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1 J Korean Soc Phys Med, 2014; 9(4): Online ISSN: Print ISSN: X Research Article Open Access 호흡근강화훈련이뇌졸중환자의호흡기능, 호흡근력과기침능력에미치는영향 조명래 김난수 1 정주현부산가톨릭대학교일반대학원물리치료학과, 1 부산가톨릭대학교물리치료학과 The Effects of Respiratory Muscle Training on Respiratory Function, Respiratory Muscle Strength, and Cough Capacity in Stroke Patients Myeong-Rae Jo, PT, BS, Nan-Soo Kim, PT, PhD 1, Ju-Hyeon Jung PT, MS Department of Physical Therapy, Graduate School, Catholic University of Pusan 1 Department of Physical Therapy, Catholic University of Pusan Received: September 1, 2014 / Revised: September 11, 2014 / Accepted: October 10, 2014 c 2014 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to examine the effects of respiratory muscle training on respiratory function, respiratory muscle strength, and cough capacity in stroke patients. METHODS: This study used a nonequivalent control group pre-post test design. We recruited thirty-four stroke patients(16male, 18female), who were assigned to intervention, or control groups. Both groups participated in a conventional stroke rehabilitation program, with the intervention groups also receiving respiratory muscle training 20 minutes a day, three times a week, for 4 weeks. Respiratory function (forced vital capacity) and respiratory muscle strength (maximal inspiratory pressure, maximal Corresponding Author : hnskim@cup.ac.kr 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. expiratory pressure) were assessed by spirometry. Cough capacity (peak expiratory flow) was assessed using a peak flow meter. The collected data were analyzed by independent and paired t-tests. RESULTS: The intervention group showed a significant increase in the forced vital capacity (FVC), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and peak expiratory flow (PEF) at the end of the program, while the control group showed no significant changes. CONCLUSION: This study showed that respiratory muscle training increased respiratory function, respiratory muscle strength, and cough capacity in stroke patients and prevented a decrease in cough capacity. These findings suggest that respiratory muscle training effect on respiratory function, respiratory muscle strength and cough capacity for rehabilitation in patients with stroke. Key Words: Stroke, Respiratory muscle training, Respiratory function, Respiratory muscle strength, Cough capacity

