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1 Brain & NeuroRehabilitation Vol. 4, No. 2, September, 2011 뇌졸중후인지기능이재활치료과정에서기능회복에미치는영향 고려대학교의과대학재활의학교실이유나ㆍ권희규ㆍ강윤규ㆍ편성범 Impact of Cognitive Function on Functional Recovery during Rehabilitation in Patients with Stroke Yu-Na Lee, M.D., Hee-Kyu Kwon, M.D., Ph.D., Yoon Kyoo Kang, M.D., Ph.D. and Sung-Bom Pyun, M.D., Ph.D. Department of Physical Medicine & Rehabilitation, Korea University College of Medicine Objective: Cognitive dysfunction is an important factor on functional recovery after stroke. This study investigated the relationship between functional outcome and cognitive status during rehabilitation after stroke. Method: This retrospective study included 80 patients with rehabilitation program after first-ever stroke. The independent variables were mini-mental status examination (MMSE) and computerized neurocognitive function test (CNT). The dependent variables were modified Barthel index (MBI), Berg balance scale (BBS), National Institute of Health Stroke Scale (NIHSS) and destination. The correlation analysis was applied. Results: Mean interval from onset to rehabilitation program was 29.5 days and duration of inpatient rehabilitation program was 31.1 days. Mean score of initial MMSE was 20.5 and CNT showed abnormal performance in at least one of the domain specific tests in all patients. The scores of MMSE, MBI, NIHSS and BBS were improved after rehabilitation program (p<0.05). Cognitive improvement contributing to the functional recovery were significant in the early participants in rehabilitation and in older patients (p<0.05). The home- group demonstrated higher scores in executive function tests (p<0.001). Visual attention, visual working memory and reasoning revealed significant correlation with the MBI score at. Conclusion: The results of present study suggest that cognitive function, especially attention and working memory, is a predictor of functional outcome after stroke rehabilitation. (Brain & NeuroRehabilitation 2011; 4: ) Key Words: cognition, function recovery, rehabilitation, stroke 서론 인지장애는뇌졸중환자의 12 56% 에서발생하며, 이중 3분의 1의환자들은적절한치료에도인지장애가지속되는것으로보고되고있다. 1-3 인지장애는뇌졸중이발병한나이, 입원시기와기간, 발병당시환자의기능적상태, 동반된다른질병등과더불어뇌졸중의기능적회복 접수일 : 2011 년 2 월 9 일, 1 차심사일 : 2011 년 3 월 28 일 2 차심사일 : 2011 년 6 월 20 일, 3 차심사일 : 2011 년 8 월 18 일 4 차심사일 : 2011 년 9 월 7 일, 게재승인일 : 2011 년 9 월 8 일교신저자 : 편성범, 서울시성북구안암동 5 가 , 고려대학교안암병원재활의학과 Tel: , Fax: rmpyun@korea.ac.kr 정도에영향을미치는인자로알려져있다. 