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1 J Korean Soc Phys Med, 2016; 11(2): Online ISSN: Print ISSN: X Research Article Open Access 이중과제동작관찰신체훈련이만성뇌졸중환자의보행능력과일상생활활동에미치는영향 이현민 이정아 1 호남대학교보건과학대학물리치료학과, 1 호남대학교대학원재활과학과물리치료전공 The Effects of Dual-task Action Observation Physical Training on the Walking Ability and Activities of Daily Living in Chronic Stroke Patients Hyun-Min Lee, PT, PhD Jeong-A Lee, PT, MS 1 Dept. of Physical Therapy, College of Health Science, Honam University 1 Major in Physical Therapy, Dept. of Rehabilitation Science, Graduated School of Honam University Received: April 4, 2016 / Revised: April 13, 2016 / Accepted: May 13, 2016 c 2016 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to determine the efficacy of dual-task action observation training (AOT) and single-task AOT related with daily living task on walking ability and ADL performance in chronic stroke patients. METHODS: Twenty-seven chronic stroke subjects were included in the study. They were randomly assigned to three task categorieds as follows: whole dual-task AOT or partial dual-task AOT or single-task AOT rehabilitation. Whole dual-task AOT observed the movement at once and partial dual-task AOT observed the movement divided into 4 parts related functional gait and activities of daily living task for 2 minutes 30 seconds. Single-task AOT observed the movement related functional gait for 2 minutes 30 seconds. Corresponding Author : leejeongacityrehab@gmail.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Both groups had physical training session for 12 minutes 30 seconds. The study was conducted for four weeks, with three training sessions a week, for twelve weeks. All subjects were evaluated for their walking ability and activities of daily living through devices, 10m walking test (10MWT), dynamic gait index (DGI), and Korea-Modified Barthel Index (K-MBI). RESULTS: A significant improvement of walking ability and ADL performance happened among dual-task AOT subjects, compared with a single-task AOT subjects, during the 4-weeks course treatment. The results of the study showed statistically significant differences in 10MWT (p<0.05) and DGI (p<0.05), and K-MBI (p<0.05). CONCLUSION: Our results indicated that dual-task AOT has a positive additional impact on recovery of walking ability and ADL performance in chronic stroke patients. Key Words: Action Observation, Activities of daily living, Dual-task, Gait, Stroke

2 84 J Korean Soc Phys Med Vol. 11, No. 2 Ⅰ. 서론뇌졸중환자는신체구조및신체기능의손상때문에일상생활활동과사회적구성원으로서의참여가제약된다 (Dobkin, 2005). 일상생활활동에필요한보행능력의상실로인해약 2/3 정도는독립적으로걸을수없으며 (Jorgensen 등, 1995), 정상인의보행속도에비해현저히낮은속도로인해독립적인이동과자동성 (automaticity) 의제한을가지게된다 (Hill 등, 1997; Pohl 등, 2002; Chen과 Patten, 2006). 이러한문제들로인해뇌졸중환자의 24~74% 가이동과기본적인일상생활활동에어려움을겪게된다 (Miller 등, 2010). 또한다양하고복합적인과제를동시에수행해야하는경우에도두가지이상의운동과제및인지과제를수행하는것이어려워진다 (Yang 등, 2007). 최근일상적인행동의체계적인관찰을이용하는새로운재활훈련방법으로동작관찰훈련 (action observation training; AOT) 이제시되고있다 (Buccino 등, 2006). 동작관찰훈련은거울신경세포시스템 (mirror neuron system; MNS) 에근거하여동작을관찰하고, 관찰한동작을모방하여반복적으로훈련하는방법이다 (Keysers 와 Gazzola, 2010). 거울신경세포시스템은인간행동의다양한형태로모방 (imitation), 의도이해 (understanding intention), 새로운기술습득등과관련됨이보고되었다 (Hickok, 2009; Martineau 등, 2010; Rizzolatti와 Craighero, 2004; Rizzolatti 등, 2001). 동작관찰훈련과정은동작에대해이해하고모방하면서운동학습 (motor learning), 운동기억형성 (motor memory formation) 과같은인지행위과정을포함하게된다 (Iacoboni 등, 2005). Gatti 등 (2013) 의연구에서는최소한운동학습의초기단계에서복잡한새로운운동과제를배우기위한전략으로운동이미지훈련보다신경계재활에서의동작관찰훈련이더효과적이라고하였다. Buccino 등 (2001) 의연구에서도과제가없이흉내만내는관찰자보다공잡기, 컵잡기, 공차기, 브레이크밟는과제와관련된동작을관찰하였을때앞운동피질 (premotor cortex) 이더활성화되었고관찰한동작을수행하였을때활성화되는뇌영역과동일하다고 보고하였다. 특히 Ewan 등 (2010) 은일상생활활동중환자가원하는과제로구성하여동작관찰훈련을하였을때기능적향상을확인하였다. 이중과제 (dual-task) 는과제를동시수행하는것으로한가지과제보다두가지또는그이상의과제를수행하는것을말한다 (O'Shea 등, 2002). 일상생활에서는매일수행해야할활동으로다양하고복합적인과제를동시에수행할수있어야한다. 신경학적결손이있는사람들은이중과제를수행하는동안보행과제및인지적과제를수행하는데어려워지기때문에 (Kizony 등, 2010), 단일과제보다일상생활활동과유사한이중과제를수행하여야한다. 최근동작관찰과관련된선행연구로는상지기민성 (dexterity) 및보행, 앉고일어서걷기 (sit to walk) 등과같은동작관찰훈련의효과는다양하게보고되고있지만 (Yang 등, 2012; Kang, 2013; Kim, 2015), 기능적보행능력과관련하여목적이있는일상생활과제를동시에적용한이중과제동작관찰신체훈련에대한연구는미흡한실정이다. 따라서본연구는만성뇌졸중환자를대상으로이중과제동작관찰신체훈련이보행능력과일상생활활동에미치는영향을알아보고자한다. Ⅱ. 연구방법 1. 연구대상및연구기간본연구는광주광역시소재 C 병원에서뇌졸중으로진단받고입원하여재활치료를받는뇌졸중환자들을대상으로하였다. 총 27명의환자를대상자를모집하여연구의목적및방법에잘이해하고참여에동의를얻은후연구를진행하였다. 연구에참여한대상자선정조건은 1) 발병후 6개월이상경과한자, 2) 한국형간이정신상태판별검사 (K-MMSE) 점수가 24점이상인자, 3) 시야결손및전정기관, 고유수용성감각에이상이없는자, 4) 하지에정형외과적질환이없는자, 5) 보조도구없이독립적으로 10m 이상보행이가능한자로하였다. 대상자들의마비측상지도수근력검사 (Manual Muscle Test, MMT) 로 Fair 이하로제한이있는

3 이중과제동작관찰신체훈련이만성뇌졸중환자의보행능력과일상생활활동에미치는영향 85 자 (Yang 등, 2012), 심부정맥혈전증을가지고있는자, 보조도구없이독립적으로 10m 이상보행이불가능한자는연구대상에서제외하였다. 2. 연구설계본연구에참여한대상자들 (N=27) 을전체이중과제동작관찰신체훈련군 (Whole dual-task action observation training, n=9) 과부분이중과제동작관찰신체훈련군 (Partial dual-task action observation training, n=9), 단일과제동작관찰신체훈련군 (Single-task action observation training, n=9) 으로제비뽑기로무작위로나누어각각배정하였다. 연구기간중치료거부및퇴원, 다른병원전원으로인한이유로전체이중과제동작관찰신체훈련군에서 1명, 부분이중과제동작관찰신체훈련군에서 1명, 단일과제동작관찰신체훈련군에서 1명이탈락하였다. 3. 훈련방법전체이중과제동작관찰신체훈련군 (Whole dualtask AOT) 및부분이중과제동작관찰신체훈련군 (Partial dual-task AOT), 단일과제동작관찰신체훈련군 (Single-task AOT) 은 4주동안주 3일, 1일 30분씩, 총 12회를실시하였다. 동작관찰훈련으로동영상은 2분 30초관찰한후 12분 30초동안과제와기능적보행과제신체훈련을반복적으로연습하였고, 15분씩총 2회기를훈련하였다. 각대상자는치료실내에마련된치료사의노트북을통해관련된동영상을관찰하였다. 각각의동영상은환자의기능적상태를고려하여쉬운동작에서어려운동작으로난이도를조절하였다. 과제의난이도로쉬운동작은한손사용과어려운동작으로는양손사용동작으로 Franceschini (2010) 의연구를바탕으로구성하였다. 1) 전체이중과제동작관찰신체훈련군 (Whole dual-task AOT) 의훈련전체이중과제동작관찰신체훈련군 (Whole dual-task AOT) 은기능적보행과제와일상생활활동과관련된과제를동시수행하는모습을촬영하였다. (1) 플라스틱컵을들고 10m 걸어가되돌아오기, (2) 쟁반들고 10m 걸어가되돌아오기, (3) 플라스틱컵을들고앉고일어서걷기, (4) 식판들고앉고일어서걷기, (5) 옷입고, 옷벗으면서 10m 걸어가되돌아오기, (6) 휴대폰통화하면서시계방향및반대방향걷기, (7) 휴대폰버튼누르면서시계방향및반대방향걷기, (8) 가방들고장애물넘기, (9) 상자들고장애물넘기, (10) 책넘기면서장애물돌아가기, (11) 신문지읽으면서장애물돌아가기, (12) 지갑에서카드빼기및지폐세면서장애물돌아가기로이루어진동영상을관찰하고관찰한동작을훈련하였다. 2) 부분이중과제동작관찰신체훈련군 (Partial dual-task AOT) 의훈련 Franceschini (2010) 의연구에서하나의동작을 3~4개의구간으로세분화하여각각의부분동작을관찰하였다. 이를바탕으로본연구에서도부분이중과제동작관찰신체훈련군 (Partial dual-task AOT) 은 12가지전체이중과제동영상을구성하고있는각각하나의동영상을 4부분의시작, 중간, 끝, 목표지점으로나누어동영상을관찰하고관찰한동작을훈련하였다. 3) 단일과제동작관찰신체훈련군 (Single-task AOT) 의훈련단일과제동작관찰신체훈련군 (Single-task AOT) 의대상자들은기능적보행과제 5가지 (1) 10m 걸어가되돌아오기, (2) 앉고일어서걷기, (3) 시계방향및반대방향걷기, (4) 장애물넘기, (5) 장애물돌아가기로동영상을관찰하고관찰한동작을훈련하였다. 4. 평가도구 1) 보행능력 (1) 10m 걷기검사 (10m walking test; 10MWT) 이검사는짧은시간에신경학적손상환자의보행속도평가방법으로신뢰도와타당도가검증된 10m 보행검사를이용하였다. 평지에서 14m의직선거리를 10m 경로의시작과끝지점에표시하고, 정상보행속도를측정하기위해시작점 2m 전에출발한다. 측정

4 86 J Korean Soc Phys Med Vol. 11, No. 2 시간은 10m를측정하고총 3회측정하여 0.01초단위까지초시계를이용하여평균값을사용한다. 이도구의검사-재검사방법에서급내상관계수는 ICC=0.95~0.96 로높게입증되었다 (Fulk과 Echternach, 2008). (2) 동적보행지표검사 (Dynamic gait index; DGI) 뇌졸중환자의보행능력을알아보기위한검사이다. 총 8문항으로각항목으로평지걷기, 속도변화하며걷기, 수평및수직으로머리움직이며걷기, 회전한후걷기, 장애물돌아가기, 장애물넘기, 계단오르기로구성되어있다. 점수는 0~24점까지이며 24점을만점으로하여 22점이상은안전하게이동할수있고, 19점미만이면노인들에게낙상위험이있다고해석하였다. 이도구는검사자내신뢰도는 r=0.96으로높게입증되었다 (Jonsdottir와 Cattaneo, 2007). 91~99점, 최소의존성, 100점은완전독립성을나타낸다. 검사-재검사신뢰도는 r=0.89, 검사자간신뢰도는 r=0.95로높게입증되었다 (Granger 등, 1979). 5. 자료분석본연구의통계학적분석은윈도우용 SPSS version 15.0을사용하였다. 연구대상자의일반적특성은기술통계를통하여평균과표준편차로나타내었고, 정규성검정을위해샤르포-윌크검정 (Shapiro-Wilk test) 을실시하였다. 각군내의훈련전과후의변화를알아보기위해대응표본 t-검정 (paired t-test) 을실시하였다. 세그룹에대한훈련전과후평균차이값을비교하기위해일원배치분산분석 (One-way ANOVA) 과사후검정으로 Scheffe를실시하였다. 측정항목에대한통계학적유의수준은 α=0.05로하였다. 2) 일상생활활동 (1) 한국판수정된바델지수 (Korean version of modified Barthel index; K-MBI) 기본적일상생활활동의기능적수준을평가하는도구로 K-MBI는 Shah 등 (1989) 이개정한 MBI 제5판을한국실정에맞도록일부문항을수정및보완하여표준화한것이다. 총 10가지의일상생활활동항목으로구성되어있으며각항목별 5점척도로점수화시킨다. 100점만점으로 0~24점, 완전의존성, 25~49점, 최대의존성, 50~74점, 부분의존성, 75~90점은약간의존성, Ⅲ. 연구결과 1. 연구대상자의일반적특성연구대상자는총 27명으로전체이중과제동작관찰신체훈련군 9명, 부분이중과제동작관찰신체훈련군 9명, 단일과제동작관찰신체훈련군 9명으로총 27명이참여하였으며, 연구대상자의일반적특성은 Table 1과같다. 모든항목에따른세그룹간의유의한차이는없었다 (p>0.05). Table 1. General characteristics of the subjects Whole dual-task AOT a Partial dual-task AOT Single-task AOT Gender (male/female) 5/4 6/3 6/3 Lesion type (hemorrhage/infarction) 4/5 3/6 7/2 Affectid side (left/right) 2/7 5/4 5/4 Age (year) 56.44± ± ±9.12 Onset time (months) 46.44± ± ±27.13 K-MMSE b (score) 27.22± ± ±1.59 Values are Mean±SD a AOT: Action observation training, b Korea-Mini Mental States Examination

5 이중과제동작관찰신체훈련이만성뇌졸중환자의보행능력과일상생활활동에미치는영향 훈련전 후의보행능력의변화전체이중과제동작관찰신체훈련군과부분이중과제동작관찰신체훈련군, 단일과제동작관찰신체훈련군모두훈련전보다훈련후에 10m 걷기검사결과에서유의하게감소하였다 (p<0.05). 동적보행지표점수는전체이중과제동작관찰신체훈련군과부분이중과제동작관찰신체훈련군에서훈련전보다훈련후에유의하게증가하였지만 (p<0.05), 단일과제동작관찰신체훈련군에서는유의한차이가없었다. 훈련전 후차이값비교에서세그룹간에유의한차이가있었다 (p<0.05). 이중과제동작관찰신체훈련군이부분이중과제동작관찰신체훈련군과단일과제동 작관찰신체훈련군에비해유의하게나타났다 (p<0.05). 부분이중과제동작관찰신체훈련군과단일과제동작관찰신체훈련군간에는유의한차이가없었다 (p>0.05) (Table 2). 3. 훈련전 후의일상생활활동의변화수정된바델지수에서는전체이중과제동작관찰신체훈련군과단일과제동작관찰신체훈련군은훈련전보다훈련후에유의하게증가하였지만 (p<0.05), 부분이중과제동작관찰신체훈련군에서는유의한차이가없었다. 훈련전 후의차이값비교에서세그룹간에유의한차이가없었다 (p>0.05)(table 3). Table 2. Comparison of Walking ability in three groups Whole dual-task AOT a Partial dual-task AOT Single-task AOT F-value (post-hoc) pre 15.81± ± ± MWT b (sec) post 11.22± ± ±2.88 Diff d -4.59± ± ±0.87 t 7.31 * 3.41 * 6.82 * * (a>b,c) pre 18.22± ± ± DGI c (score) post 22.56± ± ±5.90 Diff 4.33± ± ±2.76 t * * 0.12 Values are Mean±SD, * p<0.05 a AOT: Action observation training, b 10m walking test, c Dynamic gait index, d Difference(Post-Pre) 9.50 * (a>b,c) Table 3. Comparison of Activities of daily living in three groups K-MBI b (score) Whole dual-task AOT a Partial dual-task AOT Single-task AOT F-value (post-hoc) pre 96.00± ± ± post 99.33± ± ±4.12 Diff c 3.33± ± ± t * * Values are Mean±SD, * p<0.05 a AOT: Action observation training, b Korean version of modified Barthel index; K-MBI, c Difference(Post-Pre)

6 88 J Korean Soc Phys Med Vol. 11, No. 2 Ⅳ. 고찰본연구는만성뇌졸중환자를대상으로전체이중과제동작관찰, 부분이중과제동작관찰, 단일과제동작관찰을통해신체훈련을실시한후보행능력과일상생활활동에어떤변화가발생하였는지알아보고자하였다. 본연구결과전체이중과제동작관찰군, 부분이중과제동작관찰군, 단일과제동작관찰군에서 10MWT, DGI, K-MBI에서유의한향상이있었다. 거울신경세포가존재하는대뇌겉질의앞운동영역은여러관절의복합적인움직임으로동작을이끌어내고, 보완운동영역은몸의조화로운움직임을만드는데관여한다고보고되었다 (Kandel 등, 2000). 본연구에서전체이중과제동작관찰신체훈련군과부분이중과제동작관찰신체훈련군, 단일과제동작관찰신체훈련군, 세그룹모두 10m 걷기검사에서훈련전보다훈련후에유의하게감소하여보행속도의향상을관찰할수있었다. Yang 등 (2007) 은만성뇌졸중환자 25명을대상으로이중과제훈련군에서훈련후대조군에비해그룹간, 그룹내보행속도에유의한차이를보여본연구결과와일치하였다. 이는단일과제보다한가지또는두가지이상의운동과제를동시수행하는이중과제훈련을통해실질적인움직임을향상시키는데효과적이라고제안하였다. 또한목표지향적인과제와도달할수있는시공간적이동경로와속도, 방향과같은요소들이목표달성을위한움직임계획에관여하였고, 반복적인신체훈련이보행속도와운동학습에긍정적인효과를제공한것으로생각된다. 본연구의동적보행지표점수에서전체이중과제동작관찰신체훈련군과부분이중과제동작관찰신체훈련군그룹에서훈련전보다훈련후에유의하게증가하였다. Park 등 (2014) 의동작관찰연구에서 14가지기능적보행과제인오른쪽및왼쪽으로고개돌리며걷기, 시계방향및반시계방향으로돌기, 장애물돌아가기, 장애물넘기등으로이루어진동작관찰신체훈련군에서훈련전보다훈련후보행의기능적과제수행능력에유의하게증가되었다. 또한 Kim (2015) 의동작관찰연구에서앉고일어서걷기보행과제로이루어진 동작관찰신체훈련군에서동적보행지표점수가훈련전보다훈련후에유의하게증가되어본연구결과와일치하였다. 이는선자세와보행하는동안신체위치감각과머리의움직임에따라운동형태와근육, 관절에있는고유수용성감각에관한정보를주고받는다고하였다 (Kim, 2000). 각시스템의상호작용에의해머리의위치와몸통의움직임으로정위 (orientation) 반응인안뜰계에긍정적인영향을미쳐과제를수행하는데필요한자세조절과자세적응능력이증진된것이라고생각되어진다. 한국판수정된바델지수점수의결과도전체이중과제동작관찰신체훈련군과단일과제동작관찰신체훈련군그룹에서훈련전에비해훈련후유의한차이가있었다. 일상생활활동향상에도움을줄수있는기능적과제로제공하여목표를제시하는것은재활환경에서중요하다. 환자들은처한문제를해결하기위해인지기능에관여하는동기부여와집중, 주의요소가환경속에서유연하게적응할수있다고하였다 (Horak, 1991). Celnik 등 (2008) 의연구에따르면냉장고문열고닫기, 부엌활동등과같은관련된동영상을관찰하고관찰한동작을모방하여시행하였을때과제수행능력이향상되었다고하였다. 또한 Bae와 Kuk (2012) 의연구에서도동작관찰훈련을통해상지기능과일상생활활동수행능력이증진되었다. 이러한결과는실질적으로일상생활에서쓰이는도구를사용한동작관찰훈련이만성뇌졸중환자의일상생활활동수행능력을향상시킨것으로사료된다. 일상생활활동에서복합적인과제를해결하기위해서는전체적인상황에서과제를분석하고처리하며입력된정보들을통합시키고수정하는상호작용능력이각각의부분적인상황에서과제를해결하는방법으로제시된다 (Van Merrienboer와 Ayres, 2005). 본연구에서세그룹간의훈련전 후평균차이값을비교한결과, 부분이중과제동작관찰훈련군과단일과제동작관찰훈련군보다전체이중과제훈련군에서 10MWT, DGI에서유의한차이가있었고, K-MBI에서는유의한차이가없었다. 이는전체과제연습 (Whole task practice) 방법이훈련초에동영상관찰을통해다양한활동과과제를

7 이중과제동작관찰신체훈련이만성뇌졸중환자의보행능력과일상생활활동에미치는영향 89 제공함으로써환자스스로동작을계획, 해결하고실행하여전체적인상황을파악할수있는능동적인움직임을연속적으로보여줌으로써기능적향상에도움을준다고생각된다. 그러나 K-MBI에서는세그룹간유의한차이가없었던것은본연구에서실시한이중과제동작관찰훈련이 10가지측정항목의수준들을포함하지못하였고, 운동학습에전이효과가나타나지않는것으로사료된다. 동작관찰훈련은관찰한동작을실행하는훈련방법으로실제반복적인연습과병행하였을때학습효과를극대화시킬수있다고제안하였으며, 경험을바탕으로운동상상과운동을모방하는과정. 즉, 재학습되어기능회복에긍정적인효과를가져온다고하였다 (Page 등, 2001). 따라서, 전체이중과제동작관찰신체훈련이각각의동작을부분으로나누어진부분이중과제와단일과제동작관찰훈련군보다뇌졸중환자의기능적보행능력향상의결과를나타낸본연구의결과를뒷받침해준다고생각되어진다. 그러므로과제의난이도에따라처리및이해능력이다양하기때문에단일과제수행보다는이중과제수행이뇌졸중환자에게중요하다. 또한환자의개개인의기능적일상생활활동을포함한동작관찰훈련이뇌졸중환자의기능회복에효율적인중재방법이될수있다고생각된다. 본연구의제한점은표본크기가적고대상자선정조건에적합한환자만을대상으로연구를진행하였기때문에연구결과를일반화하기에한계가있고, 이중과제동작관찰을통한일상생활활동의과제수행능력과균형에대한평가가부족하였다. 향후연구에서는더많은연구대상자로연구가진행되어야하며, 다양한과제들로구성된동작관찰을제시하여기능적수행능력향상에대한연구가필요할것이다. Ⅴ. 결론본연구의목적은만성뇌졸중환자들을대상으로이중과제를적용한동작관찰훈련을통해보행능력과일상생활활동에미치는효과를알아보고자하였다. 본연구의결과이중과제동작관찰훈련군이단일과제동작관찰훈련군보다보행능력과일상생활활동을향상시키는데더효과가있음을알수있었다. 따라서, 임상에서물리치료와작업치료훈련에서일상생활활동과관련된다양한과제를통해동작관찰훈련을적용하고자할때긍정적인영향을얻을수있을것이다. References Bae SY, Kuk EJ. The Effects of Action Observation Physical Training on the Upper Extremity Function and Activity of Daily Living of Chronic Hemiplegic Patients. Kor J Neural Rehabil. 2012;2(2):1-9. Buccino G, Binkofski F, Fink GR et al. Action observation activates premotor and parietal areas in a somatotopic manner: an fmri study. Eur J Neurosci. 2001;13(2): Buccino G, Solodkin A, Small SL. Functions of the mirror neuron system: implications for neurorehabilitation. Cogn Behav Neurol. 2006;19(1): Celnik P, Webster B, Glasser DM et al. Effects of action observation on physical training after stroke. Stroke. 2008;39(6): Chen G, Patten C. Treadmill training with harness support: selection of parameters for individuals with poststroke hemiparesis. J Rehabil Res Dev. 2006;43(4):485. Dobkin BH. Rehabilitation after stroke. N Engl J Med. 2005;352(16): Ewan LM, Kinmond K, Holmes PS. An observation-based intervention for stroke rehabilitation: experiences of eight individuals affected by stroke. Disabil Rehabil. 2010;32(25): Franceschini M, Agosti M, Cantagallo A et al. Mirror neurons: action observation treatment as a tool in stroke rehabilitation. Eur J Phys Rehabil Med. 2010;46(4): Fulk GD, Echternach JL. Test-retest reliability and minimal

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9 이중과제동작관찰신체훈련이만성뇌졸중환자의보행능력과일상생활활동에미치는영향 91 underlying the understanding and imitation of action. Nat Rev Neurosci. 2001;2(9): Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemio. 1989;42(8): Van Merrienboer JJG, Ayres P. Research on cognitive load theory and its design implication for E-learning. Edu Technol Res Dev. 2005;53(3):5-13. Yang YP, Kim JY, Han MR et al. The Effect of Action Observation Training on Affected Side Upper Limb Dexterity in Stroke Patient: Single-subject research design. J Korean Soc Phys Med. 2012;7(1): Yang YR, Chen YC, Lee CS et al. Dual-task-related gait changes in individuals with stroke. Gait posture. 2007; 25(2):

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