Journal of The Korean Society of Integrative Medicine, 2019, 7(4), 13~21 https://doi.org/10.15268/ksim.2019.7.4.013 ISSN 2288-1174(Print) ISSN 2383-9651(Online) 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 강태욱 1 정주현 2ǂ 1 워크재활의학과병원물리치료실물리치료사, 2ǂ 김해대학교물리치료학과교수 The Effects of Abdominal Muscle Strengthening Exercise on Abdominal Muscle Strength and Respiratory Function in Stroke Patients Kang Taewook, PT, Ph.D 1 Jung Juhyeon, PT, Ph.D 2ǂ 1 Dept. of Physical Therapy, Walk Rehabilitation Hospital, Physical Therapist 2ǂ Dept. of Physical Therapy, Gimhae College, Professor Abstract Purpose : The purpose of this study was to investigate the effect of abdominal muscle strengthening exercise on abdominal muscle strength and respiratory function in stroke patients. Methods : The subjects were 14 stroke patients (10 males, 4 females) hospitalized at W rehabilitation hospital in Busan City and randomly assigned to 7 exercise groups and 7 control groups. Exercise was performed in combination with an upper and lower extremity pattern of proprioceptive neuromuscular facilitation. Measurements of abdominal muscle strength and respiratory function were made before intervention and 4 weeks after intervention. Abdominal muscle strength was assessed using a digital manual dynamometer, and respiratory function was assessed by spirometry. The collected data were analyzed with a paired t-test and independent t-test and the significance level was set as α=.05. Results : The results showed that applying abdominal muscle strengthening exercise to stroke patients showed a significant increase in abdominal muscle strength and a significant difference between groups (p<.05). Maximal-effort expiratory spirogram (MES) readings were significantly increased in forced vital capacity (FVC), and forced expiratory volume in one second (FEV 1 ), in the exercise group, and there were a significant differences between the groups in terms of FEV1 (p<.05). Slow vital capacity (SVC) was significantly increased in vital capacity (VC), tidal volume (TV), inspiratory reserve volume (IRV), and expiratory capacity (EC), and there were significant differences between the groups in VC, TV, expiratory reserve volume (ERV), EC, and inspiratory capacity (IC) (p<.05). Conclusion : Abdominal muscle strengthening exercise was effective in the abdominal muscle strength of stroke patients, and it was confirmed to have a positive effect on the enhancement of respiratory function. Therefore, it seems that exercise programs for stroke patients with respiratory weakness should include abdominal muscle strengthening exercises. Key Words : abdominal muscle strength, maximal-effort expiratory spirogram, slow vital capacity, proprioceptive neuromuscular facilitation, stroke ǂ 교신저자 : 정주현, hyuni610@naver.com 2) 논문접수일 : 2019 년 9 월 26 일 수정일 : 2019 년 10 월 24 일 게재승인일 : 2019 년 11 월 8 일 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 13
대한통합의학회지제 7 권제 4 호 Ⅰ. 서론 1. 연구의배경및필요성뇌졸중은단일질환중사망률이매우높으며, 장기간신체에장애를남기는질환으로알려져있다 (Go 등, 2014; Rabelo 등, 2016). 뇌졸중은전세계에서사망원인 2위를차지하고있으며, 우리나라에서는악성신생물 ( 암 ) 과심장질환에이어 3위를차지할정도로사회적으로많은문제를야기하고있는실정이다 (Statistics Korea, 2015). 뇌졸중은뇌에혈액을공급하는혈관의문제로인해나타나는뇌손상으로써, 신경학적결함을유발하여신체의기능저하뿐만아니라사회적기능까지저하시킨다 (Dijkerman 등, 2004). 또한운동기능과감각기능, 인지기능등의신경학적인손상으로일상생활의제한도나타난다 (Kolb & Gibb, 2007). 이러한신경학적손상으로나타나는근력저하, 운동조절능력저하, 조절된움직임상실등으로운동기능이저하되면서독립적인일상생활의어려움이나타나고, 신체활동의감소로이어지면서호흡시스템을이루고있는요소의약화도발생시켜호흡근육의효율성이떨어지는문제점이나타나고있다 (Pollock 등, 2013; Teixeira-Salmela 등, 2005). 뇌졸중환자는마비로인한신체의비대칭이발생하여, 움직임수행시비효율적인움직임을보이고, 이러한비효율적움직임은직 간접적으로호흡근육의운동성을떨어뜨려호흡주기에영향을미치게된다 (Britto 등, 2011). 특히침상생활을하는환자들은산소운반에관련된심혈관계기능과심맥박기능저하그리고마비측의가슴벽움직임과전기적활동의감소로직 간접적으로심폐기능에영향을받게된다 (Ferretti 등, 1998). 따라서뇌졸중환자의신체적기능과호흡효율성의증진을위해서는가슴벽의확장과환기, 폐용량과용적을적절히유지해야한다 (Frownfelter & Dean, 2006). 호흡은가슴우리의용적변화에따라공기가폐의안과밖으로순환하는것을말하는데 (Kisner와 Colby, 2002), 이러한환기-관류순환역할은인체의자연적인신경학적조절에의해이루어지고있다 (Pryor & Prasad, 2002). 정상적인호흡을위해서는호흡근육과가슴우리의움직임등이상호작용이잘이루어져야하는데, 이러한상호작용은호흡근의근력, 가동성, 연부조직의탄력성으로결정된다 (Fishman & Systrom, 1991). 호흡근은들숨근과날숨근으로나뉘는데, 들숨은가로막과바깥갈비사이근의작용으로이루어지고있으며, 더강한들숨을위해목빗근, 목갈비근, 등세모근, 큰가슴근, 작은가슴근, 앞톱니근등들숨보조근을사용하게된다. 날숨은들숨후호흡근의이완으로인한수동적인과정으로이루어지나, 강한날숨을하기위해배곧은근, 배가로근, 배속빗근, 배바깥빗근, 속갈비사이근을사용하게된다 (Kisner & Colby, 2002). 따라서뇌졸중환자의폐활량을증진시키기위해서는호흡근의근력운동이필요하다 (Carr & Jones, 2003). 현재뇌졸중환자의호흡기능을향상시키기위한많은연구가이루어지고있다. Song과 Park(2015) 은뇌졸중환자에게가슴우리가동술을적용한결과몸통조절을개선시켰다고하였으며, 이러한몸통조절능력은호흡기능과유의한상관관계가있다 (Elshinnawy & Khalil, 2016; Jandt 등, 2011). 또한 Sutbeyaz 등 (2010) 은뇌졸중환자를대상으로들숨근강화운동, 호흡재교육을중재하여폐기능을확인한결과들숨근강화운동군에서는노력성폐활량 (forced vital capacity; FVC) 과 1초간노력성날숨량 (forced expiratory volume in one second; FEV 1 ) 이증가하였고, 가로막호흡운동을실시한호흡재교육군에서는최대날숨속도 (peak expiratory flow; PEF) 만증가하였다고하였다. 이와같이기존의연구들은가슴우리의확장과들숨근강화를통한호흡기능에초점이맞추어져있다. 하지만 Annoni 등 (1990) 은폐기능의저하는호흡근근력이약하기때문에나타나며, 폐기능의향상을위해서는들숨기능과날숨기능을증가시키는중재가필요하다고하였다. Gomes-Neto 등 (2016) 의메타분석연구에서는뇌졸중환자에게호흡근운동을적용하였을때들숨근과날숨근의근력과지구력이향상되어호흡기능이증진된다고하였으며, Jung 등 (2014) 은뇌졸중환자를대상으로들숨근호흡운동과배근육에전기자극을시행한결과폐기능이증진되었다고하였다. 이러한결과는배근육이배안내압을조절하여호흡에관여하는것을시사하고있다 (Talasz 등, 2011). 하지만대부분의선행연구에서 14 Journal of The Korean Society of Integrative Medicine Vol.7 No.4
