治療性音樂結合荷重坐站阻力運動對雙邊痙攣型腦性麻痺兒童之療效

Abstract

背景與目的：雙邊痙攣型腦性麻痺兒童因其肌肉力量和動作控制能力之缺損，在動作功能及日常生活參與常受限制。過去研究顯示居家荷重坐站阻力訓練可增進輕度雙邊痙攣型兒童的肌力及動作功能，然兒童對參與肌力訓練的動機較低。由過去經驗可知音樂具有提昇運動意願的效果，而利用不同的音樂元素達到提示動作目的之「音樂模組知覺動作提昇法」（Patterned Sensory Enhancement，簡稱PSE），可用來改善動作控制能力；然目前尚未有研究探討PSE音樂用於腦性麻痺兒童肌力訓練的效果。本研究主在探討以治療性音樂結合六週居家荷重坐站阻力訓練，對於輕至中度雙邊痙攣型兒童的身體功能、活動及日常生活參與的成效，以及音樂對兒童阻力訓練參與程度之影響。方法：本研究共徵召22位5到13歲可獨立坐到站的雙邊痙攣型兒童，其依年齡和嚴重度分層後，隨機分派至PSE音樂組(12位)和無音樂組(10位)。由不知分組狀況的測試者評估以獲取訓練前後荷重坐站一次最大阻力、粗大動作功能量表分數、兒童生活功能評估量表的移動性和自我照顧領域的量表分數及行走功能的變化資料；並利用動作分析系統評估兒童執行坐站動作的平順度、直接程度和動作時間等動作控制參數。實驗組兒童接受為期六週，每週三次，結合PSE音樂的居家荷重坐站阻力訓練。PSE音樂由物理治療師與音樂治療師參考受試者在評估時的荷重坐站動作表現一起設計，由音樂治療師預先錄製以提昇運動興趣且增進坐站動作表現為目的之個人化音樂交由兒童使用，並於每兩週更新。控制組兒童亦接受強度相同的居家荷重坐站阻力訓練，然不提供音樂。兩組兒童均紀錄其運動參與情形，並在訓練後以動機量表評估其運動動機，利用獨立樣本t檢定或曼-惠特尼U檢定分析兩組之間的差異。針對其他變項，以重複二維多因子變異數分析比較兩組兒童之改變，顯著水準設在α=0.05，單尾檢定。結果：經過六週後，PSE音樂組兒童在功能性肌力(P=.038)、粗大動作功能量表之目標分數(P=.026)上較無音樂組有顯著進步，但PSE音樂組兒童並未較無音樂組在生活功能評估量表分數、行走功能和坐到站的動作控制參數上有更多進步，雖然若將所有兒童的前後測結果相比皆有顯著的時間主效應。在運動參與程度上，兩組兒童的運動動機無顯著差異，然PSE音樂組兒童完成的總運動次數有較多的趨勢(P=.057)。討論與結論：本研究成功將PSE音樂和居家荷重坐站阻力訓練做結合，並證實PSE音樂可協助雙邊痙攣型兒童增進其荷重坐站一次最大阻力和粗大動作功能，PSE音樂組在運動參與程度上也有較多的趨勢。無論有無音樂，所有兒童的生活參與情形、走路速度與坐站動作控制在訓練後皆有增加。未來研究可將不同類型的功能性活動與PSE音樂結合，以增進腦性麻痺兒童的日常生活表現。

Background and Purpose: Children with spastic diplegia (SD) usually have limitations in mobility functions and daily participation due to muscle weakness and poor motor control. Previous study proved that a home-based loaded sit-to-stand (STS) resistance exercise program could improve their functional muscle strength and gross motor function. However, the exercise motivation for resistance training is usually poor in children. Previous study has reported that music can be used to increase adherence. Also, the Patterned Sensory Enhancement (PSE) technique of music therapy uses different elements of music to cue body movements and could improve motor control immediately. However, no studies investigated the effects of PSE music with resistance exercise for children with CP. The purpose of this study was to investigate the effects of the loaded STS resistance exercise with PSE music on body functions, activities, participation, and exercise involvement for children with SD. Methods: Twenty-two children with SD who could stand up independently were recruited for this study. Participants were stratified by their age and severity and then randomly assigned to the PSE music (PSE) group (n=12) and the non-music (NM) group (n=10). A blinded tester evaluated the children to obtain data of one-repetition maximum (1-RM) of the loaded STS test, Gross Motor Function Measure (GMFM) goal score, scaled scores of Pediatric Evaluation of Disability Inventory (PEDI) Mobility and Self-Care domains, and walking parameters at pre- and post-training. The motion analysis of the STS movement was also conducted to gather motor control variables, such as jerk index, directness, and movement time of STS. Children in the PSE group received a home-based loaded STS exercise combined with PSE music, 3 times a week for 6 weeks. The individualized PSE music was designed by the physical therapist and the music therapist, and composed by music therapist based on the recorded video of loaded STS movement. This PSE music was aiming to increase fun and promote the exercise performance and was renewed every 2 weeks. Children in the NM group received the 6-week loaded STS exercise without music. The exercise adherence and volume were gathered by logbook. The motivation was assessed by the Intrinsic Motivation Inventory after training. The above 3 variables were compared between groups with independent t test or Mann-Whitney U test. Other outcome measures were compared between groups using two-way mixed analysis of variance. The alpha level was set at 0.05 for one-tailed test. Results: Children in the PSE group improved more in the 1-RM of the loaded STS test and goal score of GMFM than the NM group after 6-week training (P = .038 and .026, respectively). There were no time × group interaction effects for scores of PEDI, walking parameters, and motor control variables of STS, but there were significant main time effects while considered all subjects as a whole. The exercise motivation did not differ significantly between groups. However, children in the PSE group tended to complete more loaded STS repetitions than the NM group (P = .057) during the training period. Discussion and conclusion: In the present study, we successfully incorporate PSE music with the home-based loaded STS exercise for children with SD. The PSE music significantly improved the functional muscle strength and gross motor function, and had a tendency to increase the exercise volume. For all subjects as a whole, improvements were found in daily participation, walking speed, and motor control of STS. Future studies might combine PSE music with various functional activities in order to improve the performance in daily activities for children with CP.