체간안정성강화운동이뇌졸중환자의균형및에너지소모량에미치는효과 : 단일사례연구 김희한, 정경만 원광대학교병원물리치료실 대한심장호흡물리치료학회지제 5 권제 1 호, PP The Effect of Core Stability Exercise on Balanc

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1 체간안정성강화운동이뇌졸중환자의균형및에너지소모량에미치는효과 : 단일사례연구 김희한, 정경만 원광대학교병원물리치료실 대한심장호흡물리치료학회지제 5 권제 1 호, PP The Effect of Core Stability Exercise on Balance and Energy Consumption in Stroke Patients : Single-Subject Research Design Hee-Han Kim PT, MSc, Kyeoung-Man Jung PT, PhD Dept. of physical Therapy, Wonkwang University Hospital Purpose : This study was to determine the effect of core stability exercise on balance and energy consumption during walk in stroke patients. Method : This study used a single subject research design. The subjects were participated two stroke patients and received general rehabilitation therapy five times per week. The core stability exercise program was modified from preceding studies and composed of trunk muscle strengthening exercise. The balance of was evaluated by Timed Up and Go Test (TUG), the energy consumption was measured by the energy expenditure index (EEI) as the difference of heart rate, in a session. Result : The results of the evaluation in each subject were indicated that the balance test was improved, energy expenditure index were decreased during the intervention period. These effects were maintained even during the regression baseline period. Conclusion : These results showed that core stability exercise was effective in the improvement of balance and decrease energy consumption. This study suggests that core stability exercise is effective in the improvement of energy efficiency during walk in stroke patients. Key words : Balance, Core stability exercises, Energy consumption, Stroke Received: November 24, 2017 / Revised: December 11, 2017 / Accepted: December 20, 2017 Ⅰ. 서론뇌졸중환자는주로뇌손상반대측신체에발생하는근약화, 감각결손, 운동장애, 인지장애등을포함해자세조절에문제를가지게된다 (de Oliveira 등, 2008). 마비측의근력약화는뇌졸중후유증으로가장일반적인증상이며, 상지와하지및체간근육에발생한다 (Dickstein 등, 2000). 뇌졸중으로인한체간근력과고유수용성감각의저하는지구력과균형능력을감소시켜 (Karatas 등, 2004), 일어서기와보행과같이동적균형이요구되는일상생활에장애를유발해환자의삶의질을저하시킨다 (Dickstein 등, 2004). 인간의균형유지를위해체간은사지의움직임이발생하기이전에반응하여신체의동요를최소화하고안정성을제공하므로, 원위부의선택적인움직임이가능하도록한다 (Girolami 등, 2011). 뇌졸중환자의균형능력증진을위해제공되는체간안정화운동은체간근의협력수축작용을통해요추부에기능적안정성이제공되어자세조절 능력이향상되므로뇌졸중환자의균형능력과보행능력을향상시킬수있는효과적인운동방법이다 (Chung 등, 2013). 인간의효율적인보행을위해양하지의교대적인움직임이중요한데, 이때무게중심점의이동이수직과좌우방향의작은범위내에서유지될때역학적에너지와생리적에너지소비가최소화될수있다 (Waters와 Mulroy, 1999). 뇌졸중환자는비대칭적인자세로보행시하지의율동적인움직임감소와체중이동능력의저하로불안정성이증가되는데, 이때균형을유지하기위해무게중심을낮추어안정성을확보하는굴곡근위주의균형전략을사용한다. 이때굴근의활성도가과도하게증가되어정상인에비해에너지소모가증가되므로근피로와지구력의문제가초래된다 (Franceschini 등, 2013). 뇌졸중환자는신체적, 인지적결손을보상하기위한과도한노력으로심한피로가발생하는데 (van der Werf 등, 2001), 특히보행중에너지소모량은정상인과비교했을때두배정도높다고하였다 (Detrembleur 등, 2003). Houdijk 등 (2009) 은건강한사 교신저자 : 정경만주소 : 전북익산시무왕로 895, 전화 : , future1347@naver.com 체간안정성강화운동이뇌졸중환자의균형및에너지소모량에미치는효과 : 단일사례연구 25

2 대한심장호흡물리치료학회지제 5 권제 1 호, 2017 람을대상으로안정된기립상태를유지할때보다불안정한기립상태를유지될때신체에서소모되는에너지가최대 60% 까지증가함을통해신체의안정성과에너지소모량사이에직접적인상관관계가있음을보고하였다. 또한 Koyama 등 (2012) 도신발바닥이불안정한신발을신고보행할경우안정된신발을착용한경우보다에너지소모량이증가하였다고보고하였다. 따라서균형능력의정도는에너지소모량에직접적인영향을미칠수있고균형능력회복은에너지소모량을줄이는데중요한요소이다 (Houdijk 등, 2010). 그럼에도불구하고뇌졸중환자를대상으로체간안정화운동에대한균형능력과보행능력증진에대한효과들이입증되고있지만, 에너지소모량에미치는영향에관한연구는아직까지미흡한실정이다. 또한뇌졸중환자를대상으로에너지소비측면에서보행장애와기능적수행능력의변화에대한객관적자료는더욱부족한실정이다. 이에본연구는체간안정화운동이뇌졸중환자의균형능력과에너지소모량에미치는영향을확인하여효과적인임상적중재방법을제시하고자한다. Ⅱ. 연구대상및방법 1. 연구대상본연구의대상자는뇌졸중으로진단받은좌측편마비남자환자 2명을대상으로하였다. 대상자는뇌졸중진단을받은환자로재발되지아니한자, 실내에서 10m이상독립적보행이가능한자, 정형외과적문제가없는자, 한국형간이정신상태검사 (Mini Mental Status Examination-Korean version; MMSE-K) 상 24점이상인자 (Kwon과 Park, 1989) 로하였다. 대상자들의보행능력수준은독립적으로 10분이상보행이가능하였고, 하지도수근력검사 (manual muscle test; MMT) 상고관절 (hip joint) 과슬관절 (knee joint) 의근력은모두 Fair- 이상이었고, 발목관절의배측굴곡 (dorsiflexion) 과저측굴곡 (plantarflexion) 은모두 Poor+ 이었다. 수동관절가동범위는모두정상범위를보여관절제한이나타나지않았다. 대상자들은본연구의목적과실험일정에대해설명을듣고서면으로연구참여에직접동의하였다. 연구대상자의일반적인특성은표1과같다 (Table. 1). 2. 연구설계 본연구는단일사례연구방법 (single-subject research design) 중 ABA 디자인을사용하였다. 총실험은 20회기로기초선과정 (Baseline phase) A와회귀과정 (Baseline phase) A' 는체간안정화운동을실시하지않는기간으로각 5회의기초자료를수집하였고, 중재과정 (Intervention phase) B는체간안정화운동을실시하는기간으로총 10회, 1일 1회, 회당 40 분씩적용후기초자료를수집하였다. 3. 평가방법 본연구에서는뇌졸중환자의균형능력을평가하기위해일어나걸어가기검사 (Time Up & Go Test, TUG) 와에너지소모량을평가하기위해에너지소비지수 (energy expenditure index, EEI) 를사용하였다. 1) 균형능력검사 일어나걸어가기검사는동적균형능력을알아보는평가방법으로기본적인운동성과균형능력을빠르게측정할수있는검사방법이다. 측정자내신뢰도는 r=.99이고, 측정자간신뢰도는 r=.98로신뢰할만한도구이다. 본연구에서대상자는 시작 이라는구령에의해의자에서일어나전방 3m를걸어간후돌아와의자에다시앉는시간을측정하였으며, 3회측정하여평균값을구하였다 (Podsiadlo와 Richardson, 1991). 2) 에너지소모지수측정 대상자의심박수를측정하기위해가슴에전극을부착하고의자에앉아편안한상태로휴식후안정기심박수를 5분간측정하여분당평균심박수를계산하였고, 편안한속도로 5분동안트레드밀보행에서마지막 3분에대한분당평균심박수를측정하였다. 측정장비는미국 CARDIAC SCIENCE사의 Quinton Q-stress를사용하였으며, 보행시심박수에서안정시심박수차이를보행속도로나눈값으로측정하여기록하였다 (Lee와 Shin, 2010). 에너지소모지수 (EEI) = 보행중심박수 - 안정기심박수보행속도 Table 1. General Characteristic of the subjects Subject sex age(yrs) paretic side height (cm) weight (kg) time since stroke (week) 1 M 63 Left M 58 Left The Effect of Core Stability Exercise on Balance and Energy Consumption in Stroke Patients : Single-Subject Research Design

3 김희한, 정경만 4. 연구절차대상자는일반적인재활치료를매일시행하였고, 오후재활치료시간이종료된후중재와평가를시행하여자료를수집하였다. 측정결과의일관성을유지하기위해가급적중재와평가중에는음식물을섭취하지않도록권장하였고, 운동을담당하는치료사와평가를담당하는치료사를분리하여진행하였다. 5. 중재방법본연구는 4주간실험을실시하였으며체간안정화운동프로그램은회당 40분주 5회로총 10회실시하였다. 체간안정화운동프로그램은 Akuthota 등 (2008) 이제시한체간근의선택적근력강화운동을본연구에맞게수정보완하여적용하였다 (Table 2). 6. 분석방법본연구는뇌졸중환자에서체간안정화운동이균형과에너지소모량에미치는효과를알아보기위해각세션동안반복측정하여결과를기록하였고, 측정된자료는그래프를이용한시각적분석방법과기술통계량을통해분석하였다. Ⅲ. 연구결과 1. 동적균형변화동적균형검사의측정결과대상자 1은기초선 A에서평균 30.4초, 중재기 B에서는평균 26.65초, 회귀기초선 A' 에서는평균 25.12초로나타났으며, 기초선 A에비해중재기 B는평균 12.35% 가감소되었고, 회귀기초선 A' 는평균 17.36% 가감소된것으로나타났다. 대상자 2는기초선 A에서평균 30.12초, 중재기 B에서는평균 26.4초, 회귀기초선 A' 에서는평균 26.6초로나타났으며, 기초선 A에비해중재기 B는평균 12.36% 가감소되었고, 회귀기초선 A' 는평균 15.04% 가감소된것으로나타났다 (Fig 1). 2. 에너지소모지수변화편안한보행속도에서에너지소모지수측정결과대상자 1은기초선 A에서평균 1.16beat/min, 중재기 B에서는평균 0.91beat/min, 회귀기초선 A' 에서는평균 0.82beat/min로나타났으며, 기초선 A에비해중재기는평균 21.55% 가감소되었고, 회귀기초선 A' 는평균 29.31% 가감소된것으로나타났다. 대상자 2는기초선 A에서평균 1.13beat/min, 중재기 B에서는평균 1.02beat/min, 회귀기초선 A' 에서는평균 Table 2. Program of core stability exercise Warm-up (5min) * Breathing exercise * Stretching exercise Main exercise (core stability exercise) (30min) * Transversus abdominus (advance if able to perform 30reps with 8s hold) - Abdominal bracing - Bracing with heel slides - Bracing with leg lifts - Bracing with bridging * Paraspinals/multifidi (advance if able to perform 30reps with 8s hold) - Quadruped arm lifts with bracing - Quadruped leg lifts with bracing - Quadruped alternate arm and legs lifts with bracing Cool-down (5min) * Breathing exercise Fig 1. Change of timed up and go test score in session 체간안정성강화운동이뇌졸중환자의균형및에너지소모량에미치는효과 : 단일사례연구 27

4 대한심장호흡물리치료학회지제 5 권제 1 호, 2017 Fig 2. Change of energy expenditure index in session 0.93beat/min로나타났으며, 기초선 A에비해중재기는평균 9.74% 가감소되었고, 회귀기초선 A' 는평균 17.7% 가감소된것으로나타났다 (Fig 2). Ⅳ. 고찰체간안정화에관여하는근의활동은체간하부와골반주변에능동적안정성을제공하며 (Aluko 등, 2013), 이는걷기와달리기등과같이동적균형이요구되는기능적인움직임시예상하지못한자세적요동에자동적으로반응하여균형을유지하고 (Moseley 등, 2003), 효과적인보행을수행할수있도록한다 (Verheyden 등, 2006). 균형을유지할때자세가불안정해지면과도한보상작용으로굴근의활성도가증가되고에너지소모가높아져기능적인움직임시쉽게근피로가유발된다 (Massaad 등, 2010; Zamparo 등, 1995). 뇌졸중환자의피로유발은 39~72% 에서보고되고있을정도로빈번하며, 성공적인재활에장애요인으로환자의삶의질에부정적인영향을미친다 (Snaphaan 등, 2011). 따라서일상생활에서많은부분을차지하는보행중발생하는에너지소비를최소화시키는것은근피로를줄이는데중요한요소이다. 이에본연구는뇌졸중환자를대상으로체간안정화운동을적용하여보행시에너지소모량에미치는효과를알아보고자시도되었다. 본연구에적용한체간안정화운동프로그램은 Akuthota 등 (2008) 이제시한요부와골반의안정성증진을위해심부에있는복횡근을포함한체간근에점진적인근력강화를제공할수있는운동방법수정보완하여적용하였다. 본연구의동적균형검사는측정자간신뢰도가높은일어나걸어가기검사를사용하였다. 연구결과대상자 1은체간안정화운동을수행하지않는기초선보다운동을수행하는중재기와운동이종료된이후회귀기초선에서소요시간이감소되어동적균형이향상된것으로나타났다. 대상자 2도기초선보다중재기와회귀기초선에서동적균형이향상된것으로나타났다. 두명의대상자에서모두체간안정화운동후동적균형능력이향상된것으로나타났다. Chung 등 (2013) 이뇌졸중환자를대상으로체간안정화운동프로그램을주3회씩 4주간적용하여일어나걸어가기검사점수가실험군에서유의하게감소되었다는결과와일치한다. 또한 Song과 Kim(2010) 의연구에서뇌졸중환자를대상으로체간안정화운동을 8주동안시행한결과올바른자세정렬을통한동적균형능력이향상되었다는연구결과와유사하다. 체간근육은대뇌에서교차신경지배를받기때문에마비정도가상대적으로심하지않고잠재력이잘보존되어있으므로적절한중재에의한근력회복은효과적이다 (Dickstein 등, 1999). 인간의보행은신경계의통합과정으로균형을유지하면서최소한의에너지소모를통해신체를원하는장소로이동시키다 (Kim 등, 2009). 그러나뇌졸중환자는균형능력의감소로에너지소모가증가되어정상인에비해에너지의효율성이저하된다 (da Cunha 등, 2002). 본연구에서는보행의에너지효율성을평가하기위해임상에서간편하게에너지소모량을측정할수있는방법으로제시된에너지소비지수를사용하였는데, 이러한방법은심박수와산소섭취량사이에선형비례가있으므로지수화하여사용할수있다 (Rose 등, 1991). 본연구의에너지소모지수측정결과대상자 1은체간안정화운동을수행하지않는기초선보다수행하는중재기와회귀기초선에서감소된것으로나타났다. 대상자 2도기초선보다중재기와회귀기초선에서감소된것으로나타났다. 두명의대상자에서모두체간안정화운동이보행시에너지소모지수를감소시키는데효과적이었고, 운동이종료된이후에도효과가일정기간동안지속되는것으로나타났다. Lee와 Shin (2010) 은만성뇌졸중환자를대상으로흥미를유발할수있는게임운동프로그램을통해주3회, 6주간매일 1 시간씩가상현실운동프로그램을적용한결과에너지소모지수가유의하게감소하여보행효율성이증진되었다고하였다. 대칭적인하지움직임을위한선행요건으로체간안정성이요구되는데, 본연구에서시행된체간안정화운동도체간근을강화하고올바른자세정렬을통해보행시에너지소모지수가감소된것으로사료된다. 균형장애로불안정성이증가되면근육 28 The Effect of Core Stability Exercise on Balance and Energy Consumption in Stroke Patients : Single-Subject Research Design

5 김희한, 정경만 에서발생하는긴장도, 협력수축이증가되고관절모멘트가변경되어신체가수행하는전체적인기계적일이증가하게되므로효율성이감소되지만 (Detrembleur 등, 2003; Grimby, 1983), 신체분절의정확한체감각정보를통한자세조절능력의향상은신체의안정성을증진시켜보행시에너지소모를최소화하는데효과적이다 (Ijmker 등, 2013). 본연구에서체간안정화운동프로그램을두명의뇌졸중환자에게적용한결과동적균형이향상되었으며에너지소모량을나타내는에너지소모지수가감소하여보행에너지소모측면에서효과적이었으며, 뇌졸중환자를대상으로에너지소모량을감소시킬수있는중재방법으로향후진행될수있는연구의기초자료로제시할수있겠다. 본연구의제한점으로는대상자가트레드밀보행이가능한환자중 2명으로제한하였기때문에보행장애가있는뇌졸중환자들에게적용하기에는무리가있지만, 단일사례연구로진행되어향후연구에기초자료로사용할수있도록하였으며, 반복되는평가에대해학습화과정을적절하게제한하지못하였다. 향후많은수의대상자를통해보행효율성측면에서에너지소비를최소화할수있는연구가진행되어야할것으로생각된다. Ⅴ. 결론 본연구는체간안정화운동이두명의뇌졸중환자의균형과에너지소모량에미치는영향을알아보고자한것이다. 개별실험연구설계중 ABA 디자인을사용하였고, 총실험은 20회기로기초선과정 5회와회귀과정 5회는체간안정화운동을시행하지않는기초자료수집기간이었고, 중재기 10회는주5일, 1일 40분씩체간안정화운동을시행하였다. 그결과, 중재기동안의체간안정화운동시행후균형이향상되었으며, 에너지소모지수가감소하여에너지소비가감소된것으로나타났다. 또한운동이종료된이후에도일정기간동안효과가지속되는것으로나타났다. 이러한결과로볼때추후임상에서체간안정화운동을적용할때참고사항이될수있을것이며, 향후더많은뇌졸중환자를대상으로한연구가이뤄져야할것으로생각된다. 참고문헌 Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med Rep. 2008;7(1): Aluko A, DeSouza L, Peacock J. The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial. J Manipulative Physiol Ther. 2013;36(8): Chung EJ, Kim JH, Lee BH. The effects of core stabilization exercise on dynamic balance and gait function in stroke patients. J Phys Ther Sci. 2013;25(7): da Cunha IT Jr, Lim PA, Qureshy H, et al. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: a randomized controlled pilot study. Arch Phys Med Rehabil. 2002;83(9): de Oliveira CB, de Medeiros IR, Frota NA, et al. Balance control in hemiparetic stroke patients: main tools for evaluation. J Rehabil Res Dev. 2008;45(8): Detrembleur C, Dierick F, Stoguart G, et al. Energy cost, mechanical work, and efficiency of hemiparetic walking. Gait Posture. 2003;18(2): Dickstein R, Heffes Y, Laufer Y, et al. Activation of selected trunk muscles during symmetric functional activities in poststroke hemiparetic and hemiplegic patients. J Neurol Neurosurg Psychiatry. 1999;66(2): Dickstein R, Sheffi S, Ben Haim Z, et al. Activation of flexor and extensor trunk muscles in hemiparesis. Am J Phys Med Rehabil. 2000;79(3): Dickstein R, Shefi S, Marcovitz E, et al. Anticipatory postural adjustment in selected trunk muscles in post stroke hemiparetic patients. Arch Phys Med Rehabil. 2004;85(2): Franceschini M, Rampello A, Agosti M, et al. Walking performance: correlation between energy cost of walking and walking participation. new statistical approach concerning outcome measurement. PLoS One. 2013;8(2):e Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol. 2011;21(6): Grimby G. On the energy cost of achieving mobility. Scand J Rehabil Med Suppl. 1983;9: Houdijk H, Fickert R, van Velzen J, et al. The energy cost for balance control during upright standing. Gait Posture. 2009;30(2): Houdijk H, ter Hoeve N, Nooijen C, et al. Energy expenditure of stroke patients during postural control tasks. Gait Posture. 2010;32(3): Ijmker T, Houdijk H, Lamoth CJ, et al. Energy cost of balance 체간안정성강화운동이뇌졸중환자의균형및에너지소모량에미치는효과 : 단일사례연구 29

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NEUROTHERAPY 대한신경치료학회지정경만제20, 권정유진제2호 체간안정화운동이만성뇌졸중환자의보행속도및에너지소모량에미치는효과 : 단일사례연구 정경만 1, 정유진 2 1 원광대학교병원물리치료실, 2 원광대학교병원작업치료실 Effect of trunk

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