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1 Brain & NeuroRehabilitation Vol. 5, No. 1, March, 2012 뇌졸중후초기기능회복과운동유발전위및체성감각유발전위의연관성 건국대학교의학전문대학원재활의학교실, 1 경희늘푸른노인전문병원재활의학과김세원ㆍ김승범ㆍ이수영ㆍ고성은ㆍ이종민ㆍ이주영 1 Motor Evoked Potentials and Somatosensory Evoked Potentials of Upper and Lower Extremities for Prediction of Functional Recovery in Stroke Se-Won Kim, M.D., Seung-Beom Kim, M.D., Su-Young Lee, M.D., Seong-Eun Koh, M.D., Jong-Min Lee, M.D., Ph.D., Joo-Young Lee, M.D. 1 Department of Rehabilitation Medicine, Konkuk University School of Medicine, 1 Department of Rehabilitation Medicine, Kyounghee Neulfureun Geriatrics Hospital Objective: The aim of this study was to evaluate the relationship between motor evoked potentials (MEPs) or somatosensory evoked potentials (SSEPs) and the recovery of function in acute or subacute stroke patients. Method: Twenty one hemiplegic stroke patients were examined with MEPs of extensor carpi radialis, abductor pollicis brevis, tibialis anterior and abductor hallucis and SSEPs of median and tibial nerves. A separate score was defined for upper and lower extremities within the Fugl-Meyer assessment and Korean-modified Barthel index. Motor performances were evaluated simultaneously with the evoked potential assessments and at 2 weeks after the first examination. Results: The second motor function of upper extremity was significantly higher in patients with the presence of MEP or SSEP (p<0.05). The improvement of self care was correlated with the responsiveness in SSEP. Motor function of lower extremity was significantly associated with the responsiveness in MEP or SSEP (p>0.05). MEP in tibialis anterior or tibial SSEP were correlated with the mobility. Conclusion: MEP in tibialis anterior is useful in predicting in mobility after stroke. SSEP is predictive for activities in daily living after stroke. (Brain & NeuroRehabilitation 2012; 5: 24-31) Key Words: activities of daily living, motor evoked potentials, recovery of function, somatosensory evoked potentials, stroke 서론 운동유발전위검사를이용한운동기능의신경생리학적연구가도입된후이는뇌혈관질환으로인한운동장애를가진환자의기능회복을예측하기위한목적으로연구되었다. 1-7 운동유발전위는대뇌피질, 뇌척수로로연결되는전반적인운동신경계의활동정도를나타낸다. 즉, 자기자극이대뇌운동피질과연결된여러개의뇌척수로를직, 간 접수일 : 2011 년 4 월 30 일, 1 차심사일 : 2011 년 6 월 20 일, 2 차심사일 : 2011 년 9 월 1 일, 3 차심사일 : 2011 년 10 월 11 일, 4 차심사일 : 2011 년 11 월 2 일, 게재승인일 : 2011 년 11 월 7 일교신저자 : 이주영, 서울시도봉구방학동 442 번지 , 경희늘푸른노인전문병원재활의학과 Tel: , Fax: annelee77@daum.net 접적으로흥분시키면자극된뇌척수로의흥분이해당척수에서알파운동신경을통해말단근육을수축시키면서발생하는전위이다. 8 따라서운동유발전위는대뇌피질의흥분도와연관되어있으며적절한자기자극시운동유발전위가유발되지않는것은신경세포나신경줄기가죽었거나아주높은운동역치를가지고있다는것을의미한다. 9 뇌졸중환자의대뇌운동피질이손상된경우원위부의기능은현저히저하된반면근위부는상대적으로기능이보존되어있는예를관찰할수있는데이는근위부기능에추체외로가더많이관여하기때문이라는보고가있으며원위부에비해동측신경로의지배를더많이받기때문이라는문헌도있다. 10,11 따라서피질척수로와의연관성은원위부가더크며뇌졸중후원위부의근력이증진될경우일상생활능력의향상및보행의호전을관찰할수있다. 10 본연구에서검사대상이된원위부근육으로는기능을 24

2 김세원외 5 인 : 뇌졸중후초기기능회복과운동유발전위및체성감각유발전위의연관성 고려하여상지에서주관절의신전을담당하며건고정효과를통해수부의쥐는능력을증진시키는요측수근신근과큰물건을쥐는데주요한역할을하는단무지외전근, 하지에서족관절배측굴곡을담당하는전경골근과족무지의외전및굴곡을담당하는무지외전근이며동시에정중신경및경골신경의체성감각유발전위검사를실시하여각각의유발전위와상지및하지의기능회복과의연관성을관찰하였다. 12 근력의회복기전을병태생리학적으로보면뇌신경의가소성에의해평소에사용되지않던신경로가열리고, 뇌영역의재배치등이일어나며탈신경후의과민성, 절단된축삭의곁가지의재생이동반된다. 13 이러한회복에영향을미치는임상적인자로연령, 성별, 실어증, 동반질환여부, 시각장애, 감각장애, 정신및인지상태, 동작기능상태등이언급되고있다. 14,15 신경세포의손상및회복에관한정보를좀더객관적으로평가할수있는방법중에하나로유발전위검사가시행되어왔으며이중체성감각유발전위는감각신경로를이용하여평가하는방법으로 Zeman과 Yiannikas 16 는뇌졸중환자의정중신경체성감각유발전위검사를검사한결과정상군에서짧은입원기간및일상생활기능의향상을보였다고하였으며 La Joie 등 17 은뇌졸중발병 3주에서 8주사이의환자를대상으로시행한정중신경체성감각유발전위가정상인경우상지기능의회복을기대할수있다고보고하였다. 운동유발전위검사는 1985년 Barker 18 에의하여경피적대뇌피질자기자극법이소개된이후비침습적으로통증없이대뇌피질의운동중추를직접자극하여사지근육의반응을관찰함으로써기능회복을예측하는데유용성이입증되어왔으며체성감각유발전위검사보다더유용하다고보고되었다. 1-3,19,20 국내에서도수부및족부근육의운동유발전위를통해뇌졸중후기능회복을예측한연구들이보고되어왔으나상지및하지의원위부근육들의역할을고려하여각각의운동유발전위유무에따른기능회복의차이를보고한문헌은아직없는상태이다. 4-8 이에저자들은급성기및아급성기뇌졸중으로인한편마비환자를대상으로상지와하지원위부근육들의운동유발전위검사를시행한후운동기능및일상생활능력을추적관찰함으로서단기적예후판단에적합한근육을알아보고체성감각유발전위를함께측정하여그유용성을비교평가하고자본연구를시행하였다. 연구대상및방법 1) 연구대상 2006년 11월부터 2007년 7월까지재활의학과에입원하여재활치료를받았던뇌졸중환자중발병 3개월이내재활치료를시작한환자들을대상으로하였다. 이들중검사에협조가불가능한사람이거나심박동조율기와같은생체의학기구를몸에지닌환자, 양측뇌병변이있거나사지마비가있는환자는제외하였으며초기에평가한 Korean modified Barthel index (K-MBI) 점수가 95점이상으로독립적인일상생활동작이가능할정도로호전된경우도제외한총 21명을대상으로시행하였다. 2) 연구방법대상환자들은자기공명영상및뇌전산화단층촬영을통해뇌졸중의원인및병변위치를확인하고 Mini-Mental Status Examination (MMSE) 을평가하였다. 본과입원초기에운동유발전위검사및체성감각유발전위검사를시행하였고환자들의기능향상정도를측정하기위해 Fugl-Meyer Assessment (FMA) 와 K-MBI 점수를입원초기와평가 2주후에측정하였다. FMA 는운동기능평가를위해사용하였으며 33개상지수행항목과 17개하지수행항목으로구성되어있어상지및하지로분류하여점수화하였다. 21 일상생활동작수행능력을평가하기위해이용한 K-MBI 는수행항목중상지기능에연관된자조기능과높은상관관계를보인개인위생, 목욕하기, 식사하기, 옷입기항목의점수를합산한점수와하지기능에연관된이동기능과높은상관관계를보인계단오르기, 보행항목의점수를합산한점수로분류하여측정하였다 운동유발전위검사는 Magstim 경두개자기자극기 (Magstim Co. LTD, Wales, UK) 를이용하였으며자기코일의직경은 7.0 cm, 최대자장강도는 2 Tesla 이었고기록은 Medelec Synergy 근전도기 (Viasys, Healthcare, UK) 를사용하였다. 상지두부자기자극검사를위하여환자는편하게앉은자세에서코일의중심부를수부운동피질에위치시킨후조금씩이동하면서최대반응이나오는지점을찾았으며건측과환측모두실시하였다. 자극강도는최대강도의 50% 에서 100% 까지서서히증가시키면서수회자극하였고양측의단무지외전근및요측수근신근에기록전극을부착하여 2 채널로운동유발전위를기록하였다. 하지두부자기자극검사는족부운동피질을자극하였으며양측의무지외전근및전경골근에서기록하였다. 체성감각유발전위검사는 Medelec Synergy 근전도기 (Viasys, 25

3 Brain& NeuroRehabilitation:2012; 5: 24~31 Healthcare, UK) 를사용하였으며환자를이완된상태로눕힌후막대전극으로양측정중신경과경골신경을각각완관절과족관절에서자극하였고표면침전극을사용하여두피에서기록하였다. 각근육의수축이유발되는최소한의자극강도로자극하였으며초당 3회의빈도로 200 회의반복자극을주어평균하는과정을 2 3회반복하였다. 기록은국제뇌파 시스템의 Fz에참고전극을삽입하고정중신경검사시는 C3'/C4' 에, 경골신경검사시는 Cz' 에활성전극을삽입하여기록하였다. 3) 자료분석 상지와하지의초기및재활치료시작 2주후의운동기능상태및일상생활동작수행능력을평가한후각근육의운동유발전위검사및체성감각신경유발검사의반응군과무반응군에서의운동기능및일상생활동작수행능력을비교하여기능회복을예측하는데적절한검사법을알아보고자하였다. 운동유발전위및체성감각유발전위유무에따른초기와 2주후의 FMA 검사값과 K-MBI 검사값및검사값의변화량비교는 Mann-Whitney U test를사용하여분석하였고, 초기와 2주후의 FMA 및 K-MBI 검사값의변화는 Wilcoxon signed ranks test를이용하였다. 상지및하지의운동유발전위검사및체성감각유발전위유무에따라환자군을분류하여시행한일상생활동작기능및운동기능검사의변화량비교는 Wilcoxon signed ranks test를사용 Table 1. General Characteristics of the Patients Characteristics Value Demographics Age (years) ± Gender Male 14 Female 7 Time after onset (days) ± Hemiplegic side Left 9 Right 12 Stroke types Hemorrhage 6 Infarction 15 Location Cortex 12 Subcortex 8 Brainstem 1 MMSE ± Age, Time after onset, MMSE values are mean ± standard deviation. Gender, Hemiplegic side, Stroke types, Location, Dysphagia values are number of patients. MMSE: Mini-Mental Status Examination. 하였다. 통계학적분석은 SPSS (window version 12.0) 를이용하였으며 p<0.05에서유의하다고판정하였다. 결과 1) 대상환자들의일반적특성총 21명의편측성뇌졸중환자들중좌측편마비과우측편마비가각각 9명, 12명이었고뇌경색환자가 15명, 뇌출혈환자가 6명이었으며뇌병변부위는대뇌피질이 12명, 피질하부위가 8명, 뇌간이 1명이었다. 성별분포는남자 14명, 여자 7명으로나이는 ± 12.93세, 총유병기간은 ± 일이었으며 MMSE 점수는 ± (MMSE range 0 30) 이었다 (Table 1). 2) 상지의기능및운동유발전위와체성감각유발전위의연관성상지에서이환측요측수근신근및단무지외전근이동시에운동유발전위반응이나타난경우와모두반응이나타나지않은경우가각각 8명, 12명이었으며단무지외전근에서는반응이나타났으나요측수근신근에서는무반응인경우가 1명이었고, 반대로요측수근신근에서는반응이나타났으나단무지외전근에서무반응인경우는관찰되지않았다. 이환측정중신경체성감각유발전위가관찰된환자는 10명이었고관찰되지않은환자는 11명이었으며건측에서는운동유발전위및체성감각유발전위모두관찰되었다. FMA의초기상지평가점수는단무지외전근의운동유발전위및정중신경체성감각유발전위가관찰된군에서유발전위가관찰되지않은군에비해의미있게높은점수를보였으며추적평가시모든군에서유발전위유무에따른유의한점수차를보였고유발전위반응유무에따른점수변화량의차이는요측수근신근의운동유발전위에서유의하게관찰되었다. K-MBI 의자조기능점수는모든환자군에서초기및추적평가시유발전위반응유무에따른유의한차이를보이지않았고추적평가시운동유발전위의경우반응유무에관계없이모두유의하게점수가증가되었으나정중신경체성감각유발전위는반응유무에따라의미있는변화의차이를보였다 (Table 2). 3) 하지의기능및운동유발전위와체성감각유발전위의연관성하지에서는이환측전경골근및무지외전근이동시에운동유발전위반응이있는경우와모두반응이없는경우가각각 10명, 8명이었으며전경골근에서만반응을보인경우가 2명무지외전근에서만반응을보인경우가 1명이 26

4 김세원외 5 인 : 뇌졸중후초기기능회복과운동유발전위및체성감각유발전위의연관성 Table 2. Relationships Between Upper-Extremity Evoked Potentials and Occurrence of Motor and Functional Recovery EP response n FMU Self care Exam 1 Exam 2 p Exam 1 Exam 2 p MEP ECR Present ± ± ± ± Absent ± ± ± ± p * APB Present ± ± ± ± Absent ± ± ± ± p 0.034* 0.006* SSEP Median Present ± ± ± ± Absent ± ± ± ± p 0.006* 0.002* Values are mean ± standard deviation. EP: Evoked potential, MEPs: Motor evoked potentials, SSEPs: Somatosensory evoked potentials, FMU: Fugl-Meyer score of upper extremity, ECR: Extensor carpi radialis, APB: Abductor pollicis brevis *p<0.05, p-value was derived from Mann-Whitney U test. p<0.05, p-value was derived from Wilcoxon signed ranks test. Table 3. Relationships Between Lower-Extremity Evoked Potentials and Occurrence of Motor and Functional Recovery EP response n FML Mobility Exam 1 Exam 2 p Exam 1 Exam 2 p MEP TA Present ± ± ± ± Absent ± ± ± ± p 0.000* 0.000* AH Present ± ± ± ± Absent ± ± ± ± p 0.010* 0.004* SSEP Tibial Present ± ± ± ± Absent ± ± ± ± p 0.029* 0.045* Values are mean ± standard deviation. EP: Evoked potential, MEPs: Motor evoked potentials, SSEP: Somatosensory evoked potentials, FML: Fugl-Meyer score of lower extremity, TA: Tibialis anterior, AH: Abductor hallucis. *p<0.05, p-value was derived from Mann-Whitney U test. p<0.05, p-value was derived from Wilcoxon signed ranks test. 었다. 이환측경골신경체성감각유발전위가관찰된환자는 15명, 관찰되지않은환자는 6명이었으며건측의운동유발전위및체성감각유발전위는모두관찰되었다. FMA 의하지평가점수는초기및추적검사모두에서운동유발전위및체성감각유발전위반응이관찰된경우의미있게높은점수를보였으며추적검사에서운동유발전위및체성감각유발전위반응이관찰된경우모두유의한점수의증가를보였다. K-MBI 의이동기능점수는초기및추적검사모두에서운동유발전위및체성감각유발전위반응유무에따른유의한점수차는보이지않았으며전경골근의운동유발전위및경골신경체성감각유발전위가관찰된경우에서관찰되지않은경우에비해의미있는점수변화를보였다 (Table 3). 4) 운동유발전위와체성감각유발전위반응유무에따른초기기능의회복상지및하지에서운동유발전위가한부위이상관찰된군과관찰되지않은군으로분류하여체성감각유발전위반응유무에따른기능의변화를관찰하였을때운동유발전위와체성감각유발전위모두반응이있는경우상지의자조기능, 하지의운동기능및이동기능이모두유의한호전을보였다 (Fig. 1, 2). 5) 심한인지기능손상환자의유발전위및자조기능의변화인지기능의심한손상으로기능검사를적절히이행하지못하였을가능성이있는 MMSE 점수가 5점이하로평 27

5 Brain& NeuroRehabilitation:2012; 5: 24~31 Fig. 1. Distribution of patients according to presence of MEP and SSEP. FMU: Fugl-Meyer score of upper extremity, FML: Fugl-Meyer score of lower extremity, UMEP: MEP in upper extremity, LMEP: MEP in lower extremity, (+): Response, ( ): No response. Fig. 2. Changes in FMA subscores and K-MBI subscores according to presence of MEP and SSEP in upper and lower extremities. *p<0.05, p-value was derived from Wilcoxon signed ranks test. FMU: Fugl-Meyer score of upper extremity, FML: Fugl-Meyer score of lower extremity, UMEP: MEP in upper extremity, LMEP: MEP in lower extremity, (+): Response, ( ): No response. 28

6 김세원외 5 인 : 뇌졸중후초기기능회복과운동유발전위및체성감각유발전위의연관성 가된 6명의환자중운동유발전위가관찰된환자는 3명으로이중 1명은전실어증이동반되었으며자조기능은 0점으로변화를보이지않았고 1명은감각성실어증이동반되었으나자조기능은 42점에서 49점으로증가되었으며나머지 1명은오히려자조기능이 6점에서 3점으로감소되었다. 운동유발전위가관찰되지않은 3명의환자중 2 명은자조기능이 0점으로변화를보이지않았고, 1명은 3 점에서 12점으로증가되었다. 한편체성감각유발전위는상기환자중감각성실어증을동반한환자를포함한 2명을제외한 4명에서관찰되지않았다. 고찰 뇌졸중으로인한편마비환자를대상으로상지와하지의원위부근육들의유발전위검사를시행한후운동기능평가및일상생활동작능력을추적관찰함으로써운동유발전위검사를통한단기적예후예측에적합한근육을알아보고자하였다. 뇌졸중후운동기능의회복은근위부에서원위부로진행한다고알려져있으나본연구에서는경두개자기자극시상지에서단무지외전근에서만반응이있었던경우가 1명, 요측수근신근에서만반응이있었던경우가 0명이었으며하지에서는전경골근과무지외전근중한부위에서만반응이있었던경우가각각 2, 1명으로근력회복순서와운동유발전위와의연관성은확인할수없었다. 25 상지에서운동기능은초기에는단무지외전근에서시행한운동유발전위검사와체성감각유발전위검사의반응군이의미있게양호하였으나추적관찰시모든검사에서반응군과무반응군의유의한차이를보였으며그중요측수근신근의운동유발전위검사만이반응군에서무반응군과는다르게운동기능의의미있는변화를보였다. 그러나, 단무지외전근과요측수근신근이상이한반응을보이는경우가 1례에불과하여두근육의반응유무에따른예후의차이를논하기어려우며단무지외전근의반응군이유의한호전은보이지않아이근육에서만반응이있을경우상대적으로적게호전될수도있을것으로사료되며좀더많은사례를통한연구가필요할것이다. 이와연관된연구로 Turton 등 10 은근위부근육인삼각근및상완이두근의운동유발전위반응과근위부근력회복정도는연관성이적은반면원위부에해당하는요측수근신근과제 1 배측골간근운동유발전위반응은모두원위부근력회복정도와연관되어있다고보고하였다. 자조기능은모든유발전위의반응군이무반응군에비하여유의하지않지만높은점수를보였고추적검사시운동유발전위반응유무 에관계없이의미있는호전을보였으며정중신경체성감각유발전위에서만반응유무에따른호전정도의유의한차이를보였다. 이러한결과는자조기능에연관된항목들이건측의상지기능을이용하여수행할수있기때문에환측상지의기능장애를보상하고은폐할수도있어평가상의오류를유발할수있기때문으로여겨지며결과적으로자조기능의단기적예후는체성감각유발전위반응유무와연관된것으로확인되었다. 7 이는 Zeman과 Yiannikas 16 의정중신경체성감각유발전위의정상군과비정상군에서재원기간및 Barthel index의차이가있다는보고와도동일한결과이나김등 26 은정중신경체성감각유발전위의반응유무에따른상지의 Barthel index 변화가유의하지않았고오히려감각기능과더연관되어있다고하였다. 하지에서운동기능은모든운동유발전위검사와체성감각유발전위검사의반응군이의미있게양호하였으며추적관찰시유의한향상을보였고이동기능은전경골근의반응군과경골신경체성감각유발전위가관찰된경우에서무반응군에비해의미있는호전을보였다. 전경골근은보행주기중유각기에서부터초기입각기의체중부하기까지지속적으로수축되어족관절배측굴곡을유도함으로써족하수를방지하는중요한근육으로 Hendricks 등 27 의전경골근의운동유발전위가하지의근력및기능회복을예측하는데유용하다는결과와일치하며 Dobkin 등 28 의전경골근의근력이보행을예측하는데유용하다는보고와도동일한결과를보여전경골근의운동유발전위유무가무지외전근에비해뇌졸중후이동및보행여부를예측하는데유용할것으로생각된다. 29 한편후경골신경체성감각유발전위가편마비환자의하지기능의초기재활치료효과를예측하는데더도움을준다는보고도있다. 26 따라서하지운동기능의예후를예측하기위해서는무지외전근및전경골근의운동유발전위및경골신경체성감각유발전위검사가유용하며이동기능의회복을예측하는데는전경골근의운동유발전위검사와체성감각유발전위검사가적절할수있음을확인하였다. 또한상지및하지에서각각의운동유발전위및체성감각유발전위가모두관찰된경우단기적인호전을기대해볼수있을것이다. 한편낮은 MMSE 점수를보인환자들은인지기능의심한손상으로자조기능등을적절히이행하지못하여결과에영향을주었을수도있으나평가의특성상실어증이동반되었을경우일상생활기능을과소평가할가능성이있으므로이에알맞은검사를추가하여정확한인지상태를판단함과동시에일정한인지기능을유지한환자를대상으로연구를시행한다면좀더명확한결과를얻을수있을것으로사료된다

7 Brain& NeuroRehabilitation:2012; 5: 24~31 본연구에서의한계점은추적관찰기간이짧았으며환자의병변이일치하지않는다는점, 두개의원위부근육들의운동유발전위반응이다른사례가적었던점, 신경전도검사를함께실시하지않아환측의말초신경질환을배제하지못한점, 그외에도수의적수축과같은촉진방법을적용하지않아불충분한반응이얻어졌거나실행증이나무시증후군이동반되어기능검사를적절히이행하지못하여결과에영향을주었을가능성도배제하지못한점등이다. 31 한편이러한문제점을보완하면서원위부이외에추체외로의지배도함께받는것으로알려진근위부근육에서도운동유발전위를동시에검사하여추적관찰한다면피질척수로를통한근위부및원위부의운동기능회복순서를예측함과동시에뇌병변부위에따른기능회복의예후를파악해볼수도있을것으로생각된다. 결론 본저자는급성기및아급성기뇌졸중환자 21명을대상으로운동유발전위검사및체성감각유발전위검사를시행하고 2주간격으로 2회에걸쳐 FMA와 K-MBI 를평가하여다음과같은결과를얻었다. 1) 상지에서는각근육의기능과는무관하게검사한모든원위부근육에서시행한운동유발전위및체성감각유발전위반응성이상지운동기능의단기적예후와연관된것으로나타났으며정중신경체성감각유발전위가관찰된경우자조기능의회복을예측할수있는것으로나타났다. 2) 하지에서운동유발전위및체성감각유발전위반응성은하지의운동기능상태및회복과밀접한관련을보였고전경골근의운동유발전위및경골신경체성감각유발전위가관찰된경우이동기능의회복을기대해볼수있음을확인하였다. 3) 상지및하지에서각각운동유발전위및체성감각유발전위가모두관찰된경우자조기능및하지운동기능과이동기능의호전을기대해볼수있다. 참고문헌 1) Escudero JV, Sancho J, Bautista D, Escudero M, Lopez-Trigo J. Prognostic value of motor evoked potential obtained by transcranial magnetic brain stimulation in motor function recovery in patients with acute ischemic stroke. Stroke. 1998;29: ) Rapisarda G, Bastings E, de Noordhout AM, Pennisi G, Delwaide PJ. Can motor recovery in stroke patients be predicted by early transcranial magnetic stimulation? Stroke. 1996;27: ) Heald A, Bates D, Cartlidge NEF, French JM, Miller S. Longitudinal study of central motor conduction time following stroke, 2: central motor conduction measured within 72h after stroke as a predictor of functional outcome at 12 months. Brain. 1993;116: ) Kang MJ, Yoon TS, Park CI, Chun, SI. Motor Evoked Potential in Stroke. J Korean Acad of Rehab Med. 1993;17: ) Kang DW, Park SH, Lee YJ, Chun JU, Ko SB, Yoon BW, Lee KW, Roh JK. Early Transcranial Magnetic Stimulation Can Predict Motor Recovery of Subacute Stage in Acute Ischemic Stroke Patients. Korean Journal of Stroke. 2000;2: ) Kim C, Jeong JH. The Significance of Motor Evoked Potentials as a Prognostic Factor in the Early Stage of Stroke Patients. J Korean Acad of Rehab Med. 1999;23: ) Han TR, Bang MS, Lee KW. Motor evoked potentials of upper and lower extremities by magnetic stimulation in hemiparesis. J Korean Acad of Rehab Med. 1998;22: ) Jung HY, Kim TH, Park JH. Relationship of national institute of health stroke scale and motor evoked potentials in subjects with stroke. J Korean Acad of Rehab Med. 2005;29: ) Rossini PM, Barker AT, Berardelli A, Caramia MD, Caruso G, Cracco RQ, Dimitrijevic MR, Hallett M, Katayama Y, Lucking CH, Noordhout MD, Marsden CD, Murray NMF, Rothwell JC, Swah M, Tomberg C. Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application. Report of an IFCN committee. Electroencephalogr Clin Neurophysiol. 1994;91: ) Turton A, Wroe S, Trepte N, Fraser C, Lemon C. Contralateral and ipsilateral EMG responses to transcranial magnetic stimulation during recovery of arm and hand function after stroke. Electroencephalogr Clin Neurophysiol. 1996;101: ) Colebatch JG, Gandevia SC. The distribution of muscular weakness in upper motor neuron lesions affecting the arm. Brain. 1989;112: ) Thorsen RA, Occhi E, Boccardi S, Ferrarin M. Functional electrical stimulation reinforced tenodesis effect controlled by myoelectric activity from wrist extensors. J Rehabi Res Dev. 2006;43: ) Lee RG, van Donkelaar P. Mechanisms underlying functional recovery following stroke. Can J Neurol Sci. 1995;22: ) Allen CMC. Predicting the outcome of acute stroke: a prognostic score. J Neurol Neurosurg Psychiatry. 1984;47: ) Anderson TP. Studies up to 1980 on stroke rehabilitation outcomes. Stroke. 1990;21: ) Zeman BD, Yiannikas C. Functional prognosis in stroke: use of somatosensory evoked potentials. J Neurol Neurosurg Psychiatry. 1989;52: ) La Joie WJ, Reddy NM, Melvin JL. Somatosensory evoked potentials: their predictive value in right hemiplegia. Arch Phys Med Rehabil. 1982;63: ) Barker AT. An introduction to the basic principles of magnetic 30

