J Korean Soc Phys Ther Vol.26, No.2, April 2014 The Journal of Korean Society of Physical Therapy plssn 1229-0475 elssn 2287-156X Original articles 수중운동이뇌졸중환자의균형과우울에미치는효과 김세훈 1, 이동규 2, 김은경 3 1 동신대학교보건복지대학물리치료학과대학원, 2 열린병원물리치료실, 3 서남대학교물리치료학과 Effect of aquatic exercise on balance and depression of stroke patients Se-Hun Kim 1, Dong-Kyu Lee 2, Eun-Kyung Kim 3 1 Department of Physical Therapy, Graduate School, College of Health and Welfare, Dongshin University, 2 Department of Physical Therapy, Yeol-Lin Hospital, 3 Department of Physical Therapy, Seonam University Purpose: The purpose of this study was to understand the effect of aquatic exercise on balance and depression of stroke patients. Methods: For 12 participants with stroke, six members of the experimental group and six members of the control group were randomly selected and arranged. Proprioceptive Neuromuscular Facilitation (PNF) lower extremity aquatic pattern exercise was applied to the experimental group. On the other hand, participants in the control group performed PNF lower extremity pattern exercise on the ground. Both exercises were performed 30 minutes per day, five times per week, for a period of six weeks. Balance was assessed using the Berg Balance Scale (BBS) and Timed Up to Go test (TUG). Depression was measured using the Center for Epidemiologic Studies depression scale (CES-D). Results: As a result of comparison within groups, the experimental group showed significant difference for balance and depression after the experiment (p<0.05). In comparison between the two groups, the experimental group in which aquatic exercise was applied showed more significant change in balance and depression than the control group (p<0.05). Conclusion: According to the results of this study, aquatic exercise was proven to enhance the balance and decrease the depression of stroke patients. Key Words: Aquatic exercise, Stroke, Balance, Depression Ⅰ. 서론 뇌에공급되는혈류가차단되거나출혈로인하여장애가생기는뇌졸중은손상된부위에따라운동, 감각, 보행, 및균형장애등신체적장애와함께우울, 분노등의심리적장애를동반한다. 1,2 신체적기능수행에없어서는안될요소중하나인 Received Mar 18, 2014 Revised Apr 3, 2014 Accepted Apr 15, 2014 Corresponding author Dong-Kyu Lee, ldkpt@hanmail.net Copylight c 2013 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/3.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. 균형은지탱하고있는관절과기저면위로연결된신체분절들의동작을제어하고이동시변화에반응하여자세를지속적으로유지하고수행하며회복하는행동이다. 3 특히뇌졸중으로인하여감각소실, 운동조절력감소와근력약화로인해자세의안정성이결여됨으로써균형을유지하는데어려움이있으며이러한균형감각소실은뇌졸중환자들의보행과일상생활동작을수행하는데방해하는요소중하나로여겨진다. 4,5 따라서균형장애가있는뇌졸중환자들은기능적회복과독립적인생활을영위할수있도록적극적인치료가매우중요하다. 뇌졸중환자가갖는심리적장애중우울은급성기또는회복기과정에서나타나는합병증으로인지기능에부정적영향 www.kptjournal.org J Korean Soc Phys Ther 2014:26(2):104-109 104
Se-Hun Kim, et al : Effect of aquatic exercise on balance, depression of stroke patients 을미치며신체기능약화를야기하며뇌졸중환자의삶의질을저하시킨다. 2,6 이처럼뇌졸중환자의우울은치료에부정적인영향을미치는요인으로일상생활수행능력회복과치료기간을지연시키는것으로보고되고있다. 6 Son 7 은뇌졸중환자에대한연구에서우울정도가증가할수록치료동기가낮아진다고보고하였다. 또한뇌졸중환자들은일상생활동작을수행하지못한경우더심한우울을경험할수있다. 6 그러므로뇌졸중으로어려움을겪는환자들은신체적기능회복과우울감소를위한복합적인치료가시행되어야한다. 뇌졸중환자의문제를해결하기위하여전신진동운동, 컴퓨터화된자세조절훈련, 이중운동과제훈련및수중운동이효과적이라고보고되고있다. 8-11 그중에서수중운동은물이라는환경에서행하여지는운동으로물의유체역학적특성에의해지상운동에서얻을수없는안정성과운동효과를제공하며뇌졸중으로인하여균형능력이떨어지는환자들의치료를지상보다안전하게실시할수있으며균형증진, 심리적인정서상태및우울감소에도긍정적인영향을미친다고보고되고있다. 12-14 수중운동중바드라가즈링기법 (Bad Ragaz Ring Method: BRRM) 은고유수용성신경근촉진법 (Proprioceptive Neuromuscular Facilitation: PNF) 패턴을적용한치료기법으로나선형 (spiral) 과대각선 (diagonal) 패턴을사용하여고유수용기를자극함으로써신경근조절과기능을향상시키는운동치료방법이다. 15,16 Ji 등 17 은뇌졸중으로인한편마비환자에게 PNF 패턴을적용한후균형능력이증진되었다고보고되고있으며, Park 18 은뇌졸중으로인한편마비환자를대상으로수중고유수용성감각자극운동을실시한결과균형능력이유의하게개선되었다. Song과 Kim 16 의연구에서 PNF 패턴을이용한수중운동을뇌졸중환자에게적용한결과균형능력에긍정적인효과를나타냈다. 최근들어뇌졸중환자들이점차늘어나면서수중운동에대한연구도계속진행되고있다. 하지만수중운동이뇌졸중환자에게균형증진과우울감소에긍정적인효과가있다고보고되고있지만 PNF를이용한수중운동이균형및우울치료에대한효과성이증명된선행연구는부족한실정이다. 따라서본연구는 PNF를이용한수중운동이뇌졸중환자의균형증진과우울감소에미치는효과에대해알아보고뇌졸중환자의효과적인훈련방법을제시하고자한다. II. 연구방법 1. 연구대상본연구는뇌졸중환자 12명을대상으로수중운동을실시하는실험군 6명과지상운동을실시하는대조군 6명으로무작위배정하였다. 선정기준은한국형간이정신상태판별검사 (Mini-Mental State Examination-Korean version) 점수가 24점이상이며연구내용을이해하고의사소통이가능하며 Brunnstrom 4단계이상으로보조도구없이 10 m 이상독립보행이가능한자로하지에정형외과질환이없는자를대상자로선정하였다. 모든연구대상자에게연구의목적과취지를설명하였고자발적으로동의한환자를대상으로실험에참여시켰다. 2. 실험방법실험군의운동프로그램은준비운동, 수중운동, 정리운동으로구성되었다. 준비운동과정리운동은간단한스트레칭을 5분실시하였다. 수중운동은물온도 32~34, 물높이 110 cm 수중에서요추 5번과천추 1번사이에 Body ring과목에 Neck collar를착용하고바로누운자세에서율동적개시기법을이용하여 PNF 하지패턴운동을실시하였다. 수평위에서연구자는대상자발쪽에위치하여운동사슬에대한고정점으로작용을한다. 대조군의운동프로그램은준비운동, 지상운동, 정리운동으로구성되었다. 준비운동과정리운동은간단한스트레칭을 5분실시하였다. 지상운동은안정한지면에서바로누운자세에서율동적개시기법을이용하여 PNF 하지패턴운동을실시하였다. 수평위에서연구자는대상자발쪽에위치하고운동사슬에대한촉진점으로작용을한다. 수중운동과지상운동에서실시한 PNF 하지패턴은 D1과 D2 패턴으로구성되어있으며 PNF 교육을받은숙련된연구자가대상자를지도하였다. D1 패턴은고관절굴곡- 내전-외회전슬관절굴곡으로끝나는패턴과고관절신전-외전-내회전슬관절신전으로끝나는패턴이다. D2 패턴은고관절굴곡-외전-내회전슬관절굴곡으로끝나는패턴과고관절신전-내전-외회전슬관절신전으로끝나는패턴이다. 수중운동과지상운동은마비측과비마비측에 1세트당 5회씩총 10세트를 1일 30분씩 6주동안주5회실시하였다. 3. 측정도구균형능력을측정하기신뢰도와타당도가검증된버그균형척도 (Berg's balance scale, BBS) 와의자에서일어서서걸어 105 J Korean Soc Phys Ther 2014:26(2):104-109 www.kptjournal.org
김세훈외 : 수중운동이뇌졸중환자의균형과우울에미치는효과 가기검사 (Timed Up & Go Test, TUG) 를사용하였다. BBS는앉기, 서기, 자세변화등 3개영역으로나누며총 14항목으로구성되어있으며각항목은최하 0점에서최고 4점으로나누어져있고총점은 56점이며점수가높을수록균형이좋다는것을의미한다. TUG는팔걸이가있는의자에앉은상태에서출발지시와함께일어나서 3 m 를걷고난후다시제자리로돌아와서앉을때까지의시간을초 (sec) 단위로측정하였다. 우울정도를측정하기위해신뢰도와타당도가검증된우울증간이선별검사도구 (Center for epidemiologic studies Depression Scale, CES-D) 를사용하였다. CES-D 는 평소에는아무렇지도않던일들이괴롭고귀찮게느껴진다, 먹고싶지않고식욕이없었다, 어느누가도와준다하더라도나의울적한기분을떨쳐버릴수없을것같았다, 무슨일을하든정신을집중하기가힘들었다, 비교적잘지냈다, 상당히우울했다, 모든일들이힘들게느껴졌다, 앞일이암담하게느껴졌다, 지금까지의내인생은실패작이라는생각이들었다, 적어도보통사람들만큼의능력은있었다고생각한다, 잠을잘이루지못했다, 두려움을느꼈다, 평소에비해말수가적었다, 세상에홀로있는듯한외로움을느꼈다, 큰불만없이생활했다, 사람들이나에게차갑게대하는것같았다, 갑자기울음이나왔다, 마음이슬펐다, 사람들이나를싫어하는것같았다, 도무지뭘해나갈엄두가나지않았다 등우울정서 (7문항), 긍정적정서 (4문항), 대인관계 (6문항), 신체적측면 (3문항) 등총 20문항으로구성되어있으며환자직접작성한 CES-D는 4점척도로 극히드물다 0 점, 가끔있었다 1 점, 종종있었다 2 점 대부분그렇다 3 점을이용하여측정하며총점은 0점에서 60점까지로점수가높을수록우울정도가높음을의미한다. 실험군과대조군동일하게실험전에 BBS, TUG 및 CES-D 를측정하였고 6주후에다시측정하였다. 4. 자료분석모든자료들은 SPSS 12.0(SPSS Inc., Chicago, IL, USA) 을이용하여분석하였다. 모든측정값은평균과표준편차로나타냈다. 대상자의일반적인특성을알아보기위하여기술통계방법을사용하였다. BBS, TUG 와 CES-D의측정값들에대한집단내실험전과후비교를위해윌콕슨부호순위검정 (Wilcoxon signed rank test) 을시행하였고, 집단간실험전과후변화량차이를비교하기위해맨-휘트니유 (Mann- Whitney U) 검정을시행하였다. 유의수준은 α=0.05로설정하였다. Table 1. General characteristics of each groups (n=12) III. 결과 EG (n=6) CG (n=6) Gender (male/female) 3 / 3 3 / 3 Age (year) 70.33 ± 2.06 69.50 ± 2.58 Weight (kg) 70.66 ± 5.78 68.16 ± 7.41 Height (cm) 168.66 ± 8.80 167.83 ± 7.13 Paretic side (right/left) 3 / 3 3 / 3 Onset (months) 9.83 ± 1.16 10.16 ± 1.16 Values are presented as mean±standard deviation. EG: Experimental Group CG: Control Group 1. 연구대상자의일반적인특성연구대상자의일반적인특성은다음과같다 (Table 1). 실험군 6명의평균나이 70.33±2.06세, 평균체중 70.66±5.78 kg, 평균신장 168.66±8.80 cm, 마비부위는오른쪽편마비 3명, 왼쪽편마비 3명이었다. 대조군 6명의평균나이 69.50±2.58 세, 평균체중 68.16±7.41 kg, 평균신장 167.83±7.13 cm, 마비부위는오른쪽편마비 3명, 왼쪽편마비 3명이었다. 2. BBS 변화 BBS의집단내비교는다음과같다 (Table 2). 수중운동을실시한실험군은실험전 42.33±1.75에서실험후 44.66± 2.42으로유의한차이가있었고 (p<0.05), 지상운동을실시한대조군은실험전 40.16±1.47에서실험후 40.66±1.36으로유의한차이가없었다 (p>0.05). BBS의집단간비교는다음과같다 (Table 3). 수중운동을실시한실험군이지상운동을실시한대조군에비하여 BBS가유의하게개선되었다 (p<0.05). 3. TUG 변화 TUG의집단내비교는다음과같다 (Table 2). 수중운동을실시한실험군은실험전 22.16±1.16에서실험후 20.83 ±0.98으로유의한차이가있었고 (p<0.05), 지상운동을실시한대조군은실험전 20.00±1.26에서실험후 19.50± 0.83으로유의한차이가없었다 (p>0.05). TUG 의집단간비 www.kptjournal.org J Korean Soc Phys Ther 2014:26(2):104-109 106
Se-Hun Kim, et al : Effect of aquatic exercise on balance, depression of stroke patients Table 2. The comparison of variable on pre and post in inner-group Group Pre Post Z p BBS EG 42.33 ± 1.75 44.66 ± 2.42-2.060 0.039* CG 40.16 ± 1.47 40.66 ± 1.36-1.732 0.083 TUG EG 22.16 ± 1.16 20.83 ± 0.98-2.271 0.023* CG 20.00 ± 1.26 19.50 ± 0.83-1.732 0.083 CES-D EG 21.83 ± 1.16 20.33 ± 1.03-2.041 0.041* Values are presented as mean±standard deviation. *p<0.05 EG: Experimental Group CG: Control Group BBS: Berg Balance Scale TUG: Timed Up & Go Test CES-D: Center for Epidemiologic Studies Depression Scale CG 20.83 ± 1.16 20.50 ± 1.04-1.414 0.157 Table 3. The comparison of changes in variables between groups EG CG Z p BBS 2.33 ± 1.63 0.50 ± 0.54-2.233 0.026* TUG -1.33 ± 0.51-0.50 ± 0.54-2.166 0.030* CES-D -1.50 ± 1.04-0.33 ± 0.51-2.035 0.042* Values are presented as mean±standard deviation. *p<0.05 EG: Experimental Group CG: Control Group BBS: Berg Balance Scale TUG: Timed Up & Go Test CES-D: Center for Epidemiologic Studies Depression Scale 교는다음과같다 (Table 3). 수중운동을실시한실험군이지상운동을실시한대조군에비하여 TUG가유의하게개선되었다 (p<0.05). 4. CES-D 변화 CES-D의집단내비교는다음과같다 (Table 2). 수중운동을실시한실험군은실험전 21.83±1.16에서실험후 20.33 ±1.03으로유의한차이가있었고 (p<0.05), 지상운동을실시한대조군은실험전 20.83±1.16에서실험후 20.50± 1.04으로유의한차이가없었다 (p>0.05). CES-D의집단간비교는다음과같다 (Table 3). 수중운동을실시한실험군이지상운동을실시한대조군에비하여 CES-D가유의하게개선되었다 (p<0.05). IV. 고찰뇌졸중환자는적절한관리를받지못하면균형장애, 보행 장애, 협응력및근력약화등의신체적장애와우울, 분노등의심리적장애를동반하며이로인해삶의질이저하되고신체활동이제한된다. 1,2,4 이러한문제들을해결하기위해전신진동운동, 컴퓨터화된자세조절훈련, 이중운동과제훈련및수중운동등여러운동방법들이보고되고있다. 8-11 그중에수중운동은신체적장애와심리적장애에도도움을줄수있다고보고되고있으며뇌졸중, 허약한노인및정신지체아동등을대상으로활발히연구가이루어지고있다. 11,13,19 따라서본연구는 12명의뇌졸중환자를대상으로 6주간수중운동이균형증진에미치는효과를알아보고자연구를실시하였다. 본연구에서는균형능력을평가하기위해 BBS와 TUG 검사를실시하였다. 지상운동을실시한대조군에서 BBS와 TUG 는실험전보다실험후에약간증가또는감소는있었지만유의한차이는보이지않았다. 이러한이유는대상자수가적었기때문에이런결과가나타난것으로사료된다. 집단내비교에서수중운동을실시한실험군에서 BBS 점수는 107 J Korean Soc Phys Ther 2014:26(2):104-109 www.kptjournal.org
김세훈외 : 수중운동이뇌졸중환자의균형과우울에미치는효과 실험전 42.33±1.75 에서실험후 44.66±2.42 으로유의하게개선되었다. 집단간비교에서대조군에비해수중운동을실시한실험군에서유의한차이가나타났다. Park 18 은뇌졸중으로인한편마비환자를대상으로수중고유수용성감각자극운동을실시한수중운동군에서 BBS 점수는실험전 39.94±2.46 에서실험후 42.75±1.57 으로유의하게개선되었고집단간비교에서도지상운동군에비해수중운동군에서유의한향상을보였다. Han 20 과 Bae 21 는뇌졸중환자에게수중운동전, 후비교에서수중운동군에서 BBS 점수가유의한향상을보였으며본연구와선행연구에서운동방법에차이는있었지만결과는일치하였다. 이러한결과는물의유체역학적특성으로인하여전정감각과고유수용성감각이자극되어균형능력증진에긍정적인영향을주었을거라고생각된다. 22 TUG 검사결과수중운동을실시한실험군에서실험전 22.16±1.16에서실험후 20.83 ±0.98으로유의하게개선되었고집단간비교에서대조군에비해수중운동을실시한실험군에서유의한차이가나타났다. Song과 Kim 11 은뇌졸중환자를대상으로수중운동을이용하여 TUG에미치는영향에대한연구검사결과실험전 16.20±5.87에서실험후 15.16±5.53으로유의한차이를나타냈다. Lee와 Kim 23 의연구에서수중운동전, 후 TUG 검사를실시한결과실험전 11.77±1.60에서실험후 9.84 ±1.56으로균형능력의유의한향상을보였으며본연구결과와일치하였다. TUG 검사는의자에서일어나걷고난후다시의자로돌아와서앉을때까지동작을수행해야하므로 PNF 패턴을이용한수중운동시물자체가저항으로작용하기때문에근력증가에도움줄수있으므로이러한결과가나타난것으로추정되며수중에서운동은중력과반대방향으로힘이작용하여물속에서물체를위로떠오르게하는힘인부력과유체의각부분이시간적, 공간적으로불규칙하게움직이면서서로섞이는흐름인난류로인한어려운상황에서자세를유지하기위하여근섬유의활성화를촉진하였기균형증진에긍정적인도움을줄것으로생각된다. 24,25 수중환경에서 PNF D 1 과D 2 패턴운동은대각선과나선형패턴이고유수용성감각을자극하여근작용을안정화시키며이에따라하지의근력과협응능력이증진되기때문에균형능력이개선될것이다. 25,26 뇌졸중환자에게우울은초기부터시작하여만성시기에도흔히발생하며예후에부정적인영향을주는심각한합병증이며치료에있어장애요소로작용한다. 27,28 현재까지뇌졸중치료는대부분신체적측면에집중되었고심리적인 측면은무시되어왔다. 29 따라서본연구는뇌졸중환자를대상으로 6주간수중운동이우울감소에미치는효과를알아보고자연구를실시하였는데집단내비교에서수중운동을실시한실험군에서 CED-D는실험전 21.83±1.16에서실험후 20.33±1.03으로유의하게개선되었다. 특히 비교적잘지냈다, 모든일들이힘들게느껴졌다, 도무지뭘해나갈엄두가나지않았다 등의항목은실험전에우울이심했는데수중운동을실시한후에더유의하게개선되었다. 집단간비교에서대조군에비해수중운동을실시한실험군에서유의한차이가나타났다. No 14 의연구에서 12주간수중저항운동을적용한결과우울정도가유의하게개선되었다. Chang 30 의연구에서수중운동을적용한실험군에서우울감소가유의하게개선되었으며본연구와선행연구에서대상자선정에차이는있지만연구결과는일치하였다. 수중운동은물에서운동과오락을할수있는활동중하나로긍정적인신체상확립과심리적으로도움이될것이며본연구에서규칙적인운동은신체적건강을증진시키고우울과같은심리적건강에도수중운동이효과적임을재확인할수있다. 30 본연구는뇌졸중환자를대상으로수중운동을적용한결과균형증진과우울감소에효과적이라는결론을얻었다. 이러한연구결과를바탕으로임상에서 PNF 하지패턴을이용한수중운동을뇌졸중환자뿐만아나라중추신경계손상환자에게적용하면체중부하를최소화시켜관절에부담없이신체적기능을향상시킬수있으며즐겁게운동을수행할수있기때문에심리적인문제해결에도도움을줄것으로사료된다. 본연구의제한점은지역적제한과비교적적은수를대상으로연구를실시하였기때문에모든뇌졸중환자에게일반화하여해석하기에는어려움이있고본연구에참여하기전에어떤치료를받았는지고려하지못했다. 추후에는제한점을보완하여더많은대상자를선택하여연구가이루어져야할것이다. 참고문헌 1. Kelley RE, Borazanci AP. Stroke rehabilitation. Neurol Res. 2009;31(8):832-40. 2. Singh A, Black SE, Herrmann N et al. Functional and neuroanatomic correlations in post stroke depression: the Sunnybrook Stroke Study. Stroke. 200;31(3):637-44. 3. Tyson SF, Hanley M, Chillala J et al. Balance disability after stroke. Phys Ther. 2006;86(1):30-8. www.kptjournal.org J Korean Soc Phys Ther 2014:26(2):104-109 108
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