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1 근전도유발신경근육전기자극이만성편마비환자의손기능향상에미치는영향 연세대학교대학원 재활학과 김태호

2 근전도유발신경근육전기자극이만성편마비환자의손기능향상에미치는영향 지도이영희교수 이논문을석사학위논문으로제출함 2003 년 12 월일 연세대학교대학원 재활학과 김태호

3 김태호의석사학위논문을인준함 심사위원 인 심사위원 인 심사위원 인 연세대학교대학원 2003 년 12 월일

4 감사의글 오늘이있기까지많은시험과어려움속에서도내삶을이끌어주신하나님께감사드립니다. 연구의시작부터논문이완성되는끝맺음까지바쁜병원일정속에서도세심한지도를해주시며가르쳐주신이영희교수님께진심으로감사드립니다. 논문의바른방향을제시하시며물리치료사로서연구의자세를일깨워주신권오윤교수님, 다양한학문의적용으로새로운학문의영역을넓히게하신조상현교수님께감사드립니다. 학부때부터지금까지늘자상함과학자의정도를몸소보여주시는이충휘교수님, 대학원입학때부터칭찬과격려로써용기를주신정보인교수님, 따뜻한미소로관심을가져주신유은영교수님께감사드립니다. 학기중병원에서대학원을다닐수있도록많은배려와격려를해주신박영식실장님, 대학원첫발부터마치는지금까지사랑으로도와주신원종혁선생님, 논문의마지막교정까지세세하게봐주신김용욱선생님께감사드립니다. 함께졸업논문을준비하며서로에게힘이되어준이명예선생님, 황영진선생님과함께기쁨을나누고싶습니다. 부족한선배를위해몇일동안밤샘작업도마다하지않고자료정리를도와준최석호선생님, 김문환선생님, 윤성준선생님께고마운마음을전합니다. 논문을완성하기위해많은도움을주신신화경선생님, 이수영선생님, 정이정선생님, 박소연선생님, 김덕화선생님께고마운마음을전합니다. 통계처리를위해많은도움을주신예방의학교실의박준호선생님과생리학교실차승규선생님께도감사드립니다. 특별히본실험연구에참여해주신 9명의환자들께빠른쾌유를기원합니다. 멀리고향에서많은어려움속에서도자식만을염려하시고사랑해주시는아버지어머니, 늘기도의후원자가되어주시며격려해주신장인어른과장모님께깊은감사를드리며든든한지원자가되어주었던가족들께이논문을드립니다. 마지막으로힘들고어려웠던긴시간을말없이참고견디어준가장소중하고사랑하는아내와두딸예진, 예림과함께이기쁨을나누고싶습니다 년 12 월김태호드림

5 차 례 그림차례 iii 표차례 iv 부록차례 v 국문요약 ⅵ 제1장서론 1 제2장연구방법 연구대상 실험기기및도구 근전도유발신경근육전기자극치료기 표면근전도신호수집및처리 전기측각기 Modified Ashworth scale Box and Block test 실험과정및평가 전기자극치료 평가 손허리손가락관절의관절가동범위의변화 표면근전도신호처리및분석방법 적분EMG 동시수축비 11 - i -

6 2.4.3 손가락폄근의초기수축시주파수분석 통계분석 12 제3장결과 연구대상자의일반적특징 상대적적분EMG값의변화 손허리손가락관절의관절가동범위의변화 강직의변화 동시수축비의변화 손가락폄근의초기수축시주파수분석 Box and Block test 손의 Brunnstrom 회복단계에따른변화 18 제4장고찰 연구방법에대한고찰 연구결과에대한고찰 임상적의미및제언 28 제5장결론 29 참고문헌 30 부록 43 영문요약 44 - ii -

7 그림차례 Fig. 1. The EMG triggered NMES and the placement of the electrodes on extensor digitorum communis muscle 6 Fig. 2. Changes of relative IEMG of finger extensor with EMG-triggered NMES 15 Fig. 3. Changes of spasticity of finger flexor 16 Fig. 4. Changes of parameters according to Brunnstrom stages of hand 20 - iii -

8 표차례 Table 1. Characteristics of the subjects 13 Table 2. Changes of relative IEMG 14 Table 3. Changes of ROM excursion of metacarpophalangeal joint 15 Table 4. Changes of cocontraction ratio between finger extensor and flexor 17 Table 5. Changes of median frequency in contraction of finger extensor 17 Table 6. Changes of Box and Block test 18 Table 7. Changes of parameters according to Brunnstrom stages of hand 19 - iv -

9 부록차례 부록. Brunnstrom recovery stages of hand 43 - v -

10 국문요약 근전도유발신경근육전기자극이만성편마비환자의 손기능향상에미치는영향 본연구는자연적회복을기대하기어려운만성편마비환자의손가락폄근에근전도유발신경근육전기자극을적용한후, 손가락의움직임에관여하는근육의활동양상과관절움직임의변화를평가하여치료의효과를확인하고, 손의회복단계에따른치료효과를비교하여치료의적응증을제시하고자하였다. 연구대상자는발병후 1년이상이경과한만성편마비환자 9명이었다. 연구대상자는손상측의손가락폄근에근전도유발신경근육전기자극치료를하루 1시간씩, 일주일에 5회, 총 8주동안받았다. 평가는치료전, 치료 4주, 8주후에실시하였다. 30초동안손가락을최대로폈다가다시주먹을쥐는동작을반복하면서손가락폄근과굽힘근의표면근전도신호와검지의손허리손가락관절의관절가동범위를수집하였다. 그결과손가락폄근의적분EMG값과손가락굽힘근의강직이치료후에유의한차이가있었다. 9명의연구대상자중에서손의 Brunnstrom 회복 4~5단계에속한 3명에서는치료후손가락폄근의적분EMG값이증가하였으며, 손가락굽힘근의적분EMG값은감소하였고, 손가락굽힘근의강직도감소하였으며, 동시수축비도감소하였고, 손허리손가락관절의관절가동범위의변화는증가하였으며, Box and Block test의점수도증가하였다. 그러나, 능동적으로손가락펴는동작을전혀할수없는손의 Brunnstrom 회복 3단계에속한 6명의연구대상자들에서는 - vi -

