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1 J Korean Soc Phys Med, 2016; 11(2): Online ISSN: Print ISSN: X Research Article Open Access 지지면에따른호흡운동기법이배근육두께에미치는영향 배원식 이건철 경남정보대학교물리치료과 Effect of the Breathing Methods in Accordance with Surfaces during Bridging Exercises Won-Sik Bae, MS, PT Keon-Cheol Lee, PhD, PT Dept. of Physical Therapy, Kyungnam College of Information & Technology Received: February 4, 2016 / Revised: February 11, 2016 / Accepted: March 2, 2016 c 2016 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to determine the impact of stable and unstable surfaces on abdominal muscle thickness and changes in trunk muscle thickness in accordance with breathing methods during bridging exercises. METHODS: Bridging exercise on a stable surface, bridging exercise on an unstable surface, bridging exercise using a drawing-in maneuver on a stable surface, bridging exercise using a drawing-in maneuver on an unstable surface, bridging exercise using bracing on a stable surface, bridging exercise using bracing on an unstable surface. In sequence, the muscles' thickness was measured three times before and after each exercise, and the measured value was averaged. RESULTS: There were significant differences in internal oblique and transversus abdominis muscles' thickness in the drawing-in maneuver in both stable and unstable surface (p<0.05). There were no significant differences in external Corresponding Author : rptgeon@lycos.co.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. oblique muscle's thickness in the bridging exercise in both stable and unstable surface. The type of surface did not have a significant influence on the abdominal muscles' thickness. CONCLUSION: As a result of the study, the drawing-in maneuver had a greater effect than bridging or bracing maneuver on muscle thickness. We suggest that drawing-in maneuver will be more effective in a person with a weak abdominal muscle. Key Words: Abdominal drawing-in, Abdominal muscle, Bracing Ⅰ. 서론몸통안정화와관련된척주부위의근육활동은국소근육 (local muscle) 과대근육 (global muscle) 으로구분되며척추의안정된상태를유지하기위해서는국소근육과대근육들사이의조절된공동작용이중요하다 (Marshall과 Murphy, 2005; Stevens 등, 2007). 척추에직접연결되어척추의미세한조절과척추분절간안정성을제공하는근육은배가로근 (transverse abdominis; TrA) 과배속빗근 (internal oblique abdominis; IO) 과같은국소근육이며, 힘을생성하고몸통과골반의큰움직임을

