Voice Characteristics of Sasmodic Dyshonia Yun B, et al. 기질적문제가주요한원인으로간주되고있다. 3) 특히연축성발성장애의유형중하나인내전형연축성발성장애 (adductor sasmodic dyshonia, ADSD) 는전체환자중에
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1 Head and Neck online ML Comm Korean J Otorhinolaryngol-Head Neck Surg 2011;54: / DOI /kjorl-hns ISSN / eissn Voice Characteristics of Adductor Sasmodic Dyshonia before and after Botulinum Toxin-A Injection Boram Yun 1,2, Hyang Hee Kim 2,3, Yaelin Choi 4 and Hong-Shik Choi 1 1 Deartment of Otorhinolaryngology, Institute of Logoedics and Phoniatrics, Yonsei University College of Medicine, Seoul; and 2 Seech and Language Pathology, Yonsei University Graduate School, Seoul; and 3 Deartment of Rehabilitation Medicine, Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul; and 4 Deartment of Seech and Language Pathology, Myongji University Graduate School, Seoul, Korea 내전형연축성발성장애환자의보툴리눔독소 -A 주입술전후의음성특성비교 윤보람 1,2 김향희 2,3 최예린 4 최홍식 1 연세대학교의과대학이비인후과학교실, 음성언어의학연구소, 1 연세대학교대학원언어병리학협동과정, 2 연세대학교의과대학재활의학과학교실및재활의학연구소, 3 명지대학교대학원언어치료학과 4 Received October 27, 2010 Revised January 7, 2011 Acceted January 17, 2011 Address for corresondence Hong-Shik Choi, MD, PhD Deartment of Otorhinolaryngology, Institute of Logoedics and Phoniatrics, Yonsei University College of Medicine, 712 Eonju-ro, Gangnam-gu, Seoul , Korea Tel Fax hschoi@yuhs.ac Background and ObjectivesZZBotulinum toxin tye A (BTX-A) injection is well known for its effectiveness in the treatment of Sasmodic dyshonia. However, studies on the efficacy of BTX-A injection have not been attemted in Korea. Therefore, this study was carried out to investigate the effects of BTX-A. Subjects and MethodZZThe study examined 12 female atients with adductor sasmodic dyshonia. Objective assesments included aerodynamic analysis and electoroglottograhy (EGG) of each atient before and after BTX-A. Subjective assessments included using the Korean-version of Voice Handica Index-30 (KVHI-30) and a atient self-rating scale. ResultsZZAerodynamic analysis revealed that only maximum honation time (MPT) was significantly shortened after the injection of BTX-A (<0.05). In the EGG, the mean frequency distribution was significantly increased, while the mean amlitude and the mean closed quotient distribution were significantly decreased (<0.05). The KVHI-30 and atient selfrating scale scores were significantly decreased (<0.01) as well, demonstrating the effects of BTX-A on the quality of life. ConclusionZZOur results show the effects of BTX-A objectively by comaring voice characteristics, which were measured through EGG before and after BTX-A injection, as well as by determining aerodynamic characteristics. The subjective self-assessment on the quality of life is significant as it may serve as a clinically relevant measure. This study may be helful in elucidating treatment efficacy of BTX-A in many ways. Korean J Otorhinolaryngol-Head Neck Surg 2011;54: Key WordsZZSasmodic dyshonia ㆍ Botulinum toxin ㆍ Voice assessment. 서론 연축성발성장애 (sasmodic dyshonia) 는국소적근긴장이상증 (focal dystonia) 의일종으로후두근육의불수의 적인수축으로인해나타나는발성장애 (dyshonia) 이다. 1,2) 연축성발성장애는그원인이나병태생리가아직까지정확하게밝혀지고있지않으나많은환자들에게서신경학적기능장애 (neurologic dysfunction) 의증거가나타남에따라 148 Coyright 2011 Korean Society of Otorhinolaryngology-Head and Neck Surgery
2 Voice Characteristics of Sasmodic Dyshonia Yun B, et al. 기질적문제가주요한원인으로간주되고있다. 3) 특히연축성발성장애의유형중하나인내전형연축성발성장애 (adductor sasmodic dyshonia, ADSD) 는전체환자중에 83~95% 로가장많이나타나는유형으로, 2,4,5) 음성의떨림 (voice tremor) 과쥐어짜는듯한목소리 (strained-strangled voice), 음성의막힘 (voice stoage), 음성의끊김 (voice break), 목쉰음성 (hoarse voice), 음도이탈 (itch break) 등이특징으로나타난다. 6) 이들연축성발성장애의치료중하나인 botulinum toxin(btx) 주입술은연축을일으키는성대근육에 BTX를주입하여일시적으로근육을약화시키는방법으로현재가장많이사용되고있으며효과적인것으로알려져있다. 7,8) 특히, BTX의 7가지항원중 botulinum toxin tye A(BTX-A) 는유형에상관없이연축성발성장애의표준적치료로사용되고있으며, 9,10) 그효과는근육세포를화학적탈신경화 (chemical denervation) 시켜서근육의수축기능을무력화하는데있다. 11) 연축성발성장애의정확한유병률에대한보고는조사되어있지않으나, 최근 10년동안치료에 BTX-A 주입술이도입되면서, 10) 치료를받기원하는환자가증가하고있는것은사실이다. BTX-A 에관한지금까지의선행연구들을살펴보면연축성발성장애환자의 BTX-A 주입전음성특성에대하여는 Choi 등 12) 외몇몇의연구들이이루어졌으나, BTX-A 의효과에대하여객관적및주관적인평가수치로제시한연구는국내에서전혀이루어지지않았다. 따라서 BTX-A 주입후의효과나회복및지속기간에대하여환자들에게제시할때외국의연구결과나임상적경험에의지하고있는실정이다. 연축성발성장애환자의특성에관해국내에서이루어진몇몇의연구들에서는실험시대부분의연구들에서모음이나단어수준의말과제를사용하였는데, 이는실제발화에서의음성특성을정확히밝힌것이라고볼수없다. 또한 BTX-A 주입후환자는부정적의사소통태도를가지고있으며, 13) 1~2 주간기식성음성등의증상으로인해이전보다음성이좋아졌음에도불구하고만족함을느끼지못하는경우가있다. 이에대하여일정한기간후객관적검사를진행하여음성의진전정도에대한객관적수치를제시하는것과환자의삶의질평가및청지각적평가를통하여치료효과를측정하는것이필요하다. 따라서본연구에서는이러한제한점들을보완하여 BTX-A 주입전과후의음성특성을공기역학적측면과문단수준에서의 EGG 검사를통해비교하고이들의차이를객관적수치로제시함으로써임상에서예후제시및치료효과판정에도움을주고자한다. 또한주입전후의 Korean-version of Voice Handica Index(KVHI) 와환자의청지각적평가를통하여환자스스로느끼는음성변화및삶의질에대하여 알아보고자한다. 대상 대상및방법 본연구는 2009년 12월 ~2010년 4월까지강남세브란스병원이비인후과에서 BTX-A 주입을받은여성환자 23명을대상으로하였는데, 이는연축성발성장애환자의유병률이여성이우세하다는선행연구에의거하여대상군을선정하였다. 2,5) 이들은신경질환, 정신질환, 구음장애등의기타병력이없으며강남세브란스병원이비인후과를내원하여후두스트로보스코피등의음성정밀검사를통해이비인후과두경부전문의 1인에게 ADSD로진단받은후 BTX-A 주입을받았다. 그러나이들중주입후검사를받지않은 8명과재주입을받은 3명을제외하여, 12명을최종대상으로포함하였다. 대상군의평균연령은 31.58(±9.66) 세이고평균주입횟수는 2회이상이었으며, 평균 BTX-A 주입량은 1.63(±0.23) U이었다. BTX-A 주입은 EMG를이용하여두경부전문의 1인이시행하였으며편측갑상피열근에주입하였다. 음성검사음성검사는 BTX-A 주입전과주입후 4~6주사이에시행하였는데, 이는약 2주정도가지난후부터부작용이줄어들고 4주정도부터점차음성이좋아지기시작했다는선행연구들을바탕으로하였다. 14,15) 객관적평가로는성대기능검사인공기역학적검사와 EGG 검사를실시하고주관적검사로 KVHI와환자의청지각적평가를실시하였는데검사방법은다음과같다. 공기역학적검사공기역학적검사는 Phonatory Aerodynamic System (Model 6600, Kay PENTAX, NJ, USA) 를사용하여측정하였다. 공기가새어나가지않도록마스크를코와입을완전히덮을수있도록하여얼굴에밀착시킨후마스크내부에장착된 intraoral tube를앞니사이에위치시켜가볍게물게하였다. 그후평상시사용하는음도 (itch) 와강도 (loudness) 로 /a/ 를 5회산출하게한후중간 3회측정시평균값을내어평균호기류율 (mean airflow rate, MFR), 성문하압 (subglottal ressure, Psub) 및음성효율을측정하였다. 최대연장발성시간 (maximum honation time, MPT) 은마스크를얼굴에밀착한상태에서충분한흡기후평상시사용하는음도와강도로 /a/ 연장발성을최대한길게유지하도록하였다. 이를 2회반복하여측정하는데이중최대값 149
3 Korean J Otorhinolaryngol-Head Neck Surg 2011;54: 을최종분석의대상으로하였다. 16) 전기성문파형검사 Lx Seech studio(laryngograh Ltd, London, UK) 의 Seech Pattern Element Acquisition(SPEAD) 프로그램을이용하여 Electroglottograhy(EGG) 검사를시행하였다. 앉은자세에서 EGG 전극 (electrode) 을대상자의갑상연골양쪽연골판부위에고정시키고동시에마이크는대상자의입과 15 cm 정도떨어진곳에두어평상시의편안한목소리와말속도로 가을 문단을읽게하였다 ( 부록 1). 17) 녹음된문단은 Quantitative Analysis를하여평균기본주파수분포 (DFx mean), 평균음성강도분포 (DAx mean), 평균성문폐쇄율분포 (DQx mean), 주파수와강도의불규칙성 (CFx, CAx) 을측정하였다. 18) 주관적평가환자의청지각적평가는 ADSD 환자가보이는주된증상을중심으로평가문항을제작하여 BTX-A 주입전후에시행하도록하였다 ( 부록 2). 평가문항에포함된증상으로는발화시목이긴장되고조이는듯한느낌, 말소리가막히거나끊어짐, 음성의떨림, 쉰목소리이다. 평가범위는 5점척도로 0~ 4점으로구성되어있다 (0: 증상이없음, 1: 아주가끔나타남, 2: 가끔나타남, 3: 자주나타남, 4: 항상나타남 ). 그리고마지막항목으로환자스스로본인음성의전체적인중증도를 5점척도로평가하게하였다 (0: normal, 1: mild, 2: mildmoderate, 3: moderate, 4: severe). VHI는한국어로번 안한 KVHI를사용하여 BTX-A 주입전후환자의삶의질을평가하였다. 19) 통계통계분석은통계분석은 PASW(Predictive Analytics SoftWare) 통계프로그램 (version 17.0) 을사용하였다. 환자군의 BTX-A 주입전후효과를비교하기위하여 Wilcoxon signed rank test를실시하였고통계학적유의수준은 0.05 미만으로하였다. 변수들의정규성검정을위하여샤피로- 윌크검정 (Shairo-Wilk test) 으로정규성검정을한결과변수마다정규성검정결과에차이가있었으나분석의일관성을위해비모수검정으로시행하였다. 