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J Korean Soc Phys Med, 2017; 12(4): 29-37 http://dx.doi.org/10.13066/kspm.2017.12.4.29 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 전신진동이결합된흡기근훈련이뇌졸중환자의폐기능에미치는즉각적인효과 박시현 서동권 1 순천향대학교천안병원물리치료실, 1 건양대학교물리치료학과 The Immediate Effect of Inspiratory Muscle Training with Whole Body Vibration on Pulmonary Function of Stroke Patients Si-Hyun Park, PT, MS Dong-Kwon Seo, PT, PhD 1 Dept. of Physical Therapy, Soon Chun Hyang University Hospital Cheonan 1 Dept. of Physical Therapy, Konyang University Received: May 4, 2017 / Revised: May 15, 2017 / Accepted: July 2, 2017 c 2017 J Korean Soc Phys Med Abstract 1) PURPOSE: This study investigated the immediate effect of inspiratory muscle training with whole-body vibration on the pulmonary function of subacute stroke patients. METHODS: All participants (n=30) were allocated to the following groups: (1) the inspiratory muscle training group with whole-body vibration (n=10), wherein the patients received inspiratory muscle training with whole-body vibration comprising 3minutes of vibration per session and respiratory training of 30 times and 2 sessions for one day. (2) the inspiratory muscle training group with visual feedback (n=10), wherein the patients received inspiratory muscle training with visual feedback. (3) the inspiratory muscle training group (n=10), wherein the patients received Corresponding Author : parksh87@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. inspiratory muscle training. RESULTS: After the experiment, the inspiratory muscle training group with whole-body vibration exhibited significantly higher forced vital capacity, forced expiratory volume at 1 second, peak inspiratory flow rate, maximal inspiratory pressure, and chest expansion (p<.05), compared to the other groups. Inspiratory muscle training group with whole-body vibration had significantly higher peak expiratory flow rate and maximal voluntary ventilation than the other groups (p<.05). CONCLUSION: These results show that pulmonary function, maximal inspiratory pressure, and chest expansion were significantly better in the inspiratory muscle training group with whole-body vibration than in the other groups. Thus, this treatment will help recovery of pulmonary function in stroke patients. Key Words: Pulmonary function test, Respiratory muscle training, Stroke, Vibration

30 J Korean Soc Phys Med Vol. 12, No. 4 Ⅰ. 서론뇌졸중으로인한편마비환자는수의적운동기능장애, 근긴장도장애, 지각및인지장애, 감각장애, 시각장애등을동반하게되며이차적인근육불용 (disuse) 과제한된움직임은대사기능저하, 근력저하및심폐기능의약화를일으키게된다 (De Almeida 등, 2011). 특히호흡기능의장애는생명과도가장연관된장애중하나다 (Cho와 Lee, 2015). 뿐만아니라뇌졸중환자는산소포화도가낮게유지되어저산소증을보일수있으며 (Roffe 등, 2010), 심혈관계기능이상, 심장맥박기능저하와마비측흉벽움직임의감소로인하여심폐기능과횡격막기능저하가나타난다 (Kim과 Jung, 2013; Vernier 등, 1998). 또한심폐기능의문제로인해호흡근육의협동작용에필요한운동조절기능이손상되기때문에 (Britto 등, 2011), 호흡근육의근력과지구력에영향을미쳐집중적인치료를받는급성기뇌졸중환자들에게지구력을요구하는유산소운동시피로감을쉽게발생시킨다 (Estenne 등, 1993). 이는일상생활의제한과사회생활로의복귀를늦추게되는원인이된다 (Roffe 등, 2010). 호흡기능의향상을위한흡기근훈련은횡격막과흡기보조근에저항을적용하여뇌졸중환자들의흡기근육의근력과지구력을향상시킬뿐만아니라호흡순환계의협동능력을증가시켜서호흡장애를감소시킨다고보고했다 (Nici 등, 2006). 흡기근훈련은골격근강화훈련의기본원리, 과부하및특이성가역성에근거를두고적용한다 (Moodie 등, 2011). 전신진동운동은본래근섬유자체의형태와기능적발달, 생리학적요인들을향상시키는신경근훈련으로 (Ahlborg 등, 2006), 뇌졸중환자의재활에있어서새로운체성감각자극방법이다 (van Nes 등, 2006). 이러한전신진동은구심성신경섬유에반복적인자극을통해대뇌에가변적변화를가져오고 (Chollet 등, 1991), 진동자극이인체에적용되면, 골격근의근육길이에미세한변화들을경험하게된다 (Lebedev와 Poliakov, 1991). 진동자극을받은근방추수용기는활성화되며, 진동자극을직접받은근육뿐만아니라주위근육에도영향을미친다고하였다 (Kasai 등, 1992). 진동자극에관한많 은관심과다양한연구가진행되고있지만 (Tihanyi 등, 2007), 현재뇌졸중환자의호흡기능및폐기능과관련된진동의효과를나타내는연구는미비하며, 특히흡기근훈련과결합된전신진동의효과를입증한연구가없는실정이다. 이에본연구에서는전신진동이결합된흡기근훈련을적용하여뇌졸중환자의흉곽용적및폐기능, 최대흡기압력에미치는영향을알아보고향후뇌졸중환자의호흡기능개선및폐기능증진을위한중재방법으로제시하고자한다. Ⅱ. 연구방법 1. 연구대상자본연구는 K대학병원에서치료를받는뇌졸중환자중사전조건에충족한 30명을대상으로실시하였다. 연구에참여한대상자선정조건은 1) 뇌졸중발병후 6개월이내의아급성환자 2) 전선화단층촬영이나자기공명영상에의한편측뇌손상이확인된환자 3) 뇌졸중발병전폐질환의병력이없는환자 4) 흉골및늑골변형, 골절등의손상이없는환자 5) 폐기능향상을위한치료를받지않는환자 6) 검사자가말하는내용을이해할수있는한국형간이정신상태검사 (Mini-Mental State Examination-Korean for Korean; MMSE-K) 점수를 24점이상획득한자로선정하였다. 2. 실험절차아급성뇌졸중환자 30명을대상으로전신진동이결합된흡기근훈련군 10명, 시각적되먹임을이용한흡기근훈련군 10명, 흡기근훈련군 10명으로무작위배정하였다. 진동자극을위해좌우교대방식의전신진동기기 (Galileo Delta, Novotec Medical GmbH, Germany) 를사용하였으며 (Fig. 1), 전신진동이결합된흡기군훈련군은진동기기위에서바로앉은자세로훈련을하였다. 집게를사용하여코를막고한손으로흡기근훈련기를잡고다른한손으로는전신진동기기의손잡이를잡고자세를유지하면서진신진동과함께흡기근육강화훈

전신진동이 결합된 흡기근 훈련이 뇌졸중 환자의 폐 기능에 미치는 즉각적인 효과 31 2) 최대흡기압력 측정(Maximal Inspiratory Pressure) 대상자들의 최대흡기압력을 측정하기 위해서 역치 저항성 흡기근 훈련 장비(POWER breathe K5, Gaiam Ltd, Southam UK)를 사용하였다(Fig. 3). 3회를 실시하 였으며, 3개의 최대흡기압력 결과값 중에서 가장 높은 값을 기록하였다. Fig. 1. Whole body vibrator (Galileo Delta, Germany) 련을 시행하였다. 대상자는 초기 흡기근육 훈련을 하기 전 최대호기 후, 흡기를 시작하여 최대흡기압력을 측정하 고 최대흡기압력의 50%의 저항력으로 훈련을 시작하였 다(Kilding 등, 2010). 훈련은 매 회 3분씩 세트당 30회, 총 2세트를 시행하였고, 적용 주파수는 15Hz로 근 피로를 발생시키지 않는 범위로 적용하였다(Hoover와 Ashe, 1962). 폐 기능 검사, 흉곽 용적 및 최대흡기압력 측정 후, 전신진 동이 결합된 흡기근 훈련을 실시하고, 직후 폐 기능 검사, 흉곽 용적 및 최대흡기압력을 재측정하였다. 3. 실험 도구 1) 폐 기능 측정(Pulmonary function measurement) 폐 기능 검사는 폐활량계(Spirovit SP-250, Schiller AG, Switzerland)로 측정하였다(Fig. 2). 폐 기능을 수치 화 하기 위해서 노력성 폐활량, 1초간 노력성호기량, 최대 환기량, 최대호기유속, 최대흡기유속, 1회 호흡량, 분당 환기량을 측정하였다. Fig. 3. Inspiratory muscle trainer (POWER breathe K5, United Kingdom) 3) 흡기 지구력 측정 대상자는 앉은 자세에서 코마개를 착용하고 흉곽의 용적이 커지는 것을 시각적으로 확인 후 훈련을 실시하 도록 하였다. 4) 흉곽 용적 측정(Chest expansion measurement) 호흡시 흉곽의 확장 정도를 확인 하기 위해 줄자를 이용하여 흉곽용적을 측정하였다. 흡기시 흉곽용적, 호 기시 흉곽용적, 흉곽의 확장 정도를 측정하였다. 흉곽 의 확장 정도는 최대 흡기시의 흉곽둘레 측정값(cm)에 서 최대 호기시의 흉곽둘레 측정값(cm)을 뺀 값으로 하였다. 4. 자료분석 모든 통계분석은 SPSS version 18.0 for window를 이 용하였다. 연구 대상자들의 일반적 특성은 기술통계방 법을 이용하였고, 전신진동이 결합된 흡기근 훈련군, 시각적 되먹임을 이용한 흡기근 훈련군과 흡기근 훈련 Fig. 2. Spirometer (Schiller SP-250, United States) 군, 각각의 중재 후 군간 차이를 분석하기 위해서 일원

32 J Korean Soc Phys Med Vol. 12, No. 4 배치분산분석 (one-way ANOVA) 을사용하였다. 그리고각각의군내중재전후차이를비교하기위해서대응표본 t-검정 (paired t-test) 을사용하였다. 통계학적유의수준은 α=.05를기준으로하였다. 최대흡기압력변화량은유의한차이를보였으며, 전신진동이결합된흡기근훈련군, 흡기근훈련군, 시각적되먹임을이용한흡기근훈련군순서로차이가있었다 (p<.05)(table 3). Ⅲ. 연구결과 1. 연구대상자의일반적인특징세군의일반적특성은 Table 1과같고, 동질성검사에서세군간유의한차이는없었다 (Table 1). 2. 폐기능전신진동이결합된흡기근훈련중재후노력성폐활량, 1초간노력성호기량, 최대흡기유속에유의한차이가있었고, 세군간의폐기능비교에서는최대호기유속및최대환기량의유의한차이가있었다 (p<.05). 중재후폐기능변화량에대한사후검정에서 1초간노력성호기량및최대흡기유속의변화량은유의한차이를보였으며, 전신진동이결합된흡기근훈련군, 흡기근훈련군, 시각적되먹임을이용한흡기근훈련군순서로차이가있었다 (p<.05)(table 2). 3. 최대흡기압력전신진동이결합된흡기근훈련중재후최대흡기압력은유의한차이를보였다 (p<.05). 중재후세군간의최대흡기압력비교에서는유의한차이가없었다. 중재후최대흡기압력변화량에대한사후검정에서 4. 흉곽용적전신진동이결합된흡기근훈련중재후흉곽용적은유의한차이를보였다 (p<.05). 중재후세군간의흉곽용적비교에서는유의한차이가없었다. 중재후흉곽용적변화량에대한사후검정에서흡기시흉곽용적변화량에유의한차이를보였으며, 전신진동이결합된흡기근훈련군, 시각적되먹임을이용한흡기근훈련군, 흡기근훈련군순서로차이가있었다 (p<.05)(table 4). Ⅳ. 고찰전신진동은진동판에서생성된진동이몸, 팔과다리에전달되었을때발생되며, 이렇게생산된진동은직접또는간접적으로신체에영향을미칠수있다 (Rittweger, 2010). 전신진동의효과는크게간접적효과와직접적효과로나누어볼수있다. 간접적인효과는신경계통, 내분비계통에영향을미치고 (Prisby 등, 2008), 직접적인효과는근육들이나건들과같은요소들에영향을미친다고하였다 (Rittweger, 2010). Binks 등 (2001) 의연구에서는흉벽의기계적진동이 Table 1. General characteristics of all subjects (N=30) IMTV (n=10) IMTF (n=10) IMT (n=10) Sex (male/female) 10 (6/4) 10 (5/5) 10 (5/5) Age (year) 50.8±8.70 64.9±11.33 58.8±15.10 3.49 Height (cm) 164.3±10.69 159.4±9.79 162.4±11.61.17 Weight (kg) 66.4±10.56 61.7±5.66 60.7±12.64.29 Values are expressed as mean±standard deviation. IMTV: inspiratory muscle training with vibration. IMTF: inspiratory muscle training with visual feedback. IMT: inspiratory muscle training. F

전신진동이결합된흡기근훈련이뇌졸중환자의폐기능에미치는즉각적인효과 33 Table 2. Comparison of pulmonary function and variation before and after intervention within each group and between the three groups (N=30) IMTV (n=10)¹ IMTF (n=10)² IMT (n=10)³ Pretest 2.42±1.07 2.2±.70 2.04±.75.37 FVC Posttest 2.82±1.08 2.36±.70 2.22±.90.98 (L) Pre-post.39±.44.15±.46.18±.44.05 t -.81* -1.03-1.31 Pretest 1.99±.79 1.81±.48 1.82±.62.98 FEV1 Posttest 2.57±1.00 1.81±.52 2.06±.88 1.53 (L) Pre-post.58±.61.00±.34.23±.39.88 t -3.02*.02-1.87 Pretest 3.70±1.75 2.73±.91 3.14±1.25 2.32 PEF Posttest 4.30±1.29 2.51±.80 3.59±1.88 4.15 (L/s) Pre-post.60±1.62 -.22±.66.44±1.25.69 t -1.17 1.07-1.12 Pretest 1.71±.62 2.09±.81 2.08±1.13.47 PIF Posttest 2.78±.99 2.74±1.35 2.87±1.61.04 (L/s) Pre-post 1.07±.56.65±1.07.78±1.21 4.41 t -5.98* -1.91-2.04 Pretest 2.3±1.19 1.85±.84 1.75±.69.85 TV Posttest 2.5±1.49 2.01±.7 1.87±1.03 1.10 (L) Pre-post.20±.75.16±.58.12±.83.56 t -.85 -.86 -.45 Pretest 12.98±5.22 13.62±5.07 16.56±10.46 36.43 MV Posttest 15.38±7.6 13.41±7.12 16.23±8.83 20.87 (L/min) Pre-post 2.4±5.69 -.20±3.99 -.32±10.26 23.73 t -1.33.16.10 Pretest 42.21±16.61 31.05±15.01 30.22±14.9 448.53 MVV Posttest 49.96±13.25 32.56±17.14 35.51±15.39 866.51 (L/min) Pre-post 7.7±12.34 1.51±10.70 5.29±12.04 50.35 t -1.89 -.44-1.39 IMTV: inspiratory muscle training with vibration. IMTF: inspiratory muscle training with visual feedback. IMT: inspiratory muscle training. FVC: forced vital capacity. FEV1: forced expiratory volume at 1 second. PEF: peak expiratory flow. PIF: peak inspiratory flow. MVV: maximal voluntary ventilation. TV: tidal volume. MV: minute volume. *p<.05, p<.05, : ¹>³>² F Table 3. Comparison of maximal inspiratory pressure and variation before and after intervention within each group and between the three groups (N=30) IMTV (n=10)¹ IMTF (n=10)² IMT (n=10)³ Pretest 31.6±9.99 37.4±12.95 40.3±16.21 196.23 MIP Posttest 49.2±16.35 47.8±21.92 51.8±22.89 41.20 (cmh2o) Pre-post 17.60±8.85 10.40±17.37 11.50±16.39 1145.43 t -6.28* -1.89-2.21 IMTV: inspiratory muscle training with vibration. IMTF: inspiratory muscle training with visual feedback. IMT: inspiratory muscle training. MIP: maximal inspiratory pressure. *p<.05, p<.05, : ¹>³>² F

34 J Korean Soc Phys Med Vol. 12, No. 4 Table 4. Comparison of chest expansion and variation before and after intervention within each group and between the three groups (N=30) IMTV (n=10)¹ IMTF (n=10)² IMT (n=10)³ Pretest 88.99±5.35 90.29±5.54 90.7±12.29 12.63 ICC Posttest 90.12±5.72 90.89±5.52 90.85±11.08 1.87 (cm) Pre-post 1.13±8.85.73±.39.13±1.41 4.02 t -4.63* -5.85*.29 Pretest 87.64±5.05 89.11±5.73 86.6±6.53 15.90 ECC Posttest 86.7±4.91 88.55±5.66 87.09±6.99 9.07 (cm) Pre-post -.88±.66 -.68±.75.49±2.31 5.13 t 4.15* 2.84* -.66 IMTV: inspiratory muscle training with vibration. IMTF: inspiratory muscle training with visual feedback. IMT: inspiratory muscle training. ICC: inspiratory chest circumference. ECC: expiratory chest circumference. *p<.05, p<.05, : ¹>²>³ F 호흡기관계의감각을변화시킨다고하였고, 늑간근에진동적용이호흡의문제점들을증가시키거나감소시킬수있다고보고했다. Jammes 등 (2000) 의연구에서는호흡근육에적용된진동자극이호흡운동신경원의활동을일으킨다하였으며, 이러한진동자극이횡격막및흉골, 내부늑간근의활성화뿐만아니라외부늑간근의활동을증가시켜호흡기능증진에영향을미친다고보고하였다 (Leduc 등, 2001). 본연구와동일하게 Binks 등 (2001) 의연구에서는진동이호흡조절에영향을미친다고하였으며, 만약흉벽에대한진동이기도까지전달된다면이러한감각에대한반응이폐의수용기들에의해중재가능하다고하였다. 호흡조절에대한폐수용기들의여러효과중하나는폐가진동됨으로써폐수용기들을자극시키고, 구심성활동이호흡조절과진동감각에대한반응에관여한다고하였다 (Binks 등, 2001). Britto 등 (2011) 은뇌졸중환자의호흡기능향상을위해흡기근저항훈련장비를이용하여흡기근력강화와지구력에유의한변화가있었다고보고하였으며, Jo 등 (2014) 의연구에서도뇌졸중환자의호흡기능및호흡근력을향상시키기위해호흡근강화훈련을적용하였고그결과호흡기능및호흡근력에서유의한변화가있었다고보고하였다. 이러한사전연구의결과로 본연구에서는기존의흡기근훈련과전신진동을결합하여뇌졸중환자에게적용하였다. 전신진동의적용은흡기근활성및심폐기능의효율성을높이는데목적이있으며, 선행연구의흡기근훈련과전신진동을결합하여뇌졸중환자의폐기능, 최대흡기압력및흉곽용적에어떠한영향을미치는지알아보고자하였다. 본연구결과, 전신진동이결합된흡기근훈련후, 뇌졸중환자의폐기능과최대흡기압력, 흉곽용적에유의한차이가있는것으로확인되었으며, 세군간비교에서도유의한차이가나타났다. Sutbeyaz 등 (2010) 의연구에서는급성기뇌졸중환자를대상으로횡격막호흡및오므린입술호흡훈련군과흡기근훈련군, 대조군으로분류하고, 6주동안중재를하였으며, 폐기능과흡기근기능을비교하였다. 중재결과, 흡기근훈련군의노력성폐활량, 1초간노력성호기량은대조군과비교하여유의한증가가나타났으나, 최대호기속도는유의한증가를보이지않았다. 이는측정변수인최대호기유속이호기가아닌흡기에대한직접적인중재방법, 흡기근훈련에더많은영향을받았을것이라사료된다. 본연구의결과에서도전신진동이결합된흡기근훈련후뇌졸중환자의노력성폐활량, 1초간노력성호기량, 최대흡기유속, 최대흡기압력에유의한차이를보였기때문에선행연구와일치한다

전신진동이결합된흡기근훈련이뇌졸중환자의폐기능에미치는즉각적인효과 35 고할수있으며유의한차이가있었다. 본연구에서중재후세군간폐기능변화량을살펴보면, 1초간노력성호기량, 최대흡기유속값에유의한차이를보였다. 1초간노력성호기량및최대흡기유속의변화량값이증진된것은폐기능검사시노력성폐활량및최대환기량측정을위해최대호기말에복직근의사용으로흉곽주위내부압력을증가시키고전신진동을통한호흡근의활성화로호흡순환이증가되어결과값에영향을미친다고보고했다 (Mehanna와 Jankovic, 2010). Fry 등 (2007) 의연구에서는흡기근훈련이호흡기능을향상시키고그로인해호기용적이증가한다고하였다. 본연구에서도중재후전신진동이결합된흡기근훈련군의 1초간노력성호기량, 최대흡기유속에대한결과값은이전연구와일치하는결과를보였으며, 흡기근훈련의효과를증명하였다. 하지만최대호기유속, 최대환기량, 1회호흡량, 분당환기량의증가는보였지만통계적으로유의한차이는없었으며, 군간비교에서도유의한차이가나타나지않았다. 이는전신진동이호흡근및호흡보조근활성화시키는장점이있지만 (McConnell과 Romer, 2004), 본연구는전신진동이결합된흡기근훈련의즉각적인효과를보고자하였고, 뇌졸중환자의폐기능에관한모든변수들을향상시키기에는어려움이있었다고사료된다. 본연구에서는전신진동이결합된흡기근훈련후뇌졸중환자의흉곽용적에영향을미치는것으로나타났으며, 세군간흡기시흉곽용적변화량에도유의한차이를보였다. 본연구의제한점은대상자가적어서결과값을일반화하기에는어려움이있었고, 이전연구에서는장기간중재가있었지만본연구에서는즉각적인효과를보고자단기간중재를적용하여상대적으로훈련기간이짧았다고사료되며, 향후훈련의효과가얼마나지속되는지뇌졸중환자를대상으로추적연구가필요할것으로사료된다. 본연구의결과, 기존의흡기근훈련보다전신진동이결합된흡기근훈련이뇌졸중환자의폐기능과최대흡기압력, 흉곽용적증진에더효과적이라고생각된다. 호흡기능과흉곽의용적변화는밀접한관계를나타내고있으며호흡기능증진은흉곽용적을향상시키기위한치료적방법으로널리활용될것이라사료된다. Ⅴ. 결론본연구는아급성뇌졸중환자 30명을대상으로전신진동이결합된흡기근호흡훈련이폐기능, 최대흡기압력, 흉곽용적증진에미치는효과를입증하고자하였다. 그결과전신진동이결합된흡기근훈련군중재후폐기능에유의한차이가있었으며중재후군간비교에서도폐기능, 최대흡기압력및흉곽용적에유의한차이가있었다 (p<.05). 따라서, 각각의세군의호흡훈련방법에따라폐기능및최대흡기압력, 흉곽용적에영향을미치는것으로나타났으며, 특히전신진동이결합된흡기근훈련군이시각적되먹임을이용한흡기근훈련군이나기존의흡기근훈련군보다폐기능및최대흡기압력, 흉곽용적증진에효과가있음을보였다. 그러므로임상에서뇌졸중환자를중재하는방법으로좀더효과적인호흡운동이될수있을것이라사료된다. References Ahlborg L, Andersson C, Julin P, et al. Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy. J Rehabil Med. 2006; 38(5):302-8. Binks AP, Bloch-Salisbury E, Banzett R, et al. Oscillation of the lung by chest-wall vibration. Respir Physiol Neurobiol. 2001;126(3):245-9. Britto RR, Rezende NR, Marinho KC, et al. Inspiratory muscular training in chronic stroke survivors: a randomized controlled trial. Arch PhysMed Rehabil. 2011;92(2): 184-90.

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