin & Tkaczuk [43], Browne & McManus [6] 에의해처음으로소개되었으며, Norlin & Tkaczuk [44] 는 23명의경직성뇌성마비환아를대상으로 SEMLS 를받고 5년간추적조사를한결과골기형의재발이발견되지않았고정상적인성장관련발달이일어났다고보고하였으며, Nene et al [42] 은 SEMLS를받은 18명의뇌성마비환아를대상으로수술전과비교하여수술후에보행관련지표들이향상되었 다고보고하였다. 그러나최근의연구에의하면, Thomason et al [64] 은뇌성마비환아를대상으로 SEMLS 를적용한사례연구에서수술 12개월후에관절구축의감소와근육길이의정상적인회복및보행능력의향상이나타났지만, 수술후 2년동안근기능의향상은나타나지않았다고보고하였다. 또한 Seniorou et al [59] 은 SEMLS 를받은 21명의뇌성마비환아를대상으로보행능력및근력을관찰한결과, 수술 6개월후에보행능력은향상되었지만근력및운동기능이감소하였다고보고하면서, 뇌성마비환아에게서수술후운동기능향상을위한근력강화운동이필요하다고보고하였다. 근력강화운동은근력과근기능향상을위하여뇌성마비환아의치료적중재로널리사용되고있다 [10,12,16,66]. 실제로과거에는근력강화운동이뇌성마비환아의근강직의악화및관절가동범위의감소를발생시킨다고알려져금기시되어왔지만 [5], 최근선행연구에의하면, 뇌성마비환아의근력강화운동은근력및보행능력향상에효과적이라고보고하면서뇌성마비환자에게근력강화운동의중요성이강조되고있다 [1,11,40], Blundall et al [4] 은뇌성마비환아를대상으로주 2 회, 8주간에걸쳐서근력강화운동을실시한결과, 평균근력이 47% 정도증가하였으며운동후에 8 주간까지지속적으로유지되었다고보고하였다. Mockford & Caulton [40] 은뇌성마비환아를대상으로근력강화운동이근력을향상시켰으며, 보행능력과근기능에긍정적인영향을미쳤다고보고하였다. 따라서근력강화운동은뇌성마비환아의보행장애치료를위한정형외과적수술후에도근기능향상및근약증의치료에필요하다고생각된다. 또한전술한바와같이, 뇌성마비환아는균형능력의장애및반응속도의감소를보이며 [50,53], 이러한균형능력의장애는근육약화와더불어보행및운동기능의장애를발생시키는주요원인이다 [3,37]. Pape et al [46] 은균형조절능력과보행제한간에는높은상관관계를가지고있으며, 균형조절능력의향상은뇌성마비환아치료의중요한목표로중재해야한다고보고하였다 [7,24,47]. 발달성협응장애와같은다른운동신경장애에대한균형운동의긍정적인효과는보고되었지만 [27], 뇌성마비환아를대상으로균형운동을적용한연구는매우제한된숫자에불구하다. 따라서이사례연구에서는경직성하지단마비성뇌성마비환아를대상으로 SEMLS 후에근력및균형능력향상을위한치료적운동이하퇴구축, 근력및균형능력에미치는영향을확인하고, 경직성뇌성마비환아의 SEMLS 후에치료적운동의기초자료를제공하는데목적이있다. 196 안근옥, 김아람, 이호성

3 Ⅱ. 연구방법 1. 연구대상 이사례연구의연구대상은분당소재 S 병원에서좌측하지의선천적기타경직성뇌성마비진단을받고 2013년 9월 26일에좌측원위슬괵근연장술, 아킬레스건연장술및후경골근부분이전술의 SEMLS를실시한 7세여아 1명으로 SEMLS 5개월후본센터에내원하였다. 피험자는뇌성마비로인한인지장애및통증은없었으며, 보조자및보조기의도움없이독립적인보행은가능하나좌측하지의까치발보행이나타났다. 피험자의신체적특성은 <Table 1> 에제시하였으며, 피험자및피험자의부모님에게는연구의취지내용을충분히설명한후자발적으로참가동의를얻었다. Table 1. Physical characteristics of the subject Age (yrs) Height (cm) Weight (kg) 2. 측정항목 1) 하퇴둘레 하퇴둘레(Calf muscle circumference) 는서있는자세에서비탄력성테이프를이용하여 0.1 cm 단위로측정하였다. 하퇴의가장두꺼운부위의피하조직을압박하지않은상태에서둘레를측정하였으며, 환측및건측에서각각 2회씩측정하여평균값을사용하였다. 하퇴둘레는운동전및운동후에동일한방법으로측정하였다. 2) 발목관절가동범위 발목관절가동범위는무릎관절굴곡및신전상태에서의발목관절배측굴곡을측정하였다. 