2015 Volume 19 Number 2 대한신경치료학회_2015_(1,2,3)_표지.indd 8 2016. 4. 1. 오후 5:04
Neurotherapy <Aims and Scope> The Journal of Korean Society for Neurotherappy(J Korean Soc Neur Ther) engages and inspires as an international, interdisciplinary, peer-reviewed journal, deals with clinical neurorehabilitation and cross disciplinary area about the therapeutic intervention and functional recovery in all area of neurological condition including stroke, cerebral palsy, spinal cord injury, traumatic brain injury, neuromuscular disease and other multi-dimension disorders for health and life quality of human. Neurotherapy accepts original quantitative and qualitative research reports, theoretical papers, systematic literature reviews, clinical case reports and technical clinical notes. This journal is a member of the Committee on Publication Ethics(COPE) The Journal of Korean Society for Neurotherapy publishes articles of global relevance for examination, evaluation, prognosis, intervention, and outcomes for individuals with movement deficits due to neurological conditionsand other condition.
NEUROTHERAPY 2 0 1 5 대한신경치료학회지제 19 권제 2 호 대한신경치료학회지 하퇴신근촉진이반복일어서기와보행에미치는효과 1 송배영 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 5 류우정, 김다민, 김은성, 김창주, 김지혜 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 13 이지혜, 황병용, 정상미 물리치료사의직무관련특성이피로도및보행계수에미치는영향 23 이상용, 박정서, 한슬기, 이대희 하지의마사지적용이경직성뇌성마비아동의하지운동범위와일상생활활동에미치는영향 29 노효련 시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향 33 김창영, 황병용, 이상호 이중과제훈련이노인의균형에미치는영향 41 이샛별, 차예니, 이상호 테이핑이맨몸하프스쿼트세트에따라 %MVIC에미치는영향 49 이경순, 강영호, 김가희, 이재송, 이현지, 전진영, 정은식, 조성희, 최태근
NEUROTHERAPY Effects of extensor activation of the affected lower limb on repetitive sit-to-stand and walking in patient with hemiplegia 1 Bae-Young Song Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School 5 Woo-Jung Ryu, Da-Min Kim, Eung-Sung Kim, Chang-Ju Kim, Ji-Hye, Kim The Effects of Core stability Strengthening Exercise for Trunk Control and Spine Alignment in Patients with Stroke 13 Ji-Hye Lee, Byong-Yong Hwang, Sang-Mi Jung Influence of Physical Therapist's Job-related Characteristic on Fatigue and Gait Cycle Counting 23 Sang-Yong Lee, Jung-Seo Park, Seul-Ki Han, Dae-Hee Lee Effects of Massage in the Lower Extremity on Range of Motion and Activities of Daily Living in Spasticity Cerebral Palsy with Children 29 Hyo-lyun Roh The Effects of Gait Training Using on Treadmill With and Without Visual Auditory Biofeedback on Walking and Balance in Hemiplegic Patients 33 Chang-Young Kim, Byoung-Yong Hwang, Sang-Ho Lee The Effects of Dual Task Training on Balance for Elderly 41 Sat-Byeol Lee, Yea-Ni Cha, Sang-Ho Lee An Effect that Taping has on %MVIC According to Bodyweight Half Squat Set 49 Kyung-Soon Lee, Gyeong-Ho Kang, Ga-Hui Kim, Jae-Song Lee, Hyeon-Ji Lee, Jin-Yeong Jeon, Eun-Sik Jeong, Seong-Hui Jo, Tae-Geun Choi
NEUROTHERAPY 2 0 1 5 대한신경치료학회지제19권송배영제2호 하퇴신근촉진이반복일어서기와보행에미치는효과 송배영 좋은삼정병원물리치료팀 Effects of Extensor Activation of Affected Lower Limbs on Repetitive Sit-to-Stand and Walking in Patients with Hemiplegia Bae-young Song, PT Department of Physical Therapy, Good Samjeong Hospital Purpose The study was to investigate effects of extensor activation of the affected lower limb on repetitive sit-to-stand and walking in patient with hemiplegia. Methods A subject received extensor activation training on the affected lower limb. The treatment was conducted 30 minutes a day, 3 times a week for four weeks. Subject was measured with Five times sit to stand test (FTSTS) and Timed Up & Go test (TUG). Results FTSTS and TUG were reduced after the intervention from 64 seconds to 55 second and from 88 seconds to 82 seconds respectively. Conclusion This study showed that the intervention including activating extensor muscles and widening base of support on the hemi-side foot provided benefits on repetitive sit-to-stand and walking positively. Key words Extensor Activation, Sit-to-stand, Walking 책임저자 Bae-Young Song(oper0600@naver.com) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론 수의적움직임은특별한환경에서움직일때선행적자세조절 (APAs) 이발생되는적절한자세조절을필요로한다. 1) 그러므로자세조절에반응하는근육은다른근육들보다먼저활성화된다. 2) 앉은자세에서일어서기 (Sit to Stand, STS) 동작은독립적인일상생활에서필수적인요소이다. STS는안정된앉은자세로부터상대적으로불안정한선자세로의전환이포함되며, 하지와몸통근육의조화로운수축이요구된다. 3) 그리고의자에서일어날때, STS움직임패턴은의자의높이와발의위치와같은환경적인매개변수에따라다양하다. 그러나앉은자세가제한된다면, 명확한 STS궤도의모델은최적화될수있다. 4) 몸의질량분배와기저면 (base of support, BO)S 에대한신체의무게중심 (center of mass, COM) 은일어서는동안균형을유지하는데에중요한요소이므로, 신경시스템이 COM의움직임을조절하는것은사실로추정되어왔고, 안정적으로일어서기동작을수행하기위해서는충분한관절회전력, 좁아진지지면 ( 두발 ) 에압력중심을안정적으로이동시키는능력, 그리고환경에따라일어나는전략을수정하는능력 이필요하다. 5,6) Cheng 등은일어서기동작을 3단계로분류하였다. 첫번째는초기단계로참가자의몸통굴곡과수직지면반발력이감소되는단계가나타나며, 두번째로실행단계는가장짧은단계로수직지면반발력이생성되고가장많은수직반동이생성되는시기이다. 7) 세번째로서기단계는가장많은수직반동이있을때시작되어마지막서기자세로몸전체의수직힘이안정화되는시기이다. 특히앞정강근과넙다리근은일어서기동작동안질량중심앞쪽과위쪽으로이동시키는데중요하며, 넙다리뒤근과가자미근은원심성수축을통해이러한움직임의정도를조절한다. 넙다리근과앞정강근은엉덩이떼기시점전에넙다리근은엉덩이떼기직후에중요한역할을한다. 8) 앉아서일어서기동작 (sit to stand) 와서서앉기동작 (stand to sit) 동안전경골근은몸이앞으로움직이기전에발을안정화시키기위해선행적자세조절에가장대표적인근육으로보이며, 상호적인활성화패턴에따르면, 가자미근의반대작용은예상되어진다. 9,10) 그러므로발의안정성에중요한전경골근의빠른활성은가자미근의활성수준에의해좌우될수있다. 7) 그리고 sit to stand 와 stand to sit에서, 하지에대한몸통의전방움직임은움직임전에전경골근의활동타이 하퇴신근촉진이반복일어서기와보행에미치는효과 1
NEUROTHERAPY 2015;19(2):1-4 밍이필요하다. 이는 CNS가움직임의방향에대한작은변화에반응하여근육의선행적활동을조절할수있다는것을뒷받침한다. 1) 상호억제 (reciprocal inhibition) 란주동근의수축에의해서수의적인운동을할때동시에길항근이억제되는현상을말하며 11, 건강한사람의경우수의적인동작을하는동안길항근의 α-운동신경원의흥분성은척수억제경로의중추변조에의해조절되는데, 근긴장이상증에서는이상호억제기전의장애로주동근과길항근의동시수축이일어나며이로인하여운동장애가초래된다. 11,12) 그리고경직형뇌졸중환자나척수손상환자는이러한억제경로의결함으로인해주동근과길항근의수축과이완이제대로이루어지지않는다. 13) 여러문헌들은뇌졸중과관절장애및신경근육질환과같은건강상태는 STS움직임을할때특별한변화양상을보인다고말한다. 14) 뇌졸중은임상적으로뇌의침범부위에따라감각, 인지, 지각, 언어기능의손상및의식수준의변화등을포함하여다양한손상을일으키며일반적으로뇌병변부위의반대편에운동결핍으로인한마비혹은쇠약을특성으로한다. 15) 특히, 뇌졸중환자의문제점은비대칭적체중지지와비정상적인신체의균형, 체중을사방으로이동하는능력의결함, 섬세한기능을수행하는특수한운동요소의상실등으로일어서기동작시체중의중심이전, 상방으로이동하는데어려움이나타나며, 앉은위치에서일어서기동작시자신의비대칭적인움직임을인식하지못하고있다. 16,17) 만성뇌졸중환자들이여전히비효율적이고불안한방법으로기능적활동을수행하고, 재활시기동안환측사지의사용을피하면서적절하지못한움직임을통해기능적활동을하기때문에, 따라서본연구에서는환측발목의길항작용을촉진하여환자가좀더나은 sit to stand를할수있도록만드는데초점을맞추었다. 8) II. 연구방법 본연구는뇌단층화촬영 (CT) 이나자기공명영상 (MRI) 에의해뇌졸중으로진단을받고연구에참여하기로동의한, 연구조건을충족한환자 1명을대상으로주 3회 1회당 30분씩총 4주에걸쳐실시하였다. 연구대상자의선정조건은뇌졸중으로인하여편마비가된발병기간이 6개월이상인환자, 호흡계및근골격계질환의과거력이없고, 연구자가지시하는내용을이해하고따를수있는환자, 수동적배측굴곡각도에제한이있는환자, Modified Ashworth Scale 경직정도가 2단계이하인환자로정하였다. 그리고환자에대한부가적인평가로 5 번앉았다일어서기동작시시간을측정하기위한 Five Times Sit To Stand (FTSTS) 와동적균형검사인 timed up go test (TUG) 또한실시하였다. FTSTS 통해 Sit to Stand (STS) 검사를하였다. 이검사는안락하고조용한검사실에서 STS 검사수행시최대한의근긴장도를줄이기위하여충분한휴식을취하도록하였다. 등받이가없는침대 (bobath table) 에앉아양팔을가슴에교차한후상지의도움없이일어서고앉는동작을 5회실시하는데소요되는시간을측정하는것이다. 하지만본연구의대상자는일어서기동작시상지의도움이필요하여 FTSTS시상지를사용하였으며환자가평소에일어나는대로편안한 STS를실시하였다. 그리고일어선자세는체간을바로세우고슬관절과고관절을완전히신전한상태로정의하였으며, 검사에앞서대상자들에게 STS 검사를정확하게수행할수있도록구두지시와 1회의시범을보여주었고, 시작 명령에따라앉은자세에서일어서는동작을 5회반복하였다. STS 검사에소요되는시간이적을수록하지근력과동적균형능력이우수하다고할수있다. 18) TUG 는평편한바닥에팔걸이가있는의자를놓고의자에서 3m 떨어진곳에표시물을설치한다. 보행방법은평상시사용하는신발을착용하도록하며보행할때보행보조도구 ( 지팡이, 워커 ) 등을사용할수있으나발목보조기또는다른사람의물리적인도움은받지않도록한다. 보행측정시간은연구대상자가팔걸이가있는의자에편안하게앉고양발은바닥에놓여있는상태에서 일어나서반환점을돌아의자에앉으세요 라는연구자의지시에따라 3회실시하여평균시간을기록하였다. 19) 치료방법은다음과같다. 1 바로누운자세에서발의내재근 (intrinsic muscle) 을활성화시켜외재근을이완시키고교각운동을통해골반주위근에협력수축및슬괵근근위부를강화시키고지면에대해발뒤꿈치를누를수있는능력을향상시켜하지에체중을입력하여감각에자극을준다. 2 앉은자세에서골반움직임과함께코어 (core) 근육을활성화시키고, 척추의선택적움직임을만들어체간을바로세운다. 그리고발의넓은접촉면을위해발의내재근활성과발외측면의체중지지능력을향상시키고, 동측하지의근활성패턴의증진을위해새끼벌림근활성화를통한발목외번 (eversion) 과발목굴곡을할수있도록유도한다. 일어서기동작에서가자미근의구심성수축에의한뒤꿈치딛기와같은형태로발뒤꿈치를바닥방향으로내리도록천천히유도한다. 발목관절의정렬향상을위해발뒤꿈치안쪽의팽팽한연부조직이충분히길어질수있도록유지하고발목의굴곡과신전동작의반복을촉진한다. 3 One leg standing을시킴으로써무릎신전근위에서발뒤꿈치방향으로압박을가하여 sit to stand를유도한다. III. 결과 FTSTS 에서대상자는치료전 64 초에서치료후 55 초로 9 초 2 Effects of Extensor Activation of Affected Lower Limbs on Repetitive Sit-to-Stand and Walking in Patients with Hemiplegia
송배영 Table 1. Variations of Five times sit to stand and Timed up and go test (N=1) Pre-test Post-test FTSTS 64 55 TUG 88 82 FTSTS, Five times sit to stand; TUG, Timed up and go test; unit, second Figure 1. Variations of Five times sit to stand and Timed up and go test 은정상발이나회내발에비해서족저감각들이감소하게된다. 24) 따라서발의접촉면을넓혀발에서들어오는족저감각정보를많이받아들일수있게하였다. Raine등은길항근으로써가자미근의길이단축과근약화는발목굴곡을제한하며, 과도한내번 (inversion) 을보인다고하였다. 25) 이와같은비효율적인발목정렬은전경골근의보상적인근활성화로인한것이라고하였다. 그리고신경계손상으로인한편마비환자에서나타나는현상으로일어서기동작시근력약화는동작수행의속도를저하시키게되어 3 지면반발력의변화를가져오게되며 21, 일어서기동작수행시정확한자세유지를하지못해무게중심의위치변화에어려움이발생하게된다. 또한뇌졸중으로인해편마비환자들은 STS를하는동안마비측다리의체중지지를자발적으로피하게되어균형잡힌자세를취하지못한다. 이를예방하기위해서 STS동안발의위치를후방에두는것이균등한체중지지와건측하지의과사용방지를위해바람직하다고보고되었다. 26) 이러한연구결과로보았을때발의내재근을활성화시켜발의접촉면을넓게하고하퇴신근의길항작용이 STS를수행하는동안에영향을미친다는것을알수있었다. 가감소되었고 TUG 에서는치료전 88초에서치료후 6초감소된 82초로향상된결과를가져왔다. 측정결과는 Table 1 그리고 Figure 1 과같다. IV. 고찰 일상생활속에서다양한형태로가장많이사용하는동작중하나인일어서기동작은신경계손상환자의기능적인회복에필수적인요소이며, 하지의가장원위부에위치하면서작은지지면으로인체를받춰주는동시에걷거나뛰기등을담당하는발에초점을맞춰, 본연구에서는발의접촉면을넓혀하퇴신근의길항작용이앉았다일어서기에얼마만큼영향을미치는지알아보고자하였다. 20-22) 앉은자세에서일어서는동작시 FTSTS의소요시간이 1분 4초에서 55초로움직임을수행하는데걸리는시간이감소하였고, TUG의경우 1분 28초에서 1분 22초로움직임수행시간이감소하였다. 치료후 FTSTS검사시치료전보다더나은자세조절을보이며 FTSTS를수행하는데적은시간이소요되었다. 치료전에뇌졸중환자들이일어서기동작에서비마비측의체중부하가더욱크므로비마비측하지에더욱의존하는보상작용을통해비정상적으로수행시간이빨라질수있다는것을알수있었다. 23) 높은궁으로정의되는과도한회외발은중족의저운동성으로지면반발력에적절하게적응하지못하고, 과도한회외발의족저감각정보들 참고문헌 1. Aruin A, Shiratori T. Anticipatory postural adjustments while sitting: The effects of different leg supports. Exp Brain Res. 2003;151(1):46-53. 2. Ruget H, Blouin J, Teasdale N, et al. Can prepared anticipatory postural adjustments be updated by proprioception? Neuroscience. 2008;155(3):640-8. 3. Camargos AC, Rodrigues-de-Paula-Goulart F, Teixeira- Salmela LF. The effect of foot position on the performance of the sit-to-stand movement with chronic stroke subjects. Arch Phys med Rehabil. 2009;90(2):314-9. 4. Kuzelicki J, Zefran M, Burger H, et al. Synthesis of standing-up trajectories using dynamic optimization. Gait Posture. 2005;21:1 11. 5. Shumway-Cook A, Woollacott MH. Normal postural control. In Motor Control: Translating Research into Clinical Practice (3rd ed.). Philadelphia: Lippincott/ Williams & Wilkins. 2006 6. Shumway-Cook A, Silver IF, LeMier M, et al. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in communityliving older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2007;62(12):1420-7. 7. Cheng PT, Chen CL, Wang CM, et al. Leg Muscle Activation Patterns of Sit-to-Stand Movement in Stroke 하퇴신근촉진이반복일어서기와보행에미치는효과 3
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NEUROTHERAPY 2 0 1 5 류우정, 김다민대한신경치료학회지, 김은성, 김창주제19, 권김지혜제2호 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 류우정, 김다민, 김은성, 김창주, 김지혜 * 강동대학교물리치료학과 Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School Woo-Jung Ryu, Da-Min Kim, Eung-Sung Kim, Chang-Ju Kim, Ji-Hye Kim * Dept. of physical therapy, Gangdong university Purpose The purpose of this study is the improvement of the hip abductor muscle strength through exercise using theraband and Comparative analysis of the effects of a static balance taping of the ankle joint to prevent the injury of the players to school girl soccer players. Methods In this study, since its implementation four weeks the hip joint abductor muscle strengthening exercise to target the eight women's football player of the elementary school, by applying the ankle taping, in order to investigate before, the difference after the static balance ability,using the corresponding sample t- test (Paired t-test). Results When compare the front and the rear of Strengthening exercise of abductor, Static balance ability of the objects of study has significant difference after Strengthening exercise(p<0.05). Right after this experiment, there was significant difference of Static balance ability after applying tape if the joint in comparison under control(p<0.05).otherwise difference was not exist average static balance of objects of study in comparison whether applying taping of the ankle joint after exercising hip abductor muscle strengthening effects average static balance(p> 0.05). Conclusion the taping application of hip muscle strengthening exercises and static balance of ankle in this study was proven to help improve the static balance. Key words Hip Abductor, Strengthening, Ankle Taping, Static Balance, Girls Soccer Player 책임저자 Ji-Hye Kim(sweety7905@naver.com) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론 균형은신체가안정성을확보하는신경생리학적과정으로일상생활의모든동작수행에중요한영향을주며신체를평형상태로유지시키는능력이다. 1) 이는인간이목적있는활동을하며일상생활을영위하는필수적인기본요소 2 이고, 신체자세가공간에서체중심점을유지하고흔들림을적게하여많은과제들과밀접하게관련되어있는것을말한다. 3) 균형조절의요인은신경학적요인과근골격계요인으로구분할수있으며근골격계요인은기계적구조를제공하는것으로운동반응이이루어지는동안유연성, 자세정렬등을포함한다. 4) 따라서균형능력의상실은체중부하조절, 선자세에서의안정성유지, 보행능력등일상생활의원활한수행에지장을초래하며낙상이나골절등다른상해의원인이되기도한다. 5,6) 대부분하지를이용해공을다루는축구는드리블, 헤딩, 키킹등다양한기술을필요로하며이는적절한신체적요소를사용한협응력, 민첩성과높은수준의균형평형감각을요구한다. 특히킥동작은한발로지지하고스윙하는동작으로발에힘을전달해서물체를때리는형태로써걷기와달리기보다균형능력이더욱요구되어진다. 7) 축구선수들에게있어서대부분볼조절능력은지지발의균형이필수적이며균형능력이저하되면발목또는무릎인대의상해발생률이높아지므로, 축구선수의균형능력은매우중요하다. 8) 상해로인한신체장애로운동선수는경기력이저하되며스포츠활동의참여가제한되는데균형능력은이를예측하는데중요한요소이다 9,10) 스포츠활동은소아에게있어서성장발달에중요한요인으로이시기에적절하게적용하지못한경우소아에게는상해가유발될수있고성장발달에부정적으로영향을미칠수있다. 11) 힘줄이나인대, 관절등이완전히성장되지않은상태인유소년축구선수들은작은저항에도부상의위험이높고그로 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 5
NEUROTHERAPY 2015;19(2):5-12 인해이차적으로생기는타격의가능성이성인에비해크다. 12) 그러므로부상을최소로하면서균형능력을향상시킬수있는운동방법이요구되어진다. 하지근력은중력선과중력을감당할수있는정적균형에영향을미치며 13) 특히정적균형을유지하는데중요한역할을한다. 14) 기립자세혹은보행에서발을디딜때하지근육중엉덩관절벌림근은안정성을유지하면서걸음의폭을조절한다. 중간입각기에서반대측다리가지면에서떨어져있을때엉덩관절벌림근군은무게중심을외측으로옮기는활동을하기때문에매우중요하다. 15 ) 이에따라하지근력운동프로그램이균형능력과밀접한관계를가지고있다는것을알수있다. 보통균형능력을향상시키기위해사용하는훈련방법에는균형또는안정성을높이는근력훈련을강조하였고균형훈련프로그램을통해각각다른감각입력을사용해균형능력을높이는방법이있다. 3) 탄력밴드를이용한근력강화운동은근저항운동방법의한형태로근기능개선에효과적이고체중부하를이용한방법과중력및중량도구를이용한운동방법을통해다양한형태의자세또는운동이가능하고활동이비교적간편하다. 16) 탄력밴드는재활을위한도구로의료현장에서도간편하고광범위하게응용되며고무로만들어져저렴하고보관에용이한장점을가지고있다. 17) 이외에도테이프는근육에붙임으로써여러운동선수들의근육을강화시켜주며보호해주고그로인해강해진근육은관절을보호하게되어운동기능을향상시킨다. 18) 그리고자세균형을조정하고평형능력을향상시키기위해서도테이핑요법이사용되며 19) 통증이없고경제적이며효과가 24시간이상지속가능한점을장점으로들수있다. 20) 지속적으로유소년축구교실의크기와수가점점늘어나고있는추세이고이러한변화는축구발전을위한기반으로작용되고있음에도불구하고 21) 국내의선행연구에서는주로성인 22) 뇌졸중환자 23) 를대상으로한연구가있으나실제초등학교여자축구선수들을대상으로근력강화운동을균형능력향상에효과를본연구는미비하고, 특히초등여자축구부로한연구는많지않은것으로여겨진다. 때문에본연구는균형능력의향상과부상을예방하기위 한근력강화운동프로그램과발목관절테이핑을통해향후물리치료연구의기초자료로제공하기위한목적으로초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향을알아보고자한다. II. 연구방법 1. 연구대상본연구는 2014년 11월 24일부터 2014년 12월 19일까지충청북도음성군소재의 G초등학교 4학년, 5학년, 6학년에재학중인여자축구부 8명을대상으로탄력밴드를통한하지근력운동과발목관절테이핑기법이한발로섰을때정적균형에미치는영향에대하여연구를실시하였다. 이연구의참가한대상자들은다음의기준을만족하고, 축구부감독, 코치선생님협의하에연구의취지와목적에동의한대상자만을실시하였다. 대상자의신체적특성은다음과같다 < 표 1>. (1) 엉덩관절, 무릎관절, 발목관절에좌상, 염좌등질환이없는자. (2) 최근 6개월이내에하지의골절등정형외과적인문제가없는자. (3) 실험에영향을줄수있는체성감각에심각한손상이없는자. (4) 균형에영향을줄만한신경학적손상이없는자. (5) 균형유지능력에영향을주는약물을복용하지않은자. 2. 실험방법 1) 측정도구 ⑴ Air-Balance system 정적균형검사장비로선행연구에서사용되어신뢰도와타당도가인정된 Air-Balance system 3D( 주 SNS Korea) 를사용하였다. 이장비는측정자에신장에맞게발판의높낮이를조절할수있으며 360도움직임이가능하다. 체간의움직임을감지하여컴퓨터스크린의나타나는동그란공을스크린중앙으로움직이면균형점수가측정된다. 균형점수가높을수록균형능력이높다는것을의미한다. 10단계의난이도조절이 표 1. General characteristics of participant(n=8) Characteristics Mean±SD Age 12.25±0.71 Weight ( kg ) 46.88±5.63 Height ( cm ) 150.56±4.16 BMI (kg/ m2 ) 20.63±1.85 Stance Foot (Left/Right) 7(87.5%) / 1(12.5%) 6 Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School
류우정, 김다민, 김은성, 김창주, 김지혜 Table 3. Changes of Static balance Pre-post of Hip joint abduction exercise Static balance t p Pre 1208.12±328.68 Post 1633.88±191.94-5.177 0.001 Table 4. Changes of Static balance Pre-post of Hip joint abduction exercise with Thera-band Static balance t p Pre 1208.12±328.68 Post 1790.38±245.29-7.648 0.000 Table 5. Comparison of Static balance after Hip joint abduction exercise with or without Thera-band Static balance t p Pre 1633.88±191.94 Post 1790.38±245.29-1.955 0.091 가능하며난이도가높을수록균형조절이어려워진다. 자료수집은연구대상자가자신의신장에맞춰발판에올라서서옆축에신체정렬선을맞춘후고정대를골반의위앞엉덩뼈가시 (ASIS) 에위치시키고골반경사 (pelvic tilting) 가최대한일어나지않게단단히고정시켰으며우세측하지는무릎굽힘시키고비우세측하지만을이용해선상태에서가슴에손을교차시키고턱끝을안으로당기도록하였다. 그상태에서난이도 7 설정후 2분간균형을측정하여자세동요스펙토그램 (Spectrogram) 과균형점수를기록하였다. (2) 탄력밴드탄력밴드의저항을이용한근력강화운동으로주로근력향상에중점을두고실시한다. 탄력밴드는탄성강도에따라색이나누어지며특성은 < 표 2> 에나타내었다. 노란색은어린이와 노인으로빨간색은성인여성용으로초록색, 파란색은성인남성용으로만들어졌다. (3) 발목관절테이핑발목관절테이프는테이프길이의 130%-140% 정도의탄력성을가지는테이프로인간의근육탄력성과거의같다. 부착면에는약품처리가되어있지않고통기성이좋아피부자극과부작용이적은테이프로신체의자연치유력에기초를둔치료법으로최근일부에서근골격계질환의보조치료법으로사용되어효과를보고있고근막이정렬되어근기능의안정화가이루어지고관절의손상을예방하는효과가있다. 2) 운동방법본실험에서실시한운동방법은다음과같다. Table 6. Intensity of Thera-band Type of band Tension (cm) color type 20 40 60 Yellow Light 0.7 1.0 1.1 Resistance (kg) Red Mild 0.9 1.6 2.0 Green Strong 1.1 1.9 2.3 Blue Very strong 1.4 2.8 3.4 (Duncan, 1998) Table 7. Changes of Static balance Pre-post of Hip joint abduction exercise Static balance t p Pre 1208.12±328.68 Post 1633.88±191.94-5.177 0.001 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 7
NEUROTHERAPY 2015;19(2):5-12 (1) 탄력밴드탄력밴드는여아초등학생에게적합한강도의색깔을기능수준에맞추어각각최대 10RM( 실험군이동일한동작으로 10회동안밴드를잡아당길수있는횟수 ) 을기준으로저항강도를결정하여운동을실시하였다. 운동순서와동작에대한설명은부록 1에제시하였다. 대상자의평균정적균형능력은운동후 1633.88±191.94에서테이핑적용후 1790.38±245.29로증가하였으나통계적으로유의한차이는없었다 (p>.05). IV. 고찰 (2) 발목관절테이핑발목관절테이핑의방법은국제밸런스협회에서지정한방법으로, 폭 5cm테이프를길이 30cm와길이 25cm로자르고각각 2개씩준비한후먼저길이 30cm 테이프의가운데를발허리뼈아치의중심에서부터붙이기시작하여복사뼈까지붙였다. 그리고길이 25cm 테이프의가운데를아킬레스건에부착하여발목관절의앞부분에서만나도록부착하였다 3) 분석방법본연구는자료분석으로통계프로그램 SPSS 18.0ver을사용하였다. 분석방법은엉덩관절벌림운동을 4주동안실시한후정적균형능력의전 후의차이를알아보기위해대응표본 t-검정 (Paired t-test) 을사용하였다. 통계학적유의수준을검증하기위한유의수준 α는 0.05로정하였다. III. 결과 1. 엉덩관절벌림운동전 후정적균형능력비교엉덩관절벌림운동전 후에실험군과대조군의평균정적균형능력차이를알아보았다 < 표 3>. 연구대상자의평균정적균형능력은운동전 1208.12±328.68에서운동후 1633.88± 191.94로증가하였으며통계적으로유의한차이가있었다 (p<.05). 2. 엉덩관절벌림운동전, 운동후테이핑적용후정적균형능력비교엉덩관절벌림운동전, 운동후테이핑적용후실험군과대조군의평균정적균형능력차이를알아보았다 < 표 4>. 연구대상자의평균정적균형능력은운동전 1208.12±328.68에서운동후테이핑적용후 1790.38±245.29로증가하였으며통계적으로유의한차이가있었다 (p<.05). 3. 엉덩관절벌림운동후테이핑적용유무에따른정적균형능력비교엉덩관절벌림운동후테이핑적용유무에따른실험군과대조군의평균정적균형능력차이를알아보았다 < 표 5>. 연구 균형은개개인이외부의자극에대해다양한자세로의변화를통해환경에적응하기위한필수적인요소이다. 24) 또한일상생활과다양한스포츠현장에서넘어지지않기위해서뿐만아니라경기력향상을도움을줄수있는요소라는측면에서중요하며규칙적인운동이나스포츠선수들에게특별한훈련을적용함으로써발달및개선된다고보고하였다. 25) 본연구는여자축구부를대상으로탄력밴드를통한하지근력운동과발목관절테이핑기법이한발로섰을때비우세측정적균형에미치는영향을알아보고, 비우세측하지의근력강화를통한정적균형향상운동프로그램을제시하며, 향후물리치료연구의기초자료로제공하기위한목적으로실시하였다. 하지근력강화운동을실시한후정적균형능력을 Air-balance로측정하였고, 운동을실시한후하지관절에발목관절테이핑을적용하여정적균형능력을 Air-balance로측정하였다. 하지근력운동은탄력밴드를이용하여바로누운자세, 옆으로누운자세, 서있는자세로준비운동 5분, 본운동 20분, 정리운동 5분을적용하였으며주 4회씩총 4주간진행하였다. 김종우는노인 16명을대상으로 8주간연구에서허리골반근육운동, 하지근육운동을탄력밴드를이용한탄성저항운동으로적용한결과정적균형능력이향상되었음을보고하였고, 22) 도건강한남녀성인 20명을대상으로 6주간탄력밴드를이용하여엉덩관절벌림근강화운동을선자세, 옆으로누운자세, 바로누운자세에서적용한결과정적균형능력에영향을미친다고하였고, 곽철진도외래노인환자 30명을대상으로 8주간하지의탄력밴드저항운동과일반물리치료를적용한결과하지의근력을강화시켜균형능력을증진시킨다고하였다. 본연구에서도하지엉덩관절벌림근의근력강화를목적으로탄력밴드를이용한결과비우세측하지에정적균형능력이통계적으로유의한결과를나타내었다. 이는하지벌림근근력이균형을향상시키는데있어중요한요인이기때문에정적균형능력이높아진것으로생각된다. 최원호도편마비환자 30명을대상으로 4주간비마비측하지를연구자의발위에놓고마비측으로부터점점멀리벌림시키는원심성운동과일반물리치료를적용한결과실험군이대조군보다정적균형이유의하게향상되었다고하였다. 본연구에서도정적균형능력향상을목적으로탄력밴드를이용한 8 Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School
류우정, 김다민, 김은성, 김창주, 김지혜 결과비우세측하지에정적균형능력이통계적으로유의한결과를나타내었다. 이는탄력밴드를이용한근력강화가원심성운동을실시한선행연구와같이엉덩관절벌림근을강화시켜정적균형능력이높아진것으로생각된다. 조민권도뇌졸중환자 31명을대상으로한 5주간의연구에서중간볼기근과앞정강근에기능적전기자극과트레드밀훈련을동시에적용한훈련결과중간볼기근과앞정강근에기능적전기자극을적용한실험군이앞정강근에만기능적전기자극을적용한대조군보다훈련후근력과균형이통계적으로유의하게향상되었다고하였다. 본연구에서도하지엉덩관절벌림근의근력강화를목적으로탄력밴드를이용한결과비우세측발에정적균형능력이통계적으로유의한결과를나타내었다. 이는탄력밴드를이용한근력강화가기능적전기자극을실시한선행연구와같이엉덩관절벌림근을강화시켜정적균형능력이높아진것으로생각된다. 위와같은선행연구들의의견을종합한결과하지벌림근이강화되면정적균형능력을향상시키는데있어의미있는결과를나타내는것으로보여진다. 왕준극은정상성인 281명을대상으로 2주간국제밸런스테이핑협회에서지정한방법으로발목테이핑을적용한실험군과비적용한대조군을나누어평형감각검사를시행한결과발목테이핑이정상성인의자세조절에도움이된다하였고, 곽웅렬도뇌졸중환자 90명을대상으로앞정강근, 장딴지근, 스파이럴밸런스테이핑을각각적용한결과근육의긴장도를조정하여발목관절의안정성을향상시켜균형에영향을미친다고하였고, 테이핑이균형능력향상을필요로하는환자에게효과적일것이라고하였다. 본연구에서도비우세측하지의정적균형향상을목적으로발목관절테이핑을적용한결과비우세측하지의정적균형능력이통계적으로유의한결과를나타내었다. 이는발목관절테이핑이발목관절근긴장도를조절하여근기능개선에사용된다는선행연구와일치하였다. 하지만엉덩관절벌림근운동후테이핑적용유 무에따른유의한상관관계는얻어내지못하였는데, 이는초등학교측에서지정해준시간이너무짧아발목관절테이핑을적용한시간이부족하였고, 초등학생이라는점에서개개인의차이가많아집단간변인의통제가매우어렵고, 개개인의심적으로적용될수있는특성의차이가고려되지않아실제적용시각선수들의정적균형능력이통계적으로유의한변화가없을수도있기때문 12) 이라고추측된다. 위와같이연구의결과를종합하여볼때유소년여자축구부비우세측하지의정적균형증가에대해탄력밴드를이용한엉덩관절벌림근근력운동과발목관절테이핑은정적균형에긍정적인영향을미친것을알수있었다. 본연구에서의제한점은연구기간이 4주간주4회실시하였 지만대상자들의축구부코칭스텝이허락한 30분이내에준비운동, 본운동, 마무리운동을모두실시해야하여본운동시간은 20분이내로짧았고, 연구대상이 8명으로모든여자축구선수들에게일반화하는데는다소무리가있다고생각되며실험을하는동안대상자들의축구와관련된다른운동프로그램을통제할수없었기때문에축구관련운동프로그램이균형능력에영향을줄수있음을완전히배제할수없다는문제가있었고, 초등학생들을대상으로테이핑을적용하였을때개개인의차이가많아집단간변인의통제가매우어렵고, 개개인의심적으로적용될수있는특성의차이에따라결과값에유의한변화가없을수있다는점을고려하지못하였고또한대상자들의측정시간이대상자보호자의동의상 2시간으로한정되어있어하지벌림근저항운동전순수하게발목테이핑적용하여전 후의차이를비교하지못하여하지벌림근의근력향상과발목테이핑의정적균형상관관계를구체적으로제시하지못하였고, 근력측정에대해 Adolescent Back and Leg Dynamometer Package/32527A-3과같은장비는너무고가이기때문에더객관적이고구체적으로자료를수집하지못하였다. 따라서향후연구에서는연구결과를일반화시킬수있는충분한연구기간과많은인원확보가필요하다고생각된다. 더불어객관적인결과를확보하기위한근력측정도구의사용과근력강화프로그램전에테이핑을적용하여근력과균형의상관관계를더구체적으로제시하고, 대상자개개인의차이가크지않은유소년대표선수들을대상으로하는연구방법이시도되어야할것으로생각된다. 참고문헌 1. Cohen H, Blatchly CA, Gombash LL. A study of the clinical test of sensory interaction and balance. Phys Ther. 1993;73:346-54. 2. Serrington C, Lord SR, Finch CF. Physicial activity intervention to prevent falls among older people: update of the evidence. J Sci Med Sport 7(1Suppl), 43-51, 2004. 3. Shumway-Cook A, Wollacott MH. Motor control: Theory and Practical Applications, 1st ed, Baltimore: Williams & Wilkins. 1995. 4. Horak FB. Clinical Measurement of Postural Control in Adults. 1987. 5. Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: new insights for treatment of balance disorders. Phys Ther. 1997;77:517-33. 6. Shumway-Cook, Horak FH. Assessing the influence of sensory interaction on balance: Suggestion from the field. 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 9
NEUROTHERAPY 2015;19(2):5-12 Phys Ther. 1986;1548-50. 7. Adrian MJ, Cooper JM. The biomechanics of human movement. Benchmark Press, Indianapolis, Indiana, USA. 1989; 772. 8. Kim JH. Effects of Lumbar Stability Exercise Program on Trunk, Lower Extremity of Muscle Activity and Balance in Soccer Player. 2010;22(5):25-31. 9. Lee YH. The effects of cycle strength training on lower extremity muscle and balance in football players. 2014;1-41. 10. Lee JH. Sports injury and rehabilitation. Korea Coaching Development Center. 2008;10(4):31-40. 11. Choi JW. Kim BY. The Effect on Physical Growth and Health-related Fitness by Taekwondo Training of Elementary School Student, Korea Coaching Development Center. 2009;11(4):164-74. 12. Yeom SK. Analysis of Soccer player's Basic Technique Difference According to Apply Ankle Joint Tapping in the Elementary School, Chuncheon National University of Education. 2009. 13. Choi ME, Jeon MY, Choi JA. Effect of Walk Training on Physical Fitness for Prevention in A home Bound Elderly. J Korean Acad Nurs. 2000;30(5):1318-32. 14. Andrew A, Guccione, Rita A, Wong. Dale Avers. Physical Therapy of the Elderly 3 rd ed :2012. 15. Choi YH, Kim MJ. Effects of Eccentric Exercise of Hip Abductors on Gait Balance. J Kor orto M Phisi Ther. 2003;9(2):59-67. 16. Park SH, Kim HC, Park WY, The band, training and rehabilitation. Pureunsol. 2000. 17. Ham YW. Effects of Theraband Exercise on Isotonic Strength of Flexor Muscles in Upper Extremities. J Health Sci. 2000;26(1):49~56. 18. No JG. A Study of the revelation ability of muscles for the increasing flying distance of golfers through the application of the kinesio taping method. 1999. 19. Kim YS, Lee HJ. Effect of Isokinetic Muscle Power and Endurance by Appling Taping Femoral Knee Joint, KSR. 2004;15(1):803-12. 20. E G. Sports taping balance of Eogang. Green care. 2001. 21. Kang UW, Kim PS, Kim ES, et al. A Qualitative Study on the Soccer Coaching Experience of Youth Soccer Coaches. Kor J Physi Edu. 2005;44(6):89-101. 22. Kim YH, Park HG, Choi WJ, et al. The Effect of Hip Abductor Strengthening Exercise using Elastic Band on Static Balance. J Kor orto M Phisi Ther. 2009;15(1):49-57. 23. Han SS. Effects of Muscle Strengthening Exercises Using a Thera Band on Lower Limb Function of Hemiplegic Stroke Patients. J Kor Aca Nurs. 2007;37(6):844-54. 24. Fu L, Tung YR, Yang CC. et al. Balance outcomes after additional sit-to-stand training in subjects with stroke: a randomized controlled trial. 2010. 25. Stephen R. Lord P, John A. Ward MBBS, Philippa Williams, BSSExercise Effect on Dynamic Stability in Older Women: A Randomized Controlled Trial, 1996. 26. Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: new insights for treatment of balance disorders. Phys Ther. 1997;77:517-33. 27. Geurts ACH, Ribbers GM, Knoop JA, et al. Identification of static and dynamic postural instability following traumatic brain injury. 1996. 28. James Tropp, Norman C, Blumenthal, et al. Phosphorus NMR Study of Solid Amorphous Calcium Phosphate. 1984. 10 Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School
류우정, 김다민, 김은성, 김창주, 김지혜 부록 1. 탄력밴드를이용한저항운동프로그램 1. 준비운동본운동에대비하여근긴장을완화시키고부상을예방하고신체모든기능을운동적응상태로이르게하기위해준비운동으로스트레칭을 5분간실시하였다. 꽉조이지는않게한다. 이때대상자의발끝이자신의앞쪽으로향하게하면서 5초간힘을주어유지한후이완시켜 10초간의휴식시간을갖도록하고, 이를 10회반복, 3세트의운동을한다. 2. 본운동연구에적용한근력운동은 4주간주5회, 준비운동 5분, 본운동 20분, 정리운동 5분으로실시하였으며, 본연구에사용된탄력밴드의운동강도는밴드에의해발생되는밴드의신장률에의해결정되었다. 운동을시작하기전에먼저각대상자들에게전운동가동범위의길이를신장길이로하여 {( 신장된길이 - 안정시길이 )/ 안정시길이 } 100으로밴드의신장률을산출하였다. 대상자들이 100% 신장률로 10회엉덩관절최대벌림할수있는색깔의밴드를선택하여운동시켰으며준비운동과정리운동은유연성운동으로스트레칭을실시하였고, 본운동은아래와같이실시하였다. 한자세마다엉덩관절벌림을 5초간힘을주어유지한후이완시켜 10초휴식하고, 이를 10회반복 3set 의운동으로진행하였다. 2) 옆으로누운자세 (sidelying) 에서엉덩관절벌림운동대상자는침대에옆으로누운자세에서엉덩관절은중간선을지나약간이완한다. 아래쪽무릎은균형을위하여굽힘한다. 탄력성있는탄력밴드를이용하여양무릎에밴드를감고, 골반을고정하고환자는한쪽엉덩관절을바깥돌림 (lateral rotation) 없이완전운동범위까지벌림한다. 운동방법은 1) 과동일하다. 1) 바로누운자세 (supine) 에서의엉덩관절벌림운동대상자는침대에바로누운자세에서탄력성있는탄력밴드를이용하여양무릎에밴드를감고, 허리를바닥에대고누워무릎을이완한상태로양쪽엉덩관절을바깥측으로벌림한다. 밴드는느슨하지않도록꼭매지만혈액의흐름이나빠질정도로 초등학교여자축구선수들에게탄력밴드를이용한엉덩관절벌림운동과발목관절테이핑적용이정적균형에미치는영향 11
NEUROTHERAPY 2015;19(2):5-12 3) 서있는자세 (standing) 에서엉덩관절벌림운동대상자는똑바로선자세에서탄력성있는탄력밴드를이용하여우세측하지, 한쪽은가쪽의무릎에밴드를감고, 그리고한쪽엉덩관절을바깥돌림없이완전운동범위까지벌림한다. 운동방법은 1) 과동일하다. 대상자들의어린연령을감안해무리한운동을통한근육통이발생하지않도록주의하였고, 실험에참가한대상자들이정확한자세로다른근육의보상작용이나타나지않도록 ( 김동대외, 2012) 사전교육, 연습, 시범을실시하였다. 3. 정리운동마지막으로운동후에근긴장을완화시키고, 근피로를회복하기위해정리운동으로스트레칭및호흡운동으로정리운동을 5분간실시하였다. 12 Effects of Taping for Ankle and Strengthening Exercise of Hip Abductor with Thera Band on Static Balance of Girls Soccer Player in Elementary School
NEUROTHERAPY 2 0 1 5 대한신경치료학회지이지혜, 황병용제19, 권정상미제2호 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 이지혜 1, 황병용 1, 정상미 *2 1 용인대학교물리치료학과, *2 상지영서대학교작업치료과 The Effects of Core stability Strengthening Exercise for Trunk Control and Spine Alignment in Patients with Stroke Ji-Hye Lee 1, Byong-Yong Hwang 2, Sang-Mi, Jung *3 1 Dept. of Physical Therapy, Yong-In University, *2 Dept. of Occupational Therapy, Sangji Youngseo University purpose This study was to investigate the effect that the trunk stability strengthening exercise of patient with stroke had on trunk control and spinal alignment. Methods The subjects were 22 patients with a stroke, 13 subjects were allocated to the trunk stability strengthening exercise group, other 9 subjects ordinary exercise group respectively. And the trunk stability strengthening exercise was carried out for a total of 10 weeks. This study used TIS, PASS, and FES to assess trunk control. And used 4D Formetric to measure the spinal alignment. Results The results of this study are as follows. Firstly, there was a significant difference in the trunk control through the trunk impairment scale in the exercise group. Secondly, there was a significant difference in the trunk control through the postural assessment scale for stroke in the exercise group. Thirdly, both groups, there was a significant difference in basic activities of daily living, instrumental activities of daily living through Falls Efficacy Scale. And between the groups, there was significant difference. Fourthly, both groups, there was no significant difference in spinal alignment. And between the groups, there was no significant difference. Fifthly, it was shown that there was a correlation between trunk control and fall efficacy. Besides, spinal segment rotation angle showed a correlation with trunk impairment scale, postural control assessment, and fall efficacy. And the scoliotic curvature also showed a correlation with postural control assessment. Conclusion In conclusion, the 10-weeks trunk stability strengthening exercise program was effective in improving trunk control of patient with a stroke. The results, it is thought that various studies on the exercise program effective in the spinal alignment will be required for clinically improving trunk control of patient with a stroke. Key words Core stability Exercise, Trunk Control, Spine Alignment, Stroke 책임저자 Sang-Mi Jung(otjsm@hanmail.net) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론매년전세계적으로약 1,500만명의뇌졸중환자가발생한다. 뇌졸중후생존자중 500만명은영구적으로운동장애 (50~ 83%), 인지장애 (50%), 언어장애 (23~36%), 심리장애 (20%) 등의합병증을가진다. 1) 이중 33~42% 는뇌졸중후 6 년간일상생활활동에도움이필요하다. 2) 뇌졸중으로인한운동장애는이동성제한, 자세조절저하및낙상발생율을높여뇌졸중환자의독립성, 사회참여, 전반적인건강상태에악영향을미친다. 3) 그러므로뇌졸중환자의재활운동초점은자세조절과관련된운동학습에따른기능회복이다. 4) 체간조절은뇌졸중후기능적결과의중요한초기예측인자이며, 신체를바로세우면서무게중심이동을원활하게 수행할수있도록해주는체간근의활동수준에의해좌우된다. 뇌졸중은근위조절에영향을미치는체간근의기능을양측모두약화시킬가능성이있다. 5) 체간조절저하와체간근의약화는뇌졸중환자에게서발견되고있지만, 고유감각과적절한체간조절의연관성은명확하지않다. 6) 체간근은다수의골격근으로이루어져있는데, 횡경막은지붕, 골반지지근은아랫부분, 척추주위근과둔근은뒷부분, 복근은앞부분으로구성된상자형태로이루어져있다. 체간근은사지의움직임이있을때나없을때나항상신체와척추를안정화시키는코르셋역할을하기때문에자세유지에중요한역할을담당한다. 7) 그러므로안정성과움직임은척추주변근육즉, 체간근의협응력에매우의존한다. 충분한안정성 은안정성과움직임사이의최적의균형을보여주는복잡한개념이고바람직한목표이다. 8) 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 13
NEUROTHERAPY 2015;19(2):13-21 최적의체간안정성은일상생활의기능적활동이나고위수준의과제를수행하는동안사지사용을가능하게하는균형을위하여필수적인요소이다. 또한체간의동적안정성은충분한유연성, 근력, 신경조절및고유감각을필요로한다. 8) 하지만뇌졸중환자는체감각및근긴장도저하로인해체간안정성을유지하기어렵다. 9) 신체분절이올바른정렬상태에서의고유감각은신체동작의정보를중추신경계에전달하여동작을최적의상태로만든다. 10) 체감각및근긴장도저하상태에서뇌졸중환자는불안정한환경에적응하기위해체간의비대칭적자세를형성하게된다. 편향된체간조절은불균형한근육사용, 정적또는동적균형능력저하, 다양한과제수행에어려움을초래한다. 11) 또한높은피로감과비효율적인에너지소비를증가시킨다. Garland 등 (2003) 은뇌졸중환자의자세정렬후균형과제수행시, 부정렬상태보다양측하지의근활성도가증가되었고, 에너지소모가감소했다고보고하였다. 12) 따라서뇌졸중환자의기능적재활에서이상적인목표는비대칭성을감소시키는데있다. 13) 뇌졸중환자에게일어나는신체정렬의변화를고려하지않고기능해결만을추구하는치료프로그램은환자의신체정렬의변화를심화시켜환자의기능수준을향상시키고자하는치료목표를성취하기힘들어진다. 14) 낙상은노인들에게서흔히발생하며특히뇌졸중환자는낙상의고위험군에속한다. 15) 임상적인관점에서대부분의뇌졸중환자는자세조절장애로인한낙상의두려움, 과제수행시불안감그리고위험성을많이호소한다. 16) 실생활에서환자가느끼는낙상의두려움으로인하여활동이제한된다면다양한환경에서의자세조절이어려워질것이다. 낙상의두려움으로인한활동제한은자세조절을더악화시키기때문이다. 따라서자세조절과관련된낙상에대한두려움과위험률을최소화하고, 기능적이고독립적인생활을유지하는것이매우중요하다. 17) 이는결과적으로뇌졸중환자의자세조절향상을위한다양한연구로이루어졌는데중재방법으로는측방체중이동, 공을이용한방법, 일정높이의발판에발을올리는방법, 시각적되먹임훈련및청각적되먹임훈련, 고유수용성운동조절프로그램, 트레드밀을사용한보행훈련등이있다. 18-24) 그중여러선행논문에서체간조절증진을위해체간안정성운동이효과적이라고보고되어지고있으며체간안정성운동을요통환자를대상으로실시한결과통증감소, 관절가동범위증가, 일상생활활동개선, 근력과균형능력증가가이루어진다. 25,26) 하지만아직체간안정성운동이뇌졸중환자의척추정렬에미치는영향에대한연구는아직미흡한실정이다. 따라서이논문은체간안정성강화운동이뇌졸중환자의 체간조절과척추정렬에미치는영향, 그리고체간조절과척추정렬의상관관계를대해알아보고자한다. II. 연구방법 1. 연구대상및기간본연구는천안시에소재한 D병원에서입원및통원치료를받고있는뇌졸중환자중본연구의목적에충족되는조건을가진대상자 22명 ( 연구군 13명, 대조군 9명 ) 을선정하여 2013년 8월부터 2013년 10월까지주당 3회, 10주간실시하도록하였다. 운동프로그램중재및평가측정은중추신경계치료경력 5년이상의물리치료사 2명과작업치료사 1명이시행하도록하였다. 대상자선정조건은다음과같다. 1) 뇌졸중을진단받고 6개월이상경과한자 2) 의사소통이가능한자 3) 근골격계질환을가지고있지않는자 4) 30분이상훈련이가능한사람 2. 연구방법 (1) 목안정화운동먼저경부의안정성높여주는운동을선행하며, 머리를들어배주위를본다는기분으로배에힘을넣어자세를유지시킨다. 이때목을아래로당겨경부의과도한굴곡이일어나지않게한다. 경부의다열근과굴근이동시에수축되도록유도한다. 27) (2) 수정형호흡운동환자의복부에치료사손을올려섬세하게누른다. 흡기하는동안환자가복부를들어올리게만들고, 호기하는동안배꼽이아래로향하도록이동한다. 치료사의두손은아래쪽갈비뼈로이동한다. 흡기하는동안환자의갈비뼈의확장시키고호기하는동안은좁힌다. 이운동을통한복횡근수축의물리적효과는복부용량을조절할수있는복횡근을촉진시키고호기의공기흐름의속도를증가시켜호흡에기여한다. (3) 체간의대각선운동목을굴곡시키지않는자세를정확히유지하면서머리와상부체간을바닥에서들리게하고복근이충분히수축할수있도록자세를유지하고천천히내려온다. 상부체간을들어올린후에몸을대각선으로왼손이오른쪽무릎을향하도록유도하고자세를유지하고천천히내려온다. 이때환측팔은정열이유지되도록지지해주고복근이약 14 The Effects of Core stability Strengthening Exercise for Trunk Control and Spine Alignment in Patients with Stroke
이지혜, 황병용, 정상미 해서시행하기어려운경우에도환자가스스로조절할수있도록치료사가다양한방향을유도하며최소한의도움을준다. 특히복횡근과복사근의강화를촉진하는복근할로윙운동을기초로하여체간안정성을만든다. 28) 3. 측정방법및측정도구 (1) 체간손상척도 (Trunk Impairment Scale) TIS는뇌졸중환자가가지고있는체간의운동손상에대한임상적검사방법으로서앉은자세에서의정적, 동적균형능력과체간의협응능력을측정한다. 앉은자세에서의정적균형능력 3개항목, 동적균형능력 10개항목, 체간의협응능력 4개항목으로서총 17개의항목을가지고있고최소 0점에서최고 23점까지로점수를산정할수있다. 검사자간신뢰도는 r = 0.87에서 r = 0.96이고검사자내신뢰도는 r = 0.85 에서 r = 0.99 사이로높은신뢰도와내적타당도를보이고있다. 29) TIS 는체간활동의질적인수준및치료에대한평가지침서가될수있다. 30) (2) 자세조절평가척도 (Postural Assessment Scale for Stroke) PASS는 FM-B로부터수정된측정도구로서심각한자세조절장애가있는뇌졸중환자에게도쉽게적용할수있기때문에뇌졸중환자의상태를진단할수있는유용한임상적도구이다. PASS는 3가지의기본적인자세로 ( 눕기, 앉기, 서기 ) 이루어져있으며, 자세유지능력 5항목과자세변환항목 7항목으로총 12항목으로구성되어있다. PASS는 FIM과의상관관계에서높은구성타당도 (r = 0.73) 와내적신뢰도 (k = 0.88), 검사- 재검사신뢰도 (k = 0.72) 를보였다. 31) (3) 낙상효능감척도 (Falls Efficacy Scale) FES는낙상방지와관련된자신감정도를측정하는도구로 13 개항목으로구성되어있다. 1 6번항목은기본적일상생활동작과관련된균형능력을평가하고, 8 13번항목은도구적일상생활동작과관련된균형능력을평가하며, 7번항목은이동능력을평가한다. 각항목평가시 0점은전혀두렵지않은경우, 5점은어느정도자신이있는경우, 10점은매우두려운경우이며, 숫자가클수록낙상에대한두려움이크고낙상관련자기효능감이낮은것을의미한다. 한국어로번안된 FES-S의만족할만한신뢰도와타당도가입증되었으며뇌졸중환자의낙상관련자기효능감을평가하는임상적인도구가될수있음이확인되었다. (4) 3차원척추구조분석기 (4D Formetric) 본연구는독일의뮌스턴의과대학생체공학연구소에서개발 한 3차원척추구조분석기 (4D Formetric) 를이용하여측정하였다. 형태를앞, 뒤, 아래또는위에서, 그리고시상면에서바라보는것처럼척추의모양과위치, 골반의틀어진정도등을비교적정확히측정하여분석한다. 측정방법은대상자의상의를탈의하고촬영을위한발판에올라서서등을카메라쪽을향하게하고속옷을뒤쪽만꼬리뼈가보일정도로내리게하고측정한다. 사진의분석은자동적으로이루어지는데, 먼저등표면의굴곡을분석하여대칭선을찾아낸다. 이선은척추의돌기를이은선과거의유사하다. 그다음에는등표면이분석되고이에따라 4개의해부학적인정점, 즉 VP(vertebrapromonence: C7) 과 SP(sacrum point), 2개의딤플 (PSIS) 이찾아지는데좌우의딤플의중앙을 DM이라하고이를근거로체간의기울기상태를분석한다. 이장비의특징으로는빠르고정확한측정시간 (0.04~6 초 ), 할로겐램프사용으로인한방사선피폭위험이없으며, 40 여가지이상의다양한데이터를볼수있다. 또한높은재현성과객관적데이터제공그리고측정결과를통한자세및척추측만증진단이가능하다. 정확도는표면분석에대한평균편차가 0.15mm이며, 척추만곡의평균편차가 3 이다. 32) 4. 분석방법본연구에서수집된자료는 SPSS(Statistical Package for the Social Science) version 16.0 프로그램을이용하여분석하였다. 연구대상자의일반적특성, 의학적특성을평균및표준편차와빈도분석을하였다. 두그룹간의체간조절, 낙상효능감, 척추정렬을비교분석하기위하여비모수검정방법인맨휘트니 (Mann-Whitney) U검정을이용하였으며, 체간안정성강화운동후연구군과대조군의전 후를비교분석하기위하여윌콕슨부호순위 (Wilcoxon Signed-ranks) 검정을실시하였다. 또한뇌졸중환자의체간조절, 낙상효능감, 척추정렬의상관관계를알아보기위하여스피어만 (Spearman) 상관관계분석을실시하였다. 모든자료처리의유의수준은 α=.05로하였다. III. 결과 1. 대상자의특성대상자의평균연령은연구군이 47.3세, 대조군은 54.4세로두군간에유의한차이가없었다. 평균신장은연구군이 172.9cm, 대조군은 165.1cm이었고, 평균체중은연구군이 71kg, 대조군은 60.6kg으로두군간에유의한차이가있었 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 15
NEUROTHERAPY 2015;19(2):13-21 다. 발병후로부터연구에참여한시점까지의기간에서는연구군이 29.3개월, 대조군은 25.7개월로두군간의차이는없었다. MMSE-K의평균점수는연구군이 23.8점, 대조군은 22.1점이었고, K-MBI의평균점수는연구군이 64.9점, 대조군은 66.6점으로두평가모두유의한차이가없었다. 마비측은연구군에서오른쪽 6명, 왼쪽이 7명이었으며, 대조군에서는오른쪽 4명, 왼쪽이 5명으로두군간에유의한차이는없었다 (Table 1). 2. 체간안정성강화운동전 후의체간조절비교 (1) 체간손상척도체간안정성강화운동을 10주동안실시한후, 연구군과대조군의운동전후의체간능력을 TIS를이용하여비교하였다. 연구군은체간손상척도중정적균형능력, 동적균형능력, 협응균형능력, 총점모두유의하게증가하였고 (p<.01), 대조군은유의한차이는없었다 (p<.05). 두그룹간의비교에서체간손상척도중동적및협응균형능력, 총점에서유의한차이를보였다 (p.<.01)(table 2). (2) 자세조절평가척도체간안정성강화운동을 10주동안실시한후, 연구군과대조군의운동전후의자세조절능력을 PASS를이용하여비교하였다. 연구군은자세조절평가척도중자세유지능력, 자세변환능력, 총점모두유의하게증가하였고 (p<.01), 대조군은유의한차이는없었다 (p<.05). 두그룹간의비교에서자세조절평가척도중자세유지및변환능력, 총점모두유의한차이를보였다 (p.<.05)(table 3). (3) 낙상효능감체간안정성강화운동을 10주동안실시한후, 연구군과대조군의운동전후의낙상효능감을 FES를이용하여비교하였다. 연구군은낙상효능감중기본적일상생활동작능력, 이동능력, 도구적일상생활동작능력, 총점모두유의하게감소하였고 (p<.01), 대조군은이동능력을제외하고기본적일상생활동작능력, 도구적일상생활동작능력, 총점에서유의하게감소하였다 (p<.05). 두그룹간의비교에서낙상효능감중기본적일상생활및도구적일상생활동작능력, 총점에서유의한차이를보였다 (p.<.05)(table 4) Table 1. The general characteristics Experimental group (n=13) Control group (n=9) t Age (year) 447.31±10.86 454.44±13.36 0.261* Height(cm) 172.85±6.344 165.11±8.014 0.037* weight(kg) 471.00±11.59 460.56±6.314 0.037* Onset(month) 429.31±16.20 425.67±11.00 0.687* MMSE(point) 423.76±6.674 422.13±7.934 0.422* MBI(point) 464.85±20.51 466.63±24.00 0.858* Affected side ( 명 ) 오른쪽 6(46.2) 4(44.4) 왼쪽 7(53.8) 5(55.6) MMSE-K: Mini-Mental State Examination - Korean version K-MBI: Korean version - Modified Barthel Index 0.941* Table 2. The comparisons of the trunk damage before and after the trunk stability exercise Experimental group (n=13) t Control group (n=9) Before After Before After (unit: point) t Static balance *5.08±1.0 5.46±0.7-1.890** 4.88±1.0 5.25±1.2-1.604 Dynamic balance *4.00±2.3 7.62±1.3-3.071** 4.13±1.6 4.88±2.1-1.826 Coordination ability *1.69±0.9 3.62±1.3-2.877** 2.25±1.3 2.38±1.2-0.816 Total score 10.77±3.4 16.69±2.7-3.192** 11.25±2.6 12.50±3.6-1.826 * : p<0.05,** : p<0.01 16 The Effects of Core stability Strengthening Exercise for Trunk Control and Spine Alignment in Patients with Stroke
이지혜, 황병용, 정상미 3. 체간안정성강화운동전 후의척추정렬비교 (1) 척추각체간안정성강화운동을 10주동안실시한후, 연구군과대조군의운동전후의척추정렬상태를비교하였다. 연구군은척추정렬중흉추의후만각, 요추의전만각, 척추분절회전각이최대값, 척추분절회전각최소값모두유의한차이는없었고 (p<.05), 대조군도유의한차이는없었다 (p<.05). 두그룹간의비교에서흉추후만각, 요추전만각, 척추분절회전각모두유의한차이를보이지않았다 (p.<.05)(table 5). (2) 기울기 연구군은척추정렬중척추측만곡최대값, 척추측만곡최소값모두유의한차이는없었고 (p<.05), 대조군도유의한차이는없었다 (p<.05). 두그룹간의비교에서척추측만곡역시유의한차이를보이지않았다 (p.<.05)(table 6). 4. 뇌졸중환자의체간조절, 낙상효능감, 척추정렬의상관관계체간손상척도는자세조절평가척도와높은상관관계를보였고 (r=0.757), 낙상효능감과도중정도상관관계를보였다 (r= -0.555). 자세조절평가척도는낙상효능감과높은상관관계를보였다 (r=-0.783). Table 3. The comparisons of the postural control rating scale between before and after the trunk stability exercise (unit: point) Experimental group (n=13) t Control group (n=9) Before After Before After Before After Posture maintain 10.15±1.7 11.54±2.3-2.699** 11.00±2.5 11.00±2.5-0.816 Posture change 18.77±3.8 20.00±2.8-2.555** 17.37±5.2 17.50±5.2-1.342 Total score 28.92±5.1 31.54±4.7-2.956** 28.38±7.1 28.50±7.2-1.342 * : p<0.05,** : p<0.01 Table 4. The comparisons of the falling efficacy between before and after the trunk stability exercise Experimental group (n=13) Control group (n=9) t Before After Before After t (unit: point) Self balance 24.31±15.4 14.23±13.2-3.188** 26.75±18.0 21.63±16.5-2.366* Ambulation *5.54±3.0* *4.46±3.4* -2.392** *5.50±2.5* *5.38±3.0* -0.447* ADL 32.54±16.0 26.23±17.1-3.063** 32.63±18.5 30.13±18.8-2.375* Total score 61.92±34.1 44.92±33.1-3.186** 64.88±36.9 57.13±36.1-2.524* * : p<0.05,** : p<0.01 t Table 5. The comparisons of lordotic and kyphotic curve between before and after trunk stability exercise (unit: ) Experimental group (n=13) Control group (n=9) t Before After Before After t Kyphotic angle 50.62±9.4 48.31±8.7-1.381 47.38±8.9* 49.13±9.2* -0.846 Lordotic angle 29.46±6.7 30.00±5.6-0.808 27.38±12.1 27.88±12.7-0.703 Maximum rotation angle 7.08±3.5 6.38±3.7-0.671 7.87±8.6* 4.13±3.7* -0.632 Minimum rotation angle 4.85±5.2 4.54±3.4 0.000 10.50±12.0 7.75±5.2* -0.431 Values are mean±standard deviation; * : p<.05 ** : p<.01 Table 6. The scoliosis angle between before and after trunk stability exercise (unit: mm) Experimental group (n=13) Control group (n=9) t Before After Before After t Maximum scoliosis angle 6.54±5.62 8.08±8.73-0.770 11.63±5.9 14.75±8.9-1.963 Minimum scoliosis angle 6.92±5.44 5.31±3.43-1.386 3.13±3.4 3.00±4.3-0.086 Values are mean±standard deviation; *p<.05, **p<.01 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 17
NEUROTHERAPY 2015;19(2):13-21 척추분절회전각최대값은자세조절평가척도와높은상관관계를보였고 (r=-0.707), 낙상효능감과중정도상관관계를보였다 (r=0.557). 척추분절회전각최소값은체간손상척도와중정도상관관계를보였고 (r=-0.477), 자세조절평가척도와높은상관관계를보였다 (r=-0.709). 또한낙상효능감과중정도상관관계를보였다 (r=0.466). 척추측만곡최대값은자세조절평가척도와중정도상관관계를보였다 (r=-0.441). 척추정렬중에서는흉추의후만각과요추의전만각은높은상관관계를보였고 (r=0.715), 나머지는상관관계가나타나지않았다 (Table 7). IV. 고찰 균형장애는뇌졸중후일반적이며, 일상생활동작회복의지연과이동성및낙상위험증가와높은관련이있다. 33) Tyson 등은뇌졸중환자 75명을대상으로균형장애의빈도를조사한결과대상자중 83% 가균형장애를가지고있었다. 34) 이와같이균형장애는뇌졸중환자의자신감및마비측사용저하를초래하여움직임을감소시키고독립적인일상생활을불가능하게하여여러가지제한점과문제점을만든다. 하지만아직까지뇌졸중후자세조절의회복정도혹은회복속도에영향을주는최고의치료적접근에관한확실한결론은나오지않고있다. Carpes 등 (2007) 은체간안정성운동이요통환자의요통및균형에미치는영향에대해연구한결과체간안정성운동후동적균형감각에유의한차이가있었다고하였다. Suri 등은이동성에제한이있는노인을대상으로체간근과균형의연관성을알아본연구에서체간근의근력과지구력모두균형과관련성이있다고하였다. 이와같이체간근이균형에영향을미친다는것은여러연구들에서확인되었다. 35) 임상에서균형을향상시키기위해체간근강화운동은중요시되며체간정렬은체간근의회복양상을판단하는기준이된다. Bobath 역시이러한신체정렬에대한재교육을통하여뇌졸중환자의균형과보행능력을향상시키고자하였다. 뇌졸중환자의체간근을평가및측정하기위한연구들이있는데그중 McMeeken 등은초음파로측정한복횡근의두께와근전도상의근육의활성화는유의한상관관계가있다고하였다. 36) 또한 Tanaka 등은등속성장비를이용한연구에서뇌졸중환자의최대근력이일반인에비해유의하게낮았다는연구결과를보고하였다. 37) Dickstein 등은표면전극근전도를이용하여체간근을측정한결과, 뇌졸중환자의척추기립근이일 반인들에비하여유의하게약한것을발견하였다. 38) 이와같이기존연구들은체간근의근력이나두께, 활성도의변화를통해체간근및체간안정성을측정하였다. 그에비해척추정렬의변화에따른체간근및체간안정성관련연구는미비하다. 따라서본연구는체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향을알아보고체간조절과척추정렬의상관관계를알아보기위해실시하였다. Verheyden 등은뇌졸중환자 33명을대상으로체간조절향상을위해골반움직임이부가된운동을시행시킨결과, 체간손상척도가 1.01점향상되었다고보고하였다. 39) 또한 Karthikbabu 등은뇌졸중환자 30명을대상으로불안정지지면과안정된지지면에서체간안정성운동을실시한결과체간손상척도가 3.06점향상되었다고보고하였다. 42) 본연구에서도체간안정성강화운동을시행한연구군의체간손상척도가 5.92점으로향상되었다. 이는체간안정성강화운동이뇌졸중환자의체간조절향상에효과적인운동방법이라고할수있다. 요추부에서입력되는체감각정보는체간조절에중요한역할을담당한다. 척추에는극간인대, 극상인대, 황색인대, 흉요추부근막, 척주근, 요추간판, 경추후관절등의감각수용기들이있다. 이러한척추조직의넓고다양한감각수용기의분포는기능적동작수행을가능하게하는필수적인고유감각이라할수있다. Sung 등은불완전척추손상환자를대상으로 12주동안복합운동프로그램시행결과척추정렬이중립이되고복근과신근이안정화되었다고하였다. 40) 복합운동프로그램즉, 체간안정성강화운동과렛풀다운운동은하체근력및척추정렬에긍정적인효과가있다는결론은얻었다. Son 등은천장관절기능장애를가진 20대여학생을대상으로관절가동법을 8주동안시행한후골반분석과정적균형을비교하였다. 40) 그결과연구군이대조군에비해골반경사도와정적균형에서유의한차이를보였다. 결론적으로골반위치정렬은정적안정성에효과적임을증명하였다. Knott 등은청소년특발성측만증을가진환자를대상으로척추정렬을측정하여균형과측만증사이의관계에대해연구한결과유의한상관관계가없다는결론을얻었다. 41) 하지만이연구에서청소년특발성측만증환자에게측정한척추정렬은흉추의후만각과요추의전만각, 척추의앞 뒤기울기, 척추의좌 우기울기였다. 본연구에서는척추분절회전각이체간조절과높은상관관계를나타난것과차이가있다. 또한 Karthikbabu 등은뇌졸중환자의체간근의활성화에대한연구에서뇌졸중환자의체간회전은체간굴곡보다어렵다고하였다. 42) 이것은뇌졸중환자의체간회전능력저하와척추정렬중에서도척추분절회전각에대한평가가체간조절의향상을위해중요하다는것으로판단된다. 본연구결과체간안정성강화운동을시행한연구 18 The Effects of Core stability Strengthening Exercise for Trunk Control and Spine Alignment in Patients with Stroke
이지혜, 황병용, 정상미 군과일반적운동치료를시행한대조군모두척추정렬에유의한차이가없었다. 하지만체간조절과체간정렬, 특히척추분절회전각에서높은상관관계를보였다. 척추분절회전각과체간조절은서로상관관계가높다는결과를통해뇌졸중환자의체간조절을향상시키기위해서는척추정렬이중요하다고판단된다. 뇌졸중환자는중추신경계손상으로인해감각수용기의활성화가저하되어있다. 그러므로체간의감각수용기의활성화를통한체간조절의향상이뇌졸중환자에게중요하다. 본연구에서시행된체간안정성강화운동프로그램은안정성에필요한체간근만을강화시키기위해자세변화없이누운자세에서운동을시행하였다. 하지만감각수용기의활성화나기능적인측면에서이러한제한은정적선자세에서의체간정렬을바꾸기에는부족하였다. 황병용은뇌졸중환자의균형과보행능력증진을위해서는마비측하지의중둔근을포함한항중력근의근긴장도증진이필수적이며체간조절이나기능적인동작시항중력근의효율적인활동을위해서는골반과대퇴부, 그리고대퇴부와발사이의정상적인정렬이되어야한다고하였다. 23) 하지만본연구의운동프로그램이체간에만제한되어있어하지근력이나정렬에대한접근이없었다. 근활성도증가와감각수용기의활성화를위하여누운자세보다하지정렬및근력을함께고려한기능적인자세에서의운동프로그램시행이효과적일것이다. 이와같이본연구에서시행한체간안정성강화운동프로그램의제한점으로인해척추정렬에긍정적인영향을미치지못하였다고판단된다. 앞으로도척추정렬을향상시키는연구가더필요할것이며, 척추정렬을위한운동프로그램을지속적으로연구하여뇌졸중환자의척추재정렬과체간조절의연관성을알아내기위한노력이필요할것이다. 이연구는체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향을알아보기위하여실시하였다. 이연구는 2013년 8월부터 2013년 10월까지천안시에소재한 D병원에입원및통원치료를받고있는뇌졸중환자를대상으로연구군 13명과대조군 9명으로선정하여 10주동안의체간안정성강화운동프로그램이뇌졸중환자의체간조절과척추정렬에미치는영향과체간조절과척추정렬의상관관계를알아보았으며, 연구결과의요약은다음과같았다. 첫째, 체간손상척도를통한동적및협응능력에서체간안정성강화운동프로그램실시전 후유의한차이가있었으나, 대조군에서는유의한차이를볼수없어체간안정성강화를시행한연구군이체간활동의질적인수준향상을위한동적및협응능력에효과적임을알수있다. 둘째, 자세조절평가척도를통한자세유지및변환능력모두체간안정성강화운동프로그램실시전 후유의한차 이가있었으나, 대조군에서는유의한차이를볼수없어체간안정성강화를시행한연구군이자세유지및변환능력에효과적임을알수있다. 셋째, 낙상효능감척도를통한기본적일상생활및도구적일상생활동작능력에서두그룹모두전 후유의한차이가있었고, 그룹간의비교결과유의한차이가있었다. 따라서체간안정성강화를시행한연구군이자세유지및변환시낙상에대한두려움감소에효과적임을알수있다. 넷째, 척추정렬를통한흉추의후만각, 요추의전만각, 척추분절회전각, 척추측만곡에서두그룹모두전 후유의한차이가없었고, 그룹간의비교결과유의한차이가없었다. 따라서체간안정성강화프로그램만으로척추정렬이바뀌지않았다는것을알수있다. 다섯째, 체간손상척도, 자세조절평가척도, 낙상효능감은서로상관관계를보였다. 또한척추분절회전각은체간손상척도, 자세조절평가척도, 낙상효능감과의상관관계를보였고, 측만곡역시자세조절평가척도와상관관계를보였다. 척추정렬중에서도흉추후만각과요추전만각에서상관관계를보였다. 이상의결과를통해 10주간의체간안정성강화운동프로그램이뇌졸중환자의체간조절향상에효과적이었으나체간안정성강화운동프로그램만으로척추정렬이바뀌지않는다는것을알수있었다. 하지만체간조절과척추정렬에높은상관관계가있다는결과가나왔다. 이러한결과를바탕으로뇌졸중환자의체간안정성과척추정렬에효과적인운동프로그램에대한여러연구들이필요할것이고이러한노력들은뇌졸중환자의건강증진과삶의질을향상시키는데도움이될것이라사료된다. 참고문헌 1. Paul SL, Srikanth VK, Thrift AG. The large and growing burden of stroke. Curr Drug Targets. 2007;8:78-93. 2. Feigin VL, Barker-Collo S, McNaughton H, et al. Long-term neuropsychological and functional outcomes in stroke survivors: current evidence and perspectives for new research. Int J Stroke. 2008;3:33-40. 3. Desrosiers J, Noreau L, Rochette A, et al. Predictors of handicap situations following post-stroke rehabilitation. Disabil Rehabil. 2002;24(15):774-85. 4. Askim T, Indredavik B, Vangberg T, et al. Motor network changes associated with successful motor skill relearning after acute ischemic stroke: a longitudinal functional magnetic resonance imaging study. Neurorehabil Neural Repair. 2009;23:295-304. 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 19
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이지혜, 황병용, 정상미 trunk after stroke. Clin Rehabil. 2004;18:326-34. 31. Benaim C, Perennou D, Villy J, et al. Validation of a standardized assessment of postural control in stroke patients: the postural assessment scale for stroke patients(pass). Stroke. 1999;30:1862-8. 32. Hierholzer E, Drerup B. High-resolution rasterstereography. ln: D'Amico M. et al, eds. Three dimensional analysis af spinal deformities. Amsterdam, Oxford, Washington: IOS Press; 1995.435-9 33. Lamb SE, Ferrucci L, Volapto S, et al. Risk factors for falling in home-dwelling older women with stroke: the women s health and aging study. Stroke. 2003;34(2):494 501. 34. Tyson, SF, Hanley M, Chillala J, et al. Balance disability after stroke. Phys Ther. 2006;.86(1):30-8. 35. Carpes F, Reinehr F, Mota C. Effects of a program for trunk strength and stability on pain, low back and pelvis kinematics, and body balance: A pilot study. J Bodywork and Move Ther. 2007;12(1):22-30. 36. McMeeken JM, Beith ID, Newham DJ, et al. The relationship between emg and change in thickness of transversus abdominis. Clin Biomech. 2004;19(4): 337-42. 37. Tanaka S, Hachisuka K, Ogata H. Trunk rotator muscle performance in post-stroke hemiplegic patients. Am J Phys Med. 1997;76(5):366-9. 38. Dickstein R, Shefi S, BenHaim Z, et al. Activation of flexor and extensor trunk muscles in hemiparesis. Am J Phys Med Rehabil. 2000;79(3):228-34. 39. Verheyden G, Vereck L, Truijen S, et al. Additional exercises improve trunk performance after stroke: an assessor-blinded randomised controlled trial. Neurorehabil Neural Repair. 2009;23(3):281-6. 40. Sung DH, Sung SD, Park GD. The effect of complex rehabilitation training for 12 weeks on trunk muscle function and spine deformation of patients with SCI. J Phys Ther Sci. 2015;27:951-4. 41. Knott P, Musto J, Thompson S, et al. The relationship between scoliosis and balance in a population of adolescents with AIS. Scolio. 2013;8. 42. Karthikbabu S, Nayak A, Vijayakumar K, et al. Comparison of physiobaland plinth trunk exercises regimens on trunk control and functional balance in patients with acute stroke: a pilot randomized controlled trial. Clin Rehabil. 2011;25(8):709-19. 체간안정성강화운동이뇌졸중환자의체간조절과척추정렬에미치는영향 21
NEUROTHERAPY 2 0 1 5 이상용대한신경치료학회지, 박정서, 한슬기제19, 권이대희제2호 물리치료사의직무관련특성이피로도및보행계수에미치는영향 이상용 2, 박정서 1, 한슬기 2, 이대희 *2 1 대전과학기술대학교물리치료학과, 2 영동대학교물리치료학과 Influence of Physical Therapist's Job-related Characteristic on Fatigue and Gait Cycle Counting Sang-Yong Lee 2, Jung-Seo Park 1, Seul-Ki Han 2, Dae-Hee Lee *2 1 Department of Physical Therapy, Daejeon Institute of Science and Technology 2 Department of Physical Therapy, Youngdong University Purpose This study aimed to investigate the influence of physical therapist's job-related characteristic on fatigue and gait cycle and provide basic informations to improve work condition and job satisfaction of physical therapist. Methods This study targeted 30 physical therapists working in a general hospital and rehabilitation hospital. Multidimensional fatigue scale(mfs) and Pedometer(Yamas SW 650, Yamax Coporation, Tokyo, Japan) were used to measure fatigue and gait cycle. MFS consist of 19 questions and was constructed on 7 point Likertis scale to answer. Physical therapists wore Yamas Digi-walker electronic pedometer during their work hours except for the lunch time. Results In general condition and fatigue did not show significant difference all(p>.05). There is significant difference that Hospital type and House work In comparison of General condition and Gait cycle counting(p<.05). But sex, employment type, working department, educational background, exercise, alcohol availability, and past accidents, that were not significant different(p>.05). Relevance of the comparison for general status and gaitcycle counting about age, work experience, and number of patients treated had a higher negative correlation. Conclusions Physiotherapists in the work-related correlation with gaitcycle counting are considered to be higher. In the future to reflect the characteristics of physiotherapists of physical therapists work gaitcycle counting, fatigue and research on factors affecting the various aspects of management and in seeking to fatigue analysis continue to be done is needed. Key Words Physical therapist, Fatigue, Pedometer, Gait cycle counting 책임저자 Dae-Hee Lee(bobath99@hanmail.net) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론산업피로는노동부하에반응하는생체의태도이며피로자체는질병이아니라원래가역적인생체변화로써건강의장해에대한경고반응이라고말할수있다. 작업에수반되는피로는생산성의저하뿐만아니라재해와질병의요인이되므로그연구와대책은노동생산성에큰의의를가지고있다. 1) 더욱이근로자들의피로는일상생활에의부적응등을초래하여생산성을저하시키고의료이용을증가시켜결국, 사회적비용을증가시킨다. 2-5) 직무스트레스는일종의적응반응 (adaption response) 으로개인에게부과하는외부상황으로인해나타나는결과들로개인의동기나능력에맞는직무환경을제공하지못하거나개인의능력이직무환경을감당하기어려울때발생한다. 특히, 병원은전문적이고다양한직종의종사자들은협동 작업을통해환자들에게의료서비스를제공하는업무의특성으로인해타조직에비해상대적으로직무스트레스가높은경향이있다. 6) 더욱이현대사회의의료조직은구조가더욱복잡하고다차원적인구조로변화되고있어물리치료사의역할도더욱복잡해져새로운지식의습득과함께대인관계, 어려운근무조건, 업무의과다등으로스트레스를겪고있다. 뿐만아니라국민건강에대한관심의증대와노인성질환의증가로인하여물리치료실을이용하는사람들이증가하고있으나, 물리치료실을이용하는인원에비하여물리치료사들의인원과치료실규모가상대적으로작음으로인하여물리치료사들은정신적, 육체적피로가누적되고있다. 또한물리치료사는업무의특성상전문적인지식과반복적인육체적활동이동시에요구되는직종으로피로가다양화되고있다. 기존에물리치료사의피로에대한몇몇연구가보고되었으 물리치료사의직무관련특성이피로도및보행계수에미치는영향 23
NEUROTHERAPY 2015;19(2):23-28 나이것은물리치료사의업무에따른근골격계질환이나직무스트레스에집중되어있었다반면, 피로는육체적인결과에의한것도있지만피로에의해육체적인증상을나타내기도한다. 1) 그러므로물리치료사들의피로에영향을미치는다양한요인에대한다양한연구가필요하다. 이에본연구에서는물리치료사들의다양한직무관련특성을파악하고피로도를조사하며육체적인에너지소모정도를확인하므로써물리치료사들의근무조건개선및직무만족도향상을위한기초자료를제공하고자실시하였다. II. 연구방법 1. 연구대상본연구의연구대상자는서울지역소재하고있는병원에근무하는 30명의물리치료사를대상으로하였고본연구의목적과연구절차가참여자들에게충분히설명하였으며본인의동의를확인하였다. 연구대상자들의일반적인특성은 table 1과같았다. 2. 피로도측정연구대상자의피로도는 Schwartz 등 (1933) 이개발한피로조사도구 (Fatigue Assessment Inventory) 를장세진 (2000) 이우리나라직장인들의피로수준을측정하는데적합하도록한글로번역후재구성하여, 신뢰도와타당도를검정한다차원피로척도 (Multidimensional Fatigue Scale; MFS) 를사용하여측정하였다 (Cronbach α =.88). 12) 다차원피로척도는설문지형식으로총 19문항으로구성된자기보고식조사도구로피조사자가자신이지난 2주동안느꼈던피로수준에대해응답하도록리커트식 7점척도를사용한다. 다차원피로척도의점수는가장낮은수준인 전혀아니다 는 1점, 보통이다 는 4점, 가장높은수준인 매우그렇다 는 7점을먼저부여하였으며일반적피로를측정하기위한 8개문항, 상황적피로를측정하기위한 5개문항, 피로결과를측정하기위한 6개문항으로각각구성되어있다. 각항목의점수를합산하여피로도를평가한다. 3. 보행계수측정연구대상자들에게보행계수기 (Yamas SW 650, Yamax Coporation, Tokyo, Japan) 의사용법에대해충분히설명해주었고허벅지의중심선에위치한오른쪽이나왼쪽허리띠에착용하도록하였다. 보행계수기는반드시측정시간외에몸에서제거하거나손을데지않도록하며출근시보행계수를착용하게하고점심시간전에수거하여보행계수를확인하여기록하고점심시간후다시착용하게하여퇴근때에수거하여보행 Table 1. The General Characteristics General Characteristic Age Height Weight Marital status Religion Hostpital type Employment type Educational background Department Work experience Assign number of patients Work hours Recreational exercise housework Past accidents n(%) Male 8(38.1) Female 13(61.9) Under 29y 9(42.9) Over 30y 12(57.1) Under 160cm 8(38.1) 161-170cm 6(28.6) Over 171cm 7(33.3) Under 60kg 13(61.9) 61-70kg 4(19.0) Over 71kg 4(19.) Married 14(66.7) Single 7(33.3) Christianity 5(23.8) Catholic 4(19.0) Buddhism 6(28.6) Others 6(28.6) General hospital 16(76.2) Rehabilitation hospital 5(23.8) Full-time 15(71.4) Part-time 6(28.6) College graduated 7(33.3) University graduated 9(42.9) Graduate student 2(9.5) Graduated School 3(14.3) Heat, electrical treatment 11(52.4) Therapeutic exercise 10(47.6) Under 1y 7(33.3) 1y~3y 2(9.5) 3y~5y 2(9.5) Over 5y 10(47.6) Under 10 people 5(23.8) 10~20 people 8(38.1) 20~30 people 1(4.8) 30 people 7(33.3) 6 hours 1(4.8) 7 hours 2(9.5) 8 hours 17(81.0) 9 hours 1(4.8) Done 6(28.6) None 15(71.4) Under 1 hour 14(66.7) Over 1 hour 7(33.3) Done 6(28.6) None 15(71.4) 24 Influence of Physical Therapist's Job-related Characteristic on Fatigue and Gait Cycle Counting
이상용, 박정서, 한슬기, 이대희 계수를확인하였다. 4. 연구분석본연구의수집된자료는 SPSS/WIN 12.0 version을시용하여분석하였다. 연구자의일반적특성은빈도분석을하였고각각의직무관련특성들에따른피로도와보행계수의차이를알아보기위해독립표본 t-검정을하였으며, 각각의직무관련특성들과보행계수의관련성을알아보기위해피어슨상관분석을시행하였다. 유의수준 α는.05로하였다. III. 결과 2. 직무관련특성들에따른보행계수의차이보행계수는남성보다여성이더높았고대학병원그룹보다재활병원그룹이더높았으며정규직그룹보다비정규직그룹이더높았다. 열전기치료실그룹이운동치료실그룹보다더높았고전문대졸업그룹보다대학이상졸업그룹이더높았으며평소정기적으로운동을하는그룹보다하지않는그룹이더높았다. 가사노동이 1시간미만인그룹이 1시간이상인그룹보다더높았고사고경험이있는그룹이사고경험이없는그룹보다더높았다. 그러나근무지형태 ( 대학병원, 재활병원 ) 와가사노동정도 (1시간미만, 1시간이상 ) 에따른보행계수만통계학적으로유의한차이가있었고 (p<.05) 나머지항목에대해서는통계학적으로유의한차이가없었다 (p>.05)(table 3). 1. 직무관련특성들에따른피로도의차이피로도는남성보다여성이더높았고대학병원그룹이재활병원그룹보다더높았으며정규직그룹이비정규직그룹보다더높았다. 열전기치료실그룹보다운동치료실그룹이더높았고전문대졸업그룹이대학이상졸업그룹보다더높았으며평소정기적으로운동을하는그룹보다하지않는그룹이더높았다. 가사노동이 1시간미만인그룹보다 1시간이상인그룹이더높았고사고경험이있는그룹보다사고경험이없는그룹이더높았다. 그러나모든항목에서통계학적으로유의한차이를확인할수없었다 (p>.05)(table 2). 3. 직무관련특성들과보행계수의상관관계보행계수는연령과다소높은음의상관관계를보였고 (r= -.561, p<.05) 근무경력과다소높은음의상관관계를보였으며 (r=-.676, p<.05), 일평균환자수와다소높은음의상관관계를보였다 (r=-.455, p<.05). 나머지항목에대해서는유의한상관관계를확인할수없었다 (p>.05)(table 4). IV. 고찰이에본연구에서는물리치료사들의다양한직무관련특성을 Table 2. The Differences in fatigue due to work-related characteristics mean±sd Sex Male 70.63±27.22 Female 75.30±13.55 Hospital type Univ. hospital 74.50±19.79 Rehab. hostpital 70.40±19.78 Employment type Full-time 74.00±21.55 Part-time 72.33±14.05 Department Heat, electrical 73.27±20.77 Therapeutic Ex. 73.80±18.81 Educational background College graduated 79.14±8.07 Univ. graduated or higher 71.00±26.62 Recreational exercise Done 61.83±24.09 None 78.20±15.70 housework Under 1h 72.29±21.46 Over 1h 76.00±15.53 Past accidents Done 72.67±13.53 None 73.87±21.68 t -.528.404.174 -.061.777-1.853 -.406 -.125 물리치료사의직무관련특성이피로도및보행계수에미치는영향 25
NEUROTHERAPY 2015;19(2):23-28 Table 3. The difference between walking according to the coefficient of job-related characteristics mean±sd t Sex Male 2826.75±1494.74 Female 3389.77±1896.53.553 Hospital type Univ. hospital 2825.31±1207.54 Rehab. hostpital 5895.20±702.39-5.348 ** Employment type Full-time 3243.06±1677.39 Part-time 4339.17±1744.00-1.339 Department Heat, electrical 3658.18±1782.98 Therapeutic Ex. 3444.10±1754.91.277 Educational background College graduated 3764.86±1879.60 Univ. graduated or higher 4035.44±1679.79 -.304 Recreational exercise Done 2468.50±689.67 None 3991.33±1840.63-1.947 housework Under 1h 4287.14±1606.61 Over 1h 2094.43±791.08 3.380 ** Past accidents Done 3917.00±2375.47 None 3411.93±1474.54.595 * ** p<.05, p<.01 Table 4. The Correlation coefficients of job-related characteristics and walking r p Age -.561.008 ** Height.186.420 Weight.061.792 Work experience -.676.001 ** Patient number -.455.038 * Working time -.136.555 Fatigue -.030.898 * ** p<.05, p<.01 파악하고피로도를조사하며육체적인에너지소모정도를확인함으로써물리치료사들의근무조건개선및직무만족도향상을위한기초자료를제공하고자실시하였다. 본연구에서는물리치료사들의피로도를측정하기위해다차원피로척도를사용하였다. 다차원피로척도의총점수가 70점미만일경우는피로가없는상태로직장생활에문제없음을의미하고, 70-80점미만인경우는약간의피로수준을보이나직장생활에크게영향을주는수치는아님을의미하며, 총점수가 80-91점미만인경우는비교적높은수준으로규칙적운동, 휴식, 충분한수면을필요로함을의미한다. 피로도가총점수가 91점이상인경우는극도로피로의상태이며절대적인휴식과 안정, 규칙적인식사와운동, 충분한수면을필요로함을의미한다. 본연구에서성별에따른피로도는남성이 70.63±27.22, 여성이 75.30±13.55로두그룹모두, 약간의피로수준을보였으며, 남성보다여성이더높게나타났으나두그룹간유의한차이를확인할수없었다 (p>.05). 이에대해박지환등 (2014) 은물리치료사는성별에따른성역할에차이가없다고하였고성역할에따른직무만족도에도차이가없다고하였다. 13) 즉, 물리치료사는어떤한쪽에편중된성역할요구되거나선호하는직업이아니므로피로도에있어서도성별에따른차이가나타나지않은것으로생각된다. 본연구에서근무형태 ( 대학병원, 재활병원 ) 에따른보행계수는대학병원그룹이 2825.31±1207.54, 재활병원그룹이 5895.20±702.39으로대학병원그룹보다재활병원그룹이더유의하게많았다 (p<.05) 이것은대학병원에서물리치료사는상대적으로급성기환자를치료하는반면, 재활병원에서물리치료사는상대적으로만성환자중일상생활복귀를위한재활을목적으로하는환자를주로치료하기때문에활동량이더많은결과라고생각한다. 가사노동여부에따른보행계수는가사노동시간이 1시간이상인그룹이 4287.14±1606.61, 1시간미만인그룹이 2094.43±791.08으로 1시간이상인그룹이 1시간미만인그룹보다더유의하게많았다 (p<.05). 이것은이동이나활동량이 26 Influence of Physical Therapist's Job-related Characteristic on Fatigue and Gait Cycle Counting
이상용, 박정서, 한슬기, 이대희 많은젊은연령층일수록가사노동시간이짧았기때문이라고생각한다. 한편, 피로도는두그룹간에유의한차이가없었다 (p>.05). 또한정기적인운동에따른피로도도유의한차이가없었으며 (p>.05) 에너지소모량을대표하는보행계수와피로도간에도유의한상관관계를확인할수없었다 (p>.05). 이러한결과로보아물리치료사들의피로에대해육체적인요인은제한적이라고생각된다. 이에대해 Gandevia(1992) 는피로는단순하게일어나는것이아니라신체적인요인뿐만아니라정신적, 기타요인등이복합적으로작용한결과라고하였다. 14) 본연구에서보행계수는연령과근무경력그리고일평균환자수와다소높은음의상관관계를나타냈다 (-.70<r <-.40, p<.05). 이것은연령과근무경력그리고일평균환자수가많을수록활동량이적다는것을의미한다. 반면, 업무형태 ( 열전기치료실, 운동치료실 ) 에따른피로도나보행계수는유의한차이를확인할수없었다 (p>.05). 이러한사실로보아이것은연령과근무경력이많을수록환자를치료하는시간보다사무업무시간이상대적으로더많기때문이라고생각된다. 본연구는물리치료사의직무관련특성이피로도및보행계수에미치는영향을알아보고물리치료사들의근무조건개선및직무만족도를향상시키기위한기초자료를제공하였다는점에서의의가있다고생각한다. 그러나작업환경이나업무특성에차이가있는준종합병원이나의원에종사하는물리치료사들은대상에포함되지않았으므로전체물리치료사에적용하여일반화하기에는한계가있고, 물리치료사대상의선행연구가거의없는관계로연구결과를비교하기곤란한점이있었다. 그러므로향후물리치료사의업무특성을반영하여피로와보행계수에영향을주는요인에대해연구하고관리방안을모색하며다양한측면에서의피로도분석이지속적으로수행되는것이필요할것으로사료된다. V. 결론 본연구는물리치료사의직무관련특성들이피로도및보행계수에미치는영향을알아보고물리치료사들의근무조건개선및직무만족도를향상시키기위한기초자료를제공하고자실시하였다. 서울지역에소재하고있는병원에근무하는 21명의물리치료사를대상으로피로도를알아보기위해다차원피로척도설문조사를실시하였고보행계수를알아보기위해보행계수기를사용하여측정하였다. 본연구의결과는다음과같았다. 1. 피로도는근무형태, 업무형태, 학력, 운동유무, 가사노동정도, 과거사고경험에따라유의한차이가없었다 (p>.05). 2. 보행계수는근무형태, 가사노동정도에따라유의한차이가있었으나 (p<.05) 성별, 업무형태, 학력, 운동유무, 과거사고경 험에따라유의한차이가없었다 (p>.50) 3. 보행계수는연령, 근무경력, 일평균환자수와다소높은음의상관관계를보였으나 (-.70<r<-.40, p<.05) 신장, 체중, 근무시간, 피로도와는유의한상관관계를보이지않았다 (p>.05). 참고문헌 1. Cho KS. Industrial health science. 1 edition. Seoul. Sumuns. 1991;107-8. 2. Chen MK. The epidemiology of self-perceived fatigue among adults. Prev Med. 1986;15(1):74-81. 3. Manu P, Lane TJ, Matthews DA. The frequency of the chronic fatigue syndrome in patients with symptoms of persistent fatigue. Ann Intern Med. 1988;109(7):554-6. 4. David A, Pelosi A, McDonald E, et al. Tired, weak, or in need of rest: fatigue among general practice attenders. BMJ. 1990;24(301):1199-202. 5. Winningham ML, Nail LM, Burke MB, et al. Fatigue and the cancer experience: the state of the knowledge. Oncol Nurs Forum. 1994;21(1):23-36. 6. No HL. Relationship between Job Stress and Self-esteem of Physical Therapists. The journal of Korean Society of Physical Therapy. 2010;22(1):83-90. 7. Dong JE, Ryu WG, Bae SG. An Analysis of Work Stress of Physical Therapist and Reaction. International journal of automotive technology. 2008;2(1):37-58. 8. Sung YB, Seo HS, Lee JH, et al. Musculoskeletal Workload Evaluation in Physical Therapist. Journal of the Korea Academia-Industrial cooperation Society. 2012;13(9):3999-4008. 9. Han SY, No DH, Son BY, et al. Effects of Preventive Activities for Musculoskeletal Disorder on Occupational and Physical Therapists Pain and Job Stress. The Journal of Korean Society of Occupational Therapy. 2012; 20(1):29-41. 10. Kwon MJ, Kim SM. A survey on the Work-Related Musculoskeletal Disorders in Physical Therapist in Daegu. The journal of Korean Society of Physical Therapy. 2001;13(1):151-60. 11. Yong JH, Yi CH, Kwon OY, et al. Work-Related Musculoskeletal Pain and Job Stress in Physical Therapists. Phys Ther Korea. 2010;17(1):53-61. 12. Jang SJ. The study of Fatigue, health statistic data collection and Standardization of measurement. Seoul. 물리치료사의직무관련특성이피로도및보행계수에미치는영향 27
NEUROTHERAPY 2015;19(2):23-28 계축문화사. 2000 13. Park JW, Kim HB, Han SK. A Study of Job Satisfaction by Finger Length Ratio of Physical Therapists: Focused on Orthopedic Manual Therapy Field. The Journal of Korean Academy of Orthopedic Manual Physical Therapy. 2014;20(2):21-6. 14. Gandevia SC. Some central and peripheral factors affecting human motoneuronal output in neuromuscular fatigue. Sports Med. 1992;13(2):93-8. 28 Influence of Physical Therapist's Job-related Characteristic on Fatigue and Gait Cycle Counting
NEUROTHERAPY 2 0 1 5 대한신경치료학회지제19권노효련제2호 하지의마사지적용이경직성뇌성마비아동의하지운동범위와일상생활활동에미치는영향 노효련강원대학교물리치료학과 Effects of Massage in the Lower Extremity on Range of Motion and Activities of Daily Living in Spasticity Cerebral Palsy with Children Hyo-Lyun Roh Department of Physical Therapy, Kangwon National University Purpose The purpose of this study was to verify the effects of lower extremity massage for range of motion (ROM) and activities of daily living of children with cerebral palsy(cp). Methods The subject is fourteen diagnosed with spasticity CP. The group was applied effleurage, tapotement, pressure forms of massage on their hamstring and calf muscles. The intervention was offered during 8 weeks per five times a week during 30 minutes. We measurement ROM of both ankle joints and knee joints by goniometer and activity daily living(adl) by Functional Independence Measure for Children scale before and after applying massage. Results In this study, the ROM of both ankle joints and knee joints were significantly increased. For ROM were dose dependent increased different two groups. And the ability of ADL function were improved after 8 weeks. Conclusion These results suggest that massages help to improve the ROM and ADL of children with CP. Key Words Activities of daily living, Cerebral palsy, Massage, Range of motion 책임저자 Hyo-Lyun Roh(withtry@kangwon.ac.kr) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론 뇌의발달과성장이진행되는시기에감염, 외상, 허혈, 조산등의다양한이유에의한뇌의손상이원인인뇌성마비는비정상적인근육긴장도의문제와자세및운동조절에심각한문제를지니게된다. 뇌성마비는장기적인비정상적인자세와비정상적인근긴장도의변화로인해근육의길이, 방향, 움직임의방법등에대한일련의문제를가지게된다. 뇌성마비는뇌의손상부위에따라경직형 (spasticity), 무정위운동형 (athethoid), 운동실조증 (ataxia), 혼합형 (mixed type) 으로분류되어지는데, 경직형은근육에심한긴장과수축을보이며, 운동이부자유스럽고과도하며협응이거의안된다. 1) 일반적으로경직성뇌성마비에서양마비 (diplegia), 편마비 (hemiplegia) 모두관절가동범위장애나근육단축 (shorting) 이주로발생하는것으로알려져있으므로경직형뇌성마비아동은근육의약화나경직으로인하여관절강직이강하게나타나며, 운동부전으로인한근육의단축으로상지를사용하거나하지를움직이는데어려움을갖게된다. 1) 특히하지의슬괵근 과아킬레스건의단축은경직성뇌성마비의주요한특징중하나이다. 이러한종아리근육의단축은관절가동범위의제한을가져와서비정상적인운동형태와자세이상으로인하여일상생활수행의어려움을가지게되고다양한활동을수행하는데어려움을가져와서뇌성마비아동의독립적인활동을방해하는한요인이라고할수있다. 2) 뇌성마비의치료는뇌성마비아동의보행및기능을향상시키기위한고전적인접근법들은고유수용성신경근촉진법 (Proprioceptive Neuromuscular Facilitation: PNF), 브론스트롬접근법, 신경발달접근법, 보이타법등의재활치료와약물치료, 수술적치료방법이있다. 3) 그런데, 뇌성마비의치료는집중적이고장기간의치료를요하는한편가정에서의관리도뇌성마비의재활에주요한요소이다. 그러나많은교육과가정지도에도불구하고부모들은극히전문적인물리치료법을수행하는것에큰어려움을겪게된다. 따라서, 가정에서가족들이뇌성마미아동에게쉽게적용할수있는새로운방법을모색하는것이필요한것으로보인다. 마사지는특별한의학적지식이없다하더라도일반인들이 하지의마사지적용이경직성뇌성마비아동의하지운동범위와일상생활활동에미치는영향 29
NEUROTHERAPY 2015;19(2):29-32 짧은시간동안의훈련을통하여서익힐수있는기법으로가정에서쉽게접근할수있고다양한효능을지니고있다. 마사지는손을직접상대의피부에접촉시켜어루만지거나문지르고, 두드리거나잡아당기는자극요법치료적형태로서의수세기에걸쳐서전해져오고있다. 4) 마사지처치는근육계, 신경계, 감각계, 골격계, 순환계, 면역계등의생리적효과에영향을미친다. 5) 마사지는기계적으로정맥의혈류를개선하고림프액의흐름을촉진시켜부종을감소시킬뿐만아니라, 세포막의투과성을변화시키고, 혈액순환의원활한조절을통해근육의대사기능, 근육의피로회복과근육활동도원활하게이루어질수있도록도와준다. 또한, 반복적인압력자극, 피부가자극받지않으면서자극을주면말초수용기에서척수및뇌로전달시켜근육이이완되고혈관을확장시킨다. 6) 이러한마사지를가정치료의한방법으로뇌성마비아동에게적용하여재활을향상시키는방법을모색하는것도필요한일이라고본다. 이에본연구는경직형뇌성마비아동의하지에마사지를실시한후하지의관절가동범위와일상생활동작의변화정도를살펴보고자한다. 목, 대소변조절 2개항목, 이동하기 3개항목, 장소옮기기 2 개항목, 의사소통 2개항목, 사회성 3개항목의 6개하위영역총 18개항목으로구성되어있다. 항목별로완전의존 1점에서완전독립 7점까지의 7점척도로이루어져있다. Sperle 등은 WeeFIM의신뢰도를 0.93으로보고하고있다. 3. 자료분석수집된자료는 SPSS 18.0 Version을사용하여통계처리하였으며각통계방법에대한유의성검정을위해유의수준 p<.05 로하였다. 연구대상자의일반적특징은기술통계를실시하였다. 마사지적용전후의변화를비교하기위하여대응표본 t-검정을실시하였다. III. 결과 1. 연구대상자의일반적인특성본연구에참여한연구대상자는남자 8명여자 6명으로총 14 명이었다. 일반적인특성은 Table 1과같다. II. 연구방법본연구는경직형뇌성마비아동에게마사지적용이관절가동범위와일상생활동작의향상정도에대한효과를알아보고자실시하였다. 이에아래와같은결과를얻었다. 1. 연구방법및연구대상자본연구의참가대상자들은 B시에소재하고있는장애인생활시설에서거주하고있는경직형 (spasticity type) 뇌성마비로진단을받은아동 14명으로이들이거주하고있는생활시설의보호자와담당물리치료사의실험참가동의를얻어선정하였다. 연구기간은 2015년 2월부터 4월까지 8주동안실시하였으며주 5회마사지를적용하였다. 경찰법, 유날법, 고타법의마사지기법을두하지의슬괵근과종아리근육에각각 6분간약 30분동안적용하였다. 마사지전관절가동범위와일상생활능력을평가하고, 마사지적용후재평가하였다. 2. 측정도구뇌성마비아동의관절가동범위는인체각도기를사용하여발목관절의변화를측정하였고일상생활동작은아동용일상생활동작평가 (Functional Independence Measure for Children: WeeFIM) 를이용하여평가하였다 (Uniform Data System for Medial Rehabilitation, 2006). WeeFIM은신변처리 6개항 2. 관절가동범위에미치는효과하지에적용한마사지가관절가동범위에미치는효과를알아보았다 (Table 2). 오른쪽과왼쪽무릎관절폄정도는마사지적용이후에통계적으로유의하게증가하였다 (p<.01). 오른쪽과왼쪽발목관절발등굽힘정도는마사지적용이후에통계적으로유의하게증가하였다 (p<.05). Table 1. General characteristic factor Gender Age Height Weight Male(8) 11.5±4.5 143.5±5.2 43.1±0.8 Female(6) 11.0±3.0 141.8±6.3 39.8±8.3 Table 2. The effect of massage on the joint ROM ROM Pre-Massage Post-Massage M±SD t p Right knee Extension 161.25±5.22 168.55±2.31 3.32 0.01 Left knee Extension 158.70±1.26 165.75±2.30 3.17 0.01 Right Dorsiflexion 9.50±2.67 10.80±3.20 2.09 0.05 Left Dorsiflexion 9.30±0.70 10.20±1.48 2.67 0.05 30 Effects of Massage in the Lower Extremity on Range of Motion and Activities of Daily Living in Spasticity Cerebral Palsy with Children
노효련 3. 일상생활동작에미치는효과와변화하지에적용한마사지가일상생활동작에미치는효과를알아보았다 (Table 3). 마사지전후의일상생활동작의변화를비교하였을때, 통계적으로유의한변화가나타났다 (p<0.05). III. 고찰 본연구는경직형뇌성마비아동의하지에마사지를실시한후하지의관절가동범위와일상생활동작의변화정도를살펴보고자하였다. 본연구에서하지에마사지를적용한결과일상생활활동의능력과무릎및발목관절의관절가동범위가증가한것으로나타났다. 뇌성마비아동은대소운동기능과같은다양한동작기술의습득의지연을보이고, 이러한지연은운동기능장애뿐만아니라일상생활의장애를유발하기도한다. 7) 본연구에서는하지마사지적용이일상생활활동증진에효과가있는것으로나타나서뇌성마비를대상으로한오미정등의연구에서경락마사지가일상생활활동, 근지구력증진시킨다고한연구와유사한결과로나타났다. 8) 뇌성마비환자들의운동기능장애는기본적인일상생활활동을영위하는데도많은장애를가져오므로, 스스로일상생활활동수행능력을높이고만족감을줄수있는지속적인중재가필요하다. 9) 함정은등은스포츠마사지가뇌성마비아동의저항과긴장, 불수의운동을크게감소시키는이완의효과가있다고하였다. 10) 본연구에서하지에적용한마사지가하지관절가동범위증진하는것으로나타났다. 라기용은마사지가뇌성마비의하지의관절가동범위를증가시킨다고하여본연구와일치하는결과를나타내었다. 11) 따라서마사지는관절의구축과변형문제를해결하는데도움을줄수있는방법이라고할수있다. Hasson 등은마사지가말초신경과자극하여혈액과림프액을순환시켜근육으로의혈류량을증가시켜주고림프의순환을증가시켜근육과관절의회복에영향을미친다고보고하였다. 12) 또한 Field 등은마사지가근육조직에직접적인압력을가해관절가동범위증진을일으킨다고하였다. 13) 본연구의결과와선행연구에따르면마사지는일상생활동작과관절가동범위를증진시킬수있으므로가정에서쉽게적용할수있는보조관리방법으로유용한것으로보인다. 따라서하지뿐만아니라다른신체부위에도마사지를적용하여그 Table 3. The changes and the effects on the ADL ROM Pre-Massage M±SD Post-Massage Score 102.63±10.82 109.13±7.43-2.53 0.03 t p 유용성을검증하여부모교육의한방법으로제시하는것이필요한것으로보인다. 참고문헌 1. Bobath KA. neurological basis for the treatment of cerebral palsy. 2nd ed. London, England: William Heinemann Medical Books Ltd. 1980. 2. Maruishi M, Mano Y, Sasaki T, et al. Cerebralpalsy in adults; Independent effects of muscle strength and muscle tone. Arch Phys Medi Rehabil. 2001;82(5), 637-641. 3. L EJ, Park LJ, No HL. The Effects of Thera-Band for the Gross Motor Function and Balance of Children with Cerebral Palsy. Journal of Adapted Physical Activity. 2009;17(4):249-7. 4. Kim HM, Choi GS, Park JU. The Effect of massage on the lumbar Flexibility, muscle strength, muscle indurances. Journal of Exercise and Sport Science. 2000;14:215-31. 5. Nancy AM, Robert FZ, Robert JR, et al. The Comparative Effects of Sports Massage, Active Recovery, and Rest in Promoting Blood Lactate Clearance After Supramaximal Leg Exercise. J Athl Train. 1998;33(1): 30-5. 6. Kim YB, Jung DH. Effects of Therapeutic Sports Massage on Knee Pain in Patients with Knee Osteoarthritis. The Korean Journal of Physical Science Education. 2003;12(1):355-66. 7. Lepage C, Noreau L, Bernard PM. Association between characteristics of locomotion and accomplishment of life habits in children with cerebral palsy. Phys Ther. 1998;78(5):458-69. 8. Oh MJ, Choi KH. The Effect of Meridian Massage on Muscle Power, ROM, and ADL in Persons with Cerebral Palsy. Journal of Korean Academy of Fundamentals of Nursing. 2003;10(1):68-77. 9. Yu SY. Effects of pediatric massage on behavioral state and vital sign in infants with spastic cerebral palsy. Yonsei university. 2002. 10. Ham JE, Oh KS. A Study on the Effect of Sports Massage in Reflective Power and Basic Motor Control for the Cerebral Palsied Children s. Korea Sport Research. 2005;16(6):263-272. 11. La KY. The Effects of Leg Massage on the Physiological, Immune Responses and ROM of Students with Severe 하지의마사지적용이경직성뇌성마비아동의하지운동범위와일상생활활동에미치는영향 31
NEUROTHERAPY 2015;19(2):29-32 Spastic Quadriplegic Cerebral Palsy. Kyungnam University. 2008. 12. Hasson D, Arnetz B, Jelveus L, et al. A randomized clinical trial of the therapy effects of massage compared to relaxation taper ecordings on diffuse long-term pain. Psychotherapy Psychosomatic. 2004;73(1):17-24. 13. Field TS. Tactile kinesthetic stimulation effects on preterm neonates. Pediatrics 1986;77(5):654-8. 14. Bobath KA. neurological basis for the treatment of cerebral palsy. 2nd ed. London, England: William Heinemann Medical Books Ltd. 1980. 15. Sperle PA, Ottenbacher KJ, Braun SL, et al. Equivalence Reliability of the Functional Independence Measure for Children(WeeFIM) Administration Methods. Am J Occup Ther. 1997;51(1):35-41. 16. Peggy A. Houglum. Therapeutic exercise for athletic injuries. Daehanmedia. 2003. 17. Uniform Data System for Medial Rehabilitation, The WeeFIM IITM Clinical Guide Version 6.0, European journal of neurology, Buffalo, UDSMR, 2006. 32 Effects of Massage in the Lower Extremity on Range of Motion and Activities of Daily Living in Spasticity Cerebral Palsy with Children
NEUROTHERAPY 2 0 1 5 대한신경치료학회지김창영, 황병용제19, 권이상호제2호 시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향 김창영 1, 황병용 2, 이상호 *3 1 용인대학교재활복지대학원물리치료전공, 2 용인대학교물리치료학과, *3 서남대학교물리치료학과 The Effects of Gait Training Using on Treadmill With and Without Visual Auditory Biofeedback on Walking and Balance in Hemiplegic Patients Chang-Young Kim 1, Byoung-Yong Hwang, PT, Ph.D 2, Sang-Ho Lee, PT, Ph.D *3 1 Department of Physical therapy, Graduate School of Rehabilitation Welfar, Yongin University, 2 Department of Physical Therapy, Yongin University, *3 Department of Physical Therapy, Seonam University Purpose The purpose of this study was to determine effects of gait training using on treadmill with and without visual auditory biofeedback on walking characteristic and balance in 30 hemiplegic patients. Methods 30 patients who consented were randomized as two group. The control group and experimental group performed conventional physical therapy. In addition control group performed gait training using on treadmill with visual auditory biofeedback and experimental group performed gait training using on treadmill without visual auditory biofeedback. Results To find out the effect, walking characteristic by Gait Trainer 2, balance ability by BBS, FRT were three times repeatedly measured at baseline before treatment and 6 weeks after treatment. Experimental group and Control group improved more significantly after six-weeks treatment in walking speed in gait characteristic. 3After a six weeks treatment, there was no significantly difference between the two groups in gait characteristic but symmetry index(stance phase, step length) in the experimental group showed a mean difference and the positive effects higher than the control group. Control group improved more significantly after six-weeks treatment in FRT in balance ability.. After a six-week treatment, there was no significantly difference between the two groups in balance ability but BBS in the experimental group showed a mean difference and the positive effects higher than the control group. Conclusion To summarize the result of this study, it is considered that gait training using on treadmill without visual auditory biofeedback contributes to improve walking speed and FRT, gait training using on treadmill with visual auditory biofeedback contributes to improve walking speed. Key Words Visual Auditory biofeedback, Gait training, Treadmill, Gait characteristic, Balance, Hemiplegia 책임저자 Sang-Ho Lee(fetor07@hanmail.net) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론뇌졸중은후천적장애를발생시키는가장흔한원인으로처음수개월동안집중재활에도불구하고상당한장애를남기게되며발병후공통적으로편마비의증상이나타난다고하였고, 이는가동성과일상생활능력을감소시키며이차적인장애로는균형과보행능력의상실을들수있는데, 이는동작수행의어려움과낙상의위험을높여결과적으로비대칭적인자세와비정상적인보행을야기하게되며, 근력약화, 강직, 통증및균형장애등을일으키고, 이중균형장애의발생은전정, 체성, 고유감각등을조화롭게사용할수없거나입력된감각정보를운동계와통합하는중추신경계능력의부족, 비정상적인근긴 장으로인해발생한다. 1,2) 편마비환자의보행재활에서가장이상적인목표로양하지의균등한체중부하를통하여기립자세의균형을회복함으로써최종적으로독립적인보행으로회복시키는것이라고하였다. 하지만대부분의편마비환자는마비측보다는비마비측에더많은체중을부하하며마비측으로의체중지지능력은감소하고이로인하여비대칭적인보행의원인이되며정상인에비하여균형능력의불안성과보행속도의현저한감소가나타난다. 3) 보행은복잡한활동으로써균형 (balance), 협응 (coordination), 대칭적자세등이주요구성요소이며반복적인주기의연속이며, 생리학적보행패턴을유지하기위해서 시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향 33
NEUROTHERAPY 2015;19(2):33-40 보행의대칭성이확보되어야한다. 따라서, 편마비환자의보행훈련의목적은활보장의반복적인주기의수를증가시키는것과동시에보행의대칭성을회복하는것이다. 편마비환자의특징적인보행은일상생활과사회복귀에필수요소인이동성을저해하는요소인데, 이러한보행은보행주기와보행속도에있어느린보행을보이며, 마비측보장과비마비측보장간의활보장의차이, 마비측입각기가짧으며, 비마비측의긴유각기등이나타난다. 이에보행요소를뇌졸중환자의재활에있어제일중요한목적으로삼아야한다. 4,5) 트레드밀보행훈련은뇌졸중환자의보행문제점을개선하기위해사용되는기존의물리치료이외에시도되는다양한방법중하나이며, 서기훈련과보행패턴및근력강화, 균형등의운동조절을재인식시킨다고하였고, 독립보행이가능한치료시점의환자들에게체중지지트레드밀보행훈련은보행개선에효과가있다고하였다. 6) 또한트레드밀을이용한보행훈련은편마비환자에게마비측과비마비측의대칭적인보행을촉진하여보행에대한의욕을높일수있고지면에서의보행훈련보다효과적으로보행능력을향상시키는것으로보고되었다. 7). 뇌졸중환자의균형과기능향상을위한재활에는일반적으로보바스개념을이용한방법과고유수용성신경근촉진기법을이용한방법, 시각적피드백훈련 (visual feedback training) 및마비측체중이동등의방법이많이사용되어지고있으며, 그중시각, 전정감각, 고유감각되먹임등은마비측에정상적인감각을제공하여대칭적인보행능력을회복시키는데기여한다. 8-11) 최신의연구경향들은시각또는청각바이오피드백에의한연구가독립적으로이루어져다양한바이오피드백에대한연구효과가미미한실정이다. 따라서본연구자는뇌졸중으로인한편마비환자에게다양한시, 청각바이오피드백을이용한트레 드밀보행훈련을적용하여보행특성과균형능력의변화를알아보고자한다. 12,13) II. 연구방법 1. 연구대상및연구기간본연구는 2015년 6월 1일 7월 10일까지전남순천시소재의 P 재활병원에서뇌졸중으로인한편마비로진단받은후, 아래의연구조건을충족시켜본연구를수행하는데어려움이없는성인으로 K-MMSE 24점이상인자, 트레드밀에서 6분이상보행이가능한자, 발병한지 6개월이상인자, 하지의정형외과적질환이없는자, 과거에이와같은연구에참여한경험이없는자, 본연구의참여동의서를이해하고동의한환자 30명을선정하였다 (Table 1). 2. 측정도구 1) Gait Trainer 2 Gait Trainer 2(Biodex Medical system Inc, USA) 는연구대상자가실시간으로지면에닿아진발의모습을그림자영상을모니터를통해볼수있고실시간대상자보행속도 (meter/sec), 보행시간, 보장거리 (meter/sec), 입각기와유각기의대칭지수 (%) 를히스토그램을통해저장된정상범주값과비교할수있는장비이다. 본연구에서는시청각바이오피드백을통한보행훈련이목적이기때문에모니터와스피커를통한피드백을제공한상태에서보행훈련을하였으며, 연구전 후보행속도, 보행주기, 입각기와보장의대칭지수의변화를알아보기위해사전, 사후검사도구로사용하였다. 14) 대칭지수 ( 입각기, 보장 ) 의정량화를위해 Hsu 등의연구에사용된 Table 1. General characteristics of the subjects Gender Type of stroke Experimental group (N=15) Control group (N=15) Male 11(73.3) 11(73.3) Female 4(26.7) 4(26.7) Age(years) 135.73±16.46 146.13±14.95 Weight(kg) 164.53±12.75 168.53±10.21 Height(cm) 170.27±8.431 168.33±8.331 Infarction(%) 10(66.7) 9(60.0) Hemorrhage(%) 5(33.3) 6(40.0) Right (%) 9(60.0) 8(53.3) Paretic side Left (%) 6(40.0) 7(46.7) Time since onset(month) 128.33±23.45 112.07±7.501 M±SD: mean±standard deviation 34 The Effects of Gait Training Using on Treadmill With and Without Visual Auditory Biofeedback on Walking and Balance in Hemiplegic Patients
김창영, 황병용, 이상호 계산법을참고하여값을구하였다. 3) 2) Berg Balance Scale Berg Balance Scale(BBS) 는편마비환자의정적균형능력과동적균형능력을객관적으로평가하는도구로앉은자세에서일어나기, 잡지않고서있기, 선자세에서앉기, 의자에서의자로이동, 눈감고서있기, 눈뜨고양발과양팔몸에붙이고서기, 선자세에서앞으로팔뻗기, 바닥에있는물건집어올리기, 왼쪽과오른쪽으로뒤돌아보기, 제자리에서 360도회전하기, 발판위에발교대로놓기, 발을일자로두고서기, 한다리로서있기등의 14개의항목으로구성되어있으며동작마다 5단계의점수를주고총 56점으로하였으며, 41점이상은낙상위험이작으며, 21 40점은중간정도의낙상위험, 20점이하는낙상위험이높은것으로나타났다. 노인성질환과뇌졸중으로인한편마비환자에서균형능력을평가하는데널리사용되며, 본연구에서는연구전, 후균형능력을측정하기위해사용하였다. 연속 3회측정한값의평균을측정값으로사용하였다. 15) 3) Functional Reach Test 기능적팔뻗기검사 (FRT) 는편안하게선자세에서기저면을유지하면서팔을뻗어수평으로최대한닿을수있는거리를측정하는것으로측정에있어간편하며신뢰할만한검사도구로서안정성한계를비교적잘측정할수있으며임상에서균형장애를찾아내거나시간경과에따른균형수행력의변화등을검사하기위하여개발되었다. 16) 본연구에서는연구전, 후균형능력을측정하기위해사용하였다. 연속 3회측정한값의평균을측정값으로사용하였다. 4. 연구방법본연구에모든대상자를카드뽑기로연구군 15명, 대조군 15 명으로분류하고연구군에서는일반적운동치료와시청각바이오피드백이제공된트레드밀보행훈련을하였고, 대조군에서는일반적운동치료와시청각바이오피드백이제공되지않은트레 드밀보행훈련을 6주간실시하였다. 연구기간동안일반적운동치료는 5년이상의물리치료경력을지닌물리치료사가관절의신장, 근력강화, 보행훈련등을시행하는치료를말하며주 5회 30분간실시하였다. 트레드밀보행훈련프로그램은주 5회 30분간실시하며, 30분중초기 10분동안은신장운동과관절가동운동을실시하고, 중기 10분중 4분은적응운동, 6분은시청각바이오피드백을이용한보행훈련을실시한다. 마지막 10분은자전거와에르고미터를이용하여정리운동을실시한다. 17) 이때제공되는시청각바이오피드백은트레드밀에부착된모니터와스피커를통해서제공되며, 대상자는모니터에표시되는발걸음의목표지점과본인의발위치를비교하는시각적피드백과발걸음의목표지점과본인의발위치의오차에따른청각적피드백을받게된다. 대조군은동일하게수행하나시청각바이오피드백은제공하지않는다 (Table 2). 5. 분석방법수집된자료는윈도우용 SPSS ver 20.0 통계프로그램을이용하여분석하였으며, 연구군과대조군간의평균을비교하기위해서독립표본 t 검정 (independent t-test) 과전, 후차이를알아보기위해짝비교 t 검정 (paired t-test) 을실시하였다. 통계학적유의수준은 α=.05로하였다. III. 결과 1. 연구방법에따른보행의변화 1) 보행속도의변화연구군의보행속도는연구전 0.46±0.09m/s에서연구후 0.52±0.09m/s로향상되었으며통계학적으로유의한차이가있었다 (p<.00). 대조군의보행속도는연구전 0.52±0.10m/s 에서연구후 0.58±0.11m/s로향상되었으며통계학적으로유의한차이가있었다 (p<.00). 연구방법에따른집단간연구전 후변화량을비교한 Table 2. gait training using on treadmill Treatment time Warming-up (10 minute) Middle(10 minute) Cool-down(10 minute) Gait training using on treadmill with visual auditory biofeedback Method Stretching Exercise ROM Exercise 1. Adaptive Exercise (4 minute) - 0.1 0.3 cylce/sec 2. Exercise (6 minute) - 0.3 cycle/sec or more Bicycle Ergometer 시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향 35
NEUROTHERAPY 2015;19(2):33-40 결과연구군 0.05±0.04m/s, 대조군 0.06±0.02m/s로집단간차이는있었으나통계학적으로유의하지는않았다 (Table 3). 2) 보행주기의변화연구군의보행주기는연구전 0.61±0.08cycle/sec에서연구후 0.61±0.07cycle/sec로거의변화가없었으며통계학적으로유의한차이를보이지않았다. 대조군의보행주기는연구전 0.66±0.11cylce/sec에서연구후 0.67±0.10cycle/sec로증가하였으나유의하지않았다. 연구방법에따른집단간전 후변화량을비교한결과연구군 0.00±0.04cycle/sec, 대조군 0.01±0.05cycle/sec로집단간차이가있었으나통계학적으로유의하지않았다 (Table 4). 3) 입각기대칭지수의변화연구군의입각기대칭지수는연구전 93.69±21.64% 에서연 구후 95.11±16.16% 으로증가하였으나통계학적으로유의하지않았다. 대조군의입각기대칭지수는연구전 86.73±19.78% 에서연구후 87.70±19.28% 로증가하였으나통계학적으로유의하지않았다. 연구방법에따른집단간전 후변화량을비교한결과연구군은 1.42±8.79%, 대조군은 0.97±14.54% 로집단간차이가있었으나통계학적으로유의하지는않았다 (Table 5). 4) 보장대칭지수의변화연구군의보장대칭지수는연구전 95.99±27.44% 에서연구후 96.27±18.44% 로증가하였으나통계학적으로유의하지않았다. 대조군의보장대칭지수는연구전 93.67±28.34% 에서연구후 92.87±22.05% 로감소하였으며통계학적으로유의하지않았다. 연구방법에따른집단간전 후변화량을비교한결과연구군 0.27±13.06%, 대조군 -0.79±15.35% 로집단간차이 Table 3. Changes in walking speed (unit: m/s) Experimental group Control group t p pre 0.46±0.09 0.52±0.10 1.543 0.13 post 0.52±0.09 0.58±0.11 1.563 0.12 Pre-Post 0.05±0.04 0.06±0.02.194 0.84 t -5.513** -11.630** M±SD: mean±standard deviation; *p<05; **p<01 표 4. Changes in the gait cycle (unit: cycle/sec) Experimental group Control group t p pre 0.61±0.08 0.66±0.11 1.270 0.21 post 0.61±0.07 0.67±0.10 1.906 0.06 Pre-Post 0.00±0.04 0.01±0.05.485 0.63 t.360 -.980 M±SD: mean±standard deviation; *p<05; **p<01 Table 5. Change of stance symmetry index (unit :%) Experimental group Control group t p pre 93.69±21.64 86.73±19.78 -.919 0.36 post 95.11±16.16 87.70±19.28-1.141 0.26 Pre-Post 1.42±8.79 0.97±14.54 1.193 0.24 t -.628 -.258 M±SD: mean±standard deviation; *p<05; **p<01 Table 6. Changes of step length the symmetry index (unit :%) Experimental group Control group t p pre 95.99±27.44 93.67±28.34 -.228 0.82 post 96.27±18.44 92.87±22.05 -.459 0.65 Pre-Post 0.27±13.06-0.79±15.35 -.046 0.96 t -.083.201 M±SD: mean±standard deviation; *p<05; **p<01 36 The Effects of Gait Training Using on Treadmill With and Without Visual Auditory Biofeedback on Walking and Balance in Hemiplegic Patients
김창영, 황병용, 이상호 가있었으나통계학적으로유의하지않았다 (Table 6). 2. 연구방법에따른균형능력의변화 1) Berg Balance Scale 의변화연구군의 BBS는연구전 37.40±8.56점에서연구후 38.33±9.96점으로증가를보였으나통계학적으로유의하지는않았다. 대조군의 BBS는연구전 41.00±9.29점에서연구후 41.07±10.14점으로증가를보였으나통계학적으로유의하지는않았다. 연구방법에따른집단간연구전 후변화량을비교한결과연구군 0.93±2.21점, 대조군 0.06±2.54점으로집단간차이가있었으나통계학적으로유의하지는않았다 (Table 7). 2) Functional Reach Test의변화연구군의 FRT는연구전 18.30±5.05cm에서연구후 19.00±5.74cm로증가를보였으나통계학적으로유의한차이를보이지않았다. 대조군의 FRT는연구전 18.83±4.75cm에서연구후 20.26±4.94cm로증가를보였으며통계학적으로유의한차이가있었다 (p<.05). 연구방법에따른집단간연구전 후변화량을비교한결과연구군 0.70±1.86cm, 대조군 1.42±2.60cm로집단간차이가있었으나유의하지는않았다 (Table 8). IV. 고찰정상적인균형조절은감각과정과운동과정이필요하며, 운동과정은기저면내에서체중심을유지하는것과신체의흔들림을 최소화하는체간과다리의근활동을말하며, 감각과정은체성감각 ( 고유감각, 피부감각, 관절감각 ), 시각, 전정계로부터의감각입력사이의상호작용을말한다고하였다. 이중다양한시각적정보를이용한시각적피드백훈련은뇌졸중환자에게흥미유발과균형향상에도움을준다고하였으며, 시각적정보는훈련을통해감각운동의손실을보상할수있으며, 중추운동프로그램에대한정보를제공함으로써치료적효과를증폭시킬수있다고하였다. 18-20) 트레드밀보행훈련은최근들어임상적으로편마비환자나보행장애를가진환자의재활에이용되고있으며하지에체중지지와곧은자세로기능적이고반복적인걸음을내딛을수있도록자극하여실제적보행을통한보행훈련이보행을재학습하기전에독립적보행요소의조절을강조하는일반적접근보다보행능력의향상을가져왔다. 21) 그리고환자는기능적이고목표- 지향적 (task-oriented) 인접근방법인트레드밀위에서걷는동안보행의 3가지기본요소 ( 체중지지, 걸음, 균형 ) 를통합할수있게된다. 22) 따라서본연구에서는편마비환자의보행문제점개선을위하여시청각바이오피드백을이용한트레드밀보행훈련을통한보행특성과균형에미치는영향을알아보고자하였다. 본연구에서는연구군과대조군사이연구전에비해연구후에연구군의보행특성에서보행속도가유의한향상을보였으며, 보행주기, 입각기대칭지수, 보장대칭지수에서는통계학적으로유의한향상을보이지않았지만긍정적인효과를보였다. 균형능력에서는 BBS, FRT가통계학적으로유의한향상을보이지않았지만긍정적인효과를보였다. 대조군에서는보행속도에서유의한향상보였으며, 보행주기, 입각기대칭지수에서유의하지않았지만긍정적인효과를보였으나, 보장대칭 Table 7. Changes in the BBS (unit: score)table 1. General characteristics of the subjects Experimental group Control group t p pre 37.40±8.56 41.00±9.29 1.103 0.27 post 38.33±9.96 41.07±10.14.745 0.46 Pre-Post 0.93±2.21 0.06±2.54 -.767 0.44 t -1.629 -.101 M±SD: mean±standard deviation Table 8. Changes in the FRT Experimental group Control group t p pre 18.30±5.05 18.83±4.75.298 0.27 post 19.00±5.74 20.26±4.94.640 0.46 Pre-Post 0.70±1.86 1.42±2.60.275 0.78 t -1.467-2.124 M±SD: mean±standard deviation; *p<05; **p<01 (unit: cm) 시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향 37
NEUROTHERAPY 2015;19(2):33-40 지수에서 -0.79±15.35 감소하였다. 균형능력에서는 FRT에서유의한향상을보였으며, BBS에서유의한향상을보이지않았지만긍정적인효과를보였다. 이러한결과로트레드밀보행훈련은보행속도와 FRT의향상에기여하는것으로여겨지고, 시청각바이오피드백을이용한트레드밀보행훈련은보행속도의향상에기여하는것으로여겨진다. 이러한결과를통해본연구에서는시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행속도개선에기여하고보행주기, 입각기대칭지수, 보장대칭지수에긍정적인효과를보이며균형능력향상에긍정적인효과를보인것을알수있었다. 바이오피드백과보행특성에대한최근연구에서 Druzbicki 등은그들의연구에서뇌졸중환자 50명을대상으로 2주간시각적바이오피드백의유무에따른트레드밀을사용한보행훈련에서연구군환자들은입각기의단축그리고비마비측유각기길이와사이클길이증가에상당히유의한개선을보였다고하였으며또한, 두그룹간시공간매개변수또는추가적으로평가된매개변수들에서유의한차이가없었다고하였다. 12) 조남정, 이동엽은만성뇌졸중환자 21명을대상으로실시한시각리듬자극이보행과고유수용성감각에미치는영향에대한연구에서연구군은보행속도와분속수, TUG시간이유의하게증가하였고, 고유수용성감각이유의하게증가하였다. 본연구에서는시청각바이오피드백을이용한트레드밀보행훈련을 6주간적용하여보행특성중보행속도가유의하게증가하였고, 시공간보행매개변수에서는유의한차이가없었던부분이선행연구와일치하였다. 23) 바이오피드백과균형능력에대한연구에서조남정은만성뇌졸중환자 21명을대상으로 4주간시, 청각리듬자극을적용한보행훈련을실시하여기능적팔뻗기검사와 TUG에서유의한차이가있었다고하였으며, 지상구등은뇌졸중환자 26명을대상으로전신거울앞에서운동한군과거울이없는장소에서운동한군으로나누어 6주간연구를실시하여실험군과대조군모두족저압, BBS, TUG에서연구전보다연구후에통계학적으로유의한변화를보였으며, 군간비교에서훈련후에연구군이대조군에비해유의한변화를보였다고하였다. 24,25) 김연희등은뇌졸중환자 38명을대상으로정적균형훈련프로그램과동적균형훈련프로그램을적용하여시각적바이오피드백훈련이균형능력의향상을가져올수있었다고하였다. 26) 본연구에서는시청각바이오피드백을이용하여트레드밀보행훈련을실시하였으며, 균형능력을측정하기위하여 BBS, FRT를사용하였다. BBS와 FRT에서연구군과대조군모두연구전보다연구후향상되었음을알수있었으나통계학적으로유의하지않아선행연구와는다른결과를나타내었다. 본연구의결과는편마비환자의보행능력과균형능력증진을위해서는시청각바이오피드백을이용한트레드밀보행훈련이일반트레드밀보행훈련보다더긍정적인영향을미치는것을알수있었고, 충분한치료시간과치료방법이필요한것으로사료되고, 연구대상자들의유병기간이 6개월에서 60개월까지다양하였고적은수의대상자, 짧은연구기간으로인해일반화시키는데제한점이있다. 추후이러한연구의제한점을보완하여시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행특성과균형능력의향상에있어효과적인방법을제시할수있는연구가필요하다고사료된다. 본연구는시청각바이오피드백을이용한트레드밀보행훈련이편마비환자의보행과균형에미치는영향에대해알아보고자하였다. 연구군은일반적운동치료와시청각바이오피드백을이용한트레드밀보행훈련을실시하였고, 대조군은일반적운동치료와시청각바이오피드백이제공되지않은트레드밀보행훈련을실시하였다. 운동프로그램으로인한보행특성과균형의변화를알아보기위하여 Gait Trainer 2를이용한보행속도, 보행주기, 입각기대칭지수, 보장대칭지수의변화를측정하였고, BBS, FRT의변화를알아보기위하여 3회반복측정후평균값을구하고연구전 후에평가하여결과를비교분석하였다. 연구군과대조군의보행특성변화는운동전보다 6주후보행속도에서유의하게향상되었으며, 두그룹간의보행특성변화비교에서유의한차이가없었으나입각기대칭지수와보장대칭지수의평균차이에서연구군이대조군보다높아연구군에서긍정적인효과를보였다. 두그룹간의균형능력변화비교에서유의한차이는없었으나 BBS의평균차이에서연구군이대조군보다높아긍정적인효과를보였고, FRT의평균차이에서대조군이연구군보다높은효과를보였다. 이상의결과로볼때, 편마비환자에대한트레드밀보행훈련은보행속도향상에기여하고, 시청각바이오피드백을이용한트레드밀보행훈련은편마비환자의보행속도향상과보행주기, 입각기대칭지수, 보장대칭지수, 균형능력에긍정적인효과를보이는것으로사료된다. 따라서시청각바이오피드백을이용한트레드밀보행훈련은보행특성과균형능력향상에긍정적인운동방법으로제시할수있으며, 추후시청각바이오피드백을이용한트레드밀보행훈련을통한보행특성과균형에미치는영향을보다포괄적으로적용하기위하여다양한바이오피드백적용에따른편마비환자의보행과균형능력분석, 트레드밀보행훈련시근활성도의분석으로치료적접근이필요할것으로사료된다. 참고문헌 1. Vearrier LA, Langan J, Shumway-Cook, et al. An 38 The Effects of Gait Training Using on Treadmill With and Without Visual Auditory Biofeedback on Walking and Balance in Hemiplegic Patients
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NEUROTHERAPY 2 0 1 5 대한신경치료학회지이샛별, 차예니제19, 권이상호제2호 이중과제훈련이노인의균형에미치는영향 이샛별, 차예니, 이상호 * 서남대학교물리치료학과 The Effects of Dual Task Training on Balance for Elderly Sat-Byeol Lee, Yea-Ni Cha, Sang-Ho Lee * Dept. of physical Therapy, Seonam Univiersity Purpose The purpose of the study was to evaluate the effect of improving the balance in the elderly than single task. Methods 21 healthy elderly subjects dual-task training group (n = 11) and single-task training group (n = 10) 4 weeks a total of 35 minutes 3 times a week were classified as. Was the Function Reach Test, One Leg Standing Test for static balance evaluation, in order to assess the dynamic balance were the Timed Up and Go, Berg Balance Scale. Results There were significant differences in both groups according to the time in the dual task training group and training group around a single task, static balance ability evaluation of Function Reach Test and One Leg Standing Test, dynamic balance skills in comparing and evaluating the Timed Up and Go and the Berg Balance Scale (p<.05), the interaction between time and also there was a significant difference between the two groups in all evaluation methods (p<.05). In the Berg Balance Scale evaluation of the One Leg Standing Test eyes closed among its dual task training group was significantly more effective than single task training group (p<.05). Conclusions Both groups showed an effect in improving balance, which showed a dual task training is more effective than single task training. Key Words Balance, Elderly, Dual- task training. 책임저자 Sang-Ho Lee(fetor@hanmail.net) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론 균형이란감각, 운동, 인지적시스템의상호작용을통해외부의다양한환경에대하여자세를적절하게조절할수있는능력을말한다. 1) 균형은크게정적균형과동적균형으로나뉘는데, 정적균형은지면에흔들림없이서있을수있는능력을말하고, 동적균형은지지면이움직이거나스스로움직일때의균형을말한다. 2) 균형은일상생활의활동을실행할수있는능력에큰영향을미치는중요한기능적인기술로, 이러한균형능력감소는노인에게낙상의위험을증가시키고, 신체적인활동을감소시켜일상생활에많은문제를초래한다. 3,4) 이러한문제를초래하는일상생활활동은몇가지과제를동시에수행하면서균형안정성을유지해야한다. 따라서일상생활활동을함에있어서는이중과제를수행할수있는능력이필수적이다. 5) 일상생활에서이중과제를수행하는것은어렵지않지만균형능력이저하된사람, 낙상의경험이있는노인, 신경학적손상을받은환 자는이중과제를수행하는과정에서균형능력과보행능력등의손상으로일상생활에도영향을미치게된다. 6) 이중과제란하나의과제수행과더불어다른과제를수행하는것을말하며, 같은시간에두가지과제를수행하는대상의정보처리능력을평가하는것이다. 7) 인지이중과제는기립자세및보행을하는동안단어말하기나숫자세기등의인지과제를동시에수행하도록하는방법으로집중과자세조절간의상호작용을연구하기위해활용되고있다. 8) 또한인지이중과제는운동과제와인지과제를동시에수행함으로써한쪽혹은양쪽수행에영향을준다. 9) 이재한은만성뇌졸중환자에게앉은자세에서의이중과제훈련방법은신체기능을향상시키고일상생활동작을원활히할수있는훈련방법으로보고했으며, 최원재는연구를통해인지운동이중과제훈련이만성뇌졸중환자의보행, 균형능력및집중력을향상시킴으로써지능적활동을증진시키는데효과적인운동방법이라고했다. 10,11) 노정석은외부환경으로부터제공되는정보특히, 이중과제를수행할때움직임에대한집중 이중과제훈련이노인의균형에미치는영향 41
NEUROTHERAPY 2015;19(2):41-47 력이높아져균형이향상되었다고하였다. 12) 또한박해균은이중과제훈련이체간안정성과균형능력에유의한향상을보였다고보고했고, 장연식등은이중과제수행이단일과제수행보다체간조절능력과상지기능의향상에있어서더효과적이었다고하였다. 13,14) 선행연구를바탕으로보았을때일상생활활동을함에있어서이중과제훈련은필수적이며, 이러한이중과제훈련이보행과균형능력, 그리고체간조절능력향상에있어서효과적이고일상생활활동의적응에도효과적이라는것을알수있었다. 이러한이중과제훈련에관한연구는뇌졸중환자를대상으로는많이하였지만노인을대상으로한경우는미비한실정이다. 본연구는노인들을대상으로하여 4주동안이중과제훈련을실시하고, 단일과제훈련군과비교하여노인들의균형능력향상에대한자료를제공하고자한다. 록하는시작자세에서세번째손허리뼈머리의끝으로부터최대한앞으로뻗었을때의세번째손허리뼈머리끝까지의거리를측정하였다. FRT는측정자간신뢰도 (r=.98) 와측정자내신뢰도 (r=.89) 가높은검사방법으로균형을평가하기에적합한도구이다. 15) (2) 한다리서기검사 OLST의대상자의자세는양팔을벌리고양다리로똑바로선자세에서검사자의지시에따라한쪽발을바닥으로부터충분히들어올리게하여한발로서있는시간을 2회측정하여평균값을기록하였다. (3) 한발서기검사는각각눈뜬상태와눈감은상태에서실시하며, 좌측과우측각각실시한후양쪽의평균값으로결정하였다. OLST는측정자간신뢰도 (r=.99) 가높은검사방법이다. 16) II. 연구방법 1. 연구대상본연구의대상자는 2015년 1월 19일부터 2015년 2월 13일까지 4주간 N시의경로당 3곳에서 65세이상의노인 21명을대상으로한다. 대상자들은단일과제훈련군 10명, 이중과제훈련군 11명각군은무작위로선별한다. 연구대상자선정기준은독립적보행이가능한자, 6개월이내에규칙적인운동을하지않은자, 1년이내에낙상경험이있는자, 검사자의지시에따를수있는자, 심폐질환이없는자로한다. 실험에앞서모든연구대상자에게연구의목적및취지그리고실험절차와안전성에대해설명하며, 자발적으로참여하기로동의한대상자가실험에참가하였다 (Figure 1). 2. 측정방법노인들의균형능력검사는기능적팔뻗기검사 (Function Reach Test, FRT), 한다리서기검사 (One Leg Standing Test, OLST), 일어서서걷기검사 (Timed Up and Go, TUG) 그리고버그균형척도 (Berg Balance Scale, BBS) 를이용하여평가하였으며, 모든평가는한번연습후 3회측정하여평균값을결과분석에이용하였다. (1) 기능적팔뻗기검사 FRT는자발적인신체중심이동을평가하는것으로임상에서뇌졸중환자및노인을대상으로간편하고빠르게기능적균형검사를시행할수있는평가도구이다. FRT 검사시대상자의자세는똑바로선자세에서어깨넓이로두발을벌리고벽옆에선다음어깨관절을 90도굽힘하여평행하게앞으로뻗도 (3) 일어서서걷기검사 TUG는기능적인운동성과이동능력및균형능력을동시에평가할수있는방법이다. TUG 검사시대상자의자세는 46 cm높이의팔걸이가없는의자에앉은자세에서실시하였다. 이검사는대상자가검사자의시작이라는신호와동시에일어나 3 m 를걸어간후뒤로돌아와다시의자에앉을때까지의시간을측정하였다. TUG는측정자간신뢰도 (r=.98) 와측정자내신뢰도 (r=.99) 가높은검사방법이다. 17) (4) 버그균형척도 BBS는정적균형과동적균형을객관적으로평가하는척도로 14개의항목으로구성되어있으며크게앉기, 서기, 자세변화의 3개영역으로나눌수있다. 최소 0점에서최고 4점을적용하고총점은 56점이다. 이측정도구는측정자내신뢰도 (r=.99) 와측정자간신뢰도 (r=.98) 로높은신뢰도와타당도를가진도구이다. 18) 3. 연구절차본연구는이중과제훈련군과단일과제훈련군으로나누어훈련을실시한다. 훈련은 4주간주3회실시하고, 준비운동 5분본운동 30분으로총 35분간실시되며준비운동으로스트레칭을 5분간실시한다. 본운동은아래의표와같다 (Table 1)(Table 2). 19) 4. 자료분석모든자료들은 SPSS 18.0(SPSS Inc, Chicago, IL, USA) 을이용하여분석하였다. 대상자의일반적특징인나이, 키, 몸무게는독립 T-검정 (Independent t-test) 을하였다. 대상자들의군간측정항목간의정규분포여부를알아보기위하여 42 The Effects of Dual Task Training on Balance for Elderly
이샛별, 차예니, 이상호 Table 1. The single task training program (unit: minute) Warm-up stretching 5 5 Placing each foot alternately on a step 5 Walking forwards between two parallel lines 5 Exercise Kicking a ball against a wall 5 Standing up and walking to the chair 5 Stepping over obstacle 5 Moving objects 5 30 Table 2. The dual task training program (unit: minute) Warm-up stretching 5 5 Placing each foot alternately on a step and to decreasing UE support and asked to spell a word backward Walking forwards, and backwards between two parallel lines, 20 cm apart, progressing to using one line, to using a balance beam 20cm and asked to name Kicking a ball against a wall progressing to decreasing UE support, to increasing the distance from the wall, to kicking to a target, and to dribbling the ball around pilons; 5 5 5 Exercise With four standard armchairs placed at four corners of a square, 5 min of repeatedly standing up and walking to the chair directly in front, sitting, then standing up and walking to the chair on the left, progressing from using arms to not using arms, and to decreasing the seat height and asked to randomly name the numbers between 0 and 300 5 30 Stepping over obstacle,(height: 15 cm, distance: 30 cm ) and asked to recite number, days, or months backward 5 Continuously walking carrying a grocery bag, progressing to carrying a bag in each hand and asked to randomly name the numbers backward(double/three-digit) 5 Table 3. General characteristics of the subjects Simple task (n=10) Dual task (n=11) t Ager(years) *75.30±1.35* *75.72±1.17 -.239 height( cm ) 155.80±1.83* 158.27±2.12 -.166 Weight( kg ) *58.90±1.90* *58.27±3.15 -.872 *M±SD: mean±standard deviation. Shapiro-Wilk test를실시하여정규분포가인정되어두군간의차이와운동전, 후의시간에따라변화된균형의차이를알아보기위하여반복측정 2요인분산분석 (Repeated 2WayAnov a) 으로하였으며, 운동실시후에이중과제훈련군과단일과제훈련군의균형에차이를알아보기위해독립 T- 검정 (Independent t-test) 을실시하였다. 유의수준 (α) 은 0.05 로한다. III. 결과 1. 연구대상자의일반적특징본연구에서의대상자는총 21명으로단일과제훈련군 10명, 이중과제훈련군 11명으로하였다. 그결과일반적특성중연령에서단일과제훈련군은 75.30±1.35세, 이중과제훈련군은 75.72±1.17 세로집단별차이는없었다. 신장은단일과제훈 이중과제훈련이노인의균형에미치는영향 43
NEUROTHERAPY 2015;19(2):41-47 련군은 155.80±1.83 cm, 이중과제훈련군은 158.27±2.12cm, 체중은단일과제훈련군은 58.90±1.90kg, 이중과제훈련군은 58.27±3.15 kg으로집단별유의한차이는없었다 (Table 3). 2. 단일과제운동군과이중과제운동군의균형차이비교이중과제훈련군과단일과제훈련군의 FRT, OLST, TUG, BBS의전 후변화는표 4와같다. 3. 단일과제운동군과이중과제운동군의 FRT 전 후비교이중과제훈련군과단일과제훈련군의전 후변화는표5와같다. FRT는시간과시간과두군간의상호작용은유의한차이 가있었으나 (p<.05), 두군간에는유의한차이가없었다 (p>.05)(table 5). 4. 단일과제운동군과이중과제운동군의 OLST( 눈뜨고 ) 전 후비교이중과제훈련군과단일과제훈련군의전 후변화는표6와같다. OLST( 눈뜨고 ) 는시간과시간과두군간의상호작용에는유의한차이가있었으나 (p<.05), 두군간에는유의한차이가없었다 (p>.05)(table 6). 5. 단일과제운동군과이중과제운동군의 OLST( 눈감고 ) 전 후비교이중과제훈련군과단일과제훈련군의전 후변화는표7과같 Table 4. Comparison of change at pre and post intervention Variable Group Pre-intervention Post-intervention FRT (cm) OLST (eye open) OLST(eye closed) TUG (sec) BBS(sec) M±SD: mean±standard deviation FRT: Function Reach Test, OLST: Leg Standing Test TUG: Timed Up and Go, BBS: Berg Balance Scale Simple task 18.00±7.84* 21.20±8.84* Dual task 17.18±5.47* 28.09±11.19 Simple task 11.70±8.37* 16.70±9.09* Dual task 13.60±7.86* 30.30±12.63 Simple task *3.33±1.46* *4.43±1.97* Dual task *3.19±1.56* *9.86±4.09* Simple task 10.07±2.09* *9.03±1.59* Dual task *9.60±1.73* *7.30±1.40* Simple task 43.70±5.75* 47.10±5.10* Dual task 48.18±2.04* 54.45±2.73 Table 5. Comparison of FRT between groups after treatment Variable Source Type III Sum of Squares df Men Square F Time 521.365 1 521.365 39.583** FRT Group *96.585 1 *96.585.717 Time x Group 155.650 1 155.650 11.817** NM±SD: mean±standard deviation; Table 6. Comparison of OLST(open) between groups after treatment Variable OLST (Open) Source Type III Sum of Squares df Men Square F Time 1233.283 1 1233.283 73.805** Group *629.226 1 *629.226 3.652* Time x Group *358.521 1 *358.521 21.456** Type III SS: Type III sum of squares, df: degree of freedom, MS: mean square TUG: Timed Up and Go 44 The Effects of Dual Task Training on Balance for Elderly
이샛별, 차예니, 이상호 다. OLST( 눈감고 ) 는시간과두군, 시간과두군간의상호작용모두유의한차이가있었다 (p<.05)(table 7). 6. 단일과제운동군과이중과제운동군의 TUG 전 후비교이중과제훈련군과단일과제훈련군의전-후변화는표8과같다. TUG는시간과시간과두군간의상호작용에는유의한차이가있었으나 (p<.05), 두군간에는유의한차이가없었다 (p>.05)(table 8). 7. 단일과제운동군과이중과제운동군의 BBS 전 후비교이중과제훈련군과단일과제훈련군의 BBS 전-후변화는시간과두군, 시간과두군간의상호작용모두유의한차이가있었다 (p<.05)(table 9). IV. 고찰본연구는이중과제훈련과단일과제훈련이노인의균형에미치는영향을알아보고자하였다. 독립적인일상생활을하기위해서는근력과더불어균형능력또한매우중요한요소이다. 따라서노인의균형능력의감소는낙상의위험을증가시키고, 삶의질을저하시키기때문에균형능력향상은노인의삶의질향상에중요하다고할수있다. 20) 일상생활에서는이중과제, 즉여러가지과제를동시에수행하면서균형을유지하는능력이필요하다. 21) 그러나노인과같이균형이저하된사람들은이중과제조건의상황에놓여있을경우신체능력에감소가나타나고낙상과같은신체적손상의결과를초래한다. 22) 정적균형을측정하기위해 FRT와 OLST를실시하였으며, 동적균형을측정하기위해 TUG와 BBS를실시하였다. 정진희의연구에서뇌졸중환자를대상으로 8주간이중과제훈련을실시한결과저강도이중과제훈련군은운동전 21.44±2.96 cm에서운동후 27.63±2.39로, 고강도이중과제훈련군은운동전 23.75±3.41에서운동후 30.14±1.36으로 FRT에서시간에따라유의하게증가하였다. 23) 본연구에서는노인에게 4주간이중과제훈련과단일과제훈련을실시한결과 FRT에서두군모두시간에따라유의하게증가하였으나, 두군간에는유의한차이가없었다. Table 7. Comparison of OLST(closed) between groups after treatment Variable OLST (Closed) Source Type III Sum of Squares df Men Square F Time 158.231 1 158.231 43.602** Group 73.418 1 73.418 7.851* Time x Group 81.335 1 81.335 22.413** Type III SS: Type III sum of squares, df: degree of freedom, MS: mean square TUG: Timed Up and Go Table 8. Comparison of TUG between groups after treatment Variable Source Type III Sum of Squares df Men Square F Time 29.217 1 29.217 69.200** TUG Group 12.468 1 12.468 2.275 Time x Group 4.158 1 4.158 9.848** Type III SS: Type III sum of squares, df: degree of freedom, MS: mean square TUG: Timed Up and Go Table 9. Comparison of BBS between groups after treatment Variable Source Type III Sum of Squares df Men Square F Time 245.042 1 245.042 73.562** BBS Group 366.927 1 366.927 11.895** Time x Group 21.614 1 21.614 6.489* Type III SS: Type III sum of squares, df: degree of freedom, MS: mean square BBS: Berg Balance Scale 이중과제훈련이노인의균형에미치는영향 45
NEUROTHERAPY 2015;19(2):41-47 OLST에서는눈뜨고측정한결과두군모두시간에따라유의하게감소하였으나, 두군간에는유의한차이가없었다. 또한눈감고측정한결과에서는시간에따라유의한감소가나타났고, 이중과제훈련군이단일과제훈련군보다더유의한감소를보였다. 이상호의연구에서만성뇌졸중환자를대상으로 16주간이중과제훈련을실시한결과 TUG에서이중과제훈련군은운동전 19.30±4.85 초에서운동후 15.50±5.14 초로시간에따라유의하게감소하였다. 24) 이승엽의연구에서는균형손상이있는노인에게고정된주의력조건 (fixed priority, FP) 과변화된주의력조건 (variable priority, VP) 지시를이용한이중과제를실시한결과 TUG에서고정된주의력조건지시를이용한이중과제는운동전 13.71±1.19에서운동후 12.49±1.03로유의하게감소하였고, 변화된주의력조건지시를이용한이중과제에서는운동전 13.73±1.07에서운동후 11.54±0.89로유의하게감소하는결과를보였다. 25) 본연구에서는 TUG에서두군모두시간에따라유의하게감소하였으며, 두군간에는유의한차이가없었다. 김여진의연구에서뇌졸중으로인한편마비가있는환자를대상으로 8주간이중과제균형훈련을실시한결과 BBS 점수에서이중과제훈련군이운동전 39.42±3.21에서운동후 49.08±1.71로유의하게증가하였다. 26) 김현애의연구에서는편마비를진단받은만성뇌졸중환자를대상으로 8주간이중운동순환과제와이중인지순환과제를실시한결과 BBS 점수가이중운동순환과제에서운동전 31.63±2.68에서운동후 35.86±2.57로유의하게증가하였고, 이중인지순환과제에서는 31.20±2.83에서운동후 33.80±2.51로유의하게증가하였다. 27) 본연구에서는단일과제훈련군과이중과제훈련군에서모두 BBS 점수가유의하게증가하였으나, 단일과제훈련군보다이중과제훈련군에서더유의한증가를보였다. 선행연구와본연구에서 FRT는두군모두유의한증가를보였고, 본연구에서 OLST는이중과제훈련군이더유의한감소를보였정적균형향상에는이중과제훈련이더효과적일것으로사료되며, TUG와 BBS는선행연구와본연구에서모두유의한효과를보였고, BBS는본연구의결과에서이중과제훈련군이더유의한효과를나타내었으므로동적균형향상에도또한이중과제훈련이더효과적일것으로사료된다. 본연구는대상자의수가적었기때문에일반화하기가어려웠고, 훈련기간이 4주로짧았기때문에운동방법의충분한효과를보기가어려웠다는제한점을가지고있다. 향후연구에서는더장기적인기간과더많은대상자를가지고연구한다면운동의효과가더증대되어지는결과가있을것으로사료된다. 따라서본연구의결과를종합해볼때노인의균형능력향상을위해이중과제훈련이단일과제훈련보다더효과적인 것을알수있었다. 따라서균형능력이저하된노인에게는이중과제훈련을적용하는것이균형능력향상에더긍정적인영향을미칠수있는것으로사료된다. 참고문헌 1. Ji SG, Kim MK, Cha HK. The effect of dual motor task training on balance of subacute stroke patients. Journal of The Korean Society of Physical Medicine. 2013;8(1):1-9. 2. Jung SR, Won JI. Effects of dual-task training on balance and gait performance in patients with stroke. Phys Ther Korea. 2014;21(2):18-27. 3. Kim K, Seo SK, Yoon HJ, et al. Correlations between muscle strength of the ankle and balance and walking in the elderly. The journal of Korean society of physical therapy. 2008;20(1):33-40. 4. Lee SY, Ma SY, Cho GY. The effects of mat and field exercise on the balance and gait in older adults. Journal of the Korean Data & Information Science Society. 2010; 20(4):661-72. 5. Choi SS. The effect of dual tasks on gait and static standing in stroke patients. Daegu University. 2009. 6. Choi JH, Lee HS, Chang JS. Changes of postural sway and muscle activation while standing upright and performing a dual task. The journal of Korean Society of Physical Therapy. 2011;23(5):1-5. 7. Huxhum FE, Goldie PA, Patla AE. Theretical considerations in balance assessment. Aust J Phys Iot her. 2001;47:89-100. 8. Jeon HW, Chung YJ. The effect of dual-task on standing postural control in persons with chronic stroke. Phys Ther Korea. 2015;22(4):1-7. 9. Kim KA. The effects of exercise-cognitive combined dual-task program on cognitive function and depression in elderly with mild cognitive impairment. Ewha Womans University. 2014. 10. Lee JH. The effect of dual motor tast training on sitting for trunk control ability and balance in patients with chronic stroke. Sahmyook University. 2010. 11. Choi WJ. The effect of the cognitive motor dual task using the auditory feedback on chronic stroke patients' gait, balance and their attention. Sahmyook University. 2011. 46 The Effects of Dual Task Training on Balance for Elderly
이샛별, 차예니, 이상호 12. Roh JS, Yi CH, Cho SH, et al. The effect of attentional focus on the performance of dual task. Physical Therapy Korea. 2008;15(2):11-9. 13. Park HK, Cho KH, Lee WH. The effects of dual task training on postural stability and balance in chronic stroke, Journal of the Korea Academia-Industrial cooperation Society. 2011;12(8):3555-62. 14. Jang YS, Baek JY, Oh MH, et al. The effect of dual task performance on the trunk control ability and upper extremity function of patients with stroke. J Rehabil Resear. 2012;6(2):311-31. 15. Duncan PW, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192-7. 16. Springer BA, Marin R, Cyhan T, et al. Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther. 2007;30(1):8-15. 17. Podsiadlo D, Richardson S. The Timed Up & Go : a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-48. 18. Bogle Thorbahn LD, Newton RA. Use of the berg balance test to predict falls in elderly persons. Phys Ther. 1996;76(6):576-85. 19. Silsupadol P, Siu KC, Shumway-Cook A, et al. Training of balance under single and dual task condition in older adults with balance impairment. Phys Ther. 2006;86(2):269-81. 20. Harada N, Chiu V, Damron-Rodriguez J. Screening for balance and mobility impairment in elderly individuals living in residential car e facilities. Phys Ther. 1995;75:462-69. 21. Kim YJ, Son HH, Oh JL, et al. Effects of dual task balance training on balance and activities of daily living in stroke patient, Journal of the Korean Society of Physical Medicine. 2012;6(1):19-29. 22. Yang YR, Wang RT, Chen YC, et al. Dual-task exercise improves walking ability in chronic stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2007;88(10):1236-240. 23. Jung JH. Effect of dual-task training according to exercise intensity for gait, physical fitness for activities of daily living and cardiorespiratory endurance in patients with chronic stroke, Korea National Sports University. 2014. 24. Lee SH. The effects of dual task training on balance & gait for persons with chronic stroke. Yong In University. 2010. 25. Lee SY. The effect of balance training under single task and dual task conditions in older adults with balance impairment, Chosun University. 2007. 26. Kim YJ. Influence s of dual task balance training on balance and activities of daily living in stroke patient. Daegu University. 2009. 27. Kim HA, Seo KC. The Effects of task-related circuit training by type of dual tasks on the balance and gait of chronic stroke patients. Journal of The Korean Society of Physical Medicine. 2013; 8(3): 407-15. 이중과제훈련이노인의균형에미치는영향 47
NEUROTHERAPY 2 0 1 5 이경순, 강영호, 김가희, 이재송, 이현지, 전진영대한신경치료학회지, 정은식, 조성희제19, 권최태근제2호 테이핑이맨몸하프스쿼트세트에따라 %MVIC 에미치는영향 이경순 *, 강영호, 김가희, 이재송, 이현지, 전진영, 정은식, 조성희, 최태근동주대학교물리치료학과 An Effect that Taping has on %MVIC According to Bodyweight Half Squat Set Kyung-Soon Lee *, Gyeong-Ho Kang, Ga-Hui Kim, Jae-Song Lee, Hyeon-Ji Lee, Jin-Yeong Jeon, Eun-Sik Jeong, Seong-Hui Jo, Tae-Geun Choi Dept. of Physical Therapy, Dong-Ju College Purpose This study is intended to examine an effect that taping has on %MVIC according to bodyweight half squat set exercise. Methods Participants in this study are composed of 10 male college students. Rectus femoris and erector spinae was measured by using surface electromyography. SPSS(version 20) was used through normalization process for electromyography data collected before after taping. And a paired t-test was used for comparison between before and after taping treatment, and one-way repeated measures ANOVA was used for comparison between sets. Statistical significance level was fixed at.05. Results Statistically significant difference was not shown in comparing MVIC befor e after the treatment of taping applied on the rectus femoris and erector spinae. A statistically significant decrease was shown in muscle strength after taping in comparing %MVIC before after the treatment of taping applied on the rectus femoris and erector spinae. A statistically significant increase was shown in %MVIC value in comparison between sets before the treatment of taping applied on rectus femoris No statistical difference was shown in %MVIC value according to each set before the treatment of taping applied on erector spinae. No statistical difference was shown in %MVIC value according to each set after the treatment of taping applied on erector spinae. Conclusion In comparison between before and after the treatment of taping applied on rectus femoris in bodyweight half squat, the taping was efficacious, and the efficacy of taping was shown in comparison between bodyweight half squat sets as well. The efficacy of taping was shown in comparison between before and after the treatment of taping applied on erector spinae. However, the efficacy of taping was not shown in comparison between sets. Accordingly, a change in the muscle strength of erector spinae requires experimental design where it is loaded with weight or the number of sets is increased. Key Words Bodyweight Half squat, Taping, MVIC, Rectus femoris, Erector spinae 책임저자 Kyung-Soon Lee.(soonks68@hanmail.net) 논문접수일 2015 년 4 월 30 일수정접수일 2015 년 5 월 25 일게재승인일 2015 년 6 월 20 일 I. 서론맨몸하프스쿼트운동은하체근력을강화시키는대표적인운동으로널리이용되고있다. 1,2) 스쿼트운동은운동선수의능력향상및부상을예방하며, 일상생활을하는일반인에게있어서기초체력을제공하는운동으로어디에서나손쉽게할수있는운동이다. 3) 스쿼트운동은고유수용성감각을자극시키고같은힘을양쪽다리에체중을지지하기때문에큰힘을발휘한다. 또한스쿼트운동은볼기근, 넙다리네갈래근, 장딴지근에영향을미 치며많은관절의움직임을요구하는동시에몸통의근육까지발달시키는적절한운동이다. 4,5) 스쿼트운동은시상면에서허리를세우고, 안쪽으로무릎이모이지않게자세를유지하며, 무릎이발끝보다더나가지않게무릎을굽히는자세이고, 무릎의굽힘에따라패러럴스쿼트 (40 ), 하프스쿼트 (90 ), 풀스쿼트 (100 ) 로구분할수있다. 또한스쿼트운동은복합관절운동으로써엉덩관절과무릎관절, 발목관절에서움직임이나오며여러근육들과함께동작이이루어진다. 이러한이유로스쿼트운동은다양한실시방법과많은장점을가진운동으로운동시정확한자세유지가 테이핑이맨몸하프스쿼트세트에따라 %MVIC 에미치는영향 49
NEUROTHERAPY 2015;19(2):49-57 중요하다. 6) 스쿼트운동을시상면에서보았을때상체를바르게하지않고구부리게되면허리에무게가전달되어상해를입거나, 무릎굽힘시무릎이발끝보다앞으로나오게되면무릎에상해를입을수있으므로주의해야한다. 7,8) 테이핑은비신축성 (Spiral), 신축성 (Kinesio) 과밸런스테이핑으로구분되며, 최근들어테이핑은스포츠경기력향상을위해선수들에게직접적인영향을줄뿐만아니라일반인들의생활체육에상해예방을위해많이사용되고있다. 9,10) 키네시오테이핑은 1973년에일본의사켄조카세박사에의해개발된테이핑테크닉으로, 피부에적용하는유연한접착성의재질로되어있으며, 기존의테이프와는물리적특성과는다르다. 11) 키네시오테이핑방법은비정상적인움직임을제한하는임상적치료법으로널리이용되고있다. 테이핑의효과로는첫째, 근육의기능을정상화하며, 둘째, 혈액과임파액의순환을돕고, 셋째, 통증을감소시키며, 넷째, 관절의부정렬을교정하고, 다섯째, 각종스포츠손상의예방과회복에도움을준다. 13,14) 하프스쿼트동작과테이핑에관한선행연구를살펴보면김정태등은운동사슬유형에따라테이핑적용이근육의기능향상에영향을미칠수있다고보고하였다. 15) 강현주등은탄력스타킹을착용하여스쿼트운동을수행하는과정에근활성도가증가하였다고보고했으며, 곽민서등은넙다리곧은근과넙다리두갈래근에테이핑을부착한후등속성장비를사용한결과최대토크와평균파워수행모두유의하게증가하며무릎관절운동능력향상에긍정적인효과를준다고하였다. 15-17) 이성기는 Cybex를이용하여탄력테이프적용이근력, 근파워및근지구력이향상된다고보고하였다. 18) 오병진은테이핑적용이근피로물질이낮게나왔으며, 등속성근력에서는효과가있다고보고하였다. 10) 위승두등는넙다리네갈래근의테이핑적용이무릎관절의근력, 근파워에유의한영향을미쳤다고보고하였다. 19) 선행연구에서맨몸하프스쿼트동작은일반적으로부하의양과스쿼트종류에따라연구가주를이루며맨몸하프스쿼트동작에대한연구는부족한실정이다. 맨몸하프스쿼트운동은일상생활어디에서나쉽게할수있으며특히앉아서일하거나공부하는직장인과학생들에게체력을위한효과적인운동이다. 본연구의목적은테이핑처치전 후맨몸하프스쿼트운동반복세트를통해넙다리곧은근과척추세움근의근력의변화를통해테이핑의효과및근피로를유발하지않는적당한운동세트를규명하여일반인들의맨몸하프스쿼트운동에기초자료를제공하고자한다. II. 연구방법 1. 연구대상본연구는 B광역시에거주하고있는 20대남자대학생 10명으로선정하였으며, 최근 1년간근골격계상해경험이없고규칙적인웨이트트레이닝을하지않는자로일반적인운동수행능력에지장이없는대상자로선정하였다. 실험대상자는사전에연구의의와목적에대해충분히설명을듣고실험에동의하였으며대상자의신체적특성은다음과같다 (Table 1). 2. 실험설계본실험은실험장비가세팅된 D대학교운동치료실에서실시하였다. 1차실험은테이핑처치전실험으로영양섭취에따른차이를최소화하기위해서점심을동일한열량을섭취하기위해같은음식을피실험자들에게제공하였다. 식사후 15분휴식을취했으며, 5분간준비운동을실시하고, 근전도를부착하여근육별 MVIC를측정하였다. 그후 5분간휴식을취하고본실험을시도하였다. 실험대상자는맨몸하프스쿼트 1세트당 20회씩 3세트를시행하였다. 세트당휴식은 30초, 맨몸하프스쿼트시행시메트로놈을설정하여 1회당 5초씩 1세트 20회, 시간은 100초로모든피실험자가동일하게이루어졌다. 테이핑처치전 후는 7일간시간을두어테이핑전 후의트레이닝의효과를최소화하고자하였다. 테이핑처치전 후실험절차는동일하게이루어졌다. 3. 실험장비본연구에서사용된측정기구및용도는다음과같다 (Table 2). Table 1. The general characteristics Male (n=10) a mean±sd Table 2. Measuring devices Measuring devices Wireless surface EMG Kinesio Taping Age(year) Height(cm) Weight(kg) 23.10±2.65 a 175.70±4.96 69.90±7.81 model NORA-XON EMG Kinesiology 3NS Tape Production Company Telemyo clinical DTS 3NS use EMG measurements Treatment taping Computer sens R540 Samsung Data analysis 50 An Effect that Taping has on %MVIC According to Bodyweight Half Squat Set
이경순, 강영호, 김가희, 이재송, 이현지, 전진영, 정은식, 조성희, 최태근 4. 측정항목본연구에서는테이핑의처치전 후에따른근활성도를측정하기위해서다음과같은측정항목을선정하였다. 1) 테이핑처치전, 맨몸하프스쿼트실시후, 넙다리곧은근과척추세움근의 MVIC 측정 2) 테이핑처치전, 맨몸하프스쿼트실시후, 넙다리곧은근과척추세움근의 %MVIC 측정 3) 테이핑처치후, 맨몸하프스쿼트실시후, 넙다리곧은근과척추세움근의 MVIC 측정 4) 테이핑처치후, 맨몸하프스쿼트실시후, 넙다리곧은근과척추세움근의 %MVIC 측정 2) 근전도센서부착및키네시오테이핑부착 (1) 근전도센서부착근전도측정은양질의근전도자료를얻기위해면도기를사용하여피부외피층의털을제거하는사전작업을각실험대상자에게실시하고알코올을사용하여피부표면을세척하였다. 피실험자의오른쪽하지근의근전도를측정하기위하여넙다리곧은근 (Rectus femoris) 과오른쪽허리의척추세움근 (Erector Spinae) 에 2개의 EMG 센서를부착하였다. 근전도전극부착은동일한실험자가실시하여전극부착부위의오차를최소화하였다. 5. 측정방법 1) 스트레칭맨몸하프스쿼트실시전부상위험을예방하기위해동적스트레칭을실시하였다. 스트레칭은 (a) 에서 (f) 까지 6가지하체스트레칭동작을 5분간실시하였다 (Figure1). 2) 키네시오테이핑부착넙다리곧은근에키네시오테이핑부착은우선넙다리곧은근을이완한상태에서넙다리곧은근전면앞아래엉덩뼈가시 (ASIS) 바로아래에서붙여내려와무릎뼈위까지부착하였다. 척추세움근테이핑적용방법은허리를앞으로구부린상태 (a) (b) (c) (d) (e) (f) Figure 1. The lower extremity stretching sequence 테이핑이맨몸하프스쿼트세트에따라 %MVIC 에미치는영향 51
NEUROTHERAPY 2015;19(2):49-57 6. 분석방법 1) 근전도신호처리방법근전도기기와컴퓨터를연결하고근전도프로그램을작동시켜근전도신호의표본추출은 1,000Hz로하였다. 중복된파형은 80-250Hz 대역통과필터 (band pass filter)fh 필터링처리하였다. 노이즈를제거하기위해 60Hz 노치필터 (notch filter) 를사용하였다. 각근육이수축한시간동안수집된신호값은 RMS(root mean square) 로처리한후평균근전도신호량을 %MVIC로사용하였다. Figure 2. The taping and electrode attachment of the Erector spinae(es), Rectus femoris(rf) 에서양쪽 T7 가로돌기바로아래에서붙여내려와뒤위뒤엉덩뼈가시 (PSIS) 까지부착하였다 ( 그림 2). 3) MVIC 측정개인별근력의차이로인한자료분석의오류를방지하고데이터의객관성을높이기위하여최대수의적등척성수축력 (Maximal Voluntary Isometric Contraction, MVIC) 값을이용하여정량화 (normalization) 하였다. 넙다리곧은근은피실험자가검사대에걸터앉아있고실험자는근육에압박이가해지지않도록몸쪽넙다리뼈와골반사이를고정하고발목관절위쪽에저항을주었다. 척추세움근은피실험자가검사대에엎드린자세에서양팔을머리뒤로옮긴후, 보조자는하지의힘이들어가지않게고정하고척추위쪽에저항을주었다. 측정은피실험자당 3회씩실시하였고, 휴식시간은 1회후 5분씩쉬는시간을부여하였으며 3회값평균치를 MVIC로사용하였다 4) 맨몸하프스쿼트 (1) 맨몸하프스쿼트동작시발의넓이는피실험자의골반넓이로하였고, 발목각도는 Toe out 15 로하였다. (2) 맨몸하프스쿼트동작가동범위는엉덩관절의높이와무릎관절의높이가동일해지는지점까지굴곡하여신전하였다. (3) 맨몸하프스쿼트동작간에시선에따라변인들에변화를가져오기때문에시선의처리는정면을바라보도록하였다 (4) 맨몸하프스쿼트를실시하는속도는 1회당 5초로맞춘메트로놈을사용하였다. (5) 표면전극의부착과맨몸하프스쿼트동작시구간설정을용이하기위해서실험대상자의하의는반바지를착용하여실험을실시하였다. (6) 맨몸하프스쿼트개수는 1세트당 100초간 3세트를실시하였다. 1세트당휴식시간은 30초로하였다. 2) 통계처리이연구에서는테이핑부착유무에따라맨몸하프스쿼트운동반복세트시근전도자료를 NORAXON사의 TeleMyo 2400T G2을통하여얻은후 SPSS Ver.20.0을이용하여통계처리하였다. 테이핑부착유무에따라서는대응표본 t-검정 (paired samples t-test) 을맨몸하프스쿼트반복세트분석은반복측정일원분산분석 (One-way repeated measures ANOVA) 을실시하였고, 모든통계적유의확률은 p<.05로설정하였다. III. 결과 20대남자대학생 10명을대상으로테이핑처치전 후맨몸하프스쿼트세트에따른넙다리곧은근과척추세움근근력변화를분석한결과는다음과같다. 1. 테이핑처치전 후 MVIC 비교테이핑처치전 후넙다리곧은근과척추세움근의 MVIC 비교결과는다음과같다 (Table 3). 넙다리곧은근의 MVIC는테이핑처치전 536.90±12.04, 테이핑처치후 551.00±14.07으로테이핑처치유무에따라통계적으로유의한차이가나타나지않았다 (p>.05). 척추세움근의 MVIC는테이핑처치전 545.10±15.07, 테이핑처치후 562.60±13.53으로테이핑처치유무에따라통계적으로유의한차이가나타나지않았다 (p>.05). Table 3. The comparisons of MVIC values before and after the treatment of taping (unit: μv ) Rectus Femoris Erector Spinae no Taping 536.90±12.04 a 545.10±15.07 Taping 551.00±14.07 a 562.60±13.53 t -.910-1.806 *p<.05; a mean±sd 52 An Effect that Taping has on %MVIC According to Bodyweight Half Squat Set