11 치료후에손가락폄근의적분EMG값이증가하였으나, 손가락굽힘근의적분 EMG값도함께증가하여동시수축비가치료전에비해오히려증가하였다. 이로인해 3단계에속한연구대상자들은운동기능에변화가없었다. 따라서자연적회복이한계에도달한만성편마비환자일지라도, 손가락펴는동작이능동적으로조금이라도가능한손의 Brunnstrom 회복 4단계이상인환자들에게근전도유발신경근육전기자극을이용하여목표지향적이고능동적이며반복적인운동을통해손의운동기능회복에도움을줄수있을것이다. 앞으로의연구에서는많은환자를대상으로근전도유발신경근육전기자극치료후손가락폄근과굽힘근의변화에대한보다구체적인연구가필요할것이다. 핵심되는말 : 강직, 근활성, 동시수축, 신경근육전기자극, 편마비. - vii -

12 제 1 장서론 외상성뇌손상과뇌졸중으로인한편마비환자는근육의마비로인한근력의약화, 근활성 (muscle activation) 의비정상적타이밍 (timing), 강직 (spasticity), 비정상적피부반사와같은상위운동신경원증후군이나타나 (Ekman 2002) 자발적으로운동을조절할수없게된다 (Cauraugh et al. 2000). 특히편마비환자는상지에서비정상적인굽힘협력 (flexion synergy) 이진행되어독립적인관절운동이제한되며, 이로인해상지의기능적수행이어려워진다 (Duncan, and Badke 1988). 뇌졸중으로인한편마비환자의자발적인기능회복은초기 3개월까지는빠르게진행하고, 그후로는완만하게이루어지며, 12개월이지나면한계에이른다 (Cauraugh et al. 2000). 편마비환자의 40% 에서는영구적으로운동장애를동반하는만성편마비환자가되고 (Nakayama et al. 1994), 이경우에는상지의근위부보다는원위부에, 손가락을구부리는기능보다는펴는기능에보다많은운동결함이나타난다 (Parker et al. 1986). 편마비환자의손기능장애는손가락폄근의근활성의감소와길항근으로작용하는손가락굽힘근의부적절한동시활성 (coactivation) 의결과로인한것이다 (Kamper, and Rymer 2001). 중추신경계손상후뇌의회복은신경가역성에의해설명되며, 신경가역성은목표지향적이고능동적이며반복적인운동을통해촉진되는것으로밝혀졌다 (Aisen et al. 1997; Butefisch et al. 1995; Nudo, and Friel 1999). 편마비환자의운동회복과운동재학습 (motor relearning) 을위해서는이러한목표지향적이고능동적이며반복적인운동이효과적이다. 운동재학습이란중추신경계의 - 1 -

13 손상후이전에학습된운동기술들을재획득하기위하여운동수행능력을영구적으로변화시킬수있도록연습하고경험하는과정이다 (Pauri et al. 2000). 편마비환자의상지기능을회복시키기위한치료방법으로는신장운동이나근력강화운동과같은보존적치료, 신경발달학적치료법 (Bobath 1959), 고유수용성신경근육촉진법 (Knott, and Voss 1968), 근전도생체되먹임 (biofeedback) 방법 (Basmajian et al. 1982), 감각운동통합 (sensorimotor integration)(flanagan 1967), 협력작용을이용한기능적응용 (Brunnstrom 1970), 보조기, 전기자극, 마비측상지의강제유도운동치료 (constraint-induced movement therapy)(van der Lee et al. 1999) 등이사용되고있다. 그러나, 여러연구에서어느한치료법이다른치료법보다편마비환자의상지운동과기능회복에더효과적인지를검증하지못하였다 (Dickstein et al. 1986; Lord, and Hall 1986; Wagenaar et al. 1990). 상지의기능회복을위한전기자극치료중에서가장일반적인것이신경근육전기자극 (neuromuscular electrical stimulation: NMES) 이다. 신경근육전기자극치료는편마비환자의강직을줄여주고, 근력을강화시키며, 관절가동범위를증진시킨다 (Dimitrijevic et al. 1996; Levin, and Hui-chan 1994). 신경근육전기자극에는기기의정해진프로그램에의해서전위발생이조절되는주기적전기자극 (cyclic NMES) 과환자의근전도 (Electromyography: EMG) 신호를이용하여전위의발생을조절하는근전도를이용한신경근육전기자극 (EMGmediated NMES) 이있다. 근전도를이용한신경근육전기자극은수의적으로동원된운동단위의활동전위를이용하여설정된전기자극프로그램을시작하는근전도유발신경근육전기자극 (EMG-triggered NMES) 과전기자극의시작뿐 - 2 -

14 만아니라전기자극의지속및종료도환자의근전도신호에따라전위가조절되는근전도조절신경근육전기자극 (EMG-controlled NMES) 으로구분된다. 주기적신경근육전기자극은치료받는환자의인지적노력없이도반복적으로전기자극이가해져근육수축을유발하지만, 근전도유발신경근육전기자극은환자의능동적이고인지적인노력이필요하다 (Chae et al. 2001; Fields 1987). 근전도유발신경근육전기자극의원리는목표한근육을자발적으로수축할때나타나는근전도신호의진폭을평가하여역치를정하고, 능동적수축에의한근전도신호의크기가이역치를초과할때에만전기자극기로부터전기자극이목표한근육에가해지는것이다. 뇌졸중환자들은신경학적인손상후고유수용성감각, 피부감각, 집중력등이손상되거나부족하여서내재성 (intrinsic) 구심성되먹임이감소하는문제를갖고있다 (Burridge, and Ladouceur 2001). 근전도유발신경근육전기자극이운동기능을회복시키는기전은감각운동통합설에근거를두고있다. 능동적인수축에의해근육에가해지는전기자극이강한고유수용성되먹임작용을하며, 이구심성자극이체성감각피질에전달되어감각운동회로를완성시킨다 (Burridge, and Ladouceur 2001). 근전도유발신경근육전기자극치료에대한이전의연구들은급성및만성편마비환자를대상으로다양한평가방법을이용하여임상적효과를보고하였다 (Cauraugh, and Kim 2002; Cauraugh et al. 2000; Chae et al. 1998; Fields 1987; Francisco et al. 1998; Hummelsheim, Maier-Loth, and Eickhof 1997; Kraft, Fitts, and Hammond 1992; Powell et al. 1999). Cauraugh와 Kim(2002) 은만성편마비환자를대상으로손목과손가락폄근치료의효과를 - 3 -

