治療性音樂對痙攣型雙邊腦性麻痺兒童 於荷重坐站動作之立即效果

Abstract

背景與目的：肌肉無力及動作控制之缺損是造成痙攣型雙邊麻痺 (spastic diplegia，簡稱SD) 兒童動作能力不足主要問題之一。過去研究顯示荷重下進行坐站動作對於此類兒童在下肢最大伸直功率及動作順暢度有立即增進的傾向，六週荷重坐站阻力訓練也顯示對身體功能及活動能力有正面效果。然而，荷重坐站阻力訓練較費力，也會延長動作時間；兒童之阻力訓練順應性較差，較無興趣；因此於阻力訓練下合併可能增進兒童興趣之元素為一值得研究之議題。「音樂模組知覺提升法」 (Patterned Sensory Enhancement，簡稱PSE) 是一種治療性音樂，藉由音樂元素聯結聽覺與動作，提示動作型態。過去研究顯示節奏和音樂可以增加動作控制、動機，也可增進最佳表現程度、降低自覺用力程度及改善動作控制能力；然音樂的延續效應 (carry-over effects)，則尚有爭議。本研究目的為探討PSE對於雙邊麻痺兒童荷重坐站動作的執行及動機之立即效果。方法：徵召20名5到12歲粗大動作功能分類系統I-III級之SD兒童，使用數位攝影記錄、VICON 512動作分析系統以及2塊AMTI 力板、中文版內在動機量表進行資料蒐集。實驗於兩週內分別在兩天進行，第一天測定各個兒童的坐站最大荷重阻力(1RM)，並以攝影記錄兒童進行50%1RM荷重坐站的動作模式及時間， 據此，物理治療師與音樂治療師共同擬定每位兒童PSE各元素，再由音樂治療師錄製個別化PSE音樂檔案；第二天則以隨機方式讓兒童於音樂及無音樂(控制)兩種情境下分別執行連續8次荷重坐站動作，並收集運動學與動力學資料、與運動的動機強度。在音樂情境下，只在前5次提供PSE音樂，為PSE音樂情境，後3次荷重坐站動作為關掉PSE音樂，即為延續(continuation)情境。本研究變項包括下肢最大伸直功率、動作控制參數（坐站動作平順度、坐站動作直接度、坐站動作時間、軀幹最大彎曲角度、動作間變異性）、動作能力（坐站成功率、坐站前軀幹搖晃次數）與動機強度。以配對t檢定或Wilcoxon signed rank 檢定比較兒童在PSE及控制情境下之各參數是否不同。於PSE顯著優於無音樂之參數，再使用配對t檢定或Wilcoxon signed rank 檢定，比較延續情境與控制兩種情境有無不同；統計部分，α設定為 0.05 (單尾)。結果： SD兒童執行荷重坐站時，PSE音樂較無音樂可增加膝最大伸直功率顯著(p=0.042)，增進動作控制(增加質量中心順暢度(p=0.009)、縮短動作時間 (p=0.006))，及增加內在動機量表的分數(p=0.002)；動作間變異性、動作能力（坐站成功率、坐站前軀幹搖晃次數）於PSE及控制兩種情境下無顯著差異。延續情境與無音樂兩種情境下，各參數無顯著差異。討論與結論：PSE音樂對於SD兒童的膝最大伸直功率、質量中心順暢度、動作時間、最大軀幹彎曲角度和動機有立即增進作用，然無延續效應，對動作能力也無立即成效。可能因聽覺誘導聯結與練習時間太短無法有延續效應，且動作能力的學習可能需較多次數與較長時間之練習才能達成。未來研究仍需進一步探討PSE音樂對於此阻力運動的長期效應，包括肌力、動作控制、動作能力、與動機，及其神經機制。

Background and Purpose: Children with spastic diplegia (SD) are characterized with muscle weakness and movement control deficits causing limitation of motor function. For them, the immediate effects of the load on sit-to-stand (STS) movements tended to increase peak extension power and movement smoothness. The loaded STS resistance exercise training also showed positive effects on the body function and the activity level. However, children usually had poor adherence and were uninterested in resistance exercise training. They exerted very much and took longer time during the loaded STS movement. Hence, how to increase the motivation in children’s resistance training is an important issue. Patterned Sensory Enhancement (PSE) is a kind of therapeutic music which utilizes music element to cue movements. Previous studies indicated music not only enhanced motivation but also increased peak capacity, and improved movement control and the ability of the exercises. The carry-over effects of music were still controversial. The purposes of the study were to investigate immediate effects of PSE on the execution and motivation of the loaded STS movement in children with SD. Methods: This study had recruited 20 children with SD aged 5 to 12 years and GMFCS I-III. The digital video, VICON 512 motion analysis system, 2 AMTI force platforms, and the Intrinsic Motivation Inventory-Chinese version (IMI-C) were used to collect data. The experiment took 2 separate days within 2 weeks to accomplish. On the first day, the 1-Repetition Maximum (1-RM) STS load of each time was determined. The phase time and the movement execution of the 50% 1-RM load of the STS movement were recorded by a digital video. Then the physical therapist and the music therapist composed the components of the individualized PSE according to the performance of each child in the video. The music therapist composed an individualized PSE music file for each child for the second day’s study. On the second day, children conducted the loaded STS movement with 50% 1-RM load repetitively for 8 trials in Music and No-music (control) conditions assigned randomly and the video, kinematic and kinetic data of and the IMI-C were collected. In Music condition, PSE music played only in the first 5 trials as the PSE condition, and music was then switched off in the last 3 trials as the Continuation condition. The parameters included: the peak extension power of lower extremities, parameters of motor control (the smoothness, the movement time, the maximal trunk flexion angle, the directness, and the inter-trial variability), parameters of motor ability (the successful rate and the number of attempts) and scores of the IMI-C. Paired t or Wilcoxon signed rank test was used to compare the parameters between the PSE and Continuation conditions. The carry-over effects of the PSE music were examined parameters between the Continuation and the control conditions with Pair t or Wilcoxon signed rank test for those effective parameters of PSE. α was set at 0.05 (one-tailed). Results: During the loaded STS movements, comparing with the control condition, the PSE music showed effects on increased knee peak extension power (p=0.042), better motor control (better center-of-mass smoothness (p=0.009), decreased movement time (p=0.006), and maximal trunk flexion angle (p=0.036), and higher IMI-C scores (p=0.002). There were no significant effects on the inter-trial variability, and the movement abilities. The carry-over effects of the PSE music were also not significant. Discussion and Conclusion: The PSE music with the loaded STS movement to a certain degree could alter peak extension power, motor control and the motivation immediately; however, such effects could not last once the music was switched off. No significant effects on movement ability were found. The duration of entrainment contingency and learning processing may be too short to achieve the carry over effect as well as to cause the motor ability change in this study. Future studies are needed to investigate the long-term effects and its neurological mechanism of the PSE music on the resistance exercise, including muscle strength, motor control, motor ability, and motivation.