4-8 그러나뇌졸중후인지기능상태와기능적회복에대한연구는아직부족한실정이다. 또한인지기능은각성과주의력, 기억력과학습, 실행성기능, 시공간지각, 언어기능등을포함하는포괄적인개념인데비해대부분의이전연구에서는인지기능의정도를간이정신상태검사 (mini-mental status examination, MMSE) 또는 2 3개의하부인지영역만을평가할수있는검사만을포함하여환자의기능적회복에영향을미치는구체적인인지영역이무엇인지를알수없었다 이에본연구는뇌졸중이처음으로발생한환자를대상으로재활치료과정에서전반적인인지기능이기능적회복에미치는영향을분석하고, 여러하부인지영역중어떤영역이기능적회복에가장큰영향을미치는지알아보 103

2 Brain& NeuroRehabilitation:2011; 4: 103~109 고자하였다. 1) 연구대상 연구대상및방법 본연구의대상은 2006년 4월부터 2010년 8월까지고려대학교안암병원재활의학과에서뇌졸중으로입원하여전산화신경인지검사 (computerized neurocognitive function test, CNT) 를포함한인지검사와함께포괄적인재활치료를시행한환자중뇌졸중에서기능적회복이가장많이일어나는발병후 3개월내에재활치료를시작하였으며, 뇌병변이뇌전산화단층촬영 (CT) 또는뇌자기공명영상 (MRI) 에서뇌경색이나뇌출혈이확인된경우로한정하였다. 이환자중과거뇌졸중의기왕력이있거나알츠하이머병, 루이소체치매등인지기능에영향을미칠수있는신경성퇴행성질환이나우울증, 조울증등정신과적질환의기왕력을가진환자는제외하였다. 또한재활치료시작당시의식의각성정도가인지기능을평가할수없을정도로감소되어있는환자, 재활의학과입원중뇌졸중의재발또는조절되지않는수두증등으로신경과나신경외과로전과된환자및일주일미만의재활치료를받은환자는제외하였다. 총 80명의환자가조건을만족하였고, 이환자들에대하여후향적으로의무기록을통해자료를수집하였다. 대상환자의일반적특성에대하여는 Table 1에정리하였다. 2) 연구방법 (1) 연구대상분류인지기능에영향을미칠수있는여러인자들에따른 Table 1. General Characteristics of Patients General characteristics Patients (n=80) Age (years) 61.4±11.3 Sex (male/female) 47/33 Duration of hospitalization (days) 58.9±30.8 Duration of inpatient rehabilitation (days) 31.1±19.8 Interval from onset to beginning of 29.5±19.3 rehabilitation program (days) Years of education (years) 10.2±4.8 Type of stroke (ischemia/hemorrhage) 43/37 Side of lesion (right/left/others) 31/37/12 Mean AQ 79.6±22.7 Left side neglect (n) 13 BDI 13.8±10.8 Discharge to home (n) 40 AQ: aphasia quotient, BDI: Beck depression inventory 기능적회복양상을알아보기위하여환자를세분화하여분석을시행하였다. 뇌졸중의종류에따라뇌경색군과뇌출혈군으로나누었고, 재활치료의시작시기는발병으로부터 1개월이내에치료를시작한조기재활치료군과 1개월이후에치료를시작한후기재활치료군으로분류하였다. 재활치료는뇌졸중발병일로부터평균 4.4일에시작되었다. 연령에따른차이를알아보기위해세계보건기구의노인에대한정의에의거하여 65세를기준으로 65세미만군과 65세이상군으로구분하여결과를분석하였다. 이와함께재활치료후퇴원장소에따라집으로퇴원한군과다른병원으로퇴원한군으로구분하여두군의차이를알아보았다. (2) 인지기능평가자료의수집전반적인인지기능에대하여모든환자의한국어판 MMSE (Korean version of MMSE, K-MMSE) 검사결과를조사하였다 재활치료의시작과퇴원당시의점수와 K-MMSE의변화값 ( K-MMSE) 을알아보았다. 아울러전산화신경인지검사 (computerized neurocognitive function test, CNT) 를이용하여평가한주의력, 기억력, 실행성기능영역에대한검사결과를토대로세부영역의인지기능을평가하였다. 22 정방향과역방향숫자외우기 (digit span forward and backward) 와그림외우기검사 (visual span forward and backward) 를통해언어적, 시각적집중력과작업기억력을측정하고, 청각적또는시각적지속수행검사 (auditory or visual continuous performance test) 를통해경계성주의력 (vigilance) 을측정하였다. 언어적학습능력 (verbal learning test) 검사는 15개의단어를들려준후바로기억하는단어의개수와 5차례반복하여들려주었을때기억하는단어의개수를측정하여언어적기억력과학습능력을추정하였고, 20분후기억나는단어의수를통해언어적장기기억력을측정하였다. 시각적학습능력검사 (visual learning test) 는 15개의서로다른그림이제시된다는점외에는언어적학습능력과같은방법으로진행하였다. 스트룹검사 (Stoop test) 는선택적주의력과억제력정도를평가하는데본연구에서는단어의색을읽을때의정반응과, 단어자체를읽을때의정반응의정도를이용하여분석하였다. 두종류의선잇기검사 (trail making A and B) 를통하여사고의유연성과작업능력을평가하였고, 카드분류검사 (card sorting test) 를통해개념형성과사고세트의전환능력을측정하였다. 마지막으로레이븐의색채누진행렬진행검사 (Raven's colored progressive matrices) 를통하여비언어적지능을측정하였다. CNT까지는뇌졸중발병일로부터평균 30.8 일이소요되었으며, CNT 세부항목검사결과는포괄적 104

3 이유나외 3 인 : 뇌졸중후인지기능이재활치료과정에서기능회복에미치는영향 재활치료를시작한후 2주일이내에 CNT를시행한 63명의환자의자료중각세부검사결과의백분위 (percentile) 값을이용하였다. 우울감의정도는재활의학과입원당시의벡우울증검사 (Beck depression inventory, BDI) 로조사하여 14점이상인경우우울감이있는상태로판단하였다. 23,24 (3) 뇌졸중후기능적회복에대한평가 뇌졸중환자의재활치료후기능적회복정도를판단할수있는일차회복지표로집으로의퇴원여부, 재활의학과퇴원시점의수정판바델지수 (modified Barthel index, MBI) 와입퇴원시점의 MBI점수의변화 ( MBI) 를조사하여일상생활동작 (activity of daily living, ADL) 의향상정도를조사하였다. 25 MBI 점수는총점과함께하위영역으로자기관리 (self care) 와이동성 (mobility) 점수로구분한점수를기록하였다. 이와함께이차적인뇌졸중의호전지표로신경학적호전을반영하는한국판미국국립보건원뇌졸중척도 (National institute of health stroke scale, NIHSS) 와 26 환자의보행능력을반영하는버그균형검사 (Berg balance scale, BBS) 를 27 조사하여퇴원시점의점수와변화량을기록하였다. 이러한여러지표중환자의인지기능변화량을독립변수로, 재활치료후기능적회복정도및 NIHSS 변화정도를종속변수로하여두변수사 Table 2. Comparison of Test Scores at the Time of Beginning of Rehabilitation Program and Discharge At beginning At Changes K-MMSE 20.5± ±4.2* 4.5±4.6 MBI 40.3± ±20.9* 28.5±19.7 NIHSS 5.5± ±2.8* 1.9±2.7 BBS 20.0± ±16.4* 20.3±16.5 K-MMSE: Korean version mini-mental status examination, MBI: Modified Barthel index, NIHSS: National Institute of Health Stroke Scale, BBS: Berg balance scale. *p<0.05. 의의연관성을상관관계분석을통하여분석하였다. 3) 통계분석재활의학과입원과퇴원시의검사값의변화가의미있는지판단하기위하여 Wilcoxon signed rank test를시행하였으며, 각군간차이가통계학적으로의미있는지판단하기위하여 Mann-Whitney U-test를시행하였다. 여러인자들과기능적회복간의상관관계를보기위하여 Spearman 상수를적용한상관관계분석을시행하였다. 상관관계분석결과나이와많은변수들사이에상관관계가관찰되어, 나이를통제변수로대입한편상관분석을시행하였다. 통계분석에대하여 p값이 0.05보다작은경우를통계학적으로의미가있다고판단하였으며, CNT 검사의각항목들과기능적회복결과를나타내는검사들사이의상관분석에서는대입변수의수가환자수에비해많았기때문에 p값이 0.01보다작은경우를통계학적으로의미있다고판단하였다. 통계학적검정은 SPSS for Windows 12판을이용하여시행하였다. 결과 1) 재활치료전후변화 K-MMSE는평균 20.5점에서 24.7점으로재활치료기간동안의미있게호전되었다 (p<0.05). 전과당시 5명이 25점이상의점수를받아정상범위에속하였다. MBI 총점은재활치료를시작하였을때평균 40.3점에서퇴원할때평균 68.9점으로의미있게호전되었고, NIHSS 와 BBS 검사모두재활치료전후로의미있게호전되었다 (p<0.05, Table 2). 2) 전반적인지기능과기능적회복간의관계초기 K-MMSE가높을수록 NIHSS가많이호전되었으나, MBI와는상관관계가없었고 (p<0.05), K-MMSE 변 Table 3. Correlation between K-MMSE Scores and Functional Outcome Measures MBI dc K-MMSE i K-MMSE BDI Total Mobility MBI NIHSS dc NIHSS BBS dc BBS Self-care K-MMSE i K-MMSE * * K-MMSE i: Korean version mini-mental status examination at beginning of rehabilitation program, K-MMSE: changes in K-MMSE between beginning of rehabilitation program and, BDI: Beck depression inventory, MBI dc: Modified Barthel index at, S-care: self-care, MBI: changes in MBI total scores between beginning of rehabilitation program and, NIHSS dc: National Institute of Health Stroke Scale at, NIHSS: changes in NIHSS between beginning of rehabilitation program and, BBS dc: Berg balance scale at, BBS: changes in BBS between beginning of rehabilitation program and. *p<0.05, p<

4 Brain& NeuroRehabilitation:2011; 4: 103~109 화량이클수록 BBS의변화량도컸다 (p<0.05, Table 3). (1) 재활치료시작시기에따른차이조기에재활치료를받은군의경우, 초기의 K-MMSE는 NIHSS 호전정도와연관성을보였고 (p<0.001), K-MMSE 의호전정도는 NIHSS 와 BBS의호전정도와연관성을보였다 ( 각 p=0.02; p=0.04). 후기에재활치료를시작한군의경우초기의 K-MMSE 와상관관계를보인기능적회복지수는없었다 (Table 4). (2) 나이에따른차이 65세미만환자들의경우, 초기의 K-MMSE와의미있는상관관계를보인기능척도는퇴원할때의 MBI 하위항목중이동성항목이었다 (p=0.04). 또한초기 K-MMSE 가높을수록, NIHSS 에서호전정도도컸다 (p=0.001). 65세이상의환자들의경우, K-MMSE 상호전이클수록 MBI의호전이컸다 (p=0.03, Table 4). 3) 세부인지기능과기능적회복의관계역방향그림외우기검사점수가높을수록퇴원당시 MBI의총점및자기관리및이동의두하위영역의점수가높았고, 청각적지속수행검사점수가높을수록 MBI의호전정도는작았다 (Table 5). (1) 재활치료시작시기에따른차이조기재활치료군에서역방향그림외우기검사 (r=0.43, p=0.003), 시각적학습능력검사중 5회반복시의점수 (r=0.45, p=0.005) 가높을수록퇴원당시의 MBI가높았다. 후기재활치료군에서는역방향단어외우기검사점 수가높을수록퇴원당시의 MBI가낮았다 (r=-0.65, p=0.004). (2) 나이에따른차이 65세미만환자의경우 CNT 검사와기능적회복지수간의의미있는상관관계를보인항목은없었다. 그러나 65세이상의경우역방향그림외우기검사점수가높을수록퇴원당시의 MBI 중자기관리항목점수가높았고 (r=0.61, p<0.01), 퇴원할때의 NIHSS와 BBS 점수가낮았다 (r=-0.75, p=0.001; r=0.80, p<0.001). 고찰 본연구결과를요약해보면젊은뇌졸중군이재활치료기간동안 MMSE와기능적회복지수의호전정도가컸고, 세부인지영역중시각적단기기억력, 집중력, 작업기억력과전반적인사고의유연성, 실행성기능이높았다. MMSE 상호전정도는뇌졸중이후신경학적호전과연관성을보였다. 또한시각적주의력과작업기억력이좋을수록퇴원할때의 MBI의총점및 MBI 하위항목의점수가높았다 (Fig. 1). 상기결과를통해인지기능, 특히시각적주의력과작업기억력이뇌졸중이후의기능적회복과관련이있음을알수있었다. 또한본연구결과, 집으로의퇴원과연관되는요소는전반적인지기능보다는발병초기와퇴원시의일상생활의독립적수행수준과운동기능인것으로분석되었다. 하지만세부인지기능검사에서시각적단기기억력, 집중 Table 4. Correlation between K-MMSE Scores and Functional Outcome Measures according to the Subgroups MBI at Total Self-care Mobility MBI NIHSS at NIHSS BBS at BBS Age<65 K-MMSE i * K-MMSE Age 65 K-MMSE i K-MMSE * Onset time of rehabilitation program <4 weeks Onset time of rehabilitation program 4 weeks K-MMSE i K-MMSE * * K-MMSE i K-MMSE K-MMSE i: Korean version mini-mental status examination at beginning of rehabilitation program, K-MMSE: changes in K-MMSE between beginning of rehabilitation program and, MBI: Modified Barthel index at, MBI: changes in MBI total scores between beginning of rehabilitation program and, NIHSS: National Institute of Health Stroke Scale at, NIHSS: changes in NIHSS between beginning of rehabilitation program and, BBS: Berg balance scale at, BBS: changes in BBS between beginning of rehabilitation program and. *p<0.05, p<

5 이유나외 3 인 : 뇌졸중후인지기능이재활치료과정에서기능회복에미치는영향 Table 5. Correlation between Detailed Cognitive Tests and Functional Outcome after Rehabilitation Program MBI at Total Self-care Mobility MBI NIHSS at NIHSS BBS at Digit span forward Digit span backward * 0.11 Visual span forward 0.29* 0.28* 0.34* * 0.11 Visual span backward * * 0.10 ACPT VCPT Verbal learning (A1) * Verbal learning (A5) * Verbal learning (D) Visual learning (A1) Visual learning (A5) Visual learning (D) * 0.27* Color of color word Word of color word * Trail making A * Trail making B * Card sorting test Raven CPM 0.31* 0.28* * BBS MBI: Modified Barthel index, MBI: changes in MBI total scores between beginning of rehabilitation program and, NIHSS: National Institute of Health Stroke Scale, NIHSS: changes in NIHSS between beginning of rehabilitation program and, BBS: Berg balance scale, BBS: changes in BBS between beginning of rehabilitation program and, ACPT: auditory continuous performance test, VCPT: visual continuous performance test, (A1): first step test, (A5): fifth step test, (D): delayed phase, CPM: colored progressive matrices. *p<0.05, p<0.01. Fig. 1. Correlation between cognitive tests and functional outcome after rehabilitation program. There are significant correlation between cognitive function and primary functional outcome only in the tests for visual attention and memory (VSB) and auditory vigilance. The results of tests for general cognition (K-MMSE) and emotion (BDI) do not showed any correlation-ship with primary functional outcomes. (*p<0.05, p<0.01, MBI: Modified Barthel index, MBI: changes in MBI (total score) between beginning of rehabilitation program and, K-MMSE i: Korean version mini-mental status examination at beginning of rehabilitation program, K-MMSE: changes in K-MMSE between beginning of rehabilitation program and, BDI: Beck depression inventory, VSB: visual span backward test, ACPT: auditory continuous performance test, NIHSS dc: National Institute of Health Stroke Scale at, NIHSS: changes in NIHSS between beginning of rehabilitation program and, BBS dc: Berg balance scale at, BBS: changes in BBS between beginning of rehabilitation program and. 107

6 Brain& NeuroRehabilitation:2011; 4: 103~109 력, 작업기억력그리고실행기능이집으로퇴원한군에서높은것으로나타나, 인지기능또한집으로의퇴원과관련되는인자임을알수있었다. 이러한연구결과는 Stephens 등 14 과 Naugle 과 Kawczak 28 의연구결과도비슷한결과이다. Stephens 등 14 과 Naugle과 Kawczak 28 은 MMSE만으로는경한인지장애를완벽히가려낼수없으므로세분화된인지검사도구가필요하며, 집중력저하가기능적예후와관계가있다고말하였다. 본연구에서 MMSE 검사에서정상소견을보였던 6.3% 의환자모두 CNT를이용한평가에서는세부인지기능의저하를보인점또한이를뒷받침하는증거라할수있다. 29 Salter 등 6 의연구와마찬가지로본연구에서도조기에재활치료를시작한군에서더나은기능적회복을보였다. 특히인지의세부영역중시각적집중력, 작업기억력, 학습능력이일상생활의독립적수행여부와상관관계가있는것으로분석되어조기에재활치료를시작했을경우시각적인지능력이기능적회복과유의하게연관됨을알수있었다. 그러므로초기재활시점부터적극적인인지재활치료를병행하는것이기능적회복에도움을줄수있을것으로생각된다. 또한본연구에서 65세미만환자의경우인지기능과관계없이 65세이상군에비하여기능적회복이좋았다. 65세이상의경우에는초기인지기능수준이기능적회복의정도와연관되었다. 특히나이가많을수록 CNT에서집중력, 기억력, 실행기능이저하되어있었다. 이러한연구결과를통해고령의뇌졸중환자도적극적인인지재활치료를받아야함을추로해볼수있겠다. 본연구에서재활치료시작시의 MMSE가높을수록 NIHSS 의점수호전이작았다. 이는인지기능이보존되어있거나재활치료를통해인지기능의변화가클경우기능적회복이크다는다른항목들을통한결과와는상반되는결과이다. 이는 MMSE가좋은환자에서초기 NIHSS가낮고, 이에따라이후호전정도의폭이작은천장효과 (ceiling effect) 에기인하는것으로생각할수있겠다. 역상관관계를보인환자군이기능적회복정도가높았던조기재활치료군, 65세미만군, 집으로퇴원한군이었던점도앞선설명을뒷받침하는근거라고할수있다. 청각적주의력및작업기억력이높을수록 MBI의호전정도가작았는데이역시천장효과로설명할수있겠다. 본연구의제한점은대상환자를여러군으로나누어분석한연구방법에비해상대적으로적은수의연구대상을들수있다. 그러나여러비교군간대부분의인구학적인특성차이가없었고, 통계오류를줄이기위해비모수 검정과함께나이를보정한자료를사용하였으므로기본적인통계의신뢰도는확보했을것으로생각된다. 다음으로후향적방법으로연구를시행하여많은환자에서세부인지기능검사나기능회복평가가누락되어연구대상에서제외되었으며세부인지기능검사에대한변화량을포함시키지못한점을들수있겠다. 향후전향적인후속연구를통해세부인지검사의변화량도함께측정하여기능회복과의상관관계를알아보는것이필요할것이다. 본연구의장점으로는나이나재활치료로의뢰되기까지의시기에따라한정된환자를모집하거나, 실어증이나좌측편무시와같은인지기능과상호작용을가지고있는뇌졸중후유증을가진환자를제외했던이전연구와달리다양한환자를대상으로연구를진행했다는점이다. 특히연구대상에언어장애가있는환자도배제하지않았는데, 이는실어증이있는환자를제외할경우시각적인지기능에비해언어적인지기능이떨어진환자가제외될수있으며, 언어적기능에는문제가없으나전반적인인지장애나우울증과같은정서장애로인하여실어증으로잘못분류된환자군이제외될수있기때문이다. 결론 기존연구에서인지기능의저하가뇌졸중환자의기능적회복에부정적영향을미친다는것은이미밝혀졌으나, 인지기능중어떤부분이특별히더영향을미치는지에대한연구는많지않다. 본연구를통하여주의력과작업기억력이환자의일상생활동작의회복과가장관련이많음을알수있었다. 또한조기부터재활치료를시작한경우인지기능과기능회복의호전정도가더크며, 나이가많은경우젊은뇌졸중환자보다인지기능의호전정도와기능적회복간의연관성은더큼을알수있었다. 그리고집으로의퇴원여부에는여러인지기능중실행성기능이관련이많은요소로나타났다. 본연구결과를통해향후뇌졸중환자에서기능을호전시키고, 가정과사회로조속히복귀할수있도록하기위해서고식적인재활치료와함께주의력, 작업기억력, 실행성기능등의향상을위한인지재활프로그램도병행하는것이도움이될것으로생각된다. 또한고연령군에서인지손상여부를초기에정확히평가하여인지기능의손상여부와호전정도를알면기능적회복을예측하는데도움을주고개인에맞는포괄적인뇌졸중재활프로그램을수립하는데중요한지침을제공할수있을것으로생각된다. 108

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Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical