J Korean Soc Phys Med, 2018; 13(1): 1-9 http://dx.doi.org/10.13066/kspm.2018.13.1.1 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 양손운동이만성뇌졸중환자의뇌활성도와근활성도에미치는영향 박주희 이사겸 1 연세대학교물리치료학과일반대학원, 1 수원여자대학교물리치료학과 Effect of Bilateral Arm Movement on Brain and Muscle Activity in Chronic Stroke Patients Joo-Hee Park, PT Sa-Gyeom Lee 1 Dept. of Physical Therapy, Graduate School, Yonsei University 1 Dept. of Physical Therapy, Health and Food, Suwon Women s University Received: September 13, 2017 / Revised: September 28, 2017 / Accepted: December 2, 2017 c 2018 J Korean Soc Phys Med Abstract 1) PURPOSE: This study investigated the neurophysiological and behavioral adaptation during one or both hands movement in chronic stroke patients. METHODS: The study included sixteen hemiplegic stroke patients. Neurophysiological data (brain activation and muscle activation) were examined by electroencephalography (EEG) and electromyography (EMG), and behavioral adaptation was examined by wrist extension angle during wrist extension with one hand or both hands. Outcome variables of one hand or both hands were; mu rhythm of the EEG, EMG amplitude of wrist extensor and flexor muscles, and wrist angle of Myomotion 3D motion analysis. RESULTS: Our results revealed that wrist extension angle was significant increased during both hands movement Corresponding Author : Sa-Gyeom Lee sglee@swc.ac.kr, http://orcid.org/0000-0003-2854-7860 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. compared to one hand movement (p<.05). Furthermore, in affected sensorimotor area, there was significant increase in the brain activation during both hands movement compared to one hand movement (p<.05). However, there was no significant different between one hand and both hands movement in muscle activation (p>.05). CONCLUSION: According to the findings of this experiment, bilateral arm movement improved brain activity on affected sensorimotor area and wrist extension angle. Therefore, we suggest that bilateral arm movement would positive effect on stroke rehabilitation in terms of increase in brain activation on affected motor area and wrist extension during bilateral arm movement. Key Words: Bilateral arm movement, Electroencephalography, Muscle activation Ⅰ. 서론뇌졸중은뇌혈관이막히는뇌경색과뇌혈관이파열되는뇌출혈로구분되며, 뇌에혈액공급이부족하거나
2 J Korean Soc Phys Med Vol. 13, No. 1 지연되어서나타나는갑작스러운신경학적결손을의미한다 (Jang와 Yoon, 2008; Roh와 Kim, 2012). 급성기시 80% 정도의뇌졸중환자들은한쪽상지의움직임제한을경험하며 (Nakayama 등, 1994; Jørgensen 등, 1995), 그중 50~95% 의환자들은시간이지나도상지기능이회복되지않는다 (Gresham 등, 1975; Gowland 등, 1992; Nakayama 등, 1994). 또한, 30% 의뇌졸중환자들은장기간의심각한상지장애로보조없이는일상생활이불가능하다 (Young와 Forster, 2007; Langhorne 등, 2009). 따라서지난 20년간임상의치료전문가들은뇌졸중환자의상지기능회복을위해대상운동증가 (promotion of alternative movement), 유산소운동 (aerobic exercise), 억제유도운동치료 (Constraint-induced movement therapy), 집중적인목표지향적동작운동 (intensive task-directed training), 양손운동 (bilateral arm training), 그리고로봇치료등지속적인상지훈련프로그램에대한연구를진행하고있다 (Silvoni 등, 2011; Bang 등, 2013). 그중양손운동 (bilateral arm training) 은양손을동시에움직여건측손의정상적인움직임이환측손의움직임을촉진시켜환측손의장애를감소시키는목적으로시행되는운동방법이다. 많은선행연구들이양손운동의효과를확인하였는데, 환측상지의근력 (Cauraugh 와 Kim, 2002), 움직임속도 (Smith와 Staines, 2006) 와움직임패턴 (Mudie와 Matyas, 2000; Lewisand와 Byblow, 2004) 이향상되었으며, 이동시간 (Smith와 Staines, 2006) 이감소하였고, 기능적인움직임과일상생활동작 (Lee 등, 2017) 역시향상되었다고보고하였다. 최근에는두개의메타분석에서.7의효과크기 (effect size) 로양손운동이매우효과적인상지운동방법이라고보고되었다 (Stewart 등, 2006; Cauraugh 등, 2010). 하지만아직까지양손운동이어떤기전 (mechanism) 으로이러한좋은효과를보이는지에대해서는의문이남아있다 (Smith 와 Staines, 2006). 이러한의문점을해결하기위해최근연구에서는경두개자기공명영상 (Transcranial Magnetic Stimulation; TMS), 그리고자기공명영상 (magnetic resonance imaging; MRI) 과같은뇌영상진단장비를이용하여양손움직임의신경학적기전을확인하였다. TMS 연구에서는양손 움직임이환측대뇌반구의운동유발전위 (motor evoked potential) 를증가시키며 (Renner 등, 2005), 6일동안의양손운동중재후에는운동기능이향상됨과더불어건측대뇌반구의외피지도 (cortical map) 의크기가감소되었다고보고하였다 (Summers 등, 2007). 하지만, Lewis 와 Byblow (2004) 은 4주간의양손운동훈련이뇌졸중환자의환측상지기능증가에효과가없다고보고하였으며, 건측과환측대뇌반구에서운동유발전위의뚜렷한변화가나타나지않았다고보고하였다. MRI 연구에서는급성기시에는양손움직임시한손움직임시보다환측운동영역에높은활성도를보였지만, 만성기시에는한손운동이환측운동영역을더활성화시킨다고보고하였다 (Staines 등, 2001). 또한, Luft 등 (2004) 는 6주간의양손운동을수행한그룹에서손기능이향상되었으며건측감각운동영역과건측소뇌의활성도가높게측정되었다고보고하였다. 이렇듯뇌영상진단장비를이용한양손운동의효과를뒷받침해줄신경학적기전을찾으려는선행연구들이제시되었지만, 아직까지일관된결과를제시하지못하고있다. 또한, 뇌파장비 (electroencephalography: EEG) 를이용하여양손움직임동안뇌졸중환자의뇌활성도변화는연구되지않았다. 따라서본연구는양손움직임의신경학적기전을조금더명확하게밝히기위해한쪽상지만움직였을때와양쪽상지를동시해움직였을때 EEG를이용하여뇌졸중환자의뇌활성도가어떻게변화하는지확인하려고하며, 그에따른근활성도 (electromyography; EMG) 와움직임정도를측정하려고한다. Ⅱ. 연구방법 1. 연구대상자본연구는원주에위치한요양병원에외래치료를받는 16명의만성뇌졸중환자들을대상으로실험을실시하였다 (Table 1). 대상자선정기준은발병기간이 1년이상인자, 인지장애가없는자 (Mini-Mental State Examination-Korean version; MMSE-K 23점이상 ) (Folstein
양손운동이만성뇌졸중환자의뇌활성도와근활성도에미치는영향 3 Table 1. General characteristic of subjects Age Gender Onset period Affected side Lesion type BMI a MMSE-K b FMA c 1 56 male 10 year left infarction 21 28 26 2 45 male 5 year left hemorrhage 24.4 30 25 3 58 male 2 year left infarction 25.7 27 41 4 44 male 5 year left hemorrhage 25.7 30 45 5 53 female 1 year right hemorrhage 25.8 30 39 6 47 male 10 year right infarction 21.5 29 33 7 60 female 8 year right infarction 25 30 46 8 52 male 9 year left hemorrhage 23.9 30 45 9 21 male 2 year left hemorrhage 23.1 30 8 10 55 male 2 year left hemorrhage 25.5 30 3 11 43 female 10 year right infarction 20.55 30 8 12 44 male 13 year right hemorrhage 29 23 9 13 57 male 12 year right infarction 23.44 30 9 14 57 male 14 year right hemorrhage 28.3 30 9 15 47 male 10 year right hemorrhage 22.86 23 5 16 60 male 9 year right infarction 30.4 23 3 a Body mass index, b Mini-Mental State Examination-Korean version, c Fugl-Meyer Assessment 등, 1975), 상지 Fugl-Meyer Assessment (FMA) 점수가 46점미만인자 (Fugl-Meyer 등, 1975) 로선정하였다. 뇌졸중외다른신경학적질환이나상지의골절등기타정형외과적질환이있는환자는제외하였다. 모든연구대상자는실험참여에자발적으로동의를하였으며, 연세대학교원주캠퍼스생명윤리심의위원회심의를통과하였다 ( 승인번호 : 1041849-201612-BM-070-02). 2. 실험절차실험은조용한공간에서뒷받침과팔걸이가있는의자에편하게앉은상태로진행되었다. 실험자는대상자의환측에앉아대상자의환측팔을지지하여대상자가손목에힘을완전히뺀최대손목굽힘상태에서움직임을시작하도록하였다. 본실험은대상자들에게손목폄동작을수행하도록하였는데, 손목폄동작은뇌파에영향을줄수있는근전도간섭이적은비교적작은동작이며, 뇌졸중환자들에게임상적으로의미있는동작이므로선정되었다. 총실험시간은환자교육, 환자평가, 실험도구부착과본실험까지포함하여 1시간전도소요되었다. 실험자는대상자가손목폄을수행할때협동작용 (synergy) 으로인한머리움직임이나과도한어깨근육사용등이나타나근전도간섭이나타나지않도록 15분간뇌파를실시간으로보여주며, 움직임노이즈나근전도노이즈가최대한없는상태에서손목을움직일수있도록교육하였다. 실험절차는다음과같다. 먼저대상자는환측팔만을가지고손목폄동작을 20번하고, 10분휴식후환측과건측양손동시에 20번손목폄동작을수행하도록하였다. 대상자들은 시작 이라는청각적신호가들리면손목폄을수행하도록하였으며, 손목폄은시작신호 1초후부터짧으면 2초길면 5초동안수행되었으며, 손목폄동작간간격은 20초로지정하였다. 환측손목폄을전혀할수없는환자는손목폄을하려고노력하거나손목이실제로올라가는상상을하도록하였다.
4 J Korean Soc Phys Med Vol. 13, No. 1 3. 실험도구 1) 뇌파 (electroencephalography; EEG) 움직임을하는동안의뇌활성도를측정하기위해서 QEEG-8 뇌파장비 (Laxtha L, Daejeon, Republic of Korea) 를사용하였다. 먼저대상자들의두피를알코올솜으로닦아낸후, 닦은부위의알코올이충분히날아갈수있도록하였다 (Kim 등, 2010). 뇌파측정을위한전극은국제 10-20 전극배치법 (International 10-20 system of electrode placement) 에따라뇌파전극용풀 (EEG paste, Elefix, Nihon Kohden, Tokyo, Japan) 을이용하여 C3, Cz, C4, 양쪽귀뒤쪽의두개의접지전극에부착하였다. C3 는왼쪽감각운동피질 (SMA; sensorimotor cortex), Cz는중간 SMA, C4는오른쪽 SMA을나타낸다. 각대상자들의뇌파는 256 Hz 샘플링주파수,.5~100 Hz의통과필터, 60Hz 대역저지필터를통해컴퓨터에저장되었다. 2) 근전도 (electromyography; EMG) 근전도는 Noraxon Telemyo 2004T (Noraxon Inc., Scottsdale, AZ, USA) 을사용하였으며, 표면근전도의표본수집률 (sampling rat) 은 1500 Hz 였고, 고역통과필터는 10Hz, 저역통과필터는 450 Hz로설정하였으며, 60Hz 대역저지필터를이용하였다. 전극을부착하기전에피부의부착부위를알코올솜으로닦고실시하였으며, 활성전극사이간격이 3 cm인 bipolar 표면근전도전극들을환측손의손목폄근근육다발 (forearm extensor bundle) 과손목굽힘근근육다발 (forearm flexor bundle) 에부착하였다. 부착부위는 Criswell과 Cram (2010) 이출간한교재에따라손목폄근근육다발은하완등쪽 (dorsal aspect of the arm), 팔꿈치에서부터 5 cm 먼쪽근육다발에부착하였으며, 손목굽힘근근육다발은하완배쪽 (ventral aspect of the arm), 팔꿈치에서부터 5 cm 먼쪽근육다발에부착하였다. 3) 삼차원움직임분석장비 (three-dimensional motion analysis system) 손목폄각도를확인하기위해서삼차원움직임분석장비 (MyoMotion Research Pro, Noraxon Inc., Scottsdale, AZ, USA) 를이용하였다. 두개의센서의표본수집율은 100 Hz이며, 부착부위는매뉴얼 (Noraxon Inc., Scottsdale, AZ, USA) 에따라손목과하완에부착하였다. 4. 분석방법 1) 뇌활성도뇌파주파수대역분석을하기위해 Telescan 2.0 software (Laxtha L, Daejeon, Republic of Korea) 를사용하였다 (Yun와 Lee 2011). 본연구는뮤파 (mu wave; 8~13 Hz) 대역만을분석하였다. 뮤파는움직임관련뇌파이며, 뇌의감각운동영역에서움직임을실행하거나상상할때억제되는경향성을보인다. 이러한억제현상을뮤파의 Event-related desynchronization (ERD) 라고부른다 (Braadbaart 등, 2013). Steriade와 Llinás (1998) 은 ERD 의증가즉뮤파가감소되는현상은뇌활성화가증가된결과라고보고하였다. 따라서본연구는뇌활성도 (ERD amplitude) 를분석하기위해 시작 이라는청각적신호를 0 으로정의하였으며, 청각신호 4초에서 2초전즉 -4초 ~-2초동안의평균뮤파값을기초값 (baseline data) 로설정하였고, 청각신호 1초에서 2초후즉 1초 ~2 초동안의평균뮤파값을뮤파감소값으로정의하였다. 뇌활성도는아래와같은식으로구할수있다. 뇌활성도 (ERD amplitude (%)) = 뮤파감소값 - 기초값 100 기초값 C3, Cz, C4값을환자의병변부위에따라환측대뇌반구, 중간대뇌반구, 건측대뇌반구로나누어분석하였다. 2) 근활성도근활성도는 Noraxon Myoresearch ver. 1.08 (Noraxon Inc., Scottsdale, AZ, USA) 을이용하여분석하였다. 본연구에서는연구대상자가 20번손목폄동작을하는동안가운데 5번의근활성도만을측정하였으며, 손목폄시활성화되는근활성도의중앙 1초동안의값을평균내어손목굽힘근과폄근의근활성도값으로사용하였
양손운동이만성뇌졸중환자의뇌활성도와근활성도에미치는영향 5 Table 2. Mean values ± standard deviation of wrist extension angle and EMG activation during wrist extension with one hand and both hands (n=16) Angle ( ) Wrist flexor ( μv ) Wrist extensor ( μv ) One hand 28.13±30.66 10.01±10.54 31.38±27.72 Both hands 38.33±43.89 11.83±19.32 40.56±41.67 p-value.01*.47.11 *p<.05 다. 뇌졸중환자는근활성도를최대최대등척성수축 (maximal voluntary isometric contraction; MVIC) 을수행하기어렵기때문에정규화 (normalization) 하지않은근활성도값 (raw data) 을사용하였다 (Renner 등, 2005). 3) 손목폄각도손목폄각도는삼차원움직임분석장비를이용하여측정한후, myomotion research ver. 3.6 software (Noraxon Inc., Scottsdale, AZ, USA) 을이용하여분석하였다. 손목폄각도는최대손목굽힘자세에서부터얼마나손목폄을수행하였는지를측정하였다. 근활성도와같이연구대상자가 20번손목폄동작을하는동안가운데 5번의손목폄각도만을측정하여그값을평균내어사용하였다. 5. 자료분석본연구에서측정하여수집된자료는 PASW ver. 21.0 (SPSS Inc., Chicago, IL, USA) 을사용하여통계처리하였다. 환측손목또는양쪽손목을폄하는동안뇌활성도의변화를확인하기위해 2 3반복측정된이요인분산분석 (repeated measure of two-way analysis of variance)( 손 : 한손, 양손 vs 대뇌반구 : 환측, 중간, 건측 ) 을이용하였고, 유의수준은.05로하였다. 만약손과대뇌반구의상호작용 (interaction) 이유의하게나타날경우, 사후검정대응표본 t-검정 (post hoc paired t-test) 를실시하였으며, 유의수준은.01(.05/5) 로하였다. 손목폄근근활성도, 손목굽힘근근활성도, 그리고손목폄각도는대응표본 t검정 (paired t-test) 를실시하여한손과양손움직임의차이를분석하였다. 통계학적유의수준은.05로하였다. Ⅲ. 연구결과 1. 손목폄각도비교손목폄각도는환측손만으로손목폄한것보다양쪽손동시에손목폄을할때유의한증가를보였다 (p<.05)(table 1). 2. 근활성도손목폄근과굽힘근활성도는환측손만으로손목폄한것과양쪽손동시에손목폄을할때사이의유의한차이가없었다 (p>.05)(table 1). 3. 뇌활성도뇌활성도는손과대뇌반구의주효과 (mian effect) 는유의하지않았지만 (p>.05), 손과대뇌반구에서유의한상호작용이나타났다 (p<.05). 상호작용이있었기때문에단순효과 (simple effect) 를보았으며, 환측대뇌반구에서는양손으로손목폄했을때가한손으로손목폄했을때보다유의하게높은뇌활성도를보였다 (p<.01). 하지만, 중앙대뇌반구와건측대뇌반구에서는양손과한손으로손목폄했을때뇌활성도의유의한차이가없었다 (p>.01). 한손과양손손목폄했을때영역간뇌활성도차이역시나타나지않았다 (p>.01) (Fig. 1). Ⅳ. 고찰양손운동의효과는많은연구들을통해확인되었다. 하지만, 어떠한신경학적기전으로양손움직임이한손움직임을향상시키는지는아직알려져있지않다. 본연구는뇌파와근전도장비를통해아직까지명확하
6 J Korean Soc Phys Med Vol. 13, No. 1 Fig. 1. ERD amplitude of Intact hemisphere, Cz (center of hemisphere), and affected hemisphere with one hand (hemiparetic hand) and both hands. *p<.01 게제시되어있지않은뇌졸중환자의양손운동이어떤신경학적기전을가지는지살펴보고자하였다. 여러가지가설들이양손운동의효과를설명하기위해제시되었다. 첫번째가설은두손사이에는밀접한관계가존재하기때문에건측상지가환측상지에긍정적인영향을준다는것이다. Scott Kelso 등 (1981) 은양손움직임을수행할때한손이다른손을이끌어 (entrain) 대칭이되도록한다고보고하였다. 이는두손이서로다른움직임을수행할때결국한손의움직임의특징에맞춰져두손이비슷한움직임을수행하는현상에서확인할수있다. 따라서, 양손움직임시뇌졸중환자의건측손이환측손을이끌어기능이좋아지는것을설명할수있다. 두번째는양손운동시양쪽대뇌반구의활성화가나타나는데, 건측대뇌반구에서증가된활성화가환측대뇌반구의역할을보상해주어환측손움직임이향상된다는것이다. Luft 등 (2004) 은 6주간의양손운동을수행한그룹에서손기능이향상되었는데, 이그룹의건측감각운동영역과건측소뇌의활성도가증가하였다고보고하였다. 또한, 양손움직임시건측을움직임으로써활성화된건측대뇌반구가교차하지않는동측척수로 (ipsilateral pathway) 들을활성화시켜환측손의움직임을향상시킬수있다. 따라서교차하지않는척수로들 ( 동측척수시상로 (ipsilateral corticospinal tract)), 적핵척수로 (rubrospinal tract) 와고유척수로 (propriospinal tract) 이양손운동시활성화되어환측의움직임향상이있을수있다 (Mudie와 Matyas, 2000; Waller와 Whitall, 2008). 하지만건측의대뇌반구활성도가높아지는것, 특히건측의일차운동영역 (primary motor cortex) 의활성도가높아지는것은 뇌의진정한회복 (recovery) 으로는볼수없다 (Ward, 2004). 회복이잘된환자들은동작을수행할때건측, 환측상관없이동작수행반대쪽대뇌반구의뇌활성도가높아지는현상을보이지만, 회복이잘되지않은환자들은여전히건측활성도가높아진상태로유지된다 (Turton 등, 1996; Ward 등, 2003). 따라서양손운동시건측대뇌반구를보상작용으로사용하는것은정상인과같은기능향상을기대하기어렵다. 따라서, 세번째가설은양손움직임시뇌졸중환자의환측대뇌반구의활성도가높아져환측손의기능이좋아진다는것이다. Renner 등 (2005) 은양손움직임이환측대뇌반구의운동유발전위 (motor evoked potential) 를증가시킨다고, 즉활성도가높아진다고보고하였다. 또한, Mudie와 Matyas (2000) 은양손이같은동작을수행하면, 건측대뇌반구의정상적인활성도를본보기 (template) 삼아환측대뇌반구의활성도가높아져환측손의운동향상이나타난다고보고하였다. 따라서양손움직임은환측대뇌반구의활성도를높여뇌의진정한회복을유발할수있으며, 그결과환측손기능이향상
양손운동이만성뇌졸중환자의뇌활성도와근활성도에미치는영향 7 되는것으로사료된다. 본연구의결과중재를하지않았음에도불구하고양손움직임시한손움직임시보다손목폄각도가유의하게증가하였다. 하지만, 양손과한손움직임사이의손목폄근과손목굽힘근의근활성도에서는유의한차이가없었다. 이는중재의단기간의적용과그에따른즉각적효과를보았기때문으로보이며, 평균근활성도는양손움직임이한손움직임보다높은값을가지므로장기간운동을진행하게되면근활성도증가를보일것으로사료된다. 또한환측손만으로움직임을수행할때건측대뇌반구에서높은활성도를보였으며, 양손움직임을수행할때는양쪽대뇌반구가모두활성도가높게나타났다. 이는양손움직임시운동기능향상이건측대뇌반구의보상작용으로인한것이라고제시한두번째가설을뒷받침해준다. 하지만본연구에서는양손움직임시환측대뇌반구의뇌활성도가한손움직임을할때보다유의하게증가하였으므로단순히건측대뇌반구의보상작용으로만기능향상을유도했을것이라고가정하기어렵다. 따라서, 본연구에서나타난양손움직임시증가된환측대뇌반구의뇌활성도는뇌의진정한회복을야기하여손상된환측상지의움직임이나기능향상같은재활효과를가져올수있을것으로사료된다. 본연구는몇가지제한점을가지고있다. 첫번째는상대적으로적은수인 5개의전극을이용하여오직감각운동영역만을측정하여한정된정보를얻었다는점이다. 향후연구에서더많은전극을이용하면, 뇌영역간의관계를확인하여더포괄적인기전을얻을수있을것으로사료된다. 또한, 본연구는단순히한손움직임과양손움직임을비교했을뿐장기간운동시나타나는결과를예측하기에는어려움이있다. 그러므로추후연구에서는 4주나 6주중재후뇌파와근전도를측정하여양손운동의효과를살펴보는연구가필요할것으로사료된다. Ⅴ. 결론본연구는뇌졸중환자의양손움직임이뇌와근육활성도그리고움직임에어떤영향을미치는지확인해보고자하였다. 본연구의결과양손움직임시한손움직임시보다손목폄각도가유의하게증가하였으며, 감각운동영역의뇌활성도가한손움직임에비해증가하였고, 특히환측감각운동영역의뇌활성도가유의하게증가되었다. 이는양손운동시뇌졸중환자의환측뇌의회복을기대할수있을것으로사료된다. 따라서양손움직임이뇌졸중환자의재활치료에매우효과적인운동방법이라고결론지을수있다. Acknowledgements 본연구는 2017년도수원여자대학교연구과제지원에의해수행되었음. References Bang DH, Choi SJ, Shin WS. The effects of the modified constraint-induced movement therapy on upper function and activities of daily living in subacute stroke patients. J Korean Soc Phys Med. 2013; 8(2):245-52. Braadbaart L, Williams JH, Waiter GD. Do mirror neuron areas mediate mu rhythm suppression during imitation and action observation? Int J Psychophysiol. 2013; 89(1):99-105. Cauraugh JH, Kim S. Two coupled motor recovery protocols are better than one. Stroke. 2002;33(6):1589-94. Cauraugh JH, Lodha N, Naik SK, et al. Bilateral movement training and stroke motor recovery progress: a structured review and meta-analysis. Hum Mov Sci. 2010;29(5):853-70. Criswell E. Cram s Introduction to Surface Electromyography
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