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1 J Korean Soc Phys Med, 2014; 9(1): Online ISSN: Print ISSN: X Research Article Open Access 편마비환자의발목관절전략운동이균형조절능력에미치는영향 박기현 김원복 1 대구대학교대학원재활과학과, 1 대구대학교물리치료학과 The Effects of Ankle Strategy Exercise on Balance of Patients with Hemiplegia Ki-Hyeon Park, PT, MS, Won-Bok Kim, MD, MS 1 Department of Rehabilitation Science, Daegu University Gradute School 1 Department of Physical Therapy, Daegu University Received: December 16, 2013 / Revised: January 4, 2014 / Accepted: January 10, 2014 c 2014 J Korean Soc Phys Med Abstract PURPOSE: PURPOSE: The purpose of this study was to analyze the effect and examine the feasibility of an intervention of ankle strategy exercise on balance of patients with hemiplegia. METHODS: The subject were randomly allocated to three groups: ankle strategy exercise (group A), balance exercise (group B) and control (group C). Group A was received the conventional physical therapy plus ankle strategy exercises for 20 minutes in one session. Group B was received the same conventional physical therapy plus balance exercises for 20 minutes in one session. Two active groups were performed in the session 3 times a week, for a total of 6 weeks. and Group C was only received the same conventional physical therapy. Balance test was assessed using center of pressure (COP) in the anteroposterior (A-P), mediolateral (M-L) direction, Berg balance scale (BBS) and Timed Up and Go Test (TUG). RESULTS: All groups showed improvements in balance Corresponding Author : ak0907@hanmail.net parameters. In especial, the Group A was statistically significant differences in almost part evaluation items and showed more improvements in BBS and TUG parameters than Group B and Group C. and moving distance of M-L COP was more improvements than Group B. CONCLUSION: Ankle strategy exercises had more influence on balance than balance exercises and neurodevelopmental treatment. Key Words: Ankle, Ankle strategy, Balance, Hemiplegia Ⅰ. 서론뇌졸중은혈관파열또는혈행막힘에의해뇌혈액의공급이차단되었을때발생한다 (Glanz 등, 1996). 이런뇌혈관질환은인구 10만명당 50.7명이사망하며, 암에이어사망원인 2위인질환이다 (Korea National Statistical Office, 2011). 뇌졸중발생후신경학적 기능적결함이잔존하고 (Chen과 Patten, 2006), 근력약화와균형능력저하로인해균형및보행문제로일상생활능력이감소한다 (Janice와 Pei, 2007). 특히, 환경안에서여러과제를