15 Box and Block test, 운동반응시간, 근수축지속등으로평가하였다. Cauraugh 등 (2000) 은 Fugl-Meyer motor assessment, Box and Block test, 운동반응시간, 근수축지속에대해서평가하였고, Powell 등 (1999) 은손목폄근에전기자극치료후손목폄근의등척성근력과관절가동범위, 상지기능을평가하는 Action Research Arm test를통해손기능을평가하였다. Chae 등 (1998) 과 Fransisco 등 (1998) 의연구에서는 Fugl-Meyer motor assessment와 Functional Independence Measure(FIM) 의자조기술 (self care) 항목으로치료의효과를평가하였으며, Hummelsheim 등 (1997) 은손목폄근과굽힘근에반복적전기치료후장악력과 Rivermead motor assessment로평가하였다. 그러나이들연구에서는치료에적응증이되는환자를제시하지못하여연구마다치료의효과유무가다르게나타났으며, 전기자극을받는손가락폄근에대한평가만있었을뿐부적절한동시활성으로손기능에방해를일으키는손가락굽힘근에대한평가나관찰은거의없었다. 또한이전연구들에서치료효과를평가하기위하여사용된 Box and Block test, Fugl-Meyer motor assessment 등은비교적대동작을평가하는방법으로서치료가가해진근육자체의생리적, 생역학적변화를반영하지못하는제한점이있다. 본연구의목적은다음과같다. 첫째, 자연적회복을기대하기어려운만성편마비환자의손가락폄근에근전도유발신경근육전기자극을적용한후, 손가락의움직임에관여하는근육의활동양상과관절움직임의변화를평가하여치료의효과를확인하는것이다. 둘째, 손의회복단계에따른치료효과를비교하여치료의적응증을제시하는것이다

16 제 2 장연구방법 2.1 연구대상 대상자는원주시소재원주기독병원물리치료실로내원하여물리치료를받고 있는편마비환자 9 명으로하였다. 대상자의선정기준은다음과같다. 1) 외상성뇌손상, 뇌졸중으로 1년이상경과된자 2) 손가락폄근에대한도수근력평가로불가 (trace) 등급이상인자 3) 손상측의손허리손가락관절의수동적관절가동범위에제한이없는자 4) 실험중실험자의지시를이해하고수행할수있는자 5) 동반된다른신경학적이상이없는자 6) 전기자극에금기사항이없는자 본연구는실험전에본연구의목적과방법에대하여연구대상자들에게충분히설명한후동의를얻어시행하였다. 연구가진행되는기간동안연구대상자들은본연구와관련된근전도유발신경근육전기자극의적용과함께기존의물리치료, 작업치료, 약물치료등의의학적치료를계속해서받았다. 실험은 2002년 1월 8일부터 2002년 9월 20일까지실시하였다

17 2.2 실험기기및도구 근전도유발신경근육전기자극치료기본연구에사용된근전도유발신경근육전기자극치료기는 AutoMove AM 을사용하였고, 전극은 5 4 cm표면전극 2 을이용하였다. 손가락폄근 (extensor digitorum communis) 의활성전극은손목과팔꿈치사이의 3/4 지점을촉지한다음근육의주행방향으로 2 cm간격으로활성전극, 접지전극, 기준전극순으로부착하였다 (Fig 1). 전기자극의주파수는 50 Hz, 맥동폭 (pulse width) 은 200 μs, 파형은비대칭성직각이상성파형 (biphasic waveform), 최대강도가유발되기까지의시간 (ramp up) 은 2초, 자극이주어지는시간 (on time) 은 6초, 최대강도에서자극이서서히없어지는시간 (ramp down) 은 2초, 휴식기는 12초로설정하였다. Fig 1. The EMG triggered NMES and the placement of the electrodes on extensor digitorum communis muscle. 1 Danmeter, Denmark. 2 Nicolet Biomedical, USA

18 2.2.2 표면근전도신호수집및처리표면근전도신호는 MP150WSW 3 를이용하여측정하였다. 전극은지름이 2 cm인원형전극 4 을 EMG100C에연결하여사용하였다. 손가락폄근의전극은손목과팔꿈치사이의 3/4 지점에서촉지한다음근육의주행방향으로 2 cm간격으로표면전극을부착하였다. 손가락굽힘근은얕은손가락굽힘근 (flexor digitorum superficialis) 을대상으로하였으며, 손목과팔꿈치사이의 3/4 지점의안쪽에서촉지한다음근육의주행방향으로 2 cm간격으로표면전극을부착하였다. 표면근전도신호에대한피부저항을감소시키기위해부착부위를가는사포로 3~4회문질러피부각질층을제거하고, 소독용알코올로피부지방을제거한후전극을부착하였다. 수집된근전도아날로그신호는 MP150WSW으로보내져디지털신호로전환한다음, 개인용 PC에서 Acqknowledge 3.72 소프트웨어 5 를이용하여필터링과기타신호처리를하였다. 근전도신호의표본추출율은 1000 Hz이었고, 20~400 Hz의대역필터 (band pass filter) 와 60 Hz노치필터 (notch filter) 를사용하였다. 3 Biopack System Inc., Santa Barbara, CA. USA. 4 Nicolet Biomedical, USA. 5 Biopack System Inc., Santa Barbara, CA. USA

19 2.2.3 전기측각기검지의손허리손가락관절 (metacarpophalangeal joint) 관절가동범위를측정하기위해 7 cm길이의역동적전기측각기 6 를 DA100C를통해 MP150WSW에연결하여사용하였다. 전기측각기의부착부위는전기측각기의중심부가손허리손가락관절에위치하도록한다음, 양끝의탐색자를양면테이프를이용하여피부에밀착시키고, 그위를종이테이프로고정하여측정시위치이탈을방지하였다. 손가락을굽히고펴는동안의각도의변화는 Acqknowledge 3.72 소프트웨어에서근전도신호와함께수집하였다 Modified Ashworth scale 연구대상자들의손가락굽힘근에대한강직의평가는 Modified Ashworth scale (MAS) 로 3 번반복측정하였으며, 0 점에서 5 점까지 6 점척도로기록하였다 Box and Block test 손가락폄근에대한전기자극치료가상지의기능적운동수행능력을향상시키는지를평가하기위하여 Box and Block test를실시하였다. Box and Block test는길이 2.5 cm의정육면체목재블록을 60초동안이동시킨개수로측정하였다. 6 TSD130D; Biopack System Inc., Santa Barbara, CA. USA