강태욱 정주현 는날숨시배안내압을조절하여공기의배출을돕는배근육에대한중요성은간과되고있는실정이다. 2. 연구의목적본연구의목적은뇌졸중환자를대상으로날숨근에직접적으로중재를적용한배근강화운동이뇌졸중환자의배근력과호흡기능의변화에미치는영향을확인함으로써뇌졸중환자에대한날숨근강화운동의필요성을확인하고자하였다. Ⅱ. 연구방법 자세에서왼쪽하지를엉덩관절, 무릎관절 90 상태로측정자다리위에놓이도록하였고, 오른쪽상지는폄 / 모음 / 안쪽돌림패턴의시작자세를취한후측정자의손에맞닿게하였다. 움직임의시작은측정자의구두지시에의해이루어졌으며동시에상지의폄 / 모음 / 안쪽돌림패턴과하지의굽힘 / 모음 / 바깥돌림패턴을결합하여실시하였다. 배근강화운동은 1세트당 10회, 총 3세트실시하였으며, 대상자의근피로예방을위해 1세트반복후휴식시간 1분을설정하였다 (Fig 1). 대조군은 PNF 패턴을이용한배근강화운동은실시하지않고실험군과동일하게스트레칭, 근력운동, 균형운동을포함한중추신경계발달재활치료를 20분간시행하였다. 1. 연구대상 본연구에참여한대상자는부산광역시소재 W 재활병원에입원중인환자로자기공명영상촬영 (MRI), 전산화단층촬영 (CT) 으로뇌졸중으로진단받은환자 14명을대상으로하였으며, 실험군 7명, 대조군 7명으로무작위배치하였다. 대상자는연구의목적과방법에대해충분한설명을듣고자발적으로연구에참여하기로서면으로동의하였으며, 뇌졸중을진단받은지 6개월이상 2 년미만인자, 한국형간이정신상태검사 (MMSE-K) 24점이상인자, 근골격계질환으로인한호흡기의문제가없는자, 폐질환으로호흡치료를받고있지않은자를대상으로선정하였다. 2. 중재방법본연구는뇌졸중환자에게적용한배근강화운동이배근력및호흡기능을향상에어떠한영향을미치는지알아보기위해진행되었다. 실험군은스트레칭, 근력운동, 균형운동을포함한중추신경계발달재활치료를 20분간실시하였으며, 추가적으로 PNF 패턴을이용한배근강화운동을 10분간좌우교대로실시하였다. 배근강화운동은 PNF의상지폄 / 모음 / 안쪽돌림패턴과하지굽힘 / 모음 / 바깥돌림패턴을이용하였다. 대상자는바로누운 Fig 1. Abdominal muscle strength exercise 3. 측정방법및절차 1) 배근력측정뇌졸중환자의배근력을측정하기위해디지털근력측정기 (MicroFET2, HOGGAN, USA) 를사용하였다. 디지털근력측정기는몸통굽힘측정시 ICC=0.94로신뢰성이높은도구이며 (Aguiar 등, 2016), 객관적으로수치화할수있는장점이있다. 배근력의측정은의자에바로앉은자세에서환자의양손은넙다리부위쪽에위치하도록한뒤, 검사자는대상자의복장패임 (Strenal notch) 에디지털근력측정기를대고 5초간몸통굽힘하도록지시하였다. 몸통굽힘을수행하는 5초동안측정된최댓값 (Peak) 을기록하였으며, 3회측정값의평균값을사용하였다. 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 15
대한통합의학회지제 7 권제 4 호 2) 호흡기능측정호흡기능의측정을위해폐활량측정기 (Cardio7-S, BIONET, Korea) 를사용하였다. 호흡기능의측정은최대노력성날숨곡선 (Maximal-effort expiratory spirogram; MES) 을통해 FVC, FEV 1, 1초간노력성날숨량의노력성폐활량에대한비율 (FEV 1 /FVC), PEF를측정하였다. 안정시폐활량 (solw vital capacity; SVC) 은폐활량 (vital capacity; VC), 1회호흡량 (tidal volume; TV), 날숨예비용적 (expiratory reserve volume; ERV), 들숨예비용적 (inspiratory reserve volume; IRV), 날숨용량 (expiratory capacity; EC), 들숨용량 (inspiaratory capacity; IC) 을측정하였다. 정확한호흡기능의측정을위해대상자에게충분히설명을하고연구자가직접시험을보여준후측정에임했다. 호흡기능의측정자세는등받이가있는의자에엉덩관절과무릎관절을 90 굽힘하여편하게앉은자세를취하였으며, 코에서공기가새어나오는것을방지하기위해코마개를하였고, 1회용호흡필터를사용하여호흡기능을측정하였다 (Kim, 2014). 호흡기능의측정은 American Thoracic Society(2002) 에따라최소 3회이상검사하여재현성이가장큰측정값을사용하였다. 4. 분석방법본연구는뇌졸중환자에게적용한배근강화운동이배근력과호흡기능에미치는영향을알아보고자한것으로, 대상자의일반적특성은기술통계로분석하였다. 그룹간동질성과그룹간비교를위해독립표본 t-test(independent t-test) 를실시하였다. 정규성검정을위해샤피로-윌크 (Shapiro-Wilk) 정규성검정을실시하였고, 정규성을만족하여대응표본 t-test(paired t-test) 를사용하여분석하였다. 통계처리는 Window용 SPSS 22.0 ver을사용하였으며, 유의수준은 α=.05로설정하였다. Ⅲ. 연구결과 1. 연구대상자의일반적특성본연구에참여한대상자는뇌졸중환자 14명 ( 남자 10 명, 여자 4명 ) 이었다. 실험군은평균연령 62.29세, 신장 167.29 cm, 체중 63.86 kg이었고, 대조군의경우평균연령 55.42세, 신장 166.43 cm, 체중 69.14 kg이었다. 실험 Table 1. Baseline demographic and pre-result of subjects for each group (Unit) Variables Experimental group Control group t p Age (years) 62.29±12.13 a 55.42±12.28 1.051.314 Height ( cm ) 167.29±8.16 166.43±5.77.227.825 Weight ( kg ) 63.86±12.14 69.14±10.98 -.854.410 AMS (lbs) 13.46±4.20 14.19±4.05 -.331.747 FVC (l) 2.39±0.67 2.60±0.74 -.557.588 FEV 1 (l) 2.06±0.58 2.39±0.61-1.038.320 FEV 1 /FVC (%) 85.20±9.63 92.79±3.92-1.933.090 PEF (l/s) 4.34±1.54 4.71±1.39 -.477.642 VC (l) 4.86±1.85 6.63±2.63-1.460.173 TV (l) 0.50±0.14 0.78±0.37-1.899.095 ERV (l) 2.01±0.99 2.89±1.44-1.330.212 IRV (l) 2.44±0.85 2.75±0.77 -.725.482 EC (l) 2.44±1.06 3.68±1.76-1.602.141 IC (l) 4.42±1.81 5.81±2.29-1.258.234 a Mean±SD, AMS; Abdominal muscle strength, FVC; Forced vital capacity, FEV 1 ; Forced expiratory volume in one second, PEF; Peak expiratory flow, VC; Vital capacity, TV; Tidal volume, ERV; Expiratory reserve volume, IRV; Inspiratory reserve volume, EC; Expiratory capacity, IC; Inspiratory capacity 16 Journal of The Korean Society of Integrative Medicine Vol.7 No.4
강태욱 정주현 전두집단의동질성을분석한결과모든항목에서유의한차이가없었다 (Table 1). 2. 배근강화운동에따른배근력변화 배근력은실험군에서중재전 13.46±4.20에서중재후 16.13±3.53으로향상되어통계적으로유의하게증가하였지만 (p<.05), 대조군의배근력은통계적으로유의한차이가없었다. 실험군과대조군간의배근력차이를알아본결과두그룹간유의한차이가있었다 (p<.05)(table 2). Table 2. Change of abdominal muscle strength before, after 4-week of two groups Variables Group Pre Post t p t p Experimental 13.46±4.20 a 16.13±3.53-5.453.002 AMS (lbs) Control 14.19±4.05 13.95±3.35.328.754 a Mean±SD, AMS; Abdominal Muscle Strength -3.279.007 3. 배근강화운동에따른최대노력성날숨곡선변화실험군에서 FVC는 2.39±0.67에서 2.55±0.06으로, FEV 1 은 2.06±0.58에서 2.17±0.56으로중재후통계적으로유의하게증가하였다 (p<.05). 반면 FEV 1 /FVC, PEF에서는 통계적으로유의한차이는없었지만중재전보다중재후증가한것을확인할수있었다. 대조군에서는모든호흡기능에서통계적으로유의한차이가없었다. 실험군과대조군간의 MES 차이를알아본결과 FEV 1 에서유의한차이가있었다 (p<.05)(table 3). Table 3. Change of respiratory function (MES) before, after 4-week of two groups Variables Group Pre Post t p t p FVC (l) FEV 1 (l) FEV 1 /FVC (%) PEF (l/s) Experimental 2.39±0.67 a 2.55±0.68-2.916.027 Control 2.60±0.74 2.66±0.76-1.008.353 Experimental 2.06±0.58 2.17±0.56-3.329.016 Control 2.39±0.61 2.37±0.60.359.732 Experimental 85.20±9.63 86.76±8.75 -.869.418 Control 92.79±3.92 90.29±5.29 1.767.128 Experimental 4.34±1.54 5.00±2.11-1.607.159 Control 4.71±1.39 4.70±1.51.072.945-1.198.254-2.242.045-1.777.101-1.457.171 a Mean±SD, FVC; Forced Vital Capacity, FEV 1 ; Forced Expiratory Volume in one second, PEF; Peak Expiratory Flow 4. 배근강화운동에따른안정시폐활량변화실험군에서 VC는 4.86±1.85에서 5.80±1.44, TV은 0.50±0.15에서 0.79±0.22, IRV는 2.44±0.85에서 2.74±0.74, EC는 2.44±1.06에서 3.22±0.85로중재전보다중재후통계적으로유의하게증가하였다 (p<.05). 반면 ERV, IC 에서는통계적으로유의한차이는없었지만중재전보다중재후증가한것을확인할수있었다. 대조군에서는모든호흡기능에서통계적으로유의한차이가없었다. 실험군과대조군간의 SVC의차이를알아본결과 VC, TV, ERV, EC, IC에서유의한차이가있었다 (p<.05)(table 4). 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 17
대한통합의학회지제 7 권제 4 호 Table 4. Change of respiratory function(svc) before, after 4-week of two groups Variables Group Pre Post t p t p VC (l) TV (l) ERV (l) IRV (l) EC (l) IC (l) Experimental 4.86±1.85 a 5.80±1.44-2.691.036 Control 6.63±2.63 6.23±2.07 1.434.201 Experimental 0.50±0.14 0.79±0.22-2.923.027 Control 0.78±0.37 0.77±0.27.200.848 Experimental 2.01±0.99 2.48±0.75-2.246.066 Control 2.89±1.44 2.69±1.10 1.032.342 Experimental 2.44±0.85 2.74±0.74-2.547.044 Control 2.75±0.77 2.77±0.92 -.066.950 Experimental 2.44±1.06 3.22±0.85-3.639.011 Control 3.68±1.76 3.46±1.31 1.103.312 Experimental 4.42±1.81 5.04±1.39-1.774.126 Control 5.81±2.29 5.44±1.82 1.509.182-2.997.011-2.670.020-2.362.036-1.198.254-3.408.005-2.318.039 a Mean±SD, VC; Vital Capacity, TV; Tidal Volume, ERV; Expiratory Reserve Volume, IRV; Inspiratory Reserve Volume, EC; Expiratory Capacity, IC; Inspiratory Capacity Ⅳ. 고찰 뇌졸중환자는신체움직임제한으로인한대사요구량의증가와산소부족현상으로심폐시스템능력의감소가두드러진다 (Polese 등, 2013). 뇌졸중환자의호흡기능에관련된선행연구에서는정상인에비해호흡기능이절반수준임을확인하였으며, 호흡기능을향상시킬수있는운동프로그램이필요하다고하였다 (Britto 등, 2011; Messaggi-Sartor 등, 2015). 따라서본연구에서는뇌졸중환자의호흡기능향상을위한배근강화운동중재가배근력과호흡기능에어떠한영향을미치는지알아보고자하였다. 본연구에서사용한측정변인은배근육의근력과호흡기능중 MES와 SVC이었다. 배근육은호흡에관여하는근육중에서날숨근의대표적인근육이라할수있다. MES는날숨근의근력을대변하며, FVC, FEV 1, FEV 1 /FVC, PEF의항목으로구성되어있다. SVC는전반적인폐용량을확인하는검사로 VC, TV, ERV, IRV, IC, EC의항목으로구성되어있다. 배근력을증진시키기위한중재로 PNF의패턴을이용한운동을실시하였다. 본연구에서는 PNF의상지폄 / 모음 / 안쪽돌림패턴과하지굽힘 / 모음 / 바깥돌림패턴을결합한배근강화운동을중재하였으며, 중재후대조군에비해배근력이유의미하게증가한것을확인할수있었다. PNF 패턴을이용한선행연구에서는팔과다리를이용한패턴운동이배근육을강화할수있다고하였다 (Kim 등, 2011; Lee 등, 2016). 이러한결과는단일분절의움직임을이용한운동보다팔과다리의결합운동이협응능력의향상으로이어져기능적활동을증가시키며, 근작용효율을극대화시키는데효과적이기때문이라생각된다. MES의결과를확인해보면배근강화운동중재후운동군에서 FVC, FEV 1 이유의하게향상되었다. Kim 등 (2012) 의연구에서는날숨운동기구를이용하여중재한결과 FVC과 FEV 1 이증가하였다고보고하여본연구와유사한결과를보였는데, FVC는몸통의근력과밀접한관련성이있으며 (Kim, 2004), FVC와 FEV 1 은기도의저항과도밀접한관계가있다 (Miller 등, 2005). 이렇듯날숨근육의강화는 FVC와 FEV 1 을향상시키게되는데, 본 18 Journal of The Korean Society of Integrative Medicine Vol.7 No.4
강태욱 정주현 연구의배근강화운동이대상자의배근력증가로이어져강한날숨시배근육의수축으로가슴우리와가로막의이동이발생하여배내압을증가시켜기도저항을이길수있을정도의강한날숨이나타난것으로판단할수있다. 하지만 FEV 1 /FVC, PEF는통계적으로유의하지않았다. FEV 1 /FVC은기도의폐쇄정도를확인할수있으며, 70% 이하일경우폐쇄성폐질환으로진단하고있다 (Dechman & Wilson, 2004). FEV 1 /FVC은측정된폐활량에따른 1초간배출된공기의비율을측정하는결과값으로대상자들의신체적특성을고려하면유의한결과값이나타나지않을수있다고보여진다. PEF는 1초안에최대날숨할수있는공기의최대유속을의미하고, PEF 의증가는날숨근의작용이강하게일어난것이라할수있다 (Lanini 등, 2003). 하지만본연구의결과에서는통계적으로유의한결과가나타나지않았는데, 이러한결과는 PEF의측정시날숨을통해공기가밖으로나가는타이밍과기도의개방타이밍이적절해야정확한측정이되는데, 본연구의대상자는뇌졸중환자로기도의개방타이밍을조절함에있어오류가생겨측정값의수치는증가되었지만통계적으로유의한결과값이나타나지않았다고사료된다. SVC의결과를확인해보면배근강화운동중재후운동군에서 VC, TV, IRV, EC에서유의하게향상되었다. 반면 ERV, IC은통계적으로유의하지않았지만, 중재전보다중재후수치가증가하는것을확인할수있었다. SVC는전체적인폐용량을확인하기위해실시하는데, SVC 수치의정의를보면 VC는 IRV와 EC의합을말하고, EC은 TV과 ERV의합을의미한다 (Frownfelter & Dean, 2012). 이러한수치의정의를기준으로본연구의결과를보면배근강화운동을통해 EC가통계적으로유의하게증가하였는데, 이는 TV와 ERV의유량의합이증가한것을의미한다. 하지만 ERV는통계적으로유의한결과를보이지않았기에 TV의증가가영향을미쳤다고생각된다. TV는한번에들이마실수있는양을의미하고, 호흡량이증가하였다는것은호흡시호흡빈도는감소하게되어임상적으로폐활량개선에긍정적인신호라고판단할수있다. 또한일반적인호흡시해부학적무용공간에공기가남아있게되는데, 이때날숨근의근력이약해지면해부학적무용공간에공기잔량이많아 지게되어상대적으로들숨량이감소하게된다. 이러한관점에서배근강화운동을통한배근력의향상은폐의공기순환을개선시켜 VC, TV, IRV, EC의향상에긍정적인영향을미쳤다고볼수있다. Kim 등 (2011) 의연구에서는뇌졸중환자에게피드백호흡운동을중재한결과 VC, TV, IRV, ERV이증가하였다고보고하였으며, Chiara 등 (2006) 은날숨근의운동이신경학적질환을가지고있는환자의호흡기능을증진시키는데중요한역할을한다고하여본연구의결과를뒷받침하고있다. 이처럼배근력의증가는가슴우리를아래방향으로당기며, 가로막안쪽의장기를위쪽으로상승시켜가슴우리와배내압을증가시켜폐의공기가밖으로배출되는날숨작용에영향을미치게된다. 또한이러한배근의작용으로해부학적무용공간의잔기량을감소시켜들숨시더많은공기를들여마실수있게되어전반적인폐활량의증가를가져오게된다. 따라서본연구에서뇌졸중환자를대상으로측정한 MES와 SVC의모든항목에서증가된결과를확인할수있었다고사료된다. 반면본연구에참여한대상자의수가 14명으로전체뇌졸중환자로확대해석하기에는어려운부분이있으며, 대부분의대상자가남성으로성별에따른호흡패턴의특성을반영하지못한한계가있다. 또한뇌졸중환자의배근력을측정하기위한앉은자세는측정시대상자의상체무게와엉덩관절굽힘근육의작용을배제하기어려워순수한배근력을측정하기어려운제한점이있다. 따라서차후에는성별의비율을고려하고, 뇌졸중환자의순수한배근력을측정하기위한측정자세를고려하여뇌졸중환자의호흡근근력과호흡기능과의관련성을확인하는연구가추가적으로진행되어야할것으로생각된다. Ⅴ. 결론 본연구는뇌졸중환자 14명을대상으로배근강화운동을중재하여배근력과호흡기능에어떠한변화가있는지알아보고자하였다. 그결과실험군이대조군에비해배근력, FVC, FEV 1, VC, TV, IRV, EC에서유의한증 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 19
대한통합의학회지제 7 권제 4 호 가를보였다. 이러한결과로볼때 PNF 패턴을이용한배근강화운동은뇌졸중환자의배근육강화에효과적이며, 배근육의강화는호흡기능, 특히, 날숨의기능증진에긍정적인효과가있음을확인할수있었다. 따라서뇌졸중환자의배근육강화는매우중요하며, 호흡기능증진을위한프로그램에배근강화운동이포함되어야할것으로사료된다. 참고문헌 Aguiar LT, Martins JC, Lara EM, et al(2016). Dynamometry for the measurement of grip, pinch, and trunk muscles strength in subjects with subacute stroke: reliability and different number trials. Braz J Phys Ther, 20(5), 395-404. American Thoracic Society(2002). ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med, 166, 111-117. Annoni JM, Ackermann D, Kesselring J(1990). Respiratory function in chronic hemiplegia. Int Disabil Stud, 12(2), 70-80. Britto RR, Rezende NR, Marinho KC, et al(2011). Inspiratory muscular training on chronic stroke survivors: a randomized controlled trial. Arch Phys Med Rehabil, 92(2), 184-190. Carr M, Jones J(2003). Physiological effects of exercise on stroke survivors. Top Stroke Rehabil, 9(4), 57-64. Chiara T, Martic SD, Davenport PW, et al(2006). Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Arch Phys Med Rehabil, 87(4), 468-473. Dechman G, Wilson CR(2004). Evidence underlying breathing retraining in people with stable chronic obstructive pulmonary disease. Phys Ther, 84(12), 1189-1197. Dijkerman HC, Ietswaart M, Johnston M, et al(2004). Does motor imagery training improve hand function in chronic stroke patients? A pilot study. Clin Rehabil, 18(5), 538-549. Elshinnawy AM, Khalil NH(2016). Trunk control in relation to ventilatory function in chronic hemorrhagic stroke patients. Int J Ther Rehabil Res, 5(3), 6-10. Ferretti G, Girardis M, Moia C, et al(1998). Effects of prolonged bed rest on cardiovascular oxygen transport during submaximal exercise in humans. Eur J Appl Physiol Occup Physiol, 78(5), 398-402. Fishman RS, Systrom DM(1991). Preoperative cardiopulmonary exercise testing: Determining the limit to exercise and predicting outcome after thoracotomy. J Cardiothorac Vasc Anesth, 5(6), 614-626. Frownfelter D, Dean E(2006). Cardiovascular and pulmonary physical therapy. 4th ed, Philadelphia, Mosby, pp.704. Frownfelter D, Dean E(2012). Cardiovascular and pulmonary physical therapy. 5th ed, Philadelphia, Mosby, pp.139. Go AS, Mozaffarian D, Roger VL, et al(2014). Executive summary: heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation, 129(3), 339-410. Gomes-Neto M, Saquetto MB, Silva CM, et al(2016). Effects of respiratory muscle training on respiratory function, respiratory muscle strength, and exercise tolerance in patients poststroke: a systematic review with meta-analysis. Arch Phys Med Rehabil, 97(11), 1994-2001. Jandt SR, Caballero RM, Junior LA, et al(2011). Correlation between trunk control, respiratory muscle strength and spirometry in patients with stroke: an observational study. Physiother Res Int, 16(4), 218-224. Jung JH, Shim JM, Kwon HY, et al(2014). Effects of abdominal stimulation during inspiratory muscle training on respiratory function of chronic stroke patients. J Phys Ther Sci, 26(1), 73-76. 20 Journal of The Korean Society of Integrative Medicine Vol.7 No.4
강태욱 정주현 Kim BJ(2004). The effects of forceful respiratory exercise on the gait parameters in hemiplegic patients. Graduate school of Daegu University, Republic of Korea, Doctoral dissertation. Kim CB(2014). The effect of complex breathing exercise aimed at improving the inspiratory and expiratory pulmonary functions for respiratory function and gait function in stroke patients. Graduate school of Daejeon University, Republic of Korea, Doctoral dissertation. Kim K, Fell DW, Lee JH(2011). Feedback respiratory training to enhance chest expansion and pulmonary function in chronic stroke: a double-blind, randomized controlled study. J Phys Ther Sci, 23(1), 75-79. Kim KH, Ki KI, Youn HJ(2011). The effects of PNF leg flexion patterns in EMG activity of the trunk. PNF and Movement, 9(3), 19-24. Kim MH, Lee WH, Yun MJ(2012). The effects on respiratory strength training on respiratory function and trunk control in patient with stroke. J Korean Soc Phys Ther, 24(5), 340-347. Kisner C, Colby LA(2002). Therapeutic Exercise: Foundations and Technique. 5th ed, Philadelphia, F.A. Davis Company, pp.852-853. Kolb B, Gibb R(2007). Brain plasticity and recovery from early cortical injury. Dev Psychobiol, 49(2), 107-118. Lanini B, Bianchi R, Romagnoli I, et al(2003). Chest wall kinematics in patients with hemiplegia. Am J Respir Crit Care Med, 168(1), 109-113. Lee HO, Bae WS, Shin JW(2016). A Comparison of the trunk muscle activity according to the direction of upper extremity lifting using elastic band. J Korean Soc Phys Med, 11(2), 25-31. Messaggi-Sartor M, Guillen-Sola A, Depolo M, et al(2015). Inspiratory and expiratory muscle training in subacute stroke: a randomized clinical trial. Neurology, 85(7), 564-572. Miller MR, Hankinson J, Brusasco V, et al(2005). Standardisation of spirometry. Eur Respir J, 26(2), 319-338. Polese JC, Pinheiro MB, FariaCD, et al(2013). Strength of the respiratory and lowerlimb muscles and functional capacity in chronic stroke survivors with different physical activity levels. Braz J Phys Ther, 17(5), 487-493. Pollock RD, Rafferty GF, Moxham J, et al(2013). Respiratory muscle strength and training in stroke and meurology: a systematic review. Int J Stroke, 8(2), 124-130. Pryor JA, Prasad SA(2002). Physiotherapy for respiratory and cardiac problems. 3rd ed, Singapore, Churchill Livinstone, pp.170-176. Rabelo M, Nunes GS, Amante NM, et al(2016). Reliability of muscle strength assessment in chronic post-stroke hemiparesis: a systematic review and meta-analysis. Top Stroke Rehabil, 23(1), 26-36. Song GB, Park EC(2015). Effects of chest resistance exercise and chest expansion exercise on stroke patients respiratory function and trunk control ability. J Phys Ther Sci, 27(6), 1655-1658. Statistics Korea(2015). Cause of death statistics in 2014. Seoul, Statistics Korea, pp.5. Sutbeyaz ST, Koseoglu F, Inan L, et al(2010). Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomised controlled trail. Clin Rehabil, 24(3), 240-250. Talasz H, Kremser C, Kofler M, et al(2011). Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J, 22(1), 61-68. Teixeira-Salmela LF, Parreira VF, Britto RR, et al(2005). Respiratory pressures and thoracoabdominal motion in community-dwelling chronic stroke survivors. Arch Phys Med Rehabil, 86(10), 1974-1978. 배근강화운동이뇌졸중환자의배근력및호흡기능에미치는영향 21