重度、極重度腦性麻痺患者(CP)常因異常反射、肌肉張力與感覺系統障礙等問題造成發展遲緩、關節攣縮變形、動作發展困難而導致日常生活的各種障礙，對於患者家庭及整個社會更是沉重的負擔，及早給予患者復健治療訓練與適合的輔具科技可改善異常動作障礙、減少相關生理病症產生、誘發正常動作發展並極大化腦性麻痺的日常功能、培養獨立能力且增加社會參與的機會。特殊坐姿擺位支撐輔具可提供腦性麻痺患者肢體良好的支撐，減少因重力造成的異常神經肌肉作用，並增加身體靜態穩定而發展正常的動作功能表現。目前對於特殊坐姿擺位支撐系統之功能性療效評估，多以臨床觀察為主，雖然實際之助益顯而易見但大多是研究人員主觀評估描述，且腦性麻痺患者本身或個體間的變異性大，尤其針對重度和極重度CP患者之坐姿擺位的研究非常具有挑戰性，若使用團體比較設計的研究方法則較難評估每位個案的改善情況，因此甚少量化研究探討坐姿擺位對於降低異常反射、肌肉張力、發展正常動作並增加上肢功能之療效。有鑑於此，本研究之目的為以量化和質性分析探討坐姿擺位與特殊輪椅對於重度、極重度腦性麻痺兒童其異常反射、肌肉張力、姿勢控制及動作發展之影響。

　　本實驗的受試者來自成大醫院復健部共5位經復健科醫師診斷為重度、極重度痙攣型腦性麻痺之個案，本研究分為三個階段：第一階段為重度、極重度腦性麻痺個案之神經肌肉與動作功能之臨床評估，包括肌肉張力、關節活動度、神經發展、動作功能等；第二階段為應用可調式坐姿擺位評估系統和肌電訊號量測，評估腦性麻痺患者之特殊坐姿擺位，並根據臨床評估指導原則，提供合適之個別化特殊輪椅與支撐輔具的處方；第三階段為探討長期使用特殊輪椅與支撐輔具對於重度、極重度腦性麻痺之發展神經學、降低肌肉張力、改善坐姿控制和上肢動作功能等方面之療效。採用單一對象實驗設計，配合重複進行肌肉張力、關節活動度、動作功能等臨床評估與肌電訊號量測，研究並探討特殊坐姿擺位之長期療效。本研究所評估的參數包括肌肉張力、關節活動度、肌肉電訊號(IEMG)等。

　　本研究結果顯示5位受測者在EIDP評估量表之發展年齡皆有增加。在特殊輪椅介入後第一個月受測者的頭部屈曲與伸直、肩關節屈曲、髖關節屈曲等關節活動度有顯著增加，且大部分的關節角度隨著治療時間增加而漸增的趨勢。肌肉張力之肌電訊號量測結果顯示所有受測者於基準期的平均肌電訊號活性皆比治療期來得高，其中肱二頭肌、肱三頭肌和頸伸直肌於特殊擺位介入後，肌電活性可明顯地降低，在長期療效評估中大部份受試者在治療期的IEMG值比基準期的IEMG值來的低，且3位受試者(No.1、No.3、No3)的上肢與軀幹肌之IEMG值皆有明顯地降低。受測者的肱二頭肌、肱三頭肌、頸伸直肌、腰伸直肌、背伸直肌等皆隨著特殊輪椅與支撐輔具的介入時間增加而肌肉張力下降，尤其在介入後第一個月有明顯肌肉張力減少的趨勢。

　　本研究結果顯示不當的擺位姿勢不僅造成痙攣型腦性麻痺的肌肉張力增加、異常反射出現，長久更導致關節攣縮變形、動作難以發展。因此腦性麻痺之輔具提供應依據個案的臨床評估包括肌肉骨骼、神經學發展等方面及不同的個別需要，才能給予合適的特殊輪椅以滿足個案本身的需求。而所有受測者於適當擺位後能顯著改善其坐姿、促進動作發展、減少異常反射與正常化肌肉張力，而特殊輪椅與支撐輔具的介入可以降低重度、極重度腦性麻痺之身體近側高肌肉張力，亦可增加攣縮關節的活動度，然於肢體遠端的影響主要為促進其動作功能的發展和動作控制的穩定，且需要長時間的追蹤與觀察較有明顯的改善情況。然而，腦性麻痺本身與個體間的變異性相當大，因此為了量化與質化分析及探討特殊輪椅對重度、極重度腦性麻痺之影響使用單一對象實驗設計為最佳的研究方法。本研究利用坐姿擺位評估系統能夠有效地評估腦性麻痺患者坐姿擺位情況，並提供合適且個別化之特殊輪椅與支撐輔具的處方，且給予其個別化的適當擺位達到復健矯正的療效，以最小的限制達到患者最大的功能性發展。

Cerebral palsy (CP) is characterized by developmental delay, musculoskeletal deformity, and functional disabilities resulting from persisting tonic reflex, abnormal muscle tone, and sensory deficits. It is the most common childhood physical disability. Because of the motor impairments of the trunk and limbs, there is an inability to maintain antigravity postural control, thus leading to abnormal postures and the inability to sequence movement appropriately. Seating/positioning and body support devices of assistive technology have been addressed to improve sitting posture and functional activities through reducing abnormal neurological responses for cerebral palsy, but very few studies have been conducted on the therapeutic effect of specialized seating and positioning system on muscle tone, joints’ range of motion and functional performance of the severe or profound CP.

The purpose of the research was to investigate qualitatively and quantitatively the effect of proper positioning and body support devices on decreasing abnormal reflex, normalizing muscle tone and improving postural control as well as developing functional movement for severe or profound CP. The specific aims were to: (1) conduct clinical examination on neuromuscular control and motor development of severe and profound cerebral palsy, 2) conduct seating and positioning evaluation to prescribe specialized wheelchair prescriptions, and 3) systematically investigate the long-term effect of positioning on neurological development, decreasing muscle tone, seated postural control and functional performance.

Five subjects with cerebral palsy were recruited from National Cheng Kung University Hospital. The severity of spasticity was evaluated through Modified Ashworth Scale for joints’ range of motion and the reflex of neurological development, and the muscle tone was evaluated through EMG. A sitting and positioning system was applied to provide appropriate positioning and supports for fitting, also physical therapy was intervened for upper limbs. Then the anthropometric data were collected for specialized seating prescription. The customized wheelchair was provided for the subject to use at home for at least four hours every day. A Single-Case Research Design was used to evaluate the long-term effect of specialized seating for six-month follow-up. The parameters contain muscle tone, range of motion and IEMG repeated every month.

The results of clinical evaluation show that the proper seating and positioning have facilitated to improved sitting posture, decreased pathological reflexes and abnormal muscle tone for all five subjects. The results of EMG measurement indicate that specialized seating has ability to significantly decrease the muscle tone on the trunk and limbs muscle activities. The results indicate that proper sitting contributes significantly to relax the upper extremities. The spasticity of proximal joints like hip joints and knee joints are also improved.

The outcomes of follow-up evaluation show that specialized seating and positioning system indeed improve head control, upright sitting, social interaction and active environmental exploration. Normalized muscle tone and increased range of motion for most of joints are also indicated. The findings from this single-case research experiment have proved that specialized seating is efficacious to improve pathologic neuromuscular control through EMG measurement and clinical examinations. The subjects will develop their functional performances through a combined rehabilitation and specialized seating therapeutic modality.

In this research, the seating/positioning prescription and follow-up evaluation provided invaluable information to clinical evidence. The improvement on normalizing muscle tone, decreasing pathological reflex and functional movement are agreed to the literature. Although the back support is needed to be further developed for a more comfortable sitting posture, the specialized seating/positioning is particularly useful in improving the neuromuscular problems of severe and profound CP.

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