pissn Vol. 29, No. 1, February 2017 J Kor Phys Ther 2017:29(1):1-6 1229-0475 eissn 2287-156X Original Article Effects of Respiratory Muscle Strengthening Exercise on Respiratory Function and Activities of Daily Living in Stroke Patients Beom-Ryong Kim 1, Jeong-Ii Kang 2, Yong-Nam Kim 3, Dae-Keun Jeong 2 1 Department of Physical Therapy, Design Hospital, Jeonju; 2 Department of Physical Therapy, Sehan University, Yeongam-gun, Jeollanam-do; 3 Department of Physical Therapy, Nambu University, Gwangju, Korea Purpose: This study aimed to demonstrate reduction in stroke symptoms by analyzing the changes in respiratory function and activities of daily living (ADL) after respiratory muscle strengthening exercise in patients who had a stroke and thereby, propose an efficient exercise method. Methods: Twenty patients with hemiplegic stroke were divided into two groups, with 10 patients in each. The control group (CG) received the traditional exercise therapy, and the experimental group (EG) received the traditional exercise therapy combined with expiratory muscle strengthening training. The training continued for 6 weeks, 5 days a week. Forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) were measured with a spirometer, SpO2 was measured with a pulse oximeter, and ADL were assessed by using the modified Barthel index (MBI). A paired t test was applied to compare the differences before and after the intervention, and an independent t test was used to compare the differences between the groups. The level of statistical significance was set as α= 0.05. Results: The changes in the FVC and FEV1 values within the group showed significant differences only in the EG (p< 0.01). The betweengroup difference was statistically significant only for FVC and FEV1 in the EG (p<0.01). The changes in SpO2 and MBI within the group showed significant differences only in the EG and CG (p<0.01). Between-group differences were statistically significant only for SpO2 and MBI in the EG (p< 0.05). Conclusion: The interventions with active patient involvement and combined breathing exercises had a positive impact on all the functions investigated in this study. Keywords: ADL, Respiratory function, Respiratory muscle strengthening exercise, Stroke 서론뇌졸중 (stroke) 은뇌혈관의막힘이나출혈을유발시켜뇌조직에혈액공급이차단되어신경학적결손증상이나타나며, 결손부위에따라운동기능, 감각기능, 인지기능, 언어기능, 호흡기능등의손상 (impairment) 으로신체활동에심각한제한 (limitation) 을받는다. 1 뇌졸중으로인한기능부전은마비측의근력과운동조절능력저하및협응된움직임의상실등으로운동기능이현저히저하되어독립적인일상생활수행의감소로호흡근의효율성을감소시킨다. 호흡근의약화와복부근의근력저하는호흡근의단축과섬유화로이어져가슴우리와폐의유순도를떨어뜨려기침능력과객담제거능력이저하되어, 기 도내분비물이축적되어폐렴, 무기폐와같은호흡기계합병증을일으킨다. 2 또한, 뇌졸중환자들은낮은산소포화도를보이며, 저산소증으로호흡기능저하를흔하게관찰할수있다. 이런문제점들은근력과지구력이요구되는재활프로그램중재와유산소운동과정에서피로감을쉽게유발시켜기능적회복과지역사회로의복귀가늦어진다. 3 이와같이호흡근의기능은독립적인일상생활수행에영향을미치므로호흡근의기능을개선시키기위해서는호흡근강화운동이필요한실정이다. 2 Sutbeyaz 등 2 은뇌졸중환자를대상으로 6주간들숨근강화운동으로가로막과입술을오므린호흡을실시한결과폐기능과일상생활수행능력의향상을보였으며, 환자의호흡곤란을감소시켜삶의질 Received Jan 9, 2017 Revised Feb 15, 2017 Accepted Feb 22, 2017 Corresponding author Beom-Ryong Kim E-mail kimbr21@hanmail.net Copylight 2017 The Korea Society of Physical Therapy This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License (Http:// creativecommons.org/license/by-nc/4.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. www.kptjournal.org 1
The Journal of Korean Physical Therapy Beom-Ryong Kim, et al. 을향상시키는결과를가져왔다. Britto 등 4 은뇌졸중환자를대상으로 8주간최대흡기압력의 30% 저항으로들숨근강화운동을실시한결과최대들숨압과들숨근의근력과지구력이증가된결과를얻었다. 이와같이호흡에서들숨근인가로막의기능에대한중요성은잘알려져있지만가로막과함께호흡에관여하는복부근에대한중요성은간과되고있다. 들숨시에는가로막이수축하여공기가폐로들어오게하고강한날숨시에는복부근의수축과가로막을위방향으로이완시켜공기가밖으로나오게한다. 이처럼가로막과복부근의협력수축은복부내압 (intra abdominal pressure) 을조절하여호흡에관여한다. 5 복부근과관련된선행연구중 Seo 6 는뇌졸중환자를대상으로복부근강화운동을실시한결과복부근두께와보행및균형능력에향상을보였다. Oh 등 7 은뇌졸중환자를대상으로흡기근훈련기반복부근강화를실시한결과복부근두께가유의하게두터워졌고, 동적및정적균형능력에향상을보였다. 이와같이일반적으로선행연구들은복부근과관련하여보행과균형능력및복부근두께에관련된연구가주를이루고있지만, Kim 등 8 은만성요통을가진 50대여성들을대상으로복부근강화운동후 5일부터폐기능의유의한향상과허리통증의감소가나타났으며, Choi 9 는뇌졸중환자들을대상으로몸통강화운동을 6주간실시한결과복부심부근두께와폐기능에향상을보여날숨근과관련된복부심부근강화운동이필요하다고했으며, Yoon 10 은뇌졸중환자를대상으로 8주간코어운동프로그램을실시한결과흡기능력향상에효과가있다고했으며, 다른호흡운동프로그램들과병행하여대상자의호흡기능을향상하는데노력해야한다고했다. 이와같이호흡근으로복부근강화를통해서근육의두께변화, 균형과보행능력및폐기능향상에효과적이라는연구들이보고되고있지만, 뇌졸중환자들에게들숨근과복부심부근강화운동을적용하여호흡기능과일상생활수행능력의변화에효과가있는지를비교한연구는미비한실정이다. 따라서본연구에서는뇌졸중환자들에게전통적인운동치료와함께들숨근호흡운동과복부심부근강화운동을실시하여호흡기능과일상생활수행능력의변화를알아보 고최종적으로는뇌졸중환자의기능적증상을개선시키고효율적인운동방법을제공하는데연구의목적이있다. 연구방법 1. 연구대상본연구는 2015년 1월부터 2월까지 6주동안전라북도 J시소재 D병원에내원한환자를대상으로실시하였다. 대상자는뇌졸중으로인한편마비를진단받고, 1년이상 2년미만경과한 50-60대사이연령범위의뇌졸중환자로, 폐질환혹은선천적가슴우리의변형이나갈비뼈골절등의병력이없는자, 폐기능향상을위한특별한치료를받지않았던자, 연구자가지시하는내용을이해하고따를수있도록한국판간이정신상태검사 (mini mental state examination-korea, MMSE-K) 점수가 24점이상인자, 본연구에대한목적과절차의설명을충분히숙지하고동의서를받은 20명을대상으로하였다. 이들을각각전통적운동치료와호흡근강화운동을실시한실험군 (n = 10) 과전통적운동치료를실시한대조군 (n = 10) 으로무작위배정하였다. 연구대상자일반적특성은다음과같다 (Table 1). 2. 실험방법 1) 전통적운동치료프로그램전통적운동치료는 6주간, 주 5일, 1일 2회, 1회 40분씩시행하였다. 준비와정리운동, 매트운동, 중추신경계발달치료, 보행훈련을환자수준에맞게운동강도를조절하여 10분씩실시하였다. 대조군은몸통조절능력을높이기위해몸통안정성운동에초점을맞췄으며, 몸통의유연성을위한신장운동을포함하였다. 2) 호흡근강화운동프로그램들숨근과복부심부근을병행한호흡근강화운동군은전통적운동치료 40분과 POWERbreathe을이용한들숨근강화운동 20분그리고 Grenier & McGill 11 에브레이싱운동 (bracing exercise) 20분으로구 Table 1. Characteristics of participants Experimental group (n=10) Control group (n=10) p Sex (male/female) 6-4 6-4 1.00 Side of stroke (right/left) 7-3 6-4 1.00 Type of stroke (hemorrhage/infarction) 8-2 9-1 1.00 Time after stroke (month) 16.40 (3.75) a 16.80 (3.82) 0.14 Age (year) 61.40 (3.84) 61.30 (4.42) 0.76 Height (cm) 162.60 (8.98) 162.40 (9.77) 0.95 Weight (kg) 63.00 (9.58) 62.50 (7.79) 0.99 MMSE (scores) 26.20 (2.20) 25.90 (1.97) 0.06 a Mean (SD). 2 www.kptjournal.org
Respiratory Muscle Strengthening Exercise 성각각 6주간, 주 5일, 1일 1회시행하였다. 들숨근강화운동은들숨근을강화시키기위하여 POWERbreathe (POWERbreath International Ltd, UK) 장비를사용하였다. 본장비의사용방법은기립자세에서코에집게를물리고마우스피스를입에물고있는상태에서호흡을할때날숨 (expiratory) 시에는저항없이편안하지만들숨 (inspiratory) 시에는손잡이부분에부하조절스프링이있어 0 으로갈수록강도가낮아지고 10 으로갈수록강도가높아진다. 본장비를사용한들숨근강화운동은 Romer 등 12 의프로토콜을바탕으로적용하였으며, 들숨근강화운동최초시작강도는대상자별최대들숨압 (maximal inspiratory mouth pressure, PImax) 을측정하여 PImax의 50% 에해당하는압력으로주차별대상자가 1주 7회, 2-3 주 10회, 4-5주 15회, 6주 20회의흡기할수있는강도로실시하도록강조하였으며, 주기적으로부하를증가시켜서실시하였다 (Figure 1). 13 복부심부근강화운동은 Grenier & McGill 11 의브레이싱운동 (bracing exercise) 을시행하였다. 본운동의방법은대상자가무릎을 90도구부리고누운자세로허리와골반의정렬을맞춘상태에서압력생체되먹임기구 (Stabilizer, Pressure Biofeedback Unit, USA) 를허리부위에위치시킨후압력계의압력을 40 mmhg로유지시켰다. 이후복부에힘을주어복부에모든근육이빠르게수축하도록하여압력계의압력을 70 mmhg로상승시켜서유지하도록하였다. 이때몸통의근육들이밖으로퍼져나간다는느낌으로시행시켰으며배곧은근이볼록해지거나들어가면안되며, 힘을너무많이줘서호기가힘들면안되고편하게쉴수있어야한다. 11 대상자가스스로복부에압력을가하면중재자가운동이정확하게실시되고있는지되먹임 (feedback) 을주 면서 6주동안운동조절 (motor control) 의변화를확인하여 7초, 10초, 15초, 20초로점진적으로유지시간을늘려갔다 (Figure 2). 14 3) 측정항목및방법 (1) 폐기능측정폐기능 (pulmonary function) 측정은폐기능검사기 (Schiller SP-260, Medical Supply Co., Ltd, Switzerland) 를사용하였다. 대상자에게측정방법에대한충분한설명과측정시범을통하여충분한교육이이루어진상태에서실시하였다. 측정지표는최대노력성날숨에서얻어진노력성폐활량 (forced vital capacity, FVC) 과최대노력성날숨을시작한후 1초간내쉰 1초간노력성날숨량 (forced expiratory volume at one second, FEV1) 을측정하였다. 폐기능측정은앉은자세에서 3회반복측정하여평균값을기록하였다. (2) 혈중산소포화도측정혈중산소포화도 (SpO 2 [%]) 측정은대상자에게 5분이상앉은자세에서편안하게휴식을취한상태에서혈중산소포화도측정기 (MP- 110Plus, Mekics Co., Ltd, Korea) 를이용하여측정센서를건측검지에서부착시켜혈중산소포화도을측정하였다. 혈중산소포화도를 1분간측정하였으며, 그값이안정상태를나타낼때기록하였다. 15 (3) 일상생활수행능력평가수정된바델지수 (modified Barthel index, MBI) 는만성질환을가진성인의기능적독립성과일상생활수행능력을평가하는데사용된다. 10가지 Figure 1. Inspiratory muscle strengthening exercise. Figure 2. Bracing exercise. www.kptjournal.org 3
The Journal of Korean Physical Therapy Beom-Ryong Kim, et al. 일상생활영역을평가하는 5점척도로총점은 100점으로대상자의일상생활수행시직접적인관찰과면접을통하여의존도의정도를평가한다. 0점에서 24점은완전의존성, 25점에서 49점은최대의존성, 50에서 74점은중등도의존성, 75점에서 90점은약간의존성, 91점에서 99점은최소의존성을나타낸다. 16 이측정도구는기능적독립측정도구 (functional independence measure, FIM) 와높은내적인지도를보인다. 17 3. 자료처리본연구를위한자료처리방법은 Window용통계프로그램 SPSS/PC Statistics 18.0 software (SPSS Inc., Chicago, USA) 을이용하여통계처리하였다. 연구대상자의일반적인특성을 Shapiro-wilk로정규성검정을하였고, 호흡근강화운동에따른중재전과후의집단내호흡기능과일상생활수행능력에변화를비교하기위하여대응표본 t-검정 (paired t-test) 을실시하였으며, 실험군과대조군의집단간의차이를비교하기위해독립표본 t-검정 (independent t-test) 으로검정하였다. 모든통계학적유의수준은 α = 0.05로설정하였다. 결과 1. 폐기능변화비교집단내노력성폐활량 (FVC) 과 1초간노력성날숨량 (FEV1) 의변화는실험군에서유의한차이가있었고 (p < 0.01), 대조군에서는유의한차이가없었다. 집단간노력성폐활량 (FVC) 의변화에서는실험군과대조군사이에서유의한차이가있었고 (p < 0.05, 95% CI, 0.14-1.92), 1초간노력성날숨량 (FEV1) 의변화에서도실험군과대조군사이에서유의한차이가있었다 (p< 0.05, 95% CI, 0.14-1.63) (Table 2). 2. 산소포화도변화비교집단내산소포화도 (SpO 2) 의변화는실험군에서유의한차이가있었고 (p < 0.01), 대조군에서도유의한차이가있었다 (p < 0.05). 집단간산소포화도 (SpO 2 ) 의변화에서는실험군과대조군사이에서유의한차이가있었다 (p< 0.05, 95% CI, 0.09-1.11) (Table 2). 3. 일상생활수행능력변화비교집단내일상생활수행능력 (MBI) 의변화는실험군에서유의한차이가있었고 (p < 0.01), 대조군에서도유의한차이가있었다 (p < 0.01). 집단간일상생활수행능력 (MBI) 의변화에서는실험군과대조군사이에서유의한차이가있었다 (p < 0.05, 95% CI, 0.27-14.13) (Table 2). 고찰본연구에서는신체활동의감소로호흡근육의효율성이떨어진뇌졸중으로인한편마비환자 20명을대상으로전통적운동치료와호흡근강화운동을실시한실험군 10명과전통적운동치료를실시한대조군 10명으로구분하여, 주 5회 6주간중재후호흡기능 (FVC, FEV1, SpO 2) 과일상생활수행능력 (MBI) 에어떠한영향을미치는지논의하고자한다. Grenier & McGill 11 은몸통강화와안정화를위한운동방법으로임상에서많이사용하는동작은 bird dog, curl-up, plank, side bridge 등이있으며, 이러한동작은몸통을둘러싸고있는심부근육과표층근육간의협력수축 (co-contraction) 을이끌어낸다. 그러나본연구에서실시한브레이싱운동은기능적으로약화된심부의복부근육을좀더효과적으로개별수축 (isolated contraction) 시켜근력과지구력을증가시키는운동방법이다. Kang 등 18 은뇌졸중환자를대상으로브레이싱운동을 6주간중재하여호흡기능과균형능력이향상됨을알수있었으며, 본연구의운동방법의적절성을뒷받침한다. 그리고 Moodie 등 19 은가로막과들숨보조근에부하를가하여들숨근의근력과지구력을향상시키는데들숨근강화운동이계획적이고체계적으로진행될수있도록과부하 (over load), 점진성 (progressive), 개별성 (individual), 계속성 (continue), 가역성 (reversibility) 등의 5가지트레이닝기본적인원칙을바탕으로적용하는운동방법이라고하였으며, 본연구에서도이러한선행연구를바탕으로편마비로약화된호흡근육의운동성과근력및지구력을증가시키기위해들숨근강화운동을중재하였다. Jung 20 은뇌졸중으로인한편마비환자를대상으로들숨근과가슴 Table 2. Outcome measurements (N=20) Variables Experimental group (n=10) Control group (n=10) Between groups p values (95% CI) Pre-test Post-test Pre-test Post-test FVC (L) 2.47 (1.03) 3.36 (1.00) *, 2.30 (0.83) 2.33 (0.89) 0.05 ** (0.14 1.92) FEV1 (L) 2.01 (0.87) 2.87 (0.83) *, 1.97 (0.69) 1.99 (0.76) 0.05 ** (0.14 1.63) SpO 2 (%) 95.20 (1.55) 98.10 (0.57) *, 96.70 (0.95) 97.50 (0.53) * 0.05 ** (0.09 1.11) MBI (score) 61.70 (8.18) 70.10 (6.97) *, 61.50 (8.03) 62.90 (7.77) * 0.05 ** (0.27 14.13) a Means (SD), * significant difference within groups, significant difference between group. FVC: forced vital capacity, FEV1: forced expiratory volume at one second, MBI: modified Barthel index. ** p<0.05. 4 www.kptjournal.org
Respiratory Muscle Strengthening Exercise 가동성운동을중재한결과 FVC는중재전후와, 집단간비교에서모두유의한차이가없었다. 그러나 Seo 등 21 은뇌졸중으로인한편마비환자를대상으로가슴우리확장운동을중재한실험군에서 FVC가중재전후와집단간비교에서모두유의한향상을보였으며, Cho 등 22 은뇌졸중으로진단받고 1년이경과된 60세에서 75세이하편마비환자를대상으로날숨근과들숨근저항운동기구를이용하여호흡근강화운동을실시한결과 FVC는중재전후와집단간비교에서모두유의한향상을보였다. 본연구에서도호흡근강화운동군에서 FVC 는중재전보다후에유의하게개선되었다 (p < 0.01). 또한집단간비교에서도대조군에비해호흡근강화운동군에서유의한차이를보여선행연구를지지해주고있다 (p< 0.05, 95% CI, 0.14-1.92). Lee 등 23 은뇌졸중으로진단받고 6개월이상된편마비환자를대상으로앉은자세에서들숨시가로막저항운동과날숨시입술을오므린호흡운동을실시한실험군에서 FEV1은중재전후와집단간비교에서모두유의한차이를보였고, Choi 9 는뇌졸중환자를대상으로몸통강화운동을실시한결과 FEV1에서유의한향상을보였다. 이와같이선행연구들에서알수있듯폐기능을향상시키기위해서는호흡에관여하는근육들의강화운동이필요함을시사해준다. Jung과 Kim 24 은뇌졸중환자를대상으로들숨근저항운동을중재한결과, 대조군에비해들숨근저항운동을실시한실험군에서 FEV1이유의하게증가하였으며, 본연구에서도호흡근강화운동군에서 FEV1은중재전보다후에유의하게개선되었다 (p < 0.01). 또한집단간비교에서도대조군에비해호흡근강화운동군에서유의한차이를보여 (p < 0.05, 95% CI, 0.14-1.63), 선행연구와같이호흡근을강화시키는형태의운동으로지지하는결과를도출할수있었다. 그이유로는반복된호흡근강화운동을통한근력향상과근육의두께변화가복부내압과날숨능력의향상으로 FEV1의향상에영향을보였다. 25,26 Wu 등 27 은만성폐쇄성폐질환환자를대상으로들숨시가로막호흡운동과날숨시입술을오므린호흡운동을 12주간중재한결과폐기능에는효과가있었지만 SpO 2 는유의한차이를얻지못하였으며, Jung 28 은뇌졸중으로인한편마비환자를대상으로들숨근운동기구를이용하여호흡운동을실시한결과 SpO 2 에유의한차이를얻지못하였다. 그러나본연구에서는대조군과호흡근강화운동군모두에서 SpO 2 가중재전과후에유의하게향상되었다 (p < 0.01). 또한집단간비교에서는대조군에비해호흡근강화운동군에서유의한차이를보여 (p< 0.05, 95% CI, 0.09-1.11), 선행연구와상반되는결과를도출하였다. 이러한결과는운동의형태는다르지만호흡근의근력증가를통해서 SpO 2 가향상됨을알수있으며, 본연구의중재방법이 SpO 2 를향상시키는데효과적임을확인할수있었다. Kim 등 26 은뇌졸중으로진단받고 6개월이상경과한 21명을대상으로날숨근운동기구를이용한실험군에서 MBI는중재전후와집 단간비교에서모두유의한향상을보이지않았으며, Kim 29 은뇌졸 중발병일이 6 개월이상된뇌졸중환자를대상으로가슴우리확장 운동군, 유산소운동군, 대조군으로무작위배정하여중재한결과 MBI 는세집단모두중재전후에서유의한향상을보였으며, 집단간 비교에서는대조군에비해서는유산소운동군만유의한향상을보 였다. 그러나본연구에서는들숨근과호흡근강화운동군에서 MBI 는중재전보다후에유의하게개선되었다 (p < 0.01). 또한집단간비교 에서는대조군에비해호흡근강화운동군에서유의한차이를보였 다 (p < 0.05, 95% CI, 0.27-14.13). 이는 Park 과 Hong 30 의연구에서호흡기 능이일상생활활동중개인위생, 목욕하기, 식사하기, 용변처리, 옷입 기항목에서일상생활수행에서관련성이있다고하였으며, 호흡운 동이뇌졸중환자의 MBI 를향상시키는중재방법이될수있다고하 였다. 이와같은결과는폐기능이향상되면 MBI 가향상됨을알수 있었다. 본연구의호흡근강화운동은몸통안정성에기여하는복부심부 근과가로막의강화로호흡기능과일상생활수행능력을향상시키는 데효과적이었고, 안정성수축으로인해복부심부근과가로막의근 력과지구력의향상은몸통안정성이향상되는요소로작용되어호 흡기능에매우중요한요소임을확인하였다. 이러한결과를바탕으 로향후에도임상에서호흡기능과일상생활수행능력의향상을위해 복부심부근을강화시키기위한다양한연구가필요할것으로사료 된다. 본연구의제한점은 1 개의의료기관에서실험을진행하였기에 모든뇌졸중환자에게일반화하여해석하기에는어려움이있으며, 연구대상자가투여하고있는복용약물및약물의복용횟수와일상 생활등을통제하지못하였기에연구결과에영향을미칠수있다는 점이다. 참고문헌 1. Kolb B, Mychasiuk R, Williams P et al. Brain plasticity and recovery from early cortical injury. Dev Med Child Neurol. 2011;4:4-8. 2. Sutbeyaz ST, Koseoglu F, Inan L et al. Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial. Clin Rehabil. 2010; 24(3):240-50. 3. Roffe C, Sills S, Pountain SJ et al. A randomized controlled trial of the effect of fixed-dose routine nocturnal oxygen supplementation on oxygen saturation in patients with acute stroke. J Stroke Cerebrovasc Dis. 2010; 19:29-35. 4. Britto RR, Rezende NR, Marinho KC et al. Inspiratory muscular training in chronic stroke survivors: A randomized controlled trial. Arch Phys Med Rehabil. 2011;92(2):184-90. 5. Talasz H, Kremser C, Kofler M et al. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22:61-8. www.kptjournal.org 5
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