J Korean Soc Phys Ther Vol.25, No.5, October 2013 The Journal of Korean Society of Physical Therapy plssn elssn X Original articles

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1 J Korean Soc Phys Ther Vol.25, No.5, October 2013 The Journal of Korean Society of Physical Therapy plssn elssn X Original articles 점진적체중지지와보행속도증가훈련이뇌졸중환자의보행에미치는효과 김성훈 1, 최종덕 2 1 대전대학교보건스포츠대학원물리치료학과, 2 대전대학교자연과학대학물리치료학과 The Effect of Gait Training of Progressive Increasing in Body Weight Support and Gait Speed on Stroke Patients Sung-Hoon Kim 1, Jong-Duk Choi 2 1 Department of Physical Therapy, College of Health Sports Science, Daejeon University, 2 Department of Physical Therapy, College of Natural Science, Daejeon University Purpose: The aim of this study was to evaluate the effect of progressive body weight decrease combined with increasing level of overground walking speed training for patients with chronic stroke. Methods: Eighteen subjects with chronic stroke were composed of the control group (5% body weight support combined with increasing speed training) and the experimental group (progressive body weight decrease with increasing speed training); three sets, three times per week over a period of four weeks. Results: Significant differences in terms of comfortable gait speed (CGS) and the rate of change of CGS were observed between the control and experimental groups (p<0.05). However, no significant difference in the dynamic gait index was observed between the control and experimental groups (p>0.05). A significant difference in the 6 minute walking test (6MWT) was observed for the experimental group, and a significant difference in the rate of change for the 6MWT was observed between the control and experimental groups (p<0.05). Conclusion: The progressive body weight decrease combined with increasing in level of overground walking speed training may be a better and more effective method for community walking and reintegration. Key Words: Gait, Body weight support, Overground walking speed Ⅰ. 