Effects of Aquatic Rehabilitation Exercise on Physical and Cognitive Function in Older Adults with Physical Disability = 수중재활운동 프로그램이 지체장애 노인의 신체 및 인지 기능에 미치는 영향

다국어 초록 (Multilingual Abstract)

The purpose of this study was to assess the effects of participating in an 8-week aquatic rehabilitation exercise program on the outcomes of physical and cognitive functioning of elderly persons with physical disabilities, within the context of Dynamic Systems Theory, Leisure Ability Model, and External Focus of Attention feedback. It demonstrates that aquatic rehabilitation exercise is a beneficial intervention approach for augmenting functional mobility, muscular strength and endurance, and cognitive performance, with significant effects following the intervention. Post-intervention improvement in lower extremities functional outcome measures such as SPPB chair stand, gait speed, SFT 8-foot Up & Go, balance, and isokinetic indicators in lower-limb strength and muscular endurance after control for gender and age was reported. The follow‐up maintenance of SPPB, BBS, and TUG indicates that the impacts of aquatic rehabilitation are not just short‐term physiologic adaptations and reflect meaningful retention of functional improvements. These data demonstrate beneficial effects for repeated task administration, adaptations of movement and neuromuscular adaptations in aquatic environment in elderly patients with restricted exercise. Other remarkable benefits have been recorded regarding global cognitive function (MoCA) and multiple LICA subdomains, such as immediate recall, recognition, and semantic, shape, and color processing in addition to the physical gains. Those results indicate that aquatic rehabilitation exercise gives good cognitive stimulation and this is most likely due to the combined demands in terms of postural (postural control), attentional (attentional regulation), and sensorimotor (sensorimotor) integration related tasks in regards to the physical activity through aquatic movement. Consistency of cognitive gains at follow-up results further attests to the importance of a protective intervention approach in cognitive health of older adults with physical disability to develop protective effects of aquatic exercise as a cognitive effect. In principle this evidence is consistent with the Leisure Ability Model, where any increase in functional ability, which is supported by increased higher-order cognitive and psychological functioning, is expected to require continuous participation in physical activity. Indeed, the external focus of attention feedback in aquatic settings may also contribute to further mechanisms for automatic and efficient motor control which match with motor learning theory, which regards not only physical performance (for example in muscular movements and correct movement patterns), but also cognitive performance (executive function resolutions). Dynamic Systems Theory can also underpin these findings: aquatic environment promotes flexibility of task constraints which facilitate the creation of adaptive solutions to movement and self-organization. Rehabilitation inland made modest shifts, but not necessarily at the magnitude or uniformity of gains observed in the aquatic cohort. This finding aligns with prior research that has identified land-based rehabilitation is a possible factor for reduction of movement variability and task exploration in older adults with physical disabilities as it causes more mechanical load such as steering aids, balanced demands, and perceived risk of falling. Whereas, aquatic rehabilitation is safer and more responsive, resulting in superior results. This study provided empirical evidence of the benefits of aquatic rehabilitation exercise as a theory-based, clinically applicable intervention with the potential to affect physical and cognitive health in elderly persons with physical disorders. The findings highlight the need for aquatic rehabilitation as part of community-based and clinical rehabilitation efforts and to tailor interventions targeted at the general functioning and cognition needs of older adults with disabilities rather than merely physical limitations alone.

국문 초록 (Abstract)

본 연구의 목적은 지체장애 노인을 대상으로 수중재활운동 프로그램이 신체기능과 인지기능에 미치는 효과를 검증하고, 일상생활수행능력에 대한 부가적 영향을 분석하는 데 있다. 본 연구는 여가참여를 기능적 능력에서 여가 역량, 그리고 지속적 참여로 이어지는 발달적 과정으로 설명하는 여가능력모형(Leisure Ability Model)을 이론적 틀로 설정하였다.
본 연구는 반복측정 중재 설계를 적용하여 연구를 실행하였다. 지체장애 노인을 대상으로 8주간 수중재활운동 프로그램을 실시하였으며, 사전검사, 사후검사, 추적검사를 통해 효과를 분석하였다. 신체기능 변인으로는 단축형 신체수행검사(SPPB; 의자일어서기, 보행속도), 일어나서 걷기 검사(TUG), 노인체력검사(SFT; 8피트 일어나 걷기, 유연성), 악력, 등속성 하지 근력(60°/s) 및 근지구력(180°/s), 심폐지구력(Modified Physical Test), 균형능력(Berg Balance Scale)을 측정하였다. 인지기능은 몬트리올 인지평가(MoCA)와 문해 독립 인지평가(LICA)의 하위영역(즉각회상, 막대재인, 의미·형태·색채 속성)을 활용하여 평가하였으며, 일상생활수행능력은 한국판 수정 바델지수(K-MBI)를 통해 분석하였다. 통계분석은 성별과 연령을 공변량으로 보정하여 수행하였다.
연구 결과, 수중재활운동 프로그램 참여 후 하지 기능 수행력, 균형능력, 근력 및 근지구력, 유연성, 악력, 심폐지구력 등 주요 신체기능 변인에서 유의미한 향상이 나타났다. 또한 전반적 인지기능(MoCA)과 기억 및 의미처리와 관련된 LICA 하위영역에서도 유의한 개선 효과가 확인되었다. 일상생활수행능력(K-MBI) 역시 부가적 결과 변수로서 유의한 향상을 보였으며, 대부분의 신체·인지 기능 향상 효과는 추적검사에서도 유지되는 것으로 나타났다.
이러한 결과는 수중재활운동이 지체장애 노인의 신체기능과 인지기능을 동시에 증진시키는 효과적인 중재임을 시사한다. 여가능력모형에 근거할 때, 수중재활운동을 통한 기능적 능력의 향상은 인지적 여가 역량으로의 확장을 가능하게 하며, 궁극적으로 지속적인 여가 참여에 대한 재활을 높이는 발달적 중재로서의 의의를 가진다. 본 연구는 지체장애 노인을 위한 수중재활운동 프로그램의 효과성과 이론적 근거를 제시함으로써, 지역사회 및 임상 현장에서의 적용 가능성을 뒷받침하는 실증적 자료를 제공한다.

목차 (Table of Contents)

• Abstract i
• Table of Contents iv
• List of Tables vii
• List of Figures viii
• Ⅰ. Introduction 1
• 1. Study Background 1
• 2. Research Aims and Objectives 5
• 3. Research Hypotheses 6
• 4. Significance of the Study 7
• 5. Key Terms and Definition 9
• 5.1. Older Adults with Physical Disability 9
• 5.2. Aquatic Rehabilitation Exercise 10
• 5.3. Land-based Rehabilitation Exercise 11
• 5.4. Physical Function 11
• 5.5. Cognitive Function 12
• 5.6. Three-group Comparative Design 13
• Ⅱ. Theoretical Background 14
• 1. Dynamic System Theory 14
• 2. Leisure Ability Model 16
• 3. External Focus of Attention Feedback 18
• 4. Physical Function and Rehabilitation 21
• 5. Aging and Rehabilitation 23
• 6. Characteristics of the Older Adults 26
• 6.1. Physical Function of the Older Adults 29
• 6.2. Cognitive Function of the Older Adults 29
• 6.3. Health Promotion in Older Adults with Physical Disabilities 30
• 6.4. Rehabilitation Exercise and Adapted Physical Activity for Older Adults with Physical Disabilities 31
• 7. Aquatic Rehabilitation Exercise 32
• 7.1. Therapeutic Properties of Water and Clinical Implications 33
• 7.2. Aquatic Exercise Outcomes Relevant to Aging 33
• 7.3. Representative Aquatic Rehabilitation Approaches 34
• 8. Aquatic Rehabilitation Exercise for Disabilities 36
• Ⅲ. Methods 40
• 1. Study Design 40
• 2. Research Participants 41
• 3. Recruitment Process 48
• 4. Inverventions 51
• 4.1. Aquatic Rehabilitation Exercise 51
• 4.2. Land-based Rehabilitation Exercise 57
• 5. Measurements 62
• 5.1. Physical Function 62
• 5.2. Cognitive Function 65
• 5.3. Overall Health Status 66
• 6. Data Analysis 70
• 6.1. Data Preparation and Preprocessing 70
• 6.2. Descriptive Statistics and Baseline Homogenity Assessment 71
• 6.3. Primary Analysis: Main Effects and Intervention Effects Across Repeated Measures 71
• 6.4. Post Hoc Comparison 72
• 6.5. Subcomponent Analyses 74
• Ⅳ. Results 75
• 1. Baseline Homogeneity of Study Participantson 75
• 2. Outcomes of Physical Function 77
• 2.1. Effects of Aquatic and Land-based Rehabilitation Exercise on Key Physical Outcomes 77
• 2.2. Changes in SPPB Subcomponents Following Aquatic and Land-Based Rehabilitation Exercise 79
• 2.3. Changes in Physical Function at the Follow-Up Assessment 81
• 2.4. Gender-Moderated Effects on Body Composition and Cardiovascular Indicators 83
• 2.5. Gender-Moderated Effects on Physical Function Outcomes 86
• 2.6. Gender-Moderated Effects on Body Weight–Normalized Isokinetic Strength 89
• 3. Outcomes of Cognitive Function 92
• 3.1. Effects of Aquatic and Land-Based Rehabilitation Exercise on Key Cognitive Outcomes 92
• 3.2. Cognitive Changes at Follow-Up 94
• 3.3. Gender-Moderated Effects on Cognitive Function and Activities of Daily Living 96
• 3.4. Group × Time Effects Across LICA Cognitive Subdomains 98
• Ⅴ. Discussion 102
• 1. Effects of Aquatic Rehabilitation on Physical Function 102
• 2. Effects of Aquatic Rehabilitation on Cognitive Function 103
• 3. Maintenance of Physical and Cognitive Gains at Follow-Up 105
• 4. Comparison With Land-Based Rehabilitation Exercise 105
• 5. Theoretical Integration and Implications 106
• Ⅵ. Conclusion 108
• 1. Limitations and Future Directions 110
• 2. Practical Applications 111
• References 112
• Appendix A1 128
• Appendix A2 129
• Appendix A3 130
• Appendix B 131
• Appendix C 132
• 국 문 초 록 133