2 76 대한물리의학회지제 9 권제 1 호 수행하기위해기저면 (base of support) 위에서신체의균형을유지하는능력은일상생활에서가장중요한운동조절요소중하나인데, 선자세에서의불균형은뇌졸중환자의커다란후유증으로이러한자세조절의어려움은앉아서일어나기, 보행등의기능적수행까지도좋지않은영향을미친다 (Carr와 Shepherd, 2003). 또한, 편마비뇌졸중환자들은비정상적인균형능력과마비측으로체중을옮기는능력감소로인해기능적활동을영위하는데있어서상당한불편과어려움을느끼게되며 (Kim, 2005), 균형과보행운동은뇌졸중환자의재활프로그램에서중요한요소중하나이다 (Brouwer 등, 2003). 신체에따르는균형의회복에는발목관절전략 (ankle strategy) 이나고관절전략 (hip strategy), 또는두전략을함께사용해서서있는균형을유지한다 (Horak 와 Nashner, 1986). 발목관절전략은견고한지지면에서적은동요가있을때일상적으로사용되며, 제일먼저나타나는자세조절전략으로써 (Shumway-Cook과 Woollacott, 2006), 발목관절의근육수축을통해똑바로서기균형을일차적으로회복하는것을말한다 (Horak 등, 1989). 균형증진을위하여기존의연구들은발목의근력강화 (Amiridis 등, 2005 ; Imms와 Edholm, 1981 ; Lord와 Castell, 1994 ; Lord 등, 1995 ; Robinovitch 등, 2002), 가동범위증진 (Mills, 1994 ; Shigematsu 등, 2002) 등여러가지방법들을사용하였으며최근들어발목관절의기능적인운동을통한균형증진운동 (Lee 등, 2008 ; Park, 2009) 에대한연구가늘어나고있다. 최근에발목관절전략운동에관한연구에서는 Choi와 Kim(2012) 이노인여성에게발목관절전략운동을통하여균형능력이유의하게증가함을보고하였으며, 정상노인을대상으로연구가많이진행되고있다. 본연구는발목관절전략운동이편마비환자에게균형증진효과가있는지알아보고자하였다. Ⅱ. 연구방법 1. 연구대상자및기간대구광역시 S병원에뇌졸중으로진단받고입원중인성인편마비환자를대상으로본연구의취지를이해하고연구참여에동의한대상자중의사소통에어려움이있거나지시에따르기가어려운자, 하지에관절구축이있는자, 정형외과적문제가있는자를제외하였다. 최종선발된 30명을대상으로세그룹으로나누어발목관절전략운동을추가로시행한 10명, 균형운동을추가로시행한 10명, 신경발달치료만시행한 10명으로분류하여실시하였다. 실험은 6주간실시하였으며, 실험전족저압중심이동의거리비교, BBS, TUG를이용하여균형평가를하였고실험 6주후재평가를하여균형의변화를알아보았다. 2. 실험도구및측정도구 1) Aero-Step Aero-Step (Aero-Step XL, TOGU, 독일 ) 은약 8cm 높이로된 2개의에어공간으로구성되어있는데, 울퉁불퉁하고공기가들어있으며이런탄성이있는무른지면은서서균형을이루는노력자체만으로도초당, 단위면적당다양한반작용력을갖게하며, 건, 인대, 그리고관절의고유수용기를모두활성화시킬수있는장비이다. Lee(2007) 는 Aero-Step 운동은폐쇄성궤도운동을통해족관절주위근육의편심성수축을제공할뿐만아니라협조운동과다축면의체중부하운동, 특히외반모멘트부하운동을함으로써족관절주위의구심성자극을제공하여자세감각과고유수용성감각을향상시킨다. 이를통해협력근수축을촉진하고길항근의근육수축을느리게하는작용을하기때문에균형능력증진전략으로적합하다고하였다. 2) Mat scan system 기립시 COP의이동거리를보기위해서저항식압력센서인 Mat Scan system (Tekscan Inc. 미국 ) 을사용하였

3 편마비환자의발목관절전략운동이균형조절능력에미치는영향 77 다. Mat system을사용하여측정하는방법은정적인상태에서대상자의체중을측정하여프로그램에입력하고압력측정판위에서대상자가편하게선자세에서시선은전방을보게하여 10초간측정하였다. COP의이동거리는녹화시간동안 400 frame으로저장된 COP 의이동거리를 ASCII파일을이용하여각 frame의순서에따라차이값을모두절대값으로더하여 0.33을곱한후 inch로단위변환하여분석하였으며, 좌 우중심의이동거리 (Mediolateral moving distance of Center of pressure, M-L COP) 와전 후중심의이동거리 (Anterioposterior moving distance of Center of pressure, A-P COP) 로나누어평가하였다. 3) Berg 균형척도 (BBS) 균형능력을평가하기위해 Berg 등 (1992) 의 Berg 균형척도 (BBS) 를사용하였다. 이검사의평가시간은대체로 15분이소요되며보행속도와상관관계가매우높은것으로알려져있다. 한명의숙달된검사자에의해 6주동안 2회의평가를실시하였으며실험전에각조건의자세를설명하고, 시범을보인후몇번의연습을거쳐측정자세와방법에익숙해진다음에측정하였다. 며, 운동시에는발목관절전략을위하여고관절과슬관절의움직임을실험자가의식적으로제한하며, 필요에따라치료사의관찰및지도를실시하였고, 발목관절전략운동이어려운환자는운동시간내치료사의도움을통하여동작을숙지후실시하였다. 환자의안전을위해치료사는항상환자앞에서지켜보고있었다. 운동방법은다음과같다. 딱딱한맨바닥에서서하는운동 - 천천히양발의발뒤꿈치들어올리고내리는발목관절전략운동 - 양발의앞쪽을들어올리고내리는발목관절전략운동 - 교대로한발서기발목관절전략운동 쿠션볼위에서하는운동 - 균형을유지하고정적으로서있는발목관절전략운동 - 앞 뒤, 좌 우, 그리고대각선방향으로몸을기울이는발목관절전략운동 Aero-Step 위에서하는운동 - 균형을유지하고정적으로서있는발목관절전략운동 (Fig. 1) 4) Timed Up and Go Test (TUG) 이검사는 46cm높이의팔걸이가있는의자에앉은자세에서일어나 3m를왕복하여다시앉는시간을측정하였다. 측정시자신이평소신는신발과보조도구를사용할수있으나보호자혹은치료사의도움은받지않는다. 이검사는동적균형및기능적인동작들을평가하는데타당도가높은것으로나타났다 (Podsiadlo 와 Richardson, 1991). 3. 중재방법 1) 그룹 A( 발목관절전략운동그룹 ) 발목관절전략운동으로는딱딱한맨바닥에서서서하는운동, 쿠션볼을이용하는운동, Aero-Step을이용한운동 (Lee 등, 2008) 등세가지방법으로구성되었으 Fig 1. Ankle strategy exercise on Aero-Step; Balance on two feet to Aero-Step. and solemnize affected side hand to arm support. (Necessary, give assistance for safety in front of patient.)

78 대한물리의학회지제 9 권제 1 호 - 앞 뒤, 좌 우, 대각선방향으로몸을흔드는발목관절전략운동 (Fig. 2, 3) 2) 그룹 B( 균형운동그룹 ) Heo(2007) 의연구에서사용한운동프로그램으로 Janda의감각운동훈련프로그램을참고하여정적, 동적, 기능적단계에서의자세변화를통해기저면과체중심의변화를제공하였다. 필요에따라치료사의관찰및지도를실시하였다.

몸통회전운동 - 양발을어깨넓이로벌리고신체정렬을맞춘후몸통을좌 우로회전 옆으로걷기운동 - 마비측 건측으로옆으로걷기운동 체중이동운동 - 딱딱한바닥에서반무릎자세자세로좌 우로체중지지몸통회전운동은 3분씩 2세트를실시하였고, 1세트는눈을뜨고, 2세트는눈을감고하였다. 옆으로걷기운동과체중이동운동은 2분씩 2세트를하였다. 각세트운동후에는 2분동안휴식을하였다.

4 78 대한물리의학회지제 9 권제 1 호 - 앞 뒤, 좌 우, 대각선방향으로몸을흔드는발목관절전략운동 (Fig. 2, 3) 2) 그룹 B( 균형운동그룹 ) Heo(2007) 의연구에서사용한운동프로그램으로 Janda의감각운동훈련프로그램을참고하여정적, 동적, 기능적단계에서의자세변화를통해기저면과체중심의변화를제공하였다. 필요에따라치료사의관찰및지도를실시하였다. 운동방법은다음과같다. Fig 2. Ankle strategy exercise on Aero-Step(weight bearing to affected side); Solemnize hand on arm support to weight bearing to affected side. And keep stay for 10 sec. 몸통회전운동 - 양발을어깨넓이로벌리고신체정렬을맞춘후몸통을좌 우로회전 옆으로걷기운동 - 마비측 건측으로옆으로걷기운동 체중이동운동 - 딱딱한바닥에서반무릎자세자세로좌 우로체중지지몸통회전운동은 3분씩 2세트를실시하였고, 1세트는눈을뜨고, 2세트는눈을감고하였다. 옆으로걷기운동과체중이동운동은 2분씩 2세트를하였다. 각세트운동후에는 2분동안휴식을하였다. 3) 그룹 C( 대조그룹 ) 운동치료는운동발달이론에기초한신경발달치료를실시하였으며, 하루에 30분씩 6주동안주 5회적용하였다. Fig 3. Ankle strategy exercise on Aero-Step(weight bearing to lesser affected side); Lift hand on arm support to weight bearing to lesser affected side. And keep stay for 10 sec. 딱딱한맨바닥에서서하는운동은 3분씩 2세트를실시하였고, 1세트는눈을뜨고, 2세트는눈을감고하였다. 쿠션볼과 Aero-Step 위에서하는운동은 2분씩 2세트를실시하였고, 눈을뜨고안전을위하여한손을팔지지대위에올리고실시하였다. 각세트운동후에는의자에앉아 2분동안휴식을하였다. 4. 통계처리통계처리는 SPSS 18.0 for window를이용하였고, 각그룹내전 후의균형의변화를비교하기위하여 paired t test를사용하였고, 그룹간균형의변화를비교하기위하여 One-way Anova를사용하였다. 통계적유의수준 α는.05로하였다. Ⅲ. 결과 1. 연구대상자의일반적특성본연구에참여한대상자총 30명의평균연령은

5 편마비환자의발목관절전략운동이균형조절능력에미치는영향 세이었고, 남자가 8명, 여자가 22명이었다. 마비부위는왼쪽편마비가 15명, 오른쪽편마비가 15명이었고, 뇌졸중발병기간은평균 33.66개월이었다. 평균신장은 162.2cm, 평균체중은 58.43kg이었다. 2. 균형능력의변화 1) 족저압중심의이동거리비교각그룹별전 후의균형의차이에서그룹내 M-L COP 비교에서그룹 A와그룹 B가유의한차이가있었다 (Table 1). 각그룹간균형의차이값비교에서도유의한차이가있었으며, 사후검정결과그룹A와그룹B가유의하였다 (Table 2). A-P COP 비교에서는그룹 A와 그룹 B가유의하게차이가있었고 (Table 1), 각그룹간차이값비교에서는유의한차이가없었다 (Table 2). 2) 균형능력비교각그룹내 BBS의전 후차이에서모든그룹에서유의하게차이가있었다 (Table 1). 각그룹간차이값비교에서도유의한차이가있었으며, 사후검정결과그룹A가그룹B와그룹C와유의한차이가있었다 (Table 2). 또한 TUG도각그룹내전 후차이에서모든그룹에서유의하게차이가있었다 (Table 1). 각그룹간차이값비교에서도유의한차이가있었으며, 그룹간사후검정결과그룹A 가그룹B 와그룹C 와유의한차이가있었다 (Table 2). Table 1. A comparison of period for each groups. M L COP A P COP BBS TUG * p <.05, ** p <.01 pre week 6 weeks t p Group A 0.97± ± ** Group B 0.57± ± * Group C 0.66± ± Group A 0.38± ± * Group B 0.27± ± * Group C 0.13± ± Group A 44± ± ** Group B 42.1± ± ** Group C 44.5± ± ** Group A 21.6± ± ** Group B 25.6± ± ** Group C 23.7± ± ** Table 2. A comparison of difference value of post variation - pre variation value for each groups. Group A Group B Group C F p Post-hoc M - L COP 0.52± ± ± * B < A A P COP 0.22± ± ± BBS 7.7± ±2 4± ** B,C < A TUG 5± ±0.91 3± ** B,C < A * p <.05, ** p <.01

6 80 대한물리의학회지제 9 권제 1 호 Ⅳ. 고찰본연구에서는편마비환자를대상으로 6주간의발목관절전략운동 ( 그룹 A) 과균형운동 ( 그룹 B), 운동치료 ( 그룹 C) 를적용하여균형증진효과를알아보고자하였다. 각그룹별 M L COP는그룹 A와그룹 B에서유의하게감소하였고대응표본검정에서도두그룹만유의하였다. 또한각그룹간차이값비교에서도유의하게감소하였다. 사후검정결과그룹A가그룹B와유의한차이가있었다. 이런결과는발목관절전략운동그룹의균형능력이향상되었음을나타내는것으로 Kim 등 (2007) 은 8주간발목강화운동과기능적전기자극치료를병행하여적용하였을때실험전에비해실험후균형능력은 10.5%, 자세동요는 22.6% 감소하였다고한다. Jean-Francois 등 (2005) 은과제지향적운동과발목관절고유수용성감각입력을받은실험그룹에서 COP의유의한차이가있었다고하였다. 또한 Sheth 등 (1997) 은돔형식보드위에서균형유지운동시발목관절주변근육의강화와장딴지근의수축하는시간이줄어드는효과가있다고하였으며, 본연구와같은결과가나왔다. A P COP는그룹 A와그룹 B에서유의하게감소였고대응표본검정에서도두그룹만유의한차이가있었지만, 각그룹간차이값비교에서는유의한차이가없었다. Lee 등 (2008) 은균형손상노인을대상으로한연구에서자세에따른정적균형능력은눈을뜬자세와눈을감은자세에서좌 우방향동요보다앞 뒤방향동요가더증가하였다고보고하였으며, 발목전략운동군이근력강화운동군과대조군에비해자세동요가유의하게감소하였지만본연구에서는그룹간차이는보이지않았다. 이는동요시흐트러진균형을회복하려는안쪽장딴지근의근수축개시시간및앞정강근과안쪽장딴지근의수축개시시간차의단축그리고발목관절의발등쪽굽힘각도의감소에기인한결과로생각된다고하였다. 각그룹내 Berg 균형척도의수행점수에서세그룹모두유의하게증가하였다. 대응표본검정에서도모든그룹이유의한차이가있는것으로나타났다. 각그룹 간차이값비교에서는유의한차이가있었으며, 사후검정결과그룹A 가그룹 B와그룹C 에대해유의한차이가있었다. Seo 등 (2010) 은발목시 지각자극을이용한감각되먹임훈련에서동적보행지수평가를하였는데실험전 후에서는실험그룹과대조그룹모두에서유의한차이가있는것으로나타났고그이유로각그룹에실시한기본적인물리치료의효과로설명하였다. 그러나실험전 후의변화율의비교에서는실헙군이대조군에비해더많이향상된것으로나타났으며, 이는발목관절전략운동의효율성을보여준다고하였다. Kim(2002) 은편마비환자에게하지재정렬프로그램을시행한후 BBS의수행점수가실험전 후유의하게감소하였다고본연구와같은결과가나왔다. 각그룹내 TUG 수행시간에서세그룹모두유의하게감소하였고, 대응표본검정에서도세그룹모두유의한차이가있는것으로나타났다. 각그룹간차이값비교에서는유의한차이가있었으며, 사후검정결과그룹A 가그룹B 와그룹 C에대해유의한차이가있었다. Park(2009) 은발목관절고유수용성운동조절프로그램훈련에서훈련그룹의 TUG 점수가유의하게감소하였고그는발목관절고유수용성운동조절을통해발목관절의위치감각이나근력및다양한체중지지율의증가에따른동적균형능력이향상된것으로생각된다하였다. 본연구는뇌졸중으로인한편마비환자에게일정기간발목관절전략운동과균형운동을실시하였을때환자의균형능력에미치는영향을알아보기위하여시행하였다. 연구결과발목관절전략운동그룹이균형운동그룹이나운동치료그룹보다전반적인균형능력이향상된것으로나타났다. 본연구의제한점으로짧은훈련기간과추적평가기간이없어치료효과의지속여부를단정하는데제한점이있다. 뇌손상으로인한편마비환자의기능회복중균형능력의개선은삶의질을결정하는중요한요인이되므로편마비환자의기능능력의수준에따라발목관절전략운동을시키면균형능력향상이필요한환자에게유용한훈련방법이된다고생각한다.