20 2.3 실험과정및평가 전기자극치료연구대상자들에게적용한근전도유발신경근육전기자극은동일시간, 동일장소에서실시하였다. 치료는하루 1시간씩, 일주일에 5회, 총 8주동안실시하였다. 근전도유발신경근육전기자극치료는먼저손가락폄근에전극을부착한후연구대상자로하여금손가락을최대한펴게하고서이때전기자극기에나타나는근전도신호의최대값을역치로정하였다. 연구대상자가능동적으로손가락을펴는동안, 근전도신호가역치에도달하게되면전기자극기로부터전기자극이손가락폄근에가해진다. 전기자극의강도는손가락이충분히펴질수있을정도로설정하였다. 근전도유발신경근육전기자극은목표지향적이고능동적이며반복적인치료이므로대상자들로하여금스스로적극적으로참여하도록전기자극에대한방법을충분히설명하였으며, 손가락폄근의근전도신호가설정된역치에도달하도록격려하였다. 연구대상자가손가락폄근을능동적으로수축하는동안, 상지의굴곡협력패턴과같은반사패턴을사용하는것을최대한억제하도록지시하였다

21 2.3.2 평가치료효과를알아보기위해서근전도를이용한적분EMG(integrated EMG: IEMG), 손허리손가락관절의관절가동범위, 동시수축비 (cocontraction ratio: CCR), 주파수분석, 강직, Box and Block test를이용하여평가하였다. 모든평가는최초치료전, 치료 4주후, 치료 8주후, 총 3회실시하였다. 대상자로하여금책상위에팔을편안히올린상태에서 30초동안손가락을최대로폈다가다시주먹을쥐는동작을반복하게하였다. 그동안의손가락폄근과굽힘근의근전도신호를수집하였으며, 동시에손허리손가락관절에서의관절가동범위를측정하였다. 모든평가는 3번씩반복측정하였으며, 자료정렬은 3번측정의평균값을사용하였다. 측정시의피로를줄이기위하여측정간 3분씩의휴식시간을주었다 손허리손가락관절의관절가동범위의변화전기자극치료후의손가락의움직임에대한호전성을평가하기위하여검지의손허리손가락관절의관절가동범위를측정하였다. 전기측각기에의해수집된검지의손허리손가락관절의관절가동범위는손가락을펴고굽히는동작을반복하는동안의각도의변화 (ROM excursion) 의총합으로구하였다

22 2.4 표면근전도신호처리및분석방법 적분EMG 근전도유발신경근육전기자극의효과에대한정량적근전도값을적분EMG를통해관찰하였다. 30초동안수집된근전도신호는절대값처리후적분EMG를구하였다. 표면근전도신호의개인차및개인내부위별차이를최소화하여전반적인변화추세를관찰하기위해서는정규화 (normalization) 과정이필요하다. 최초치료전 3번반복측정된 30초동안의적분EMG의평균값을 100으로놓고이후의값들을정규화 (%) 하였다 동시수축비손가락을펴는동작시손가락폄근과굽힘근의동시활성의정도를파악하기위하여동시수축비를구하였다. 30초동안반복되는손가락펴는동작들중에서두번째로손가락펴는과정을선택하여자료를수집하였다. Acqknowledge 3.72 소프트웨어에서손가락폄근의활성이시작되는지점부터손가락이최대로펴지는지점까지선택하여텍스트파일로저장한다음엑셀프로그램에서수식처리하여평균값을구하였다. 손가락을펴는동작시각각의시점에서주동근인손가락폄근의값이손가락굽힘근의값보다작을수있으므로, 동시수축비는 Damiano 등 (2000) 이제시한방법에의해공식 (1) 과같이구하였다. CCR Antagonist value Agonist value Minimal EMG value 공식 (1) Maximal EMG value

23 2.4.3 손가락폄근의초기수축시주파수분석 전기자극치료후의손가락폄근의운동단위의동원양상을알아보기위하여주 파수분석을하였다. 손가락을펴는동작시손가락폄근의중앙주파수 (median frequency: MDF) 근전도자료값들은 MatLab 신호처리프로그램을이용하 여구하였다. 중앙주파수스펙트럼분석의신호처리과정은 0.5초동안 500개근전도신호를 FFT(fast Fourier transformation) 대상구간 (epoch) 으로하여하나의 MDF를대표값으로구하였다. 다음대상구간은첫구간의 75% 인 375개근전도신호값이중첩되도록하여이동평균 (moving average) 을구하였다. 30초동안의손가락펴기와쥐기를반복하는과정중에서손가락이펴지는첫구간을선택하였으며, 손가락폄근의수축개시후 1초구간에서 MDF 8개의평균값을구하였다. 2.5 통계분석 전기자극치료전, 치료 4주후, 치료 8주후의적분EMG값, 관절가동범위, Box and Block test, 주파수분석, 동시수축비등의변수에차이를알아보기위하여반복측정일요인분산분석 (repeated measures one way ANOVA) 을실시하였다. 치료전, 치료 4주후, 치료 8주후의강직의변화는프리드만 (Friedman) 검정을실시하였다. 유의성을검정하기위하여유의수준 α는 0.05로하였다. 자료의통계처리는상용통계프로그램인윈도용 SPSS 10.0을사용하였다. 7 Math Works Inc. MA. USA

24 제 3 장결과 3.1 연구대상자의일반적특징 연구대상자 9명의평균나이는 39.2세였으며, 모두남성이었다. 유병기간은발병후 13개월부터 69개월까지였고, 평균 24.4개월이었으며. 임상적으로기능회복이거의한계에도달하였다. 연구대상자의진단명은뇌졸중이 7명 (77%), 외상성뇌손상이 2명 (33%) 이었다. 마비측은오른쪽마비가 6명 (66%), 왼쪽마비가 3명 (44%) 이었다. 손의 Brunnstrom 회복단계에의한분포는 3단계가 6명, 4단계 1 명, 5단계 2명이었다 (Table 1). Table 1. Characteristics of the subjects (N=9) Subjects Age (years) Sex Dx Affected side Time since injury(months) Brunnstrom stages of hand 1 40 M CVA a Rt M TBI b Rt M CVA Rt M CVA Lf M CVA Rt M TBI Rt M CVA Rt M CVA Rt M CVA Lf Mean±SD 39.2± ±18.0 a CVA: cerebrovascular accident. b TBI: traumatic brain injury

25 3.2 상대적적분 EMG 값의변화 근전도유발신경근육전기자극후손가락폄근의상대적적분EMG값은치료전에비해서치료 4주후, 치료 8주후에서유의하게증가되었다 (p<0.05)(table 2)(Fig 2). 치료시기에따른손가락폄근의상대적적분EMG값의차이를비교하기위하여사후검정을한결과, 치료전과치료 4주후, 치료전과치료 8주후사이에서유의한차이가있었다 (Fig 2). 치료 4주후와 8주후사이에는유의한차이가없었다. 손가락굽힘근의상대적적분EMG값은치료전에비해서 4주후, 8주후에증가하였으나, 유의한차이는없었다 (Table 2). Table 2. Changes of relative IEMG (N=9) Muscle Evaluation Mean±SE a Sum of square Finger Pre Tx c 100.0±0.0 d extensor with 4weeks Tx 168.8±15.2 NMES b 8weeks Tx 189.8±16.4 Mean of square Degree of freedom F p Finger flexor without NMES Pre Tx 100.0±0.0 4weeks Tx 135.9±41.3 8weeks Tx 141.4± a SE: standard error. b NMES means EMG-triggered NMES. c Tx means treatment. d All values are (%) against initial IEMG value

26 200 * * Relative IEMG(%) Pre Tx 4 weeks Tx 8 weeks Tx Fig 2. Changes of relative IEMG of finger extensor with EMG-triggered NMES. Units of the Y axis is (%) against initial IEMG value. * Post-hoc analysis after repeated ANOVA p< 손허리손가락관절의관절가동범위의변화 검지의손허리손가락관절의관절가동범위는치료전에비해서치료 4 주후, 8 주 후증가하였으나, 유의한차이는없었다 (Table 3). Table 3. Changes of ROM excursion of metacarpophalangeal joint (N=9)( ) Evaluation Mean±SE Sum of square Mean of square Degree of freedom F p Pre Tx 97.8±32.3 4weeks Tx 192.9± weeks Tx 224.6±

27 3.4 강직의변화 MAS 로측정한손가락굽힘근의강직은치료전에비해치료후에유의하게감 소하였다 (p<0.05). 치료시기별강직의차이를비교하기위하여사후검정을한 결과치료전과치료 8 주후사이에서유의한차이가있었다 (Fig 3). 4 Spasticity(scales) * 0 Pre Tx 4weeks Tx 8weeks Tx Fig 3. Changes of spasticity of finger flexor. Units of the Y axis is scales of spasticity according to MAS(0~5). Values of the bar are mean±se. * Post-hoc analysis after Friedman test p<

28 3.5 동시수축비의변화 손가락을펴는동안의손가락폄근과손가락굽힘근의동시수축비는치료전 에비해치료 4 주후감소하였으나 8 주후에는다시증가하였으며, 유의한차이 는없었다 (Table 4). Table 4. Changes of cocontraction ratio between finger extensor and flexor (N=9) Evaluation Mean±SE Sum of square Mean of square Degree of freedom F p Pre Tx 0.54±0.06 4weeks Tx 0.50± weeks Tx 0.52± 손가락폄근의초기수축시주파수분석 손가락폄근의초기수축시의중앙주파수는치료전에비해치료 4 주, 8 주후에 높게나타났으나, 유의한차이는없었다 (Table 5). Table 5. Changes of median frequency in contraction of finger extensor (N=9) Evaluation Mean±SE Sum of square Mean of square Degree of freedom F p Pre Tx ±4.27 4weeks Tx ± weeks Tx ±

29 3.7 Box and Block test Box and Block test 에서는치료전에비해치료 4 주, 8 주후에점수가증가되 었으나, 유의한차이는없었다 (Table 6). Table 6. Changes of Box and Block test (N=9)(blocks) Evaluation Mean±SE Sum of square Mean of square Degree of freedom F p Pre Tx 5.44±3.25 4weeks Tx 7.66± weeks Tx 8.33± 손의 Brunnstrom 회복단계에따른변화 손의 Brunnstrom 회복 4~5단계에속한연구대상자들은손가락폄근의적분 EMG값이치료전에비해유의하게증가하였으며 (p<0.05), 손가락굽힘근의적분EMG값은치료전에비해감소하였으나, 유의한차이는없었다. 손가락굽힘근의강직은점차감소하였으나, 유의한차이는없었으며, 동시수축비는치료전에비해감소하였다. 손허리손가락관절의관절가동범위는치료후유의하게증가하였으며, Box and Block test의점수는치료전에비해유의하게증가하였다 (p<0.05)(table 7)(Fig 4). 3단계에속한연구대상자들은손가락폄근의적분EMG값이치료전에비해유

30 의하게증가하였으며 (p<0.05), 손가락굽힘근의적분EMG값은치료전에비해증가하였으나, 유의한차이는없었다. 손가락굽힘근의강직은치료후에감소하였으나, 유의한차이는없었으며, 동시수축비는치료전에비해다소증가하였다. 손허리손가락관절의관절가동범위는치료후유의하게증가하였으며, Box and Block test의점수는치료전 후로변화가없었다 (Table 7)(Fig 4). Table 7. Changes of parameters according to Brunnstrom stages of hand (N=9) Stage Parameter Pre Tx 4 weeks Tx 8 weeks Tx p* Stage 4~5 (n=3) Stage 3 (n=6) IEMG of extensor(%) ± ± ± IEMG of flexor(%) ± ± ± ROM excursion( ) ± ± ± Cocontraction ratio 0.60± ± ± Spasticity(scales) 2.33± ± ± Box and Block test (blocks) 16.35± ± ± IEMG of extensor(%) ± ± ± IEMG of flexor(%) ± ± ± ROM excursion( ) 36.76± ± ± Cocontraction ratio 0.52± ± ± Spasticity(scales) 2.50± ± ± Box and Block test (blocks) All values in the cells are mean±se. *p value from repeated ANOVA

31 Relative IEMG of extensor(%) stage 4-5 stage 3 * * Relative IEMG of flexor(%) stage 4-5 stage 3 0 Pre Tx 4weeks Tx 8weeks Tx 0 Pre Tx 4weeks Tx 8weeks Tx ROM excursion( ) stage 4-5 stage 3 * ** * Pre Tx 4weeks Tx 8weeks Tx Spasticity(scales) stage 4-5 stage 3 Pre Tx 4weeks Tx 8weeks Tx stage 4-5 stage 4-5 Box&Block (blocks) stage 3 * ** Cocontraction ratio stage Pre Tx 4weeks Tx 8weeks Tx 0.0 Pre Tx 4weeks Tx 8weeks Tx Fig 4. Changes of parameters according to Brunnstrom stages of hand. All values are mean±se. *Repeated ANOVA according to treatment time p<0.05. **Significantly different between group of stage 4~5 and stage 3( p<0.05)

