PNF and Movement, 2019; 17(1): 1-9 https://doi.org/10.21598/jkpnfa.2019.17.1.1 Print ISSN: 2508-6227 Online ISSN: 2508-6472 Case Study Open Access 편측무시환자에게실시간초음파영상을이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과 - 단일사례연구 - 김지선 기경일 1 강태우 2 1) 다빈치병원재활치료부, 1 대한 PNF 학회대전충남도회, 2 우석대학교보건복지대학물리치료학과 The Effects of Task-Oriented Training for Left Trunk Flexion Pattern Using Real-Time Ultrasound Imaging -A Single-Subject Experimental Study- Ji-Seon Kim Kyong-Il Ki 1 Tae-Woo Kang 2 Department of Rehabilitation, Davinci Hospital 1 KPNFA Daejeon-Chungnam Branch 2 Department of Physical Therapy, College of Health & Welfare, Woosuk University Received: February 9, 2019 / Revised: February 20, 2019 / Accepted: February 20, 2019 c 2019 Journal of Korea Proprioceptive Neuromuscular Facilitation Association 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. Abstract Purpose: This study investigates the effects of task-oriented training for a left trunk flexion pattern using real-time ultrasound imaging in a stroke patient with unilateral neglect symptoms. Methods: This study used the ABA experimental design, which is a single-subject research method among individual case research methods. For the ABA experimental design, changes in the degree of unilateral neglect, balance ability, and the thickness of the lateral abdominal muscle were visually analyzed during the baseline process, in the intervention period, and after the intervention. The experiments were performed 24 times in total for 8 times in each of the 3 periods. The unilateral neglect was measured using the Albert test, balance ability was measured using the Berg balance test, and the thickness of the lateral abdominal muscle was measured using ultrasound imaging. The subject was a 50-year-old male patient with unilateral neglect caused by right cerebral hemorrhage. He performed task-oriented training for a voluntary left trunk flexion pattern using real-time ultrasound imaging during the intervention period. Results: The result of comparing the data collected during the intervention period with the data point average of the baseline process showed that balance ability improved and the tendency line was above the baseline. The tendency line of unilateral neglect was below the baseline and showed a decreasing tendency. The thickness of the lateral abdominal muscle showed an increasing Corresponding Author : Tae-Woo Kang (ktwkd123@woosuk.ac.kr)
2 PNF and Movement Vol. 17, No. 1 trend and the tendency line was above the baseline. Conclusion: The results of this study suggest that the task-oriented training for left trunk flexion pattern using real-time ultrasound imaging has a beneficial effect on balance ability, the degree of unilateral neglect, and the strength of the lateral abdominal muscle in unilateral neglect patients. Key Words: Neglect, Ultrasonography, Trunk flexion pattern Ⅰ. 서론편측무시 (neglect) 는손상뇌반구의반대측신체정보에대한인식과처리기능이결여되어있는것을의미한다 (Marshall & Robertson, 2013). 이와같은한쪽신체분절에대한반응의제한은신체분절의근력약화와균형능력감소에많은영향을미치게되며 (Jehkonen et al., 2000), 편측무시증상이있는뇌졸중환자들은편측공간무시로인해몸통균형능력에문제가나타난다 (van Nes et al., 2009). Pérennou 등 (1999) 과 van Nes 등 (2009) 는편측무시가신체균형에좋지않은영향을미친다고하였다. 편측무시를위한치료적접근방법은하향식접근법 (top-down) 과상향식접근법 (bottom-up) 으로구분된다. 하향식접근법은외재적인자극이나명령을이용하는방법으로이에반응하여무시측을탐색하며새로운기술을배우는방법이다. 하향식접근법으로시각적탐색 (visual scanning), 상상연습 (mental practice) 이있다 (Fanthome et al., 1995; Gordon et al., 1985; Niemeier et al., 2001). 상향식접근법은무시측에제공되는자극을통해무시측에대한지각을향상시킴과동시에과제수행능력을높여주는방법이다. 상향식접근법으로프리즘안경, 눈패치, 몸통돌림과같은방법들이있다 (Barrett & Burkholder, 2006; Beis et al., 1999; Wiart et al., 1997). 하지만, 최근연구에서눈패치와몸통돌림, 팔다리활동과인식훈련, 그리고몸통돌림과시각적자극같이서로다른두접근법을결합한접근법이효과적이라고하였다 (de Sèze et al., 2001; Fong et al., 2007; Robertson et al., 2002). 편측무시를위한다양한치료적접근방법중시각적되먹임 (visual feedback) 과몸통돌림을결합한훈련이편측무시증상을감소시킨다고하였다 (Wiart et al., 1997). 몸통돌림시외측복부근육인배가로근 (transverse abdominal muscle, TrA), 배속빗근 (internal abdominal oblique muscle, IO), 배바깥빗근 (external abdominal oblique muscle, EO) 은중요한역할을하는것으로알려져있다. TrA 와 IO는같은방향으로 EO는반대방향으로몸통을돌림시키며, 양쪽의 IO와 EO가수축하면몸통을굽힘시키는것으로알려져있다 (Urquhart & Hodges, 2005). TrA와 IO는안쪽에위치하고있어근수축활동을관찰하는것이어렵다. 실시간초음파영상 (real time ultrasound image, RTUI) 을이용한시각적되먹임은 TrA와 IO의두께변화에대한정보를즉각적으로제공이가능하다 (Giggins et al., 2013). RTUI 는초음파화면에나타나는근육층의두께로근육의기능을측정하는비침습적인방법이다 (Bunce et al., 2004; Teyhen et al., 2005). 또한외측복부근육의기능증가를위해능동적인고유수용성신경근촉진법 (proprioceptor neuromuscular facilitation, PNF) 의패턴을이용한훈련이효과적이라고알려져있다 (Gong, 2015). 편측무시환자는자세조절과기능적인활동이감소되어있다 (van Nes et al., 2009). 편측무시환자들은신체중심선에서벗어나몸통이비대칭적으로한쪽으로편향되며, 이로인해자세안정성이감소된다 (Pérennou et al., 1998). 편측무시환자에게수의적인왼쪽방향으로몸통돌림을적용한중재방법이효과적인것으로알려져있으며, 외측복부근육은몸통돌
편측무시환자에게실시간초음파영상을이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과 3 림과자세안정성에중요한역할을하는근육으로알려져있다. 따라서본연구에서는편측무시증상이있는뇌졸중환자에게 RTUI를이용한왼쪽굽힘굴곡패턴을적용한과제지향적훈련의효과를알아보고자하였다. Ⅱ. 연구방법 1. 연구대상본연구는발병후 16개월이지난만성뇌졸중환자를대상으로하였다. 연구대상자는오른쪽대뇌내출혈로뇌내혈종 (intracranial hematoma) 제거술과머리뼈절개술 (craniotomy) 을시행한편측무시환자로신장 168cm, 체중 69.4kg인 50세남성이었다. 편측무시는선나누기검사 (line bisection test) 를이용해측정하였다. 연구대상자는선나누기검사에서 1/4인치이상의편향된양상을보여편측무시가있는것으로나타났다. 본연구의목적에따른평가와중재의시행이가능할수있도록보조도구없이 5분이상독립적으로선자세를유지할수있는환자로선정하였다. 어깨관절의근육을제외한왼쪽팔의근력은 2/5이었으며, 엉덩관절의근육을제외한왼쪽다리의근력은 2/5이었다. 경직도 (spasticity) 는근육경직척도 (modified Ashworth scale, MAS) 를이용해측정하였으며, 팔굽힘근은 MAS 2, 다리는 MAS 1이었다. 또한, 한국판간이정신상태검사 (mini-mental state examination-korean version) 에서 25점으로인지능력에문제가없는것으로나타났다. 연구대상자는편측시야결손 (hemianopsia) 나행위상실증 (apraxia) 과같은증상은없었다. 연구를진행하는동안연구대상자는병원에서제공되는일반적인재활치료를받았으며, 재활치료시편측무시를위한치료는포함되지않았다. 2. 실험설계 몸통굽힘패턴 (trunk flexion pattern) 의과제지향적훈련 (task-oriented training) 을적용한후그효과를알아보기위해개별사례연구방법 (single-subject experi mental research design) 중단일사례연구방법인 ABA 실험설계를사용하였다. 총실험회기는 24회로기초선과정, 중재기간그리고중재이후기간으로구분하여각각 8회씩시행하였다. 기초선과정과중재이후기간에는일반적인재활치료를시행하였으며, 중재기간동안에는왼쪽몸통굽힘패턴을이용한과제지향적훈련을추가적으로실시하였다. 일반적인재활치료는팔과다리의근력증가를포함한보존적인치료와기능적활동을위한매트운동과보행훈련을실시하였다. 중재기간동안연구대상자에게 RTUI를이용한왼쪽으로몸통굽힘패턴을적용하여편측무시를위한과제지향적훈련을실시하였다. 중재이후기간은몸통굽힘패턴을적용한과제지향적훈련의지속효과를알아보기위해실시하였다. 반복되는측정의학습효과를피하기위해각회기마다하루씩간격을두고시행하였다. 3. 측정도구 1) 편측무시알버트검사 (Albert test) 를이용해편측무시를검사하였다. 알버트검사는 A4 크기의검사용지위에 2.5cm 길이의선이중앙에 4개, 왼쪽과오른쪽에각각 18개로총 40개의선이그려져있다. 연구대상자의체간중앙에검사용지를위치시키고, 먼저평가자가중앙 4개의선을표시하여시범을보인후연구대상자가나머지 36개의선을찾고표시하도록했다. 알버트검사의점수는 ( 무시한선의개수 / 총선의개수 ) 100 으로계산하였다. 알버트검사는신뢰도와타당도가높은측정방법이다 (Brem et al., 2014; Cha & Kim, 2015). 본연구는편측무시증상이있는뇌졸중환자에게
4 PNF and Movement Vol. 17, No. 1 2) 균형능력기능적균형을측정하기위해균형잡기검사 (Berg balance test, BBS) 를실시하였다 (Blum & Korner- Bitensky, 2008; Sibley et al., 2011). BBS 는 14개의균형측정으로구성되며, 각항목의점수는 0 4 점으로총점은 56점이다. 뇌졸중환자를대상으로한측정에서측정자가신뢰도가높은측정방법이다 (Lisa & Nicol, 2006). 3) 외측복부근육두께외측복부근육의두께를측정하기위해 5 MHz 볼록형탐촉자초음파 (achieve CST, V2U healthcare, Singapore) B-모드를사용하였다. 초음파를이용해휴식시와복부드로우-인 (abdominal draw-in maneuver, ADIM) 시 TrA, IO, EO의수축을측정하였다. 초음파탐촉자는 12번째갈비뼈와엉덩뼈능선사이 2.5cm 내측에위치하도록하였다 (Teyhen et al., 2005). 초음파측정후초음파화면에서 TrA의근막끝부분에서내측으로 2cm 수평선을그은후수평선과수직으로선을그어 TrA, IO, EO의두께를측정하였다 (Hodges et al., 2003). 연구대상자는엉덩관절과무릎관절을굽힘하고바로누운자세 (hook-lying position) 에서측정을실시하였으며, 양쪽외측복부근육의두께를모두측정하였다. 휴식과 ADIM 을무작위로실시하였으며, 각각 3번씩측정하였다. ADIM은 " 배꼽을등쪽으로움직이세요." 라고구두지시를내렸다 (Mannion et al., 2008; Stetts et al., 2009). 각동작을 5초동안유지하도록하였으며, 각동작간에 30초의휴식시간을갖도록하였다 (Ishida et al., 2012). 4. 중재방법 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련은정확한 TrA의수축을위한 ADIM 훈련단계와편측무시를위한 RTUI를이용한훈련단계로 구분하여실시하였다. ADIM 은 TrA의단독적인수축이가능한훈련방법이다 (Teyhen et al., 2005). 첫단계에서연구대상자는엉덩관절과무릎관절을굽힘하고바로누운자세에서를취하였다. 초음파화면은연구대상자의왼쪽눈높이에맞춰위치하도록하였다. TrA 수축의변화를초음파화면을통해실시간으로볼수있도록하였다. 연구대상자는몸의중심에서왼쪽으로 15-35도몸통을수의적으로돌림하도록하였다 (Fong et al., 2007). ADIM을실시하는동안정확한 TrA의수축을즉각적으로수정하며실시하도록하였다. 두번째단계는연구대상자가바로선자세에서실시하였으며, 초음파의위치와근육의수축은첫단계와동일한방법으로진행하였다. 연구대상자는몸통을왼쪽으로회전하여초음파화면을볼수있도록하였다. 근육의수축은 5초동안유지하였고, 각각의단계를 10회씩 3세트반복훈련하였다. 5. 자료분석본연구에서는기초선과정, 중재기간그리고중재이후에편측무시정도, 균형능력그리고외측복부근육의두께변화를평가하기위해측정된자료는시각적으로분석되었다. 각측정회기에서수집된자료는그래프상점으로표시하고그값에대한경향선으로분석을실시하였다. Ⅲ. 연구결과각회기별로측정된자료는 Fig. 1과 Fig. 2에제시되었다. 기초선과정과비교하여중재기간과중재이후기간의자료점을연결한경향선이다른양상을보였다. 먼저, 중재기간동안 BBS는최소 2점에서최대 8점까지향상되었으며, 기초선과정의자료점평균값을연장한경향선보다위에위치하는것으로나타났다. 중재기간동안알버트검사는최소 2점에서최대 7점까지감소되었으며, 기초선과정의자료점평균값을
편측무시환자에게실시간초음파영상을이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과 5 Fig. 1. Comparison of individual data across the baseline, intervention, and follow-up phases. (A) Berg balance test (BBS). (B) Albert test. Solid transverse lines indicate the celeration line in each phase. Fig. 2. Comparison of individual data across the baseline, intervention, and follow-up phases. (A) Thickness of right side transverse abdominis. (B) Thickness of right side internal oblique. (C) Thickness of right side external oblique. (D) Thickness of left side transverse abdominis. (E) Thickness of left side internal oblique. (F) Thickness of left side external oblique. Solid and dotted transverse lines indicate the celeration line in resting position and abdominal drawing-in maneuver, respectively.
6 PNF and Movement Vol. 17, No. 1 연장한경향선보다아래위치하는것으로나타났다 (Fig. 1). 중재기간동안 ADIM을실시하였을때오른쪽과왼쪽 TrA의두께변화는기초선과정의자료점평균값을연장한경향선보다위에위치하는것으로나타났다. 중재기간동안 ADIM 을실시하였을때양쪽 IO와 EO의두께변화는기초선과정의자료점평균값을연장한경향선보다아래위치하는것으로나타났다 (Fig. 2). Ⅳ. 고찰편측무시는운동, 감각그리고인지감소의결과로나타나며 (van Nes et al., 2009), 이로인해비대칭적인몸통의편향으로자세의안정성이감소하게된다 (Pérennou et al., 1998). 따라서, 편측무시환자들은균형, 보행과같은기능적인능력이저하한다 (van Nes et al., 2009). 몸통의비대칭성은편측무시그리고기능능력과높은상관성이있다. RTUI 는편측무시환자들에게수의적인몸통움직임훈련을적용시유용하게사용할수있다. 본연구는편측무시증상이있는뇌졸중환자에게 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과를알아보고자하였다. 연구의결과 RTUI를이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련이편측무시정도, 균형능력그리고외측복부근육의두께변화에효과적인것으로나타났다. 본연구에서는편측무시환자에게 RTUI를이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련을실시하였다. RTUI 를이용한중재방법은외측복부근육의정확한수축에대한정보를제공하여재교육과진단방법으로유용하게사용되어지고있다 (Beazell et al., 2011). RTUI 를이용한중재방법은외측복부근육의두께변화를즉각적인관찰이가능하여환자들에게정확한 TrA, IO 그리고 EO의수축정보를제공하여효과적인교육이가능할수있었다. 건강한사람의경우양쪽외측복부근육의두께가대칭적으로나타난 다 (Ikai et al., 2003). 본연구의연구대상자는왼쪽외측복부근육의두께가오른쪽보다얇았다. 특히, 연구대상자가 ADIM 을실시하였을때양쪽근육의두께차이가더크게나타났다. 따라서연구대상자에게양쪽외측복부근육의대칭성회복을위한훈련의필요성을알수있었다. 이는 RTUI를이용해왼쪽으로몸통굽힘패턴을적용한과제지향적훈련이편측무시와균형능력, 그리고 TrA의수축능력향상에도움이되고이월효과가있는것으로해석될수있다. 선행연구들에서는편측무시의재활치료방법으로시각과청각적인되먹임, 눈패치, 왼쪽몸통돌림이주로제시되고있다 (Fong et al., 2007; Gordon et al., 1985; Karnath et al., 1993; Spinelli & Di Russo, 1996; Wiart et al., 1997). 시각과청각적인되먹임방법은환자들에게중재법실행후성공과실패에대한정보만을제공하는것으로알려져있다 (Wiart et al., 1997). 왼쪽방향으로몸통돌림훈련은시각적오류를감소시키는것으로나타났다 (Karnath et al., 1993; Wiart et al., 1997). Fong 등 (2001) 은눈패치를착용한상태에서수의적인몸통돌림을실시한그룹에서편측무시정도의감소와기능적인능력이증가하였다보고했다. 이는 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련의결과편측무시정도와균형능력그리고외측복부근육의두께변화에서기초선기간보다중재기간동안긍정적인영향을보인본연구의결과와일치한다. TrA는능동적인활동시정상적인운동조절에중요하게작용하는것으로알려져있다 (Hodges, 1999). 본연구의결과 TrA의두께가증가하였다. 따라서이와같은결과가상하지의움직임시몸통의안정성을제공하여균형능력을증가시키는데긍정적인영향을미친것으로생각된다. 본연구는편측무시증상이있는뇌졸중환자를대상으로 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과를알아보기위해 ABA 단일사례연구방법을사용하였다. 단일사례연구방법은임상적인견지에서대상자의구체적인반응을체계적으로연구할수있는실험방법으로여겨진다
편측무시환자에게실시간초음파영상을이용한왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과 7 (Portney & Watkins, 2000). 그러나본연구에서는한명을연구대상자로하였기때문에본연구의결과를일반화하기에는어려움이따른다. ABA 단일사례연구방법에따른중재적용에따라기초선과정과중재이후기간동안일반적인재활치료를시행하였으며, 중재기간동안왼쪽몸통굽힘패턴을이용한과제지향적훈련을추가적으로실시하였다. 중재기간동안추가적인중재적용에따른운동량증가에의해기능향상의결과가나타났을수있다. 따라서향후연구에서는이러한점을보완하여많은연구대상자를포함하고보다오랜기간동안 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련에대한연구가지속적으로시행되어야할것이다. Ⅴ. 결론본연구는편측무시증상이있는뇌졸중환자에게 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련의효과를알아보기위해시행하였다. 그결과 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련이편측무시정도, 균형능력그리고외측복부근육의두께변화에효과적인것을알수있었다. 따라서본연구의결과 RTUI를이용해왼쪽몸통굽힘패턴을적용한과제지향적훈련의적용이편측무시환자들의중재방법으로유익한것으로생각된다. 본연구는한명을대상자로본연구의결과를일반화하기에는어려움이있으므로, 향후많은수의대상자를통한연구가계속이루어져야할것이다. References Barrett AM, Burkholder S. Monocular patching in subjects with right hemisphere stroke affects perceptualattentional bias. Journal of Rehabilitation Research and Development. 2006;43(3):337-346. Beazell JR, Grindstaff TL, Hart JM, et al. Changes in lateral abdominal muscle thickness during an abdominal drawing-in maneuver in individuals with and without low back pain. Research in Sports Medicine. 2011;19(4):271-282. Beis JM, André JM, Baumgarten A, et al. Eye patching in unilateral spatial neglect: efficacy of two methods. Archives of Physical Medicine and Rehabilitation. 1999;80(1):71-76. Blum L, Korner-Bitensky N. Usefulness of the Berg balance scale in stroke rehabilitation: a systematic review. Physal Therapy. 2008;88(5):559-566. Brem AK, Unterburger E, Speight I, et al. Treatment of visuospatial neglect with biparietal tdcs and cognitive training: a single-case study. Frontiers in Systems Neuroscience. 2014;8:180. Bunce SM, Hough AD, Moore AP. Measurement of abdominal muscle thickness using M-mode ultrasound imaging during functional activities. Manual Therapy. 2004;9(1):41-44. Cha HG, Kim MK. The effects of repetitive transcranial magnetic stimulation on unilateral neglect of acute stroke patients: a randomised controlled trial. Hong Kong Physiotherapy Journal. 2015;33(2):53-58. De Sèze M, Wiart L, Bon-Saint-Côme A, et al. Rehabilitation of postural disturbances of hemiplegic patients by using trunk control retraining during exploratory exercises. Archives of Physical Medicine and Rehabilitation. 2001;82(6):793-800. Fong KN, Chan CC, Au DK. Relationship of motor and cognitive abilities to functional performance in stroke rehabilitation. Brain Injury. 2001;15(5):443-453. Fong KN, Chan MK, Ng PP, et al. The effect of voluntary trunk rotation and half-field eye-patching for patients with unilateral neglect in stroke: a randomized controlled trial. Clinical Rehabilitation. 2007;21(8): 729-741.
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