2 400 J Korean Soc Phys Med Vol. 9, No. 4 Ⅰ. 서론뇌졸중은세계적으로가장높은유병률과장기간의장애를발생시키는질환중하나이다 (Goldstein 등, 2011). 뇌졸중으로인해발생한운동피질과피라미드로의손상은편측마비의증상을나타내며, 그결과자세근육의긴장도와수의적움직임의비정상화로인한운동조절장애와체간근육의동시수축이나타나게된다 (De Almeida 등, 2011). 따라서호흡에필요한호흡근육의운동조절기능도손상될수있다 (Britto 등, 2011). 그러나뇌졸중질환과같은신경학적손상을받은환자들은주로좌식생활을하기때문에힘든활동이나흉부감염으로인해갑작스럽게산소요구량이증가하는상황이발생되기전까지는호흡문제가간과되기쉽다 (Sutbeyaz 등, 2010). 선행연구에따르면뇌졸중환자는동일한연령과성별의건강한대조군과비교해보았을때, 호흡기능이대조군에비해 50% 정도감소됨을알수있고 (Khedr 등, 2000). 이런호흡기능의감소는심혈관계사망률및유병률을증가시킨다 (van der Palen 등, 2004). 뇌졸중환자의호흡기능감소는뇌손상으로인한편마비로가로막과갈비사이근, 배근육같은호흡근육의협동작용에필요한운동조절기능이손상되고 (Jandt 등, 2011), 흉벽의운동학적기전이파괴되기 (Lanini 등, 2003) 때문이다. 이로인해호흡근육의전체적또는부분적약화가초래되어흡기근과호기근의근력이감소한다 (Teixeira-Salmela, 2005). 또한뇌손상은삼킴이나기침관련된수의적조절기능도손상시킬수있다. 뇌손상부위에따라증상은다를수있으나, 뇌졸중환자는대부분노인이므로노화로인한감퇴가동반되어삼킴곤란빈도가증가한다 (Martino 등, 2005). 삼킴곤란은폐렴과같은흉부감염의위험을세배이상 (Martino 등, 2005), 흡인했을때에는열배이상증가시킨다 (Smith Hammond 등, 2009). 기도로의이물질의유입과흡인을방지하는기침의기능을고려할때, 뇌졸중환자에게있어서수의적기침은매우중요한문제라고할수있다 (Addington 등, 2008). 수의적기침은공기를들이쉬고, 성문을닫고복근 과흉부근육을동시에수축하여흉곽내압력을높이고, 성문을열면서흉부근육과복근을최대로수축하여폐와기도로부터공기를강하게내보내는 3단계로구성된다 (Widdicombe와 Fontana, 2006). 기침을효율적으로하기위해서는적절한흡기근과호기근의근력이필요하다. 그런데뇌졸중환자의경우호흡근의근력이약화되기때문에효율적인기침이어려워져흡인과흉부감염의빈도가증가한다 (Lanini 등, 2003). 호흡근의기능은환자의운동능력향상과운동에대한심장호흡계가정상적으로반응하는것에기여하는데, 이러한호흡근기능을개선시키기위해서는근력의증가가수반되어야한다. 따라서호흡근이손상되어호흡기능에부전이나타나면호흡근훈련이필요하다 (Sutbeyaz 등, 2010). 호흡훈련은호흡근이약화된환자에게호흡근의기능을향상시킬뿐만아니라 (Lee 등, 2009), 운동능력을증가시키고호흡곤란을개선시키고삶의질을향상시킬수있다 (Sutbeyaz 등, 2010). 가로막을포함한호흡근은형태적으로나기능적으로골격근이므로다른골격근처럼적절한생리적부하를이용한훈련에따라개선된반응을유도할수있다 (Enright 등, 2011). 그러므로대다수고령인뇌졸중환자에게노화와더불어증가할수있는흉부감염을예방하고기침의효율성을증가시킬수있는호기근및흡기근훈련에관한연구가필요하다고생각한다. 그러나현재까지뇌졸중환자의호흡기능향상을위한중재로흡기근강화훈련이강조되어왔다. Chiara 등 (2006) 은호기근훈련 (expiratory muscle training: EMT) 이신경학적질환인다발성경화증환자의최대호기압 (maximum expiratory pressure: MEP) 을증가시키고, 중등도의장애를갖고있는환자에게는최대수의적기침능력을개선시킨다고보고하였다. 따라서뇌졸중환자에게도포괄적인호흡기능을개선하고기침의효율성을높이기위해서는호기근저항훈련을함께실시하여야할것이다. 이에본연구의목적은뇌졸중환자의호흡기능과기침의효율성을개선시킬수있는호기근및흡기근훈련을실시하여, 그효과를폐기능, 호기근및흡기근근력, 기침능력을측정하여규명하는것에있다.