서론 뇌졸중은뇌혈관의파열, 폐색으로인해발생하는신경학적 손상을일으키는질병으로, 1 신체적, 인지적, 사회적그리고의 Received Sep 10, 2013 Revised Oct 6, 2013 Accepted Oct 7, 2013 Corresponding author Jong-Duk Choi, Copylight c 2013 The Korea Society of Physical Therapy This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License ( creativecommons.org/license/by-nc/3.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. 사소통장애등을나타낸다. 2,3 뇌졸중후발생하는보행장애로인해 80% 이상환자에서보행능력의손상을보이며, 4 급성뇌졸중환자의 3분의 2는독립적인보행을할수없다. 5 뇌졸중환자의보행능력은질병발생후회복되는양상을보이지만, 40% 에서는보행을위한보조가필요하고, 60% 는지역사회보행에제한을받는다. 6 뇌졸중후나타나는비정상적인보행양상은감소된보행속도, 7 마비측의짧은입각기와긴유각기등이며, 8 이러한보행양상을보상하기위해비마비측하지에서는증가된입각기와감소된유각기를나타낸다. 9 뇌졸중후치료의중요한지표로작용하는보행 J Korean Soc Phys Ther 2013:25(5):

2 Sung-Hoon Kim and Jong-Duk Choi : Gait Training of Progressive Body Weight Support with Increasing Speed 능력은일상생활수행및지역사회환경으로의복귀를위해필요하다. 10 그러나중증의뇌졸중환자는감소된보행속도와비정상적인보행양상으로 11 인해지역사회및일상생활수행을위한보행수준을달성하기어렵고, 12 또한복잡한환경에서다른과제를수행하며보행해야하는지역사회보행은뇌졸중환자에게제한되어진다. 13 뇌졸중환자의평균보행속도는 0.23~0.73 m/s 범위이다. 14 Perry 등 15 은집안에서보행 ( 중증장애 ) 속도는 0.4 m/s, 제한된지역사회보행 ( 중등도장애 ) 속도는 0.4~0.8 m/s이며, 지역사회보행 ( 경증장애 ) 속도는 0.8 m/s로뇌졸중후, 보행을분류하였다. 보행속도가 0.8 m/s이상이면, 지역사회보행이가능하다고하였다. Moseley 등 16 은트레드밀보행이급성 만성뇌졸중환자에게유용하고, 율동적인보행증진에효과적이라고제시했다. 또한트레드밀훈련후, 속도와지구력측면에서기능적보행의증진을보였다. 17 하지만, 지면보행보다트레드밀보행에서 2.5 배정도더높은에너지소모를보였고, 트레드밀보행이낙상위험이크고, 높은협응력과균형을필요로하므로보행속도감소로이어질수있는단점이있다. 18 최근에신경학적환자를대상으로발전한보행훈련방법중, 체중에대한비율을지지해주는하네스시스템이있다. 하네스시스템으로환자가트레드밀에서보행훈련하는동안하지의부하가줄어들게된다. 19 이중재방법은낙상에대한두려움을없앨수있는장점이있고, 20 지면보행훈련동안안전하게보행훈련을할수있게한다. 21 체중지지를이용한보행재훈련은지역사회보행속도와지구력, 기능적균형그리고하지운동회복에있어서더성공적인보행회복으로이어질수있다. 22 체중지지와트레드밀을이용한느린보행, 다양한속도보행, 빠른보행연구에서빠른보행훈련군이느린보행훈련군에비해지면보행속도가더크게증진되는경향을보였고, 만성뇌졸중환자를대상으로체중지지와트레드밀을이용한보행훈련이정상보행속도에근접한속도로훈련한다면더효과적이라고제시했다. 23 Hesse 등 24 은빠른속도로트레드밀보행훈련후, 항중력근이활성화되고, 이동효율이증가되었다고했다. 하네스시스템과트레드밀을이용한다양한선행연구들이보고되었지만, 체중지지정도를일정하게달리한보행훈련, 보행속도의차이를이용한훈련이대부분이었다. 트레드밀보행훈련은율동적이고대칭적보행패턴을유지하도록환자의노력을증가시킨다고하였다. 25 이로인해정상적인지 면보행속도에근접한트레드밀속도로보행훈련을실시한연구는부족한실정이다. 지역사회보행이가능하다고 Perry 등 15 이제시한보행속도 0.8m/s에근접한트레드밀속도로보행훈련을적용하기에는제한점이있다. 이제한점을하네스시스템으로체중지지비율을높여 ( 즉, 상대적인체중감소 ) 지면보행속도에근접한속도의트레드밀보행훈련을도와주고자한다. Barbeau 과 Visintin 26 는트레드밀속도를높이는과정에서보행을촉진시키기위해체중지지비율을증가시키는것이필요했다고하였다. 이에본연구는하네스시스템을사용하여상대적인체중감소와지면보행속도에근접한속도의트레드밀보행훈련이보행수행능력에미치는효과를알아보고지역사회보행을위한기초자료를제공하고자하였다. 본연구의가설은다음과같다. 첫째, 체중지지비율의증가로인한상대적인체중감소와안정적인최대보행속도로보행훈련을실시한실험군과일정한체중지지와안정적인최대보행속도로보행훈련을실시한대조군간중재전 후보행속도변화에차이가있을것이다. 둘째, 실험군과대조군간중재전 후보행기능변화에차이가있을것이다. 셋째, 실험군과대조군간중재전 후보행능력에차이가있을것이다. II. 연구방법 1. 연구대상본연구는 2013년 2월부터 3월까지대전광역시소재 D병원에서뇌졸중으로진단받고입원중인뇌졸중발병기간이 6개월이상경과된만성뇌졸중환자중본연구참여에동의한 18명을대상으로시행하였다. 보행보조도구를사용하거나, 사용하지않고 10 m 이상걸을수있는자, 6분이상보행이가능한자, 다른정형외과적문제가없는자, 뇌졸중이외의다른신경학적문제가없는자를연구대상선정기준으로설정하였다. 2. 실험방법본연구는만성뇌졸중환자 18명을대상으로, 안정보행속도검사와 6분보행검사, 동적보행지수를실시하여비교하였다. 1) 실험도구 (1) 하네스시스템체중지지시스템은 SHUMA DA-2000( 수동식 ) 을사용하였다. 이시스템은성인용구조틀과높이를조절할수있는손잡이로 253 J Korean Soc Phys Ther 2013:25(5):

3 김성훈, 최종덕 : 점진적체중지지와보행속도증가훈련이뇌졸중환자의보행에미치는효과 구성되어졌다. 이기구에현수장치를설치하여체중지지를할수있도록설계되어있다. 현수의끈은하복부와골반을지지해준다. (2) 트레드밀트레드밀 (AP2010-2, apsuninc, Seoul, Korea) 은속도조절이가능하도록전면에계기판이부착되어있다. 속도는최저 0.1 km/h부터최고 6.0 km/h까지이며, 속도조절은 0.1 km/h씩증 감이가능하다. 안전키를환자의몸과계기판에부착하여, 안전키가분리되면트레드밀이중지되어낙상사고를방지하도록설계되어있다. 2) 측정도구 (1) 기능적보행지수 (Functional Ambulation Category, FAC) 보행을 6단계로구분하며, 보행불가능한경우 0점, 보행시지속적인지지가필요한경우 1점, 보행시간헐적인도움이필요한경우 2점, 보행시신체적접촉없이지시, 관찰이필요한경우 3점, 독립적으로평지보행은가능하지만, 계단이나불안정한지면, 경사로를보행할때도움이필요한경우 4점, 독립적보행이가능한경우 5점으로구분되어있다. 다발성경화증환자에서신뢰도는 0.98이었으며 27, 뇌졸중환자의검사, 재검사간신뢰도는 0.99이었다. 28 (2) 안정보행속도 (Comfortable Gait Speed) 안정보행속도는대상자에게총 14 m를걷게하고, 전후 2 m 를제외하고 10 m 길이에서대상자본인이가장안정하다고느끼면서편하게걷는속도를측정하였다. 10 m 걷는속도를 1회연습과정을거친후 3회반복측정하여평균값을구하였다. 이검사는측정자간, 측정자내신뢰도는 r=0.97, p<0.05 로매우높은측정방법이다. 29 (3) 6분보행검사 (6-Minute Walking Test) 보행지구력을알아보기위해 6분보행검사를실시하였다. 6분보행검사는바닥에 20 m의직선거리와 20 m지점의반환점을표시하여시행하였다. 검사전준비운동은시행하지않았으며, 검사동안가능한빠르게많은거리를걷도록하였으나걷는속도와휴식시간은환자의능력에맞추어스스로조절할수있도록하였다. 6분보행검사는측정자내신뢰도가 r=0.90로높은것으로보고되었다. 30 (4) 동적보행지수 (Dynamic Gait Index) Shumway-Cook과 Woollacott 31 에의해개발된동적보행지수는노인의보행활동시낙상의위험과기능적인안정성을평가하기위해만들어졌다. 또한곡선보행능력을측정할수있게고안되었다 m 걷기, 보행의속도변화, 보행하면서좌우로고개돌리기, 보행하면서위아래로움직이기, 4개의계단오르고내리기, 보행하면서장애물넘기, 보행하면서 180도회전후멈춰서기, 보행하면서장애물가로지르기, 총 8개보행과제의기능적보행척도로구성되어있다. 노인에게서 19점이하이면낙상의위험이큼을의미한다. 노인을대상으로한측정자내신뢰도는 ICC=0.96이다. 33 3) 실험절차본연구에서는만성뇌졸중환자 18명을대상으로대조군과실험군을의미하는 2개의종이중 1개를뽑게하여대조군과실험군에각각 9명씩무작위배정하였다. 트레드밀보행훈련은주 3회, 1회 20분씩, 총 4주간 12회를실시하였다. 필요한경우안정성을부여하기위하여트레드밀에부착되어있는손잡이를잡게하였다. 초기체중지지비율은대조군, 실험군모두 5% 에서시작하였다. 이는대조군과실험군모두에서체중이지지되고있으며안전하게보행훈련이실시되고있음을나타내고자하는목적이었다. 또한, 트레드밀속도를증가시키는보행훈련과제에서낙상에대한두려움을감소시키고자하는목적이었다. 최초트레드밀속도는 10 m 최대보행속도를기초로하여트레드밀에서다리끌림없이보행할수있는안정적인최대보행속도로보행훈련을시작하였다. 점진적으로트레드밀속도를 0.1 km/h씩증가시켜 34 지면보행속도를달성하고자하였다. 이때, 대상자가피로감또는통증을호소하거나호흡에이상이있을시에는이전속도로유지하였다. 대조군은 5% 체중지지비율을유지하면서트레드밀속도를 0.1 km/h 씩증가시켜보행과제를수행하도록하였다. 실험군은 5% 체중지지에서시작한후, 트레드밀속도를 0.1 km/h씩증가시킬때체중지지비율을높여상대적으로체중감소가이뤄지도록하였다. 각군은트레드밀에서환자의안전을위하여환자 1명당물리치료사 1명을배치하였다. 4) 자료처리통계분석은 SPSS/Win 18.0 을이용하여대상자의일반적특성과기능적보행지수 (FAC) 에서는평균과표준편차를구하였다. 대조군과실험군에대한동질성검정은 Mann- Whitney Test로분석하였다. 트레드밀보행훈련전 후의 J Korean Soc Phys Ther 2013:25(5):

4 Sung-Hoon Kim and Jong-Duk Choi : Gait Training of Progressive Body Weight Support with Increasing Speed Table 1. General characteristics of subjects (N=18) Variable Control group (n=9) Experimental group (n=9) P Age (yrs) 56.8 ± ± Height (cm) ± ± Weight (kg) 63.8 ± ± Paretic side (right/left) 3/6 3/6 FAC 3.67 ± ± Values are presented as mean±standard deviation. FAC: functional ambulatory category Table 2. Comparison of gait speed between Control and Experimental group CGS(m/s) Control group (n=9) Experimental group (n=9) P Pre 0.44 ± ± 0.25 Post 0.47 ± ± 0.24 p Rate of change(%) 8.69 ± ± * Values are presented as mean±standard deviation. CGS: comfortable gait speed *p < 0.05, p < 0.01 보행속도, 보행기능, 보행능력은 Wilcoxon Signed Ranks Test 를사용하였다. 대조군과실험군간의차이를비교하기위해 Mann-Whitney Test를실시하였다. 통계학적유의수준은 P<0.05로하였다. III. 결과 1. 연구대상자들의일반적인특징본연구에참여한연구대상자의일반적인특징은전체대상자 18명중여자가 4명, 남자가 14명이었으며, 평균연령은 53.4±9.3세, 평균신장은 164.9±7.8 cm, 평균체중은 65.3±10.8 kg이었다. 대조군과실험군간의일반적특성 ( 연령, 신장, 체중 ) 과기능적보행지수 (FAC) 는통계학적으로유의한차이가없어동질한것으로나타났다. 자세한사항은다음과같다 (Table 1). 2. 실험군과대조군중재후보행속도변화안정보행속도변화는중재전, 대조군 0.44 m/s, 실험군 0.39 m/s 에서중재후, 대조군 0.47 m/s, 실험군 0.47 m/s로보행속도가향상되었으며, 통계학적으로유의한차이가있었다 (p<0.01). 안정보행속도변화율에대한집단간비교에서는대 조군과실험군간유의한차이가있었다 (p<0.05) (Table 2). 3. 실험군과대조군중재후보행기능변화동적보행지수는중재전, 대조군 13.78점, 실험군 13.22점에서중재후, 대조군 17.89점, 실험군 18.22점으로향상되었으며, 통계학적으로유의한차이가있었다 (p<0.01). 동적보행지수변화율에대한집단간비교에서는대조군과실험군간유의한차이는없었다 (p>0.05)(table 3). 4. 실험군과대조군중재후보행능력변화 6분보행검사에서대조군은중재전 m에서중재후 m로향상되었으나통계학적으로유의한차이는없었다 (p>0.05). 실험군은중재전 m에서중재후 m으로향상되었고통계학적으로유의한차이가있었다 (p<0.01). 6분보행검사변화율에서는대조군과실험군간유의한차이가있었다 (p<0.05)(table 4). IV. 고찰본연구는만성뇌졸중환자를대상으로정상적인지면보행속도에근접한안정적인최대보행속도를달성할수있도록 255 J Korean Soc Phys Ther 2013:25(5):

5 김성훈, 최종덕 : 점진적체중지지와보행속도증가훈련이뇌졸중환자의보행에미치는효과 Table 3. Comparison of gait function between Control and Experimental group DGI 6MWT(m) Control group (n=9) Experimental group (n=9) P Pre ± ± 5.49 Post ± ± 4.29 p Rate of change(%) ± ± Values are presented as mean±standard deviation. DGI: dynamic gait index *p < 0.05, p < 0.01 Table 4. Comparison of gait capacity between Control and Experimental group Control group (n=9) Experimental group (n=9) P Pre ± ± Post ± ± p Rate of change(%) 6.22 ± ± * Values are presented as mean±standard deviation. 6MWT: 6-minute walking test *p < 0.05, p < 0.01 체중지지를이용한트레드밀훈련이보행기능에미치는효과를알아보기위해뇌졸중이발병한지 6개월이상경과된만성뇌졸중환자 18명을대상으로선정하였다. 일정한 5% 체중지지와안정적인최대보행속도로트레드밀보행훈련을실시한대조군 9명과초기 5% 체중지지와안정적인최대보행속도에서시작하여트레드밀속도가증가될수록체중지지비율을증가시켜상대적인체중감소로보행과제를수행할수있게실시한실험군 9명으로나누어각각 20분씩주 3회, 4주간훈련을실시하였다. 그결과대조군은 CGS, DGI 항목에서통계학적으로유의하게증가되었으며, 실험군에서는 CGS, DGI, 6MWT에서유의하게증가되었다. 이는김재현등 35 이뇌줄중환자 5명을대상으로 8주간전동식트레드밀훈련후, 측정한 CGS 연구결과와일치한다. 본연구 CGS에서는대조군이평균 0.44 m/s에서 0.47 m/s 로통계학적으로유의하게향상되었으며, 실험군에서도평균 0.39 m/s에서 0.47 m/s로통계학적으로유의하게향상되었다. 또한집단간 CGS 변화율에서도대조군은 8.69, 실험군은 36.32로두집단간통계학적으로유의한차이가있었다. 이는김좌준등 34 이뇌졸중환자 30명을대상으로체중지지트레드밀보행군과지면보행군훈련후, 보행속도가체중지지트레드밀보행군이지면보행군에비해통계 학적으로향상되었다는결과와일치하며, 보행속도증가가지면보행군에비해체중지지트레드밀보행에서더빠른속도로보행훈련을할수있었기때문이라고제시했다. 또한뇌졸중환자 18명을대상으로초기 40% 체중지지와트레드밀보행훈련후, 10 m 보행속도에서훈련전 0.48 m/s에서훈련후 0.58 m/s로유의한차이가있었고, 보폭비율에서도훈련전 73.11% 에서훈련후 81.12% 로통계학적으로유의한차이를나타냈다. 36 김은정등 37 는뇌졸중환자 30명을대상으로트레드밀보행훈련군, 지면보행훈련군, 불안정면보행훈련군, 세그룹에서모두보행속도가유의한증가를나타냈으나, 훈련후세군간의전 후변화량에서는통계학적으로유의한차이가없었다. 그러나이는본연구결과 CGS에서실험군과대조군간변화율에있어유의한차이를보인결과와는상이한결과이다. Kelvin과 Margaret 38 은뇌졸중환자 30명을대상으로속도를매개변수로실험한연구에서, 속도의존적트레드밀훈련군이안정속도트레드밀훈련군에비해보행속도와보행길이에서통계학적으로유의한향상을나타냈다고제시했다. 속도의존적트레드밀훈련군에서실험전에비해훈련후에서보행속도의 120% 증가와보행길이의 55% 증가가있었다. 두집단간비교에서도보행속도와보행길이 (stride length) 에서통 J Korean Soc Phys Ther 2013:25(5):

6 Sung-Hoon Kim and Jong-Duk Choi : Gait Training of Progressive Body Weight Support with Increasing Speed 계학적으로유의한차이가있었고, 본연구의 CGS 결과와일치한다. 본연구에서는보행에서사용되는일반적인평가뿐만아니라, 보행의기능적인평가를위해동적보행지수를사용하였다. 대조군의전 후비교에서평균동적보행지수는 점에서 17.89점으로실험전에비하여통계학적으로유의하게향상되었다. 또한실험군도평균동적보행지수가 점에서 18.22점으로실험전에비교하여통계학적으로유의하게향상되었지만, 두집단간동적보행지수변화율에서는통계학적으로유의한차이가없었다. 이와같은결과는두군모두에서안정적인최대보행속도과제를성취하면서, 보행의속도변화, 보행하면서장애물가로지르기, 장애물넘기, 보행하면서균형유지하는항목에서기능적으로향상되었기때문이라고추론할수있다. 6MWT에서, 대조군은실험전 m에서실험후 m로 4.5% 향상을나타냈지만통계학적으로유의한차이는없었다. 실험군에서는실험전 m에서실험후 m로 20.4% 의유의한향상을나타냈으며, 두집단간 6MWT 변화율에서도통계학적으로유의하게증가되었다 (p<0.05). 또한측정시점과군사이에서 6MWT 항목은통계학적으로유의한교호작용을보였다 (p<0.05). 이러한결과는체중지지비율을증가시켜, 상대적인체중감소를통해정상적인지면보행속도에근접한속도훈련을목표로트레드밀보행과제를수행한실험군이 6MWT에서보행지구력을향상시키는데긍정적인효과가있으며, 집단간변화율에서도긍정적인효과를나타냈다. 김상엽 39 이뇌졸중환자 20명을대상으로실험한연구결과, 트레드밀보행군에서 6MWT는실험전 m에서실험후 m로증가하여통계학적으로유의하게나타났고, 대조군에서도실험전 후통계학적으로유의한차이가나타났다. 두집단간비교에서는실험전통계학적으로차이가없었는데, 실험후통계학적으로유의한차이가있었다. 이러한차이는보행속도의증가와단하지지지기의증가, 건측유각기의증가로인해동일시간에더많은거리를보행할수있게되었다고제시했다. 뇌졸중환자를대상으로이연구에서 6MWT는지역사회보행활동성을예측할수있다고제안했다. 일정거리를보행할수있는능력은지역사회이동과지역사회복귀에중요한요소이다. 6MWT는지역사회보행에대한예측변수로서통계학적으로유의하게나타났다. 또한보행에있어상위기능을가진환자에게실내보행과지역사회보행을평가하는데좋은도구라고제시했다. 자가선택보행속도보다 6MWT가실내보행과지역사회 보행을평가하는예측변수로서통계학적으로유의하다고 제시했다. 40 Pohl 41 은속도의존적트레드밀훈련군, 제한된 속도트레드밀훈련군과고전적인보행훈련군모두에서실험 전 후보행속도, 보행길이, 분속수와기능적보행범주 (FAC) 보행훈련군에비해분속수는실험전 81.6 에서실험후 로, 보행길이에서는실험전 0.42 에서실험후 0.72 로더큰 향상을나타냈다. 본연구에서실험군이 6MWT 에서유의한 향상을나타냈고, 집단간변화율에서도유의하게증가되어 Geroge 40 가제시한일정거리를보행할수있는능력즉, 지역 사회이동과지역사회복귀에긍정적인효과를보였다고할수 있다. 본연구의제한점은실험군과대조군의대상자수가적기 때문에결과를일반화하기어렵고, 기능적보행검사로서 DGI 만을시행하였으므로결과해석에있어서제한이있다. 앞으로의연구에서는보다많은대상자로뇌졸중환자의 보행능력뿐만아니라보행기능증진을위한효과적인중재 방법에관한연구를시행할필요성이있다. 본연구결과를종합해볼때, 만성뇌졸중환자를대상으 로체중지지비율을증가시켜, 상대적인체중감소를통한안 정적인최대보행속도로보행훈련과제를수행한실험군과 일정한체중지지와안정적인최대보행속도로보행훈련 과제를수행한대조군에서보행속도, 보행기능향상에긍 정적인효과를나타냈으며, 보행능력은실험군에서만더 나은결과를보였다. 이는지역사회이동과지역사회복귀에 긍정적인요소로작용하는보행능력과관련되어, 일정한 체중지지비율과지면보행속도로트레드밀보행훈련을 수행하는과제가보행능력증진에제한적이라는것을의 미하며, 만성뇌졸중환자의재활치료과정중, 보행능력향 상을위한지면보행속도훈련과제를달성할수있는추가 적인중재가필요하다고사료된다. 