결과 ADSD 환자군의공기역학적검사결과, MPT는 BTX-A 주입전에비해주입후통계적으로유의하게더짧아졌으나 MFR과 Psub 및음성효율은주입전과후의유의한차이가없었다 (<0.05)(Table 1). EGG 결과, 평균기본주파수분포는주입전보다주입후통계적으로유의하게높아졌고평균음성강도분포와평균폐쇄율분포는통계적으로유의하게감소하였다 (<0.05)(Table 2). 그러나주파수불규칙성과강도불규칙성은주입전과후통계적으로유의한차이를보이지않았다. 주관적평가인 KVHI 점수와환자의청지각적평가점수는주입전에비해통계적으로유의하게감소되었다 (<0.01)(Table 3 and 4). Table 1. Results of aerodynamic study in adductor sasmodic dyshonia atients before and after BTX-A injection MFR (Lit/sec) Psub (cmh 2 O) VE (m) MPT (sec) Wilcoxon signed rank test. BTX: botulinum toxin, MFR: mean airflow rate, Psub: subglottal ressure, VE: voice efficiency, MPT: maximum honation time Table 2. Results of electroglottograhy in adductor sasmodic dyshonia atients before and after BTX-A injection DFx (Hz) CFx (%) DAx (db) CAx (%) DQx (%) Wilcoxon signed rank test. BTX: botulinum toxin, DFx: distribution of fundamental frequency, CFx: frequency irregularity, DAx: distribution of amlitude, CAx: amlitude irregularity, DQx: distribution of closed queotient 150
4 Voice Characteristics of Sasmodic Dyshonia Yun B, et al. Table 3. Results of KVHI scores in adductor sasmodic dyshonia atients before and after BTX-A injection KVHI (score) Wilcoxon signed rank test. KVHI: Korean-version of Voice Handica Index, BTX: botulinum toxin Table 4. Results of atient s self rating scales in adductor sasmodic dyshonia atients before and after BTX-A injection Patient s self rating scales (score) Wilcoxon signed rank test. BTX: botulinum toxin 고찰 ADSD 여성환자군의 BTX-A 주입전후의효과를알아보고자공기역학적검사를시행한결과, MPT는 BTX-A 주입전에비해주입 4~6주후통계적으로유의하게줄어들었다. 이에대해 Zwirner 등 20) 의연구에서 BTX-A 주입전에비해주입후가통계적으로유의하지는않지만줄어드는경향을보여본연구와맥락을같이하였다. 또한 BTX-A 주입전 MPT는중위수 초 ( 사분위수범위 7.41) 로국내연구에서제시한정상여자성인 MPT 평균 (± 표준편차 ) 인 (±4.49) 초와비교하였을때짧은경향을보이기도하였다. 21) 이는발성시성대근이불수의적으로수축하게되고목에힘을주는발성을하게됨으로써공기의흐름을적게사용하여 BTX-A 주입전에는 MPT가다소길어지는경향이있었으나, 주입후편측갑상피열근을마비시킴으로써공기의흐름이원활해져 MPT가줄어든것으로해석할수있다. 한편, BTX-A 주입후유의하게줄어든 MPT는 MFR과 Psub 및음성효율과도관련이있을것으로예상하였으나통계적으로유의한차이는없었다. 본연구에서 MFR이 BTX-A 주입전에비해주입후유의하게증가하지않은이유중하나로환자의보상작용을예상할수있는데, 실제로 12명의환자중 2명의환자가주입전에비해주입후 MFR이감소하였고 MPT 는증가하는모습을보였다. ADSD 환자는발성시성대가연축되는것을극복하기위하여일부러속삭이는듯한음성 (whisered voice) 을사용할수있는데, 이러한경우환자의주입전 MFR이증가되어나타날수있으며더불어 MPT는짧아지는경향을보일수도있다. 22) Lx Seech studio 의 SPEAD프로그램을이용하여 EGG 검사를시행함과동시에음향학적분석도동시에시행한결과, 평균기본주파수분포는주입전에비해주입 4~6주후통계적으로유의하게높았고주파수불규칙성은낮아지는경향이있었으나유의한차이는보이지않았다. Zwirner 등 20) 의연구에서도평균기본주파수가주입전에비해주입후 높아지는경향이있어본연구와비슷한양상을보였으나통계적으로유의하지않았고기본주파수에대한표준편차 (standard deviation of fundamental frequency) 는통계적으로유의하게낮아지는결과를보였는데, 이연구에서는여성환자군뿐만아니라남성환자군까지포함시켰고, 과제가단모음 /a/ 발성으로본연구의연구대상과과제가다르므로결과에차이를나타낸것으로보인다. 문단읽기를과제로한 Hwang 등 18) 의연구에서주입전환자군의평균기본주파수분포는 (±33.57) Hz로정상군인 (±18.51) Hz보다유의미하게낮은결과를보였고, 주파수불규칙성도 27.73(±20.6)% 로정상군인 7.88(±9.96)% 보다유의하게높은결과를보였다. 본연구에서도주입전환자의평균기본주파수분포가 Hz( 사분위수범위 53.1), 주파수불규칙성이 23.67%( 사분위수범위 27.81) 로기존의선행연구와비슷한결과를보여환자군이정상군과비교하였을때대체로낮은기본주파수를갖고있으며주파수가안정적이지못하다는것을알수있었다. 평균음성강도분포는주입전에비해주입후통계적으로유의하게감소하였고강도불규칙성은주입전과후에통계적으로유의한차이를보이지는않았으나, 주입전중위수가 8.07%( 사분위수범위 4.84) 에서주입후 5.4%( 사분위수범위 3.27) 으로크게감소하는경향을보였다. 평균음성강도분포의감소는 BTX-A 에의해성대기능이제한됨으로써발생한결과로볼수있다. 평균성문폐쇄율분포는 BTX-A 주입전에비해주입 4~6주후통계적으로유의하게감소되었다. 이는성대내전에어려움이있는 ADSD 환자들이 BTX-A 주입전발화시성대에힘을주어발성하여성문폐쇄율이증가되었다가주입후성대가갑작스럽게연축하는것이줄어들면서주입전보다힘이덜들어가는편안한발성을하여성문폐쇄율이줄어든것으로볼수있다. 앞에서제시한공기역학적검사와 EGG 검사는연축성발성장애환자의 BTX-A 주입전후음성개선에대하여객관적지표를제시하긴하나이는평가자의기준에서시행한 151
5 Korean J Otorhinolaryngol-Head Neck Surg 2011;54: 것이므로환자본인이주관적으로느끼는효과에대해서는반영하지못한다. 23) 실제환자들중에서는 BTX-A 주입후객관적결과가향상되었음에도불구하고그효과를느끼지못하며본인의음성에대하여만족하지못하는경우를볼수있었다. 따라서 BTX-A 주입전후환자의삶의질을평가하기위하여심리측정적도구인 KVHI와환자보고에의한청지각적평가를시행한결과, KVHI 점수는주입전에비해주입 4~6주후통계적으로유의하게감소되었다. Benninger 등 24) 은 VHI를사용하여 BTX-A 주입전후환자의삶의질을평가한선행연구에서주입전보다후에신체적, 기능적, 정서적영역에서모두유의하게점수가줄어들어본연구와일치하는결과를보였다. 본연구에서 BTX-A 주입전환자군의 KVHI 점수는중위수가 90점 ( 사분위수범위 29.5) 으로선행연구들과비교하여크게차이를보이진않았으며, 주입후 45점 ( 사분위수범위 46.25) 으로유의하게감소하였으나기존연구들이제시한정상군에비해서는매우높은편이다. 또한 BTX-A 주입전과후의점수차이의변이가 0~100 점으로매우크게나타났다. 이는 BTX-A 주입후가주입전에비해쥐어짜는듯한목소리나음성의떨림등의증상들이줄어들기는하였으나, 개인차가있고큰목소리를낼수없으며기식화된음성이나타나는등완전히정상적인음성이아니므로여전히환자들은음성과관련된일상생활에서불편함이남아있다는것을예상할수있다. 그러나환자의청지각평가점수는주입전에비해주입후청지각적평가점수가통계적으로유의하게감소되어 BTX-A 주입후음성에대한향상여부는환자본인이스스로음성을평가할때에도주입전보다주입후음성이크게개선되었음을알수있었다. 추후연구에서는남성환자군포함및대상자수를늘리고연령대별로데이터를수집하여 BTX-A 주입전후에관하여성별및연령에따른변화를비교분석하는연구를비롯하여, 본연구에서통제하지못한 BTX-A 의주입횟수, 주입량, 중증도및기간에따른효과에대한연구가이루어져야할것이다. Acknowledgments This aer summarizes the first authorʼs Masterʼs thesis. REFERENCES 1) Woodson G, Hochstetler H, Murry T. Botulinum toxin theray for abductor sasmodic dyshonia. J Voice 2006;20(1): ) Meyer TK. The larynx for neurologists. Neurologist 2009;15(6): ) Swenson MR, Zwirner P, Murry T, Woodson GE. Medical evaluation of atients with sasmodic dyshonia. J Voice 1992;6(4): ) Mehta RP, Goldman SN, Orloff LA. Long-term theray for sasmodic dyshonia: acoustic and aerodynamic outcomes. Arch Otolaryngol Head Neck Surg 2001;127(4): ) Hoffman MR, Jiang JJ, Rieves AL, McElveen KA, Ford CN. Differentiating between adductor and abductor sasmodic dyshonia using airflow interrution. Laryngoscoe 2009;119(9): ) Braden MN, Johns MM 3rd, Klein AM, Delgaudio JM, Gilman M, Haner ER. Assessing the effectiveness of botulinum toxin injections for adductor sasmodic dyshonia: clinician and atient ercetion. J Voice 2010;24(2): ) Ascher B, Kla P, Marion MH, Chanteloub F. [Botulinum toxin in the treatment of frontoglabellar and eriorbital wrinkles. An initial study]. Ann Chir Plast Esthet 1995;40(1): ) Pearson EJ, Saienza CM. Historical aroaches to the treatment of Adductor-Tye Sasmodic Dyshonia (ADSD): review and tutorial. NeuroRehabilitation 2003;18(4): ) Jankovic J, Brin MF. Botulinum toxin: historical ersective and otential new indications. Muscle Nerve Sul 1997;6:S ) Chang CY, Chabot P, Thomas JP. Relationshi of botulinum dosage to duration of side effects and normal voice in adductor sasmodic dyshonia. Otolaryngol Head Neck Surg 2007;136(6): ) Cannito MP, Kahane JC, Chorna L. Vocal aging and adductor sasmodic dyshonia: resonse to botulinum toxin injection. Clin Interv Aging 2008;3(1): ) Choi HS, Lee JH, Kim IS, Koh YW, Oh JS, Bae JH, et al. The Acoustic and aerodynamic asects of atients with sasmodic dyshonia. J Korean Soc Logoed Phoniatr 2000;11: ) Choi SH, Sim HS, Choi HS. Study on the communication attitudes of adductor sasmodic dyshonia atients. Korean J Commun Disord 2004;9: ) Cantarella G, Berlusconi A, Maraschi B, Ghio A, Barbieri S. Botulinum toxin injection and airflow stability in sasmodic dyshonia. Otolaryngol Head Neck Surg 2006;134(3): ) Aronson AE, McCaffrey TV, Litchy WJ, Liton RJ. Botulinum toxin injection for adductor sastic dyshonia: atient self-ratings of voice and honatory effort after three successive injections. Laryngoscoe 1993;103(6): ) Park SY, Kim J, Lim SE, Nam DH, Choi HS. The ercetual evaluation and aerodynamic analysis of sasmodic dyshonia. J Korean Soc Logoed Phoniatr 2008;19: ) Kim H. Percetual, Acoustical, and Physiological Tools in Ataxic Dysarthria Management: A case reort. Proceedings on the 2nd Conference in The Korean Society of Phonetic Sciences and Seech Technology; ) Hwang YS, Kim J, Choi HS. Characteristics of connected seech in ADSD. J Korean Soc Seech Sci 2009;1: ) Kim J, Lim SE, Park SY, Choi SH, Choi JN, Choi HS. Validity and reliability of Korean-version of voice handica index and voice-related of quality of life. J Korean Soc Seech Sci 2007;14: ) Zwirner P, Murry T, Swenson M, Woodson GE. Acoustic changes in sasmodic dyshonia after botulinum toxin injection. J Voice 1991;5(1): ) Kim B. Maximum honation time and articulation diadochokinetic rate, seech rate of standardized assage in the healthy Korean Youths and middle-agers [master]. Seoul, Korea: Yonsei Univ.; ) Finnegan EM, Luschei ES, Gordon JD, Barkmeier JM, Hoffman HT. Increased stability of airflow following botulinum toxin injection. Laryngoscoe 1999;109(8): ) Langeveld TP, van Rossum M, Houtman EH, Zwinderman AH, Briaire JJ, Baatenburg de Jong RJ. Evaluation of voice quality in adductor sasmodic dyshonia before and after botulinum toxin treatment. Ann Otol Rhinol Laryngol 2001;110(7 Pt 1): ) Benninger MS, Gardner G, Grywalski C. Outcomes of botulinum toxin treatment for atients with sasmodic dyshonia. Arch Otolaryngol Head Neck Surg 2001;127(9):
6 Voice Characteristics of Sasmodic Dyshonia Yun B, et al. 부록 1. 가을문단 가을 우리나라의가을은참으로아름답다. 무엇보다도산에오를땐더욱더그빼어난아름다움이느껴진다. 쓰다듬어진듯한완만함과, 깎아놓은듯한뾰족함이어우러진산등성이를따라오르다보면, 절로감탄을금할수가없게된다. 붉은색, 푸른색, 노란색등의여러가지색깔들이어우러져, 타는듯한감동을주며나아가신비롭기까지하다. 숲속에누워서하늘을바라보라. 쌍쌍이짝지어져있는듯한흰구름, 높고파란하늘을쳐다보고있노라면과연예부터가을을천고마비의계절이라일컫는이유를알게될것만같다. 가을에는또한오곡백과등먹거리가풍성하기때문에결실의계절이라고도한다. 햅쌀, 밤, 호두뿐만아니라대추, 여러가지떡, 크고작은과일들을맛볼수있는데, 가을의대표적인명절인추석에우리는이것들을쌓아놓고조상님들께차례를지내기도한다. 또한, 가을은독서의계절이라고도하여책을읽으며시시때때로명상에잠기기도하는데, 독서는우리에게마음을살찌우고아름답게하는힘을주기때문이다. 부록 2. 청지각적평가검사지 ( 환자용 ) 이름 : 나이 : 만세날짜 : 다음의질문에대해본인이느끼는증상이어느정도인지숫자에동그라미 ( 또는 V 표 ) 로표시하십시오. 0= 증상이없음 (normal) 1= 드물게나타남 (mild) 2= 때때로나타남 (mild-moderate) 3= 자주나타남 (moderate) 4= 항상나타남 (severe) 1. 말할때목이긴장되며조이는느낌이있다 말할때음성의떨림이나타난다 말할때막히거나끊어지는증상이있다 말할때쉰목소리가난다 현재전반적인음성상태에대해표시해주십시오 총 /20 점 153
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