[논문]뇌졸중 환자의 상지기능 개선을 위한 말초감각신경자극과 과제 지향적 훈련의 동시 적용 효과: 단일 맹검 무작위대조군실험

김선호; 원경아; 정은화

doi:10.22683/tsnr.2020.9.4.007

뇌졸중 환자의 상지기능 개선을 위한 말초감각신경자극과 과제 지향적 훈련의 동시 적용 효과: 단일 맹검 무작위대조군실험
The Effects of Simultaneous Application of Peripheral Nerve Sensory Stimulation and Task-Oriented Training to Improve Upper Extremity Motor Function After Stroke: Single Blinded Randomized Controlled Trial 원문보기

Therapeutic science for rehabilitation = 재활치료과학, v.9 no.4, 2020년, pp.7 - 20

김선호 (영광 재활 병원 작업치료실) , 원경아 (인천광역시 광역치매센터) , 정은화 (극동대학교 작업치료학과)

초록
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목적 : 본 연구는 뇌졸중 환자들의 상지기능 개선을 위해 말초신경감각자극과 과제지향적 훈련의 동시적용하여 효과를 알아보는 것이다. 연구방법 : 본 연구는 29명의 편마비 환자를 대상으로 수행하였다. 말초신경감각자극과 과제지향적 훈련을 동시에 적용한 실험군은 14명, 과제지향적 훈련만 실시한 대조군은 15명으로 주5회, 회기당 30분씩, 총 4주간 진행하였다. 결과측정은 손목과 어깨근육의 자발적 근수축 비율과 상자와 나무토막 검사, 잡기와 쥐기의 근력, Action Research Arm Test를 사용하여 중재 전·후로 측정하였다. 결과 : 4주간의 중재 후 짧은노쪽손목폄근, 노쪽손목굽힘근의 근 활성도와 잡기 근력, Action Research Arm Test에서 실험군은 대조군 보다 유의한 개선을 나타냈다. 결론 : 말초신경감각자극과 과제지향적 훈련의 동시적용은 과제지향적훈련만 하는 것보다 뇌졸중 환자의 상지기능 개선에 보다 효과적이었다.

Abstract ▼ AI-Helper

Objective : This study aimed to investigate the effect of simultaneous application of peripheral nerve sensory stimulation and task-oriented training on the improvement of upper extremity motor function after stroke. Methods : This study included 29 patients with hemiplegia. The 14 subjects were in the peripheral nerve sensory stimulation and task-oriented training group for 4 weeks (30 min/d, 5 d/wk), while the 15 control group subjects underwent only task-oriented training for the same duration. The outcome measures were the percentage of voluntary baseline muscle contractions of the wrist and shoulder and Box and Block Test, grip and pinch strength, and Action Research Arm Test. Results : After 4 weeks, muscle activity of extensor carpi radialis, flexor carpi radialis and grip strength and Action Research Arm Test were significantly higher in the experimental group. Conclusion : Simultaneous application of the peripheral nerve sensory stimulation and task-oriented training was found to be superior to task-oriented training for improving upper extremity motor function of adults with stroke.

주제어

표/그림 (5)

그림 Figure 1. Flow Diagram of Subjects in the Study
표 Table 1. Content of Task-Oriented Training
표 Table 2. Characteristics and Baseline Assessment Results of Study Participants
표 Table 3. Changes in Muscle Activity, Hand Strength, BBT, ARAT Within Group
표 Table 4. Difference Between Groups

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문제 정의

The clinical significance of this study is that it can be applied in clinical situations to improve upper limb function of stroke patients. PNS is relatively safe and less fatigue inducing than FES, and can be easily applied with upper extremity training such as TOT.
This pilot study demonstrated the feasibility of simultaneous use of PNS and TOT for recovery of upper limb dysfunction in stroke patients. The results of this study showed that muscle activity, hand grip strength, and upper limb function were significantly higher in the PNS plus TOT group than the TOT group.
This study aimed to investigate the effect of simultaneous application of PNS and TOT on the improvement of upper extremity motor function after stroke.

가설 설정

There were several limitations in this study. First, the sample size was small. Second, the participants were chronic stroke patients, and shoulder and hand function loss was mild, with a Brunnstrom stage average of 4 or more.

제안 방법

The Wilcoxon signed rank test was used to test for significance before and after intervention. An analysis of covariance was used to compare changes between the groups, and the covariance was set as a pre-assessment of each group. Statistical significance was set at p<.
Box and Block Test (BBT) was used to evaluate the dexterity of the affected upper extremity of the participant in this study. BBT measures the number of blocks that are successfully moved from one side of the subject to the other over a period of 60 s (Chanubol et al.
EG performed PNS combined with TOT, and the training was conducted a total of 20 sessions, 5 days a week for 4 weeks. In the CG, only TOT was performed, and the training was conducted similarly to the EG.
Surface electromyography (sEMG) is a test that measures the electrical activity of muscles by using electrodes that are attached to the skin. In this study, it was used to measure muscle activity of the flexor carpi radialis (FCR), extensor carpi radialis (ECR), and anterior fibers of the deltoid (AD).
In this study, we used FES-1000-FES EMG (Cyber Medic, Seoul, Korea) to provide PNS to the participants. It has two channels in total, and can be controlled with frequency of 1–200 Hz, output current of 0–99 mA, and pulse width of 20µs-50µs.
All subjects provided informed consent before study inclusion according to the Declaration of Helsinki 2004. Selected patients were randomly assigned to 14 patients in the experimental group (EG) and 15 in the control group (CG). During the intervention, 4 patients in the EG and 5 in the CG were dropped out because of the reasons such as rejection of treatment, discharge.
The assessments were conducted one-on-one within the hospital’s occupational therapy room.
The inclusion criteria were as follows: Patients diagnosed with stroke via MRI/CT medical record; Patients aged 20 years and older; Patients with an onset at least 12 months prior to the study; Patients without cognitive impairments (MMSE-K ≧24) (Folstein, Folstein, & McHugh, 1975); Patients who have a Brunnstrom stage of the shoulder and hand of 3 or more; Patients who understand the study’s purpose and can provide consent for participation.
This study investigated the effect of TOT on stroke patients while providing PNS to induce changes in muscle activity, hand grip, and upper extremity function. These variables are meaningful to the clinician because they are important for rehabilitation goals of stroke patients, including a return to daily life activities.
This was a single-blind study, and subjects were allocated randomly to the experimental or control group using a random number generated by computer software. The study was conducted after approval from the Ethics Committee of Yonsei University School (Approval number.

대상 데이터

29 patients who met the criteria for the study were selected from 41 patients who were admitted to Y hospital who were considered to be able to participate in the study.
A simple randomization method using a computer randomization program was used to assign 14 subjects to experimental group, and 15 to control group. All sessions were conducted by one occupational therapist with six years of clinical experience.
, Kuopio, Finland), with a total of eight channels. In this study, five channels were used. The EMG signal sampling rate was 1000 Hz, and a band pass filter of 10–500 Hz and a notch filter of 60 Hz were used.
MMSE-K is widely used in clinical practice to easily assess the cognitive level of patients with brain damage and older adults. It consists of 12 items from a total of 6 categories, and less than 24 points out of 30 points is considered an indication of cognitive impairment. In this study, patients with score of 24 or more were enrolled.
The electrode for the ulnar nerve was attached to the flexor carpi ulnaris, branching from the ulnar nerve and attaching to the wrist (Burridge & Ladouceur, 2001). The electrode used was a square disposable electrode of 5 x 5 cm. The stimulus was provided for 30 min at a frequency of 10 Hz, a pulse width of 10 ㎲, and an on-off duty cycle to ensure that there was no pain or visual contraction of the muscle (Ikuno et al.
The surface electromyography equipment was an ME6000 (Mega Electronics Ltd., Kuopio, Finland), with a total of eight channels. In this study, five channels were used.
This study was conducted from September 2017 to August 2018 and recruitment took place from September 1 to 30. A simple randomization method using a computer randomization program was used to assign 14 subjects to experimental group, and 15 to control group.

데이터처리

The homogeneity of the experimental group and the control group before the intervention was verified using the chi-squared (χ²) and Mann-Whitney U tests. The Wilcoxon signed rank test was used to test for significance before and after intervention. An analysis of covariance was used to compare changes between the groups, and the covariance was set as a pre-assessment of each group.
The differences between the two groups were analyzed using an ANCOVA because of the differences in muscle activity before the intervention. After the intervention, there was a significant difference (p=.
The homogeneity of the experimental group and the control group before the intervention was verified using the chi-squared (χ2) and Mann-Whitney U tests.

이론/모형

The intervention method was based on the study by Kim, Park, Jung, & Yoo (2016) (Table 1).

성능/효과

The differences between the two groups were analyzed using an ANCOVA because of the differences in muscle activity before the intervention. After the intervention, there was a significant difference (p=.041) between the two groups, with 695.60% RVC and 511.20% RVC increase in the muscle activity of the ECR. The muscle activity of the FCR also showed a significant difference (p=.
015) (Table 4). In both groups, significant changes were observed in the ARAT results before and after the intervention (Table 3), and EG showed a significant improvement (p=.018) (Table 4).
In addition, there were limitations to generalization due to the lack of RCT studies or short intervention periods. In conclusion, studies on peripheral sensory nerve stimulation in korean stroke patients are insufficient, and studies that simultaneously conducted two interventions to reduce the intervention time are also insufficient.
This change in muscle activity may lead to improvement of motor recovery. In this study, hand grip improvements were significant only in grip strength, not in pinch strength. TOT used in this study affected the plasticity of the cerebral cortex, but did not provide a direct challenge to improve hand muscle strength during tasks, and the location where the PNS was applied was also not significant.
Changes in the motor unit due to stroke will modify the pattern of muscular activation, making the muscles unable to selectively move (Wagner, Dromerick, Sahrmann, & Lang, 2007). In this study, there was a difference between the groups of muscle activity because the PNS in experimental group stimulated the direct nerve root which could affect the grasping and releasing function of the hand. This increase in muscle activity implies an increase in the number of muscle fibers forming the exercise unit and induces the growth of muscle fibers through neurological plasticity and changes in myofibrils.
First, the sample size was small. Second, the participants were chronic stroke patients, and shoulder and hand function loss was mild, with a Brunnstrom stage average of 4 or more. In the future, it is necessary to investigate the effect of providing PNS and TOT in patients with severe upper extremity function impairment.
This pilot study demonstrated the feasibility of simultaneous use of PNS and TOT for recovery of upper limb dysfunction in stroke patients. The results of this study showed that muscle activity, hand grip strength, and upper limb function were significantly higher in the PNS plus TOT group than the TOT group. These results are consistent with the results of previous studies that combined prior PNS and TOT.
The results of this study showed that the muscles activity of the ECR and FCR in the experimental group and the control group was significantly increased before and after the intervention, and the muscle activity of experimental group was significantly greater than that of control group. Changes in the motor unit due to stroke will modify the pattern of muscular activation, making the muscles unable to selectively move (Wagner, Dromerick, Sahrmann, & Lang, 2007).
In the future, it is necessary to investigate the effect of providing PNS and TOT in patients with severe upper extremity function impairment. Third, it is difficult to confirm whether the treatment effects were maintained because they were evaluated within 24 hours of the intervention. Future studies are needed to confirm that treatment effects are maintained through at least 1-2 weeks of follow-up.

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표제어: PCR

동의어: Packet Collision Rate

용어 설명 출처 목록 (6)

용어 설명: PCR은 세균 특이성이 있는 primer를 이용하여 적은 수의 세균이 있을지라도 쉽게 검출할 수 있는 유용한 방법이며, 이를 이용하여 구강 내 치면세균막이나 타액에서 직접 세균을 검출할 수 있게 되었다[8].

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