32 제 4 장고찰 4.1 연구방법에대한고찰 본연구에서는근전도유발신경근육전기자극의효과에대한정량적근전도값을적분EMG를통해평가하였다. 표면근전도신호의진폭을반영하는적분 EMG는활성화된운동단위의수와발화율 (firing rate) 과연관이있다 (Basmajian, and De Luca 1985). Hakkinen과 Komi(1983) 는근력강화훈련동안근력의증가를적분EMG의증가를통해보고하였다. 그러나이러한방법은모든실험조건을일정하게유지한상태에서도비교적정량화하기쉬운시간평면에서의진폭이편차가크고, 전극의위치나종류에따라현저하게영향을받는단점이있다 (Stulen, and De Luca 1978). 본연구에서도항상같은종류의전극을사용하고, 전극의위치도일정한부위에부착하려고하는등, 실험조건을항상동일하게하려고노력하였으나, 위와같은단점을완전히배제하지는못하였다. 근육의동시수축은관절의안정성과운동의정밀성을필요로하는동작을할때, 관절의뻣뻣함 (stiffness) 을증가시키기위해사용되는가장일반적인운동조절전략의하나이다 (Damiano et al. 2000). 그러나근육의동시수축이과도하거나부적절한경우에는주어진과제를수행하는것이어렵다. 동시수축이나타날때, 길항근의근활성정도를정량화하기위해서여러방법들이사용되었다. 길항근값을주동근값으로나눈비율로구하는방법은서로반대되는근육사이에서 (Myklebust et al. 1986), 또는같은근육이상반된일을수행할때사용된다 (Baratta et al. 1988). 다른연구에서는길항근값을전체활동 ( 길항근 + 주동근 ) 값

33 으로나눈비율로구하거나 (Levin, and Hui-Chan 1994), 상반된두근육이일정한시간동안근전도값에서서로겹쳐지는영역을계산하여동시수축을구하였다 (Unnithan et al. 1995). Damiano 등 (2000) 은뇌성마비아동이보행할때와등속성운동을할때무릎폄근과무릎굽힘근의동시수축을길항근값을주동근값으로나눈비로구하였는데, 특히보행시는구간마다주동근과길항근이계속바뀔수있으므로각각의시점에서두근육의근전도값중에서최소 EMG값을최대 EMG값으로나누어계산하였다. 이러한계산방법은동적인움직임으로길항근의근전도값이주동근값보다커질수있을때동시수축을정확히계산할수있다. 본연구에서도위와같은방법으로동시수축비를구하였다. 전기자극후에손가락폄근의운동단위동원양상을알아보기위하여본연구에서는중앙주파수분석을하였다. 일반적으로중앙주파수는근전도상에서주파수변동을가장잘반영하는스펙트럼지수이기때문에운동단위의변화에대한분석에자주사용되었다 (Gerdle et al. 1991; Linssen et al. 1991). Kupa 등 (1995) 은근약화의특성을설명하기위해근섬유들의운동단위동원형태와흥분율의조절능력을평가하는방법으로표면근전도를이용한중앙주파수분석을사용하였다. 본연구는대조군이없는실험설계였다. 본연구에참여한연구대상자들은발병후자연적기능회복이한계에도달한 12개월이지난만성편마비환자들이었다 (Cauraugh et al. 2000). 만성편마비환자를대상으로한근전도유발신경근육전기자극치료에관한이전의연구에서는대조군의상지기능이거의변화가없는 것으로보고하였다 (Cauraugh, and Kim 2002; Cauraugh et al. 2000; Fields 1987; Hummelsheim, Maier-Loth, and Eickhof 1997; Kraft, Fitts, and

34 Hammond 1992; Powell et al. 1999). 박동식등 (1995) 은뇌졸중후상지운동기능의자발적회복이이루어지는시기가발병후 6개월이내로제한되며, 발병후 6개월이지난만성뇌졸중환자에서보존적재활치료는상지운동기능의증진에는효과가적었으며, 신경생리학적촉진방법의치료효과도확실하지않다고하였다. 그러나, 연구의내적타당도를높이기위해서앞으로의연구에서는대조군을이용한통제된실험설계가필요하다. 4.2 연구결과에대한고찰 본연구에서는근전도유발신경근육전기자극치료후손가락폄근에대한상대적적분EMG값이유의하게증가하였음을보여주었다. 많은연구에서근전도유발신경근육전기자극후손목폄근이나손가락폄근의근전도값이치료전에비하여증가했음을보고하였다. Bowman 등 (1979) 은 30명의편마비환자를대상으로 4주간위치되먹임 (positional feedback) 전기자극을손목폄근에적용하여, 손목폄근의근력과관절가동범위가증가하였음을보고하였다. Fields(1987) 는손목폄근과앞정강근 (tibialis anterior) 에전기자극을적용하여근전도값과관절가동범위가증가되는결과를얻었다. Cauraugh 등 (2000) 은손가락과손목폄근에 2주동안의전기자극치료를적용하여근수축지속력에서유의한효과를보았고, Cauraugh와 Kim(2002) 은전기자극치료가근수축지속력과운동반응시간에효과가있음을보고하였다. 본연구에있어서의상대적적분EMG값의증가는손가락폄근에대한전기자극의직접적인영향으로써, 신경근육전기자극이나기능적전기자극을이용하여근력의증가에효과가있음을입증한기존연구의결