참고문헌 1. Kim MH, Lee WH, Yun MJ. The effects on respiratory strength training on respiratory function and trunk control in patient with stroke. J Kor Soc Phys Ther. 2012;24(5): Yang DJ, Park SK, Lee JH, Kang JI, Chun DH. Influence of transition from the half-kneel to standing posture in hemiplegic patients. J Kor Soc Phys Ther. 2011;23(5): raun SM, Beurskens AJ, van Kroonenburgh SM et al. Effects of mental practice embedded in daily therapy compared to therapy as usual in adult stroke patients in dutch nursing homes: Design of a randomised controlled trial. BMC Neurology. 2007;7: J Korean Soc Phys Ther 2013:25(5):

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8 Sung-Hoon Kim and Jong-Duk Choi : Gait Training of Progressive Body Weight Support with Increasing Speed ambulation of stroke. J Kor Soc Phys Ther. 2005;17(3): Kim JH, An SH, Bae SS. Preliminary study of ambulation training on electromechanical gait trainer in stroke patients. Journal of the Korean Society of Physical Medicine 2006;1(1): Kim MJ, Lee JH. Effect of body weight support treadmill training on gait and standing balance in patients with hemiplegia. Physical Therapy Korea. 2003;10(1): Kim EJ, Jung JM, Kim TH, Bae SS. The effects of plantar foot pressure and muscular activity on treadmill gait training in stroke patients. Journal of the Korean Society of Physical Medicine. 2009;4(3): Lau KW, Mak MK. Speed-dependent treadmill training is effective to improve gait and balance performance in patients with sub-acute stroke. Journal of Rehabilitation Medicine. 2011;43(8): Kim SY. Effect of treadmill training on walking velocity and gait endurance in patients with chronic hemiplegia. J Kor Soc Phys Ther. 2004;16(2): Fulk GD, Reynolds C, Mondal S et al. Predicting home and community walking activity in people with stroke. Archives of physical medicine and rehabilitation. 2010;91(10): Pohl M, Mehrholz J, Ritschel C et al. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients a randomized controlled trial. Stroke. 2002;33(2): J Korean Soc Phys Ther 2013:25(5):

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