untitled

Size: px

Start display at page:

Download "untitled"

재승 뇌
5 years ago
Views:

1 Brain & NeuroRehabilitation Vol. 6, No. 1, March, 뇌졸중후편마비보행에서단하지보조기의효과 메타분석 연세대학교의과대학재활의학교실및재활의학연구소 김덕용ㆍ김승기ㆍ박종범ㆍ양진규 Effects of Ankle Foot Orthosis on Post-stroke Hemiplegic Gait A Meta-analysis Deog Young Kim, M.D., Ph.D., Seung Ki Kim, M.D., Jong Bum Park, M.D. and Jin Kyu Yang, M.D. Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine Objective: The aim of this meta-analysis was to investigate the effects of ankle foot orthosis on adult post-stroke hemiplegic patients' walking ability and pattern. Method: We searched for the case controlled clinical trials about the effects of ankle foot orthosis (AFO) for walking ability and pattern using quantitative gait analysis in adult post-stroke patients, which published between January 1950 and July 2012 in PubMed, and searching engine of Journal of Korean Academy of Rehabilitation Medicine. The mean standardized difference (MSD) and a 95% confidence interval (CI) were estimated for gait ability and pattern using fixed effect models. Results: Sixteen of the 56 articles were included in this analysis. The selected studies involved a total of 274 patients. The walking speed, cadence, the portion of double limb supporting, stride length on affected side, the portion of swing period on unaffected side, and symmetry of swing period were improved by AFO. The oxygen cost was decreased by AFO. The AFO did improve ankle dorsiflexion at initial contact, maximal ankle dorsiflexion at swing phase, but the ankle plantar flexion at push-off did not. Conclusion: The ankle foot orthosis has some evidence to improve the walking ability and gait pattern in post-stroke hemiplegic patients. (Brain & NeuroRehabilitation 2013; 6: 1-8) Key Words: gait, hemiplegia, meta-analysis, orthotic devices, stroke 서론 뇌졸중은가장흔한성인장애를일으키는질환으로환자들중 70 80% 환자에서보행이가능하다고알려져있으나, 보행이가능한환자중에대부분의환자에서비정상적인보행양상을보인다. 발병후 3개월에는반수의환자에서정상인에비해보행속도가떨어지고, 약 54 80% 의환자에서보행장애를보이는것으로알려져있다. 1 이러한보행장애를해결하는것은뇌졸중재활에서매우중요한영역중에하나이다. 뇌졸중후가장특징적인비정상적인보행양상은유각기동안슬관절이굴곡이감소되는뻐정다리보행 (stiff- knee gait), 입각기동안슬관절이과신전되는전반슬 (genu recurvatum), 입각기에서 교신저자 : 김덕용, 서울시서대문구성산로 , 연세대학교세브란스병원재활의학과 Tel: , Fax: kimdy@yuhs.ac 배측굴곡의감소와유각기에과도한족저굴곡이다. 2,3 또한보행속도가감소하고, 분속수와활보장이감소하고, 양하지지지기가증가되며, 건측에비해마비측의입각기기간이짧다. 4-7 이러한비정상적인보행양상에의해에너지소모가증가되게되어, 8 보통산소소모율 (O 2 rate) 은정상인의보행에비해큰차이는없으나, 산소소모비 (O 2 cost) 는정상인의 4배이상으로보행시매우많은에너지가소모되게된다. 이러한비정상적인편마비보행 (hemiplegic gait) 은선택적근육조절능력의소실과느린움직임및이를보상하려는건측의작용에의하거나, 5 근력약화및균형감각의소실때문이라설명되고있다. 9 이러한비정상적인보행을관찰하고비정상적인지표를정량화하고, 그원인을찾아내어, 병력과이학적검사로부터얻은피검자의다른정보를관찰자의지식과경험을조합하여종합하는것을보행분석이라고한다. 이러한보행분석은근골격계질환뿐만아니라신경계질환에서임상적으로보행이상유무및이상정도를파악하고, 이 1

2 Brain& NeuroRehabilitation:2013; 6: 1~8 를일으키는원인을규명하고, 나아가치료에대한평가하는데유용하게이용된다. 지금까지알려진보행분석방법은기술적인보조장비없이할수있는관찰적분석 (observational analysis) 에서부터복잡하고값이비싼장비를사용하는삼차원동작분석 (three dimensional motion analyses) 에이르기까지다양하다. 10,11 보행분석은측정하려고하는주체에따라시공간적지표분석 (spatiotemporal analysis), 운동형상학적분석 (kinematic analysis), 운동역학적분석 (kinetic analysis), 동적근전도 (dynamic electromyography), 및에너지소비량측정 (energy expenditure measurement) 으로나누어생각할수있다. 12 뇌졸중후비정상적인보행양상중에서유각기동안의 족저굴곡현상 (ankle equinus) 은보통족관절배측굴곡의약화나족저굴곡근의경직또는구축에의해나타나게되며, 유각기동안발끌림현상을초래하고, 족저굴곡근의경직또는구축의경우입각기에서는슬관절의과신전을초래하게된다. 이러한유각기동안의과도한족저굴곡현상을해결하기위한방법으로기능적전기자극이나단하지보조기등이소개되고있다. 이중단하지보조기는임상적으로가장널리이용되고있는방법으로유각기에발끌림이있는편마비환자나족관절의내외측의불안정, 근육불안정및경직성편마비환자등에게사용하여보행중발뒤꿈치접지를유발하고, 발목의내외측이불안정할때환측의입각기를정상화시키며, 진출을도와주고, 유각기중발끌림을방지하며, 하지의움직임도좀더대칭적으 Table 1. Major Information of Selected Sixteen Clinical Trials Authors Journal Subject Study design Types of orthosis Familiarization Measure Hesse S Int J Rehabil Res 19 subacute/chronic Within Rigid double-stopped Immediate Temporospatial (1996) AFO Hesse S Stroke (1999) 21 subacute/chronic Within Rigid double-stopped Immediate Temporospatial AFO Tyson SF Clin Rehabil (2001) 25 subacute, chronic Cross-over Hinged PLS Immediate Temporospatial Danielsson A J Rehab Med (2004) 10 chronic Within Carbon composite AFO Immediate Temporospatial, Energy consumption Wit DC Clin Rehabil (2004) 20 chronic Within Non-articualted AFO Immediate Temporospatial Franceschini M Clin Rehabil (2003) 9 chronic Within AFO Immediate Temporospatial, Energy consumption Gok H Clin Rehabil (2003) 12 subacute/chronic Within Plastic, Metallic AFO Immediate Temporospatial, Kinematic Marcus P Clin Rehabil (2006) 28 subacute Within Semi-rigid Immediate Temporospatial double-stopped AFO Thijssen DH Arch Phys Med Rehabil (2007) 27 chronic Within HKAFO 3 weeks Temporospatial, Energy consumption Chen CC Arch Phys Med Rehabil (2010) 14 subacute/chronic Cross-over Anterior/posterior AFO Immediate Temporospatial, Kinematic Yamamoto S Prosthet Orthot Int (2011) 10 chronic Cross-over AFO with oil damper 3 weeks Temporospatial, Kinematic Erel S Clin Rehabil (2011) 14 chronic Within Dynamic AFO 3 months Temporospatial Kim MJ J Korean Acad 30 subacute/chronic Within Posterior leaf-spring Immediate Temporospatial Rehab Med (1994) AFO Jang SJ J Korean Acad Rehab Med (1999) 15 chronic Within 5 degree Ankle DF AFO Immediate Temporospatial, Kinematic Chon JS J Korean Acad Rehab Med (2000) 10 subacute/chronic Within Hinged PLS Immediate Temporospatial, Kinematic, Energy consumption Rah UW J Korean Acad Rehab Med (2001) 10 chronic Within : patients, AFO: ankle-foot orthosis, PLS: posterior leaf spring. PLS Immediate Temporospatial, Energy consumption 2

3 김덕용외 3 인 : 뇌졸중후편마비보행에서단하지보조기의효과 메타분석 로만들어보폭및보행속도를증가시키고가능한적은에너지의소모로정상에가까운보행을도와주는것으로알려져있다. 6,9,13-17 그러나아직단하지보조기에대한임상연구는많으나, 메타분석을통한유용성에대한증거를입증하고자하는노력은아직부족하다. 이에저자는본글에서메타분석을이용하여단하지보조기가뇌졸중후편마비보행에어떤효과를나타내는지객관적인증거를알아보고자하였다. 본론 뇌졸중후편바비환자의보행에단하지보조기의효과에대한체계적인문헌고찰을위한문헌검색은 PubMed ( 와대한재활의학회지홈페이지의검색엔진을이용하였다. PubMed 에서의문헌고찰을위한검색식은 (cerebrovascular accident OR CVA OR intracranial hemorrhage OR ICH OR cerebral infarction OR stroke OR hemiplegia) AND (gait) AND (orthosis) 로하였 고, 또한 18세이상성인, randomized controlled trial으로제한하여검색하였고, 검색기간은 2012년 7월까지로제한하였다. 그결과 46편의논문이검색되었고, 이중상지보조기등단하지보조기이외의다른보조기에관련된논문이나, 영어나한국어가아닌다른언어로기술된경우, 관찰연구이거나객관적이고정량화된보행지표의평균및표준편차가제시하지않은경우, 적절한대조군이제시되어있지않은경우를제외하여 12편논문을선택하였다. 또한대한재활의학회지홈페이지에서같은방법으로검색하여 10편의논문이검색되었고, 동일한제외기준에의해 6편의논문을제외하고 4편의논문을선택하여국외 12편, 국내 4편총 16편의논문을메타분석을위해선정하였다 (Table 1). 13,15,18-31 문헌검색및선택기준적용은 2명의연구자가독립적으로수행하였다. 분석할보행지표선정은최소한두편이상의연구가있는경우에로한정하였고, 메타분석은 Comprehensive Meta Analysis V2 프로그램 (Biostat, Englewood, USA) 을이용하여고정효과모델 (fixed effect model) 로분석하였 Fig. 1. Comparison of walking speed (m/sec) between with and without AFO. Fig. 2. Comparison of cadence (step/min) between with and without AFO. 3

4 Brain& NeuroRehabilitation:2013; 6: 1~8 고, 여러연구들의결과의분석값은평균표준차이 (mean standardized difference) 와 95% 유의구간으로표시하였고, p 값이 0.05미만인것을통계학적의미가있는것으로정의하였다. 1) 시공간적지표단하지보조기를착용시, 미착용시에비해보행속도는평균 0.07 m/sec (95% 유의구간 ) 만큼유의있 게증가되었고 (p = 0.000), 분속수또한평균 5.56 step/ min (95% 유의구간 ) 만큼유의하게향상되었다 (p = 0.016) (Fig. 1, 2). 평균이환측활보장의차는 7.89 cm (95% 유의구간 ) 로보조기착용시, 미착용시에비해유의하게향상되었으나 (p = 0.005) (Fig. 3), 정상측활보장은 1개의연구밖에없어분석을하지못하였고, 이환측및정상측모두에서보폭은단하지보조기착용여부에따른유의한차이를보이지않았 Fig. 3. Comparison of stride length (cm) on affected side between with and without AFO. Fig. 4. Comparison of step length (cm) between with and without AFO (A: affected side, B: unaffected side). Fig. 5. Comparison of double supporting time (%) between with and without AFO. 4

5 김덕용외 3 인 : 뇌졸중후편마비보행에서단하지보조기의효과 메타분석 Fig. 6. Comparison of portion of phase (%) on affected side between with and without AFO (A: portion of stance phase, B: portion of swing phase). Fig. 7. Comparison of portion of phase (%) on unaffected side between with and without AFO (A: portion of stance phase, B: portion of swing phase). 다 (p = 0.221) (Fig. 4). 평균양하지지지기의비중은보조기착용시미착용시에비해 4.59% (95% 유의구간 ) 유의하게감소하였다 (p = 0.000) (Fig. 5). 이환측평균입각기비중은보조기착용시 2.54% (95% 유의구간 ) 감소하는경향을보였고 (p = 0.059), 평균유각기비중은 2.59% (95% 유의구간 ) 증가하는경향 (p = 0.054) 을보였으나단하지보조기착용여부에따른유의한차이를보이지않았다 (Fig. 6). 반면정상측평균입각기비중은보조기착용시미착용시에비해 4.54% (95% 유의구간 ) 유의하게감소하고 (p = 0.000), 평균유각기비중은 5.15% (95% 유의구간 ) 유의하게증가함을알수있었다 (p = 0.000) (Fig. 7). 단하지보조기착용여부에따른평균입각기대칭성의차는 0.48% (95% 유의구간 ) 로유의한차이를보이지않았으나 (p = 0.841), 평균유각기대칭성의차는 11.83% (95% 유의구간 ) 로보조기착용시유의하게대칭적이됨을알수있었다 (p = 0.002) (Fig. 8). 2) 에너지소모량평균산소소모율 (O 2 rate) 은단하지보조기를착용시, 미착용시에비해 0.07 ml/kg/min (95% 유의구간 ) 만큼감소하는경향을보였으나유의한차이는보이지않았고 (p = 0.702), 산소소모비 (O 2 cost) 는단하지 5

6 Brain& NeuroRehabilitation:2013; 6: 1~8 Fig. 8. Comparison of symmetry at swing phase (%) between with and without AFO (A: stance phase, B: swing phase). Fig. 9. Comparison of energy consumption between with and without AFO (A: oxygen rate (ml/kg/min), B: oxygen cost (ml/kg/m)). 보조기를착용시, 미착용시에비해평균 0.08 ml/kg/m (95% 유의구간 ) 로유의하게감소하였다 (p = 0.003) (Fig. 9). 3) 운동형상학적지표족관절의운동형상학적지표에서보조기착용시미착용시에비해초기접지기의족관절배측굴곡은평균 7.35 o (95% 유의구간 ) 유의있게향상되었고 (p = 0.000), 유각기의최대족관절배측굴곡은착용시미착용시에비해평균 8.14 o (95% 유의구간 ) 유의하게향상되었다 (p = 0.000) (Fig. 10). 입각기최대족관 절배측굴곡은평균 1.95 o (95% 유의구간 ) 향상되는경향을보였으나유의한차이를보이지않았고 (p = 0.218), 추진기 (push off) 에서의족관절족저굴곡은평균 1.13 o (95% 유의구간 ) 감소하는경향을보였으나유의한차이는보이지않았다 (p = 0.437) (Fig. 10). 그밖에슬관절및고관절, 골반의운동형상학적지표에서는양군간에유의한차이를보이지않았거나, 자료가적어분석하지못하였다. 본연구의제한점은다음과같다. 첫째, 단하지보조기의효과에대한선행메타분석이없어직접비교가불가능하였다는점, 둘째, 기존연구들간의분석방법의차이로 6

7 김덕용외 3 인 : 뇌졸중후편마비보행에서단하지보조기의효과 메타분석 Fig. 10. Comparison of ankle kinematic parameters between with and without AFO (A: ankle dorsiflexion at initial contact ( o ), B: maximal ankle dorsiflexion at stance phase ( o ), C: ankle plantar flexion at push-off phase ( o ), D: maximal ankle dorsiflexion at swing phase ( o )). 인해메타분석이가능한연구논문수에한계가있다는점, 그리고분석에이용된연구들에사용된단하지보조기의종류가다양하여이로인한영향을충분히배제하기어려웠다는점이다. 하지만본연구는뇌졸중후편마비환자의보행에있어서단하지보조기의효과에대한메타분석을시행함으로써단하지보조기의효용성을시사하는높은수준의근거중심결과를제공한의의가있으며, 추후연구의방향성을제공한데의의가있다하겠다. 결론 본메타분석을통해뇌졸중후편마비환자에서단하지보조기가보행속도의향상, 보행효율개선및족관절의 움직임에도움을주는것을확인할수있었다. 하지만분석이가능한임상연구수가적어추후이에대한많은연구가필요할것으로생각된다. 참고문헌 1) Braddom RL. Stroke syndromes. In: Harvey RL, Roth EJ, Yu DT, Celnick P, eds. Physical Medicine & Rehabilitation. Philadelphia: Saunders; 2010: ) Kim DY, Park CI, Jang YW, Ahn SY, Na SI, Park YS. The relationship between weight-bearing and stiff-knee gait in hemiplegic patients. J Korean Acad Rehabil Med. 2004;28: ) Waters RL, Garland DE, Perry J, Habig T, Slabaugh P. Stiff-legged gait in hemiplegia: Surgical correction. J Bone 7