35 과와도일치한다 (Granat et al. 1993; Ragnarsson et al. 1988; Sipski et al. 1993). 근력강화훈련초기 2~8주동안의근력증가는속근섬유의운동단위동원능력의증가에의한신경훈련기전 (neural training mechanism) 이주요원인이며, 그이후의근력증가는전체근육중속근섬유의조성비증가로인한근비대가발생함으로써이루어진다 (Hakkinen, and Komi 1983; Kraemer, Fleck, and Evans 1996). 본연구에서도 8주동안의근전도유발신경근육전기자극치료후적분EMG값의증가되었는데, 이것은신경훈련기전이기여한것으로, 손가락폄근의운동단위동원능력이증가함으로써근활성이증가한것으로생각된다. 본연구에서는손가락폄근에근전도유발신경근육전기자극을한후손가락굽힘근의강직이유의하게감소하였다. 강직을감소시키기위해사용되는전기자극방법은크게세가지로나눌수있다. 강직이존재하는주동근에직접전기자극을하는방법 (Daly et al. 1996; Robinson, Kett, and Bolam 1988) 과강직근의길항근에전기자극을하는방법 ( 김성우등 1998; Pease 1998; Seib et al. 1994; Hines, Crago, and Billian 1993), 강직근의피부분절에전기자극을하는방법 ( 김용욱등 2003; Bajd et al. 1985; Potisk, Gregoric, and Vodovnik 1995) 등이있다. 본연구에서는강직이있는손가락굽힘근에대해서길항근으로작용하는손가락폄근에전기자극을함으로써상호억제 (reciprocal inhibition) 의증가로강직이감소한것으로생각된다. 상호억제란주동근이활성화될때주동근의 Ia 구심성전달에의해억제성중간뉴런이반대되는작용을하는근육의운동신경원활성도를억제시키는현상으로, 척수수준의억제성경로에해당한다 (Crone, and Nielsen 1994). Ia 구심성전달에의한억제성중간뉴런의상호억제정도를측정하기위해서는길항근에특정조건의전기자극을가한후작용근의 H-반사의진

36 폭이감소되는정도를검사해야한다 (Crone et al. 1987). 본연구에서는 H-반사를검사하지못하였기때문에, 앞으로근전도유발신경근육전기자극에의한강직의감소를상호억제의증가로증명하기위한연구가필요할것이다. 손가락폄근의초기수축시의중앙주파수는유의한차이를보이지는않았지만, 전기자극치료전에비해치료후에약간증가하였다. 전기자극을이용하여근력강화를하였을때중앙주파수가저주파수대역에서고주파수대역으로이동하는현상은근섬유직경, 속근섬유의선택적인동원력, 근육내전도속도등의증가로설명할수있다 (Molina, Galan, and Garcia 1997). 본연구에서의초기수축시의중앙주파수증가는근전도유발신경근육전기자극을통해서손가락폄근의속근섬유의동원이증가되고발화율이개선된결과로생각된다. 손의 Brunnstrom 회복 4~5단계에속한 3명의연구대상자들은치료전에비하여, 치료 4주, 8주후에의미있는변화가나타났다. 약화된손가락폄근의근활성이증진되었으며, 손가락을펴고굽히는동안의손가락굽힘근의근활성은줄어들었으며, 손가락굽힘근의강직도감소하였다. 손가락폄근과굽힘근의동시수축도감소하였고, 손가락관절의운동이크게향상되었으며, 상지의기능적평가인 Box and Block test에서도점수가증가하였다. 3단계에속한연구대상자들은치료후에손가락폄근의근활성이증가하였으나, 손가락굽힘근의근활성도함께증가하여동시수축이치료전에비해오히려증가하였다. 또한손가락관절의관절운동변화가유의한차이는보였으나, 이는통계적인차이일뿐, 실제 30초동안의반복적인동작에서움직임의변화는치료전에비해차이가거의없었다. 이들연구대상자들은대뇌피질부위의폭넓고심한손상을가진환자들이며, 대동작을담당하는근육의조절은어느정도가능하지만,

37 원위부의손가락을움직이는동작과같은미세한근육에서는선택적인분리운동이거의불가능하다. 3단계에속한대상자들에게는 8주동안의전기자극치료가뇌또는척수수준에서의운동조절체계에영향을못미친것으로생각된다. 편마비환자의손기능에장애를일으키는원인중하나인손가락폄근과굽힘근의동시수축은손의 Brunnstrom 회복 4~5단계에속한연구대상자들에게서치료후감소하는양상을보였다. 이는손가락폄근의근활성증진과함께, 손가락굽힘근의근활성이줄어들고, 강직이감소함으로써동시수축이줄어든것으로생각된다. 본연구에서는예비실험에서정상성인 20명을대상으로같은방법으로동시수축비를구하여보았는데, 그결과는평균 0.18로나타났다. 본연구결과에서동시수축이줄어든연구대상자들도정상인의값보다는높은값을보여주었다. Kamper와 Rymer(2001) 은뇌졸중환자가손가락을펼때정상인에비해손가락폄근의근전도활동값은낮으며, 오히려손가락굽힘근의근전도활동값이정상인보다높게나타남으로써, 뇌졸중환자의손기능장애에손가락폄근의근약화와함께손가락굽힘근의부적절한동시활동이나타남을보고하였다. Kamper 등 (2003) 은정중신경과척골신경에국소마취를하여, 강직이있는손가락굽힘근의활동을줄임으로손허리손가락관절의능동적관절운동의호전을보고하였다. 만성편마비환자에있어부적절한손기능은강직과같은신경학적활동 (Thilmann et al. 1991), 다관절의협응의변화 (Beer et al. 2000), 폄근과굽힘근의부적절한동시활성 (Dewald et al. 1995), 감소된상호억제 (Nakashima et al. 1989) 의결과로인한것이다. 운동전략의선택과운동실행이일차운동영역과전운동영역피질에서조절되고, 운동의진행과정은두정엽후부 (posteriorparietal cortex) 와전운동영역에서조절된다 (Ghez 1991). 편마비환자에서는척수사이

38 신경원과알파운동신경원에게하행성척수흥분과억제를전달하는입력체계가손상되어최종적인운동출력에장애를일으키는것으로알려져있다 (Dobkin 1996). 전기자극치료후운동기능의회복을보인 3명의연구대상자들에게서보여진본연구의결과는근전도유발신경근육전기자극이편마비환자의운동회복과운동재학습에도움을준다는기존의연구를뒷받침한다. 운동재학습은운동, 기술, 과제 ( 보행분석, 표준화된손기능검사, 일상생활동작의평가등 ) 를평가함으로써외재적으로측정할수있고, 내재적으로는신경계의조직화를관찰함으로써측정할수있다 (Burredge, and Ladouceur 2001). 많은연구에서뇌조직화의변화가기능의변화를반영하는것을보여주었다. 비정상적운동유발전위 (motor evoked potentials) 와같은신경생리학적변화는편마비의단계와상관성을가지고있으며 (Tsai et al. 1992), 동물연구에서는감각피질을제거하고, 손가락을움직여손상된피질주변에있는뇌의영역에서움직임에대한자극입력을받고있다는것과 (Jenkins, and Merzenich 1987), PET를이용하여뇌졸중후임상적인회복정도와산소소모량의감소와의상관성에대한연구 (Tsai et al. 1992) 가그증거들이다. 또한, Ridding 등 (2000) 과 Liepert 등 (2000) 의연구에서말초신경의전기자극에대한반응으로뇌지도화 (brain maping) 를통해뇌의재조직화의변화가일어남을보고하였다. 이러한연구는말초부위의자극은뇌의재조직화에영향을주고, 뇌의재조직화가기능적변화와관련이있음을보여준다. 근전도유발신경근육전기자극에의한고유수용성생체되먹임과구심성자극은감각운동피질에서장기간강화작용을유발하고, 감각운동신경원의흥분성을개선하여감각운동피질의기능적재조직화에기여함으로써운동학습과재학습을촉

39 진한다 (Francisco et al. 1998). 4.3 임상적의미및제언 본연구를통해자연적회복이한계에이른만성편마비환자일지라도, 손의 Brunnstrom 회복 4단계이상인환자군과같이능동적으로손가락펴는동작이조금이라도가능한환자들에게근전도유발신경근육전기자극치료가운동기능회복에도움이된다는것이확인되었다. 이와비슷한회복단계를보이는환자들의경우, 임상에서치료적목적으로흔히사용하고있는주기적신경근육전기자극대신근전도유발신경근육전기자극을사용함으로써, 목표지향적이고, 능동적이며, 반복적인운동을통해, 손가락폄근의근력과근활성을증가시키고, 손가락굽힘근의강직과동시수축을감소시켜서손의운동기능회복에보다더효과적인치료를시행할수있을것이다. 앞으로의연구에서는보다많은환자를대상으로하여, 근전도유발신경근육전기자극적용후, 손가락폄근과굽힘근에대한보다구체적이고과학적인평가방법을통해강직감소와동시수축의감소에대한기전을밝혀야할것이다. 또한평가에있어서동작분석기와표면근전도를함께이용하여상지의여러관절과손목관절, 손가락관절의움직임을함께평가하는것이필요할것이다

40 제 5 장결론 본연구는발병후 1년이상경과한만성편마비환자 9명을대상으로, 손가락폄근에근전도유발신경근육전기자극을적용한후, 손가락의움직임에관여하는근육의활동양상과관절움직임의변화를평가하여치료의효과를확인하고, 손의회복단계에따른치료효과를비교하여치료의적응증을제시하고자하였다. 그결과손가락폄근의적분EMG값과손가락굽힘근의강직이치료후에유의한차이가있었다. 9명의연구대상자중에서손의 Brunnstrom 회복 4~5단계에속한 3명에서는치료후손가락폄근의적분EMG값이증가하였으며, 손가락굽힘근의적분EMG값은감소하였고, 손가락굽힘근의강직도감소하였으며, 동시수축비도감소하였고, 손허리손가락관절의관절가동범위의변화는증가하였으며, Box and Block test의점수도증가하였다. 그러나, 능동적으로손가락펴는동작을전혀할수없는손의 Brunnstrom 회복 3단계에속한 6명의연구대상자들은치료후에손가락폄근의적분EMG값이증가하였으나, 손가락굽힘근의적분EMG값도함께증가하여동시수축비가치료전에비해오히려증가하였다. 이로인해 3단계에속한연구대상자들은운동기능에변화가없었다. 따라서자연적회복이한계에이른만성편마비환자일지라도, 손가락펴는동작이능동적으로조금이라도가능한손의 Brunnstrom 회복 4단계이상인환자들에게근전도유발신경근육전기자극을이용하여목표지향적이고능동적이며반복적인운동을통해손의운동기능회복에도움을줄수있을것이다. 앞으로의연구에서는많은환자를대상으로근전도유발신경근육전기자극치료후손가락폄근과굽힘근의변화에대한보다구체적인연구가필요할것이다

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54 부록. Brunnstrom recovery stages of hand. Stage Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Classification Flaccidity Little or no active finger flexion Mass grasp; use of hook grasp but no release; no voluntary finger extension; possibly reflex extension of digits Lateral prehension, release by thumb movement; semivoluntary finger extension, small range Palmar prehension; possibly cylindrical and spherical grasp, awkwardly performed and with limited functional use; voluntary mass extension of digits, variable range Stage 6 All prehensile types under control; skills improving; Full range voluntary extension of digits; individual finger movements present, less accurate than on opposite side

55 ABSTRACT Effects of EMG-triggered Neuromusclular Electrical Stimulation to Improve on Hand Function in Patients With Chronic Hemiplegia Kim, Tae Ho Dept. of Rehabilitation Therapy (Physical Therapy Major) The Graduate School Yonsei University This study investigated the effects of EMG-triggered neuromuscular electrical stimulation (NMES) on the finger extensor at different stages of hand recovery in patients with chronic hemiplegia who had reached spontaneous recovery plateaus. The subjects were nine patients who had chronic hemiplegia over one year after the disease onset. EMG-triggered NMES was applied to the extensor digitorum communis for 1 hour a day, 5 days a week, for 8 weeks. Surface EMG signals from the extensor digitorum communis and flexor digitorum superficialis were recorded during repeated finger extension and flexion at 30-second intervals. The parameters were evaluated before treatment, and 4 and 8 weeks after treatment. The study

56 found significant differences in both the integrated EMG (IEMG) value for the finger extensor and the spasticity of the finger flexor. Three subjects who were at the fourth and fifth Brunnstrom recovery stage for the hand had increased IEMG values for the finger extensor, decreased IEMG values and spasticity of the finger flexor, a decreased cocontraction ratio between the finger extensor and flexor, increased ROM excursion of the metacarpophalangeal joint, and higher scores for the Box and Block test. Six subjects at the third Brunnstrom recovery stage for the hand had an increased IEMG value for the finger extensor, a simultaneous increase in the IEMG value for the finger flexor, and an increased cocontraction ratio as compared with before treatment. Therefore, hand function did not change in the subjects in the third Brunnstrom recovery stage. Although chronic hemiplegia reaches spontaneous recovery plateaus, goal-oriented active repetitive movement training using EMG-triggered NMES facilitates hand function in hemiplegics who can actively move their finger extensor. Further studies of EMG-triggered NMES in many subjects should provide more concrete data on the changes in the finger extensor and flexor. Key Words : Cocontraction, Hemiplegia, Muscle activation, Neuromusclular electrical stimulation, Spasticity

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