臺灣博碩士論文加值系統

中文摘要
研究背景:
水療的定義為在身體的外側施加冷或熱水用以治療疾病，其生理效應包括溫熱效應及物理效應。水療運用在神經運動障礙兒童已經有數十年的時間，然而目前為止並沒有高階實證醫學的文獻探討兒童水療的療效，並且也缺乏對於身體功能、日常生活活動及活動參與度等全方位的評估。除此之外，大多數的文獻綜合多種神經運動障礙疾病而缺乏針對腦性麻痺(腦麻)兒童單一族群的研究。因而在此設計針對痙攣性腦麻兒童的兒童水療，並且評估其在身體功能、動作活動表現及社會參與度等三方面的效應。
研究目的：
量化兒童水療對於腦麻兒童身體功能、日常生活活動表現以及社會參與度的影響。
研究方法：
本實驗採用單盲、前瞻性、實驗組與對照組設計。二十位確定診斷為痙攣型腦麻且年紀為4至12歲孩童參與此試驗。這二十人依照意願分為兩組實驗組及對照組兩組，實驗組參加醫院進行、物理治療師執行的兒童水療組，對照組則維持原有的傳統復健治療組。這些參與者依照粗動作功能分類、年齡、性別及診斷作為配對。經過12週後，分別測量身體功能、動作活動表現功能以及社會參與度，並比較兩組間變化值的差異。臨床功能的測量在身體功能方面包含關節活動度及張力測試；動作活動功能在精細動作方面以布魯因斯克-歐西瑞司基動作評量( Bruininks-Oseretsky Test of Motor Proficiency，簡稱BOTMP)之分測驗八作為評估; 在粗動作功能方面則選取粗動作功能評量( Gross Motor Function Measure，簡稱GMFM-66)作為評估工具；在日常生活活動表現則以文蘭式適應量表評估；至於社會參與度則以腦性麻痺兒童生活滿意度問卷(Cerebral Palsy Quality of Life Questionnaire for Children ，簡稱CPQOL)作為測量。另外我們選用身體活動舒適度量表來評估實驗參與水療時的樂趣。
統計方面，參與者的基本資料使用描述性統計來表現。基本資料及試驗前的臨床評估資料使用曼惠二氏檢定法(Mann-Whitney test) 來測試兩組間是否有差異。 兩組治療前後臨床評估的變化值的差異性同樣使用曼惠二氏檢定法(Mann-Whitney test)來檢測。本研究以p 值小於0.05為統計上有顯著差異。


研究結果：
在起始點的人口統計學資料、臨床評估數據、疾病嚴重程度以及腦麻型態上兩組間並無差異。經過三個月的水療介入後，實驗組與對照組在粗動作功能評量(p=0.004&;lt;0.05)評估之粗動作活動表現變異量及以身體活動舒適度量表評估之參與水療之樂趣 (p=0.019&;lt;0.05)在兩組間有顯著差異。除此之外在身體功能表現包括被動關節活動度及張力值測量的變異量在兩組間並無差異。另外在文蘭式適應量表評估日常生活活動及腦性麻痺兒童生活滿意度問卷評估社會參與度，在兩組間均無差異。另一項有趣的發現是雙下肢受影響者及粗動作功能分類為二的腦麻兒童可以在水療中獲得較多的進步。
結論
水療的特性包括浮力原理，流體靜力壓及流體動力學之白努力原理，浮力中心的概念等，均會促進身體的自我感覺、姿勢及平衡動作控制，以及肌力的加強。進而促進腦麻兒童精粗動作活動表現像是粗動作功能評量的進步。另外三個月的治療時間不足夠將動作活動的改變影響，表現在生活品質改變上。更大型的研究及較長時間的水療介入研究，是未來進一步的研究方向。在臨床應用上，可考慮應用於團體治療以提高社會參與度及活動參與時的舒適度。

Abstract
Background
Aquatic therapy is defined as the external application of hot or cold water for the treatment of disease. Physiological effects of aquatic therapy include thermal effects and mechanical effects. Aquatic intervention had been applied in children with neuromotor impairment for years, yet there have been only a few studies providing literature of high level evidence to investigate the comprehensive effects of pediatric aquatic therapy including motor function, activity, and participation. Otherwise, literature specific to the effects of aquatic therapy in children diagnosed with cerebral palsy (CP) has been very limited. Herein, we design a case -control study in pediatric aquatic therapy to evaluate the effects of aquatic therapy for children with spastic type CP.
Purpose
To investigate the effects of pediatric aquatic therapy on body function, activities and social participation in children with spastic CP.
Method
This study was designed as a single blinded, prospective, case control study. Finally 20 children with spastic type CP aged from 4 to 12 years old were included. These children were divided into the study and the control groups according to their preference. The study group participated in the pediatric aquatic therapy in hospital; the control group continued the original rehabilitation program. The participants were matched by their gross motor function classification (GMFCS), age, sex and diagnosis. After 12 weeks of the training program, we evaluated body function, motor activity, and social participation again; we also and compared the change score between each group. The clinical measurements of body performance include range of motion (ROM), modified Ashworth score (MAS); the fine motor activity was measured subtest VIII of the Bruininks- Oseretsky Test of Motor Proficiency (BOTMP); the gross motor activity was measured by the Gross Motor Function Measure (GMFM -66) and the daily activity was measured by Vineland Adaptive Behavior Scale (VABS); the Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL) was used for measuring of participation. In addition, we used the Physical Activity Enjoyment Scale ( PACES) for evaluating the enjoyment of aquatic therapy.
Descriptive statistics were used to describe the demographic data. The Mann-Whitney test was used to test the difference in clinical measurements at the baseline assessmentand change scores in clinical measurements between these two groups of subjects. A p <0.05 was defined as statistically significant.
Results
There were no statistical significant in baseline demographic data, clinical measurements, severity, and type of cerebral palsy in these two groups. After three months of aquatic intervention, there was a statistical significance in the change scores of gross motor activity as measured by GMFM-66 (p=0.004<0.05) and enjoyment as measured by PACES scale between the PAT group the control group (p=0.019<0.05). Otherwise, there was no statistical significance in the body function as measured by passive ROM, MAS, and change score in daily activity as evaluated by VABS, and in participation as evaluated by CP-QOL. Another interesting finding is that there is more improvement in spastic diplegia type CP and children with CP in GMFCS level II.
Conclusions
The gross motor functions, but not adaptive activities and quality of life, improved after aquatic therapy in children with CP, especially high GMFCS levels. These findings may suggest aquatic therapy can facilitate body awareness, posture and balance control, and strengthen the muscle, and increasing enjoyment and motivation to enhance the motor functions through the mechanism of buoyancy, hydrostatic pressure and the Bernulli’s law, and the concept of metacenter. However, the short duration (three months intervention) and relative low intensity aquatic therapy is not enough to change the adaptive activities and quality of life in these children. Further experience of application aquatic therapy in facilitation motor activity with larger case number and longer duration is needed. Clinical application with group therapy for increasing social participation and enjoyment in activity should be consideration.

Table of Contents
Recommendation ………………………………………………………ii
Credential………………………………………………………………iii
Copyright Transfer Agreement… …… ………………………………..iv
Acknowledgment…………………..……………………………………v
English Abstract…………………………………………….…………..vi
Chinese Abstract………………………………………………………..ix
Table of Contents……………………………………………………….x
Table of Figure contents………………………………………………..xv
Table of Table contents…………………………………………………xvi
CHAPTER I Introduction……………………………………. …. ..... 1
1.1 Background…………………………………………… ……. 1
1.1.1 Buoyancy and the principle of Archimedes…..……… .2
1.1.2 Hydrostatic Pressure and Pascal’s law………...……… 3
1.1.3 Bernoulli’s law ..……………………………………. 3
1.1.4 Bougier’s theorem and the concept of the metacenter ...3
1.2 Review of Related Studies…………………………………. ..7
1.3 Objective of the Study……………………………… ….. …..14
1.3.1 Purpose…………………………………. …….………14
1.3.2 Hypotheses ………………………………. …. …….. ..14
CHAPTER II Experimental Setup……………...……………………..15
2.1 The Operative Definitions…… ………………………………15
2.1.1 The Halliwick Concept……………………...……………15
2.1.2 Cerebral palsy…………...……………………………... ..15
2.1.3Spasticity………………………………………………….16
2.2 The Design of Experimental Procedure………………………..16
2.2.1 Participant Recruitment ……..………………….………..16
2.2.2 Inclusion Criteria ………………..………………….……17
2.2.3Exclusion Criteria ………………..……………………….17
2.2.4 Intervention Program……..……………………..……….17
2.2.5 Program of Control Group…………....………………….20
2.3 Measurements and Tools ……………………………………..24
2.3.1 Measurements……………………………………………24
2.3.2 Tools……………………………………………………..25
2.3.3 Data Analysis………………………………………. …...31
2.3.4 Reliability...………………………………………. ……..31
CHAPTER III Experiment Results………………….…………... 32
3.1 Participants Recuirment ..………………………………… . ...32
3.2 Baseline Data………………………… .. …………………….34
3.3 Reliability …………………………………………………….38
3.4 Intervention Results ………………………………………......38
CHAPTER IV Discussion
4.1 Discussion…………………………………………………......50
4.2 The Attendance Rate and Safety Consideration……………….50
4.3 The Achieved-Goals in Point of Ten…………………………..51
4.4 Body Function…………………………………………………52
4.5 Motor functions and Adptaive Activities………………...……52
4.6 Participation…………………………………………………...55
4.7 Limitation of the Study………………………………………..56
4.8 Clinical Application and Future Study..………………………56
CHAPTER V Conclusion
Conclusion…………………………………………………………..58
REFERENCES……………………………………………….… ….59
Appendices………………………………… ………………………64





















Table of Figures Contents
Fig 2.1 Study Design………………………………………………….22
Fig 3.1 Summery of Recruitment of Study Population …………….33
Fig 3.2 Goal Attempted After 12 Weeks Training…………………… 38
Fig 3.3 The Disturbation of GMFCS Level of PAT and Control Group………… ………………………………………………………...39
Fig 3.4 The Relationship of the Change of GMFM-66 and GMFCS level.………………………………………………………………….…43
Fig 3.5 The Relationship of Type of CP and Change in GMFM……...45














List of Tables
Table1.1 Summary of Related Articles….…………………………....11
Table 2.1 The Ten-Point-Program…………………………………….18
Table 2.2 Flow chart of Study Design ……………………………… .23
Table 2.3 Contents of BOTMP………………………………………..27
Table 2.4 Summary of Test and Measure……………………………..30
Table3.1 Demographic and Clinical Data in Children with CP….....35
Table3.2 The Baseline Measurements of the Participants Included in Analysis ……………………………………….… …………………….37
Table 3.3 Change in Spasticity and PROM…………………………...40
Table 3.4 Change Scores in Fine Motor and Gross Motor in PAT and Control Group …………………………………………………………..42
Table 3.5 Table 3.5 Change of GMFM-66 score in each GMFCS level
……………………………………………………………………..……44
Table 3.6 Change of GMFM-66 score in Different Type of CP………46
Table 3.7 Change Scores in Adaptive Activities Evaluated by Vineland Adaptive Behavior Scale in PAT and Control Group…………………...47
Table 3.8 Change Score in quality of life evaluated by CP-QOL in PAT and Control Group………………………………………………………48
Table3.9 Difference of PACES between PAT and Control Group ……49

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