무릎관절굴곡상태에서의발목관절배측굴곡은가자미근의구축을측정하는검사로무릎관절을 90 굴곡상태에서최대배측굴곡을측정하였으며, 무릎관절신전상태에서의발목관절배측굴곡은비복근의구축을측정하는검사로무릎을신전한상태에서최대배측굴곡을측정하였다. 발목관절가동범위는전자각도계(Baseline, Fabrication Enterprises Inc, White Plains, NY, USA) 를이용하여외복사뼈를중심축으로비골두에위치하도록하였으며, 다른한축은종골의외측면에위치하여측정하였다. 중족근관절및족근중족관절의영향을받지않는순수한발목관절배측굴곡을측정하기위하여전족부는각도계정렬에사용하지않았다 [71]. 발목관절배측굴곡가동범위는운동전및운동후에동일한방법으로측 정하였다. 3) 균형능력 균형능력은정적균형능력측정인외발서기검사 (Single leg stance) 를실시하였다. 피험자는양팔을허리에올려놓은상태에서외발로서있는자세로들어올린다리가땅에닿거나허리에서팔이떨어질때까지의시간을초단위로측정하였다 [61]. 외발서기는눈을뜬상태에서건측다리, 눈을감은상태에서건측다리, 눈을뜬상태에서환측다리및눈을감은상태에서환측다리순으로측정하였다. 각측정간의휴식시간은 150초로하였으며, 휴식시간동안앉은자세에서휴식을취할수있도록하였다. 측정전피험자가외발서기검사방법을이해할수있도록연습기회를제공하였으며 [8], 외발서기는운동전및운동후에동일한방법으로측정하였다. 3. 치료적운동 이사례연구에서사용한근력강화및균형능력향상을위한운동프로그램은 Blundell et al [4] 의연구에서진행된운동프로그램을수정및보완하여수행하였다. 본운동시작전준비운동으로 10분간대근육군의스트레칭을실시하였다. 본운동은발목관절움직임향상, 하지근력강화및균형능력의향상을위한프로그램으로구성하여한명의치료사의감독하에진행하였다. <Table 2> 에제시한것처럼, 치료적운동프로그램은발목관절움직임향상을위한발목관절가동술을 5 분간실시하였으며, 균형능력향상을위한보수볼(BOSU, Thera-band, USA) 을이용한균형운동및계단오르기와내리기운동을수행하였다. 근력강화운동으로는한다리로서서발뒤꿈치들기및한다리로뛰기운동을실시하였다. 본운동후정리운동으로 10 분간의스트레칭을실시하였다. 치료적운동은 1일 40 분, 주3 회, 8 주간에걸쳐서실시하였다. 모든운동은근력및근지구력의향상과운동학습능력을촉진시키기위하여최대반복횟수로진행하였으며, 각운동간휴식 Table 2. Exercise protocol Order (Time) Type Intensity (Time) Warm-up (10 min) Therapeutic Exercise (30 min) Cool-down (10 min) Stretching Ankle joint mobilization Balance exercise with BOSU Single leg heel raise Single leg jump Walking up and down stairs Stretching 5 min maximum number of repetitions Rest : Between exercise: 1 min 경직성뇌성마비로인한하지단마비환아의일단계다수준수술후치료적운동의효과 197

4 운동과학, 2015 년, 제24권제2 호, 시간은 1 분으로하였다. 점진적운동강도의증가를위하여초기최대반복횟수의목표를 10 회로설정하였으며, 목표반복횟수를초과하여수행할경우목표반복횟수를 2~3회증가시켜설정하였다. 하지만, 피험자가 7세뇌성마비환아의특성상목표한횟수를수행하지못하는경우에는점진적으로최대반복을할수있도록구두로독려하였다. Ⅲ. 연구결과 1. 하퇴둘레의변화 하퇴둘레의변화는 <Table 3> 에제시한바와같이, 환측의하퇴둘레는운동전의 cm와비교해서운동후에 cm로향상되었으며, 건측의하퇴둘레는운동전의 cm와비교해서운동후에 cm 로향상되었다. 또한하퇴둘레의건측대비환측의비율은운동전의 94.07% 와비교해서운동후에 95.75% 로향상되었다. Table 3. Change in calf circumference before and after the exercise. before after un-side side un-side side Calf circumference (cm) Values are mean un-side : unaffected side, side : affected side 2. 관절가동범위의변화 관절가동범위의변화는 <Table 4> 에제시한바와같이, 환측의무릎굴곡시발목관절의배측굴곡가동범위는운동전의 와비교해서운동후에 로향상되었으며, 건측의무릎굴곡시발목관절의배측굴곡가동범위는운동전의 와 Table 4. Change in ankle dorsiflesion ROM before and after the exercise. before after un-side side un-side side Ankle dorsiflexion with knee flexion ( ) Ankle dorsiflexion with knee extension ( ) Values are mean un-side : unaffected side, side : affected side 로향상되었다. 환측의무릎신전시 비교해서운동후에발목관절의배측굴곡가동범위는운동전의운동후에의배측굴곡가동범위는운동전의 와비교해서 로향상되었으며, 건측의무릎신전시발목관절 와비교해서운동후에 로향상되었다. 또한무릎굴곡시발목관절배측굴곡가동범위의건측대비환측의비율은운동전의 75.00% 와비교해서운동후에 98.30% 로향상되었으며, 무릎신전시발목관절배측굴곡가동범위의건측대비환측의비율은운동전의 70.18% 와비교해서운동후에 93.19% 로향상되었다. 3. 균형능력의변화 균형능력의변화는 <Table 5> 에제시한바와같이, 환측의눈을뜬상태에서외발서기는운동전의 1.46초와비교해서운동후에 초로증가하였으며, 건측의경우에는운동전에 초와비교해서운동후에 초로감소하였다. 환측의눈을감은상태에서외발서기는운동전에 0.73초와비교해서운동후에 1.60 초로증가하였으며, 건측의경우에는운동전에 8.15 초와비교해서운동후에 8.63 초로증가하였다. 또한눈을뜬상태에서외발서기의건측대비환측의비율은운동전에 7.68% 와비교해서운동후에 57.87% 로향상되었으며, 눈을감은상태에서외발서기의건측대비환측의비율은운동전에 8.96% 와비교해서운동후에 18.54% 로향상되었다. Table 5. Change in OLS before and after the exercise. before after un-side side un-side side OLS test with eyes opened (sec) OLS test with eyes closed (sec) Values are mean un-side : unaffected side, side : affected side Ⅳ. 논의 이사례연구에서는경직성뇌성마비로인한하지단마비환아의 SEMLS 후 8 주간의치료적운동의적용이하퇴둘레, 비복근구축및균형능력에미치는영향을검토한결과, 하퇴둘레, 무릎굴곡시족관절배측굴곡관절가동범위, 무릎신전시족관절배 198 안근옥, 김아람, 이호성

5 측굴곡관절가동범위, 눈뜨고외발서기및눈감고외발서기의기능이향상되었다. 따라서이사례연구에서는경직성뇌성마비로인한하지단마비환아의 SEMLS 후치료적운동이하퇴구축의감소와근력및균형능력향상에효과적이라는것이시사되었다. 이사례연구에서는근력및균형능력향상을목표로 Blundell et al [4] 의연구에서사용된치료적운동프로그램을수정보완하여적용하였다. 구체적으로발목관절움직임향상을위한발목관절가동술, 균형능력향상을위한보수볼을이용한균형훈련및계단오르기와내리기운동, 하지근력강화를위한힐레이즈(heel raise), 싱글레그점프(single leg jump) 로구성하여운동학습및근력, 근지구력의향상을위하여최대반복횟수로진행하였다. 뇌성마비환아의하지근력약화는보행장애및운동기능의제한을발생시키는주요원인중하나로서 [39,62], Seniorou et al [59] 의연구에의하면, SEMLS 6개월후에근육연장술을한근육에서 45% 정도이상의근력이감소하였으며, 수술 1년후에는 50% 이상의근력이감소하였다고보고하였다. 