Geriatric Rehabilitation 2011; 1: Review Article 노인의균형 : 생리학적및재활적접근 김은주 국립재활병원재활의학과 Balance in the Elderly : Physiologic and Rehabilitation Appr
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1 Review Article 노인의균형 : 생리학적및재활적접근 김은주 국립재활병원재활의학과 Balance in the Elderly : Physiologic and Rehabilitation Approach Eun Joo Kim, M.D. Department of Rehabilitation Medicine, National Rehabilitation Hospital, Seoul , Korea Abstract Balance, the ability to maintain the center of gravity over the base of support within a given sensory environment, is composed of several subcomponents and influenced by several systems (sensory, musculoskeletal, and central and peripheral nervous systems). With advancing age, changes related to normal aging and those associated with diseases, can affect the integrity and function of those systems and also affect the balance system, which requires a complex integration of many components. Balance dysfunction has important implications for social activity because this is a major cause for injury, falls, and loss of physical functioning in the elderly. Therefore, a thorough assessment into the cause of balance dysfunction in an elderly patient is essential to the implementation of appropriate treatment, usually a multidisciplinary approach. Key Words Elderly, Balance 접수일 : 2010년 11월 23일게재승인일 : 2011년 1월 23일교신저자 : 김은주주소 : 서울시강북구수유5동 520 국립재활병원재활의학과 Tel : Fax : silverzoo@medimail.co.kr 서론 균형 (balance) 이란주어진환경내에서자신의기저면 (base of support, BOS) 위에신체중심 (center of gravity, COG) 을유지하는능력으로다양한인자들의영향을받는일련의복합과정 (complex neuro-musculo-skeletal process) 이다. 1 즉, 하나의시스템이나정향 (righting), 평형 (equilibrium) 반사의결과물이라기보다많은감각-운동-인지반응들의상호작용에기인된복합운동기술이라할수있 다. 이에신체의움직임에대한감각계의인지, 중추신경계를통한감각운동정보통합, 이에대한근육반응과환경에대한올바른운동대응전략 (movement strategies) 의생리학적이해, 노인에서균형문제를야기할수있는원인들의고찰및균형능력을적절히평가할수있는다양한방법들을통해도출된통합적인노인균형에대한재활적접근에대해논하고자한다. 29
2 본론생리학적개념 (Physiologic Concept) 감각양식및감각재조정 (sensory modalities and sensory re-weighting) : 균형유지를위해서는 3가지 [ 체성감각 (somatosensory), 시각 (visual), 전정 (vestibular)] 감각이중요한역할을하는데각환경에따라다양한감각정보가들어오게되면중추신경계는하나의시스템에우선권 (priority) 을부여함으로써균형을조절한다. 정상성인이견고한기저면 (BOS) 위에서있다면주로발을통해습득되는체성감각정보 (70%) 를사용하며전정 (20%) 이나시각 (10%) 정보는부가적이다. 반면서있는바닥이불안정해지면중추신경계는전정이나시각정보에더많은비중을부여하여감각재조정 (sensory re-weighting) 을함으로써자세안정성을유지하게된다. 2 이러한조정활동들은일상생활활동의안전한수행을위해필수적이다. 특히, 상기 3가지감각기능에문제가있는경우라면이러한감각재조정이더욱중요하며, 알츠하이머치매의경우감각기능에는문제가없더라도감각재조정능력이저하되어균형문제가야기될수있다. 근골격계제어 (musculoskeletal constraints) 및대응전략 (strategies) : 자세를안정적으로유지하기위해서는다양한기저면 (BOS) 에서자신의신체중심 (COG) 을적절히유지해야하는데, 이때족관절의기능 ( 관절운동범위, 근육의긴장도, 근력, 협응력등 ) 이중요하다. 3 또한 안정성의한계 (limits of stability, LOS) 라는개념은개인이기저면을바꾸지않고자신의신체중심을움직여균형을유지할수있는범위를일컫는용어로써발을중심으로역원뿔모양을이루고있다. 이러한 안정성의한계 (LOS) 는중추신경계를통해정확한판단이이루어지므로뇌손상이나파킨슨병환자의경우균형문제가야기될수있으며, 균형문제가있는노인에있어서는 안정성의한계 (LOS) 를구성하는범위가작거나이에대한중추신경계의인식이왜곡된경우가있을수있다. 4 또한, 중추신경계에서는기립자세를유지하기위해적절한운동대응전략을활성화하게되는데, 족관절운동전략 (ankle movement strategy), 고관절운동전략 (hip movement strategy), 걸음전략 (stepping strategy) 3가지로나누어볼수있다. 평지에서느리고작은외부자극을받았다면족관절 전략을, 좀더빠르고큰외부자극을받았거나기저면이좁은경우는고관절전략을, 외부자극에의해신체중심이기저면을벗어나게되면걸음전략을사용하게된다. 5,6 노인의경우에는느리고작은자극에도흔히고관절전략을사용하는경향이있으며, 상황에맞는적절한균형전략을사용하는것이낙상예방에중요하다고할수있겠다. 7 노인의균형문제 : 노인의균형능력저하를야기하는원인들을살펴보면전정계, 감각계, 시각, 근골격및신경계, 심혈관계손상및약물등과같이다양하고폭넓은원인들이관여하고있다. 유모세포 (hair cell) 의감소, 전정안구반사 (vestibulo-ocular reflex, VOR) 의기능저하뿐만아니라노화에따른안 ( 眼 ) 기능 ( 시력, 시야, 채도, 눈부심, 암순응등 ) 변화에의해균형능력이영향을받을수있다. 8,9 또한, 연령이증가할수록관절가동범위와척추유연성이감소하고균형을유지하기위한발목근력의반응시간 (reaction time) 이증가되며근육량및근력이감소하고교감신경계의반응도가저하되어기립성저혈압이유발될수있다. 뿐만아니라인지- 운동반응 (cognitive-motor response) 이느려지는데, 이는말초감각계의변화때문이아니라정보를처리하는중앙처리과정이느리기때문으로볼수있다. 10,11 이외에도노화관련질환들 ( 퇴행성, 감염성, 외상성등 ) 은균형유지를위한다양한요소들의효율성을떨어뜨리게되며, 이러한균형관련요소들은단독 (one) 이아닌다수 (multiple) 의요소들이함께작용하여심각한균형문제를야기할수있다. 평가 (Assessment) 노인에서균형을유지하기위해제한받는요소들과보상하는전략들이개인에따라다르므로균형에문제가있는노인들에서상기의생리학적개념과전략들을적절히평가하는것이필요할것으로생각된다. 우선병력 ( 낙상병력, 약물복용 ) 청취와함께신경학적, 감각기능, 자세및보행검사- 시력, 안구운동, 감각, 고유수용감각, 협응력, 소뇌기능, 근력등-가필요하며균형능력검사시에는정적균형뿐만아니라동적균형상태도평가해야한다. 가장간단한평가법인자가측정법 (self report measurement) 은균형과관련된신체적문제를직접적으로평가는방법은아니지만얼마나자신이안전하다고느끼는 30
3 김은주 : 노인의균형 : 생리학적및재활적접근 지를알수있는방법으로치료방향에도움을줄수있다. 자가측정한검사에비해자신이더균형에관하여안전하다고느낀다면집의환경이검사환경보다더위험할수있다는것을의미하여중재가필요할수있음을시사하며, 반대로검사결과에비해자신이더불안정하다고느낀다면낙상의경험이있거나균형능력에대한자신감이저하되어활동에제한을받는다고해석할수있다. 이러한경우적절한균형조절을위한중재를받지못한다면더큰문제가야기될수있을것이다. 가장흔히사용되는자가측정법은 Fall Efficiency Scale (FES), Activities-specific Balance Confidence Scale (ABC scale) 이다. 12,13 FES 측정을통해낙상이불안정도와연관되어있다는점을알수있었으며, 좀더고기능의일상생활기능평가가추가된 modified FES 측정을통해낙상유무간의차이를구별해낼수있었다. 12 또한, ABC scale 은신체적기능과낙상간의연관성을점수범위로나타내었는데, 50-80% 점수범위라면은퇴한노인이나만성질환을가진노인수준인중간정도의신체기능 (moderate physical functioning) 상태, 50% 이하라면재가요양을받는노인수준인신체기능 (low physical functioning) 상태로생각할수있다고한다. 13 그리고, 균형과연관이있는단독인자들을평가하는단인자 (single-item) 평가법또는균형과연관된다양한인자들다수를포함하는다인자 (multidimensional) 평가법을사용할수있다. 단인자평가법에는 Romberg 검사, 한쪽다리로서기 (single limb stance), tandem 검사등이있으며적용하기쉬워선별검사로일반적으로사용되지만균형능력의한가지면만평가하기때문에치료계획을세울때에는제한성이있을수있다. 14 전산화동적자세측정기 (Computerized Dynamic Posturography) 는감각기관검사 (sensory organization test) 를통해감각 ( 시각, 체성감각, 전정계 ) 기관기능, 중앙통합기전 (central integrating mechanism), 적절한대응전략선택, 운동반응의적절성및효율성등을구분하여평가할수있는방법으로감각기관검사 (sensory organization test, SOT), 운동조절검사 (motor control test, MCT), 적응력검사 (adaptation test) 등으로구성된다. 감각기관검사 (SOT) 에서는환자의눈, 발, 관절에전달되는정보를 6가지로다양하게변화시켜다양한감각적변동상황을재연하여개인별감각계의효율성을평가하고적절한대응반응이있는지를평가할수있으며, 운동조절검사 (MCT) 에서는발판의전후방향으 로의이동에따른자세반응능력을측정하여반응시간, 기울기등을측정하게된다. 15 다인자평가법은낙상의위험성을예측하기위해고려해야할많은인자들을선별해서만들어진평가법으로, 다양한측면을평가하여하나의점수로합산한다는점에서유용하지만치료가필요한유발인자를구별해내는것이어려울수있다. 그러므로치료가필요한균형문제를구별해내기위해서는평가수행동안세심히관찰하거나필요한단인자평가를추가로시행하는것이좋다. 가장널리사용되는방법인버그균형검사 (Berg Balance Scale, BBS) 는 14항목으로구성되어총점 56점, 40점이하이면중등도위험, 20점이하이면낙상의고위험군으로볼수있으나그기준은연구에따라다양하게분류되고있다. 16,17 Performance Oriented Mobility Assessment (POMA) 는총 28점만점 ( 균형점수16점, 보행점수 12점 ) 으로 24점이하이면중등도, 18점이하이면낙상의고위험`군으로분류할수있다. 18 최근에는균형평가시스템검사 (Balance Evaluation Systems Test, BESTest) 를사용하기도하는데, 앞서설명한균형의생리학적측면의항목들을포함하며총점 108점만점의검사방법이다. 19 그외에도복잡한균형수행과제가포함된보행평가를통해서균형통합능력과이동 (mobility) 동안균형능력을평가할수있다. 그중하나인기능적보행검사 (Functional Gait Assessment) 는다양한보행과제 ( 고개돌림, 속도조절, 뒤로보행, 눈감고보행등 10항목 ) 의수행능력을평가하는방법이며, 동적보행지표 (Dynamic Gait Index) 는 8항목 24점만점으로 19점이하이면낙상의위험성이있다고해석한다. 20 재활 (Rehabilitation) 평가를통해밝혀진균형문제를야기한원인인자들 ( 관절가동범위, 근력, 감각저하, 통증, 부적절한운동전략등 ) 과기능적제한 (functional limitation) 을기초로재활치료를시작하게된다. 균형훈련을통하여적절한운동대응전략을사용할기회를제공하고배워서습득하게하는것이중요하며, 운동강도에대한정형화된기준은아직없지만적어도일주일에 4-5일은실시하는것이도움이된다고한다. 21 또한, 노화에따른감각기능의변화로인해균형에대한감각정보의사용에어려움이있다면초기에는사용가능한모든감각정보를이용하여훈련하다가차츰감각정보를줄여나가는것이원칙이다. 보행훈련는걸음전략을추가로연습하거나다양 31
4 한환경에서훈련을하는것이좋을것으로생각된다. 결론 전정훈련 (vestibular exercise) : 전정계재활 (vestibular rehabilitation) 은균형계의항상성 (homeostasis) 을회복하는데목적이있다. 즉, 어지럼증감소, 균형능력증진, 낙상위험도등을감소시키는것이목표이며이는전정안구반사 (VOR) 정확도, 자세조절, 안구운동기술을향상시킴으로가능하며, 적응훈련 (adaptation exercise), 습관훈련 (habituation exercise), 대치훈련 (substitution exercise), 균형훈련 (balance exercise), 보행훈련 (gait exercise) 등이포함된다. 22,23 이러한전정계재활은증상초기에시작할수록회복에도움이되며노화관련균형문제를가진경우에는기본프로그램에시야안정 (gaze stabilization), 안구운동 (ocular motor), 동적균형훈련프로그램을포함하는것이도움이될수있다. 23 최근연구에따르면균형문제는정상노화과정의한부분이라기보다신경근육계및감각계의기능저하와연관되어있는경우가흔하므로노인균형에대한적극적인평가가필요할것이다. 또한노인균형은젊은이들의균형과크게다르지않지만노인에게야기된균형문제는결론적으로훨씬심각하고운동및감각대응전략습득능력이느리므로일상생활에제한을받지않는초기에되도록신속하고적절하게성공적인대응전략을제공하는것이필요할것으로생각된다. References 균형훈련 (balance training) : 균형훈련의일반적원칙은필요한균형전략들을이용할수있도록훈련하고기능적활동을포함한훈련동작들을시행하는것이며배운훈련동작이일반화될수있는내용을포함하는것이좋다. 또한노인들의균형훈련에서안전관리가중요하며, 운동의빈도에대한명확한기준은없으나일반적으로적어도주당 4-5일의훈련이필요하다. 감각기관훈련은균형에잘사용하지않는감각을이용하여훈련하고다른감각들을이용한보상법을훈련하는데, 기본원칙은초기에는모든사용가능한감각정보를사용하여훈련하다가차츰감각정보를제거해나간다는것이다. 14 과거연구에서지역사회거주노인들에게운동을시행하면균형능력향상에도움이된다고하였다. 낙상예방을위한적절한운동방법 ( 유형, 기간, 강도등 ) 의기준은명확하지않았지만, 그럼에도불구하고적어도 10주이상은운동을지속해야하며, 낙상예방을위해서는주택개조뿐만아니라교육이더불어필요하다고하였다. 24 또한낙상예방을위한운동프로그램연구를살펴보면운동내용을크게근력운동, 균형운동, 지구력 / 유산소운동 3가지로나누어시행하였을때운동만으로도낙상예방에도움이되는데, 적어도 3개중 2개의운동프로그램이포함되는것이도움이된다고한다 Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing 2006;35(Suppl 2): Peterka RJ. Sensorimotor integration in human postural control. J Neurophys 2002;88: Tinetti ME, Speechlev M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Eng J Med 1988;319: McCollum G, Leen TK. Form and exploration of mechanical stability limits in erect stance. J Mot Behav 1989;21: Horak FB. Clinical measurement of postural control in adults. Phys Ther 1987;67: McIlory WE, Maki BE. Age-related changes in compensatory stepping in response to unpredictable perturbations. J Gerontol A Biol Sci Med Sci 1996;51: Maki BE, Edmondstone MA, McIlory WE. Age-related differences in laterally directed compensatory stepping behaviors. J Gerontol A Biol Sci Med Sci 2000;55: Konrad HR, Girardi M, Helfert R. Balance and aging. Laryngoscope 1999;109: Harwood RH. Visual problems and falls. Age Ageing 32
5 김은주 : 노인의균형 : 생리학적및재활적접근 2001;30(Suppl 4): Stelmach GE, Worringham CJ. Sensorimotor deficits related to postural stability: implications for falling in the elderly. Clin Geriatr Med 1985;1: Teasdale N, Stelmach GE, Breunig A. Postural sway charateristics of the elerly under normal and altered visual and support surface conditions. J Gerontol A Biol Sci Med Sci 1991;46: Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of falling. J Gerontol A Biol Sci Med Sci 1990;45: Myers AM, Fletcher P, Myers AH. Discriminative and evaluative properties of the activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci 1998;53: Wrisley D. Balance testing and training. In: Kaffman TL, Barr JO, Moran ML. editors. Geriatric Rehabilitation Manual. Philadelphia:Elseviers;2007: Monsell EM, Furman JM, Herdman SJ. Computerized dynamic platform posturography. Otolaryngol Head Neck Surg 1997;117: Berg KO, Wood-Dauphinee SL, Williams JI. Measuring balance in the elderly:validation of an instrument. Can J Public Health 1992;83(Suppl 2): Berg KO, Wood-Dauphinee SL, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27: Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34: Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther 2009;89: Wrisley DM, Marchetti GF, Kuharsky DK. Reliability, internal consistency, and validity of data obtained with the functional gait assessment. Phys Ther 2004;84: American Geriatric Society, British Geriatric Society, American Academy of Orthopedic Surgeons Panel on Falls prevention 2001 Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc 2001;49: Herman SJ, Schubert MC, Tusa RJ. Strategies for balance rehabilitation: fall risk and treatement. Ann N Y Acad Sci 2001;942: Matsumura BA, Ambrose AF. Balance in the elderly. Clin Geriatr Med 2006;22: Close JC, Lord SL, Menz HB. What is the role of falls? Best Pract Res Clin Rheumatol 2005;19: Costello E, Edelstein JE. Update on falls prevention for community-dwelling older adults: Review of single and multifactorial intervention programs. J Rehabil Res Dev 2008;45:
NEUROTHERAPY 대한신경치료학회지노효련, 신은지제20, 권곽성원제3호 뇌졸중환자에서버그균형척도와수행지향적운동성평가의낙상위험도를활용한상관관계분석 노효련, 신은지, 곽성원 * 강원대학교보건과학대학일반대학원 Correlation between Berg
NEUROTHERAPY 2 0 1 6 대한신경치료학회지노효련, 신은지제20, 권곽성원제3호 뇌졸중환자에서버그균형척도와수행지향적운동성평가의낙상위험도를활용한상관관계분석 노효련, 신은지, 곽성원 * 강원대학교보건과학대학일반대학원 Correlation between Berg Balance Scale and Performance-Oriented Mobility Assessment
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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
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WHO 의새로운국제장애분류 (ICF) 에대한이해와기능적장애개념의필요성 ( 황수경 ) ꌙ 127 노동정책연구 제 4 권제 2 호 pp.127~148 c 한국노동연구원 WHO 의새로운국제장애분류 (ICF) 에대한이해와기능적장애개념의필요성황수경 *, (disabi
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Development of a Physical Therapy System for Enhancement of Balance Ability Seunghoon Lee 1, Younggeun Choi 1, Hyewon Lee 1, Wonsup Lee 1, Taekho You 1, Myounghwan Ko 2, Jongkwan Park 2, Minjung You 2,
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Brain & NeuroRehabilitation ol. 6, No. 2, September, 2013 http://dx.doi.org/10.12786/bn.2013.6.2.58 뇌질환환자의균형및자세평가 국립재활병원재활의학과 김은주 Assessment of Balance and Posture in Brain Disorders Eun Joo Kim, M.D.
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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
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The e-business Studies Volume 17, Number 6, December, 30, 2016:275~289 Received: 2016/12/02, Accepted: 2016/12/22 Revised: 2016/12/20, Published: 2016/12/30 [ABSTRACT] SNS is used in various fields. Although
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