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1 Brain & NeuroRehabilitation Vol. 6, No. 2, September, 뇌신경계질환에서균형및협조운동훈련 연세대학교의과대학재활의학교실및재활의학연구소 조성래 Balance and Coordination Training for Brain Disorders Sung-Rae Cho, M.D., Ph.D. Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine Neuromuscular coordination is the process in the activation of muscle contraction patterns with appropriate forces and sequences coupled with simultaneous inhibition of other muscles to carry out desired activity. Through coordination training, engram can be developed as automatic preprogrammed multi-muscular patterns in extrapyramidal system by repetitive training millions of time, whereas control is the ability to voluntarily activate a single muscle in pyramidal system with conscious awareness. The development of coordination depends on voluntary repetition of precise performance with simple components until engram is formed. Balance training begins with therapeutic standing using a tilt table and a prone stander. Thereafter, patients with stable static posture proceed to dynamic balance training and progressive gait training using parallel bars and gait aids such as walker or cane. Balance training as a comprehensive early rehabilitation program can effectively improve balance performance. As a therapeutic modality for balance and coordination, neurologic music therapy for sensorimotor training consists of rhythmic auditory stimulation (RAS), patterned sensory enhancement, and therapeutic instrumental music performance (TIMP). RAS has been shown to increase the effect of gait training by stimulating reticulospinal tract in extrapyramidal system as the underlying mechanism. TIMP using keyboard playing has been introduced as therapeutic modality to enhance sequential and programmed coordination with precise execution and independent movement of individual fingers. Therefore, clinical application of neurologic music therapy might be considered to improve balance and coordination in patients with neurological diseases. (Brain & NeuroRehabilitation 2013; 6: 68-72) Key Words: balance, coordination, neurologic music therapy, rhythmic auditory stimulation, therapeutic instrumental music performance 서론 균형 (balance) 및협조운동 (coordination) 은기저핵 (basal ganglia), 소뇌 (cerebellum) 뿐만아니라해마 (hippocampus), 시상 (thalamus), 뇌간 (brain stem), 대뇌피질 (cerebral cortex) 및척수 (spinal cord) 의종합된활동에의해서이루어진다. 또한관절과근육의운동에서나오는구심성감각을통한적절한감각되먹이기 (sensory feedback) 정보가균형및협조운동을조절하는데중요하다. 따라서균형및협조운동의이상은뇌졸중, 뇌성마비, 파킨슨병및근긴장이상증 (dystonia) 등과같은다양한신경계질환에서발생하며, 병변부위에따라임상적으로특징적인비정상적형 교신저자 : 조성래, 서울시서대문구신촌동 , 연세의료원재활병원재활의학과 Tel: , Fax: srcho918@yuhs.ac 본논문은교육과학기술부한국연구재단의미래기반기술개발사업 ( ) 의지원을받아작성된논문임. 태가발생한다. 이러한균형및협조운동에필요한요소는 1) 관절가동범위및근력과같은생체역학적요소, 2) 시각, 전정기능, Table 1. Resources Required for Balance and Coordination Training Resources Biomechanical Sensory Motor/movement Cognitive Detailed items Range of motion Strength Visual sense Vestibular sense Somatosensory sense Propriocetive sense Sensory integration Reactive movement Voluntary movement Attention Learning Spatial orientation 68

2 조성래 : 뇌신경계질환에서균형및협조운동훈련 체성감각, 관절고유감각및감각통합기능과같은감각요소, 3) 반사적및자발적운동요소, 4) 집중력, 학습능력및공간개념과같은인지적요소등이있으며, 이들을강화시키는치료가모두균형및협조운동훈련이될수있다 (Table 1). 본논문에서는균형및협조운동훈련에대한개요를살펴보고, 이를강화시키는치료법중하나인신경학적음악치료에대해기술하고자한다. 본론 1) 신경근육협조운동 (Neuromuscular coordination) 협조운동은원하는활동을수행하기위해, 적절한힘과연속동작의근육수축과정에의한운동으로, 원하는활동에필요하지않은근육수축은동시에억제되어야한다. 이러한협조운동은주로추체외로계 (extrapyramidal system) 를통한프로그램화되어있는활동으로, 예를들어수백만번이상의반복훈련에의해엔그람 (engram) 이형성되고내재화되어여러근육에서자동적인활동이나타나게된다. 이와반면에, 의식하는상태에서추체로계 (pyramidal system) 를통해필요한근육을자발적으로수축하는조절 (control) 능력에의해원하는활동이일어나게된다. 2) 협조운동훈련 (Coordination training) 협조운동훈련의목적은원하는활동을위해각각의근육을자발적으로사용하는조절능력에비하여더빠르고, 정확하고, 강한패턴으로협조운동능력을향상시키는것이다. 앞서기술한바와같이, 이러한협조운동훈련은추체외로계를통해무의식적이고, 자동적으로진행되므로, 피질척수로 (corticospinal pathway) 에의해조절되는능력에비해빠르고, 강하며, 복잡하고, 숙련된근육수축이일어나게된다. 즉, 엔그람은반복훈련에의해형성되며, 이러한엔그람이자동적으로형성될때까지는정확한동작으로자발적인반복운동을시행하여야하며, 반대로원하지않는비정상적인패턴은억제시켜야한다. 협조운동훈련의방법으로정확한동작을수행할수있도록단순한동작부터훈련해야한다. 이러한단순화작업은정확한동작의빈도를일정하게증가시키며, 비정상적인패턴으로활동하는비율을낮추게된다. 즉, 정확한동작으로활동하는훈련을반복적으로시행함으로써, 중추신경계내에협조운동에대한엔그람을형성시킬수있다. 이후정확한동작수행이지속되는범위내에서반복훈련 의강도를증가시켜, 환자가정확한동작을수행할수있는최적의능력으로향상시켜야한다. 이러한협조운동훈련은결과적으로내재된능력을강화시키고, 심리적인보상 (reward) 효과도있게된다. 3) 균형훈련 (Balance training) 자동적인자세균형은앞서설명한협조운동에의해서제공되므로, 보행과같은동작을수행하기전에, 먼저중력에대해머리및신체의안정된자세가형성되어야한다. 즉, 균형장애소견을보이는환자들은경사침대 (tilt table) 및 prone stander 기구를사용하여, 먼저치료적목적의바로서기훈련을시행하고, 이후안정된자세가형성되면 parallel bar 및보행보조도구인 walker 또는 cane 등을이용하여, 기능적목적의동적 (dynamic) 균형훈련및보행훈련을시행하게된다. 또한기본적으로하지근력을향상시키기위한근력운동과관절고유감각을포함한여러감각기능을향상시키기위한감각자극훈련을시행하여야한다. 최근에는 EMG 및 force platform biofeedback을통한동적균형훈련을시행할수있으며, 독립적인보행이불가능한환자의보행훈련으로부분체중부하트레드밀및로봇을이용한점진적보행치료도가능한상태이다. 4) 균형훈련의효과뇌신경계질환에서균형훈련의효과에대한기존의보고를살펴보면, 급성기뇌졸중환자에서전문적인균형훈련프로그램후 Berg balance scale (BBS) 등으로평가된균형능력이향상되었다고보고된다. 1-5 그러나, 대부분의연구에서기본물리치료를시행받은대조군도모두균형능력이향상되어, 두군간의비교에서유의한차이를보이지않았으므로, 이에대한해석에는주의를요한다. 1-4 특히, 급성기인경우주 5회, 90분이상으로운동을시행하는것은과하여몸에무리가될수있다. 1 만성기뇌졸중환자에서도개별화된균형훈련및그룹치료프로그램이효과가있으며, 6,7 치료를받지않는경우균형능력이악화될수있으므로, 지속적인관리가반드시필요하다. 7 본논문에서는운동프로그램의종류에따라유산소운동, 포괄적균형운동및감각자극운동등으로나누어균형훈련의효과를아래와같이살펴보았다. (1) 유산소운동 (Aerobic exercise) Au-Yeung 등은만성기뇌졸중환자에서총 12주동안 tai chi 운동을시행하였을때, 전후및좌우로무게중심의이동 (shifting) 능력이향상되었고, 이후 6주동안치료효과가지속되었다고보고하였다. 8 그러나, Timed up and 69

3 Brain& NeuroRehabilitation:2013; 6: 68~72 go test로평가된기능적이동 (mobility) 능력은대조군에비해유의한차이를보이지않아, 상기운동은서기균형능력은향상시키나, 보행기능까지는향상시키지못하는것으로생각된다. 한편 Barbeau 및 Visintin 은아급성기뇌졸중환자에서주 4회, 총 6주동안체중지지하에보행훈련을시행하였을때, 중증장애및 65 85세의노인환자에서균형능력이향상됨을보고하였다. 9 즉, 보행훈련을시행하는경우, 보행기능뿐만아니라, 균형능력도같이향상되는소견을보였다. 또한, Noh 등은만성기뇌졸중환자에서하루 1시간, 주 3회, 총 8주동안수중치료 (aquatic therapy) 를시행하였을때, BBS 점수및무게중심이동능력과하지근력이대조군에비해유의하게향상되는소견을보고하였다. 10 (2) 포괄적재활운동 (Comprehensive exercise) 아급성기뇌졸중환자에서하루 90분, 총 12 14주동안치료사와일대일로포괄적인재가 (home-based) 재활운동프로그램을시행하였을때, 대조군에비해 BBS 점수가유의하게향상되었고, 이차뇌졸중발생율도감소하였다. 11 그러나, 급성기뇌졸중환자에서는기본적인자가 (self-initiative) 운동만으로도집중적인재활치료를받은경우와유사한효과가있었고, 12 만성기뇌졸중환자에서는상지운동프로그램만시행한대조군과도유사한소견을보여, 뇌졸중후조기치료가더중요한요소로생각된다. 13 (3) 감각자극훈련 (Multisensory training) Marigold 등은만성기뇌졸중환자에서여러종류의감각자극프로그램을통한 agility 운동을시행하였을때, step reaction time에서유의하게향상된소견을보여, 낙상빈도를줄일수있는효과가있다고보고하였다. 14 그러나, 여러연구에서감각자극을시행한경우, BBS 점수로평가된균형능력은대조군에비해유의한차이를보이지않았고, 14,15 기본재활치료에감각자극훈련을추가한경우에도상승효과를보이지않아, 16 감각자극훈련만으로는균형능력의증진에효과적이지않은것으로판단된다. 5) 신경학적음악치료 (Neurologic Music Therapy) 신경계질환환자의재활에적용되는여러치료법중음악을이용한신경학적음악치료는신체, 언어, 인지기능의재활을중심으로이루어지는음악치료영역내특수기법으로음악에대한신체반응에대한과학적연구를바탕으로개발되었다 (Table 2). 이러한신경계환자의균형및협조운동기능을향상시키려는신체재활을위해리듬청각자극 (rhythmic auditory stimulation), 패턴화된감각증진 (patterned sensory enhancement) 및치료적악기연주 (therapeutic instrument music performance) 와같은세가지방법을사용할수있다. 리듬청각자극기법은주로보행훈련을위해연구가활발히진행되었는데, 규칙적으로제공되는청각자극이뇌로전달되어움직임에대한단계별근육움직임의준비뿐만아니라효율적인보행을유도하는기법이다. 17 또한패턴화된감각증진기법은구체적인리듬패턴을통해일상생활에필요한기능적운동을다시배우고연습하는목적으로사용되며, 치료적악기연주는악기를이용한상지운동을통해기능적인움직임을유도하도록개발되어손가락의협조운동의향상을위한목적으로활용된다. (1) 리듬청각자극 (Rhythmic Auditory Stimulation; RAS) 리듬청각자극은음악적요소인리듬이신체의움직임에영향을줄수있는특성을이용하여, 보행훈련에사용하는신경학적음악치료법중하나이다. 규칙적으로제공되는청각자극인리듬은환자에따라개별적으로적용하여보행속도, 분속수 (cadence) 및패턴등을일정하게유도함으로써최대한효율적으로보행할수있도록한다 Thaut 등은반복적인외부청각자극이내부신경계에영향을주어, 청각자극과근육의움직임이동조화 (entrainment) 되고신체의움직임을보다효율적으로조절할수있다고제안하였다. 20,21 즉, 근육운동을조절하는추체외로계인망상척수로 (reticulospinal tract) 를자극하여, 대뇌피질을통과하지않고피질하영역에서정보가처리되어 Table 2. Classification of Neurologic Music Therapy Classification Sensorimotor training Speech and language training Cognitive and psychological training Detailed items Rhythmic audiatory stimulation (RAS) Patterned sensory enhancement (PSE) Therapeutic instrumental music performance (TIMP) Melody intonation therapy (MIT) Attention training Memory training Psychosocial behavior training 70

4 조성래 : 뇌신경계질환에서균형및협조운동훈련 무의식적으로신체의움직임을유도하는것으로추정된다. 22 이러한이론은신경학적손상에의해내부의리듬신호가정상적으로이루어지지않을때, 외부청각자극을제공하여신체의움직임이원활해진다는근거를제시하였고뇌졸중, 21,23 외상성뇌손상, 19,24 파킨슨병, 23,25 뇌성마비 26,27 등의중추신경계질환에서보행개선에효과적인것으로보고되었다. 특히, 김등은뇌성마비성인에서리듬청각자극을통한보행훈련을시행하였을때, 비정상적인골반전방경사및고관절굴곡패턴이특징적으로감소되는소견을보고하였다. 26,27 (2) 패턴화된감각증진 (Patterned Sensory Enhancement; PSE) 패턴화된감각증진기법은간단한리듬패턴뿐만아니라구체적이고기능적인리듬패턴을이용하여일상생활에필요한기능적운동을다시배우고연습하는치료법이다. 예를들면, 팔을뻗어서물체를잡는동작을위하여, 팔을뻗을때의리듬, 손을펴는리듬, 물체를잡을때의리듬과같은세가지의리듬패턴을통해훈련할수있다. 즉, 음악적요소인리듬, 멜로디, 하모니등을통해일상생활에필요한기능적운동과활동에필요한시간및공간적신호와힘의신호를제공하여, 팔과손의움직임, 옷입기, 앉았다일어나는동작등을훈련할수있다. (3) 치료적악기연주 (Therapeutic Instrumental Music Performance; TIMP) 치료적악기연주는건반악기또는타악기를사용하여상지의기능적인움직임패턴을향상시키려고개발된치료법이다. 악기의선택, 연주방법의응용, 연주자세의변형등을통해손가락의민첩성, 독립적인움직임의증진, 협응력증진, 손가락의움직임범위확장, 악력및근력의향상을위한목적으로활용된다. 최근에는건반연주를통한손가락기능의향상을확인하고자 MIDI (Musical Instrument Digital Interface) 라는컴퓨터소프트웨어를키보드에연결하여건반을누르는강도와연주템포를측정하여효율적인재활프로그램으로서활용이가능하다. 치료적악기연주에관련된연구는주로뇌졸중환자를대상으로이루어지고있으며수지악력, 기민성등의상지기능향상에대한긍정적인결과를나타났다 또한외상성뇌손상, 뇌출혈, 뇌종양등의다양한뇌손상환자에서도상기치료를통해손가락움직임의속도및건반누르는강도가증가하고, 수지기능검사결과가향상되는소견을보였다. 31 결론 본논문에서는신경근육협조운동에대한개념을살펴보았고, 협조운동훈련및균형훈련치료법을확인하였다. 또한, 뇌신경계질환환자에서균형훈련의효과에대한기존보고를살펴보고, 균형및협조운동을강화시키는치료법인신경학적음악치료를소개하였다. 이러한신경학적음악치료중에서운동및감각기능을향상시킬수있는방법으로리듬청각자극, 패턴화된감각증진및치료적악기연주가있으며, 특히리듬청각자극및치료적악기연주는각각보행및수지기능을향상시킬수있으므로, 신경학적재활치료의하나로고려해볼수있다고사료된다. 참고문헌 1) Allison R, Dennett R. Pilot randomized controlled trial to assess the impact of additional supported standing practice on functional ability post stroke. Clin Rehabil. 2007;21: ) Pyoria O, Talvitie U, Nyrkk H, Kautiainen H, Pohjolainen T, Kasper V. The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study. Dis Rehabil. 2007;29: ) Langhammer B, Stanghelle JK, Lindmark B. Exercise and health-related quality of life during the first year following acute stroke. A randomized controlled trial. Brain Inj. 2008; 22: ) Hidler J, Nichols D, Pelliccio M, et al. Multicenter randomized clinical trial evaluating the effectiveness of the Lokomat in subacute stroke. Neurorehabil Neural Repair. 2009;23: ) Chan DY, Chan CC, Au DK. Motor relearning programme for stroke patients: a randomized controlled trial. Clin Rehabil. 2006;20: ) Fritz SL, Pittman AL, Robinson AC, Orton SC, Rivers ED. An intense intervention for improving gait, balance, and mobility for individuals with chronic stroke: a pilot study. J Neurol Phys Ther. 2007;31: ) Stuart M, Benvenuti F, Macko R, et al. Community-based adaptive physical activity program for chronic stroke: feasibility, safety, and efficacy of the Empoli model. Neurorehabil Neural Repair. 2009;23: ) Au-Yeung S, Hui-Chan C, Tang J. Short-form tai chi improves standing balance of people with chronic stroke. Neurorehabil Neural Repair. 2009;23: ) Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Arch Phys Med Rehabil. 2003;84: ) Noh DK, Lim JY, Shin HI, Paik NJ. The effect of aquatic 71

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72 순천향의과학 : 제14권 2호 2008 Fig.1. Key components of the rehabilitation evaluation of patients with the rheumatic diseases. The ICF provides a good frame

72 순천향의과학 : 제14권 2호 2008 Fig.1. Key components of the rehabilitation evaluation of patients with the rheumatic diseases. The ICF provides a good frame Journal of Soonchunhyang Medical Science 14(2) p.71~82 December 2008 71 류마티스 관절염의 재활치료 오 기 영 순천향 대학교 의과대학 재활의학교실 Rehabilitation Interventions for the Patient with Rheumatoid Arthritis Ki-Young Oh Department