7 편마비환자의발목관절전략운동이균형조절능력에미치는영향 81 Ⅴ. 결론본연구는발목관절전략운동이균형에미치는영향을보았다. 본연구는발목관절전략운동이균형운동보다환자의균형능력을향상시키는데더효과적이라는것을확인할수있었다. References Amiridis IG, Arabatzi P, Violaris P, et al. Static balance improvement in elderly after dorsiflexors electrostimulation training. Eur J Appl Physiol. 2005;94(4): Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73(11): Brouwer BJ, Walker C, Rydahl SJ, et al. Reducing fear of falling in seniors through education and activity programs: a randomized trial. J Am Geriatr Soc. 2003;51(6): Choi SH, Kim CY. The Influences of the Intensive Ankle Joint Strategy Training on the Muscular Strength and Balancing Ability in the Elderly Women. J KAIS. 2012;13(12): Carr JH, Shepherd RB. Stroke rehabilitation : guidelines for exercise and training to optimize motor skill. Butterworth-Heinemann Chen G, Patten C. Treadmill training with harness support: selection of parameters for individuals with poststroke hemiparesis. J Rehabil Res Dev. 2006;43(4): Glanz M, Klawansky S, Stason W, et al. Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the randomized controlled trials. Arch Phys Med Rehabil. 1996;77(6): Heo BH. The Effect of Balance Exercise on Unstable Surface on Balance Abilities of Individuals with Visual Imapairment. Sahmyook University. Korea Horak FB, Nashner LM. Central programing of postural movements: adaptation to altered support-surfacecon Fig. urations. J Neurophysiol. 1986;55(6): Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: a review. Neurobiol Aging. 1989;10(6): Imms FJ, Edholm OG. Studies of gait and mobility in the elderly. Age Ageing. 1981;10(3): Janice JE, Pei FT. Gait training strategies to optimize walking ability in people with stroke: Expert Rev Neurother. 2007;7(10): Jean-Francois B, Jean P, Boucher L et al. Balance training following stroke: effects of task-oriented exercises with and without altered sensory input. Int J Rehabil Res. 2005;29(1):51 9. Kim YH. Effects of Realignment at Lower Extremities on the Balance and Walking in the People with Chronic Stroke. Graduate School of Rehabilitation Health science, YongIn University. Korea Kim KH. Effects of weight transfer training using visual perception on balance in hemiplegic patients. Dankook Univercity. Korea Korea National Statistical Office. Cause of death statistics Lee JW, Kwon OY, Lee CH, et al. Effect of Ankle Strategy Exercise on Improvement of Balance in Elderly with Impaired Balance. Korean J Health Promot Dis Prev. 2008;8(3): Lee SH. The Differences between Aero step Exercises and Weight training on Posture, Physical Fitness, Balance, and Hormone Levels in the Elderly. Ewha Womans University. Korea Lord SR, Castell S. Physical activity program for older persons: Effect on balance, strength, neuromuscular control, and reaction time. Arch Phys Medi Rehabil. 1994;75(6): Lord SR, Ward JA, Williams P, et al. The effect of a 12 month exercise trial on balance, strength and falls

8 82 대한물리의학회지제 9 권제 1 호 in older women: A randomized controlled trial. J Am GeriatrSoc. 1995;43(11): Mills EM. The effect of low-intensity aerobic exercise on muscle strength, flexibility, and balance among sedentary elderly persons. Nurs Res. 1994;43(4): Nurse MA, Nigg BM. Thr effect changes in foot sensation on plantar pressure and muscle activity. Clin Biomech. 2001;16(9): Park YH. The Effects of Ankle Proprioceptive Control Program on the Balance and Walking in the Persons with Stroke. Sahmyook University. Korea Podisiadlo D, Richardson S. The timed UP & GO: A test basic functional mobility for frail elderly person. J Am Geriatr Soc. 1991;39(2): Robinovitch SN, Heller B, Lui A, et al. Effect of strength and speed of torque development on balance recovery with the ankle strategy. J Neurophysiol. 2002;88(2): Seo DK, Oh DW, Lee SH. Effectiveness of Ankle Visuoperceptual Feedback Training on Balance and Gait Functions in Hemiparetic Patients. KPTSA. 2010;22(4): Sheth P, Yu B, Laskowski ER, et al. Ankle disk training influeces reaction times of selected muscle in a stimulated ankle sprain. Am j Sports mede. 1997; 25(4): Shigematsu R, Chang M, Yabushita N, et al. Dance based aerobic exercise may improve indices of falling risk in older women. Age Ageing. 2002;31(4): Wilson EL, Madigan ML, Davidson BS, et al. Postural strategy changes with fatigue of the lumbar extensor muscles. Gait Posture. 2006;23(6):

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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