發展障礙兒童運動功能的評量與分析

Evaluation and Analysis of Motor Function for Children with Developmental Disability

王慧儀(Hui-Yi Wang)

指導教授 ： 鐘育志

高雄醫學大學/醫學院/醫學研究所/博士(2005年)

摘要

在各類發展障礙兒童中，腦性麻痺、脊髓肌肉萎縮症，及唐氏症兒童為其中常見的三類失能兒童，其各自呈現不同的運動失能特徵。在給予失能兒童療育介入時，使用合適的分析評量方法，能使專業人員充份地了解、及更為有效率地矯治失能情況。以下的研究目的有二：其一為、針對以上三類發展障礙兒童的運動失能相關問題，探討使用評估工具或測量方法進行評量及分析的情況；其二為、探討與此些發展障礙兒童運動功能改變情況有相關性的因素。本研究包括三個研究部分。
第一部分：取得81名平均年齡為3.6±1.8歲的腦性麻痺兒童，以粗動作功能分類系統(GMFCS)作分級，以了解其運動失能的嚴重程度。使用粗動作功能量表(GMFM)，在平均每相隔3∼6個月之間進行了1∼4次的運動功能評估，以取得GMFM總分（分別以第一版本GMFM-88總分及第二版本GMFM-66總分呈現）。研究結果為：建立得年齡與GMFM總分的迴歸直線模型，取得2~6歲間腦性麻痺兒童的GMFM總分估計值，並比較得不同GMFCS等級的患者間，隨年齡之GMFM總分變化趨勢的差異情況。另分析結果顯示GMFM-66量表較GMFM-88量表有較佳的臨床評估反應性。此外，區辨分析的結果顯示，復健治療頻率、兒童年齡、動作障礙等級、家中手足數，及治療特性的3個因素：治療架構、治療互動及家長為中心等變項為區辦個案具有較多或較少GMFM總分進步量之有意義相關因素。
第二部分：取得44名年齡在1.6∼23.3歲的脊髓肌肉萎縮症(SMA)患者。其中40名接受肌力測量，包括25名第II型及15名第III型SMA。此外，兩類型患者中分別有27名及17名接受關節活動度測量。使用徒手肌力測量法共評估71群肌肉的肌力喪失程度。評估結果顯示患者之軀幹及髖關節處肌力較差，而手肘屈曲肌、手腕屈曲肌及伸展肌、手指屈曲肌及橫隔膜肌則呈現較大的肌力。第II型SMA患者之左側上肢平均肌力比其右側顯著地較低。在兩類型患者中，上肢屈曲肌肌力顯著地高於其拮抗伸直肌肌力。第II型SMA患者的下肢屈曲肌力顯著地大於其拮抗伸直肌肌力。在關節活動度方面，使用量角器測量48個關節動作。測量結果顯示在第II型SMA中，89 %的患者有膝伸直角度不足及52 %有踝背曲角度不足，攣縮指數大於1（顯示該動作有發生關節攣縮的高度危險性）的動作有膝及髖伸直、肘外旋、肩外展及踝背曲。在年齡小於2歲的個案中出現攣縮的動作有膝伸直、踝背曲及踝蹠曲。第III型患者關節角度不足的程度較為輕微，分別有53 %患者呈現踝背曲及29 %膝伸直角度不足。此類型個案出現關節攣縮者其年齡均在7歲以上。此外，關節攣縮動作的數目分別與年齡及運動失能程度間有顯著的正相關性。
第三部分：取得20名3∼6歲的唐氏症兒童，使用動作熟練度量表(BOTMP)評測兒童的站立行走平衡能力，另再測量其水平及垂直跳躍的距離及跳躍動作的品質等級。在介入為期6週的跳躍動作活動課程後，分析結果呈現患童的行走平衡能力及跳躍運動功能有顯著的進步。
從以上評量分析的結果，以臨床應用的角度進行相關的討論與建議。

關鍵字

發展遲緩兒童 ； 運動功能障礙 ； 運動評量

並列摘要

Cerebral palsy, spinal muscular atrophy and Down syndrome are three main types of disability or diagnoses in children with developmental disability. These three types of children exhibit different features of motor dysfunction. Appropriate clinical analysis and evaluation could facilitate more complete understanding of and more effective in managing their disabled conditions. The first purpose of this study was to investigate the assessments of motor related abilities for these children. The second purpose was to examine significant variables correlated to the change of motor function. The study consisted of three main parts.
The first part: 81 children with cerebral palsy, with mean age of 3.6±1.8 years, were recruited. The Gross Motor Function Classification System (GMFCS) was used for examining their severity of motor disability. Gross Motor Measure Function (GMFM) was administrated for assessing each child’s gross motor function for one to 4 times in an interval of 3 to 6 months between assessments. The two versions of scaling scores, GMFM-88 total score (scaling of the first version of GMFM) and GMFM-66 total score (scaling of the second version of GMFM) were derived. In the results, the two versions of GMFM total scores were predicted by their age using the developed regression straight-line models. It was also found that the trends of GMFM score changes in the 5 levels of GMFCS subjects were different. Several variables were found as important factors, which significantly contribute to the extent of motor change. These factors were treatment frequency, child’s age, GMFCS level, number of siblings, and three variables regarding the content and quality of treatment intervention for the children, which were named as treatment structure, treatment interaction, and parent centered approach.
The second part: A total of 44 individuals with spinal muscular atrophy (SMA), aged 1.6 to 23.3 years, were enrolled. Assessments of muscle strength and joint range of motion (ROM) were conducted. Forty of them, 25 subjects with type II SMA and 15 subjects with type III SMA, underwent strength assessments for 71 muscle groups using the method of manual muscle testing. The results showed that in both types of subjects, trunk and hip musculatures possessed lower strength scores, whereas elbow flexors, wrist flexors and extensors, finger flexors, and diaphragms had relatively higher strength scores. In type II SMA the average score of left arms was lower than that of right arms. Arm flexor scores were higher than arm extensor scores in both types. Regarding the assessments of joint ROM, 27 subjects with type II SMA and 17 subjects with type III SMA were assessed with transparent goniometers. A total of 48 motions were measured. The results showed that there were 89 % of the subjects with type II SMA whereas 29 % type III SMA experienced knee extension limitation. 52% of subjects with type II and 53% type III SMA exhibited ankle dorsiflexion limitation. In type II SMA, the motions of knee and hip extension, elbow supination, shoulder abduction and ankle dorsiflexion had a contracture index of greater than one (high risk of joint contracture). In children with type II SMA, whose age less than two years, their limited motions were knee extension, ankle dorsiflexion and plantarflexion. All the subjects with type III SMA who exhibited ROM limitations were older than 7 years. The number of motions with limited ROM positively correlated with age and arm functional grade for type II SMA.
The third part of this study: Twenty children with Down syndrome aged 3 to 6 years were recruited. The Bruininks Oseretsky Test of Motor Proficiency and jumping tests were used for assessing their performances of upright balance control and jumping movements. After a 6-week motor training course, the children exhibited significantly improved balance and jumping performances.
From the views of clinical implications, the above study results were discussed and some suggestions of clinical practices were also offered.

並列關鍵字

motor evaluation ； motor function dysfunction ； children with developmental delay

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