Such results may indicate that it can be a considerable chal- lenge for strokepatients to maintain balancein dorsiflexion.
Posture control to maintain balance is performed by a com- plicated interaction between the sensory andthe muscu- loskeletal system and is integrated and modified within the central nervous system by reacting to environmental changes [23,34]. In this context, the experimental group undergoing balance training with plantar flexor stretching might have experienced an improvement in proprioception andbalance ability by transmission of somatesthesia from the joint or muscle receptors inthe environment in which their bodies swayed and repeated movements were applied by an appro- priate ankle strategy in order to maintain balance. However, there was no significant difference inthe time taken inthe 10MWT before and after the training, despite improvement inbalance ability, perhaps because even the increased angle ofthe AROM did not reach the functional angle (10 degrees) that is needed for walking. Also, other functions related to walking other than joint angle may contribute to the insigni- ficance.
Cakar et al.  also showed a significant increase in BBS, FRT, and PST values after wearing an AFO and improved overall balance.
This study proved to be consistent withthe results of pre- vious studies, which means that treadmill exercise with an elastic AFO is effective in increasing the static and dynamic balance ability ofstroke survivors. The ankle joint strategy andthe hip joint strategy are used to keep the COG within the stability limits. Ankle joint strategy requires movement and stability at the ankle. Limited ankle movement or loss ofbalance results inthe use of hip joint strategies . The use of an elastic orthosis allows patients to freely adjust the an- gle ofthe ankle. Since the heel is open, more sensations com- ing from the ground can be transmitted to the upper nervous system, thus contributing more to stability at the ankle. In addition, if ankle stability increases, the range of motion at the ankle also increases. For this reason, treadmill training with an AFO has a significant effecton weight transfer abil- ity and dynamic balance ability.
Dept. of Physical Therapy, College of Health Science, Cheongju University
요 약 본 연구는 만성뇌졸중 환자의 균형과 보행에 대한 12 주간의 시각 되먹임 균형 훈련의 효과를 비교하기 위 하여 시행되었다 . 연구대상자는 총 20 명으로 실험군과 대조군에 10 명씩 무작위로 할당되었다 . 실험군은 근력 , 자세조 절 그리고 기능적 훈련을 포함한 보존적 물리치료와 시각 되먹임을 이용한 균형훈련을 각각 15 분씩 시행하였으며 , 대조군은 30 분안 보존적 물리치료를 시행하였다 . 균형 및 보행 능력에 대한 측정은 기능적 도달 검사 (Function Reach Test, FRT), 일어서서 걷기 검사 (Timed Up and Go Test, TUGT), 6 분 걷기 검사 (6 Min Walk Test, 6MWT) 사용하여 시행되었다 . 집단 내 비교에서 실험군은 모든 변수에서 통계학적으로 유의하게 향상되는 것으로 나타났으나 (p<.05), 대조군은 모든 변수에서 통계학적으로 유의한 차이를 보이지 않았다 (p>.05). 집단 간 비교에서 있어서는 FRT 와 6MWT 에서 통계학적으로 유의하게 향상되는 것으로 나타났다 (p<.05). 본 연구의 결과는 시각 되먹임을 사용한 균형 훈련이 만성 뇌졸중 환자의 균형과 보행 향상을 위해 긍정적으로 사용될 수 있다는 것을 의미한다 . 본 연구의 결과 를 일반화하기 위해서는 보다 많은 대상자들을 포함시킨 장기간의 연구가 계속 이루어져할 것이다 .
4. 측정도구 및 방법
1) 안정성 한계(Limits of Stability, LOS)
안정성 한계는 HUBER (HUBER 360® EVOLUTION, LPG System, France)를 사용하여 측정하였다. 장치는 선 자세에서 능동적으로 움직일 때 최대 안정성 한계를 측정하기 위한 것으로 지시하는 8개의 방향인 전방, 후방, 좌측, 우측 및 각각의 사선 방향으로 체중심을 이동할 때 이를 분석하는 방식으로 이루어져 있다. 대 상자는 바로 선 자세에서 어깨너비 정도 다리를 벌리도 록 한 다음 정면에 위치한 모니터를 주시하게 하였다.
Thirty patientswith hemiplegia (caused by cerebro- vascular accident) initially participated in this study. All ex- perimental protocols and procedures were explained to each subject and approved by the institutional review board of Sahmyook University, South Korea. All subjects provided written informed consent prior to study enrollment. The in- clusion criteria were as follows: an ability to follow verbal instructions; an Korean version of Mini-Mental State Examination score of ＞21; no obvious limitation in passive range of motion of ankle joints; and an ability to walk 10 me- ters without any form of assistance. Patients with brain stem and/or cerebellum damage or any other disease/condition that could affect gait were excluded. After explaining the purpose of this study, 4 patients decided not to participate while 26 patients agreed to participate inthe pre-test.
조준행 김로빈 무릎 움직임의 제한이 보행 기전에 미치는 영향 한국사회체육학회지 , . . 2018;72:429-36.
최동성 손민균 발목관절 보조기 착용이 뇌졸중 편마비 환자의 균형에 미치는 영향 한국생활환경학회지 , . . 2014;21(5):837-44.
Bedoya-Belmonte JJ, Rodríguez-González MDM, González-Sánchez M, et al. İnter-rater and intra-rater reliability ofthe extended TUG test in elderly participants. BMC Geriatr 2020;20(1):56.
나) 버그 균형 척도 검사(Berg balance Scale, BBS) 뇌졸중 환자의 앉기, 서기, 자세 변화 시 기능적 균형 능력을 측정하기 위해 버그 균형 척도를 실시하였다.
이 측정도구는 전체 14개의 항목으로 각 항목 당 점수는 0점부터 4점까지의 5점 척도이고 총 점은 56점이며, 점 수가 높을수록 균형이 좋음을 의미한다. 각 항목은 의자 의 등받이에 기대지 않고 바른 자세로 앉기, 한 다리로 서 있기, 두 발을 붙이고 잡지 않고 서있기, 한 발 앞에 다른 발을 일자로 두고 서있기, 왼쪽과 오른쪽으로 뒤돌 아보기, 선 자세에서 앞으로 팔을 뻗쳐 내밀기, 바닥에 있 는 물건을 집어 올리기, 두 눈을 감고 잡지 않고 서 있기, 앉은 자세에서 일어나기 제자리에서 360도 회전하기, 의 자에서 의자로 이동하기, 한 발 앞에 다른 발을 일자로 두고 서있기, 앉은 자세에서 일어나기, 선 자세에서 앉기, 일정한 높이의 발판 위에 발의 교대로 놓기로 구성되어 진다. 버그 균형 척도를 뇌졸중 환자에게 적용하였을 때 신뢰도는 0.98로 매우 높은 신뢰도를 기록한다.
This study was a randomized controlled trial. Participants were assigned to either an experimental (n=12) or a control group (n=11) using a random permuted block design and sealed envelopes. The experimental group received addi- tional 3D balance training for 30 min/day, 5 days/week for 4 weeks. Both groups received a regular 30-min conservative physical therapy session based on neurodevelopmental therapy. Before and after the 20 sessions, walking ability andbalance were evaluated by a blinded examiner.
Architecture ofthe elastic band orthosis consists of heel opened toe socks and two straps. Sock length is toe to mid-
metatarsal area andthe heel is opened. Straps are attached on both sides ofthe socks. The long strap, which is attached onthe medial side, goes over the top ofthe lateral malleolus and is turned around to the opposite side and then fastened with Velcro and that may pull up the foot so that it can assist in dorsiflexion. The short strap, which is attached onthe lateral side ofthe socks, goes across top ofthe foot and is fastened with Velcro, which may assist with eversion. This aid may help in prevention of spastic foot drop, leading to improve- ment ofwalking ability. Heel contact (heel strike, heel off) plays an important role during walking. Through heel con- tact to obtain proprioception, pressure and leg recruit pattern information can be obtained . This movement can act as a switch ofthe stance phase. Therefore, open-heeled elastic band orthosis can provide greater communication of body scheme information to the central nervous system. In addi- tion, a recent study reported that open-heeled AFO de- creased external rotation ofthe foot. Elastic band orthosis made of fabric is lighter, cheaper, and convenient for wear- ing shoes compared with conventional plastic AFOs. Light weight ofthe orthosis is useful for weakened muscles ofthe legs instrokepatients.
BWSTT is now largely performed to enhance thebalanceand gait speed ofstrokepatientsin clinical practice .
There are, however, conflicting views about the clinical relevance of BWSTT. Middleton et al.  reported that there was a significant difference inbalanceand gait speed between strokepatients who underwent BWSTT and those who underwent overground gait training (OGT), but there was no difference in between group comparison. Combs- Miller et al.  reported a significant improvement of self- selected walking speed inthe OGT group compared to that inthe BWSTT group. Furthermore, Bonnyaud et al.  re- ported that the times recorded for the TUG test decreased in both the BWSTT and OGT groups. In the current study, there was a significant improvement in BBS, TUG, 10MWT, and FGA scores withthe addition ofthe task of kicking a ball to an existing 5-week BWSTT. It was indicated that there was a difference of recovery time. This was because the time of onset of subacute or chronic stroke subjects were dif- ferent. This study, using dual-task training, produced dis- tinctly different results compared with previous studies us- ing single task training. Previous studies have indicated that a task-orientated intervention as a complex training method improved both walking distance andwalking speed ofstroke
The results of this study show that applying the single-leg stance in hemiplegia patients will increase sensory input and muscles activation ofthe affected lower extremity and im- prove the asymmetric weight bearing toward a more sym- metric distribution. Additionally, it was demonstrated that voluntary movement of lower-extremity muscles to increase sensory input is more effective. Furthermore, concerning the gait cycle, it was found that the short stance phase time due to the unstable weight bearing ofthe affected leg improved through the single-leg stance. However, it was not sufficient to affect the symmetry of gait because ofthe complex mech- anism of gait. In addition, this study was conducted on left hemiplegia patients who have sensory recovery problems involving the disorder of improper recognition ofthe body due to right brain damage, andtheeffect was not clearly demonstrated as the measurement was performed only once.
Patellar taping improves patellar tracking inthe patellofe- moral groove and not in simple fixation of muscle in clinical settings. This improvement has a positive effectonthe pa- tients' gait without pain, re-aligning complete rangeof mo- tion of these patients . McConnell patellar taping meth- od is a taping method which maintain fixed positional fault by repositioning. This method stimulates skin, tendon, and muscle stimulation thus improving joint position sense and proprioception by reducing pain and enhancing recovery ofpatients. Ernst et al.  showed that patellar taping onthe knee joint improved the alignment ofthe patella and stability ofthe knee joints. Also, patella taping produced beneficial effects onbalance ability ofthe knee joint and function ofthe lower extremity. In knee osteoarthritic patients, Crossley et al.  confirmed that non-elastic taping immediately soft- ened the inflammated tissues and improved the alignment ofthe lower extremity, thus enhancing their balance ability and physical posture with decreased pain. Usage of patellar tap- ing created pressure on joints, thus providing stability. This re-alignment ofthe patella and increased stability ofthe joint region led to improvement in gait ability.
The test for this study was conducted before the beginning and after completion ofthe 3-month water exercise pro- gram. To examine the asymmetry in gait, 3-dimensional mo- tion analysis was performed using eight infrared ray cam- eras and one force platform, andthe sampling frequency was set at 100 Hz and 1,000 Hz. First, selected research subjects who agreed to the test were explained about the procedure, and asked to wear the top and bottom tights and put on markers. After sufficient warm-up, they performed thewalking motion on a 10-m track installed in this laboratory.
This study examined theeffectof treadmill gait trainig on dynamic balanceand gait functions instrokepatients.
Stroke patients experience muscle weakness and sensory changes, which can cause dysfunctions, such as difficulties in trunk control, instability ofbalance, low gait ability, and difficulty in performance ofthe activities of daily living . Balance is the ability to maintain the center of gravity ofthe body within the base of support with minimal postural sway . In a study reported by Harris et al. , the high risk of fall due to reduced balanceand gait disturbance re- mained after discharge and added difficulty in performance of activities of daily living among strokepatients.
The effectof BWSTT transfers over to ground locomo- tion [24,32]. It is believed that the results of this study may have implications to real life.
The limitation of this study was that any effectin chronic stroke patient could not be for certain because subjects were subacute patients. The lasting effectof BWSTT after train- ing was unclear since there was no follow-up. The treadmill speed had been increased to subjective judgment ofthe patient. Further research is required withthe use of heart rate monitoring for deciding treadmill speed and to generalize these findings.
We can conclude that applied and re-aligned region ofthe patella and enhancement of proprioception has led to the im- provement in gait ability.
Due to the small sample size, chronological changes in data ofstrokepatients were difficult to attain. Therefore, it is difficult to generalize the results of this study this study inthe clinical world. Also, this study only measured dynamic standing balance among various balance types. In further studies, theeffectof patellar taping on various balance types should be investigated to generalize the results on all types ofstrokepatients. From these limitations, follow-up tests would be appropriate to compensate for the limitations of this study.
the quadriceps muscle, which serves as an extensor muscle ofthe knee, has affected thewalking speed and postural sta- bility ofpatientswithstrokeand there is considerable struc- tural and functional deterioration ofthe plantar flexor mus- cle compared to healthy adults [3,8]. In particular, chronic stroke survivors with a gait speed slower than 0.8 m/s showed thinner quadriceps muscle thickness andthe worst static balance compared to healthy adults . In addition, the volume, moment, and activation ofthe plantar flexor muscle ofstroke survivors were all lower than that of healthy adults, and fascicle lengths and extensibility were decreased due to stiffness [3,9]. A previous study showed that stretching the lower limb muscles, including the plantar flexor muscle, improved ambulation speed andthe struc- tural changes inthe muscle . However, there are only a few studies that examine how this altered muscle structure affects physical function.
Dong Hoon Kim 1 , Kyung Hun Kim 2*
1 Physical Therapist, Department of Physcial Therapy, Bundang Jesaeng Hospital
2 Professor, Department of Physcial Therapy, Gimcheon University
요 약 본 연구의 목적은 기능적 전기자극을 병행한 거울치료가 만성 뇌졸중 환자의 균형과 보행능력에 미치는 영향을 알아보기 위함이다. 선정기준에 따라 만성 뇌졸중 환자를 35명을 대상으로 세군으로 실시하였다. FMT군은 기능적 전기자 극을 병행한 거울치료(n=11), MT군은 거울치료를 시행하였고(n=12), CON군(n=12)은 일반적인 물리치료를 시행하였다. 훈 련은 1일 30분, 1주 5번, 총 4주간 시행하였다. 중재 전·훈련 4주 후에 균형과 보행능력을 검사실시하였다. 훈련결과 기능적 전기자극을 병행한 거울치료 훈련군이 버그균형척도, 신체의 이동거리, 활보장, 분속수, 그리고 평균보행속도에서는 거울치 료군과 대조군에 비해 통계학적으로 유의한 차이를 보였다. 그러므로 기능적 전기자극 치료와 거울치료 융합은 뇌졸중 환자 의 균형과 보행능력을 위한 효과적인 중재로 활용 될 수 있으며, 다양한 뇌졸중 환자를 위한 지속적인 융합중재개발이 요구 된다.
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주제어 : 융합, 고유수용성 운동프로그램, 뇌졸중, 고유수용성 감각, 버그균형척도
Abstract This study to investigate the effects of proprioceptive motor program on proprioceptive andbalance ability for patientswith chronic stroke. Twenty nine subjects were recruited by means of a convenience sampling from Gyeonggi-do B hospital. The subjects were divided into two group: a proprioceptive motor program and general physical therapy(n=15), general physical therapy(n=14). The stimulation and exercises were conducted for 30 min per day, three days, per week for six weeks. All participants were assessed before and after taping training using proprioceptive, berg balance scale(BBS), timed up and go test(TUG), andbalance ability was measured using a BioRescue. After training, the change values ofthe proprioception andbalance ability in experimental group were significantly greater than control group(p<0.05). This findings show that progressive and proprioceptive motor program training convergence can be effective for strokepatients proprioception andbalance ability. Continued development of convergence interventions for chronic strokepatientswith proprioception andbalance ability inthe practice are suggested.