또한 SEMLS 1년후에 SEMLS 전과비교하여근력및운동기능의저하를보인다고보고하면서, 근력및운동기능의향상을위해서는수술후치료적운동의중재가필요하다고보고하였다. Kawakami et al [31] 은하퇴둘레는근육량을측정하는간편하고널리사용되는방법으로이중에너지방사선흡수계측법 (Dual-energy X-ray absorptiometry; DXA) 을이용한골격근량및하퇴둘레간의상관관계분석에서남성(r=0.81) 과여성(r=0.73) 모두에서양의상관관계가나타난다고보고하였다. 이사례연구에서환측하퇴둘레는운동전의 cm와비교해서운동후에 cm로증가하였으며건측하퇴둘레는운동전의 cm와비교해서운동후에 cm 로증가하였다. 또한하퇴둘레에서건측대비환측의비율은운동전의 94.07% 와비교해서운동후에 95.75% 로향상되었다. 따라서이사례연구에서뇌성마비환아에게 SEMLS 후수행된치료적운동이근육량을향상시켜하퇴둘레를증가시켰다고생각된다. 가자미근및비복근은보행시체중지지와입각기및유각기시발목관절의각도조절의중요한역할을하는하지근육으로 [32], 가자미근및비복근의구축은근기능및일상생활기능을악화시키는중요한요인이다 [36]. Curtis et al [9] 은 6명의뇌성마비환아를대상으로 10주간무릎굴곡및신전상태에서의발목배측굴곡훈련을적용한결과, 배측굴곡가동범위를 5 정도증가시켰으며, 운동기능을향상시켰다고보고하면서배측굴곡가동범위의증가로인해운동기능의향상이나타났다고보고하였 다. 또한 Mu et al [41] 은 226명의뇌성마비환아를대상으로치료적운동을적용한결과, 발목관절배측굴곡가동범위의증가, 근긴장의감소및운동기능이향상되었다고보고하였다. 이사례연구에서사용한발목관절배측굴곡가동범위는뇌성마비와같은신경근계질환자의경직성첨족(equinus) 변형을측정하기위해개발된검사로서무릎굴곡상태및무릎신전상태에서의족관절배측굴곡의관절가동범위를측정하여가자미근및비복근의구축정도를파악하는데사용되었다 [60]. 이사례연구에서환측의무릎굴곡시족관절배측굴곡관절가동범위는운동전의 12.9 와비교해서운동후에 17.3 로향상되었으며, 무릎굴곡시족관절배측굴곡관절가동범위의건측대비환측의비율은운동전의 75.00% 와비교해서운동후에 98.30% 로향상되었다. 따라서이사례연구에서는뇌성마비환아에게치료적운동의적용이가자미근및비복근의구축을감소시켜배측굴곡가동범위를증가시켰으며, 배측굴곡가동범위증가로인해운동기능이향상될가능성이있다고생각된다. 그러나이사례연구에서는치료적운동이운동기능에미치는효과에대해서는검토하지않았기때문에이점에관해서는향후추가연구가필요하다고생각된다. 외발서기는일상생활에서걷기, 달리기, 방향전환, 계단이용과같은많은운동에필수적인요소로 [29], 외발서기검사는환아의진단과관찰에서널리사용되는간편하고재연성이높은균형검사방법이다 [23]. 이사례연구에서눈을뜬상태에서의환측하지외발서기는운동전의 1.46와비교해서운동후에 초로증가하였으며, 눈을뜬상태에서의건측하지외발서기는운동전의 19.02초와비교해서운동후에 18.42초로나타났다. 또한눈을감은상태에서의환측하지외발서기는운동전의 0.73초와비교해서운동후에 1.60 초로증가하였으며, 눈을감은상태에서의건측하지외발서기는운동전의 8.15초와비교해서운동후에 8.63 초로나타났다. 눈을뜬상태에서외발서기의건측대비환측비율은운동전의 7.68% 와비교해서운동후에 57.87% 로향상되었으며, 눈을감은상태에서외발서기의건측대비환측비율은운동전의 8.96% 와비교해서운동후에 18.54% 로향상되었다. 선행연구에의하면, 뇌성마비환아의균형능력은일상생활능력과밀접한관련성이있으며 [18,34], 일반적인아이들과비교하였을때경증및중등도의기능적운동장애를가진뇌성마비환아들에게서도균형능력의저하와더불어촉각및고유신경감각의저하가나타난다고보고하였다 [56,69,70]. Rose [52] 와 Roncesvalles et al [51] 은균형조절능력향상을위한훈련이자세조절근육반응, 방향특이적반응및자세동요변화에따른근활성반응조절능력을향상시킨다고보고하였으며, El-Shamy & Abd El Kafy [13] 는뇌성마비환아에게 3개월간의균형훈련을 경직성뇌성마비로인한하지단마비환아의일단계다수준수술후치료적운동의효과 199

