Journal of The Korean Society of Physical Medicine, 2013; 8(4): 505-512 http://dx.doi.org/10.13066/kspm.2013.8.4.505 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 전산화인지치료와고유수용성감각운동이뇌졸중환자의뇌파변화에미치는영향 김신균 1 김창숙 2 김경 3 이윤미 4 이진환 1 1 대구대학교대학원재활과학과, 2 구미대학교물리치료과, 3 대구대학교물리치료학과, 4 구미대학교작업치료과 The Effect of EEG through Proprioceptive Exercise and Computerized Cognitive Therapy on Stroke Shin-Gyun Kim, PT, MS 1, Chang-Sook Kim, PT, PhD 2, Kyoung Kim, PT, PhD 3 Yoon-Mi Lee, PT, PhD 4, Jin-Hwan Lee, PT, MS 1 1 Department of Rehabilitation Science Graduate School, Daegu University 2 Department of Physical Therapy, Gumi University 3 Department of Physical Therapy, Daegu University 4 Department of Occupational Therapy, Gumi University Received: August 6, 2013 / Revised: August 19, 2013 / Accepted: August 24, 2013 c 2013 Journal of the Korean Society of Physical Medicine Abstract PURPOSE: The purpose of this study applied computerized cognitive therapy and proprioception exercise to stroke patients and analyzed improvement in their changes in Electrocephalogram(EEG). METHODS: The subjects were 30 patients who were diagnosed with stroke and they were randomly selected to a proprioceptive training group(n=15), a cognitive training group(n=15). The experiment was performed for three times per week for 6 weeks and EEG was measured before and after the experiment. RESULT: Before and after the experiment in each group of experiments, the α-and β-wave study showed significant changes but, there was no significant difference in the change between groups before and after the experiment. CONCLUSION: From the above results, the cognitive training and the proprioception training have a positive Corresponding Author : canpt@naver.com impact in stroke patients EEG changes, but it is difficult to suggest a better therapeutic interventions. However, as compared with that the cognitive training