J Korean Soc Phys Med, 2018; 13(2): 75-87 https://doi.org/10.13066/kspm.2018.13.2.75 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 유성호 오덕원 1 대전웰니스병원, 1 청주대학교보건의료대학물리치료학과 A Content Analysis of Physical Therapy for Postural Control and Mobility in Children with Spastic Diplegia: A Cross-sectional Study Sung-Ho Yoo, PT Duck-Won Oh, PT, PhD 1 Dept. of Physical Therapy, Daejeon Wellness Hospital 1 Dept. of Physical Therapy, College of Health Science Cheongju University Received: March 27, 2018 / Revised: March 29, 2018 / Accepted: April 24, 2018 c 2018 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to describe and analyze the components of physical therapy interventions to enhance postural control and mobility in children with spastic diplegia. METHODS: Thirsty-eight physical therapists working in rehabilitation settings volunteered to record the components of physical therapy interventions used during 894 treatment sessions for 179 children with spastic diplegia presenting with difficulties in postural control and mobility. Descriptive statistics were used to analyze the general characteristics of the therapists, the patients, and the frequency of the Corresponding Author : Duck-Won Oh odduck@cju.ac.kr, https://orcid.org/0000-0001-7430-7134 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. interventions. A one-way analysis of variance (ANOVA) and chi-square test were used to describe the components of the interventions and the goals of treatment. RESULTS: In clinical practice, physical therapists primarily used methods including Hands-on: facilitation (n =1990, 36.47%) and Hands-off: practice (n=1355, 24.83 %). Only 13.96% (n=762) of the interventions allowed patients to be independent or active outside of the treatment sessions. Interventions reflecting the therapeutic aims were performed for sitting (17.53%), standing (18.25%), and walking (27.39%). CONCLUSION: Physical therapists mostly used therapistled interventions to treat impaired postural control and mobility in children with spastic diplegia. Interventions to facilitate independent activity or practice outside the treatment sessions are infrequently used. These types of interventions were used regardless of the aims of treatment. Key Words: Mobility, Physical therapy, Postural control, Spastic diplegia
76 J Korean Soc Phys Med Vol. 13, No. 2 Ⅰ. 서론뇌성마비란태아혹은영아의뇌에발생하는비진행성손상으로운동및자세의장애를초래하여활동의제한이발생하는영구적인장애이다 (Rosenbaum 등, 2007). 뇌성마비의감각및운동증상은평생관리하여야하는것으로, 학교및일상생활에큰영향을미친다. 그러므로뇌성마비는많은건강및교육서비스가필요하며, 기능, 삶의질, 교육적성과를높이기위해서는일상생활활동을수행하는동안직면하게되는기능적과제들을극복할수있도록전문적인중재를계획하여시행하는것이중요하다 (Schiariti 등, 2015). Oskoui 등 (2013) 의메타분석보고에따르면, 뇌성마비유병률은 1,000명출생당 2.11명으로보고되었으며, 이중만삭아는 1,000명당 1명이며, 재태기간 32-36주의중도미숙아는만삭아보다 6-10배뇌성마비가더발생하고, 32주미만의극도미숙아는중도미숙아보다 10배더높은것으로알려져있다. 출생시체중 1kg 미만의극도저체중아는생존율이낮기때문에 1-1.5kg 중도저체중아에비하여뇌성마비발생률이낮은것으로알려져있다. 뇌성마비는신경운동의형태에따라강직형 86.5%, 무정위운동형 5.9%, 운동실조형 5.3%, 저긴장형 2.2% 로나타나며, 침범된부위별로는편마비 38.8%, 양하지마비 37.5%, 사지마비 20.9%, 삼지마비 2.8% 로보고되고있다 (Smithers-Sheedy 등, 2016). 대운동기능분류시스템 (gross motor function classification system, GMFCS) 에따른비율은 1단계 35.5%, 2단계 24.5%, 3단계 10.7%, 4단계 12.2%, 5단계 14.1% 로보고되었다. 일반적으로, 강직성양하지마비는신생아또는조산아동들에게서나타나는뇌실주위백질연화증 (periventricular leukomalacia) 으로인해발생하며, 또한두개내출혈, 질식 (asphyxia), 독소등의원인에의해서도발생한다 (McMichael 등, 2015; Shevell 등, 2003). 강직성양하지마비는기능손상이주로다리에서심하게나타나며, 팔의근육은전반적으로영향을덜받거나전혀영향을받지않는다. 다리에서의과도한강직은걷는것을어렵게만들기때문에, 대부분의강직성양하지마비 아동들은무릎의굴곡과요추의전만이증가하여발가락으로서고걷는발끝보행 (tip toe gait) 형태가나타나며, 또한내전근의과도한수축으로인해다리가교차하며걷는가위보행 (scissor gait) 형태도나타난다 (Piña-Garza, 2013). 지난 10년간, 뇌성마비에대한기초적인정보와치료근거는급속하게확장되었으며지속해서변화되어왔다 (Novak 등, 2013). 이러한경향은최신의전문정보를취합하고수렴하기어렵게만드는요인이되었으며, 이때문에물리치료사는종종적합한평가와치료방법을선택하기위한임상의사결정과정에어려움을느끼고있다. 최신의치료적근거에기초하지못한중재를적용하는물리치료로인하여 10-40% 의뇌성마비아동들은효과가입증된치료중재를제공받지못하고있으며, 20% 의아동들은효과적이지못할뿐만아니라종종유해한중재를제공받고있는것으로나타났다 (Flores-Mateo와 Argimon, 2007; Rodger 등, 2005; Saleh 등, 2008). 그러므로임상현장의물리치료사들은강직성양하지마비아동들에게새롭고, 안전하며, 더욱효과적인중재를제공해줄수있도록최근의치료적근거를탐구하여적용하는노력이필요하다. 강직성양하지마비아동들의건강과기능을증진시키고이차적인문제를예방하기위하여체력훈련 (fitness training), 보톡스, 전기자극치료등이임상적으로사용되고있다. 또한, 아동들의신체발달과기능증진을위하여신경발달치료와함께목표- 지향적훈련 (goal-directed training) 과상황-초점치료 (context-focused therapy) 등이효과적인중재방법으로소개되고있다 (Novak 등, 2013; Novak, 2014). 그러나적용되고있는물리치료중재의구체적인내용과절차의기록에대한명확성과세밀함이결여되어있어중재와관련된다양한측면의효과성을분석하는것이매우어려운실정이다 (Pomeroy와 Tallis, 2002). 또한강직성양하지마비아동들의물리치료분야에서사용되고있는여러가지종류의중재들이있음에도불구하고, 중재정의에대한통일성부족과중재적용의기초적인틀과체계성의결여로인하여중재과정을세부적이고정확히조사하는것이현실적으로어렵다 (Marsden과 Greenwood, 2005).
강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 77 Table 1. General characteristics of physical therapists and children with spastic diplegia involved in this study Values Physcial Therapists (n=38) Age (years) 28.42±3.31 a Gender (male/female) 6/32 Work experience (years) 5.16±3.16 Specialized training (yes/no) 28/10 Academic degrees (associate/bachelor/master) 13/22/3 Children with spastic diplegia (n=179) Age (years) 6.08±3.53 Gestational age (weeks) 32.21±4.22 Level of GMFCS b (I/II/III/IV/V) 11/50/49/54/15 a mean±sd, b gross motor function classification system. 중재에대한정확하고상세하게보고하는것은임상에서성공적으로물리치료중재를적용하도록이끌수있으며, 메타분석과같이치료중재의효용성을검증하는연구들을위한중요한기초가될수있으므로임상물리치료의발전을위하여매우필요한일이다. 중추신경계질환의중재기록에대한문제점을해결하기위하여중재기록에관한연구들이있었으며, 이를통해물리치료중재에대한세부적이고구체적인기록과분석의중요성이더욱부각되고있다 (Tyson 등, 2009; Tyson과 Selley, 2004, 2006). 그러나아직까지강직성양하지마비아동들의물리치료에대한중재기록과중재절차의내용분석에대한연구는시행되지않았다. 이에따라, 본연구의목적은신경계환자들에대한물리치료중재기록지를이용하여소아전문물리치료사들이강직성양하지마비아동을치료할때어떤종류의중재를적용하는지기록하고분석하는것이다. 이연구의가설은물리치료사들의치료중재가목표에적합하게이루어지리라는것이다. Ⅱ. 연구방법 1. 연구대상자본연구는소아전문물리치료사 38명을대상으로강직성양하지마비아동 179명의물리치료중재기록을취합여진행하였다. 본연구에서자료수집은강직성양하지마비아동을 1주일에한번이상치료하는소아전문물리치료사들의중재기록을통해이루어졌다. 각설문지는개별봉투에넣은후소아치료전문병원의소아담당물리치료사에게보내졌다. 총 49명의치료사에게아동 245명을대상으로 1225부의기록지를배부하였으나이중 239부가회수되지않아 986부의자료가취합되었다. 그리고회수된자료중답변오류가있는 61부와대상자선정조건에부적합한 31부를제외한 894부의기록지를최종분석에이용하였다. T able 1은본연구의대상의물리치료사들과강직성양하지마비아동들의일반적인특성을설명하는것이다. 본연구는물리치료사들의중재행위에대한기록을기본자료로하는것이므로, 개인정보및치료행위에대한윤리성과관계없는것이며 (Tyson과 Selley, 2004), 이에따라윤리승인과정은생략되었다. 2. 물리치료중재기록본연구에참여한물리치료사들은총 12개병원의물리치료실에서근무하고있었으며, 각각본인이적용하는중재행위의빈도를기록지의양식에따라기록하였다. 실제로수행하는치료중재를기록하기위하여강직성양하지마비아동의나이, 심각성, 합병증유무등에상관없이모든중재행위를기록하도록요구하였다. 본연구에서강직성양하지마비아동에대한물리치료중재는사용하는중재를직접기입하여기록하는 뇌졸중물리치료중재기록 (stroke physiotherapy intervention recording tool) 의항목을사용하여기록되었다 (Tyson 과 Selley, 2004). 자료를수집하기전에물리치료사들이중재기록지에서사용된중재및용어에대해충분히이해할수있도록기록지내중재및용어에대한설명서를함께제공하였다. 사용한물리치료중재의적용시간에따라 5분미만은 1로, 5-10분은 2로, 10-15분은
78 J Korean Soc Phys Med Vol. 13, No. 2 Table 2. Items of the intervention recording tool used Category Teaching carers assist Providing equipment or training Teaching independent practice Others Mobilisations Facilitation and Practice [Components of activities] [Whole activities] Exercise Interventions Positioning, Stretching exercises, Bed mobility, Transfers, Walking indoors, Outdoor walking, Stairs, Wheelchair skills, Use of manual handling equipment, Use of AFOs/splints AFOs, Other splints, Walking aids, Transfer equipment Stretching exercises, Strengthening exercises, Resisted exercises, Cardio-vascular exercises, Bed mobility, Sit-to-stand, Transfers, Walking indoors, Outdoor walking, Stairs Gym ball, Postural perturbations, Sensory stimulation, Other Trunk mobilisations, Shoulder girdle mobilisations, Specific muscle mobilisations, Specific joint mobilisations Movement of the leg, Movement of the arm, Sitting, Standing, Walking, Bed mobility, Sit-to-stand, Transfer, Stairs, Falls routine Movement of the leg, Movement of the arm, Static sitting, Dynamic sitting, Static standing, Dynamic standing, Free walking, Walking with aids, Walking with help, Ourdoor Walking, Bed mobility, Sit-to-stand, Transfers, Stairs, Falls routine Stretching exercises, Strengthening exercises, Resisted exercises, Cardio-vascular exercises Table 3. Frequency with which interventions were used Frequency of Interventions use (n) Total 5456 Facilitation (hands-on) Total 1990 (36.47%) Frequency of use to sitting balance (n) Frequency of use to standing balance (n) Frequency of use to walking (n) Whole activity 1145 222 437 486 Component 845 273 307 265 Practice (hands-off) Total 1355 (24.83%) Whole activity 866 74 233 559 Component 489 89 144 256 Exercises 770 (14.11%) 109 254 407 Teaching independent practice 551 (10.09%) 90 173 288 Mobilisations 459 (8.41%) 198 117 144 Teaching carers assist 171 (3.13%) 31 46 94 Others 120 (2.19%) 28 48 44 Providing equipment or training 40 (.73%) 18 15 7 3으로, 15-20분은 4로코드화하여기록하였다. 물리치료중재기록은 8개의항목과각각의세부항목으로 이루어져있다 (Table 2)( 부록 1)(Tyson 과 Selley, 2004).
강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 79 Table 4. Frequency with which interventions were used in relation with treatment aims Aim Interventions Frequency use (n) Total 1146 Include Sitting in interventions 201 (17.53%) Facilitating the whole activity; static sitting 60 (5.23%) Sitting Facilitating of component; sitting 48 (4.18%) Facilitating the whole activity; dynamic sitting 35 (3.05%) Practising of component; sitting 23 (2.01%) Practising the whole activity; dynamic sitting 22 (1.91%) Practising the whole activity; static sitting 13 (1.13%) Total 1780 Include Standng in interventions 325 (18.25%) Facilitating the whole activity; static standing 10 5(5.89%) Standing Practising the whole activity; static standing 62 (3.48%) Facilitating of component; standing 53 (2.97%) Facilitating the whole activity; dynamic standing 39 (2.19%) Practising the whole activity; dynamic standing 36 (2.02%) Practising of component; standing 30 (1.68%) Total 2566 Include Walking in interventions 703 (27.39%) Practising the whole activity; free walking 118 (4.59%) Practising the whole activity; walking with aids 104 (4.05%) Practising of component; walking 84 (3.27%) Facilitating the whole activity; walking with help 71 (2.76%) Walking Facilitating the whole activity; free walking 68 (2.65%) Practising the whole activity; walking with help 67 (2.61%) Facilitating of component; walking 46 (1.79%) Practising the whole activity; outdoor walking 43 (1.67%) Facilitating the whole activity; walking with aids 29 (1.13%) Teaching independent practice; walking indoors 28 (1.09%) etc. 45 (1.75%) 3. 통계방법본연구에서수집된자료의분석을위하여윈도우용 SPSS (Statistical Package for Social Science) version 18.0 을사용하였다. 본연구에참여한물리치료사와강직성양하지마비아동의일반적특성은기술통계로설명하였으며, 사용된중재는빈도순으로정렬되었다. 강직 성양하지마비아동및물리치료사의일반적특성에따라중재내용과치료목표사이의차이, 그리고사용된중재와치료목표사이의차이를비교하기위해일원분산분석 (one-way ANOVA) 를사용하였고, 유의한차이가있는경우사후검정으로본페로니 (Bonferroni) 방법을실시하였다. 명목척도 ( 물리치료사의중추신경계
80 J Korean Soc Phys Med Vol. 13, No. 2 Table 5. The case mix profile of physical therapists and children with spastic diplegia at the aim of treatment Physical therapists (n=38) Age (years) Work experience (years) Specialized training (yes/no) Gender (male/female) Children with spastic diplegia (n=179) Age (years) Gestational age (weeks) a mean±sd 95% CI Aim Values p Upper Lower 29.33±3.20 a 26.87 31.79 Standing balance 28.00±2.64.647 26.40 29.60 Walking 28.27±4.00 26.05 30.49 5.78±2.72 3.68 7.88 Standing balance 5.00±2.82.757 3.29 6.71 Walking 4.80±3.62 2.79 6.81 30/6 Standing balance 48/11.402 Walking 55/29 6/31 Standing balance 8/50.929 Walking 10/74 5.34±3.93 4.05 6.64 Standing balance 6.58±3.92.237 5.55 7.60 Walking 5.95±2.98 5.39 6.61 31.45±4.60 29.93 32.96 Standing balance 32.63±4.36.399 31.50 33.77 Walking 31.17±3.85 31.32 33.01 전문교육유무와성별 ) 와치료목표사이의비교는카이-제곱 (χ 2 ) 검정을사용하였다. 통계적유의수준은.05 로하였다. Ⅲ. 연구결과 1. 사용된중재별빈도 Table 3은전체적으로사용된중재에대한빈도를설명하고있다. 총 5456건의중재가기록되었고, 1회의치료에서평균 6개의중재가사용되었다. 가장빈번히사용된중재인촉진의빈도는 36.47% 이었으며, 가장적게사용된중재인장비사용방법에대해교육하기의빈도는.73% 였다. 주로치료사가환자를직접접촉하여 치료하는치료사중심의중재가사용되었으며, 가장빈번하게사용된중재는치료사가환자를직접접촉하여치료하는촉진, 연습, 운동, 독립적인연습을위한환자교육의순으로나타났다. 특히, 중재의 13.96% 만이강직성양하지마비아동이치료시간밖에서독립적이거나활동적일수있게하는것이었다 (Table 3). 2. 목표별사용된중재의빈도 Table 4는치료목표와관련되어서사용된중재에대해설명한것이다. 앉기자세회복을위해서사용된중재들은치료사가수동적으로강직성양하지마비아동의사지의움직임을촉진하는것과가동술로나타났다. 가장빈번히사용된중재는활동의요소촉진하기
강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 81 Table 6. Treatment aim on choice of interventions 95% CI Interventions Treatment aim p Upper Lower.10.24 Teaching Carers assist Standing balance.345.10.21 Walking.14.31.04.16 Providing equipment or training Standing balance.000.03.08 Walking.00.03.28.56 Teaching independent practice Standing balance.006.46.70 Walking.31.85.09.21 Others Standing balance.102.11.22 Walking.07.14.09.20 Mobilization Standing balance.000.32.49 Walking.29.44 1.29 1.35 Facilitating the components Standing balance.000.88 1.15 Walking.58.79 1.00 1.34 Facilitating whole activity Standing balance.003 1.33 1.66 Walking 1.07 1.31.38.59 Practising the components Standing balance.079.39.59 Walking.53.70.27.52 Practising whole activity Standing balance.000.65.93 Walking 1.21 1.49.45.76 Exercise Standing balance.002.75 1.00 Walking.85 1.09 중다리의움직임, 체간가동술, 견갑가동술, 전체적인활동촉진하기중정적앉기순이었으며 앉기 가포함된중재를사용한빈도는 17.53% 로나타났다. 서기자세회복을위해서사용된중재들중가장빈번히사용된 중재는스트레칭운동, 전체적인활동촉진하기중정적서기, 활동의요소촉진하기중다리의움직임, 근력강화운동순이었으며, 서기 가포함된중재를사용한빈도는 18.25% 였다. 걷기회복을위해서사용된중재
82 J Korean Soc Phys Med Vol. 13, No. 2 Table 7. Bonferroni comparison to establish where significant differences lay 95% CI Intervention Treatment aim Treatment aim P Upper Lower Sitting Standing.094 -.01.1 Providing equipment or training Sitting Walking.000.000.03 Standing Walking.155.155 -.01 Sitting Standing.094 -.41.10 Teaching independent practice Sitting Walking.000.000 -.55 Standing Walking.155.155 -.36 Sitting Standing.000.46.83 Mobilization Sitting Walking.000.000.52 Standing Walking 1.000 1.000 -.10 Sitting Standing.000.19.69 Facilitating the components Sitting Walking.000.000.53 Standing Walking.000.000.13 Sitting Standing.025 -.62 -.03 Facilitating whole activity Sitting Walking 1.000 1.000 -.29 Standing Walking.006.006.07 Sitting Standing.003 -.68 -.11 Practising whole activity Sitting Walking.000.000-1.22 Standing Walking.000.000 -.79 Sitting Standing.047 -.54.00 Exercise Sitting Walking.002.002 -.61 Standing Walking.898.898 -.31 중빈번히사용된중재는스트레칭운동, 근력강화운동, 전체적인활동연습하기중자유걷기, 독립적인연습을가능하기위해환자에게근력강화운동의교육순이었으며, 걷기 가포함된중재를사용한빈도는 27.39% 로나타났다 (Table 4). 3. 물리치료사와강직성양하지마비아동의일반적특성과목표사이의비교 Table 5는물리치료사와강직성양하지마비아동의일반적인특성과목표사이의비교결과를설명하는것이다. 물리치료사나이, 성별, 업무경력, 중추신경계전문교육유무와치료목표사이의비교에서는유의한차이가나타나지않았으며 (p>.05), 또한강직성양하지 마비아동의나이, 재태기간과치료목표사이의비교에서도유의한차이가나타나지않았다 (p>.05)(table 5). 4. 사용된중재와목표사이의비교 Table 6, 7은중재와치료목표사이의비교결과를설명하는것이다. 사용된중재중장비사용, 독립적인연습, 가동술, 활동의요소촉진, 전체적인활동촉진, 전체적인활동연습, 운동항목에서유의한차이가있었다 (p<.05). 사후분석결과, 장비사용에포함된중재들은걷기보다앉은자세균형회복을위해더빈번히사용되는것으로나타났다. 독립적인연습을위한환자교육하기에포함된중재들은앉은자세의회복보다걷기를위해사용되었다. 가동술에포함된중재들은걷기
강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 83 / 선자세의회복보다는앉은자세의회복을위해더빈번히사용되었다. 활동의요소촉진하기에포함된중재들은걷기 / 선자세의회복보다앉은자세의회복을위해, 걷기보다선자세의회복을위해더많이사용되었다. 전체적인활동촉진하기에포함된중재들은앉은자세균형회복 / 걷기보다선자세의회복을위해사용되었다. 전체적인활동연습하기에포함된중재들은앉은자세 / 선자세의회복보다걷기를위해, 앉은자세의회복보다선자세균형회복을위해더많이사용되었다. 또한, 운동에포함된중재들은앉은자세의회복보다선자세 / 걷기의회복을위해더많이사용되었다 (Table 6, 7). Ⅳ. 고찰일반적으로, 임상현장의물리치료사들은강직성양하지마비와같은중추신경계손상을받은환자들의자세조절과운동성을향상시키기위해어떠한물리치료를시행할것인지에대해많은고민을하고있으나, 실제로사용하는중재를어떻게기록하고분석할것인지에대한연구는매우드물다 (Tyson 등, 2009). 본연구는소아전문물리치료사들이강직성양하지마비아동들의자세조절과운동성을증진시키기위하여사용되는중재를기록하여분석한최초의연구이다. 본연구의결과는물리치료사들이치료의목표와상관없이치료사중심의중재를주로적용하고있는것으로나타났으며, 치료시간이외의독립적이거나일상생활에서의수행에대한중재는거의사용하지않은것으로나타났다. 본연구에서소아전문물리치료사들이강직성양하지마비아동들의치료를위하여 촉진 의중재를가장빈번히사용 (36.47%) 하는것으로나타났다. 전통적으로사용되는뇌성마비치료방법의목적은물리치료사가수동운동치료기법을사용하여움직임의질을향상시키고근육의긴장도를정상화함으로써환자의비정상적인움직임을예방하고, 정상적인활동을가능하게하는움직임을유도하는것이다. 이러한치료의특성은물리치료중재중의하나인 촉진 으로설명되며, 임상현장에서가장많이사용되고있다 (Lennon과 Ashburn, 2000; Lennon, 2001). 물리치료사가환자를직접도수접촉하여시행하는 촉진 은수동적인중재이며, 이를표방하는대표적인치료는신경발달치료 (neurodevelopmental treatment, NDT) 이다. NDT는특별한핸들링기술을이용하여근긴장도, 반사, 비정상적인움직임패턴, 자세조절, 감각, 인지및기억등감각운동요소들을조절하는것을목적으로하는뇌성마비에대한치료개념이다 (Butler와 Darrah, 2001). 미국뇌성마비발달의학회 (American Academy of Cerebral Palsy and Developmental Medicine) 에따르면 NDT를받은환자가약간의운동범위에서즉각적인개선을보였지만, 기능적인활동의회복, 정상적인운동발달의촉진, 구축의예방, 비정상적인운동반응의억제등의효과에대한일관성있는증거는없다고하였다 (Butler와 Darrah, 2001). 또한 Novak 등 (2013) 은 NDT를더효과적인치료로볼수있는정황은없으며, 강직성양하지마비아동들에게임상에서전통적인 NDT를계속해서사용하는것을합리화하기어렵다고보고했다. 본연구에서두번째로가장빈번히사용된중재는 연습 이었다 (24.83%). 연습 은물리치료사의직접적인도수접촉없이면밀한감독하에뇌성마비아동들이활동요소들을연습하는것이다. 이에반해독립적인연습을위해환자교육하기 (10.09%), 보호자혹은건강관리전문가교육하기 (3.13%), 장비사용방법에대해교육하기 (.73%) 등과같은치료시간이외의활동을장려하려는시도는 14% 정도에불과하였다. 대부분의물리치료사들은운동패턴의개선 ( 또는 운동의질 ) 이자동으로기능향상을가져올것이라고믿기때문에, 치료시간이외의활동을관리하는것이필요하다고생각하지않을수있다 (Lennon, 2001). 그러나 Novak 등 (2009) 에따르면, 치료실에서의연습이가정프로그램으로연결되었을때운동활동, 자기관리, 기능에서의증진이나타났다고보고했다. 그러므로치료실에서의연습으로인해운동패턴의개선이보인다면, 반드시치료시간이외의활동관리도함께시작되어야한다. 본연구의전반적인결과는가동술, 촉진, 연습과같은치료사중심의중재 (therapist-led intervention) 를주로사용 (69.71%) 하는것으로나타났으며, 이러한중재
84 J Korean Soc Phys Med Vol. 13, No. 2 는치료시간동안치료사가주도하여환자들에대한전반적인치료를안내하고지도 / 감독하는것을의미한다 (Tyson과 Selley, 2004). 또한, 목표에따른사용된중재의결과에서는물리치료사들이강직성양하지마비아동들의앉기자세, 서기자세, 걷기의회복을위하여이와직접적으로관련된중재를상대적으로적은빈도로사용 (21.05%) 하고있는것으로나타났다. 선행연구들의결과는 NDT와같은신경손상지향적인치료법이근거가충분하지못하고, 그효용성에대한문제를제기하고있다 (Helders 등, 2001; Damiano, 2006). 최근의치료개념은운동학습의원리를반영하여목표- 지향적으로구성된기능훈련이효과를크게강조하고있다 (Ma 등, 1999; Schmidt와 Lee, 2005). 이러한운동학습의개념으로인해최근의뇌성마비치료패러다임은기존의촉진 / 억제기술에서보다역동적이고목표-지향적훈련으로변화되고있다 (Barbeau와 Fung, 2001; Carr와 Shepherd, 2003). 또한, 최근의연구들에서기능적인활동과제를반복연습하는과제-지향훈련이나유사한프로그램의효과가매우큰것으로보고되었다 (Leroux 등, 2006; Peurala 등, 2005). Polatajko와 Cantin (2010) 은운동학습이론에근거한수행-기반 (performance-based) 또는하향식 (top-down) 접근법을설명하였으며, 이러한중재들이신체구조와기능등근본적인장애와는관련없이특정과제또는목표훈련에직접적으로초점을맞추고있기때문에기능향상에보다효과적일수있다고하였다. 그러므로강직성양하지마비아동들에대한치료적중재는목표또는과제에적합한직접적인운동과제를반복연습하는방향으로이루어져야할것이다. 본연구는향후연구에서보완될수있는몇가지제한점을가지고있다. 첫째, 본연구는뇌성마비중강직성양하지마비아동을치료하는소아전문물리치료사에국한하여진행되었다. 그러므로본연구의결과는강직성양하지마비형태이외의다른뇌성마비아동에대한결과로해석될수없다. 둘째, 본연구에서는강직성양하지마비아동에대한중재기록을위하여뇌졸중환자들의중재기록지의항목들을사용하였다. 중추신경계가손상된성인환자와아동환자의신체 특성이다를수있고중재항목간의차이가있을수있으므로중재기록에대한타당성의문제가제기될수있다. 향후의연구는이러한제한점을보완하여모든형태의뇌성마비아동의물리치료중재를기록하여분석할수있도록진행되어야하며, 또한뇌성마비에특화된물리치료중재를기록하고분석할수있는전문기록지의개발이이루어져야할것이다. Ⅴ. 결론물리치료중재에대한정확하고상세한기록은임상에서성공적인중재의적용을가능하게하고, 질높은연구의기본적인토대가된다. 본연구의목적은물리치료사들이뇌성마비중강직성양하지마비아동을치료할때어떤종류의중재를적용하는지기록하고분석하는것이다. 본연구의결과는소아전문물리치료사들이강직성양하지마비아동들의자세조절과운동성을위해치료사중심의중재를주로활용하고있는것으로나타났으며, 치료시간이외환자가일상생활에서독립적혹은능동적수행에대해장려하는중재는거의사용하지않은것으로나타났다. 이러한결과는최근의치료적인근거에적합하지않은것으로판단된다 (Novak 등, 2009, 2013; Polatajko와 Cantin, 2010). 따라서치료시간내에서의연습및훈련이과제또는목표 -지향적으로선택되어사용되어야하며, 치료시간외독립적인활동또는일상생활에서의수행즉, 가정프로그램등으로연결되어야한다고할수있다. 향후의연구는본연구에서나타난제한점을보완하여모든뇌성마비유형환자를대상으로하고, 많은대상자와다양한치료환경에서연구가이루어져야할것이다. 본연구는물리치료를받고있는강직성양하지마비아동들에게적용되고있는중재를기록하고분석한첫번째연구로, 뇌성마비아동들에게어떠한중재를사용하는지기록하고분석하여기술하였다는데큰의미가있다. 또한, 향후의뇌성마비아동에대한물리치료연구를위해유용한정보를제공해줄수있을것이다.