6 운동과학, 2015 년, 제24권제2 호, 적용한결과, 균형회복시간의단축및반응속도의감소가나타났다고보고하였다. 또한낙상위험성관련지표의감소를보여뇌성마비환아에게서낙상의위험성이감소하였다고보고하였다. 따라서이사례연구에서근력및균형능력향상에초점을맞춘치료적운동의적용이뇌성마비환아의균형능력을향상시켰으며, 낙상의위험성을감소시킬가능성이있다고생각된다. 이연구에서의제한점은뇌성마비중가장드물게나타나는단마비환아 1명을대상으로한사례연구로서이연구에서사용한운동프로그램이여러지절에움직임제한을가진뇌성마비환아에게효과적이라고결론지을수는없다. 하지만이연구에서사용한운동프로그램은뇌성마비환아의하지근력증가, 발목구축감소및균형능력향상을위한저항운동의수행가능성을확인하였으며, 향후뇌성마비환아를대상으로하는연구에서긍정적인효과를주기위한운동프로그램설계에대한정보를제공할것으로생각된다. Ⅴ. 결론 이사례연구에서경직성뇌성마비로인한하지단마비환아의 SEMLS 후 8주간의치료적운동은뇌성마비환아에게하퇴둘레, 족관절배측굴곡관절가동범위및균형능력을향상시켰으며, 이러한하퇴구축의감소와근력및균형능력의향상이보행능력을향상시킬가능성이시사되었다. 향후 SEMLS 후치료적운동의일반화를위해서는보다많은피험자를대상으로다양한근기능및보행능력등에미치는상세한효과를검토할필요가있다고생각된다. References [1] AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA (2008).AEffAcAAAAAAssAAfAphysAAAhAAApyAAAdAcAAdAcAAAAAAdAcAAAAAA AAAAAAAAAAAAsAAAAchAAdAAAAwAAhAcAAAbAAAApAAsy:AAAfAcAsAdAAAAAAw.A American Journal of Physical Medicine & Rehabilitation, 87(6):A 478A501. [2] BAAAAAAABCAAAAssAAAAADAAAAAbAAAAFA(2012).AThAAAffAcAsAAfAAAAAAA faaaaaaahasasaaaaaaaagyaaacaaaayaaadawaaaadaaaagagaaaaaaachaadaaaa waahacaaabaaaapaasy.aclinical biomechanicsaa27(3):a [3] BAAcAAEEA(1994).AThAAsAAsAAAfAbAAAAcA.ADevelopmental Medicine & Child NeurologyAA36(5):A [4] BAAAdAAAA AWAA AhAphAAdA ABAA DAAAA CAAA AdAAsA ADAA CAhAAAA BA.A (2003).AFAAcAAAAAAAsAAAAgAhAAAAAAAAgAAAAcAAAbAAAApAAsy:AAApAAAAAsAAdyA AfAAAgAAApAcAAcAAAAAAAAAAAgAcAAssAfAAAchAAdAAAAAgAdA4A8AyAAAs.A Clinical RehabilitationAA17(1):A4857.A [5] BAbAAhAKA(1980).AA Neurophysiological Basis for the Treatment of Cerebral PalsyAA2AdAAd.ALAAdAA:AWAAAAAAAAAAAAAAAAABAAAsALAd.A [6] BAAwAAA AOAA AA AcAAAAsA FA (1987).A OAAAsAssAAAA saagaaya faaa baaaaaaaaacaaaacaaaaaafaaawaaaaaabadafaaaaaaasaaaaspasaacadapaagaa.a Journal of Pediatric OrthopaedicsAA7(3):A [7] BAAAAAAA PAA QAAAAsA CAA AA WAAAAcAAAA AA (1998).A AAscAAA AcAAAAAAAAA chaaacaaaasaacsaafasaaacaabaaaacaacaaaaaaaaaachaadaaaawaahaspasaaca caaabaaaapaasy.agait PostureAA8(3):A [8] CAAsAAAVAAgAsAAAAAAGAAAGAAAAgAAAA(2014).ADAAAAApAAAAAAfAAAAAwA AAdAxAAfAbAAAAcAAAAAAdAAAsAwAAhAAAAAAAAcAAAAAAAdAdAAAAApAAAAAAA dasabaaaaaas.aplos OneAA9(5):AA [9] CAAAAsADAAABAAcAAAAAAAAAygAAdABA(2014).AThAAAffAcAAAfAAAAAAAAgAAAA AAAAAAAAAcAAAAAdyAAAAcAsAAAdAAAAAAAAAAAAdAAsAfAAxAAAAAAdAgAAssA AAAAAA faacaaaaa AAA chaadaaaa waaha caaabaaaa paasy.a Developmental NeurorehabilitationAA17(6):A393A397. [10] DAAAAAAADLAAKAAAyALEAAAAVAAghAACLA(1995).AEffAcAsAAfAqAAdAAcApsA faaaaasaaascaaasaaaagahaaaagaaaacaaachagaaaaaaachaadaaaawaaha spasaacadapaagaa.aphysical therapyaa75(8):a A [11] DAddAKAAATAyAAAANFAAAADAAAAAAADLA(2002).AAAsysAAAAAAcAAAAAAwA AfAAhAAAffAcAAAAAAssAAfAsAAAAgAhAAAAAAAAgApAAgAAAsAfAAApAApAAAwAAhA caaabaaaapaasy.aarchives of Physical Medicine and RehabilitationAA 83(8):A [12] DAddAKAAATAyAAAANFAAAAGAAhAAAAKA(2003).AAAAAAdAAAzAdAcAAAAcAAA AAAAAAAfAsAAAAgAhAAAAAAAAgAAAAyAAAgApAApAAAwAAhAcAAAbAAAApAAsy.A Developmental Medicine & Child NeurologyAA45(10):A [13] EAAAhAAyAAAAAAbdAEAAKAfyAEAA(2014).AEffAcAAAfAbAAAAcAAAAAAAAAgA AAA pasaaaaaa baaaacaa caaaaaaa AAdA AAsAA AfA faaaa AAA chaadaaaa waaha dapaagaca caaabaaaa paasy.a Disability and RehabilitationAA 36(14):A 1176A1183. [14] EAgsbAAgAAAAAAAssAAAAAAAOAAAAAKAA(2000).AAAAAAAspAsAAcAAyAAAdA saaaagaha AAA chaadaaaa waaha spasaaca dapaagaca caaabaaaa paasy.a Developmental Medicine & Child NeurologyAA42(1):A [15] EAgsbAAgAAAAAAAssAAAAAAAPAAAATAA(1999).AChAAgAsAAAAAAAAAA spasaacaayaaadasaaaagahafaaaawaagasaaacaaaaadaasaaaahazaaaayaaada physacaaa AhAAApyA faaa spasaaca caaabaaaa paasy.a Journal of NeurosurgeryAA91(5):A A [16] EAgsbAAgA AAAA AAssA AAAA CAAAAAsA DAA (2006).A AAcAAAsAAgA AAAAAA saaaagahaaaaaapaaaaagaaaaaadafaacaaaaaaaachaadaaaawaahacaaabaaaa paasy:aaapaaaaasaady.apediatric Physical TherapyAA18(4):A [17] GAgAA AAA (1990).A AAAgAcAAA AAAAAAAAAA AfA AAAAA dysfaacaaaaa AAA caaabaaaapaasy.aclinical Orthopaedics and Related ResearchAA253:A [18] GAAAAAAATAAgALCAATAAgAYAAAAAWAAgACAA(2008).APsychAAAAAAcA paapaaaaasa AfA faacaaaaaaa baaaacaa AssAssAAAAA AAA chaadaaaa waaha caaabaaaa paasy.a Neurorehabilitation and Neural RepairAA 22(6):A 745A753.A [19] AAAAEGA(2001).ATAAAAAAAAAAfAAAAAAAAscAAAAAAAdAAAscAAAsAAAAAAAA paabaaasaaaacaaabaaaapaasy.adevelopmental NeurorehabilitationAA 200 안근옥, 김아람, 이호성

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[29] AAAssAAAEAAAAAgAAAAAAAAAAAschfAAdAAA(2004).AOAAAAAgAsAAAcAAAAA haaaahya yaaaga AAdA AAdAAAyA AdAAAs:A AAAAsAAAA AfA pasaaaaaa saaadaaass?.aclinical BiomechanicsAA19(7):A688A694. [30] AAAgAAWAAAAAAAGAAAAKAAAA(2013).AEffAcAAAfAsAAAAgAhAAAAAAAAgAAfA AAAAAApAAAAAAfAAxAAsAAAAsAAAcAAAAAAAAAAAAAyAAAAAAAcAAAAAAAAgAAAA paaaaaaaasaaaadagaassaaaaaaafaacaaaaaafachaadaaaawaahacaaabaaaa paasy.ajournal of Physical Therapy ScienceAA25(10):A1259A1263. [31] KAwAAAAAAAAAAAAAAAAAAAAAAAAAdAAKAATAAAAAANAAAAwAdAAAAAAAAA AAA(2014).ACAAfAcAAcAAfAAAAcAAAsAAAsAAAAgAAAAAAAAAAAAfAAAscAAA AAssAfAAAdAAgAAsAAgAsAAcApAAAAAAAAAApAAAsAAAAAAAAdAwAAAA.A Geriatrics & Gerontology InternationalAAdAA:A /ggA A [32] KAAAAAAKAAAAAAAAALAAABAA(2014).AAAAAAAAAshApAbAAwAAAALAwAAALAAbA AAscAAA AAAAcAAAAA AAdA FAAcAAAAA AAA CAAAbAAAA PAAsy.A Journal of Physical Therapy ScienceAA26(1):A63A66. [33] KAbAAAKAAAALAAAAAAAAA(1994).ACAAAbAAAApAAsy.AThe New England Journal of MedicineAA330(3):A188A195. [34] KAAbAAAWAAAAAAAchAyAAAAAEAAsAAhAAAAAAAAAAAAAAAAAwAAAWA(2013).A EffAcAsAAfAAAsAAspAcAfAcAAAAAAAAgAAAAfAAcAAAAAAAAbAAAAyAAAAchAAdAAAA waaha AAAdA AAA AAdAAAAAA caaabaaaa paasy.a Developmental NeurorehabilitationAA16(6):A410A417. [35] LAAbAAAALAAAAFAAdAAAAA(2000).AFAAcAAAAAAAAAdAcAAAAcAAAsAgAAfAcAAcAA AfAsAAAAAAAAAAscAAAAAchAAAcAAAA.AMuscle & NerveAA23(11):A A [36] LAAAAACAANAAAAAAAAKAAAAshAAAADAsAAAAAAAAKAAAAAAAAAFAAAAAAA(2010).A CAAAbAAAAPAAsyAAAsAAAAAA.ABAAAAAAAAAAAxAAAAssAssAAAAAAAAAAAAAAAAAAA AAdAAfAAAAcAAAAfAAAAAwAAAAAAbAspAsAAcAAyAAAAchAAdAAAAwAAhAcAAAbAAAA paasy:aaaaaaaaaaaaaaacaasaasasasaaaaaaaa.aeuropean Journal of NeurologyAA17(sAppAA2):A9 37. 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