3 호흡근강화훈련이뇌졸중환자의호흡기능, 호흡근력과기침능력에미치는영향 401 Ⅱ. 연구방법 반적특성은 Table 1 에요약하였다. 1. 연구대상본연구는 P시소재에 ooo재활병원에서실시하였다. 컴퓨터단층화촬영이나자기공명영상에의해뇌졸중으로진단을받고 12개월이경과된편마비환자중 60세에서 75세이하의남녀노인 38명을대상으로하였다. 모든대상자는본연구의취지를이해하고자발적으로본연구에참여하기로동의한자로하였다. 연구대상자의참여기준은강제폐활량이정상예측치의 80% 미만으로제한성폐질환에해당하고, 한국형간이정신상태판별검사 (MMSE-K) 점수가 24점이상이고, 신경계재활을위한물리치료를받고있으나폐기능의향상을위해특별한치료를받고있지않고, 복부수술을시행하지않은대상자로하였다. 또한, 연구에서의제외기준은선천적흉곽의변형이나늑골골절및폐, 신장, 내분비계, 정형또는류마티스질환으로인해호흡기계훈련이불가능하거나, 부정맥이나협심증으로불안정한심혈관계상태를갖고있는자로하였다. 연구대상자는총 38명이었으나대상자중훈련프로토콜을제대로수행하지못한 4명에대상자를제외하고총 34명이연구에참여하였다. 대상자는실험군 17 명, 대조군 17명으로배치하였으며, 모든대상자의일 2. 일반적인물리치료본연구에참여한두집단모두에게뇌졸중환자를위한일반적인물리치료를 4주간주 5회 20 30분씩실시하였다. 3. 호흡근강화훈련프로토콜뇌졸중환자를위한호흡근강화훈련프로토콜은전문교육을받은치료사가실험군에게만추가적으로호흡근강화훈련프로토콜을 4주간주 3회실시하였다. 호흡훈련은흡기근저항훈련기 (Threshold Inspiratory Muscle Trainer, Respironics Inc., USA) 와호기근저항훈련기 (Threshold Positive Expiratory Pressure, Respironics Inc., USA) 를사용하여호기군훈련과흡기군훈련을각 3세트씩실시하며, 1세트는 3회반복하였다 (Chiara 등, 2006). 또한훈련전대상자의최대흡기압 (MIP) 과최대호기압 (MEP) 을측정후개별적으로훈련강도를설정하였으며, 훈련강도는개별적인운동반응에따라최대흡기압 (MIP) 과최대호기압 (MEP) 의 40%, 60%, 80% 3단계로저강도에서고강도로점증시키도록설계하였다. 호흡훈련의강도는호흡훈련을실시한후 Borg (1982) 의운동자각도측정에서 11점이하를나타낼경우강도를점증시켰으며, 대상자가어지러움이나혈압 Table 1. General characteristics of subjects (Mean±SD) Variable Intervention group Control group t or χ² p Sex (male/female) 8/9 8/ Paretic side (left/right) 7/10 8/ Age (years) 66.29± ± On set duration (months) 18.29± ± Hight (cm) ± ± Body weight (kg) 58.72± ± FVC (L) 1.71± ± MIP (mmhg) 20.41± ± MEP (mmhg) 23.94± ± PEF (L/min.) ± ± FVC: forced vital capacity, MIP: maximum inspiratory pressure, MEP: maximum inspiratory pressure, PEF: peak expiratory flow

4 402 J Korean Soc Phys Med Vol. 9, No. 4 상승등불편감을호소할때는훈련을중단하고강도를조절하였다. 4. 측정방법 1) 폐기능폐기능을측정하기위해폐활량계 (Pony Fx, Cosmed Srl, Italy) 를사용하였다. 정확한폐활량측정을위하여검사대상자가이해할수있도록충분한설명을하고시범을보여준다음고관절을 90 굴곡하여앉은자세에서실시하였다. 제한성폐질환의유무를확인하기위해노력성폐활량 (FVC) 을측정하였고, 폐쇄성폐질환를확인하기위해 1초간노력성호기량 (FEV 1) 을측정하였다. 또한, 1초간노력성호기량의노력성폐활량에대한비를이용하여폐쇄성폐질환의유무를판단하였고, 최대호기속도를측정하여기도저항을확인하였다 (Kim, 2011); American Thoracic Society, 1991). 그리고폐기능측정값은재현성이가장큰수치를사용하였다. 2) 호흡근의근력압력측정기 (Pony Fx, Cosmed Srl, Italy) 를사용하여올바른자세에서최대흡기압 (MIP) 과최대호기압 (MEP) 으로측정하였다. 정확한측정을위하여검사대상자가이해할수있도록충분한설명을하고시범을보여준다음고관절을 90 굴곡하여앉은자세에서실시하였다. 측정은총 3회측정하고재현성있는가장큰수치를선택하였다. 3) 기침능력기침능력은유럽과미국호흡기학회의측정변화기준에맞추어개발된최대호기량측정기 (Micro peak, Carefusion, UK) 를사용하여측정하였으며, 정확한측정을위하여검사대상자가이해할수있도록충분한설명을하고시범을보여준다음똑바로선자세에서실시하였다. 측정방법은눈금자를아래쪽으로맞춘다음, 일어서서깊게숨을들이마신후, 유속계마우스피스를 입으로물고입술로감싸게한다. 이때혀로구멍을막지않도록주의시키고. 할수있는한도내에서최대로힘껏빨리불도록하였다. 측정은총 3 4회반복측정하였으며측정간에는 1분간휴식을취한후측정하였다. 측정값은재현성이가장큰수치를선택하였다. 5. 통계분석및자료처리본실험에서수집된자료는 PASW statics for Windows (version 18.0) 를이용하여통계처리하였다. 각집단의중재전후의변화는 paired t-test로분석하고, 두집단간의전후변화량의차이는 independent t-test로분석하였다. 통계검정의유의수준 α = 0.05로정하였다. Ⅲ. 연구결과 1. 연구대상자의일반적특성본연구에참여한대상자들의일반적특성은 (Table 1) 과같으며실험전두집단의동질성을분석한결과연령과신장, 체중, 발병기간, 노력성폐활량 (FVC) 등의대상자의일반적특성과폐기능에서유의한차이가없었다. 2. 호흡기능과호흡근력에대한효과실험군에서중재후노력성폐활량 (FVC) 은유의하게증가하였지만 (p<.05), 대조군에서는유의한변화가없었다 (p>.05). 최대흡기압 (MIP) 과최대호기압 (MEP) 도실험군에서유의하게증가하였으나 (p<.05), 대조군에서는유의한변화가없었다 (p>.05). 실험전에는실험군과대조군사이에유의한차이가없었으나, 4주중재후노력성폐활량 (FVC) 과최대흡기압 (MIP), 최대호기압 (MEP) 에서두집단간의실험전후변화량에서유의한차이가있었다 (p<.05)(table 2). 3. 기침능력에대한효과실험군에서는중재후기침능력의유의한증가가나타났으며 (p<.05), 대조군에서는중재후기침능력의유

5 호흡근강화훈련이뇌졸중환자의호흡기능, 호흡근력과기침능력에미치는영향 403 Table 2. Comparisons of FVC, MIP, MEP, and PEF between intervention group and control group FVC (L) MIP (mmhg) MEP (mmhg) PEF (L/min.) Group Intervention Control Intervention Control Intervention Control Intervention Control Pre-test Post-test Post-Pre t p M±SD M±SD M±SD 1.71± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.92 t p FVC: forced vital capacity, MIP: Maximum inspiratory pressure, MEP: Maximum expiratory pressure, PEF: peak expiratory flow 의한감소가나타났다 (p<.05). 또한, 두집단간의실험전후기침능력의변화량에는유의한차이가있었다 (p<.05)(table 2). Ⅳ. 고찰대다수고령인뇌졸중환자는노화와더불어입원후오랜시간동안의침상생활로신체활동빈도가감소되어호흡기능저하가나타난다 (Kashihara 등, 1994). 그리고호흡근육의마비로인한호흡근육의약화로수의적기침능력이나객담제거능력이감소되며, 삼킴곤란과흡인의빈도가증가됨으로써기도내분비물이축적되어폐렴, 무기폐등의여러가지호흡기계합병증을일으킬수있다 (Fugl-Meyer 등, 1983; Martino 등, 2005). Kim (2011) 은뇌졸중환자를대상으로일반적인운동치료를 6주간주 5회 30분간실시한대조군과일반적인운동치료와함께 6주간주 3회 30분씩호흡훈련을 실시한호흡훈련군간의연구에서호흡훈련군에서는노력성폐활량 (FVC) 이유의한증가를보였지만, 대조군에서는훈련전후유의한차이를보이지않았다고보고하였다. 또, Sutbeyaz 등 (2010) 은아급성기뇌졸중환자를대상으로흡기근훈련군과호흡재교육훈련군, 대조군으로분류하고 6주동안주 6회의중재를적용한후에폐기능을비교하였는데흡기군훈련군에서노력성폐활량 (FVC) 의유의한증가가나타났다고보고하였다. 본연구에서는 4주간이라는짧은중재기간이었지만환자의호흡근력에따라저강도에서고강도로개별적으로점증시키며호흡훈련을실시한결과폐기능이향상되었다. 이러한결과는호흡훈련의기간은 4 12주, 빈도는주 2 5회, 훈련시간은 20 30분을실시해야효과가있다는연구 (British thoracic society, 2011) 를뒷받침한다. 최대흡기압 (MIP) 과최대호기압 (MEP) 은호흡부전평가나인공호흡기이탈여부를예측하는데사용되기도하지만, 신경근육질환자의흡기근력과호기근력을간접적으로측정하기위해자주사용된다 (Kim 등,

6 404 J Korean Soc Phys Med Vol. 9, No ). Sutbeyaz 등 (2010) 은아급성기뇌졸중환자를대상으로한 6주간의흡기근훈련이최대흡기압을향상시킨다고하였다. 또 Saleem 등 (2005) 은 4주동안특발성파킨슨환자에게호기근육강화훈련에서호기압능력의향상으로호기근력에미치는효과를제시하였다. 그리고 Lee (2013) 는만성뇌졸중환자에게 6주간주 5회일반적인운동치료를실시한대조군과일반적인운동치료와함께호흡재교육을주 5회 30분간실시한실험군사이에중재전후 MIP와 MEP 변화량에서유의한차이가있다고하였다. 그리고실험군에서 3주중재후보다 6주중재후 MIP와 MEP가유의하게증가하였다. 선행연구의결과와같이본연구에서도실험군에서중재 4주후 MIP와 MEP가유의하게증가하여중재전후의대조군과 MIP와 MEP의변화량을비교했을때유의한차이가있었다. 기침은감기등에의해분비물이생길때이분비물을외부로배출시켜폐렴등의합병증을발생하지않게하는우리몸의중요한보호기능이다 (Leith 등, 1968). Kim (2011) 은뇌졸중환자를대상으로일반적인운동치료를 6주간주 5회 30분간실시한대조군과일반적인운동치료와함께 6주간주 3회 30분씩호흡훈련을실시한호흡훈련군의기침능력 (PEF) 을비교하였다. 그결과호흡훈련군은중재후유의하게기침능력이증가하였으나대조군에서는유의한변화가없었다고하였다. 또한두집단간중재전후기침능력의변화량을비교한결과에서도유의한차이가있었다. 본연구에서도선행연구와유사하게실험군에서는 4주호흡훈련후기침능력이증가하였으나, 대조군에서는 4주후기침능력이감소하였다. 이러한대조군의기침능력의감소는본연구의대상자의연령이선행연구의대상자의평균과비교하여고령이기때문으로사료된다. 뇌졸중환자를대상으로한본연구에서 4주라는짧은중재기간에도불구하고개별적으로점증적인고강도훈련을실시한실험군에서호흡기능, 호흡근력, 기침능력이증가하였으나, 대조군에서는기침능력의감소하였다. 이를통해노인뇌졸중환자의기침능력은짧은기간에도감소가할수있다는것을확인하였고, 이러한기침기능의저하는흉부감염, 폐렴, 흡인과같 은문제를유발할수있는위험요인이될수있다. Jung (2013) 의뇌졸중환자를대상으로한선행연구를고찰한결과, 뇌졸중으로인해발생하는이차적손상으로운동수행능력과운동내성이감소하고호흡근의근력과협응저하로인해호흡기능이감소하는것을알았다. 본연구에서는이런문제들을해결하고자호흡근강화훈련을적용하였고, 짧은중재기간에도의미있는연구결과를확인하였다. 본연구결과를바탕으로뇌졸중환자의재활프로그램에호흡근강화훈련이긍정적인영향을미칠것으로사료된다. 앞으로의연구에서는더많은뇌졸중환자를대상으로호흡근강화훈련의장기간중재에따른예후변화에대한연구가이루어져야할것으로생각된다. Ⅴ. 결론본연구에서는뇌졸중환자에게 4주간의호흡근강화훈련이호흡기능, 호흡근력과기침능력에미치는영향에대해알아보았다. 그결과호흡근강화훈련으로실험군에서는호흡기능, 호흡근력과기침능력에서모두증가하였으나대조군에서는기침능력이감소하였다. 이처럼대부분의고령인뇌졸중환자에게호흡근강화훈련을하지않을경우기침능력감소와같은부정적양상을나타낼수있으며이런양상은또다른이차적문제들을야기할수있다고사료된다. 따라서뇌졸중환자에게호흡근강화훈련과같은중재가필요하다고생각된다. References American Thoracic Society. Lung function testing :selection of reference values and interpretative strategies. Am Rev Respir Dis. 1991;144(5): Addington WR, Stephens RE, Phelipa MM, et al. Intraabdominal pressures during voluntary and reflex cough. Cough. 2008;4:2.