강직성양하지마비아동의자세조절과운동성을위한물리치료의중재내용분석 : 단면연구 85 References Barbeau H, Fung J. The role of rehabilitation in the recovery of walking in the neurological population. Curr Opin Neurol. 2001;14(6):735-40. Butler C, Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol. 2001;43(11):778-90. Carr JH, Shepherd RB. Neurological rehabilitation: Optimizing motor performance. Oxford. Butterworth-Heinemann. 2003. Damiano D. Activity, activity, activity: Rethinking our physical therapy approach to cerebral palsy. Phys Ther. 2006; 86(11):1534-40. Flores-Mateo G, Argimon JM. Evidence based practice in postgraduate healthcare education: A systematic review. BMC Health Services Research. 2007;7(1): 119. Helders PJM, Engelbert RHH, Gulmans VAM, et al. Paediatric rehabilitation. Disabil Rehabil. 2001;23(11):497-500. Lennon S, Ashburn A. The Bobath concept in stroke rehabilitation: A focus group study of the experienced physiotherapists perspective. Disabil Rehabil. 2000; 22(15):665-74. Lennon S. Gait re-education based on the Bobath concept in two patients with hemiplegia following stroke. Phys Ther. 2001;81(3):924-35. Leroux A, Pinet H, Nadeau S, et al. Task-oriented intervention in chronic stroke: Changes in clinical and laboratory measures of balance and mobility. Am J Phys Med Rehabil. 2006;85(10):820-30. Ma HI, Trombly GA, Robinson-Podolski C, et al. The effect of context on skill acquisition and transfer. AJOT. 1999;53(2):138-44. Marsden J, Greenwood R. Physiotherapy after stroke; define, divide and conquer. J Neurol Neurosurg Psychiatry. 2005;76(4):465-6 McMichael G, Bainbridge MN, Haan E, et al. Whole-exome sequencing points to considerable genetic heterogeneity of cerebral palsy. Mol Psychiatry. 2015;20(2):176-82 Novak I, Cusick A, Lannin N, et al. Occupational therapy home programs for cerebral palsy: Double-blind, randomized, controlled trial. Pediatrics. 2009;124(4): 606-14. Novak I, Mcintyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013; 55(10):885-910. Novak I. Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. J Child Neurol. 2014;29(8):1141-56. Oskoui M, Coutinho F, Dykeman J, et al. An update on the prevalence of cerebral palsy: A systematic review and meta-analysis. Dev Med Child Neurol. 2013; 55(6):509-19. Peurala SH, Titianova EB, Mateev P, et al. Gait characteristics after gait-oriented rehabilitation in chronic stroke. Restor Neurol Neurosci. 2005;23(2):57-65. Piña-Garza JE. Fenichel s clinical pediatric neurology: A signs and symptoms approach (7th ed). WB Saunders Co. 2013. Polatajko HJ, Cantin N. Exploring the effectiveness of occupational therapy interventions, other than the sensory integration approach, with children and adolescents experiencing difficulty processing and integrating sensory information. AJOT. 2010;64(3): 415-29. Pomeroy V, Tallis R. Neurological rehabilitation: A science struggling to come of age. Physiother Res Int. 2002; 7(2):76-89. Rodger S, Brown GT, Brown A, et al. Profile of pediatric occupational therapy practice in Australia. Aust Occup Ther J. 2005;52(4):311-25. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8-14.
86 J Korean Soc Phys Med Vol. 13, No. 2 Saleh M, Korner-Bitensky N, Snider L, et al. Actual vs. best practices for young children with cerebral palsy: A survey of pediatric occupational therapists and physical therapists in Quebec, Canada. Developmental Neurorehabilitation. 2008;11(1):60-80. Schiariti V, Selb M, Cieza A, et al. International classification of functioning, disability and health core sets for children and youth with cerebral palsy: A consensus meeting. Dev Med Child Neurol. 2015;57(2):149-58. Schmidt RA, Lee TD. Motor control and learning: A behavioral emphasis (3rd ed). Champaign. Human Kinetics. 2005. Shevell M, Majnemer A, Morin I, et al. Etiologic yield of cerebral palsy: A contemporary case series. Pediatr Neurol. 2003;28(5):352-9. Smithers-Sheedy H, Mcintyre S, Gibson C, et al. A special supplement: findings from the Australian cerebral palsy resister, birth years 1993 to 2006. Dev Med Child Neurol. 2016;58(2):5-10. Tyson S, Connell L, Lennon S, et al. What treatment packages do UK physiotherapists use to treat postural control and mobility problems after stroke? Disabil Rehabil. 2009;31(18):1494-500. Tyson S, Selley A. A content analysis of physiotherapy for postural control in people with stroke: An observational study. Disabil Rehabil. 2006;28(13-14): 865-72. Tyson S, Selley A. The development of the stroke physiotherapy intervention recording tool (SPIRIT). Disabil Rehabil. 2004;26(20):1184-8.