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1 Brain & N eurorehabilitation Vol. 2, No. 1, March, 2009 편측무시의치료 전북대학교의학전문대학원재활의학교실, 의과학연구소및임상의학연구소 고명환 Management of Neglect Myoung-Hwan Ko, M.D., Ph.D. Department of Physical Medicine and Rehabilitation, Institute for Medical Sciences and Research Institute of Clinical Medicine, Chonbuk National University Medical School A large number of patient with a nondominant parietal lobe brain lesion have visuospatial neglect of hemispace. This hemispatial neglect significantly contributes to disability after brain disease because it has a negative impact on self-care, mobility, learning, and safety awareness in itself and has been found to be associated with poor functional recovery from brain disease. Although numerous therapeutic methods of neglect has been studied, there was limited evidence to confirm the effect of those treatments for this complex and multifactorial syndrome. To promote understanding of neglect rehabilitation, in this review, the effectiveness and practical methods of several different types of therapies will be discussed. (Brain & NeuroRehabilitation 2009; 2: 51-56) Key Words: brain disease, neglect, rehabilitation 서론 Heilman 등 1 은편측무시 (hemispatial neglect) 를 failure to report, respond, or orient to novel or meaningful stimuli presented to the side opposite a brain lesion, when this failure cannot be attributed to either sensory or motor defects 라고정의하였다. 그러나 편측무시 (neglect) 는여러다양한병태생리적원인에의하여발생하며, 또한그증상도다양한양상으로발현되는일련의복합증후군이라할수있어서이를정확히정의하는것자체도쉽지않다. 편측무시는다양한형태의뇌질환에의하여발생되는데, 특히주로비우성반구 ( 우측대뇌반구 ) 에병변이발생하는경우동반된다. 우측대뇌반구의뇌졸중환자에서편측무시의발현율은 13 81% 로연구자들에따라다양하게보고되는데, 일반적으로우측대뇌반구뇌줄중환자의 2/3정도에서편측무시가동반되는것으로받아들여지고있다. 2,3 뇌줄중환자에서편측무시는근력의저하정도에비하여안거나서는자세에서균형을잡기어렵고, 낙상 교신저자 : 고명환, 전북전주시덕진구금암동 , 전북대학교병원재활의학과 Tel: , Fax: mhko@chonbuk.ac.kr 등의위험이증가하고, 일상생활수행시커다란장해를초래하게되어재활치료의효과를떨어뜨려최종적인기능의회복정도에크게저하시키는요인이된다. 4 따라서편측무시에대한적절한치료는재활치료프로그램에서매우중요한부분이라할수있다. 본종설에서는현재제시되고있는치료방법들을살펴보고그효과를분석한연구결과들을정리하여실제임상에서효과적으로적용할수있는치료방법은무엇이며그적용방법은어떠한지알아보고자한다. 본론 1) 치료전략수립편측무시는복합적인원인에의하여유발되므로그치료방법또한하나의정례화된치료방법에의하여이루어지는것이아니고다양한치료전략에따라여러가지의치료방법이시도되고있다. 이처럼여러방법들이시도되고있다는것은그만큼편측무시에대한치료가쉽지않다는것을말해주는것이라할수있다. 교과서나논문에발표되는종설들을살펴보면, 아직까지도발표자들에따라편측무시의치료방법을정리하는데있어서 카테고리 를분류하는방법자체도큰차이들을보이고있다. 그중에서 Pierce 등 5 이 2002년에발표한편측무시에대한치료방법의분류가이해가쉬울것으로생각되어소개 51

2 Brain& NeuroRehabilitation:2009; 2: 51~56 하면다음과같다. I. Treatments Targeting Arousal Deficits 1) Dopamine agonist therapy 2) Phasic alerting treatment II. Treatments Targeting Deficient Visual Attention Scanning treatment with/without computer III. Treatments Targeting Spatial Representation Deficits 1) Hemispheric activation approaches 2) Constraint-induced therapy 3) Treatments targeting intact dorsal stream function 4) Mental imagery training 5) Prism treatment 6) Eye patching and hemispatial glasses 7) Caloric stimulation 8) Optokinetic stimulation 9) Neck vibration therapy 10) Trunk rotation therapy 반면, Barrett 등 6 은편측무시치료에대한몇가지다른개념의분류방법을기술하였다. 첫번째분류방법은치료의메커니즘을 top-down 과 bottom-up 개념으로나누는것으로, top-down 은스캐닝치료법 (scanning treatment) 이대표적인방법으로, 환자로하여금강제적이고능동적으로무시측을계속보도록훈련하는방법으로이때외부적인자극이나도움을줄수도있고주지않을수도있다. bottom-up 접근은외부의환경에변화를주어재인식이되도록하는방법으로대표적인예로환자의병상을재배치하여모든간호를환자의무시측에서해주는방법이다. 또다른분류방법은 endogenous 와 exogenous 로치료자이외에는특별한도구나재료를사용하지않고이루어지는치료를 endogenous 로분류하고특별히제작된도구나재료를사용하는치료법들은 exogenous 방법으로분류하였다. 이외에도여러또다른분류방법이제시되기도하는데, 7,8 이처럼현재사용되고있는치료방법들도그치료효과가어떠한메커니즘에의하여발현되고있는지조차아직정립되어있지않은실정이다. 편측무시의치료효과를극대화하기위해서는현재환자가가지고편측무시의유형 (subtype) 을잘파악하여주문제점이무엇인지를찾아낸후이에맞는적절한치료방법을선택실시하는것이중요하다하겠다. 2) 약물치료편측무시에대한약물치료는주로각성 (arousal) 을증진시키기위한목적으로사용되는데, 대표적으로도파민제 제와노르아드레날린제제가사용된다. 5,6,9 연구자에따라차이는있지만, Bromocriptine (15 30 mg/day), Apomorpine (2 mg/day), Methylphenidate (20 mg/day), Carbidopa/ Levodopa, Amantadine 등이효과적인것으로발표되고있고, 더불어글루타메이트제제, 세로토닌제제등도효과가있다는보고가있다. 5,9 이러한약제들은 Corticolimbic-reticular pathway 를활성화시키므로써그효과가나타나는것으로생각되어지고있다. 19 3) 각성 (Arousal) 및주의력 (Attention) 증진각성과주의력을증진시키는방법으로는무시측에대하여외부적인청각, 시각적인자극을주는방법을사용하거나또는치료실에서고식적방법이나컴퓨터를이용하여시각적스캔닝을증진시키는치료방법들이효과적으로시도되고있다. 5,6,20,21 스캐닝치료법은특별한치료도구없이간단한 paper-and-pencil task 만을이용하여치료자의도움하에고식적으로이루어지고있는대표적인치료방법으로현재까지도널리사용되고있다. 그러나이러한방법들은치료전후단기적으로편측무시검사상에는호전을보이지만장기적인효과나실제생활에서의호전에대한효과는아직불분명하다. 6,20,21 4) Spatial representation 증진또다른치료접근법은무시측의 representation 을증진시키는방법이다. 이를위하여다양한치료방법들이시도되고있는데, 마비측의상하지에대한자극을통하여우측대뇌반구의활성화를유도하는방법과마비측에대한다양한자극기법 (Caloric stimulation, Optokinetic stimulation, Neck vibration, Electrical stimulation of neck) 을통한치료방법, 그리고눈가리기법을이용하여무시측으로시야를유도하는방법, 프리즘을이용하여무시측의 representation 이좋아지도록하는방법들이있다. 건측 ( 우측 ) 억제운동치료도편측무시를호전시키는것으로알려져있다. (1) 경부자극 (Neck vibration, Neck electrical stimulation): 경부자극법의효과는무시측에대한단순한외부자극으로주의력이향상되어효과가나타나는것이아니고, 무시측공간의 representation 의증진을유도함으로써효과를나타내는치료방법이다. 즉, 목뒤쪽의좌측에만진동또는전기자극을가하면좌측후경부근육의길이가변화되어근방추체를활성화시킴으로써체내에서머리와몸의균형및위치감각에변화가유도되어인체는자기의몸이반대편 ( 우측 ) 으로편향되어있다고느끼게되고스스로중심선을동측 ( 좌측 ) 으로이동하는것으로알 52

고명환 : 편측무시의치료 려져있다. 22-25 따라서좌측편측무시환자에서좌측의후경부에진동이나전기자극을실시하면좌측에대한시공간지각이증가되는치료효과를볼수있다는연구결과들이발표되고있다. 5,9,20 (2) 눈가리기법 : 안대나안경을이용하여우측의시야를가리는방법이편측무시의치료방법의하나로임상에서많이사용되어지고있다.

26 또한눈의편측주시는상측소구 (superior colliculi) 의자극에의하여일어나는데이는반대측성으로우측상측소구가자극되 면좌측으로편측주시가일어나고좌측상측소구가자극되면우측으로편측주시가일어난다. 따라서 Fig.

5,20,21,28 이치료방법역시무시측 ( 좌측 ) 의감소된 representation 을증진시키는방법이다. 즉, Fig. 2에서보는바와같이좌측이두꺼운프리즘안경을착용하면시공간이우측으로편향되어보이므로인체는이를보상하기위하여중심선을좌측으로이동하게되고, 이러한효과는프리즘안경을벗고난이후에도일정기간지속되게된다.

3 고명환 : 편측무시의치료 려져있다 따라서좌측편측무시환자에서좌측의후경부에진동이나전기자극을실시하면좌측에대한시공간지각이증가되는치료효과를볼수있다는연구결과들이발표되고있다. 5,9,20 (2) 눈가리기법 : 안대나안경을이용하여우측의시야를가리는방법이편측무시의치료방법의하나로임상에서많이사용되어지고있다. 우측의시야를가리는방법은크게두가지로오른쪽한쪽눈전체를가리는방법 (single-eye patching) 과양쪽눈의오른쪽시야절반을각각가리는방법 (hemifield patching) 이일반적으로사용되고있다. 지금까지의연구들에의하면, 우안만전체가리는방법은거리감이상실되어환자에게불편감을주며그효과도미흡하기때문에양안의오른쪽시야절반을가리는방법이더효과적인것으로발표되고있다. 26 또한눈의편측주시는상측소구 (superior colliculi) 의자극에의하여일어나는데이는반대측성으로우측상측소구가자극되 면좌측으로편측주시가일어나고좌측상측소구가자극되면우측으로편측주시가일어난다. 따라서 Fig. 1에서보는바와같이우안만가리는경우 (B) 보다는양안의우측시야를모두가리는경우 (C) 에우측상측소구가좀더선택적으로자극되어좌측주시를효과적으로이끌어낼수있는것으로설명하고있다. 27 (3) 프리즘안경 : 편측무시의치료에관한연구들에서가장많이다루어지고있고그효과도충분히입증되고있는치료방법중의하나가프리즘안경치료라할수있다. 5,20,21,28 이치료방법역시무시측 ( 좌측 ) 의감소된 representation 을증진시키는방법이다. 즉, Fig. 2에서보는바와같이좌측이두꺼운프리즘안경을착용하면시공간이우측으로편향되어보이므로인체는이를보상하기위하여중심선을좌측으로이동하게되고, 이러한효과는프리즘안경을벗고난이후에도일정기간지속되게된다. 1998년 Rossetti 등 29 이 12명의편측무시환자에게 5분간 Fig. 1. Effects of using an eye patch on spatial neglect. Singleeye patching of right eye (B) and right hemifield patching (C) (From Swan L. Unilateral spatial neglect. Phys Ther 2001;81: ). Fig. 2. Leftward effects of rightward prism therapy (From Parton A, Malhotra, Husain M. Hemispatial neglect. J Neurol Neurosurg Psychiatry 2004;75:13-21). 53

4 Brain& NeuroRehabilitation:2009; 2: 51~56 프리즘안경을착용시킨후그효과가 2시간까지지속되었다는프리즘안경치료의효과를발표한이래많은연구들이이루어졌는데, 특히그효과가장기적으로지속된다는연구결과들이발표되고있다. Frassinetti 등 30 은우측대뇌반구에병변이발생한환자들에게 20분간프리즘안경을착용하고보상훈련을실시하였는데, 하루 2회씩총 2주간시행한후, 치료종료후 5주째까지치료효과가지속됨을보고하였다. 5) 최신치료방법최근에는가상현실을이용한치료효과가발표되고있다. 31,32 가상현실치료방법은실제생활을재연하면서치료효과를얻고자하는것으로편측무시의복합적인원인과양상에상관없이환자의실생활기능회복에직접적인도움이되도록하는것을목표로개발되고있다. 몇몇연구들에서긍정적인치료결과들이발표되고있으나, 좀더많은연구가필요하다하겠다. 또한최근대뇌피질의활성도를조절하여기능의호전을이루고자하는새로운치료방법인비침습적뇌자극방법이편측무시회복에도시도되고있다. 이중에서반복경두개자기자극 (repetitive transcranial magnetic stimulation, rtms) 방법을이용한연구결과가보고되고있는데, 고빈도 (5 Hz 이상 ) 의 rtms는대뇌피질의활성도를증가시키고저빈도 (1 Hz 이하 ) 의 rtms 는활성도를감소시킨다는연구결과를토대로고빈도의 rtms를손상측 ( 우측 ) 대뇌반구의두정엽에가해주거나저빈도의 rtms를비손상측 ( 좌측 ) 에가하여방법을통하여대뇌활성도의균형을회복함으로써편측무시증상을호전시키는연구들이이루어져긍정적인결과들이발표되고있다 반복경두개자기자극과유사한효과를가지고있는경두개직류전류자극도최근시도되고있는데아직까지는발표된연구결과는매우적다. 본저자등은편측무시를보이는뇌졸중환자를대상으로대뇌피질의활성도를증가시키는것으로알려진양극의직류전류를 2 ma 강도로 20분간좌측두정엽에실시하여선나누기검사와모양지우기검사에서의미있게호전되는결과를얻어최근발표하였다. 37 6) 치료시고려사항반면, 편측무시의치료과정중에는몇가지주의하고고려해야할사항있다. Barrett 등 6 은편측무시환자의치료과정중에는편측무시를유발하거나악화시킬수있는약물의사용여부를반드시점검하라고제안하고있다. 특히, 도파민차단제, 진정제, 항불안제, GABA제제, 벤조다이아제핀, 항콜린제등이편측무시를조장할수있는중요약물 이므로치료중에이러한약물의사용에대하여주의를기울여야한다. 또한, 자극박탈 (stimulus deprivation) 에의하여도편측무시가악화될수있다. 예를들어무시측의상하지에부종치료를위하여탄력스타킹을오래착용하거나보조기의무분별한착용도편측무시를조장하는것으로알려져있다. 더나아가, 현재치료방법으로사용되고있는것중에도이러한자극박탈로인하여오히려무시현상을조장할수있는데, 눈가리치료법을시도한후오히려무시현상이더악화되었다는보고가있다. 38,39 이외에도앞서제시한치료방법들을잘못적용하였을경우도부정적인결과가초래될수있으므로치료과정중에는항상효과에대한평가-재평가가이루어져야한다. 결론 편측무시에대한치료는, 지금까지발표되고있는객관적인치료효과분석에대한논문들을종합해보면, 비우성 ( 우측 ) 대뇌반구손상환자는반드시 perception 을회복증진시키는치료가필요하며포괄적재활치료에의하여의미있게호전될수있는것으로확인되고있다. 40 그러나, 각각의치료법들은그한가지방법만으로는효과에대하여충분한증거가부족하기때문에, 여러가지치료방법들이포괄적으로적절히프로그램밍되어이루어져야할것이다. 즉, 편측무시는복잡한신경병태생리에의하여유발되므로실제임상에서는이를치료하기위하여환자에게가능한많은치료방법들을다양하게적용하여적극적으로치료하고자하는노력이중요하다고말할수있겠다. 또한올바른치료방법의선택및치료효과의분석을위해서정확한편측무시평가방법의개발역시중요한과제라할수있다. 참고문헌 1) Heilman KM, Watson RT, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E, eds. Clinical Neurospychology. 2nd ed. New York: Oxford Univ Pr; 1985: ) Stone SP, Wilson B, Wroot A, Halligan PW, Lange LS, Marshall JC, Greenwood RJ. The assessment of visuo-spatial neglect after stroke. J Neurol Neurosurg Psychiatry. 1991; 54: ) Bisiach E, Perani D, Vallar G, Berti A. Unilateral neglect: personal and extra-personal. Neuropsychologia. 1986;24: ) Roth EJ, Harvey RL. Rehabilitation of stroke syndromes. In: Braddom RL, ed. Physical Medicine & Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders; 2000;2:

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975_983 특집-한규철, 정원호

975_983 특집-한규철, 정원호 Focused Issue of This Month Gyu Cheol an, MD Department of Otolaryngology ead & Neck Surgery, Gachon University of College Medicine E - mail : han@gilhospital.com Won-o Jung, MD Department of Otolaryngology