that directly involved in the cognitive and brain activation, the proprioception training have changes on brain activation. Therefore, of Clinical therapeutic interventions, the proprioception training can be presented effectively to the changes in brain activation in stroke patients. Key Words: Computerized cognitive therapy, EEG, proprioceptive exercise, Stroke Ⅰ. 서론뇌파는뇌의활동상태와활성상태를보여주는중요한정보를가지고있으며, 의식상태와정신활동에따라변하는특정한패턴을가진다. 정신현상이나운동, 감각등을관장하는최고중추인인간의뇌는약 100억
506 대한물리의학회지제 8 권제 4 호 개의뉴런 (neuron) 들은각각시냅스에의해서로연결되어지며, 하나의뉴런표면에는 8000개이상의시냅스가있으며, 신경세포의결합형태나활동에의해안정막전위, 활동전위, 시냅스후전위등을유발하는데뇌파는이러한수많은신경세포의활동을외부에서측정하고기록한것이다 (You, 2011). 임상에서뇌파검사는대뇌피질의수많은신경망의총괄적인활동을대상으로간질의진단, 분류및치료를평가하는데중요한검사기법이며, 국소적, 기질적뇌병변이나특이한파형을보이는신경질환, 의식장애, 뇌혈관질환등을진단하는데유용하다 (Sokhadze 등, 2008). 뇌의활동수준을알아볼수있는뇌파는약 1 60Hz 의주파수와 5 300μV( 보통은 20 100μV) 의전위변동을나타는데일반적으로서파는델타파, 세타파, 알파파로, 속파는베타파, 감마파등으로구분하여설명한다 (Lee 등, 2001). 알파파는주로안정시눈을감고진정한상태에서나타나며, 눈을뜨고물체를주시하거나정신적으로흥분하면알파파는억제된다. 세타파, 델타파역시서파에속하는데뇌종양환자에서관찰되기도하지만유아에서정상상태에서도나타나며정상적인성인에서수면중에관찰되는주성분이기도하다. 속파인베타파는중심부 (central area) 나이마부에서우세하게나타난다. 진폭은보통 20μV 정도이다. 일반적으로델타파와같이천천히진동하는리듬은뇌심부에서발생하는것으로알려져있으며, 머리표면의전부위에서함께나타나는경향을보인다. 알파파의경우시상에있는신경세포들과대뇌피질에있는신경세포들사이의긴신경섬유를통한흥분성, 억제성상호작용에의해발생하고, 베타파는대뇌피질에있는신경세포들사이의흥분성, 억제성상호작용에의해발생한다고알려져있다 (Grillon과Buchsbaum, 1986; Andressi, 1995). 신경학적손상을일으키는뇌순환장애로잘알려진뇌졸중은뇌혈관에의한혈액공급에문제가발생하여뇌의해부학적부위에기능부전이나타나는질환이다. 뇌졸중으로인해나타나는신경학적증상은뇌손상반대쪽신체부위에나타나는편마비나편부전마비, 실어증이나구음장애와같은언어장애, 반맹증과같은시각 적결손, 감각결손, 삼킴장애, 실행증, 인지기능장애와우울증과같은정서적인문제들이있다 (Randomski와 Trombly, 2008). 이로인해대부분의뇌졸중환자들은독립성을제한받고일상생활활동수행에서장애의요소로작용하게되어결국전반적인사회화에제약이초래되어어려움을겪게되며, 이러한뇌졸중환자의기능적독립에는운동, 지각, 인지적요소가서로영향을주고받는데 AMPS(assessment of motor and process skills) 등환자에대한평가에서도 4가지요소의연관성이강조되고있다 (Cederfeldt 등, 2009). 뇌졸중후나타나는인지와지각능력의손상은운동기능의장애, 일상생활활동수행의제한및정서장애와함께기능회복에가장문제가되는장애중하나이기때문에뇌졸중환자들의기능훈련프로그램을위하여인지기능의정확한평가와치료가요구된다 (Mercier 등, 2001). 전통적인인지치료는주의및집중, 시지각, 언어, 기억, 문제해결능력을향상시키기위한인지적전략이사용되는데 (Wood와 Fussy, 1990) 최근많이사용되고있는전산화인지치료프로그램은일반적인인지치료의일반적자극법, 행동교정법, 기능적적응법등의방법과달리게임과같은프로그램을통해문제해결능력을향상시키는컴퓨터훈련을사용한다 (Chen 등, 1997). 또, 인지장애가있는뇌졸중환자나뇌손상환자를대상으로인지치료프로그램을적용하여인지기능의향상과신체적기능의향상이보고되었다 (Shin 등, 2002; Shin 등, 2008). 뇌졸중으로인해나타나는대표적인신경학적증상중하나인운동기능약화는근력뿐만아니라근지구력의감소및관절의안정성과고유수용성감각의손상이주요인인데, 이중고유수용성감각은신체의위치나자세의인식, 각각의운동면에서의움직임에관여하는모든관절의각도와각속도, 그것들의움직임의비율에대한정보를중추신경계에제공하고, 역동적인관절안정성을유지하는데가장큰역할을수행하며정상적인움직임을유도하고외부손상으로부터관절을안전하게보호하는역할을한다 (Docherty 등, 2004). 고유수용성감각기능의저하는자세조절과보호반사능력, 관절의운동능력, 및외부요동에대처하는균형능력이
전산화인지치료와고유수용성감각운동이뇌졸중환자의뇌파변화에미치는영향 507 저하되고결국보행능력에도문제를초래하게된다 (Edwards,1996). 뇌졸중환자에게공을이용한고유수용감각자극운동법을적용한결과, 균형능력이향상되었고 (Edwards,1996), 고유수용성감각운동을노인여성에게 16주간적용한연구에서평형감각기능이향상된결과가나타났다 (Oak 등, 2006). 또, 근육과건내의고유수용기의자극은운동기능과관절가동범위를증가시켜보행능력을증진시킬수있다 (Ferber 등, 2002). 현재까지뇌졸중환자의치료에중요한목표는보행과균형등운동능력을향상시켜일상생활에복귀하도록하는것이다. 운동능력을개선하기위한중재법으로평행봉보행, 트레드밀훈련, 고유신경근촉진법및보바스치료등의다양한방법이적용되고있다. 운동기능향상을위한또다른치료적중재로인지기능향상을위한치료프로그램이제시되고있는데 (Kang과 Son, 2011; Rovio 등, 2005; Weuve 등, 2004), 이러한치료법의대부분은운동기능향상에초점을두고있다. 인지와지각능력은운동기능수행, 일상생활활동의수행등기능회복에중요한요소이기때문에뇌졸중환자들의기능훈련프로그램을위해인지기능의정확한평가와치료는필수이다 (Han 등 2002). 본연구는뇌졸중환자의운동능력개선을위한여러치료적중재법중고유수용성감각운동을적용해운동기능을향상시키는치료중재가뇌파의변화에미치는영향에대해알아보고인지능력향상을위한전산화인지재활치료와비교하여뇌활성화상태변화에효과적인지알아보고자한다. Ⅱ. 연구방법 1. 연구대상및기간본연구는 2012년 8월부터 2012년 9월까지대구에소재한 K 병원에서입원하여치료를받는뇌졸중환자중본연구의취지를이해하고참여에동의한 30명을대상으로실시하였다. 대상자는고유수용성감각자극운동군 15명, 전산화인지치료군 15명로분류하였으며전산화단층치료 (CT) 나자기공명영상 (MRI) 을통해뇌졸중진단을받고 6개월이상경과한자, 근골격계질환 이나심혈관계질환이없는자, 독립적기립균형을유지할수있는자, 연구자가지시하는내용을이해할수있는자, 운동시지각검사도구 (MVPT) 를통해편측무시를포함한시지각능력에장애가없다고판별된자, 한국형간이정신상태판별검사 (MMSE-K) 에서 19 점이상을받은자, 건측팔의수의적움직임이가능하고손으로전산화인지재활프로그램의버튼조작이가능한자로선정하였다. 2. 실험방법연구의대상자는초기평가로한국형간이정신상태판별검사 (mini-mental state examination-korea version : MMSE-K1) 와편측무시를포함한시지각능력의장애를보기위해시지각검사 (motor-free visula perception test : MVPT) 를시행하여기준점수에해당하는지확인한후선정하였다. 대상자는기본적인신경계물리치료와작업치료를받으며추가적으로고유수용감각운동과전산화인지치료를각각 30분씩, 주 3회, 총 6주동안시행하였다. 고유수용감각운동과전산화인지치료는다년간경험이풍부하고전문적인교육을받은물리치료사와작업치료사각각 3명에의해이루어졌으며운동에대한순응을고려하여실험 3주차에고유수용감각운동의난이도를올리도록하였다. 전산화인지치료는환자의수행수준에따라난이도가자동으로조절되는데수행수준이자동으로저장되어다음회기에반영될수있어마지막치료회기에는환자의수행수준내에서가장높은난이도의과제를수행할수있도록하였다. 초기평가와재평가는일관성을유지할수있도록연구자와각 1명의물리치료사와작업치료사에의해시행하였다. 3. 측정방법및측정도구 1) 고유수용감각운동뇌졸중환자를위한고유수용감각운동프로그램은아직개발되거나알려진것이없으나고유수용감각을위한운동프로그램은널리이용되고있다 (Oak 등,
508 대한물리의학회지제 8 권제 4 호 2006; Lee, 2006). 본연구는 Rose(2006) 가고안한노인들을위한낙상예방프로그램에서뇌졸중환자가수행하기쉽고근긴장도의증가를최소화할수있는적합한운동위주로응용하여적용하였다. 본연구에서적용한고유수용감각운동은준비운동 5분, 본운동 20분, 정리운동 5분의총 30분으로시행되었고본운동은볼 (Gym ball, Italy) 과에어로-스텝 (TOGU, Germany) 을사용하여볼위에앉아서균형잡기, 앉은자세에서발바닥은붙이고엉덩이와무릎을앞뒤, 좌우로이동하기, 앉은자세에서한발들기와에어로-스텝을이용하여바로서서균형잡기, 바로선자세를유지하면서엉덩이를앞뒤, 좌우로이동하기, 제자리걸음하기등의방법을실시하였다. 운동에대한순응을고려하여실험 3주차에고유수용감각운동의난이도를올리도록하였다. 2) 전산화인지재활프로그램 (Rehacom, Germany) 독일에서개발된인지재활프로그램 (Rehacom) 은주의력훈련 (attention training), 기억력훈련 (memory training), 관리기능훈련 (executive functions), 시야훈련 (visual field training), 시각- 운동협응력훈련 (visuo-motor abilities), 작업훈련 (occupational training) 의영역으로구성되어있으며조작기구 (Rehacom panel) 가조이스틱과큰버튼으로구성되어조작이쉽고컴퓨터와친숙하지않은환자에게도접근성이용이한장점이있다 (Cho, 2010). 본연구에서는 Erickson과 Dahlin-Ivanoff(2002) 의연구에서인지기능의향상에좋은결과를보인프로그램인주의력훈련영역의반응행동, 기억력훈련영역의단어기억력, 관리기능훈련영역의쇼핑프로그램을적용하고자한다. 3) 뇌파본연구에서는뉴로닉스 (NERUONISC, 미래엔지니어링사, 대한민국 ) 를이용하여측정하였으며, 외부환경적요인에영향을받을수있으므로일정한조도와온도가유지될수있는창문이없는검사실에서수행하였다. 연구대상자에게뇌파측정의방법과주의사항을 미리설명하고편안한의자에앉게하고 3분간휴식을취한후고정된자세로전방의응시지점을응시하도록하고 3분동안뇌파를측정한다. 이때뇌파측정의정확도를위해서말을하지않고움직임이없는상태로있도록하여뇌파측정동안잡파 (artifacts) 의혼입을줄이고자하였다. 뇌파측정을위해 32개의전극이부착된모자 (ElectroCap사, Eaton, Ohio, USA) 를머리에착용시켜평가하였고머리에부착하는전극의배치는국제뇌파및임상뇌대사학회연맹 (International Federation of Societies for Electroencephalograph and Clinical Neurophysiology) 에서추천하는 10-20 시스템을따른다. 본연구에서는상대적뇌파의증감에따라집중력을알아볼수있는절대 / 상대 α파와절대 / 상대 β파를구하여, 구체적인상대파중중요한 α파와 β파를구하였다. 4. 자료분석방법수집된자료는 SPSS vesion 18.0 을이용하여통계처리를하였다. 연구대상자의일반적인특성은기술통계를이용하여분석하고, 고유수용감각운동군, 전산화인지치료군의뇌파변화에대한훈련전 후비교검증을위하여전, 후비교는대응비교 t 검정을이용하였고군간비교는독립 t-검정을이용하였다. 통계학적유의수준 (α) 은.05 이하로하였다. Ⅲ. 연구결과 1. 대상자의일반적특징본연구대상자의일반적인특성은고유수용운동군 15명의평균나이는 55.93±11.16세, 성별은남자 9명, 여자 6명, 평균신장은 165.4±10.45cm, 평균체중은 64.20±13.53kg, 뇌졸중유형은뇌경색 8명, 뇌출혈 7명, 유병기간은 17.13±4.08개월, 마비부위는오른쪽마비 6명, 왼쪽마비 9명이었으며, 전산화인지치료치료군 15 명의평균나이는 53.53±13.63, 성별은남자 8명, 여자 7명, 평균신장은 165.0±8.29cm, 평균체중은 65.00±9.94kg,
전산화인지치료와고유수용성감각운동이뇌졸중환자의뇌파변화에미치는영향 509 뇌졸중유형은뇌경색 7 명, 뇌출혈 8 명, 유병기간은 18.00±3.25 개월, 마비부위는오른쪽 7 명, 왼쪽 8 명이었다. 연구대상자의일반적특성에대한동질성검정에서두그룹간유의한차이는없었다 (Table 1). Table 1. General characteristic of subjects Variable NSRTG(n=15) SSRTG(n=13) p Age(years) 55.93±11.16 53.53±13.63.602 Gender(Male/Female) 9 / 6 8 / 7.724 Body Weight( kg ) 64.20±13.53 65.00±9.94.843 Height( cm ) 165.4±10.45 165.0±8.29 908 Paretic side(r/l) 6/9 7/8 1.00 Time since stroke 17.13±4.08 18.00±3.25.761 * p<.05 Mean±SD: Mean±standard deviation PTG: Proprioceptive training group, CTG: Cognitive training group 2. 뇌파의변화 1) 알파파와베타파의치료전후비교치료전후에따른두그룹의알파파와베타파의변화 는다음과같다. 고유수용감각운동군의알파파변화는치료전 32.96±0.71μV에서 40.02±0.29μV로, 전산화인지치료군은 33.02±0.33μV에서 40.28±0.15μV로나타났으며고유수용군의베타파변화는 16.76±0.29μV에서 18.82±0.05μV로, 전산화인지치료군은 16.57±0.17μV에서 19.11±0.41μV로두그룹모두훈련후유의한향상을보였다 (Table 2). 2) 그룹간알파파와베타파의비교고유수용감각운동군과전산화인지치료군의알파파와베타파의변화를비교한결과그룹간의유의한차이는없었다 (Table 3). Ⅳ. 고찰뇌졸중은뇌손상부위와정도에따라운동장애, 감각기능장애및인지장애등이유발되고여러장애요소의복합작용으로운동조절능력이상실되어편마비의비대칭적인자세, 균형장애, 보행능력의저하및섬세한운동기능의어려움을초래하게된다 (Kwon과 Lee, Table 2. The results of alpha wave and beta wave on each group at pre-post test (unit: μv) α-wave β-wave pre-test post-test t pre-test post-test t PTG(n=15) 32.96±0.71 40.02±0.29-9.60* 16.76±0.29 18.82±0.05-7.37* CTG(n=15) 33.02±0.33 40.28±0.15-19.37* 16.57±0.17 19.11±0.41-5.31* * p<.05 Mean±SD:Mean±standarddeviation, PTG:Proprioceptive training group, CTG:Cognitive training group Table 3. The results of alpha wave and beta wave on each group at pre-post test (unit: μv) Group PTG (n=15) CTG (n=15) Value difference M±SE α-wave 40.02±0.29 40.28±0.15-0.26±0.16-1.58 β-wave 18.82±0.05 19.11±0.41-0.29±0.41-0.69 * p<.05 Mean±SD:Mean±standard deviation, PTG:Proprioceptive training group, CTG:Cognitive training group t
510 대한물리의학회지제 8 권제 4 호 2003; Han 등, 2002; Geiger등, 2001). 뇌졸중환자의치료에중요한목표는보행과균형등운동능력을향상시켜일상생활에복귀하도록하는것이며이러한목표를위한여러가지운동치료중재법과운동기능향상을위한인지치료가이루어지고있다. 본연구는뇌졸중환자의운동능력개선을위한고유수용성감각운동을통해뇌파의변화를인지능력향상을위한전산화인지기능치료와비교하여운동능력개선이뇌활성의변화에효과적인지알아보고자하였다. 단시간내에비침습적으로대뇌의활성상태변화를평가하는방법으로사용되는도구인뇌파 (EEG) 검사의목적은뇌의신경학적변화와활성상태를관찰하는것이다 (Floernce 등, 2004). 본연구에서는뇌파의증감에따라뇌의안정상태와창의력상태를나타내는알파파와논리적사고, 문제해결상황에서활성화되는베타파의변화를측정하였다 (Kim과 Jang, 2001; Egner등, 2001). 치료전과후의그룹내변화에서고유수용감각운동군의알파파변화는치료전 32.96±0.71μV에서 40.02±0.29μV로향상되었고전산화인지치료군도 33.02±0.33μV에서 40.28±0.15μV로유의하게향상된결과를보였다. 또한베타파변화는고유수용감각운동군이 16.76±0.29μV에서 18.82±0.05μV로, 전산화인지치료군이 16.57±0.17μV에서 19.11±0.41μV로향상된결과를보였다. 알츠하이머병의초기에알파파의감소와세타파의증가가보여진다고하는데 (Coben, 1985), 본연구결과에서나타난알파파의증가는뇌의안정상태에고유수용감각운동과전산화인지치료가영향을미친다고할수있겠다. 일반노인과치매노인을대상으로컴퓨터인지재활프로그램을적용하여뇌파의변화를비교한결과일반노인군에서활동지수와집중지수가증가하였고통계학적으로유의하지는않았으나치매노인군의뇌활성도의증가가나타났다 (Kang 등, 2009). 또, 일반노인에게균형운동과컴퓨터보조인지치료를 6주간적용한뒤뇌파의변화를본결과알파파, 베타파에서치료전후유의한향상을보였는데 (Lee, 2011), 본연구의고유수용감각운동과전산화인지치료후나타난뇌파의향상은뇌졸중환자의안정상태, 주의집중력, 문제해결능력 등의뇌활성상태에각각의치료가영향을미친것으로생각할수있다. 또 Hall 등은전두엽퇴화에의한인지기능장애노인에게유산소운동을적용하였더니뇌의혈류량향상이나타났고인지기능향상에효과가있었다고하였고 (Halla, 2001), Roth(2005) 의연구결과, 운동이뇌파생신경호르몬 (brain derived neurotropin factor) 의증가를유발하여정상뇌세포파괴를보호하고새로운뇌세포생성에도움을준다고하였다. 본연구에서는전산화인지치료군과고유수용감각운동군의치료전후뇌파에미치는영향을비교하여알아보고자하였는데, 두그룹간의뇌파변화는통계학적으로유의하지않은결과를보였고 Lee(2011) 는균형운동과컴퓨터보조인지치료를일반노인에게적용한뒤대뇌의각구역별로뇌파의변화를비교한결과두그룹간에알파파와베타파에차이가없는것으로보고하였다. 뇌졸중환자의기능회복치료에서인지기능은인간이사고나감지의대상을생각하고느끼고기억하는과정을의미하는대뇌피질의기능으로뇌손상을일으키는수많은신경질환혹은노화에의하여저하될수있다고하였다 (Lee, 2003). 본연구의제한점으로는뇌의각구역별에따른뇌파검사보다특정뇌파에한하여측정하여고유수용감각운동과전산화인지치료가뇌의여러영역에미치는영향을알아보지못했다. 따라서향후연구에서는뇌졸중의치료적중재가뇌의각영역별뇌파의변화를알아보고뇌활성상태를연구해야할것이다. Ⅴ. 결론본연구에서는고유수용성감각운동이운동기능향상에미치는영향보다대뇌활성화에미치는영향과전산화인지치료와비교하여뇌파의변화및뇌활성상태를알아보았다. 전산화인지치료군의치료전후에서안정상태와주의집중력및문제해결능력에관한뇌의활성상태가나타났고고유수용감각운동군에서도치료전후좋은결과를보였으나두치료군을비교한결과에서유의한차이는보이지않았다.
전산화인지치료와고유수용성감각운동이뇌졸중환자의뇌파변화에미치는영향 511 이상의결과에서전산화인지치료와고유수용감각운동이뇌졸중환자의뇌파변화에각각긍정적인영향을미친다고할수있으나더나은치료적중재법을제시하기는어렵다. 그러나인지와뇌활성화에직접적인영향을미치는전산화인지치료의결과만큼고유수용감각운동치료에서뇌활성화변화를보인것은뇌졸중환자의뇌활성화변화를위한임상의치료적중재에고유수용감각운동치료을적용해야할것으로사료된다. References Andressi JL. Psychophysiology: Human Behavior & Physiological Response, Edition Lawrence Erlbaum Associates. Inc. 1995. Cederfeldt M, Gosman-Hedstro G, Savborg M, et al. Influence of cognition on personal activities of daily living(p-adl) in the acute phase : The Gdthenburg cognitive stroke study in elderly. Arch Gerontol Geriatric. 2009;49(1):118-22. Chen SHA, Thomas JD, Glueckauf RL, et al. The effectiveness of computer-assisted cognitive rehabilitation for persons with traumatic brain injury. Brain Injury. 1997;11:197-209. Cho YM, The Effects of Computerized Cognitive Rehabilitation on Cognitive Function in Elderly Post-stroke Patients, Dept of Physical Education Graduate School,. Daegu University. Master s Thesis. 2010. Coben LA, Danzinger W, Storandt M. A longitudinal EEG study of mild senile dementia of Alzheimer s type: changes at 1 year and 2.5 years. Electroencephalogr Clin Neurophysiol. 1985;61:101-12. Docherty CL, Arnold BL, Zinder SM, et al. Relationship between Two Proprioceptive Measures and Stiffness at the Ankle. Journal of Electromyography and Kinesiology. 2004;14(3):317-24. Edwards S. Neurological Physiotherapy: A Problem-solving Approach. New York: Churchill Livingstone. 1996. Egner T, Gruzelier JH. Learned self-regulation of EEG frequency components affects attention and event-related brain potential in humans. NeuroReport. 2001;12(8): 4155-9. Eriksson M, Dahlin-Ivanoff S. How Adults with Acquired Brain Damage Perceive Computer Training as a Rehabilitation Tool: A Focus-group Study. Scand J Occup Ther. 2002;9(3):119-29. Ferber R, Osternig LR, Gravelle DC. Effect of PNF stretch techniques on knee flexor muscle EMG activity in older adults. J Electromyogr Kinesiol. 2002;12:391-7. Geiger RA, Allen JB, O Keefe J, et al. Balance and Mobilityon Stroke: Effects of Physical Therapy Interventions With and Without Biofeedback/Forceplate Training, Phys Ther. 2001;81(4):995-1005. Grillon C, Buchsbaum MS. Computed EEG topography of response to visual and auditory stimuli. Electroencephalogr Clin Neurophysiol. 1986;63(1):42-53. Halla CD, Smith AL, Keelec SW. The impact of aerobic activity on cognitive function in older adults: A new synthesis based on the concept of executive control. Eur J Cognit Psychol. 2001;13(1):279-300. Han TR, Bang MS, Kim JH, et al, Rehabilitaion Medicine, Seoul: Koonja, 2nd, 2002. Kang JH. Son HJ. The Effects of 12-week Combined Exercise training on Body Composition, Cognition and Depression in Eldery women. The Korean Journal of Sports. 2011;9(3):1-10. Kang WG, Kang MH. Yang JR, et al. The Comparison of EEG Activity by Computer Assisted Cognitive Rehabilitation Program in the Normal Elderly and the Elderly With Dementia. J Korean Soc Occup Ther. 2009;17(3):1-13. Kim YJ, Jang NK, A Study on the Use of the Prefrontal Brain Waves for the Assessment of Brain Hemisphericity, The Korean Society of Biology Education, 2001;29(1):87-97. Kwon HC, Lee SL. The Relationship Between Activities of
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