8 Brain& NeuroRehabilitation:2013; 6: 1~8 Joint Surg Am. 1979;61: ) Brandstater ME, de Bruin H, Gowland C, Clark BM. Hemiplegic gait: analysis of temporal variables. Arch Phys Med Rehabil. 1983;64: ) Brunnstrom S. Recording gait patterns of adult hemiplegic patients. Phys Ther. 1964;44: ) Lehmann JF, Condon SM, Price R, delateur BJ. Gait abnormalities in hemiplegia: their correction by ankle-foot orthoses. Arch Phys Med Rehabil. 1987;68: ) Wagenaar RC, Beek WJ. Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech. 1992;25: ) Olney SJ, Griffin MP, Monga TN, McBride ID. Work and power in gait of stroke patients. Arch Phys Med Rehabil. 1991;72: ) Perry J. The mechanics of walking in hemiplegia. Clin Orthop Relat Res. 1969;63: ) Kim BO. Methods in clinical gait analysis. J Korean Acad Rehabil Med. 1994;18: ) Yune SH, Kim BO, Lee JW, Park SK, Kim CJ, Park SJ. Analysis of normal gait with a 3-dimensional motion analyzer. J Korean Acad Rehabil Med. 1992;16: ) Perry J, Burnfield JM. Gait analysis system. In: Perry J, Burnfield JM, eds. Gait Analysis: Normal and Pathological Function. Thorofare: SLACK; 2010: ) Hesse S, Luecke D, Jahnke MT, Mauritz KH. Gait function in spastic hemiparetic patients walking barefoot, with firm shoes, and with ankle-foot orthosis. Int J Rehabil Res. 1996; 19: ) Corcoran PJ, Jebsen RH, Brengelmann GL, Simons BC. Effects of plastic and metal leg braces on speed and energy cost of hemiparetic ambulation. Arch Phys Med Rehabil. 1970;51: ) Kim MJ, Lee SA, Kim SK, Sung IY. The study for gait speed of stroke patients: Comfortable versus maximum safe speed. J Korean Acad Rehabil Med. 1994;18: ) Kim YH, Chang IS, Kim BO. Plastic ankle-foot orthosis (afo) for hemiplegic ambulation. J Korean Acad Rehabil Med. 1984;8: ) Yamamoto S, Ebina M, Kubo S, Kawai H, Hayashi T, Iwasaki M, Kubota T, Miyazaki S. Quantification of the effect of dorsi-/ plantarflexibility of ankle-foot orthoses on hemiplegic gait: a preliminary report. J Prosthet Orthot. 1993;5: ) Chen CC, Hong WH, Wang CM, Chen CK, Wu KP, Kang CF, Tang SF. Kinematic features of rear-foot motion using anterior and posterior ankle-foot orthoses in stroke patients with hemiplegic gait. Arch Phys Med Rehabil. 2010;91: ) Danielsson A, Sunnerhagen KS. Energy expenditure in stroke subjects walking with a carbon composite ankle foot orthosis. J Rehabil Med. 2004;36: ) de Wit DC, Buurke JH, Nijlant JM, Ijzerman MJ, Hermens HJ. The effect of an ankle-foot orthosis on walking ability in chronic stroke patients: a randomized controlled trial. Clin Rehabil. 2004;18: ) Erel S, Uygur F, Engin Simsek I, Yakut Y. The effects of dynamic ankle-foot orthoses in chronic stroke patients at three-month follow-up: a randomized controlled trial. Clin Rehabil. 2011;25: ) Franceschini M, Massucci M, Ferrari L, Agosti M, Paroli C. Effects of an ankle-foot orthosis on spatiotemporal parameters and energy cost of hemiparetic gait. Clin Rehabil. 2003;17: ) Gok H, Kucukdeveci A, Altinkaynak H, Yavuzer G, Ergin S. Effects of ankle-foot orthoses on hemiparetic gait. Clin Rehabil. 2003;17: ) Hesse S, Werner C, Matthias K, Stephen K, Berteanu M. Non-velocity-related effects of a rigid double-stopped anklefoot orthosis on gait and lower limb muscle activity of hemiparetic subjects with an equinovarus deformity. Stroke. 1999; 30: ) Pohl M, Mehrholz J. Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients. Clin Rehabil. 2006;20: ) Thijssen DH, Paulus R, van Uden CJ, Kooloos JG, Hopman MT. Decreased energy cost and improved gait pattern using a new orthosis in persons with long-term stroke. Arch Phys Med Rehabil. 2007;88: ) Tyson SF, Thornton HA. The effect of a hinged ankle foot orthosis on hemiplegic gait: Objective measures and users opinions. Clin Rehabil. 2001;15: ) Yamamoto S, Fuchi M, Yasui T. Change of rocker function in the gait of stroke patients using an ankle foot orthosis with an oil damper: Immediate changes and the short-term effects. Prosthet Orthot Int. 2011;35: ) Chon JS, Chun Sl, Kim DA, Yoon TJ, Seo CH, Seok H, Ohn SH, Chang YC. Comparison of gait analysis and energy consumption between various types of plastic ankle foot orthoses in hemiplegic patients. J Korean Acad Rehabil Med. 2000;24: ) Jang SJ, Kim BJ, Kim CW, Kang MJ, Kim BS. Effect of plastic ankle foot orthosis and functional electrical stimulation on hemiplegic gait. J Korean Acad Rehabil Med. 1999;23: ) Rah UW, Yang JI, Lee IY, Park HK, Park SI, Im SH, Moon HW, Cho JR. Effects of plastic ankle-foot orhtosis on hemiplegic ambulation. J Korean Acad Rehabil Med. 2001;25:

386-390.hwp

386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon