Serebral palsili çocuklarda sanal gerçeklik terapisinin motor fonksiyonlara, günlük yaşam aktivitelerine ve ruhsal uyuma etkisi /
Yazar: BURCU METİN ÖKMEN
Danışman: UZMAN MERYEM DOĞAN ASLAN
Sağlık Bakanlığı / Ankara Fizik Tedavi Ve Rehabilitasyon Eğitim ve Araştırma Hastanesi / Fizik Tedavi ve Rehabilitasyon Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2010
Konu: Fiziksel Tıp ve Rehabilitasyon = Physical Medicine and Rehabilitation

Özet:
Çalışmanın amacı yatarak rehabilitasyon gören SP'li çocuklarda sanal gerçeklik terapisinin motor fonksiyonlara, günlük yaşam aktivitelerine ve motivasyona etkisini araştırmaktır. 
Çalışmaya T.C. Sağlık Bakanlığı Ankara Fizik Tedavi ve Rehabilitasyon Eğitim ve Araştırma Hastanesi Gazi ek binasında Nisan 2009-Eylül 2009 tarihleri arasında yatarak rehabilitasyon programı uygulanan serebral palsili çocuklardan çalışmaya uygun  olan 41 hasta alındı. Hastalar randomize olarak çalışma ve kontrol olmak üzere 2 gruba ayrıldı.
Çalışmaya 5-15 yaşları arasında, kooperasyon kurulabilen, oturma dengeleri mevcut olan, üst ekstremite PROM'ları açık olan ve ciddi spastisitesi olmayan hastalar dahil edildi. 5 yaşından küçük veya 15 yaşından büyük, ağır mental retardasyonu olan, kooperasyon kurulamayan, oturma dengeleri olmayan, üst ekstremitelerinde kontraktürleri bulunan ve ciddi spastisitesi olan hastalar çalışmaya alınmadı.
Tüm hastaların yatışlarında etyolojik faktörleri(prenatal, natal, postnatal) de içeren ayrıntılı anamnez bilgileri alındı. Hastaların yaş ve cinsiyet  kaydedildi. Hastalara ayrıntılı fizik  ve nörolojik muayene yapıldı. CP tipleri belirlendi. 
Çalışma grubuna alınan 21 hastadan 14'ü (%66) erkek, 7'ü (%34) kız, kontrol grubuna alınan 20 hastanın 14'ü (%70) erkek, 6'sı (%30) kızdı. Hastaların yaş ortalamaları çalışma grubunda 8,81±2,48 (5-15), kontrol grubunda 8,15 ± 1,84 (6-12) idi. Tonus bozukluğuna göre CP tiplemesinde çalışmaya alınan hastaların 20'si (%95,2) spastik tip, 1'i (%4,8) atetoid tip iken, kontrol grubundaki hastaların 19'u (%95) spastik, 1'i (%5,0) miks tip idi. Tutulan vücut kısmına göre Cp tiplemesinde çalışma grubundaki hastaların 15'i (%71,4) diplejik, 5'i (%23,8) quadriplejik, 1'i (%4,8) triplejik tip iken, kontrol grubundaki hastaların 12'si (%60) diplejik, 4'ü (%20) quadriplejik, 4'ü (%20) hemiplejik tip idi. Etyoloji prenatal, natal ve postnatal nedenler olarak değerlendirildiğinde çalışma grubundaki hastaların 3'ünde (%14,3) natal, 1'inde (%4,8) postnatal, 3'ünde (%14,3) prenatal+natal, 9'unda (%42,9) natal+postnatal, 5'inde (%23,8) prenatal+natal+postnatal nedenler tespit edildi. Kontrol grubundaki hastaların ise 4'ünde (%20) prenatal+natal, 12'sinde (%60) natal+postnatal, 4'ünde (%20) prenatal+natal+postnatal nedenler tespit edildi. 

Hastaların el fonksiyonları Bimanuel Fine Test(BFMF) ve MACS ile, el beceri fonksiyonları ABILHAND-Kids ile, fonksiyonel düzeyleri Functional Mobility Scale (FMS)  ve  Gross Motor Function Classification System (GMFCS) ile,  günlük yaşam aktiviteleri The Functional Independence Measure of Children (WeeFIM) ile, ruhsal uyum ve motivasyon düzeyleri Hacettepe Ruhsal Uyum Ölçeği  ile değerlendirilmiştir.
Hastaların tümüne fizyoterapist tarafından haftanın 5 günü nörofizyolojik ve konvansiyonel tedavi yöntemleri uygulandı. Hastaların hepsine hastanenin iş uğraşı terapisti tarafından iş uğraşı terapisi uygulandı. 
Çalışma grubuna yukarıda bahsedilen tedavilere ek olarak haftada 3 gün 1'er saatten 4 hafta boyunca toplam 12 seans Play Station 2 Eye Toy oyunu oynatıldı. 
Sonuç olarak sanal gerçeklik terapisi uygulanan çalışma grubundaki hastalarda kontrol grubundaki hastalara göre BFMF, MACS, ABILHAND Kids, Hacettepe Ruhsal Uyum Ölçeği içe dönüklük, dışa dönüklük, belirti ve toplam düzeylerinde anlamlı düzeyde iyileşme tespit edilmiştir. GMFCS, FMS, WeeFIM düzeylerinde her iki grupta da anlamlı iyileşme saptanırken, gruplar arasında istatistiksel açıdan anlamlı düzeyde fark saptanmamıştır.
Çalışmamızın sonuçları serebral palsili çocuklarda konvansiyonel tedavi yöntemlerine ek olarak sanal gerçeklik terapisi uygulamasının motor fonksiyonlara, günlük yaşam aktivitelerine ve motivasyona yararlı etkilerinin olduğunu göstermiştir.

Abstract:
The present study aimed to investigate the effect of virtual reality therapy on motor functions, daily living activities and motivation in children with CP who received inpatient rehabilitation. 
Forty-one patients were included from the children with cerebral palsy who received inpatient rehabilitation program in the Gazi Additional Hospital Building of T.C. Ministry of Health Ankara Physical Therapy and Rehabilitation Training and Research Hospital between April 2009 and September 2009. The patients were randomly divided into two groups, namely, the study and control groups.
The patients who were in the age range of 5 to 15 years, who could cooperate, who had sitting balance, in whom the PROMs of upper extremities were open and who did not have severe spasticity were included. The patients younger than 5 years or older than 15 years, those with severe mental retardation, who were unable to cooperate, who did not have sitting balance, who had contractures in the upper extremities and who had severe spasticity were excluded from the study.
Detailed anamnesis information including etiologic factors (prenatal, natal, postnatal) was obtained during the hospitalizations of all patients. The age and gender of the patients were recorded. Detailed physical and neurological examination was performed. The types of CP were identified. 
Of 21 patients enrolled into the study group, 14 (66%) were male, 7 (34%) were female and of 20 patients enrolled into the control group, 14 (70%) were male and 6 (30%) were female. The mean age of the patients was 8.81 ± 2.48 years (5-15 years) in the study group and 8.15 ± 1.84 years (6-12 years) in the control group. Of the patients with CP typing included in the study, 20 (95.2%) were spastic and one (4.8%) had the athetoid type while whereas 19 patients (95%) were spastic, one (% 5,0) had the mix type in the control group. In the CP typing according to the body part involved, 15 patients in study group (71.4%) were diplegic, five patients (23.8%) were quadriplegic, one patient (4.8%) was triplegic in the study group whereas 12 patients (60%) were diplegic, four patients (20%) were quadriplegic and four patients (20%) were diplegic in the control group. When the etiology was evaluated as prenatal, natal and postnatal causes, three patients (14.3%) had natal, one patient (4.8%) had postnatal, three patients (14.9%) had prenatal+natal, nine patients (42.9%) had natal + postnatal and five patients (23.8%) prenatal + natal + postnatal causes in the study group. In the control group, four patients (20%) had prenatal+natal, 12 patients (60%) had natal + postnatal, four patients (20%) were determined to have prenatal + natal + postnatal causes. 

The manual functions of the patients were assessed with Bimanual Fine Motor Function (BFMF) test and MACS, the functions of hand skill functions were assessed with ABILHAND-Kids, their functional levels were assessed with Functional Mobility Scale (FMS) and  Gross Motor Function Classification System (GMFCS) , daily life activities were assessed with The Functional Independence Measure of Children (WeeFIM), psychological adaptation and motivation levels were assessed the Hacettepe Psychological Adaptation Scale.
Neuropsychological and conventional treatment methods were applied to all the patients by a physiotherapist for five days per week. Occupational therapy was administered to all the patients by an occupational therapist of the hospital. 
In addition to the treatments mentioned above, the patients in the study group were made to play PlayStation 2 Eye Toy game during four weeks for an hour for three days per week. 
In conclusion, a significant improvement was observed in terms of BFMF, MACS, ABILHAND Kids, Hacettepe Psychological Adaptation Scale introversion, extroversion, symptoms and total levels in the study group to whom virtual reality therapy was administered compared to the patients in the control group. A significant improvement was detected in terms of the GMFCS, FMS, WeeFIM levels in both groups while no statistically significant difference was found between the groups.
The results of our study showed that the application of virtual reality therapy in addition to conventional treatment methods in children with cerebral palsy had beneficial effects on motor functions, daily life activities, and motivation.