8 김세원외 5 인 : 뇌졸중후초기기능회복과운동유발전위및체성감각유발전위의연관성 nerve stimulation. J Clin Neurophysiol. 1991;8: ) D'Olhaberriague L, Gamissans JME, Marrugat J, Valls A, 267 Ley CO, Seoane JL. Transcranial magnetic stimulation as a prognostic tool in stroke. J Neurol Sci. 1997;147: ) Macdonell RAL, Donnan GA, Bladin PF. A comparison of somatosensory evoked and motor evoked potentials in stroke. Ann Neurol. 1989;25: ) Fugl-Meyer AR, JӓӓskӧL, Leyman I, Olesson S, Steqlind S. The post-stroke hemiplegic patient, I: a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7: ) Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14: ) Shah S, Vanclay F, Cooper B. Improving the sensitivity of the barthel index for stroke rehabilitation. J Clin Epidemiol. 1989; 42: ) Han YJ, Park BK, Shin HS, Kang YK, Pyun SB, Paik NJ, Kim SH, Kim TH, Han TR. Development of the Korean Version of Modified Barthel Index (K-MBI): Multi-center Study for Subjects with Stroke. J Korean Acad of Rehab Med. 2007; 31: ) Warabi T, Inoue K, Noda H, Murakami S. Recovery of voluntary movement in hemiplegic patients. Correlation with degenerative shrinkage of the cerebral peduncles in CT images. Brain. 1990;113: ) Kim JH, Han TR, Lee SJ. The posterior tibial somatosensory evoked potentials in the hemiplegic patients. J Korean Acad of Rehab Med. 1993;17: ) Hendricks HT, Pasman JW, van Limbeek J, Zwarts MJ. Motor evoked potentials of the lower extremity in predicting motor recovery and ambulation after stroke: a cohort study. Arch Phys Med Rehabil. 2003;84: ) Dobkin BH, Firestine A, West M, Saremi K, Woods R. Ankle dorsiflexion as an fmri paradigm to assay motor control for walking during rehabilitation. Neuroimage. 2004;23: ) Perry J. Gait analysis: Normal and Pathologic Function. Thorofare, NJ: SLACK Inc; 1992: ) Kwon JY, Kim JS, Park SW, Jang SJ, Kim BS. Influence of Aphasia on the Cognitive Screening Test in Stroke Patients with Unilateral Cerebral Hemispheric Lesion. J Korean Acad of Rehab Med. 2002;26: ) Han TR, Kim JH, Lim JY. Proper facilitation technique for bilateral motor evoked potentials by transcranial magnetic stimulation. J Korean Acad of Rehab Med. 2000;24:

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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