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1 Brain & Neuroehabilitation Vol. 5, No. 1, arch, 2012 만성뇌졸중환자에서하지균형조절훈련기의훈련효과 대구파티마병원재활의학과, 1 경북대학교의과대학재활의학교실 변승득ㆍ조동현ㆍ최원덕ㆍ홍용호ㆍ이지인ㆍ이양수 1 Effects of the Balance Control Training in Chronic emiplegic Stroke Patients Seung Deuk Byun,.D., Dong yun Cho,.D., Won Duck Choi,.D., Yong o ong,.d, Zee hn ee,.d. and Yang Soo ee,.d. 1 Department of ehabilitation edicine, Dae-gu atima ospital, 1 Department of ehabilitation edicine, Kyung Pook National University College of edicine Objective: To investigate the training effects on balance and gait ability using balance control trainer combined with partial weight-bearing system in chronic hemiplegic stroke patients. ethod: A prospective crossover clinical trial was designed. The subjects consisted of 16 chronic hemiplegic stroke patients. All patients had a stroke more than six months. n addition to conventional physical therapy (PT), patients in group A were trained with the balance control trainer for 0 min/day, 5 day/week, for first 2 weeks and then received only conventional physical therapy for 2 weeks. The other patients in group B received only conventional PT for first 2 weeks and then were trained with the balance control trainer for 0 min/day, 5 day/week, for next 2 weeks, with additional conventional PT. We evaluated with clinical tests including functional ambulation categories (AC), Berg balance scale (), 6 min walking distance (6mWT), timed up and go (TUG), Korean-modified barthel ndex (K-B) and muscle strengthening of knee extensor (T knee) before training, 2 weeks and weeks after training in those patients. esults: After training, subjects in experimental period (2weeks period of conventional PT+Balance control trainer in group A&B) showed more improvement than those in control period (2 weeks period of only conventional PT in group A&B) in AC,, 6mWT, TUG, K-B (p<0.05). Conclusion: We think the balance control trainer combined with the partial weight-bearing system can be a useful tool for improving balance and gait ability in chronic hemiplegic stroke patients. (Brain & Neuroehabilitation 2012; 5: 2-) Key Words: balance, physical therapy, stroke 서론 뇌졸중후편마비환자는기립시비대칭적자세를취하게되며, 1 비정상적인보행양상이나이동거리의제한등의보행이상이동반되는경우가많고, 이를개선하여최대한정상적인보행에도달하기위해다양한치료방법들이연구되고있다. 2-6 편마비환자에서효과적인자세균형및제어능력의증진은이를통한기립위안정성및체중부하조절력을향상시킬수있어매우중요하게생각되어지고있으며, 균형능력향상을위해다양한균형훈련시 접수일 : 2012 년 2 월 9 일, 1 차심사일 : 2012 년 월 5 일, 2 차심사일 : 2012 년 월 9 일, 게재승인일 : 2012 년 월 9 일교신저자 : 조동현, 대구시동구신암동 , 대구파티마병원재활의학과 Tel: , ax: naftacho@hanmail.net 스템 (balance training system) 이사용되고있다. 다양한균형훈련시스템은고정되어있는힘판위에서서시각및청각등의다양한되먹임기전을통해피검자가자신의압력중심점 (center of pressure, COP) 에대한움직임을보면서특정과제를수행하는것으로균형장애의평가및치료도구로써이용되고있다. -9 최근에는일반인들을대상으로시각적되먹임을이용하여균형훈련을통해게임을하도록하는 Wii fit balance board system (Nintendo co, Kyoto, Japan) 게임기가개발되어사용되고있으며, 이러한균형훈련은반복적인움직임의학습보다는문제를해결해가면서움직임을학습하는것이효과적이라는 Shumway-Cook의운동학습이론에기초를두고있다. 그러나, 힘판시각적되먹임치료를통한기립대칭성 (stance symmetry) 이기립균형의임상적평가에서뿐만아니라무게중심의수직이동이포함된 앉았다서기 와같은기능적동작의수행 (performance of functional activities) 까 2

2 변승득외 5 인 : 만성뇌졸중환자에서균형조절훈련기의훈련효과 ig. 1. Configuration of balance control trainer of lower extremity. 지개선시킨다는명확한증거는부족한상태이다. 11,12 또한일반인에게사용되고있는 Wii fit 게임기의경우안전성과난이도등의문제로편마비환자들에게적용하기에는어려움이있어그효과를연구하기에는제한이있다. 본연구의목적은체중의좌우수평적이동뿐만아니라, 슬관절의움직임을통한무게중심의수직이동요소를고려하여시각적되먹임과보다과제지향적인하지운동이가능하도록제작된하지균형조절훈련기를어느정도의기립및보행은가능하나균형감각의감소등으로인하여원활한보행에어려움이있는만성기편마비환자들에게적용한후, 균형및보행능력을향상을위한치료방법으로사용가능한지알아보고자하였다. 연구대상및방법 1) 연구대상뇌졸중으로입원한환자중고관절신전근력이 등급 (air) 이상으로기립상태를유지할수는있는발병후 6개월이상경과된만성기편마비환자들을대상으로하였다. 인지기능의저하 ( 간이정신상태검사상 2점이하 ) 가있거나, 시각및지각장애가심한경우, 하지근골격계의이상이나손상이있는경우, 고위험도의심장질환및다른중등도이상의내과적질환이있는경우는연구에서제외하였다. 또한치료중연속해서 회이상치료를받지못하거나전체치료횟수의 0% 를채우지못한자는연구에서탈락되도록하였다. 총 16명의환자를무작위로 A군 명과 B군 명으로분류하여연구를진행하였고, 모든환자들에게충분한정보를제공하여동의한경우연구에참여하도록하였다. 본연구는연구를시행한기관의임상연구윤리심의위원회의승인을받은후시행되었다. ig. 2. The balance control trainer of lower extremity consists of the Wii fit balance board which detects the degree of weight shifting to right or left side, tilting sensor which detects the degree of affected knee flexion, and the computerized system which enables to perform the apple harvesting game using these data. 2) 연구방법 (1) 하지균형조절훈련기본연구에사용된하지균형조절훈련기는현재하지재활훈련장치로상품화된 BalPro (an&tel co, Gumi, South Korea) 의원형 (prototype) 모델로서경북대학교의학전문대학원재활의학교실과경북대학교공과대학가상현실연구소가협력하여자체제작되었다. 하지균형조절훈련기는체중부하의좌우이동정도를감지할수있는센서가내장되어있는 Wii fit balance board system (Nintendo co, Kyoto, Japan), 슬관절각도를인식할수있는두개의기울기센서 (tilting sensor), 그리고, 이들정보들을이용한게임소프트웨어가포함된컴퓨터본체및시각적되먹임이가능한스크린으로구성되었다 (ig. 1). 또한기립상태로동적인체중이동시낙상의우려가있는대상환자들의안전을위하여체중탈부하시스템 ( 하네스및고정대 ) 을이용하였다 (ig. 2). Wii fit balance board system 을이용하여발판내부에내장된압력감지자 (pressure sensor) 들이환자의압력중심점을감지하여환자의체중의좌우이동에따라게임시표식자 (cursor) 가좌우로이동되도록하였다 (ig. ). 또한무릎바깥쪽으로붙여진두개의기울기센서 (tilting sensor) 들은슬관절신전및굴곡각도를인식하여게임시표식자가상하로움직이도록하였다 (ig. 2). 이들감지자들을이용하여체중의좌우이동및슬관절의신전

imaginary line drawn vertically through the center of mass and the surface of the balance boardand weight. The sensors on the board can accurately measure up to 150 kg (0 pounds).

3 Brain& Neuroehabilitation:2012; 5: 2~ ig.. The wii-fit balance board system has bluetooth and contains multiple pressure sensors that are used to measure the user's COP (center of pressure)-the location of the intersection between an imaginary line drawn vertically through the center of mass and the surface of the balance boardand weight. The sensors on the board can accurately measure up to 150 kg (0 pounds). 굴곡에따라화면상손모양의표식자가좌우및상하로이동하면서나무에무작위로달려있는사과열매를따는게임 ( 사과수확게임, apple harvesting game) 이시행되도록하였다 (ig. ). 사과수확게임은무작위로나무에열려있는사과를다땄을경우장면이바뀌면서새로운사과가나무에나타나도록제작되었다. (2) 고식적재활치료와하지균형조절훈련기를이용한훈련 A 군에서는기존의고식적재활치료와함께하지균형조절훈련기를이용한훈련을하루 0분, 주 5일, 2주간추가로실시하였고, 이후 2주간은고식적재활치료만시행하여총 주간훈련을시행하였다. B 군에서는첫 2주간은고식적재활치료만시행하였고, 이후 2주간은동일한방법으로고식적재활치료외에하지균형조절훈련기를이용한훈련을추가로시행하여총 주간훈련을시행하였다. 하지균형조절훈련기를이용한훈련은첫 분간은체중이동및슬관절의굴곡을하여스크린의커서를움직이는연습을시행하였으며그다음 20분간사과수확게임을실시하면서체중의좌우이동및슬관절의신전, 굴곡훈련을시각적되먹임을통하여반복하도록하였다. () 균형및보행능력의평가가 ) 임상적평가 : A 군과 B 군의모든환자총 16명을대상으로임상적평가척도로써버그균형지수 (Berg balance scale, ), 기능적보행분류 (functional ambulation categories, AC), 6분보행검사 (6 minute walking test, 6mWT), 일어나서걷기검사 (timed up and go, TUG), 한국형수정바델지수 ig.. This figure shows the apple harvesting game. According to weight shift to either side, the hand moves to right or left side, and according to the degree of knee flexion, the hand moves up or down side. When the hand touch apples on screen, apples disappear. When all apples have disappeared, apples re-appear on the screen randomly, and new game started. (Korean modified Barthel index, K-B), 그리고도수근력검사 (manual muscle test, T) 로슬관절신전근력을측정하였다. 나 ) 치료효과의평가 : 치료시작전, 치료시작 2주째, 그리고치료종료시점인치료 주째에평가를시행하였다. A 군의첫 2주동안의결과와 B 군의 2주에서 주사이의결과를더하여실험기간동안의변화를구하였고, A 군의 2주에서 주사이의결과와 B 군의첫 2주동안의결과를더하여대조기간동안의변화를구하여실험기간과대조기간의각평가항목들에대한호전정도를분석하였다. () 통계분석방법 통계분석은 window용 SPSS 12.0 version 을이용하였다. 실험기간과대조기간각각에서치료시작전과치료시작 2주뒤에평가한측정치들을 Wilcoxon signed rank test를이용하여평가하였으며두군간측정치들의변화의정도를비교하기위해 ann-whithey U-test를이용하였고, p value가 0.05 미만인경우통계적으로의미있는것으로해석하였다. 1) 대상환자들의특성 결과 대상환자들은총 16명으로이들중남자가 12명, 여자가 명이었고, 연령은평균 55.±12.6세, 유병기간은평균 9.9±.1개월이었다. 우측편마비환자가 명, 좌측편마비환자가 명이었고, 발병원인으로뇌경색이 11명,

4 변승득외 5 인 : 만성뇌졸중환자에서균형조절훈련기의훈련효과 Table 1. Demographic Data of Subjects Subject number Sex Age (years) Onset (months) Affected side Cause of stroke ocation of lesion T (knee extensor) ean ± S.D ± ±.1 CA CA CA ACA CA CA CA CA CA CA CA. ± 0.5 Values are mean ± S.D. : ale, : emale, : eft, : ight, : emorrhage, : nfarction, : Basal ganglia, CA: iddle cerebral artery, ACA: Anterior cerebral artery. Table 2. The easurement Values of Clinical Parameters at Pretraining Period Clinical parameters AC 6mWT TUG K-B T knee easurement values 2. ± ±. (meters) 2.0 ±.9 (sec) 6.5 ± ± 6.5. ± 0.5 Values are mean ± S.D. AC: unctional ambulation categories, 6mWT: 6-minute walking test, TUG: Timed up and go test, : Berg balance scale, K-B: Korean-modified barthel index, T: anual muscle test. Table. The Changes of Parameters in Experimental Period (n = 16) AC 6mWT (meters) TUG (sec) K-B T KNEE Before 2. ± ± ±.9. ± ± 6.. ± 0.5 After 2 weeks 2.9 ± 1.1* 215. ±.5* 1. ±.2* 2. ± 6.* 5.5 ±.*. ± 0.5 Values are mean ± S.D. AC: unctional ambulation categories, 6mWT: 6 minute walking test, TUG: Timed up and go test, : Berg balance scale, K-B: Korean-modified barthel index, T: anual muscle test. *p<0.05. 뇌출혈이 5명이었다 (Table 1). 2) 치료시작전균형및보행능력의평가결과총 16명의환자들에서치료시작전측정한버그균형지수 () 는평균 6.5 ± 6.6점, 기능적보행분류 (AC) 는평균 2. ± 0.점, 6분보행검사 (6mWT) 는평균 1.6 ±. 미터 (meters), 일어나서걷기검사 (TUG) 는평균 2.0 ±.9 초, 한국형수정바델지수 (K-B) 는평균 0.0 ± 6.5점, 슬관절신전근력은평균. ± 0.5이었다 (Table 2). ) 실험기간에서 2주간훈련후평가결과의비교실험기간의치료시작전과치료시작 2주뒤의측정결과 들을비교시슬관절신전근력을제외한버그균형지수 (), 기능적보행분류 (AC), 6분보행검사 (6mWT), 일어나서걷기검사 (TUG), 한국형수정바델지수 (K-B) 에서통계적으로유의하게호전된소견을보였다 (p<0.05)(table ). ) 대조기간에서 2주간훈련후평가결과의비교대조기간의치료시작전과치료시작 2주뒤의측정결과들을비교시 6분보행검사 (6mWT) 에서통계적으로유의하게호전된소견을보였고나머지임상적평가척도들에서는통계적으로유의한차이를보이지않았다 (p<0.05)(table ). 5

5 Brain& Neuroehabilitation:2012; 5: 2~ Table. The Changes of Parameters in Control Period (n = 16) AC 6mWT (meters) TUG (sec) K-B T KNEE Before 2.6 ± ± ± ±.6 2. ±.1. ± 0.5 After 2 weeks 2.6 ± ± 92.* 19. ±. 0.0 ± ±.5. ± 0.5 Values are mean ± S.D. AC: unctional ambulation categories 6mWT: 6 minute walking test, TUG: Timed up and go test, : Berg balance scale, K-B: Korean-modified barthel index, T: anual muscle test. *p< ) 실험기간과대조기간사이의 2주간훈련후호전정도의비교 실험기간과대조기간에서 2주간훈련후각임상적척도들의변화를절대값으로비교한결과실험기간에서버그균형지수 (), 기능적보행분류 (AC), 6분보행검사 (6mWT), 일어나서걷기검사 (TUG), 한국형수정바델지수 (K-B) 에서대조기간과비교하여통계적으로유의한차이를보여더의미있게호전된소견을보였다 (p<0.05)(table 5). 고 편측하지의체중부하감소로인한기립자세에서의체중부하의비대칭성은편마비뇌졸중환자에서흔히발생하는문제점중의하나로, 이는운동기능과일상생활동작수행을하는데부정적인영향을미치는것으로알려져있다. 1,1 따라서, 일반적으로편마비환자에서보행을위한재활치료시편측하지에체중부하를증진시키도록치료를우선적으로시행하고있다. 15,16 다양한균형훈련시스템과같은균형훈련기를이용한힘판시각적되먹임치료는이러한기립대칭성을보다효과적으로향상시킬수있는것으로보고되고있다. 1,1 그러나, Winstein 등 19 은 주간의시각적되먹임치료가기립시정적인대칭적균형능력을증진시킬수는있으나보행시하지의비대칭적양상을의미있게감소시키지는못하는것으로보고하였다. Nichols 20 와 Betker 등 21 은환자의참여도와순응도가증가하고낙상횟수의감소및무게중심의진폭범위를감소시킴을보고한반면, Geiger 등 22 과 Walker 등 2 의연구에서는동적및정적균형능력의전반에걸쳐유의한효과가없음을보고하였다. 또한힘판을이용한시각적되먹임치료가보행을포함한기능적동작의수행에있어의미있는향상을보인다는명확한증거는아직까지 찰 Table 5. Comparison of Changes in easurement Values of Clinical Parameters between Experimental Period and Control Period Clinical parameters AC 6mWT (meters) TUG (sec) K-B T knee Changes in experimental period 0. ± 0.5* 2.9 ± 2.0*.6 ±.9* 5. ± 2.* 5.2 ± 1.9* 0.2 ± 0. Changes in control period 0.0 ± ± ± ± ± ± 0.0 Values are mean ± S.D. AC: unctional ambulation categories, 6mWT: 6-minute walking test, TUG: Timed up and go test, : Berg balance scale, K-B: Korean-modified barthel index, T: anual muscle test. *p<0.05. 부족한상태이다. 2 이는독립적보행및일상생활동작의수행에있어필수요소인의자에앉은자세에서일어나거나다시앉는동작과같은무게중심의수직이동의요소가치료에포함되지않았기때문으로, 25-2 보행이나일상생활동작과관련된과제지향적 (task-specific) 학습이아니기때문으로생각된다. 본연구에서는균형및보행능력을평가혹은치료시이러한기능적동작의요소가반영되어야할것으로생각되어, 다양한균형훈련시스템의한계를보완하여체중의좌우이동뿐만아니라, 무게중심의수직적이동및슬관절조절의요소를반영할수있도록개발된하지균형조절훈련기를이용하였다. 또한본연구에서원활한보행에어려움이있는만성기편마비환자들을대상으로하였으므로훈련시가장중요하게생각한점이환자들의안전이었다. 이를위해체중탈부하시스템을사용하여안전을확보하고자하였고, 필요시고정대를손으로잡고지지가가능하도록하였다. 대상환자 16명중낙상이나탈락자없이높은순응도를보였다. 또한연구를진행중대부분의환자들에서고식적재활치료로다게임을통한과제지향적학습이훨씬더흥미롭고만족도가높다고답하였다. 현재까지뇌의자연적회복과가소성에대한대부분의연구에서발병후 6개월까지를대부분의회복이일어나는기간으로보고있다 본연구에포함된환자들은중등도이상의균형및보행능력의장애가있고 6개월이상경과된만성기의편마비환자들을대상으로하여자연적신경회복을배제하고자하였고, 고식적재활치료와함께하지균형조절훈련기를이용한치료를추가로실시한후고식적재활치료만을실시한경우와비교하여그효과를알아보고자하였다. 치료시작전실험군과대 6

6 변승득외 5 인 : 만성뇌졸중환자에서균형조절훈련기의훈련효과 조군의임상적특성을동일하게하는것이어려우므로본연구에서는교차실험을통하여 A군과 B군에속한각각 명의환자들에게서로다른두가지훈련방법을교대로시행하여총 16명의동일한대상으로서하지균형조절훈련기를사용한실험기간과사용하지않은대조기간으로분류하여연구를시행하였다. 실험결과에서실험기간의경우슬관절신전근력을제외한모든측정치들이훈련전보다통계적으로유의하게호전되었으나, 대조기간의경우 6분보행검사 (6mWT) 를제외한모든측정치에서통계적으로유의한호전을보이지않았고, 실험기간과대조기간사이의측정치의호전정도를비교시에도버그균형지수 (), 기능적보행분류 (AC), 6분보행검사 (6mWT), 일어나서걷기검사 (timed up and go, TUG), 한국형수정바델지수 (K-B) 에서실험기간과대조기간사이에통계적으로유의한차이를보여하지균형조절훈련기를이용한훈련을추가로시행하는것이편마비환자의균형및보행기능향상을위한더좋은치료방법임을알수있었다. 본연구의제한점으로타당도및신뢰도에대한검증을하지않아실제임상에서평가도구로써사용되기위해서는이에대한추가적인연구가필요할것으로생각되며, 뇌경색및뇌출혈환자모두를포함하였으나, 보다균일한환자군을대상으로하거나편마비환자뿐만아니라균형조절능력이떨어진다양한환자군을대상으로추가적인연구도필요할것으로생각된다. 본연구에서는평가도구로서뇌졸중환자의전반적인기능평가도구들을이용하였으나, 좌우체중부하비율 (weight bearing ratio) 이나자세흔들림 (postural sway) 등균형능력에대한보다객관적인평가를이용한연구도추가적으로필요할것으로생각된다. 또한치료시작 주이후추적관찰을하지않아치료효과의장기적지속여부에대한추가적연구도필요할것이다. 결론 독립적보행이불가능한만성기편마비뇌졸중환자의균형및보행능력의향상을위한재활훈련시무게중심의수직이동을고려하여보다과제지향적이고기능적인요소가포함된하지균형조절훈련기를이용한훈련을고식적재활치료와함께병행한다면균형및보행기능향상에도움이될것으로생각된다. 참고문헌 1) Brandstater E, Bruin, Gowland C, Clark B. emiplegic gait: analysis of temporal variables. Arch Phys ed ehabil. 19;6:5-5 2) oseley A, Stark A, Cameron D, Pollock A. Treadmill training and body weight support for walking after stroke. Cochrane Database Sys ev. 2005:CD0020 ) orish T, Sandin KJ, oth EJ, Noll S. Stroke rehabilitation:. rehabilitation evaluation and management. Arch Phys ed ehabil. 199;5:S-S51 ) Patton J, Brown DA, Peshkin, Santos-unné JJ, akhlin A, ewis E, Colgate EJ, Schwandt D. Design and development of a robotic overgroud gait and balance therapy device. Top Stroke ehabil. 200;15: ) ayr A, Kofler, Quirbach E, atzak, rohlich K, Saltuari. Prospective, blinded, randomized crossover study of gait rehabilitation in stroke patients using the lokomat gait orthosis. Neurorehabil Neural epair. 200;21:0-1 6) usemann B, uller, Krewer C, eller S, Koeniq E. Effects of locomotion training with assistance of a robotdriven gait orthosis in hemiparetic patients after stroke: a randomized controlled pilot study. Stroke. 200;:9-5 ) im KB, Na Y, ee J, wang O. Effect of balance board training with tactile stimulation on affected leg in hemiplegic patient. J Korean Acad ehab ed. 2002;26: ) Nichols DS. Balance retraining after stroke using force platform biofeedback. Phys Ther. 199;: ) iston A, Brouwer B. eliability and validity of measures obtained from stroke patients using the Balance aster. Arch Phys ed ehabil. 1996;:25-0 ) Shumway-Cook A, Woollacott. otor control: translating research into clinical practice. rd ed. Philadelphia: ippincott Williams & Wilkins; 200:- 11) Barclay-Goddard, Stevenson T, Poluha W, offatt E, Taback SP. orce platform feedback for standing balance training after stroke. Cochrane Database Syst ev. 200;1: CD ) ichards C, alouin, Wood-Dauphinee S, Williams J, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys ed ehabil. 199;: ) Winstein CJ. Knowledge of results and motor-learningimplications for physical therapy. Phys Ther. 1991;1:-19 1) Dickstein, Nissan, Pillar T, Scheer D. oot-ground pressure pattern of standing hemiplegic patients-major characteristics and patterns of involvement. Phys Ther. 19;6: ) De aart, Geurts AC, Dault C, Nienhuis B, Duysens J. estoration of weight-shifting capacity in patients with postacute stroke: a rehabilitation cohort study. Arch Phys ed ehabil. 2005;6: ) Winstein CJ, Gardner E, cneal D, Barto PS, Nicholison DE. Standing balance training: effect on balance and locomotion in hemiparetic adults. Arch Phys ed ehabil. 199; 0: ) Nichols DS. Balance retraining after stroke using force

7 Brain& Neuroehabilitation:2012; 5: 2~ platform biofeedback. Phys Ther. 199;: ) iston A, Brouwer B. eliability and validity of measures obtained from stroke patients using the Balance aster. Arch Phys ed ehabil. 1996;: ) Winstein CJ, Gardner E, cneal D, Barto PS, Nicholison DE. Standing balance training: effect on balance and locomotion in hemiparetic adults. Arch Phys ed ehabil. 199; 0: ) Nichols DS. Balance retraining after stroke using force platform biofeedback. Phys Ther. 199;: ) Betker A, Szturm T, oussavi ZK, Nett C. Video game-based exercises for balance rehabilitation: a single-subject design. Arch Phys ed ehabil. 2006;: ) Geiger A, Allen JB, O'Keefe J, icks. Balance and mobility following stroke: effects of physical therapy interventions with and without biofeedback/forceplate training. Phys Ther. 2001;1: ) Walker C, Brouwer Bj, Culham EG. Use of visual feedback in retraining balance following acute stroke. Phys Ther. 2000;0:6-95 2) Barclay-Goddard, Stevenson T, Poluha W, offatt E, Taback SP. orce platform feedback for standing balance training after stroke. Cochrane Database Syst ev. 200;1: CD ) irbagheri, Tsao C, Settle K, ilaonitkul T, ymer WZ. Time course of changes in neuromuscular properties following stroke. Conf Proc EEE Eng ed Biol Soc. 200;200: ) Kriz J, alancette-ébert. nflammation, plasticity and real-time imaging after cerebral ischemia. Acta Neuropathol. 2009;11: ) Takatsuru Y, ukumoto D, Yoshitomo, Nemoto T, Tsukada, Nabekura J. Neuronal circuit remodeling in the contralateral cortical hemisphere during functional recovery from cerebral infarction. J Neurosci. 2009;29:01-06

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황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic