Brain & NeuroRehabilitation Vol. 7, No. 1, March, 2014 http://dx.doi.org/10.12786/bn.2014.7.1.21 뇌졸중후상지기능개선을위한재활치료의전략 부산대학교병원재활의학과, 1 부산대학교의학전문대학원재활의학교실및양산부산대학교병원의생명융합연구소신명준ㆍ김상훈ㆍ이창형 1 ㆍ신용일 1 Optimal Strategies of Upper Limb Motor Rehabilitation after Stroke Myung Jun Shin, M.D., Sang Hun Kim, M.D., Chang-Hyung Lee, M.D., Ph.D. 1 and Yong-Il Shin, M.D., Ph.D. 1 Department of Rehabilitation Medicine, Pusan National University Hospital, 1 Department of Rehabilitation Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital The purpose of this review is to provide a comprehensive approach for optimal strategies of upper limb motor rehabilitation after stroke. Stroke is a common, serious, and disabling global health-care problem. Optimal organization of rehabilitation for stroke patients has been extensively documented. However, between 30% and 66% of individuals with stroke do not obtain satisfactory motor recovery of the affected upper limb with rehabilitative interventions. The recovery of the affected upper extremity depends on intensity, task progression, and repetition to neural plasticity, namely, the ability of central nervous system cells to modify their structure and function in response to external stimuli. Recently, constraint-induced movement therapy, motor imagery, action observation, or mirror therapy has emerged as interesting options as add-on interventions to standard physical therapies. In this review, we will discuss to establish a framework by which several promising interventions for neural plasticity. (Brain & NeuroRehabilitation 2014; 7: 21-29) Key Words: neuroplasticity, rehabilitation, stroke, upper extremity 서론 뇌졸중후감각-운동기능장애는세면하기, 식사하기, 소대변처리하기, 옷입고벗기, 목욕하기, 보행및이동동작수행하기등기본적인일상생활기본동작의수행에어려움을초래하여뇌졸중환자의삶의질을저하시키는가장중요한원인이다. 특히, 운동장애는뇌졸중의후유장애중가장흔한장애로일상생활을영위하는데큰제한요인으로작용하는데, 운동장애중에서상지기능이일상생활동작수행능력, 사회활동또는레크레이션활동과연관성이높다고알려져있다. 1,2 하지만상지기능회복에관 Correspondence to: Yong-Il Shin, Department of Rehabilitation Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeumeup, Yangsan 626-770, Korea Tel: 055-360-2872, Fax: 055-360-4251 E-mail: rmshin@pusan.ac.kr This work was supported by a clinical research grant from Pusan National University Yangsan Hospital in 2014. 한연구들은긍정적이지못한편이다. 200명이상을대상으로한전향적코호트연구에서뇌졸중후초기움직임이전혀없거나미미한움직임을보이는심각한상지마비가있는경우 25개월이상의추적평가에서 14% 에서만완전회복을보였으며, 30% 에서는부분적인회복을보였다고보고하였다. 3 다른체계적문헌고찰연구에서는초기에심각한상지마비가있는뇌졸중환자에서단지 5% 만이정상적인상지기능을회복하였고, 20% 정도만일부상지기능을회복하였다고한다. 4 이처럼상지운동기능의회복을최대화하기위한재활치료는뇌졸중재활에서중요한부분이며향후극복해야할과제이다. 본종설에서는최근새로이부각되고있는상지기능개선을위한재활치료방법에대해알아보고, 뇌졸중후상지재활에대한최적의전략에대해논의하고자한다. 본론 수동적또는능동적운동, 경험, 학습등을통한재활치료가신경가소성 (neural plasticity) 을중재하고회복 (recovery) 을촉진한다는것은뇌신경재활의이론적배경이된다. 5 21
Brain& NeuroRehabilitation:2014; 7: 21~29 그러나이렇게사용되고있는회복이라는용어가신경손상 (neural deficit) 의개선 (amelioration) 과기능적향상 (functional improvement) 이라는개념에모두사용되어일부혼란스러운경우가있다. 여기에서우리의최종목표가뇌졸중후손상된기능의향상이라고가정한다면재활치료는다음과같은영역에서최적의전략을수립해야할것이다. 1. 신경해리의전환 - reversal of diaschisis 2. 손상된신경의직접적인재생 - Direct restoration the original (damaged) neural circuits 3. 손상된기능을수행하기위한근접한또는연관된신경회로의간접적인회복 - Indirect restoration adjacent or related neural circuits perform the original functions 신경해리 (diaschisis) 는일부의신경들이손상된이후비교적먼거리의살아있는신경들이활동성이낮아지거나기능에문제가발생하는것으로, 대사감소, 신경혈관문제 (neurovascular uncoupling), 그리고비정상적인신경전달물질때문에발생하는것으로알려져있다. 6 손상된세포의재생또는신경회로의복구는자발적회복 (spontaneous recovery), 반복되는훈련, 병변반대측의역할증대, 피질척수체계 (corticospinal system) 의축삭재구성 (axonal remodeling) 등이관여하는것으로알려져있으며, 이모두를이용하여최대한의기능적향상을이끌어내는전략이필요한것이다. 7-12 이렇게손상된기능의향상을위한신경가소성과연관된치료 (remediation; restitution + substitution) 전략, 13 이외에도정상적인기능을활용하여일상생활동작수행능력을향상시키거나보조기구또는보조공학 (assistive technology) 등을활용한보상치료 (compensation) 전략이있을수있으나, 본종설에서는최적의치료전략과관련된신경가소성측면의접근, 근거중심의학적분석에기반한치료방법에따른접근, 최근에부각되고있는치료방법들에대해알아보고, 재활치료에대한한국형표준진료지침을소개하고자한다. 1) 기능회복과관련된신경가소성 (Neural plasticity) Frost 등에의하면원숭이실험연구에서원위부손동작과연관된 M1 (distal forelimb area) 에허혈성뇌경색을유발한뒤, 특별한훈련을하지않고 12주이후에그부위와연관된배쪽전운동피질 (ventral premotor cortex, PMv) 의손연관영역에대한뇌지도 (motor mapping) 를분석한결과뇌경색유발전에비해손연관영역이 45% 이상증가됨을확인하였다. 14 이런뇌의자발적인재조직화 (spontaneous reorganization) 는신경가소성 (neural plasticity) 의대표적인예라고할수있다. Nudo 등은이러한대뇌운동피질영역의재조직화가마비된손을사용하지않으면줄어들고, 적절한재활치료를시행하면늘어나는것을확인하여, 15 재활치료의중요성을입증하였다. 한편 Kleim 등은단순한운동및활동이아닌과제지향적훈련만이이러한대뇌운동피질의재조직화의극대화에긍정적인영향을준다고하였다. 16 또한 Chklovskii 등은피질의배선도 (wiring diagram) 에대한개념을도입하여학습과관련된신경의연결성 (neural connectivity) 의변화가발생한다고설명하였으며, 기존에연결된뉴런들의 weight 변화 ( 기존연결된회로중특정연결이강화되는것 ) 이외에 wiring 변화 ( 새로운연결회로가생성되는것 ) 가발생하는구조적가소성 (structural plasticity) 이존재한다고기술하였다. 이러한신경가소성의입증을기반으로뇌졸중이후재활치료의근거가확립되었으며, 재활치료의중요성이더욱부각되고있다. 2) 치료방법에따른분류및증거들신경가소성을증가시키는방향으로재활치료전략을수립하여야한다는것에대한이견은없다. 이러한신경가소성을증가시키기위해서는뇌병변주위뇌조직에대한활성화와반대편뇌조직의억제를통한대뇌반구간억제 (inter-hemispheric inhibition) 의역전을통한뇌병변주위뇌조직에활성화를유도하여야한다. 특히뇌병변주위조직의활성화를유도하기위해서는중추신경계단위에서직접적으로활성화하는방법과말초신경계및근골격계의자극을통해간접적으로활성화하는방법이있을수있다 (Fig. 1). 뇌졸중후상지기능회복을위한여러가지재활치료방법에대한체계적인분석에의한근거와권고수준연구에따르면다음과같다. 17 뇌졸중후상지기능의회복을위한치료방법중무작위대조군연구를통한강력한근거를가진효과적인치료법은구속유도운동치료 (Constraintinduced movement therapy, CIMT) 와로봇-보조훈련 (Robot-assisted training) 이대표적이다. 구속유도운동치료는 21개의무작위대조군연구결과를분석했을때, 대부분의메타분석에서상지기능의회복에중등도이상의효과가있다고분석되었다 (SMD 0.73[95% CI, 0.54 to 0.91]). 로봇-보조훈련에대한연구는 10개의무작위대조군연구결과를가지고있으며, 중등도이상의효과가있다고분석되었다 (SMD 0.81[95% CI, 0.40 to 1.22]). 다음으로치료효과의근거가규명된것으로양측상지훈련 (bilateral training), 운동연상훈련 (mental practice, SMD 0.84[95% CI, 0.34 to 1.33]), 고강도집중훈련 22
신명준외 3 인 : 뇌졸중후상지기능개선을위한재활치료의전략 Fig. 1. Strategies of neuromodulation for stroke recovery. = Facilitation or activation. = Inhibition or inactivation. (high-intensity therapy), 반복적인과제수행훈련 (repetitive task-oriented training), 전기자극치료 (electrostimulation therapy), 근전도를이용한생체되먹임훈련 (electromyographic biofeedback training, SMD 0.41[95% CI, 0.05 to 0.77]), 미러치료 (mirror therapy) 등이있다. 위와같은치료방법들은효과를밝히기위한연구방법의설계가미흡하거나기능개선의효과가상대적으로작아치료효과와이점이있으나일부연구에서는이런부분들이불확실한것으로분석되었다. 이중에서도운동연상훈련 (mental practice), 전기자극치료 (electrostimulation therapy), 근전도를이용한생체되먹임훈련 (electromyographic biofeedback training) 은근거에대한설명력은작으나중등도이상의효과가있다고분석되었다. 상지에사용하는보조기나부목에의한상지기능회복효과는낮은것으로보고되었다. 뇌졸중후상하지기능장애에대한보바스치료와같은신경생리적치료 (Neurophysiological approaches, Bobath) 의효과에대해서는많은논란의여지가있으나메타분석에의하면상하지모두에서효과가증명되지않았다 ( 상지 SMD 0.11[95% CI, 0.14 to 0.36], 하지 SMD 0.06[95% CI, 0.32 to 0.43]). 이는치료가시작된역사에비해연구설계에서무작위대조군연구가매우적으며, 치료의성격상대조군연구가어려운제한점등을고려한해석과향후연구설계가필요할것으로판단된다. Langhorne 등은체계적고찰을통해서여러가지재활치료방법에대한용어정리와증거수준을제시하였다 (Table 1). 13 이러한여러가지재활치료방법들을환자개개인에게차별화되고적절하게적용하고병합할것인가 가상지기능회복을위한최적의재활치료전략이될것이다. 3) 기능회복을최대화하기위한부가적인치료방법 (1) 구속유도운동치료 (CIMT) 상지기능훈련중구속유도운동치료 (constraint-induced movement therapy, CIMT) 는건측상지의운동을제한하여환측상지의형상화 (shaping) 와반복적과제수행훈련 (repetitive task-oriented training) 을유도하는것이다. 이는환측상지의학습된불용현상 (learned-nonuse phenomenon) 을극복하고운동기능의호전을얻게하는것을목적으로 1993년 Taub 등이고안한방법으로그효과는이미여러연구에의해증명되었다. 18-20 초기의 CIMT는 2주동안, 수면시간을제외한시간동안건측상지에보조기를착용하여운동을제한하고, 매일 6시간동안집중적으로환측상지를사용하는치료였다. 18 치료대상군이좁고순응도가떨어지는문제때문에치료현실을감안하여횟수와시간, 대상등이변형된방법 (modified CIMT) 도많이사용되고있다. 21,22 그리고 CIMT의적용시기또한만성기위주의치료에서벗어나, 아급성기에서도널리사용되고있다. 23,24 일부의연구자는만성기환자의경우 CIMT 시행이후얻은기능적호전이치료후 4년이경과하여도유지된다고보고하였다. 그러나 CIMT 에대한분석연구에서팔기능의향상에는효과가있으나손기능향상에대한효과는상대적으로떨어져 ( 상지 SMD 0.73[95% CI, 0.54 to 0.91], 손 SMD 0.17[95% CI, -0.07 to 0.42]) 이를극복하기위한다양한부가적인치료방법의개발이필요하다. 17 23
Brain& NeuroRehabilitation:2014; 7: 21~29 Table 1. Summary of the evidence for specific rehabilitation treatments by Langhorne P, Bernhardt J, and Kwakkel G., 2011, Lancet. Beneficial or likely to be beneficial (Arm) ㆍ CIMT or modified CIMT for arm impairment and motor function; selected use (A, B) ㆍ Robot-assisted training for upper limb function; selected use (A, B) Uncertain benefit (Arm) ㆍ Bilateral training for motor function of arm; not mentioned or selected use (B) ㆍ Mental practice for arm function; selected patients (B, C) ㆍ High-intensity therapy for arm function; not recommended or recommended (B) ㆍ Repetitive task training for arm function; not recommended or recommended (B) ㆍ Electrostimulation for arm function; not mentioned, not recommended, or selected use (B) ㆍ Electromyographic biofeedback for arm function; not recommended or selected use (A, B) ㆍ Mirror therapy for arm impairment; selected use (A, B) ㆍ CIMT or modified CIMT for hand function; selected use (A, B) ㆍ EMG biofeedback for hand function; not mentioned or not recommended (B) ㆍ Electrostimulation for hand function; not mentioned or not recommended (B) ㆍ Robotics for hand function; selected use (B) Other ㆍ Specific therapy approaches (Bobath, motor relearning, mixed); no recommended approach (A) Unknown effect (Arm) ㆍ Splinting or orthoses for arm function; not recommended (B, C) Guideline recommendation categories: recommended=recommended use for a substantial proportion of stroke patients; selected use=might be considered in selected patients or circumstances; not mentioned=no specific recommendation made; not recommended=not recommended for routine use (outside the context of a clinical trial). Guideline grade of recommendation categories: (A)=based on robust information from randomised trials that is applicable to the target population; (B)=based on less robust information (from experimental studies); (C)=consensus or expert opinion. (2) 운동연상 (Motor Imagery) 운동연상은주어진운동에대하여작업기억 (working memory) 안에서내적으로만연습 (rehearsal) 되는직접적으로운동이일어나지않는역동적인상태 (dynamic state) 를가리킨다. 26 즉, 말초신경및근골격계단위에서주어진운동이명시적으로나타나지는않지만중추신경계에서는이미학습된기억안에서주어진운동에따른뇌신경계의활성화가나타나는역동적인상태를가리킨다. 운동연상이뇌활성화에미치는영향에대한뇌영상연구에서일차운동피질 (primary motor cortex, M1), 전운 (supplementary motor cortex, SMA), 대상피질 (cingulated cortex), 두정엽 (parietal cortex) 등이관여하는것으로보고하였다. 27-31 전기생리적연구방법의하나인경두개자기자극연구에서도운동역학적운동연상 (kinesthetic motor imagery) 이일차운동피질의흥분성을증가시키는것으로나타나, 운동연상이직접적으로뇌기능활성화에기여한다는근거를명확하게뒷받침하고있다. 32 이렇게운동연상중에활성화된뇌영역은실제적인운동수행 (motor execution) 중에활성화되는영역과유사하여운동연상에따른뇌영역의처리과정이실제운동수행중의처리과정과유사한경로를공유하는것으로추정하고있다. 한편모든운동연상의뇌기능적영상연구에서두정엽의역 할이필수적인것으로확인되었으며, 실행증 (apraxia) 환자와같이두정엽에문제가있는환자에서는운동연상의효과가나타나지않는것으로확인되었다. 33,34 뇌졸중재활에서운동연상은많은연구에서효과를가지는새로운치료기법으로보고되었으며, 운동연상이뇌졸중후건강한상지의사용이편리하여마비측의상지를이용하지않게되는학습된비사용 (learned non-use) 또는환측운동불능 (hemiakinesia) 과같은어려움의극복에도움을줄수있다고하였다. 35 이러한운동연상은환측상지와관련된손상된뇌운동피질영역의사용-의존성뇌재조직화 (use-dependent brain reorganization, plasticity) 에직접적인영향을주어기능회복에기여하는것으로생각된다. Braun 등의체계적고찰연구와 2011년 Cochrane review 에서여러가지다른재활치료만시행한경우와비교할때운동연상훈련을함께부가적으로시행할경우상지운동기능을호전시키는데효과가있다고하였으나, 명확한결론을내리기에는근거가부족하다고하였다. 36,37 그이후발표된논문들에서도단독치료로서효과를입증해내지못했기때문에추가적인연구들이필요하겠다. 운동연상은치료중위험이없고, 대부분의환자가쉽게받아들여쉽게재현할수있으며, 실제로움직임을재현할수없는중증의마비환자에서손상된뇌영역의활성 24
신명준외 3 인 : 뇌졸중후상지기능개선을위한재활치료의전략 화를유도할수있는장점을가지는치료방법이기에다른훈련과병행한다면상지의기능회복을위해서추가적인이득을얻을수있을것으로기대한다. 38,39 그러나두정엽에병변이있는경우사용할수없으며, 실제로환자가잘수행하는지여부를알수없는단점을가진다. (3) 운동관찰 (Action Observation) 운동관찰에대해이해하기위해서는미러신경계 (mirror neuron system) 에대한이해가필요하다. 미러신경계의존재는마카크 (macaque) 원숭이에서처음으로보고되었다. 원숭이의전운동피질 (premotor cortex) 영역은해부학적, 화학적, 생리학적으로구분되는 12개의영역으로세분화할수있는데, 이중 F5라불리우는 40 전운동피질배쪽부분의전방부위 (rostral part of ventral premotor cortex) 가손과입의목표-지향적움직임또는다른원숭이가수행하는운동을관찰할때신경활성도가증가함을밝혀 41 운동관찰이마치거울에사물을비추는것과같다하여미러신경계라명명되었다. 이곳은사람에서브로카영역의상동기관으로생각하고있다. 42,43 원숭이연구에서밝혀진바에따르면미러신경계는다음과같은경우에만활성화되었다. 1) 생물학적반응체인손과물체간의상호작용이있는운동관찰때 ( 기구가물체와상호작용하는것을관찰한경우에는활성화되지않음 ); 2) 대상물체없이운동수행을흉내만내는경우에는활성화되지않음 ; 3) 대상물체만시각적으로제시한경우에도활성화되지않았다. 이와같이직접적으로신체의일부 ( 손, 발, 입 ) 가목표-지향적인운동을수행하는것을관찰할때만미러신경계가활성화되어, 이곳이운동인지 (action recognition) 와운동학습 (motor learning) 에중요한역할을하는것으로추정하고있다. 사람에서의미러신경계에대한보고는 Fadiga 등에의해처음으로보고되었다. 44 후향적연구들에의해서손의움직임에대한운동관찰시왼쪽아래이마이랑 (left inferior frontal gyrus) 의브로카영역, 중간관지이랑 (middle temporal gyrus), 위쪽관자고랑 (superior temporal sulcus) 이관여하는것으로알려졌다. 45 이중브로카영역은최근에언어표출뿐아니라손움직임의운동묘사에중요한역할을하는것으로알려졌다. 46-48 또한운동관찰에대한뇌영상연구에서손과팔의실제적인움직임또는움직임에대한계획수행 (action planning) 중에활성화되는영역과같은뇌영역이운동관찰에의해서도활성화되는것을밝혀, 운동관찰이실제적인운동수행과같은피질-척수신경계의경로를공유함을알게되었다. 46,49 이와같이운동관찰시나타나는미러신경계에서의뇌활성화패턴이실제적인운동수행중에나타나는뇌활성화와유사하며, 움직 임의관찰중동시간대에미러신경계의활성화가일어난다는점등은운동관찰이뇌졸중후손상된뇌운동영역의활성화를위한재활치료의수단으로사용될수있음을시사한다. 뇌졸중후마비로인하여운동이불가능한상태에서라도실제적인운동수행없이쉽게적용할수있는목표-지향적인운동관찰이가능한빨리적용될경우효과적인뇌가소성의촉진을가져올수있을것이다. 그러므로무작위대조군연구는부족하지만이러한여러가지근거를바탕으로운동관찰을통한마비된상지와관련된운동피질의활성화를유발하여뇌가소성증진을유도할수있는재활치료방법으로고려해볼수있을것이다. 50,51 (4) 미러치료 (Mirror therapy) 상지기능훈련중미러치료 (mirror therapy) 는 1996년 Ramachandran 등이거울을이용한시착 (visual illusion) 효과를통해환지통 (phantom limb pain) 의치료에효과가있다고하여처음소개되었다. 52 이후뇌졸중환자에게서 3-4주간의미러치료이후 Fugl-Meyer Assessment 및미세손동작의향상을입증함으로써, 환측상지의기능중관절가동범위, 속도, 정확도에치료효과가있음이알려졌다. 53 그이후무작위대조군연구들과체계적고찰연구에서상기기능의회복에효과가있음이규명되었다. 54,55 또한기능적전기자극단독시행에비해미러치료와기능적전기자극치료를병행한경우더욱효과적이라는보고가있어, 56 다른훈련과병행할때상지의기능회복을더촉진할수있는전략적인치료방법으로활용가능성이높다고판단된다. 또한경도의마비로인하여목적적인운동또는훈련을할수없거나중증의마비로인하여목적적인운동을전혀할수없는경우에도건측상지의움직임을거울을통해관찰함으로써뇌병변부위의활성화를유도할수있는장점과집이나병실에서쉽게수행할수있는장점을가지고있다. 4) 상지재활치료에대한한국형표준진료지침 (2012년) 57 뇌졸중환자에서운동기능회복을위해운동치료의강도 ( 또는양 ) 를증가시키는것이강력히권고된다. ( 권고수준 A, 근거수준 1+) 운동기능향상을위한운동재학습, 신경생리적접근, 생역학적접근등여러치료방법들을환자의상태에따라조합하여개별적으로적용할것을강력히권고한다. ( 권고수준 A, 근거수준 1+) 상지근력약화가있는뇌졸중환자에서상지근력강화운동은상지의근력과신체기능을향상시키기위해 25
Brain& NeuroRehabilitation:2014; 7: 21~29 Table 2. Level of Evidence Level Evidence 1++ High quality meta-analyses, systemic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systemic reviews, or RCTs with a low risk of bias 1- Meta-analyses, systemic reviews, or RCTs with a high risk of bias 2++ High quality systemic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion RCT: Randomized controlled trials. Table 3. Grade of Recommendation Grade Recommendation Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of recommendation. A At least one meta-analysis, systemic review, or RCT related as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies related as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies related as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies related as 1++ or 1+ C A body of evidence including studies related as 2+, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies related as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies related as 2+ GPP Recommended best practice based on the clinical experience of the guideline developmental group. RCT: Randomized controlled trials. 강력히권고된다. ( 권고수준 A, 근거수준 1++) 과제지향적훈련이이동기술과보행기술의향상을위해강력히권고된다. ( 권고수준 A, 근거수준 1+) 뇌졸중환자에서특정과제의호전을위해과제특이적훈련을강력히권고한다. ( 권고수준 A, 근거수준 1+) 상지운동능력향상과기능적회복을위해운동및기능적훈련을시행해야한다. ( 권고수준 A, 근거수준 1++) 운동기능향상을위한여러운동치료방법중어떤한치료방법의효과가더우월하다고할수있는근거는부족하다. ( 권고수준 B, 근거수준 1+) 뇌졸중아급성기및만성기의편마비환자들중, 손목의능동적신전, 엄지손가락의능동적외전및 2개이상손가락의능동적신전이 10도이상이고이동과보행의독립적수행시균형능력이충분히있는경우, 건측상지운동제한치료법을강력히권고한다. ( 권고수준 A, 근거수준 1++) 뇌졸중후상지기능향상을위해서실제움직임을사용한재활훈련에덧붙여운동심상훈련을해야하며, ( 권고수준 B, 근거수준 2++) 실제움직임훈련이없이심상훈련단독으로는시행되어서는안된다. ( 권고수준 B, 근거수준 1+) 뇌졸중환자의상지운동기능회복을위해거울치료가강력히권고된다. ( 권고수준 A, 근거수준 1+) 기능적전기자극은뇌졸중환자의상지, 특히전완과손목의움직임회복에도움되므로강력히권장된다. ( 권고수준 A, 근거수준 1++) 기능적전기자극을이용한양손운동, 또는작업특이적운동은뇌졸중환자의상지기능회복에도움이되므로강력히권고한다. ( 권고수준 A, 근거수준 1+) 뇌졸중환자의견관절아탈구에기능적전기자극치료가강력히권고된다. ( 권고수준 A, 근거수준 1++) 만성뇌졸중환자에서중증도의마비된상지에대한기능적전기자극치료는제한된수준에서기능회복에추 26
신명준외 3 인 : 뇌졸중후상지기능개선을위한재활치료의전략 천된다. ( 권고수준 C, 근거수준 2++) 상지기능을위해근전도를이용한생체되먹이치료는다른재활치료와같이시행할경우추천된다. ( 권고수준 C, 근거수준급 2+) 상지를사용한일상생활동작수행에어려움이있는환자는해당동작에대한훈련및적절한보조도구의사용이권유된다. ( 권고수준 D, 근거수준 4) 근거수준은진료지침을정하는데에사용된근거문헌의질적인수준에따라질적으로우수한분석일경우 1++ 부터시작하여질적수준이낮은방향으로 4까지분류하였다 (Table 2). 권고수준은근거수준의정도에따라 A, B, C, 및 GPP (Good Practice Point) 로표기하였다 (Table 3). 결론 뇌졸중후상지의운동기능회복은국소적신경가소성또는뇌내신경망의재구성과같은광범위한범위에서의신경가소성, 급성기의신경가소성, 만성기의신경가소성등다양한패턴의뇌가소성에의해이루어진다. 이와같은다양한패턴의신경가소성은얼마나빨리재활치료가시작되었는가와가소성의증진에필요한적절한재활치료와학습이얼마나많이이루어졌는가에의해결정된다. 그러므로뇌졸중이후상지기능의회복을극대화하기위해서는환자개개인에최적화된재활치료방법을적용하고, 가능한고강도로많은시간동안치료를시행하는전략적접근이필요하다. 이러한측면에서생각할때, 운동연상, 운동관찰, 미러치료등은심각한마비가있는환자에게서도적용가능하며, 초기에도위험성없이시행할수있어전략적치료방법으로활용가치가높다고판단된다. 여러가지재활치료방법에대한근거창출을위한노력과새로운치료방법의개발을통해뇌졸중후다양한장애를가진환자개개인에게최적화된재활치료프로그램을제공하기위한각고의노력이요구된다. 참고문헌 1) Dromerick AW, Lang CE, Birkenmeier R, Hahn MG, Sahrmann SA, Edwards DF. Relationships between upperlimb functional limitation and self-reported disability 3 months after stroke. J Rehabil Res Dev. 2006;43:401-408 2) Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors' quality of life during subacute recovery. Stroke. 2005;36:1480-1484 3) Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75:852-857 4) Hayward K, Barker R, Brauer S. Interventions to promote upper limb recovery in stroke survivors with severe paresis: a systematic review. Disabil Rehabil. 2010;32:1973-1986 5) Bowden MG, Woodbury ML, Duncan PW. Promoting neuroplasticity and recovery after stroke: future directions for rehabilitation clinical trials. Curr Opin Neurol. 2013;26: 37-42 6) Wieloch T, Nikolich K. Mechanisms of neural plasticity following brain injury. Curr Opin Neurobiol. 2006;16:258-264 7) Pekna M, Pekny M, Nilsson M. Modulation of neural plasticity as a basis for stroke rehabilitation. Stroke. 2012;43: 2819-2828 8) Duncan PW, Goldstein LB, Matchar D, Divine GW, Feussner J. Measurement of motor recovery after stroke. Outcome assessment and sample size requirements. Stroke. 1992;23: 1084-1089 9) Richards LG, Stewart KC, Woodbury ML, Senesac C, Cauraugh JH. Movement-dependent stroke recovery: a systematic review and meta-analysis of TMS and fmri evidence. Neuropsychologia. 2008;46:3-11 10) Zemke AC, Heagerty PJ, Lee C, Cramer SC. Motor cortex organization after stroke is related to side of stroke and level of recovery. Stroke. 2003;34:e23-28 11) Enzinger C, Johansen-Berg H, Dawes H, Bogdanovic M, Collett J, Guy C, Ropele S, Kischka U, Wade D, Fazekas F, Matthews PM. Functional MRI correlates of lower limb function in stroke victims with gait impairment. Stroke. 2008;39:1507-1513 12) Liu Z, Zhang RL, Li Y, Cui Y, Chopp M. Remodeling of the corticospinal innervation and spontaneous behavioral recovery after ischemic stroke in adult mice. Stroke. 2009;40:2546-2551 13) Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011;377:1693-1702 14) Frost SB, Barbay S, Friel KM, Plautz EJ, Nudo RJ. Reorganization of remote cortical regions after ischemic brain injury: a potential substrate for stroke recovery. J Neurophysiol. 2003;89:3205-3214 15) Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996;272:1791-1794 16) Kleim JA, Barbay S, Nudo RJ. Functional reorganization of the rat motor cortex following motor skill learning. J Neurophysiol. 1998;80:3321-3325 17) Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8:741-754 18) Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke. 1999;30:586-592 19) Sirtori V, Corbetta D, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in stroke patients. Cochrane Database Syst Rev. 2009:CD004433 27
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