J Korean Soc Phys her Vol. 24, No. 5, October, 2012 pissn 1229-0475 eissn 2287-156X he Journal of Korean Society of Physical herapy Original Article 뇌졸중환자의상지체감각자극을통한감각, 손기능, 자세조절및일상생활수행력의변화 송보경 용인대학교대학원물리치료학과 Effect of Somatosensory Stimulation on Upper Limb in Sensory, Hand unction, Postural Control and ADLs within Sensorimotor Deficits after Stroke Bo-Kyung Song Department of Physical herapy, Graduate School, Yong In University Purpose: his study examined the improved sensory, hand function, postural balance and activities of daily living (ADL) through somatosensory stimulation, such as the facilitation of functional reaching and tactile, proprioceptive stimulus of the upper limb (UL) and hand. Methods: Seventeen stroke patients having problems with motor and somatosensory deficits were selected in Bobath Memorial Hospital adult rehabilitation center. he patients were divided into two groups; the sensorimotor deficit group (SMDG) and motor deficit group (MDG). Somatosensory stimulation on the UL, physical therapy and occupational therapy were carried out three times a week over a six week these treatments were performed in both group period. o compare each group, the following assessment tools were used: such as tactile detection thresholds (D), two point discrimination on the affected side (PDas), unaffected side (PDus) stereognosis (S) manual function test, hand function on the affected side (Has) and unaffected side (Hus), Postural Assessment Scale for Stroke (PASS) and Korean version Modified Barthel Index (K-MBI). Results: In the SMDG, somatosensory stimulation on the UL was statistically important for D, PDas, PDus (except for the thener), S, hand function on Has, on Hus, PASS length of displacement with foam (LDSEO), and K-MBI. In the MDG, somatosensory stimulation on the UL was important for D, PDas, PDus (except index finger) length of displacement with the eyes open, LDSEO, Has, Hus, PASS and K-MBI. In addition, there was a significant difference in the PASS between SMDG and MDG. Conclusion: Somatosensory stimulation on the UL affects the sensory, hand function, postural control and ADLs performance. Keywords: Hand, Somatosensory disorders, Postural balance, Activities of daily living I. 서론 Received September 1, 2012 Revised October 11, 2012 Accepted October 15, 2012 Corresponding author Bo-Kyung Song, bbo70@hanmail.net Copyright 2012 by he Korean Society of Physical herapy his is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 뇌졸중환자의운동및감각기능의손상은일반적인증상으로자세조절및과제활동에큰어려움을준다. 1 특히감각손상은접촉감각및고유수용성감각과같은체감각의손상을의미하며뇌졸중환자의절반에서체감각손상을보고하고있다. 2 이러한체감각손상은재활과정에서과제인식의어려 J Korean Soc Phys her 2012:24(5):291-299 291
Bo-Kyung Song: Effect of Somatosensory Stimulation on Sensory, Hand unction, Postural Control and ADL after Stroke 움으로새로운과제학습습득에어려움을줄뿐만아니라개인의안정성, 기능적인결과및삶의질에부정적인결과를준다. 또한뇌졸중환자의체감각손상의유무에따라치료기간의차이, 치료과정에서의기능획득에대한치료효과의차이가나타나체감각손상을동반한뇌졸중환자는순수하게운동기능손상만을동반한뇌졸중환자에비해기능적예후가좋지않다. 뇌졸중환자의체감각손상은환자의서기와앉기와같은기능적인자세의비대칭성을증가시키고체중이동의어려움과자세조절에영향을준다. 4,5 현재뇌졸중환자의감각기능및신체기능향상을위하여시지각되먹임훈련, 6 경두개자기장과직류전류를이용한대뇌감각영역의자극, 7 전기자극을통한체감각증진, 8 강제유도동작치료, 9 과제중심훈련 10 등과같은다양한방법과효과가보고되고있다. 하지만본연구는접촉감각, 접촉구별및고유감각등과같은체감각결손에대한치료를중심으로연구를진행하고자하였다. 따라서본연구는뇌졸중환자의상지체감각자극통하여감각및운동손상유무에따라손의감각, 손기능, 자세조절및일상생활수행력의어떠한효과와차이가있는지알아보고자한다. II. 연구방법 1. 연구대상본연구는경기도분당에위치한 BMH 병원재활의학과에입원중인환자들중에사전검사를통하여연구참여의동의와함께 17명의환자를선정하였다. 본연구에서정하는대상자의조건은다음과같다. 1) 신경과및재활의학과전문의로부터뇌졸중으로인한편마비진단을받은자, 2) 뇌졸중의발병일이 개월에서 12개월사이로다시재발하지않은자, 11 ) 환자의나이가 65세이하인자, 4) 마비측손에감각자극시인식이가능한자, 5) 혼자서앉아있기가가능한자, 6) 외과적질환이나시각장애를갖고있지않은자로뇌졸중의진단외의질환 ( 예 : 말초신경질환, 파킨슨병, 치매등 ) 을가지고있지않은자, 7) 한국형간이정신상태판별검사 (Korea version Mini Mental State Examination) 점수가 21점에서 26점의경도이상으로연구자의감각자극에정확히표현할수있는자, 8) 연구의내용을이해하고적극적으로참여할것을동의한자. 2. 연구방법과절차본연구에참여한환자에게양적감각검사중접촉감지 (Semmes-Weinstein monofilaments, Stoelting, Wood Dale, IL, USA) 검사를실시하여.61 두께의정상값의감지유무에따 라감각운동손상군과운동손상군으로나누었으며, 두치료군모두에게주 5회의물리치료와작업치료와체감각훈련을주 회 40분간총 6주간 18회를추가로실시하였다. 치료전, 후의평가를통해각치료군의감각, 손기능, 자세조절능력및일상생활수행력의효과를알아보았다. 본연구에서적용된상지의체감각자극은 Smania 등 12 과 Champion 등 1 이제안한내용을참고하여구성하였다. 체감각자극은손부위와어깨부위로나누어진행하였다. 바르게앉은자세에서치료대위에마비측아래팔부위를접촉하고엄지손가락을고정한후짧아진 2번째에서 5번째손가락의외재근길이를정상화하였다. 그리고내재근의길이를변화하여두근육군의고유감각을자극하며점진적으로손가락전체의능동적인움직임을증진시켰다. 1 손에통증이느껴지지않은범위에서치료도구를이용하여촉각, 촉각구별, 물체인식을위해자극하였다. 처음체감각자극을시행할때시각을사용하여물체조작을하도록하였고, 반복자극을할때시각을제한하여물체를조작하도록하였다. 손뻗기와잡기는환자가손을뻗어나무블록과같은물건을잡도록하고다양한모양과크기를치료에사용하였다. 쥐기는원통형모양의물체및막대등을이용하여공간에유지하도록하였다. 11 어깨부위는치료대에바로누운자세나바로앉은자세에서어깨복합체의동작을촉진하였는데치료사는어깨뼈의안정가동성을증가시키고어깨회전근과어깨세모근, 위팔두갈래근, 위팔세갈래근등의어깨근육의고유감각을활성화하였다. 최종적으로손과어깨복합체가함께움직이는과정과손의쥐기기능을이용하여손뻗기와손의공간유지등의기능적활동과연결하도록하였다. 12. 측정도구및방법 1) 감각검사편마비환자의감각손상정도를알아보기위하여 Julkunen 등 11 이제시한양적감각검사중접촉감지 (Semmes-Weinstein monofilaments, Stoelting) 검사를사용하였다. 접촉감지와두점구별검사는전완부, 무지구, 소지구, 엄지손가락과검지손가락손끝을측정하였고, 모노필라멘트 1.65 두께부터감각검사에적용하고최소한.61 을인식해야정상감각값으로하였다. 두점구별검사는 Dellon Disk-Criminator 2 Point (Sammons Preston, Bolingbrook, IL, USA) 를사용하였고엄지손가락, 검지손가락손끝, 무지구, 소지구, 전완부위를검사하였다. 입체인식검사는연필, 동전과같이일상에서쉽게사용되는 17개의물건과 17개의물건을그려놓은카드로구성된 Stereognosis Kit (Sammons Preston) 을사용하여검사하였다. 292 J Korean Soc Phys her 2012:24(5):291-299
송보경 : 뇌졸중환자의상지체감각자극을통한감각, 손기능, 자세조절및일상생활수행력의변화 환자는손의촉각을통해 17개의서로다른물건을인식하는데입체인식에서는접촉매칭방법을사용하였다. 14 2) 손기능검사 (Manual unction test, M) 일본동북대학의학부재활의학과에서개발된본검사는뇌졸중으로인한편마비환자의상지기능및동작능력측정검사도구로상지의운동기능회복정도를비교적객관적으로측정하고마비측과비마비측상지를각각평가할수있는장점을동시에가지고있다. 15 검사내용은상지운동 (4항목 ), 쥐기 (2 항목 ), 손가락조작 (2항목 ) 등으로어깨의자발적운동각도를통한근력평가, 손의움직임범위정도, 쥐기능력, 운반능력등으로구성되었다. ) 뇌졸중자세평가척도 (Postural Assessment Scale for Stroke, PASS) 본검사는 ugl-meyer 균형척도항목을수정보안하여뇌졸중환자의균형측정뿐만아니라뇌졸중환자의자세조절수행능력을평가하기위해만들었다. 그리고자세조절장애가있는환자에게적용가능하도록난이도가있는평가항목으로이루어져있어간단하게평가할수있기때문에편마비환자의상태를진단할수있는유용한임상적도구로활용되어왔다. PASS 는 가지의기본적인자세인눕기, 앉기, 서기로구성되었으며자세유지 5항목과자세변환 7항목으로총 12항목이며점수는최소 0점에서최고 점을적용하여총 6점이만점으로구성되었다. 활활동을 10개의세부항목으로나누고도움의정도에따라 5 단계로점수화하고총점은 100점이다. 특히다른평가도구에비해평가의편리함, 높은정확도, 일관성, 민감도, 그리고통계처리의용이함등으로널리사용되며자조활동과운동성에대한훈련시지표가되었다. 19 4. 자료분석본연구는 SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA) 을이용하여통계처리하였고연구대상자의일반적인특성및두집단군의검사결과에대한평균과표준편차는기술통계로분석하였다. 본연구의모든분석은비모수검정을실시하고유의수준은 α=0.05 으로검정하였다. 치료군의치료전, 후접촉감지, 두점구별, 인체인식력, 손기능, 자세조절능력및일상생활수행력의차이검증은윌콕슨의부호검정 (Wilcoxon signed ranks test) 으로실시하였고치료군간의접촉감지, 두점구별, 인체인식력, 손기능, 자세조절능력및일상생활수행력은맨휘트니 U검정 (Mannn-Whitney U test) 을실시하였다. III. 결과 1. 연구대상자의일반적특성연구대상자는총 17명으로감각운동손상군은 11명, 운동손상군은 6명이며구체적인내용은 able 1과같다. 4) 감각상호작용및수정균형검사 (clinical test of sensory interaction on balance) 본검사는정량평가가가능한 force platform system (model OR6-7-2000, Advanced Mechanical echs Inc., Watertown, MA, USA) 을사용하여선자세에서눈을뜬상태와눈을감은상태에서 10초를측정하였고이어서 5 cm 높이의스펀지매트로제작된부드러운지지면위에서게한후같은방법으로눈을뜬상태와감은상태에서 10초간측정하고무게중심점의이동거리에대한평균을구하였다. 5) 한국판수정바델지수 (Korean version Modified Barthel Index, K-MBI) 본검사는호주의물리치료사 Barthel과의사 Mahoney가 1965 년에고안한일상생활수행평가도구인 Barthel Index 를 Shah 등 16 Shah 와 Muncer 17 가수정보완한 5판을우리나라실정에맞게일부항목을수정보완하여한국어로번역한후통계적인표준화과정을거쳐개발되었다. 18 본검사는일상생 able 1. General characteristics of the subjects Variable SMDG (n=11) MDG (n=6) Age (year) Height (cm) Weight (kg) Duration (month) ype Infarction Hemorrhage umor Paretic side Right Left Gender Male emale 45.18±16.76 16.82±6.1 60.51±6.68 10.00±2.57 5 2 5 6 4 7 51.67±19.01 160.67±6.86 59.10±8.9 11.00±2.45 4 2 0 Values are presented as number or mean±standard deviation. SMDG: sensorimotor deficit group, MDG: motor deficit group. J Korean Soc Phys her 2012:24(5):291-299 29
Bo-Kyung Song: Effect of Somatosensory Stimulation on Sensory, Hand unction, Postural Control and ADL after Stroke 2. 체감각자극전, 후의접촉감지, 두점구별및입체인식변화 able 2와같이, 감각운동손상군의접촉감지는모든부위에서치료전, 후값에차이가있었다 (p<0.05). 두점구별은마비측의모든부위와비마비측의엄지손가락끝을제외한모든부위에서치료전, 후값에차이가있었다 (p<0.05). 입체인식검사도치료전, 후값에차이가있었다 (p<0.01) (able 2). 운동손상군의접촉감지는모든부위에서전, 후의값에차이가있었 으며 (p<0.05). 두점구별의마비측의모든부위와비마비측의검지손가락끝을제외한모든부위에서치료전, 후에도차이가있었다 (p<0.05). 그리고입체인식도치료전, 후의값에차이를보였으나유의하지않았다 (p>0.05) (able 2).. 체감각자극전, 후 M, PASS 및체중심이동거리, K-MBI 변화 able 과같이감각운동손상군의마비측및비마비측 M, able 2. Comparison of D, PDas, PDus and S within SMDG and MDG Variable Before test After test z p SMDG MDG D (mm) PDas (mm) PDus (mm) S (point) D (mm) PDas (mm) PDus (mm) S (point) H H- IN- H H- IN- H H- IN- H H- IN- H H- IN- H H- IN-.54±1.07.72±1.12.79±1.04.87±0.91.96±0.87 17.09±.88 14.00±5. 1.18±4.14 10.6±4.2 8.82±.19 11.55±4.7 7.27±2.24 8.09±2.95.91±1.51.82±1.40 5.00±5.57.09±0.47.0±0.41.22±0.25.22±0.25.9±0.27 10.8±2.2 10.00±1.67 9.00±1.55 8.±.50 7.17±2.86 6.8±2.40 6.±2.25 5.67±1.7.67±0.82.±0.52 9.8±4.58.10±1.4.5±1.19.6±1.18.29±1.12.6±1.09 1.64±4.88 11.82±5.40 10.91±.59 8.55±.96 7.09±.45 9.45±4.52 6.6±2.80 6.7±2.80 2.91±1.04.00±0.6 7.64±6.74 2.8±0.04 2.49±0.17 2.56±0.21 2.49±0.17 2.64±0. 9.17±2.04 8.67±1.86 7.8±1. 6.8±2.71 5.8±2.86 5.50±2.26 5.50±2.59 4.17±1.47.±0.52.00±0.00 11.50±4.76-1.960-2.524-2.677-2.670-2.689-2.814-2.694-2.871-2.751-2.565-2.850-1.681-2.220-2.414-2.060-2.677-2.207-2.226-2.02-2.214-2.22-2.271-2.271-2.070-2.041-2. -2.271-2.26-2.070-1.414-1.414-2.22 0.05* 0.00 0.09 0.0* 0.02* 0.0* 0.0* 0.0* 0.0* 0.0* 0.0* 0.02* 0.02* 0.0* 0.16 0.16 Values are presented as mean±standard deviation. D: tactile detection thresholds, PDas: two point discrimination on affected side, PDus: two point discrimination on unaffected side, S: stereognosis, SMDG: sensorimotor deficit group, MDG: motor deficit group, : forearm, : thenar, H: hypothenar, H-: thumb tip, IN-: index finger tip. *p<0.05, p<0.01, p<0.00. 294 J Korean Soc Phys her 2012:24(5):291-299
송보경 : 뇌졸중환자의상지체감각자극을통한감각, 손기능, 자세조절및일상생활수행력의변화 able. Comparison of Has, Hus, PASS, LDEO, LDEC, LDSEO, LDSEC, and K-MBI within SMDG and MDG Variable Before test After test z p SMDG MDG Has (point) Hus (point) PASS (point) LDEO (cm) LDEC (cm) LDSEO (cm) LDSEC (cm) K-MBI (point) Has (point) Hus (point) PASS (point) LDEO (cm) LDEC (cm) LDSEO (cm) LDSEC (cm) K-MBI (point) 11.6±8.18 0.82±1.54 26.7±1.85 10.84±.4 10.46±2.42 10.2±2.72 10.48±1.96 62.64±9.27 18.67±10.19 0.50±0.84 26.17±2.99 10.20±.01 9.19±1.5 10.20±2.06 10.4±1.82 66.50±8.26 12.90±7.87 1.6±0.92 0.64±1.21 10.68±1.9 10.40±2.2 10.61±.68 11.01±2.16 7.82±7.78 20.50±11.11 1.00±1.10 1.±1.51 12.00±2.9 9.62±1.07 11.69±2.04 10.02±1.05 76.17±10.74-2.555-2.121-2.966-0.178-0.56-1.512-0.979-2.944-1.890-1.72-2.207-2.214-1.581-2.214-0.949-2.207 0.01 0.0* 0.00 0.86 0.72 0.0* 0.4 0.00 0.06 0.08 0.02* 0.0* 0.11 0.0* 0.4 0.0* Values are presented as mean±standard deviation. Has: hand function of affected side, Hus: hand function of unaffected side, PASS: Postural Assessment Scale for Stroke, LDEO: length of displacement with eye open, LDEC: length of displacement with eye close, LDSEO: length of displacement with foam surface and eye open, LDSEC: length of displacement with foam surface and eye close, K-MBI: Korean version Modified Barthel Index, SMDG: sensorimotor deficit group, MDG: motor deficit group. *p<0.05, p<0.01, p<0.00. PASS 및 K-MBI 가치료전, 후의값에차이를보였다 (p<0.05). Length of displacement with eye open (LDEO), length of displacement with eye close (LDEC), length of displacement with foam surface and eye close (LDSEC) 는유의한차이는보이지않았지만 (p>0.05), length of displacement with foam surface and eye open (LDSEO) 에서는치료전, 후의값에차이를보였다 (p<0.05) (able ). 운동손상군마비측및마비측 M는치료전, 후의값에차이가있었으나유의한차이는보이지않았고 (p>0.05), PASS, K-MBI 전, 후의값에차이가있었다 (p<0.05). LDEO, LDSEO 에서는치료전, 후의값에차이를보였으나 (p<0.05), LDEC와 LDSEC 에서는치료전, 후의값에차이가있었으나유의한차이는보이지않았다 (p>0.05) (able ). 4. 체감각자극에대한치료군간의감각기능, 손기능자세균형및일상생활수행력의비교두치료군간의접촉감지, 마비측두점구별, 입체인식력, 마비측과비마비측의 M, LDEO, LDEC, LDSEO, LDSEC 및 K-MBI 에서유의한차이를보이지않았고 (p>0.05). PASS 에서 는유의한차이를보였다 (p>0.05) (able 4, 5). IV. 고찰 뇌혈관손상으로인한뇌졸중환자의감각및운동기능장애는마비측의비사용을학습하여마비측의기능을악화시키며자세조절및기능활동에어려움을준다. 20 본연구는뇌졸중으로인한체감각손상및근약화등의장애특성을가진 17 명의뇌졸중환자를대상으로상지의체감각자극이감각, 손기능, 균형및일상생활수행능력에어떠한영향을주는지알아보고자하였다. 본연구의측정도구로 M, PASS 및 K-MBI 을사용하였다. M는상지의기능회복과정과일상생활수행력을실용적이며객관적으로평가하기쉽게고안되었다. 21 Chai 와 Lee 22 에의해정상표준치가연구되었으며최근뇌졸중환자를대상으로한 Miyamoto 등 2 의연구에서검사및재검사신뢰도, 검사자간신뢰도는모두 k=0.95 로, 손의브론스트롬운동회복단계와의 k=0.80 이상의높은상관성을입증하였다. PASS 는 functional independence measure 와의상관관계에서높은구성타당도 (r=0.7) 와검사자간신뢰도 (k=0.88), J Korean Soc Phys her 2012:24(5):291-299 295
Bo-Kyung Song: Effect of Somatosensory Stimulation on Sensory, Hand unction, Postural Control and ADL after Stroke able 4. Comparison of the Das, PDas, PDus and S between SMDG and MDG Variable SMDG MDG z p D PDas PDus S H H- IN- H H- IN- H H- IN- -0.4±0.66-0.7±0.54-0.4±0.51-0.59±0.59-0.60±0.58 -.45±2.88-2.18±2.18-2.27±2.05-1.82±2.2-1.7±2.5-2.09±1.04-0.91±1.58-1.6±1.80-1.00±1.00-0.82±1.25 2.64±2.91-0.41±0.45-0.54±0.8-0.66±0.41-0.7±0.0-0.75±0.7-1.67±1.0-1.±0.52-1.17±0.75-1.50±1.05-1.±0.82-1.±0.52-0.8±0.41-1.50±1.22-0.±0.52-0.±0.52 1.67±0.82-0.908-1.015-1.70-0.811-1.14-1.458-0.947-1.561-0.427-0.219-1.687-0.657-0.414-1.415-0.686-0.11 0.6 0.1 0.42 0.26 0.15 0.15 0.4 0.19 0.67 0.88 0.12 0.59 0.7 0.22 0.59 0.75 Values are presented as mean±standard deviation. D: tactile detection thresholds, PDas: two point discrimination with affected side, PDus: two point discrimination with unaffected side, S: stereognosis, SMDG: sensorimotor deficit group, MDG: motor deficit group, : forearm, : thenar, H: hypothenar, H-: thumb tip, IN-: index finger tip. able 5. Comparison of Mas, Mus, PASS, LDEO, LDEC, LDSEO, LDSEC and K-MBI between SMDG and MDG Variable SMDG MDG z p Has Hus PASS LDEO LDEC LDSEO LDSEC K-MBI 1.55±0.69 0.55±0.69.90±1.15 0.16±2.67 0.06±1.94-0.92±2.15-0.5±1.44 11.18±4.87 1.8±.06 0.50±0.55 5.17±1.60-1.80±0.10-0.4±0.57-1.48±0.45 0.2±0.81 9.67±4.2-0.726 0.000-1.746-1.715 0.000-1.09-1.208-0.714 0.47 1.00 0.05* 0.09 1.00 0.19 0.2 0.48 Values are presented as mean±standard deviation. Mas: Manual unction test on affected side, Mus: Manual unction test unaffected side, PASS: Postural Assessment Scale for Stroke, LDEO: length of displacement with eye open, LDEC: length of displacement with eye close, LDSEO: length of displacement with foam surface and eye open, LDSEC: length of displacement with foam surface and eye close, K-MBI: Korean version Modified Barthel Index, SMDG: sensorimotor deficit group, MDG: motor deficit group, Has: hand function on affected side, Hus: hand function on unaffected side. *p<0.05. 검사재검사신뢰도 (k=0.72) 를보였고, 24 균형평가도구인버그균형척도 (Berg Balance Scale) 와함께치료사가사용하기쉬게구성되었고환자개개인의심리수준과변화를감지할수있는평가도구로적합하다고하였다. 25 그리고통계적인표준화과정을거쳐우리나라실정에맞게수정보완된 K-MBI 는검사자내신뢰도의 Spearman 계수가재활의학과교수, 재활의학과전공의, 작업치료사가각각 r=0.9~1.00, r=0.87~0.99 그리고 r=0.97~1.00 으로매우높았으며검사자간신뢰도는 k=0.95~0.98 로매우높게입증되었다. 18 따라서본연구에서사용된측정도구는재활과정에서환자의기능적변화를쉽게평가하는데적합한도구로사료된다. 본연구에서적용한상지체감각자극은두치료군의접촉감지, 두점구별및입체인식력에유의한결과를보였다. Julkunen 등 11 은감각기능의회복기간과관련하여접촉감지는 개월부터, 두점구별은 개 296 J Korean Soc Phys her 2012:24(5):291-299
송보경 : 뇌졸중환자의상지체감각자극을통한감각, 손기능, 자세조절및일상생활수행력의변화 월에서 12개월사이에감각회복변화가일어났다고보고하였다. 하지만 Yekutiel 과 Guttman 26 은감각손상을동반한만성편마비 20명의환자를대상으로체계적인감각기능회복훈련을시행한결과촉각, 두점구별인식, 입체인식등의감각기능에유의한차이가있다고보고하였다. 이는연령, 손상부위및발병후기간이감각회복에중요한요소이지만체계적인감각자극이감각회복에중요한요소로작용한다고할수있다. 이는본연구에서진행한어깨와손부위의체계적인체감각자극이감각기능향상에기여하였다고여겨진다. 상지와손기능은 1차로손뻗기요소와물건조작에필요한손의쥐기, 조작요소로설명할수있다. 이러한기능요소는우선적으로시각정보와체감각정보의처리과정이필요한데특히공간내물체의위치와물체의특성의구별하는시각정보와손의접촉감각, 두점구별및입체인식은과제를정확하게수행하는데필수적인요소로설명할수있다. 27 본연구에서는뇌졸중환자를운동및감각손상유무를따라환자의감각기능및손기능에어떠한효과를알아보고자하였고, 6주간의체감각자극은접촉감지, 접촉구별및지각력증진과손의외, 내재근과어깨복합체주위근육의고유감각를활성화에중점을두었다. 이러한 6주간의치료과정은 1차적으로두치료군의접촉감지, 두점구별향상, 물체인식의감각기능이향상되었고 2차적으로마비측과비마비측의 M 및 PASS 에향상을보였다. 손의접촉감각은신체인식력과항중력기능에도작용하는데정상인을대상으로진행한연구에서선자세에서딱딱한표면에손끝접촉은신체요동을감소시키는데도움을주었다. 이는손의체감각정보가자세조절요소에있어공간내신체위치를인식하는공간인식에강력한도움요소로작용함을의미한다. 28 또한반복적인구심성정보를받은중추신경계는감각정보를조직화하여체간및신체의동작을정교하게이루게하여자세조절을가능하도록하고입력되는감각정보를통합하여중력선에대하여움직이는방향에따라신체를유지하도록인식하는신체인식력을증진시킨다. 29,0 뇌졸중으로인한편마비는체감각, 상지기능의저하뿐만아니라자세조절과관련된근활동의손상으로보행, 옷입기동작, 이동과같은과제수행및일상생활수행력에도영향을미친다. 1 Dickstein 등 2 은편마비환자의마비측광배근, 외복사근및복직근의선행성근활동의감소로인하여자세조절의어려움뿐만아니라체간의항중력기능저하로나타나며이는이차적으로어깨뼈, 어깨관절의해부학적정렬과생역학적특성의변화, 근약화로인한신경근활동변화로어깨의비효율적인동작을만든다고하였다. 따라서본 연구에참여한치료군의감각기능향상은일차적으로신체의움직임에인식하는도움요소에영향을주었을것으로사료되며특히감각운동치료군의손기능의변화는손의사용증가로이어져공간인식과체간의안정성에도움이되고감각되먹임과손기능향상을통해신체의안정성에상호작용하여 PASS 점수에도영향을주었을것으로생각된다. 4 이는연구에서의실시한상지체감각자극을통해두치료군의 PASS, 감각운동군의 LDSEO 와운동손상군의 LDEO 와 LDSEO 의유의한결과는손의감각및손기능의향상과자세조절간의연관성을설명할수있는결과라할수있다. 마지막으로신체기능중에서상지및손의기능은일상생활활동수행과작업능력을위해가장중요한부분으로설명된다. 뇌졸중으로인한상지기능의저하는대부분일상생활동작을어렵게하고체간의안정성을방해하여물체에대한뻗기, 조작의어려움을준다. 5 그리고손의기민과민첩성은일상생활활동에중요한요소로설명할수있다. 6 본연구의체감각자극은감각운동손상군과운동치료군의마비측뿐만아니라비마비측손기능에도변화를주었는데이러한결과는두치료군의일상생활수행능력에도움을주었을것으로사료된다. Lee와 Kim 7 은입원중인뇌졸중환자의일상생활활동에영향을미치는여러요인중건측상지와손기능이일상생활동작수행간에상관성이있다고하였다. 따라서뇌졸중으로인한편마비는한손의과도하고지속적인사용은민첩성을저하시키고일상생활의의존성과과제수행을어렵게한다. 7 따라서손의감각및손기능향상은과제의난이도를쉽게하고사용의빈도를증가시켜일상생활의습득을촉진하고향상시킨다. 하지만뇌졸중환자의일상생활활동수행향상을위해서는보상기술의습득능력, 지각과인지의손상유무및회복상태, 효과적인훈련프로그램등이고려되어야할사항이라고보고하였다. 8 따라서일상생활의활동력을증진하기위하여환자의여러가지요소중운동기능뿐만아니라지각기능, 인지기능및체계적인운동학습과정이고려되어야한다. 본연구는뇌졸중환자의감각손상유무로치료군을분류하여상지체감각자극이손감각, 손기능, 자세조절및일상생활수행력증진에어떠한효과가있는지를알아보고자 17 명의뇌졸중환자를두치료군으로분류하여 6주간의체감각자극을실시하였다. 감각운동손상군은접촉감지, 마비측모든부위와무지구제외한비마비의두점구별, 입체인식, M, PASS, LDSEO, K-MBI 에서유의한차이를보였고 (p<0.05), 운동손상군은접촉감지, 마비측모든부위, 엄지손가락끝을제외한비마비의두점구별, PASS, LDEO, LDSEO, K-MBI 에서 J Korean Soc Phys her 2012:24(5):291-299 297
Bo-Kyung Song: Effect of Somatosensory Stimulation on Sensory, Hand unction, Postural Control and ADL after Stroke 유의한차이를보였다 (p<0.05). 또한두치료군간의 PASS 에서 유의한차이를보였다 (p<0.05). 이상의결과로볼때뇌졸중 환자의감각및운동손상에따른상지체감각자극은감각, 손 기능, 자세조절능력및일상생활수행력증진에효과적이었 으며특히감각및운동손상을동반한뇌졸중환자의자세조 절능력에도움이되었다. 이는뇌졸중환자의신체의치료범 위의확대하여신체기능증진에도움이될것으로사료된다. 본연구의제한점으로는상지체감각자극을실시한시간이 외의환경을통제하기어려웠으며적은뇌졸중환자를대상으 로하였기에특성의차이를일반화하는데어려움이있을것으 로사료된다. 참고문헌 1. Geurts AC, de Haart M, van Nes IJ et al. A review of standing balance recovery from stroke. Gait Posture. 2005;22():267-81. 2. Carey LM. Somatosensory loss after stroke. Crit Rev Phys Rehabil Med. 1995;7(1):51-91.. Lin JH, Hsueh IP, Sheu C et al. Psychometric properties of the sensory scale of the ugl-meyer Assessment in stroke patients. Clin Rehabil. 2004;18(4):91-7. 4. Patterson KK, Parafianowicz I, Danells CJ et al. Gait asymmetry in community-ambulating stroke survivors. Arch Phys Med Rehabil. 2008;89(2):04-10. 5. 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