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1 J Korean Soc Phys Med, 2015; 10(1): Online ISSN: Print ISSN: X Research Article Open Access 흉곽확장저항운동이뇌졸중환자의흉곽가동범위와최대흡기압에미치는영향 김창범 최종덕 1 대전대학교대학원물리치료학과, 1 대전대학교자연과학대학물리치료학과 Effects of Chest Expansion Resistance Exercise on Chest Expansion and Maximal Inspiratory Pressure in Patients with Stroke Chang-Beom Kim, PT, MSc, Jong-Duk Choi, PT, PhD 1 Department of Physical Therapy, Graduated School of Daejeon University 1 Department of Physical Therapy, College of Natural Science, Daejeon University Received: October 16, 2014 / Revised: November 21, 2014 / Accepted: December 3, 2014 c 2015 J Korean Soc Phys Med Abstract 1) PURPOSE: This study compared the effects of chest expansion resistance exercise (CERE) and breathing retraining (BRT) on stroke patients chest expansion and maximal inspiratory pressure(mip), thereby intending to present an effective intervention method for enhancing their respiratory functions. METHODS: The subjects were 30 stroke patients and randomly and equally assigned to a CERE group (10), a BRT group (10), and a control group (10). The intervention was applied to each group five times per week, 30 minutes per each time, for six weeks. A tapeline was used to measure upper and lower chest expansion and MIP prior to and after the intervention and the results were compared. RESULTS: After the intervention, the upper and lower Corresponding Author : choidew@dju.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. chest expansion was considerable in the CERE group (p<.01), significant in the BRT group (p<.05) but was not significant in the control group (p>.05). According to the post-hoc test result, the upper and lower chest of the CERE group and the BRT group significantly expanded compared to that of the control group (p<.05) and the upper and lower chest of the CERE group statistically significantly expanded relative to that of the BRT group (p<.05). According to the MIP evaluation result, the CERE group saw considerable improvement (p<.01) and the BRT group underwent significant changes (p<.05), but there were no significant changes in the control group (p>.05). The post-hoc test result was that the CERE group and the BRT group saw significant improvement compared to the control group (p<.05) and the CERE group experienced statistically significant enhancement relative to the BRT group (p<.05). CONCLUSION: As an intervention for respiratory function improvement, CERE is considered effective for strengthening respiratory muscles and promoting chest expansion through manual resistance by a therapist. Key Words: Chest expansion, IMT,PNF, Stroke

2 Ⅰ. 서론뇌졸중은국소부위폐쇄또는출혈에의하여발생되며, 인지장애, 언어장애, 감각장애, 운동장애등다양한신경학적장애를발생시키는질환중하나이다 (Mercier 등, 2001). 뇌졸중환자들은움직임감소와비대칭적신체정렬등의이유로폐용량및흉곽의움직임감소등이발생하며, 그결과로인하여원활한산소전달이이루어지지못하기때문에, 활동시필요한에너지를생성하기힘들어진다 (O Sullivan와 Schmitz, 2007). Teixeira-Salmela등 (2005) 은동일한연령대의정상인에비하여뇌졸중환자들의호흡근력과하복부활동력의감소를보인다고하였다. 뇌졸중환자의호흡기능감소는손상초기 6개월동안크게나타나지않으나, 그이후로운동손상의정도에따라심각한기능감소를보이며, 이러한호흡기능의주요원인은근약화, 저긴장성, 그리고체간근의비협응으로인한흉곽확장의운동제한이다 (Annoni등, 1990). 또한흉곽가동범위의감소로인하여폐의탄력성역시제한되며, 그로인해호흡기능에문제를일으키게된다 (Fugl-Meyer 등, 1983). 이처럼흉곽의운동성은중요한호흡기전의요소이다. 흉곽의운동성증진은호흡근의원활한수축을유도시킴으로인하여호흡조절능력향상, 기침능력향상, 폐활량증진, 신체정렬등에긍정적인영향을미치기때문에, 호흡기능과흉곽의운동성은밀접한상관관계를가진다 (Jennifer와 Prasad, 2008). 기존의연구에의하면뇌졸중환자는비슷한연령의건강인과비교하여최대흡기압 (maximal inspiratory pressure; MIP) 이유의하게감소되었으며, 평상시호흡하는동안흉곽의움직임역시유의하게감소한경향을보였다 (Teixeira- Salmela등, 2005). Sutbeyaz등 (2010) 의연구에서의하면, 뇌졸중환자의호흡기능향상은호흡근의기능과더불어운동능력의향상, 그리고삶의질에긍정적인영향을준다고하였으며, 뇌졸중환자의호흡기능향상을위한연구가계속이루어져야한다고하였다. 호흡기능향상을위한중재중호흡재교육훈련 (breathing retraining exercise; BRT) 은입술을오므린호흡과횡경막호흡이결합된운동으로서횡경막위치의 정상화, 호흡장애감소, 호흡횟수감소, 호기시기도의압력감소, 흉곽의움직임증진, 환기기능증진, 운동수행능력증진의목적을갖는운동이다 (Troosters등, 2005). 고유수용성신경근촉진법 (proprioceptive neuromuscular facilitation, PNF) 의호흡운동은흉곽의가동범위를증진시키고횡경막과더불어중요호흡근의근력을증진시킴으로써최대흡기압과최대호기압의증진등호흡기능향상을목적으로하는운동이라고하였으며 (Adler 등, 2014), 이러한 PNF 호흡운동은호흡기능향상에매우효과적인중재방법이라고하였다 (Seo와 Cho, 2014). 뇌졸중환자의호흡기능의감소는일반적으로발생하는문제점이며, 이에따른호흡기능증진은중요한치료목표로여겨지고있으나, 현재흉곽의가동범위증진과최대흡기압증진등의같은목적을가지는중재방법인 BRT와 PNF의호흡운동을기초로한흉곽확장저항운동 (Chest Expansion Resistance Exercise; CERE) 의효과를비교한연구는없다. 따라서본연구의목적은 BRT와 CERE가뇌졸중환자의흉곽확장과 MIP에미치는효과를비교하여, 임상에서뇌졸중환자에게호흡기능증진을목적으로중재시보다효과적인방법을제시하고자하였다. Ⅱ. 연구방법 1. 연구대상본연구는 2014년 4월 10일부터 7월 13일까지용인시소재의 B재활요양병원에서실시하였다. 실험참가자는뇌졸중으로진단받은후 6개월이상경과된편마비환자중흡기근약화가있는자 ( 기대 PImax< 80%), 방사선검사및흉부이학적소견에서폐질환이없는자, 지시하는내용을이해하고따를수있는한국형간이정신상태판별검사 (MMSE-K) 점수가 24점이상인자를대상으로본연구에대한취지와과정에관하여설명을통해자발적으로동의한 30명을대상으로하였다. 연구대상자는 CERE 군 10명, BRT군 10명, 대조군 10명으로무작위배정하여진행하였다.

3 2. 연구도구및측정방법 1) 흉곽가동범위흉곽의가동성을평가하기위하여흉곽확장검사를시행하였다. 검사는바로선자세에서줄자를사용해상부, 하부흉곽에서최대호기와최대흡기시의흉곽둘레의길이를측정하여, 그차이를측정값으로사용하였다. 상부흉곽확장평가는쇄골중섬선과3번째늑간공이만나는지점, 그리고 5번째흉추극돌기에측정펜으로각각표시하고줄자를지면과평행하게연결하여호기측정후흡기동안팽창정도를측정하였다. 하부흉곽확장평가는측정펜으로 10번째흉추극돌기와검상돌기를표시하고, 표시된두점을줄자를이용하여지면과평행하게연결하여호기측정후흡기동안팽창정도를측정하였다 (Susan 등, 2007). 각각의측정은실험전 후맹검실험자가총 3회측정한후평균값을이용하여분석하였다. 2) 최대흡기압최대흡기압을측정하기위하여 MicroRPM(Micromedical Ltd. UK) 을사용하였으며, 환자는의자에바로앉은자세에서측정하였다. 흡기시마우스피스를최대한입에밀착시키고, 코마개를이용하여압력의손실을최대한줄인상태에서, 대상자는마우스피스를입에물고최대로흡기하였을때측정된값을이용하여분석하였다. MIP 역시실험전 후맹검실험자가총 3회를측정한후평균값을이용하여분석하였다. 3. 중재방법 1) 흉곽확장저항운동대상자는환측을위로하여옆으로누운자세를취한다. 치료사는대상자의머리에서대상자의발을보며선상태를기준으로 6시와 1시의연장선위에위치한다. 치료사의손의위치는측면흉곽중심부위의정점을기준으로전 후면의늑골을감싸듯이촉진하여, 대상자가호기한후흡기를시작으로치료사는촉진한부위 에저항을제공하였다. 이때저항은환자의흡기를방해하지않는범위내에서최대의저항을제공하였으며, 저항의방향은대상자의흉곽움직임과반대방향인꼬리뼈방향으로적용하였다. 환자가흡기후호기동안에도 숨을천천히내쉬세요 라는구두지시와함께지속적인저항을제공함으로써환자의적극적인호흡운동을유도하였다 ( 그림 1). 운동은 1세트가 15회로총10 세트를시행하였으며, 준비 정리운동 2세트, 각세트가끝난후 30초간의휴식시간을제공하여총 30분간실시하였다. 2) 호흡재교육훈련호흡재교육훈련은대상자가바로누운자세에서체간전체를이완시킨후한손은흉골중간부위에, 그리고나머지한손은횡격막부위를촉진한다. 그후흡기동안횡격막위에촉진한손을밀며상복부가팽창하게유도한후호기동안오므린입술로천천히상복부가하강하게하였다. 이때흉골위에위치한손으로최대한흉골의움직임이일어나지않도록집중하게하였으며, 흡기와호기의시간적비율은 1:2가되도록하였다 (Jones 등, 2003). 운동은 1세트가 15회로총10세트를시행하였으며, 준비 정리운동 2세트, 각세트가끝난후 30초간의휴식시간을제공하여총 30분간실시하였다. CERE군과 BRT군모두중재시어지러움, 매스꺼움, 피로등을호소하면충분한휴식을취한후증상이사라지면다시운동하였으며, 대조군은CERE군과 BRT군이각각의운동을시행하는동일한시간동안흉곽확장과최대흡기압에영향을미치지않는전동하지운동기를이용하여수동운동을수행하였다. 각그룹은 1회 30분, 주 5회, 6주동안각각의중재를시행하였으며, 모든그룹의참여자는신경계물리치료, 작업치료등일반적인재활치료를병행하였다. 4. 분석방법본연구에서수집된자료들은 SPSS ver. 18.0을이용하여통계처리하였다. 연구대상자의일반적인특성은기술통계를이용하

4 Table 1. General characteristics of the subjects CERE b (n 1=10) BRT c (n 2=10) Control(n 3=10) Age (year) 65.40±3.21 d 67.10± ±3.60 Gender (male/female) 5/5 6/4 4/6 Height (cm) ± ± ±6.10 Weight (kg) 69.39± ± ±7.50 Time since stroke (month) 30.90± ± ±4.70 Body mass index 25.41± ± ±2.63 MIP a (%predicted) 71.12± ± ±5.01 a maximum inspiratory pressure, b chest expansion resistance exercise, c breathing retraining, dmean±standard deviation. Table 2. Comparison of chest expansion in the three group Upperchest Expansion(cm) Lower chest Expansion(cm) CERE a (n 1=10) BRT b (n 2=10) Control(n 3=10) Pre 2.35±0.97 c 2.2± ±0.41 Post 4.15± ± ±0.93 p 0.00 *,** 0.01 * 0.59 Pre 2.15± ± ±0.44 Post 3.7± ± ±0.44 p 0.00 *,** 0.00 * 0.68 a chest expansion resistance exercise, b breathing retraining, c mean±standard deviation * significant difference with control group, ** significant difference with breathing retraining groupand control group. 여평균과표준편차를표시하였고, 정규성검정을위하여사피로-윌크 (Shapiro-Wilk) 검정방법을실시하였다. 각군에서치료전 후의 upper, lower thoracic excursion과 MIP 차이를비교하기위해대응표본 t-검정 (paired t-test) 을실시하였다. 세군의중재방법에따른결과차이를비교하기위해중재전, 중재후, 전 후변화량을일원배치분산분석 (one-way ANOVA) 방법으로검정하였고, 사후분석으로 Scheffe분석을사용하였다. 통계학적유의수준 α는.05로하였다. Ⅲ. 연구결과 1. 연구대상자의일반적특성본연구에참여한대상자는 CERE군 10명, BRT군 10명, 대조군 10명으로총 30명이참여하였으며, 연구 대상자의일반적인특성은 Table 1과같다. 모든항목에서각그룹간유의한차이는없었다 (p>.05). 2. 흉곽확장의실험전 후비교상부흉곽확장의중재전 후비교결과 CERE군과 BRT군은유의한차이를보였으나 (p<.05), 대조군은유의한차이를보이지못하였다 (p>.05). 하부흉곽확장전 후비교역시결과 CERE군과 BRT군은중재전 후유의한차이를보였으나 (p<.05), 대조군은유의한차이를보이지못하였다 (p>.05). 더불어 CERE군은상부, 하부흉곽확장전 후비교에서매우큰향상을보였다 (p<.01). 사후검정결과 CERE군과 BRT군은대조군과비교하여유의한향상을보였으며 (p<.05), BRT군과비교하여 CERE군은통계적으로유의한향상을보였다 (p<.05)(table 2).

5 Table 3. Comparison of maximum inspiratory pressure in the three group CERE b (n 1=10) BRT c (n 2=10) Control(n 3=10) Pre 53.30±7.42 d 49.20± ±4.85 MIP a (cmh 2O) Post 70.20± ± ±3.82 p 0.00 *,** 0.01 * 0.76 a maximum inspiratory pressure, b chest expansion resistance exercise, c breathing retraining,dmean±standard deviation, * significant difference with control group, ** significant difference with breathing retraining group and control group. 3. 최대흡기압의실험전 후비교최대흡기압의중재전 후차이를비교한결과 CERE 군과 BRT군은유의한차이를보였으나 (p<.05), 대조군은유의한차이를보이지못하였다 (p>.05). 그리고 MIP 또한 CERE군은매우큰향상을보였다 (p<.01). 사후검정결과대조군과비교하여 BRT, CERE군모두유의한차이를보였으며 (p<.05), BRT군과비교하여 CERE군이더유의하게향상하였다 (p<.05)(table 3). Ⅳ. 고찰 Fig. 1. Chest expansion resistance exercise 본연구는뇌졸중환자를대상으로 CERE와 BRT가흉곽확장과 MIP 증진에미치는효과를비교하였다. 호흡에있어서필수적인근육은흉골주위의내늑간근, 외늑간근, 사각근, 횡경막이있다. 이중횡격막은흡기중복근의받침대역할을하여흉곽의확장운동을원활하게하며, 호기중에는복압을증가시켜흉곽이원위치로돌아가는것을용이하게해주는등흉곽의움직임에매우중요한역할을한다 (Celli, 1994). 또한흉곽의운동성이감소한상태로지속된다면비대칭적인체간정렬을이루게되며, 이결과로인하여호흡기능에중요한역할을차지하는횡경막역시비대칭적인정력을이루게됨으로써호흡기능에부정적인결과를초래하게된다 (Hauge, 1973). 이처럼호흡에있어서흉곽의움직임은매우중요한부분을차지하며, 흉곽의운동감소는호흡기능에부정적인영향을미치게될것이다. 일반적인편마비뇌졸중환자들은마비측의늑간근, 복부근육과횡경막의부분적또는전체적인약화가있다고보고되었으며 (Przedborski등, 1988; Sutbeyaz, 2010), 가벼운운동중에도가쁜숨을쉬며, 정상적이지못한호흡패턴을가지고있다 (Nebahat등, 2004). 더불어호흡근의기능부전과운동장애점수 (motor disability scores) 는통계적으로유의한연관성이있다고증명되었다 (Khedr등, 2000). 이러한연구결과는호흡근의근력과흉곽확장정도가뇌졸중환자의호흡기능과밀접한연관성이있음을증명해주었으며, 흉곽확장의증가는호흡기능이향상되었음을반증하는근거가될것이다. 뇌졸중환자의호흡기능의감소는여러가지원인이있지만흡기용량, 최대흡기용량 (Roth EJ와 Noll SF, 1994) 과더불어호흡근의근력약화, 흉곽의가동범위감소가주된원인으로생각된다고하였다 (Przedborski 등, 1988). 따라서본연구는뇌줄중환자를대상으로하여흉곽확장의증가를중요한치료목적으로포함하는중재방법인 CERE와 BRT가뇌졸중환자의흉곽확

6 장에미치는효과를비교하고, 더불어그에따른 MIT의변화를측정하여호흡근의근력변화를비교하였다. 흉곽의확장가동범위평가를위하여상부, 하부흉곽확장을평가하였다. CERE군은대조군에비하여두가지평가에서모두유의한향상을보였으며, 이러한결과는 PNF 호흡운동이흉곽의가동범위를증가시킨다는내용을증명하는근거가될것이다 (Adler 등, 2104; Voss 등, 1985). BRT군역시두가지평가에서모두 control group에비하여유의하게증가하였으며, 이는비록폐쇄성폐질환환자를대상으로진행되었던연구지만 BRT가흉곽의움직임을증가시킨다는내용과같은결과를보여주었다 (Troosters등, 2005). 하지만사후검정결과 CERE군이 BRT군에비하여통계적으로더유의한향상을보여주었다. 이러한결과는뇌졸중환자의흉곽가동범위증진을목적으로중재를제공할때 CERE가 BRT보다더효과적이라는것을증명하였다. MIP 평가에서역시 CERE군과 BRT군이대조군에비하여통계적으로유의하게향상되었다. BRT군이대조군과비교하여유의한향상을보였다는결과는, 입술을오므린호흡과횡경막호흡운동을통하여호흡기능증진을이룬다는 BRT의목적과부합한다 (Troosters 등, 2005). 하지만 MIP 역시사후검정결과 CERE군이 BRT 군에비하여유의한향상을보였다. 비록정상인을대상으로진행된실험이었지만탄력저항밴드와결합된 PNF의호흡재활운동은호흡기능향상에효과적이며, 특히 MIP와 MEP 증진에매우효과적이었다는결론은본연구의결과를지지해줄것이라고생각된다 (Gluckman과 Heymann, 1996). 원활한흉곽의운동성은최대흡기압과최대호기압, 흡기용량, 노력성폐활량과결합되기때문에, 호흡근의근력과더불어폐의기능과연관성이깊다고하였으며 (Lanza등, 2013), 일차섬유근육통을대상으로한연구에서흉곽확장의감소는호흡근력의감소로인한최대흡기, 호기압과관련이있을것으로보인다 (Özgöçme과 Ardicoglu, 1999). 또한만성뇌졸중환자가비슷한연령의건강인과비교하여최대흡기압과흉곽확장등의능력이감소되어있다는결과는 (Teixeira-Salmela 등, 2005), 최대흡기압과흉곽확장의연관성을반증하는 것으로서, 흉곽가동범위평가에서 BRT군보다더큰증가를보인 CERE군이최대흡기압평가에서더큰변화를보인결과를지지해줄것으로생각된다. 더불어만성폐쇄성폐질환환자를대상으로한연구에서, 폐기능과흉곽의확장가동범위개선에있어서흉벽확장운동이효과적이라는연구결과 (Leelarungrayub 등, 2009) 와동일한결과를보여주었다. 본연구의결과뇌졸중환자의흉곽확장과최대흡기압증진을위하여 CERE가 BRT보다더큰개선이있었음을증명하였으며, 이는치료사의도수저항에의한 CERE가 BRT보다더욱효과적인것을증명한결과라고생각된다. 또한BRT군역시흉곽확장과최대흡기압측정결과대조군에비하여통계적으로유의한증진을보임으로서 BRT의효과역시증명하였다. 본연구는중재를시행하는치료사의경험이나역량에따라서 CERE의효과가다르게나타날수있다는제한점이있으며, 대상자수가적어서일반화하는데어려움이있다. 따라서앞으로의연구에서는더많은대상자에게 CERE의효과를연구할필요가있을것이며, CERE를더욱정량화할필요가있을것으로사료된다. Ⅴ. 결론뇌졸중환자의호흡기능저하는일반적인증상이며, 그에따른적극적인중재가필요하지만임상에서는간과되고있는현실이다. 본연구는이러한상황을기반으로뇌졸중환자의호흡기능증진을위한중재를시행할때보다효과적인방법을제시하고자시행되었다. 본연구의결과 CERE군과 BRT군이대조군에비하여유의한향상을보였으며, CERE군이 BRT군에비하여더큰향상을보였다. 따라서뇌졸중환자의호흡기능증진을위하여가능하다면치료사의적극적개입에의한 CERE를추천하며, 그렇지못할경우 BRT 역시호흡기능증진에효과적일것으로생각된다. 더불어CERE 와함께, 홈프로그램으로BRT를병행한다면뇌졸중환자의호흡기능개선에더큰향상을기대할수있을것이라고사료된다.

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