7 호흡근강화훈련이뇌졸중환자의호흡기능, 호흡근력과기침능력에미치는영향 405 Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5): British Thoracic Society Standards of care Subcommitee on Pulmonary Rehabilitation. Pulmonry rehabilitation. Thorax. 2011;56(11): Britto RR, Rezende NR, Marinho KC et al. Inspiratory muscular training in chronic stroke survivors :arandomized controlled trial. Arch Phys Med Rehabil. 2011;92(2): Chiara T, Martin AD, Davenport PW, et al. Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Arch Phys Med Rehabil. 2006;87(4): De Almeida IC, Clementino AC, Rocha EH, et al. Effects of hemiplegy on pulmonary function and diaphragmatic dome displacement. Respir Physiol Neurobiol. 2011;178(2): Enright SJ, Unnithan VB. Effect of inspiratory muscle training intensities on pulmonary function and work capacity in people who are healthy: a randomized controlled trial. Phys Ther. 2011;91(6): Fugl-Meyer AR, Linderholm H, Wilson AF. Restrictive ventilatory dysfunction in stroke: its relation to locomotor function. Scand J Rehabil Med Suppl. 1983;9: Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(2): Jandt SR, Caballero RM, Junior, et al. Correlation betwwen trunk control, respiratory muscle strength and spirometry in patients with stroke. Physiother Res Int. 2011;16(4): Jung JH. The effects of inspiratory muscle training and mobilization with breathing retraining on respiratory function in patients with stroke. Department of physical therapy graduate school catholic university of pusan. Master s thesis Kashihara H, Haruna Y, Suzuki Y, et al. Effects of mild supine exercise during 20 days bed rest on maximal oxygen uptake rate in young humans. Acta Physiol Scand Suppl. 1994;616: Khedr EM, EI Shinway O, Khedr T et al. Assessment of corticodiaphragmatic pathway and pulmonary function in acute ischemic stroke patients. Eur J Neurol. 2000;7(3): Kim BR, Chun MH, Kang SH. Change of respiratory function following rehabilitation in acute hemiplegic stroke patients. Korean academy of rehabilitation medicine. 2009;33(1):21-8. Kim MH. The effects of respiratory function, trunk control and functional ADL following respiratory strength training in patients with stroke. Department of physical therapy graduate school sahmyook university. Master s thesis Lanini B, Bianchi R, Romagnoli I et al. Chest wall kinematics in patients with hemiplegia. Am J Respir Crit Care Med 2003;168(1): Lee MH. Effects of the neck stabilizing exercise combined with the respiratory reeducation exercise on breathing function in patients with stroke. Department of rehabilitation science graduate school daegu university. Doctor s thesis Lee JH, Kwon YJ, Kim k. The effect of chest expansion and pulmonary function of stroke patients after breathing exercise. The journal Korean society of physical therapy. 2009;21(3): Leith DE. Cough. Phys Ther. 1968;48: Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12): Saleem, A. F., C. M. Sapienza, et al. Respiratory muscle strength training: treat and response duration in a patient with

8 406 J Korean Soc Phys Med Vol. 9, No. 4 early idopathic Parkinson s disease. Neurorehabilitation. 2005;20(4): Smith Hammond CA, Goldstein LB, Horner RD et al. Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest. 2009;135(3): Sutbeyaz ST, Koseoglu F, Inan L et al. Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial. Clin Rehabil. 2010;24(3): Teixeira-Salmela LF, Parreira VF, Britto RR, et al. Respiratory pressures and thoracoabdominal motion in community-dwelling chronic stroke survivors. Archives of PMR. 2005;86(10): van der Palen J, Rea TD, Manolio TA et al. Respiratory muscle strength and the risk of incident cardiovascular events. Thorax. 2004;59(12): Widdicombe J, Fontana G. Cough: what s in a name? Eur Respir J. 2006;28(1):10-5.

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar