Brain & N eurorehabilitation Vol. 2, No. 2, September, 2009 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 성균관대학교의과대학삼성서울병원재활의학교실및뇌졸중센터, 1 한림대학교성심병원재활의학과, 2 성균관대학교의과대학마산삼성병원재활의학교실 김민수ㆍ온석훈 1 ㆍ장현정 2 ㆍ하현근ㆍ이강우ㆍ김연희 Development of Algorithm for Patient Specific Rehabilitation of Acute Stroke Patient Min Su Kim, M.D., Suk Hoon Ohn, M.D. 1, Hyun Jung Chang, M.D. 2, Hyun Gun Ha, P.T., Peter K.W. Lee, M.D. and Yun-Hee Kim, M.D. Department of Physical Medicine and Rehabilitation, Stroke and Cerebrovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 1 Sacred Heart Hospital, Hallym University, 2 Masan Samsung Hospital, Sungkyunkwan University School of Medicine Objective: Team approach for patient-specific rehabilitation for acute stroke patient is important to minimize loss of function and facilitate recovery as well as cost effectiveness. We tried to establish acute stroke rehabilitation algorithm to maximize efficiency of delivering patient-specific and comprehensive rehabilitation in acute stroke patients. Method: We developed the clinical algorithms through the informal consensus development process by thorough discussions within the rehabilitation team members. Before and after adoption of the rehabilitation algorithms in clinical activity, we investigated satisfaction of patients and staffs by questionnaire. In addition, length of hospitalization was assessed. Results: Ten algorithms were developed on the general rehabilitation, physical, occupational, and speech therapy, dysphagia, cognitive rehabilitation, nursing care and complication, and psychosocial rehabilitation. Every algorithm was comprised to take care of patients from the acute stage of rehabilitation to long term management. After algorithms to the clinical practice, total mean score of satisfaction was significantly improved in patients and staffs (p<0.05). Mean length of stay for rehabilitation tended to decline without statistical significance. Conclusion: Algorithm for patient specific acute stroke rehabilitation could contribute to increase the level of satisfaction among patients and staffs. (Brain & NeuroRehabilitation 2009; 2: 118-133) Key Words: acute stroke, algorithm, rehabilitation, satisfaction 서론 뇌졸중은전체환자의 40% 에서중등도의기능장애가남는것으로알려져있으며, 미국의경우 2008년약 650 억달러에달하는비용을뇌졸중치료에지출할정도로사회적, 경제적으로부담이큰질병으로매년발생률이증가하고있다. 1,2 따라서비용대비효과를높이기위해선진각국은뇌졸중전문학회를중심으로증거에기반한 접수일 : 2009 년 1 월 31 일, 1 차심사일 : 2009 년 2 월 25 일, 2 차심사일 : 2009 년 3 월 10 일, 3 차심사일 : 2009 년 4 월 30 일게재승인일 : 2009 년 5 월 25 일교신저자 : 김연희, 서울시강남구일원동 50 번지 135-710, 삼성서울병원재활의학과 Tel: 02-3410-2818, Fax: 02-3410-0052 E-mail: yun1225.kim@samsung.com 뇌졸중임상진료지침을만들고실제진료에적응을권장하고있으며, 뇌졸중재활은중요한항목으로되어있다. 3 임상진료지침이란특정임상환경에서필요한보건의료서비스에대해의료진과환자의적절한의사결정에도움을주기위하여개발된것으로, 4 최근의료비의절감및양질의의료서비스제공을위하여의료각분야에서유용하게사용되고있다. 5 미국의 AHCPR (Agent for Health Care Policy and Research) 은 1995년에뇌졸중재활치료항목에대해광범위한재검토를시행하고급성기뇌졸중재활치료에대한개괄적인 19가지임상진료지침을발표하였으며, 6 2005년미국뇌졸중학회 (American Stroke Association) 는뇌졸중의다양한합병증에대한치료및기능회복을위한치료에대해그간의연구결과고찰을통하여알고리즘으로구성된임상진료지침을발표하였다. 2 캐나다에서도 2006년에증거에기반한뇌졸중재활임상진료지침을만들었는데, 이에대한순응도가치료결과와밀접 118
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 한관련이있다는증거를제시하였다. 7 이러한뇌졸중재활임상진료지침은공통적으로다양한팀의협동에의한접근및치료를강조하고있다. 2,8 뇌졸중후이러한임상진료지침에의거한재활치료는환자의회복과정을촉진시키고기능장애를최소화하는것은잘알려져있으며, 환자의기능회복은환자본인에게만족감을주고잠재적으로는장기적관리를위한비용을감소시킬수있다는점에서매우중요하다. 9 그러나뇌졸중에의한장애는매우다양하여치료팀원들이전문적지식이부족하거나충분한훈련이되어있지못할경우포괄적인치료과정에누락이발생되기쉬우며환자의개별적인장애에적절히대응하는치료가주어지지못하는경우도흔하게볼수있다. 이에본연구에서는급성기뇌졸중환자에게환자각각의증상에따라각치료팀원에의한개별화된평가와치료를실시하고상호연계하며적절한추적관찰을통하여환자의증상에맞춘개별적이고효율적인재활서비스를제공하여뇌졸중환자의기능회복을극대화하는데도움이될수있도록임상적으로유용한재활치료알고리즘을개발하고, 이를시행함으로써환자와보호자, 의료진의만족도와재원일수변화를알아보고자하였다. 1) 연구대상알고리즘시행전후환자및보호자의만족도조사를위하여, 본원에입원중인뇌졸중발생후 1개월이내환자를대상으로알고리즘시행전 72명과시행후 78명중각각 25명씩을환자정보를모르는상태에서무작위로선정하였다. 전후에선정된환자모집단간에나이, 성별, 뇌졸중유형, 좌우편마비, 배우자유무, 사회적지지기반정도, 교육수준과설문조사당시기능수준에있어서양군간의차이는관찰되지않았다 (Table 1). 알고리즘시행전후의료진의만족도변화를조사하기위하여각팀원의약 25% 인의사 4명, 운동치료사 10명, 작업치료사 4명, 간호사 5명, 언어치료사 1명, 사회복지사 1명을무작위추첨을통해대상자로선정하였다. 또한위에서언급한동일한모집단으로, 알고리즘시행전 72명과시행후 78명의 3개월간평균재원일수를조사하여변화여부를조사하고자하였다. 2) 방법 (1) 알고리즘의개발방법본연구에서비공식적합의유도접근법 (informal consensus development) 을사용하였으며, 주제선정후세부항목을구성할때미국뇌졸중학회에서발표한뇌졸중재활임상진료지침을참고하였다. 2,10 이것은증거에기초한접근법을이용하여증거의질, 연구의총괄적인질, 중재의전체적인효과및연구의종류에따라각세부항목의등급을매기었는데 A는항상적응이되는치료로강력히추천, B는치료가일반적으로도움이되는중재, C는치료를고려, D는도움이되지않으며때로는해로움, I는도움이되는것에대해논란이있음등 5단계로분류된다. 2,10 본연구에서는각주제세부항목에서 A, B, C등급인항목과 I등급에서합의개발팀에의한추천항목으로알고리즘을구성하였다. 주제선택시 Baker와 Feder 11 이제시한임상진료지침개발우선순위결정기준을참고하였다. 우선순위를갖는주제로는시간과비용을들이는노력을정당화할수있는중요성을지니는것, 복잡한주제로다수의권고안이나올수있는것, 실제로행해지는진료에상당한변이가있을수있는것, 과거타당한지침이없는것이다. 11 본연구에서 Table 1. Characteristics of the Patients Involved in Survey 연구대상및방법 Age (years) Gender Male (n (%)) Female (n (%)) Stroke type Infarction (n (%)) Hemorrhage (n (%)) Hemiplegia Left (n (%)) Right (n (%)) Marital status Never (n (%)) Married (n (%)) Widowed (n (%)) Separated (n (%)) Divorced (n (%)) Social support Full support (n (%)) Less than full (n (%)) Education Less than high school (n (%)) High school graduate (n (%)) College (n (%)) Postgraduate (n (%)) MBI MBI: Modified Barthel index. Pre-algorithm, n = 25 64.0 ± 12.7 14 (56) 11 (44) 16 (64) 9 (36) 17 (68) 8 (32) 1 (4) 21 (84) 3 (12) 0 (0) 0 (0) 20 (80) 5 (20) 6 (24) 6 (24) 12 (48) 1 (4) 59.0 ± 20.4 Post-algorithm, n = 25 67.0 ± 14.8 12 (48) 13 (52) 13 (52) 12 (48) 15 (60) 10 (40) 0 (0) 22 (88) 2 (8) 0 (0) 1 (4) 21 (84) 4 (16) 5 (20) 7 (28) 11 (44) 2 (8) 53.0 ± 13.6 119
Brain& NeuroRehabilitation:2009; 2: 118~133 는급성기뇌졸중환자의전입또는처음입원시평가, 운동치료, 작업치료, 언어치료, 인지치료, 삼킴장애치료, 사회사업, 배뇨관리, 어깨통증관리, 피부관리등총 10개주제를선정하였다. 또한합의개발팀 (consensus development group) 은뇌졸중환자의재활치료에대한임상경험이풍부한재활의학과전문의, 운동치료, 작업치료, 언어치료및인지치료실의선임치료사및재활전문간호사로구성하였다. (2) 알고리즘의실행및교육일반적으로임상에서진료지침을실행하는데있어충분한보급과지원체계, 관련인력에대한충분한훈련, 정확하게수행이되고있는지확인하기위한모니터링체계및문제점이발생했을경우그것을규명하고수정하는것은기본적인실행요건및점검요소이다. 12,13 본합의개발팀도가능한임상진료지침수행이균일하게시행될수있도록뇌졸중재활치료에관여하는의사, 간호사, 치료사, 사회사업가등에게 1개월동안집중적으로알고리즘에대한교육을실시하였다. (3) 알고리즘의대상및평가임상진료지침이정확히수행되었는가를평가하는항목으로자원이용의감소, 자원이용감소가의료의질관리로 전환되고있는지여부, 의료제공자의업무만족도에영향을주었는지여부등크게 3가지로구성된다. 12,13 본연구에서는자원이용을확인하기위해알고리즘시행전과시행이후각각 3개월간급성기뇌졸중재활환자평균재원일수를조사하였다. 그리고의료의질관리전환을확인하기위해설문지를통해알고리즘시행전후환자와환자가설문이불가능한경우보호자의재활치료에대한만족도를조사하였다. 모든환자에게간이정신상태검사 (mini mental status examination, MMSE) 를시행하였으며, 26점이하의인지기능장애가있는환자는직계가족보호자를대상자로하였다. 설문지는 Reker 등 14 이이용한설문지를참조하여뇌졸중환자에특이적서열형문항으로, 입원재활치료에대한 15가지항목으로구성하였다. 각재활치료실에대한만족도를조사하기위해서설문지의 5번문항은각치료실별로 5가지항목으로수정하여사용하였고면접조사방식을사용하였다 (Appendix 1). 또한의료진의업무만족도에대한영향을확인하기위해설문조사를실시하였고, 알고리즘의핵심항목인업무효율의증진 (4항목: 1, 6, 8, 9) 과체계적인재활치료를제공하기위한의료진간의의사소통증진을확인하는항목 (6항목: 2 5, 7, 10) 등총 10항목으로구성하였다. 그리 Fig. 1. General assessment on admission to Department of Rehabilitation Medicine. PT: Physical therapy, ADL: Activity of daily living, OT: Occupational therapy, CT: Cognitive therapy, ST: Speech & language therapy. 120
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 고뇌졸중재활치료를담당하고있는의사, 간호사, 치료사등을포함한의료진중무작위로 25명을선정해, 알고리즘시행전후업무만족도를조사하였다 (Appendix 2). Table 2. Improvement of Satisfaction Level of Patients after Implicating Acute Stroke Rehabilitation Algorithm Item Pre-score Post-score 1. Therapeutic plan 2. Prognosis and possible complication 3. Nursing education 4. Rehabilitation therapy education 5. Therapy progress 5-1. Physical therapy 5-2. Occupational therapy 5-3. Modality therapy 5-4. Speech therapy 5-5. Congnitive therapy 6. Progress as schedule 7. Information on time and course 8. Information on community-based rehabilitation 9. Psychosocial service 10. Overall service on inpatient rehabilitation Mean *p<0.05. 80.8 ± 3.7 80.8 ± 4.2 85.6 ± 4.5 82.4 ± 7.0 84.0 ± 5.2 84.0 ± 6.2 80.8 ± 6.9 72.8 ± 4.3 68.0 ± 3.1 70.4 ± 4.0 76.0 ± 6.2 77.6 ± 5.4 70.4 ± 4.8 72.8 ± 5.9 76.8 ± 6.6 77.5 ± 5.5 88.8 ± 6.2* 86.4 ± 4.1* 88.8 ± 7.7 88.8 ± 5.2* 94.4 ± 4.0* 91.2 ± 7.6* 92.0 ± 7.2* 77.6 ± 4.3* 75.2 ± 4.5* 79.2 ± 6.8* 82.4 ± 6.2* 79.2 ± 7.6 75.2 ± 3.0* 80.0 ± 4.6* 92.8 ± 3.2* 84.8 ± 6.5* 환자및의료진만족도조사의모든평가항목에서 5점은매우만족, 4점은만족, 3점은보통, 2점은조금불만족, 1점은불만족으로숫자로점수화하였다. 각항목당 125점이만점이며, 변화를용이하게확인하기위하여점수는백분율로표시하였다. (4) 통계분석자료분석과비교는 Windows SPSS 12.0 Korean version 프로그램을사용하였다. 전후집단간의차이를확인하기위하여나이는독립표본 t-검정, 성별, 편마비, 뇌졸중유형, 배우자유형은카이제곱검정을사용하였고, 또한교육수준은선형대선형결합법, 사회적지지기반정도분석에는 Fisher s exact test를이용하였다. 알고리즘시행전후환자및보호자와의료진의설문조사점수는 Wilcoxon signed rank test를이용하여차이를분석하였다. 재원일수변화를확인하기위하여독립 t 검정법을사용하였으며, 모든통계분석의유의수준은 p값이 0.05 미만인경우로하였다. 결과 1) 알고리즘의개발급성기뇌졸중환자전입또는처음입원시평가, 운동치료, 작업치료, 언어치료, 인지치료, 삼킴장애치료, 사회 Fig. 2. Algorithm for assessment and therapy at physical therapy. 121
Brain& NeuroRehabilitation:2009; 2: 118~133 사업, 배뇨장애치료, 어깨통증치료, 피부관리에대한 10 개의알고리즘을개발하였다. (1) 급성기뇌졸중환자의처음전입시평가 급성뇌졸중후신경학적증상이안정화되면가능한빨리초기환자평가를통해기능평가와보호자에대한적극적인중재를하며, 각치료실이전문화된팀으로환자에대해접근하고이를팀회의를통해공유하도록알고리즘을구성하였다 (Fig. 1). Table 3. Change of Satisfaction Level of Staffs Item number Pre-score Post-score *p<0.05. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Mean 65.6 ± 3.1 68.0 ± 4.4 64.8 ± 3.2 66.4 ± 5.5 62.4 ± 4.7 72.8 ± 5.0 65.6 ± 4.1 62.4 ± 6.2 60.0 ± 6.1 63.2 ± 3.4 65.1 ± 3.6 70.4 ± 4.6 79.2 ± 5.2* 81.6 ± 4.1* 76.0 ± 3.3* 73.6 ± 2.5* 74.4 ± 3.0 82.4 ± 3.9* 67.2 ± 4.2 76.0 ± 5.1* 72.8 ± 3.2* 75.4 ± 4.8* (2) 운동치료운동치료알고리즘은근위약정도와기능상태에따라 7가지유형으로나누어각유형에따라적절한치료기법을과제지향형태로구성함으로써적절한과제지향접근치료가될수있도록알고리즘을구성하였다 (Table 2) (Fig. 2). (3) 작업치료작업치료알고리즘은근위약과감각결손정도에따라 8가지유형으로분류하여접근하였으며이들역시위에서언급한과제지향접근법에기반하였다. 모든유형에서도구적일상생활동작평가를초기및퇴원전에평가하도록하였으며, 이에대한보호자교육을모든유형에서받을수있도록알고리즘을구성하였다 (Table 3) (Fig. 3). (4) 말-언어치료언어치료알고리즘은평가, 치료, 재평가로구성하였으며, 의료진과보호자도환자와의사소통하기가어렵기때문에언어치료사는그들에게의사소통기술을교육하는것도필요하다는점을고려하여이에대한교육을언어치료및말하기치료과정에모두포함하였다 (Fig. 4). (5) 인지치료알고리즘에서는초기간이정신상태검사등의평가를통해인지장애가의심될경우전산화평가또는고식적인인지평가를통해객관적인정보수집을할수있도록하였 Fig. 3. Algorithm for assessment and therapy at occupational therapy. ADL: Activity of daily living. 122
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 Fig. 4. Algorithm for speech assessment and therapy. Fig. 5. Algorithm for cognitive assessment and therapy. 123
Brain& NeuroRehabilitation:2009; 2: 118~133 다. 주의집중력및시지각장애, 기억력장애, 집행기능장애로나누어각각의전문화된치료를받을수있도록하며, 특히시공간무시가있는환자들은기능적응훈련에 초점을맞추어치료받을수있도록구성하였다 (Fig. 5). (6) 삼킴장애치료 삼킴장애알고리즘에서평가는증거가명확한변형바 Fig. 6. Algorithm for swallowing assessment and therapy. NPO: Nothing by mouth. Fig. 7. Algorithm for psychosocial assessment and planning by social worker. 124
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 륨삼킴검사및병상연하평가등을시행하되치료는합의개발팀에서제시한치료로구성하였다 (Fig. 6). (7) 사회사업사회사업알고리즘은환자와보호자의걱정을최소화하고쌍방향간의사소통이원활하게하기위하여사회사업가가정보제공및교육을위해충분한중재를할수있도록하며, 가족과같은보호자의구체적인협조와이해가부족할경우가족미팅을통해보완할수있도록구성하였다 (Fig. 7). (8) 배뇨장애관리배뇨장애관리알고리즘에서는과다한잔뇨량으로인한방광기능및신기능저하를막기위하여배뇨기록지, 환자및보호자교육을강화하도록구성하였다 (Fig. 8). (9) 피부통합성관리피부통합성관리알고리즘은적절한침상자세교육, 특별매트의사용및적절한드레싱등과같은기본적인피부통합성관리와중등도욕창이있는환자의경우재활병동에서구성된욕창전문팀을통해집중적으로관리하며보호자에게충분한교육이될수있도록구성하였다 (Fig. 9). (10) 어깨통증관리어깨통증알고리즘은통증원인을확인하기위한어깨 X-선촬영, 3상골스캔, 초음파검사등을시행하고, 통증예방을위하여전기자극치료, 어깨보조기, 외상방지를위한자세교육을시행하도록구성하였다. 또한보존적치료로통증조절이적절하게되지않을경우관절강내주사치료, 외측회전과외전에초점을둔스트레칭운동, 기능적전기자극치료, 열전기치료등을받을수있도록하였으며, 회전근파열등이동반되어있을경우자기공명관절조영술을시행하고수술적치료를받을수있도록흐름도 Fig. 8. Algorithm for bladder assessment and management. CIC: Clean intermittent catheterization. Fig. 9. Algorithm for skin integrity assessment and management. EPUAP: European pressure ulcer advisory panel. 125
Brain& NeuroRehabilitation:2009; 2: 118~133 Fig. 10. Algorithm for shoulder pain assessment and management. LOM: Limited range of motion of shoulder, MR: Magnetic resonance, OS: Orthopedic surgery, IA: Intra-articular, NSAID: Non-steroidal anti-inflammatory drug, ROM: Range of motion. 로표시하였다 (Fig. 10). 2) 알고리즘시행전후비교 (1) 환자의치료만족도알고리즘시행후환자의만족도는 77.5 ± 5.5점에서 84.8 ± 6.5점으로유의하게향상되었다 (p = 0.002) (Table 2). 알고리즘시행전후입원기간중간호교육 ( 항목 3) 과치료시간에대한안내와진행 ( 항목 7) 을제외한모든항목에서통계적으로유의한만족도증가를보였으며, 특히전반적인재활치료서비스 ( 항목 10) 에대한만족도가크게향상되었다. (2) 의료진의만족도의료진의만족도는알고리즘시행전 65.1 ± 3.6점에서시행후 75.4 ± 4.8점으로유의하게증가하였다 (p<0.001) (Table 3). 각항목별로보았을때환자상태에대한정보 ( 항목 2), 환자의전반적인재활치료과정에대한이해 ( 항목 3), 퇴원시목표 ( 항목 4), 환자치료에있어정보공유 ( 항목 5), 치료계획의수립 ( 항목 7), 업무효율 ( 항목 9), 의료진간의의사소통 ( 항목 10) 에대한만족도가알고리즘시행후유의하게증가하였다. (3) 재원일수급성기뇌졸중으로인한알고리즘시행전후 3개월동 안의환자당평균재원일수는통계적으로유의한차이는없었다. 그러나재원일수가 18.7 ± 4.7일에서 16.7 ± 3.8 일로감소하는경향을보였다. 고찰 알고리즘을개발하는방법은비공식적합의유도접근법 (informal consensus development), 공식적합의유도접근법 (formal consensus development), 증거에기초한접근법 (evidence based approach), 명시적지침개발법 (explicit guideline development) 등크게 4가지로나뉜다. 4 공식적합의유도접근법은명목집단기법, 델파이 (Delphi) 방법등을통하여익명성을보장한상태로전문가의의견을수렴함으로써전문가간에나타날수있는상호작용을배제할수있는장점이있으나, 전문가집단의의견에근거하므로전문가패널구성에따라합의결과가달라질수있어지침의재현성에문제가있을수있다. 4 증거에기초한접근법은메타분석등을통해기존의연구결과를체계적으로종합하고이를임상적의사결정의근거로삼는방법으로, 타당한관련정보가부족하여판단이어려운부분이있으며, 표본추출상의비뚤림등으로일반적인결론을도출하기어려울수있다는단점이있다. 4 명시적지침개발 126
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 법은분석대상이되는의료행위의비용과편익을명확하게규정하고각결과가나타날확률의추정치를도출하여환자와의료진및정책결정자가이를근거로대안들의비용과편익을비교할수있도록한방법이다. 4 그러나이방법으로지침을개발할경우막대한시간과비용, 노력투자가필요하다. 본연구에서저자들은비공식적합의유도접근법을채택하였는데, 이방법은전문가들의공개토론을통해합의를도출하여지침을작성하는기법으로세계적으로가장많이사용되고있다. 4 이개발방법은다른방법들에비해상대적으로쉽고, 빠르며, 분석방법이복잡하지않다는장점이있으나, 증거가대부분전문가의견과토론에의해결정되므로전문가들의집단역학에따라쉽게결과가좌우되며타당성자체에대한논란을피하기어려운문제점을가지고있다. 4 따라서본연구에서미국뇌졸중학회에서제시한뇌졸중재활진료지침에서환자에게도움이된다는증거가밝혀진항목위주로알고리즘을구성하여개인성향에의한패널비뚤림을최소화하도록하였다. 급성뇌졸중후재활치료를시작하는총괄알고리즘에서신경학적증상이안정화되었을경우빨리재활치료를시작해야하며, 여러분야의전문가로조직된팀으로긴밀하게접근하는것이환자의예후에영향을끼친다는점은부각되고있다. 2,8,15,16 보호자는의사결정및치료계획수립시적극적으로참여하는것은중요하며, NIHSS (national institutes of health stroke scale), FIM (functional independence measure) 와같은표준화된기능평가도구로급성기뇌졸중환자의기능상태를평가하는것은도움이되는것으로알려져있다. 17 또한퇴원후재활치료가중단되지않게지역사회또는외래통원재활치료로연결하는것이좋으며, 이것은환자상태와기능, 사회및가정의뒷받침정도를확인해야한다. 2 근위약은뇌졸중후매우흔한장애로, 운동치료알고리즘을개발할때근위약정도와기능상태에따라 7가지유형으로나누어접근하여치료하는방식을택하였다. 이것은과제지향적접근법이흔히사용하는신경발달치료 (neurodevelopmental therapy, NDT) 보다기능호전에더도움이된다는연구가많으며, 2,18 각유형에따라적절한과제를갖고치료받을수있도록고려한것이다. 여러연구에서운동치료를할때기능적향상에근거가있는치료로는근력강화운동, 유산소운동, 부분체중부하트레드밀, 위약등으로인해근수축장애가있는환자에게기능성전기자극치료 (functional electrical stimulation, FES), 자세교육과관절범위운동 (range of motion exercise), 스트레칭등이알려져있다. 2 작업치료알고리즘은근위약과감각결손정도에따라 8가지유형으로분류하여접근하였으며이들역시위에서언급한과제지향접근법에기반하였다. 최근많은연구에서도구적일상생활동작 (instrumental activities of daily living, IADL) 에대한평가및훈련을강조하고있는데, 가능하면퇴원전간단한식사를준비하고치우기, 안전교육, 약복용, 응급구조요청등에대한최소한의기술을교육하고퇴원하는것을추천하고있다. 19 또한건측운동제한치료법 (constraint-induced therapy, CIT) 은감각결손및인지장애가없는환자에게서 2주이상, 6 8시간동안받을경우효과가있다고알려져있다. 2,20 말-언어장애는뇌졸중환자의 40% 이상에서발생하는데, 미국뇌졸중학회임상진료지침에서는모든환자에게있어듣기, 말하기, 읽기, 쓰기등을포함한의사소통능력에대한평가하고, 장애가있는환자에게있어퇴원전재평가하는것을추천하고있다. 2 또한말-언어장애가있는환자는의사소통기술을회복시키기위해가능한조기에치료를실시하고변화를관찰해야하며, 환자에게적절한보상기법을가르치는것이중요하다. 2 뇌졸중후인지장애는흔하며특히집중력, 기억력, 실행능력저하는일상생활수행에있어좋지않은영향을준다. 2 시공간무시가동반되어있을경우환자의안전도문제가되며예후에중요한영향을끼친다. 21 인지장애가의심되는모든환자는학습, 기억, 시공간무시, 집중력, 실행증, 문제해결능력을포함한인지에대한정확한평가가필요하며, 인지재훈련프로그램을받는것이필요하다. 21 삼킴장애는뇌졸중재원환자의약 45% 에서발생한다고알려져있으며, 삶의질에중대한영향을끼치고흡인이있을경우치명적흡인성폐렴의위험이증가한다. 2 또한영양실조도 30% 에서나타난다고알려져있으며, 이것은회복을느리게하고재활치료의효과를반감시킨다. 22 미국뇌졸중학회는모든환자에서입으로식사를시작하기전간단하고유효한침상검사를이용하여삼킴기능을선별, 침상에서시행한선별검사에이상이있을경우, 음성일지라도흡인이나삼킴장애가흔하게발생하는뇌줄기뇌졸중, 다발성뇌졸중, 거짓숨뇌마비등의환자에게는변형바륨삼킴검사 (modified barium swallowing test, MBS test) 를시행하는것을추천하고있다. 2,22 모든환자는충분한정신사회적평가와중재를위하여사회사업가로의뢰되어야하며, 가족중재및상담은서로간의상충되는의견을조정하고치료정보를공유하는데필요하다는점은잘알려져있다. 23,24 사회사업가는사는지역등과같은인구학적정보, 교육수준, 직업및고 127
Brain& NeuroRehabilitation:2009; 2: 118~133 용, 군대와법적문제, 가족간의관계및보호자가처한상황, 종교와문화활동, 평소여가활동, 수입과집상태와같은자원을파악하고이를문서화하여의료진에게제공하고, 보호자교육을담당하는것이중요하다. 23,24 배뇨장애는약 50% 환자에게나타날정도로흔하며, 많은중등도이상의급성기뇌졸중환자는퇴원후에도배뇨장애가있는상태로남아있어보호자에게큰부담이된다. 2 미국뇌졸중학회에서는요로감염을예방하기위해가능한빠른도뇨관의제거, 빈뇨, 요의, 배뇨곤란등의증상파악, 방광스캔이나간헐적도관삽입을통한잔뇨측정등을시행할것을추천하고있다. 2 또한요실금이있을경우주기적인도관을사용하여신속하게배뇨시키면서, 개별적인방광훈련프로그램을실시하는것이도움이된다고알려져있다. 25 압력궤양은모든입원환자의약 9% 에서발생하며, 요양원에서는약 23% 에서관찰된다. 2 압력궤양은치료하기어렵고비용과시간이많이소요되어, 입원기간을증가시킨다. 6 본알고리즘에서는유럽압력궤양조언패널 (European Pressure Ulcer Advisory Panel) 에서제시한분류법을사용하여환자의유효한압력궤양위험도를평가하였으며, 26 상지의감각운동장애로인해발생하는어깨통증은뇌졸중환자의 72% 에서발병후첫 1년동안최소 1회이상경험하는것으로알려져있다. 27 어깨통증은재활치료와기능회복을늦추는데, 환자가관절운동시통증으로인해근력향상을방해할뿐만아니라휠체어, 보행보조도구를사용하는데도제한을가져오기때문이다. 27 급성기뇌졸중재활치료의질을평가하는데있어서기능적향상뿐만이아니라환자의만족도는중요한지표이다. 급성기뇌졸중재활치료를적절히받았다할지라도, 뇌졸중전상태의기능까지입원기간중완전히회복되는환자는많지않으며, 작은장애라도남기마련이다. 여러연구에서재활치료에대한환자의만족도는퇴원후만족스러운일상생활을하고, 개인이기능회복을위한노력을지속하는데있어서중요한역할을하며치료의질을평가하는데유효한도구로사용할수있다고주장하였다. 14,28 또한치료에대한만족도는환자와의료진간의신뢰를향상시킴으로써차후추가적인치료를추천하고, 지속적인경과관찰을시행할수있도록한다. 14 본연구에서알고리즘시행후간호교육과환자치료시간에대한안내와진행항목에서만족도는증가하는경향을보였으나통계적으로유의한차이는없었다. 비록집중적으로알고리즘에대한간호사교육을실시했음에도불구하고종합병원의특성상타과환자들과병실을공유함으로써재활간호에만집중할수없는환경적요인에기인했으리라생 각된다. 그러나전반적으로환자만족도는유의하게증가였으며, 이를통해알고리즘이긍정적인영향을주었다는점을확인하였다. 미국뇌졸중학회임상진료지침뿐만아니라, 다른연구에서도원활한의사소통을통해잘조직된의료진간에적절하게협동하는것은환자의예후에중대한영향을끼친다고알려져있다. 2,16,29 본연구에서재활의학과의사, 간호사및각치료실의치료사들을무작위로추출하여알고리즘시행전후직원만족도조사시평균만족도에있어유의한증가가관찰되었는데, 이는알고리즘이업무만족도에긍정적인영향을끼쳤다고판단된다. 각항목별로보았을때의료진간의의사소통을평가하는항목 ( 항목 2 5, 7, 10) 은모두알고리즘시행후유의한증가를보였으나업무효율을평가하는항목 ( 항목 1, 6, 9, 10) 에서는전반적으로통계적으로유의한차이를보이지않았다. 이는알고리즘교육기간이 1개월로짧았고, 의료진이알고리즘에상대적으로익숙하지않았기때문이라판단된다. 장기적으로보았을때, 업무효율에대한것은향후추가적인연구가필요하다고생각된다. 그러나알고리즘이의료진간의의사소통증진을향상시키고일부업무효율을높임으로써환자의전반적인재활치료과정과재활서비스에대한만족도증가에기여하였다. 본연구에있어평균재원일수는 18.7일에서 16.7일로통계적유의성은없었으나감소하는경향을보였다. 이는알고리즘에의해자원이용이감소하였으며, 그감소된비용으로더많은급성기뇌졸중환자를치료하는데전환되어효과적인자원이용에기여했다고생각된다. 이러한점은최근미국과뉴질랜드의급성기뇌졸중재활치료를비교한전향적코호트연구에서도확인할수있다. 30 이연구에서미국이뉴질랜드에비해입원기간이더짧은데비해기능적향상은더많이이루어진것을발견하였으며, 이는미국이뉴질랜드에비해낭비하는시간없이재활치료에더충분한시간을할애하고, 더집중적으로시행했기때문이라고설명하고있다. 30 이러한긍정적인결과에도불구하고본연구는몇가지제한점이있다. 비공식적합의유도접근법으로인한단점을최소화시키도록노력하였으나, 합의개발팀의관점에따라중요하다고생각한항목이실제로유용하지않은항목일수도있어주제에따라논란이있을수있다. 또한결과지표로환자및직원만족도와평균재원기간의변화를제시하였으나, NIHSS (national institutes of health stroke scale) 와 FIM (functional independence measure) 등과같은기능지표또는다른유용한측정도구부족으로인해결과지표의향상이실제환자의기능적향상에기여 128
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 하였는지는불명확하다. 그리고급성기뇌졸중후입원재활치료에만초점을맞추어, 환자가퇴원후장기적인효과를보였는지는확인하기어려우며, 모집단의수가작아대표성에대한논란이있을수있다. 우리나라실정에맞게알고리즘을제작하려고노력하였으나, 시설부족으로모든병원재활의학과에일괄적용하기어렵다는점도본연구의한계점이다. 이러한점은차후연구에서극복해나아가야할점이라생각된다. 결론 본연구는우리나라에서팀협동에의한환자에게개별화된치료를제공하는급성기뇌졸중재활알고리즘을만드는최초의시도로서단기적으로급성기뇌졸중입원환자에게적용하여환자의치료만족도와직원간의의사소통증진에기여하였다. 앞으로지속적인연구와협의를통하여우리나라실정에맞는증거중심및효율적인팀협동에의한급성기뇌졸중진료지침을만들어나감으로써적절한의료의질관리를통해환자의기능회복에기여하리라생각된다. 감사의글 본논문은 2006년도 ( 재 ) 인성의과학연구재단의지원 ( 과제번호 CA68581) 을받아수행된연구임. 참고문헌 1) Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O'Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y. Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25-146 2) Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-143 3) Hong GS, Kim JY. Delvelopment of quality evaluation index for stroke. Korean J Stroke. 2006;8:17-25 4) Huttin C. The use of clinical guidelines to improve medical practice: main issues in the United States. Int J Qual Health Care. 1997;9:207-214 5) Ryu SH, Kim CB, Gang MG, Go SB. Development of clinical guidelines and quality of medical care. Korean Medical Journal of QA. 1996;3:154-176 6) Gresham GE, Duncan PW, Stason WB. Post-stroke rehabilitation, clinical practice guideline. 1st ed. Rockville: AHCPR Publication; 1995:16-24 7) Teasell R, Foley N, Bhogal S, Bagg S, Jutai J. Evidence-based practice and setting basic standards for stroke rehabilitation in Canada. Top Stroke Rehabil. 2006;13:59-65 8) Langhorne P, Duncan P. Does the organization of postacute stroke care really matter? Stroke. 2001;32:268-274 9) Helfand M. Incorporating information about cost-effectiveness into evidence-based decision-making: the evidence-based practice center (EPC) model. Med Care. 2005;43:33-43 10) Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D, Zorowitz R. Veterans affairs/ department of defense clinical practice guideline for the management of adult stroke rehabilitation care: executive summary. Stroke. 2005;36:2049-2056 11) Baker R, Feder G. Clinical guidelines: where next? Int J Qual Health Care. 1997;9:399-404 12) Korea institute of health services management. Quality upgrade of medical service. 1st ed. Seoul: Hanhaksa; 1998: 40-78 13) Samsung Medical Center QA team. Concept and cases of clinical pathway. 1st ed. Seoul: Samsung medical center; 1999:3-18 14) Reker DM, Duncan PW, Horner RD, Hoenig H, Samsa GP, Hamilton BB, Dudley TK. Postacute stroke guideline compliance is associated with greater patient satisfaction. Arch Phys Med Rehabil. 2002;83:750-756 15) Cifu DX, Stewart DG. Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil. 1999;80:S35-39 16) Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, Kalra L. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet. 2001;358:1586-1592 17) Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC, Broderick JP, Libman R, Levine SR, Brott T. Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-pa Stroke Trial. Neurology. 2000;55:952-959 18) Wagenaar RC, Meijer OG, van Wieringen PC, Kuik DJ, Hazenberg GJ, Lindeboom J, Wichers F, Rijswijk H. The functional recovery of stroke: a comparison between neuro-developmental treatment and the Brunnstrom method. Scand J Rehabil Med. 1990;22:1-8 19) Ginsberg GM, Hammerman-Rozenberg R, Cohen A, Stessman J. Independence in instrumental activities of daily living and its effect on mortality. Aging (Milano). 1999;11:161-168 20) Hakkennes S, Keating JL. Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Aust J Physiother. 2005;51:221-231 21) Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino JT, Harley JP, Laatsch L, Morse PA, Catanese J. Evidence-based cognitive rehabilitation: updated review of the literature from 129
Brain& NeuroRehabilitation:2009; 2: 118~133 1998 through 2002. Arch Phys Med Rehabil. 2005;86: 1681-1692 22) Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia. 2001;16:7-18 23) Smith J, Forster A, House A, Knapp P, Wright J, Young J. Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev. 2008:CD001919 24) Tsouna-Hadjis E, Vemmos KN, Zakopoulos N, Stamatelopoulos S. First-stroke recovery process: the role of family social support. Arch Phys Med Rehabil. 2000;81:881-887 25) Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2000:CD002113 26) Defloor T, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Lubbers M, Witherow A, Bale S, Bellingeri A, Cherry G, Clark M, Colin D, Dassen T, Dealey C, Gulacsi L, Haalboom J, Halfens R, Hietanen H, Lindholm C, Moore Z, Romanelli M, Soriano JV. Statement of the European Pressure Ulcer Advisory Panel--pressure ulcer classification: differentiation between pressure ulcers and moisture lesions. J Wound Ostomy Continence Nurs. 2005;32:302-306 27) Van Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in hemiplegia. Arch Phys Med Rehabil. 1986;67:23-26 28) Ware JE Jr, Phillips J, Yody BB, Adamczyk J. Assessment tools: functional health status and patient satisfaction. Am J Med Qual. 1996;11:S50-53 29) Strasser DC, Falconer JA, Herrin JS, Bowen SE, Stevens AB, Uomoto J. Team functioning and patient outcomes in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86:403-409 30) McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. Arch Phys Med Rehabil. 2005;86:S115-S120 130
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 APPENDIX 1. Questionnaire of Patient s Satisfaction 항목만족대체로만족보통다소불만족불만족 1. 재활치료시앞으로의치료계획설명에만족한다 2. 나의예후및가능한합병증에대한설명을충분히들었다. 3. 입원기간중간호교육에만족한다. 4. 재활치료교육에대해만족한다. 5. 재활치료경과는만족한다. 5-1. 운동치료에대해만족한다 5-2. 작업치료에대해만족한다 5-3. 열ㆍ전기치료에대해만족한다 5-4. 언어치료에대해만족한다 5-5. 인지치료에대해만족한다 6. 치료과정이예상대로진행되어좋다 7. 치료시간에대한안내와진행이잘되었다 8. 퇴원후환자돌봄에대한교육에만족한다 9. 사회사업서비스정보에만족한다 10. 전반적으로재활치료서비스에대해만족한다 APPENDIX 2. Questionnaire of Stroke Rehabilitation Staff s Satisfaction 항목만족대체로만족보통다소불만족불만족 1. 환자와관련된본인의업무집중도가증가하였다 2. 환자상태에정보를더잘알게되었다 3. 환자의재활치료과정에대한정보를더잘알게되었다 4. 환자의퇴원시목표를잘알고있다. 5. 환자에대한정보공유가잘되어업무에도움이되었다 6. 환자의나에대한치료에대한순응도가증가하였다 7. 환자치료계획수립시도움이되었다 8. 나는환자에대한재활치료의질이증가했다고생각한다 9. 나의업무효율성이증가했다고생각한다. 10. 나는의료진간의의사소통이더원활해졌다고생각한다 131
Brain& NeuroRehabilitation:2009; 2: 118~133 APPENDIX 3. Physical Therapy Contents according to Type of Disability Type Type 1 Conditioning exercise (Tilt table, standing frame) Contents of therapy Sitting with arms on the table Passive transfer education Type 2 Type 3 Type 4 Type 5 Type 6 Type 7 Supine: head control, deep breathing exercise, PROM Supine: head control, deep breathing exercise, PROM Sitting: arms supporting, arms on the table Sitting with trunk mobilization (mat or therapeutic ball) Active transfer education Sit to stand training Standing balance training Standing balance training Gait training with device and FES Active transfer education Sit to stand training Sitting balance training Trunk mobilization (mat or therapeutic ball) Sit to stand training Standing balance training (dynamic) Gait training with device Standing balance training (dynamic) Reeducation functional gait (single cane or without equipment) Mental imagery training, FES Passive or active transfer education Sitting balance training Sit to stand training on the Bobath table Stall bar or P-bar standing, FES Strengthening exercise P-bar gait training with FES Strengthening exercise Strengthening exercise PWBT Standing balance training Strengthening exercise PWBT Strengthening exercise PWBT ADL or vocational training Strengthening and endurance exercise Treadmill exercise PROM: Passive range of motion, FES: Functional electric stimulation, PWBT: Partial weight bearing treadmill, ADL: Activity of daily living. 132
김민수외 5 인 : 급성기뇌졸중환자의맞춤식재활치료를위한알고리즘의개발 APPENDIX 4. Occupational Therapy Contents according to Type of Disability Type Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7 PROM and AAROM Proximal part strengthening Scapular mobilization Spasticity inhibition Motor facilitation Bilateral activity Exclude spasticity inhibition PROM and AAROM Proximal part strengthening Scapular mobilization Spasticity inhibition Motor facilitation Bilateral activity Distal part strengthening Add CIT program PROM and AAROM Distal part strengthening Grasp and release training Fine motor training Bimanual training CIT program Exclude sensory stimulation Upper extremity general strengthening Fine motor training Hand dexterity training Sensory stimulation Contents of therapy Sensory stimulation FES (shoulder, wrist, intrinsic muscle) Resting splint Bed side activity education ADL & IADL evaluation, training, education Others same as type 1 Fine motor training Bimanual training Sensory stimulation FES (shoulder, wrist, intrinsic muscle) Bed side activity education ADL & IADL evaluation, training, education Others same as type 3 Sensory stimulation FES (shoulder, wrist, intrinsic muscle) Adaptive device Bed side activity education ADL & IADL evaluation, training, education Others same as type 5 Prevocational training Bed side activity education ADL & IADL evaluation, training, education Type 8 Add CIT program Others same as type 7 PROM: Passive range of motion, AAROM: Active assisted range of motion, FES: Functional electric stimulation, CIT: Constraint induced therapy, ADL: Activity of daily living, IADL: Instrumental ADL. 133