2 34 J Korean Soc Phys Med Vol. 11, No. 2 만들어전체적인몸통안정성에관여하는근육은배곧은근 (rectus abdominis; RA) 과배바깥빗근 (external oblique abdominis; EO) 과같은대근육들이다 (Bergmark, 1989). 만약이들근육의한쪽에단축또는약화가생기면골반과척추의정렬을바꾸는불균형을초래하게되며, 특히배근육의약화로이들근육이길어지게되면허리앞굽음증과골반의앞쪽치우침이증가하여허리통증을유발할수있다고하였다 (Kendall 등, 1993). 따라서허리통증의예방과치료그리고자세조절을위한몸통및허리의안정화에대한많은연구들이다양한운동방법을통하여적용되고있다 (Son, 2015; Bang, 2015; Lee 와 Kim, 2014). 몸통의안정성을위해몸통바깥근육과몸통깊은근육의특성을이용한운동처방들이많이연구되고있으며대표적으로배드로잉- 인기법 (abdominal drawingin maneuver) 과브레이싱수축 (bracing) 등이있다 (Richardson 등, 1992). 배드로잉-인방법은배벽을안쪽으로당김으로써배가로근과배속빗근을수축시켜배내압을증가시키는운동방법이다. 배드로잉-인방법은배를지지하거나뒤쪽치우침골반운동에비해뭇갈래근 (multifidus) 과배가로근의안정화에가장좋은효과를가진다고하였다 (Kisner와 Colby, 2010). 또한배근육의활성화는엉덩관절의근육들이당기는힘에대항하여골반을안정화시키는데있어서필수적인요소로작용하며몸통에미치는힘들은골반이안정된상태일때다리와엉덩관절에효율적으로전달된다고하였다 (Neumann과 Gill, 2002). Ha 등 (2013) 의연구에서는복부드로잉-인이동반된교각운동시표층근육은이완되고심부근육이보다선택적으로활성화된다고보고하였다. 29쌍의몸통깊은근과바깥근이협응하여배내압을상승시킴으로써척추관절을단단하게만들어몸통을안정화시키는방법을브레이싱수축이라고한다 (McGill, 2001). 이러한이론을뒷받침하기위해 Grenier와 McGill(2007) 은드로잉-인과브레이싱수축시척추의안정성을컴퓨터시뮬레이션으로측정한결과드로잉-인보다브레이싱이척추의압박력을줄여주고안정성을더증진시켰다고하였으며, Vera-Garcia 등 (2013) 은드로잉-인과브레이싱수 축중외부적동요에대항해서허리의전위를줄이는데에는드로잉-인보다브레이싱이더효과적이라고하였다. 교각운동은무릎을세워누운자세에서진보된형태이며발에체중부하와함께무릎서기자세를수행하기위한중요한동작이면서앉아서서기의조절을발달시키며골반운동을촉진시키는데유용하다. 또한보행의디딤기준비를위해척추의아래부위와엉덩관절의폄근을강화시킨다 (O'Sullivan 등, 2003). 드로잉-인과브레이싱, 교각운동등의몸통안정성증진을위한운동처방에대한논의가있었고, 스포츠나물리치료영역에서폭넓게이용되고있지만, 아직적절한운동의선택에대한명확한제시는없다 (McGill과 Karpowicz, 2009). 불안정지지면은몸통의중심안정화운동수행시고유수용기자극을통해대뇌의운동기관을활성화시켜균형감각및균형유지능력을증가시킨다고하였다 (O'Sullivan과 Twomey, 1997). 또한안정된지지면에서의운동보다더큰활동을유발시켜몸통의안정성을증가시킬수있다 (Stevens 등, 2006). 불안정지지면에서의몸통안정화운동이안정지지면에서실시한몸통안정화운동과비교하여몸통근육의활성도와두께가더증가되는지에대한연구들이있지만 (Vera-Garcia 등, 2000; Lehman 등, 2005), 불안정지지면에서몸통안정화운동시몸통근육의활성도에변화가없다고한연구들도있다 (Marshall과 Murphy, 2005). 따라서불안정지지면에서의몸통안정화운동이실제근육과관절의고유수용기를더활성화시켜몸통을안정화시키는지에대해서는아직까지명확하지않다. 그리고지지면에서브레이싱과드로잉-인수축에따른몸통의안정성, 그리고몸통근육의활성도를비교한연구는있으나, 배근육의두께를비교한연구는부족한게현실이다. 따라서본연구의목적은교각운동시안정지지면과불안정지지면이배근육의두께에미치는영향과호흡운동기법에따라배의깊은근육과바깥근육의두께변화를알아보고자함이다.

지지면에따른호흡운동기법이배근육두께에미치는영향 35 Ⅱ. 연구방법 1. 연구대상본연구는지지면에따른호흡운동기법이배근육의실시간초음파영상구조에미치는영향을알아보기위하여부산광역시에위치한 K대학 20대의건강한남, 여총 32명을선발하였다. 대상자들은연구에영향을미칠만한신경계및근육뼈대계의병력과기능장애가없으며대상자선정당시규칙적이거나체계적인운동을하고있지않은자로선정하였다.

3 지지면에따른호흡운동기법이배근육두께에미치는영향 35 Ⅱ. 연구방법 1. 연구대상본연구는지지면에따른호흡운동기법이배근육의실시간초음파영상구조에미치는영향을알아보기위하여부산광역시에위치한 K대학 20대의건강한남, 여총 32명을선발하였다. 대상자들은연구에영향을미칠만한신경계및근육뼈대계의병력과기능장애가없으며대상자선정당시규칙적이거나체계적인운동을하고있지않은자로선정하였다. 모든대상자는연구내용에대해충분한설명을들은후자발적으로실험동의서에서명하고참여하였다. 2. 측정도구실험대상자에대한호흡운동기법에따른세가지배근육의두께를측정하기위한도구로는진단용초음파측정기구 (My lab one World, Esaote, Italy) 를사용하였으며근육및표층전용으로직선형태의탐촉자를사용하였다. 3. 측정방법갈고리누운자세 (hooklying) 와교각운동에서배바깥빗근, 배속빗근, 배가로근을측정하였고, 측정부위는실험대상자의오른쪽아래부위 (right lower quadrant) 로위앞엉덩뼈가시 (anterior superior iliac spine; ASIS) 와 나란하게하여안쪽으로 2 cm 아래쪽으로 2 cm되는부분에서실시하였다. 각근육의두께측정은영상의정중앙에서수직선을그어흰색영상으로나타나는근막의위경계끝지점에서아래경계끝지점을연결하여길이를측정하였다 (Fig. 1). 4. 실험방법측정자는실험대상자들의실험동작의이해를위해사전교육을실시하였고, 사전교육에서는교각운동, 배드로잉-인훈련그리고배브레이싱훈련을진행하였다. 실험대상자들은한운동이끝나고다음운동을실시하기전의휴식시간을 10분으로하였다. 실험은 (1) 안정지지면에서교각운동, (2) 불안정지지면에서교각운동, (3) 안정지지면에서드로잉-인훈련을적용한교각운동. (4) 불안정지지면에서드로잉 -인훈련을적용한교각운동. (5) 안정지지면에서브레이싱을적용한교각운동, (6) 불안정지지면에서브레이싱을적용한교각운동순으로하였다. 양발바닥에토구를적용하여불안정지지면을제공하였고각운동들은 3번씩반복한후배근육의두께를측정하여평균값을측정하였다. 1) 교각운동시작자세는갈고리누운자세로엉덩관절 45, 무릎관절 90 굽힘자세로눕고, 양팔은약 30 벌림하고손바닥은지면으로향하게하였으며, 무릎과양발은어깨넓이로벌리고발바닥은지면에 11자로두도록하였다. 실험대상자는 엉덩이를드세요 라는측정자의지시에따라골반을들어올린후 유지하세요 라는지시에따라 5초간유지하였다. Fig. 1. IO, EO, TrA thickness photographing image 2) 배드로잉-인배드로잉-인훈련은압력생체피드백기구 (stabilizer, Chattanooga group Inc., Hixson, U.S.A) 를사용하여실시하였다 (Fig. 2). 배드로잉-인훈련은갈고리누운자세에서압력생체피드백기구를참가대상자의허리에위치하도록하였고, 검사자는대상자에게날숨할때처럼배가약간들어가도록배꼽을위쪽과뒤쪽으로당기도록지시하였다. 이때대상자는압력생체피드백기구에

36 J Korean Soc Phys Med Vol. 11, No. 2 로그램을사용하였다. 단순교각운동, 드로잉-인운동, 브레이싱운동적용시지지면에따른근육의두께차이를비교하기위해독립표본 T검정 (Independent t-test) 을실시하였고각운동방법에따른평균값의분석을위해일원배치분산분석 (one-way ANOVA) 을사용하였다.

운동을시행하는동안압력생체피드백기구의압력을일정하게유지한상태에서 (Lee 등, 2011) 측정후교각운동을실시하고 10초간유지하며재측정하였으며이때자연스럽게호흡을유지하도록하였다.

4 36 J Korean Soc Phys Med Vol. 11, No. 2 로그램을사용하였다. 단순교각운동, 드로잉-인운동, 브레이싱운동적용시지지면에따른근육의두께차이를비교하기위해독립표본 T검정 (Independent t-test) 을실시하였고각운동방법에따른평균값의분석을위해일원배치분산분석 (one-way ANOVA) 을사용하였다. 또한사후분석은 Scheffe 검정을사용하였다. 통계학적유의성을검정하기위한유의수준 α=0.05로하였다. Fig. 2. Abdominal drawing-in exercise 연결되어있는압력계를보고 60 mmhg인상태에서 10 mmhg 증가시켜 5초간자세를유지하도록하였다. 운동을시행하는동안압력생체피드백기구의압력을일정하게유지한상태에서 (Lee 등, 2011) 측정후교각운동을실시하고 10초간유지하며재측정하였으며이때자연스럽게호흡을유지하도록하였다. 3) 브레이싱브레이싱은갈고리누운자세에서누군가배를치려할때반사적으로배에힘이들어가듯허리를중심으로앞쪽, 뒤쪽, 왼쪽, 오른쪽으로배를팽창시킨다는생각을가지면서허리골반부를수축하되자연스럽게호흡을유지하도록하였다 (Liebenson, 2007; McGill 등, 2003) (Fig. 3). Ⅲ. 연구결과 1. 연구대상자의일반적특성본연구에참여한대상자들의일반적인특성은다음과같다. 20대성인남자 11명, 여자 20명총 31명으로평균신장은남자 ±4.02 cm, 여자 ±3.84 cm, 평균몸무게는남자 73.72±12.36 kg, 여자 52±6.05 kg으로나타났다. 2. 호흡운동방법에따른배근육두께변화안정지지면과불안정지지면에서호흡운동방법에따른배근육의두께변화를비교하기위해일원배치분산분석으로분석한결과다음과같은결과를얻었다. 1) 안정지지면배가로근과배속빗근은드로잉기법적용시교각운동과브레이싱기법보다근육두께의평균값이높았으며, 통계학적으로유의한차이를보였다 (p<0.00). 그러나배바깥빗근은교각운동적용시근육두께의평균값이가장높았으나통계학적으로유의한차이는없었다 (Table 1). Scheffe 방식을사용하여사후분석을실시한결과, 배가로근과배속빗근은드로잉기법이교각운동과브레이싱기법보다평균값이유의하게컸다. Fig. 3. Abdominal bracing exercise 5. 자료분석자료의통계처리를위해윈도우용 SPSS ver.21.0 프 2) 불안정지지면배가로근은드로잉- 인기법적용시근두께평균값이가장높았으며, 통계학적으로유의한차이를보였다 (p<0.00). 배속빗근도드로잉-인기법적용시평균값이

5 지지면에따른호흡운동기법이배근육두께에미치는영향 37 Table 1. Thickness of the abdominal muscle according to breathing method in the stable surface Muscle Bridging Drawing-in Bracing F p TrA 4.13± ± ± I0 7.28± ± ± EO 5.37± ± ± TrA; Transverse Abdominis IO; Internal Oblique EO; External Oblique Table 2. Thickness of the abdominal muscle according to breathing method in the unstable surface Muscle Bridging Drawing-in Bracing F p TrA 4.05± ± ± I0 7.55± ± ± EO 5.27± ± ± 가장높았으며, 통계학적으로유의한차이를보였다 (p<0.05). 그러나배바깥빗근은교각운동적용시근육두께의평균값이가장높았으나통계학적으로유의한차이는없었다 (Table 2). Scheffe 방식을사용하여사후분석을실시한결과, 배가로근은드로잉기법이교각운동과브레이싱기법보다평균값이유의하게컸고배속빗근은드로잉기법이교각운동보다평균값이유의하게컸다. 3. 지지면에따른배근육두께변화각각의운동방법에서지지면에따른배근육의두께변화를비교하기위해독립 T검정으로분석한결과다음과같은결과를얻었다. 교각운동, 드로잉-인, 브레이싱기법적용시안정지지면과불안정지지면에따른배가로근, 배속빗근, 배바깥빗근모두 95% 신뢰수준에서유의한차이가없었다 (Table 3, Table 4, Table 5). Table 3. Thickness of the abdominal muscle according to surface in the bridging Muscle Stable surface Unstable surface t p TrA 4.13± ± IO 7.29± ± EO 5.37± ± Table 4. Thickness of the abdominal muscle according to surface in the drawing-in Muscle Stable surface Unstable surface t p TrA 6.54± ± IO 9.16± ± EO 5.05± ± Table 5. Thickness of the abdominal muscle according to surface in the bracing Muscle Stable surface Unstable surface t p TrA 4.39± ± IO 7.43± ± EO 4.46± ±

6 38 J Korean Soc Phys Med Vol. 11, No. 2 Ⅳ. 고찰본연구는교각운동시안정지지면과불안정지지면이배근육의두께에미치는영향과호흡운동기법에따라배의깊은근육과바깥근육의두께변화를알아보기위하여교각운동, 드로잉-인, 브레이싱기법을사용하여초음파를통해배근육의두께를측정하였다. 허리손상을예방하고치료하기위해서는척추의안정성이필요하다 (O'Sullivan, 2000). 몸통안정화운동은허리통증의예방과치료, 근력과운동능력을강화하는목적으로사용되고있으며 (Akuthota와 Nadler, 2003), 척추의안정성을얻기위해서는몸통근육의동시수축이필수적인요소이며 (Lehman 등, 2005; Marshall 과 Murphy, 2005; Stevens 등, 2006), Magee (1999) 는몸통의안정화운동이자세가불안정할때힘을조절하며척추가외적부하에잘적응할수있는자세인척추의중립자세를유지할수있도록의식적혹은무의식적으로움직임을조절할수있도록도와주는운동이라고하였다. 본연구에서는안정지지면과불안정지지면에서각각의호흡운동기법을적용하였을때드로잉 -인기법에서깊은근육인배속빗근과배가로근의평균값은유의하게높았고교각운동기법에서배바깥빗근의평균값은가장높았지만통계적유의성은없었다. 배드로잉-인운동기법은신경근을재훈련시키고배가로근의운동감각각성에도움을준다고하였으며 (Richardson 등, 1999; Souza 등, 2001; Maffrey 등, 1996) 배깊은근육과자세안정성을증진시키기위해주로많이사용된다 (Chon, 2011). Yun 등 (2013) 은뇌줄중환자에게복합운동과드로잉- 인병행훈련을통해배가로근, 배속빗근의근활성도가유의한차이가있음을보고하였고 Ha 등 (2013) 은교각자세에서드로잉-인훈련후깊은근육인배가로근과배속빗근의두께가증가하였고배바깥빗근은두께가감소하였다고보고하여본연구결과와일치하였다. 교각운동은누운자세에서무릎을 90 굽힘한후골반을들어올리는운동으로몸통과엉덩관절폄근육을강화시킨다 (O'Sullivan 등, 2003). Lee 등 (2014) 의연 구에서는교각운동시내전근수축을동반하였을때배속빗근과배바깥빗근의두께에유의한차이가없었다고하였으며 Stevens 등 (2007) 도교각운동시배바깥빗근의근활성도는유의한차이가없다고보고하였다. 본연구에서는교각운동시배바깥빗근의두께가가장컸지만통계적유의성은없었다. 브레이싱은배벽을팽팽하게당겨허리를가쪽으로벌어지도록교육시키며, 모든앞-가쪽배근육을활성화하는데초점을맞추고있다 (Beith 등, 2001; Jull과 Richardson, 2000). 브레이싱은운동적특성으로배곧은근과배가로근, 배속빗근의근활성이모두커지지만배곧은근에대한배가로근과배속빗근의상대적근활성이커지므로몸통안정화에기여할것으로생각된다. 본연구결과브레이싱은배가로근과배속빗근의두께에서는교각운동기법보다는평균값이높았지만통계적유의성은없었다. Lehman 등 (2005) 은안정지지면보다불안정지지면이근육과관절의고유수용기를더욱활성화시켜동적안정성을만들어주는데더효과적이라고하였다. 그러나 Saliba 등 (2010) 은지지면에따라배가로근의두께에유의한영향을미치지않았다고보고하였다. 또한 Imai 등 (2010) 도불안정지지면이몸통깊은근에는영향을미치지않지만, 몸통바깥근에는영향을미친다고하였다. Vera-Garcia 등 (2000) 은불안정지지면에서윗몸일으키기를할때배곧은근과배바깥빗근의활성도가증가되었다고하였다. 반면에불안정지지면에서몸통안정화운동은몸통깊은근만선택적으로활성화시켜척추분절의안정성을만들어준다고보고하였다 (Kim, 2005; Stuge 등, 2004). 본연구에서는지지면에따른배근육의근육두께는통계적으로유의한차이가보이지않았다. 본연구는건강한성인남녀를대상으로선정하였기때문에환자나모든연령대의사람들에게일반화하는데제한이있고, 초음파를이용하여실시간으로배근육의두께를측정하였기때문에충분한훈련기간을가지고배근육의근활성도를함께측정하는것이더정확한연구결과를가져올것이라고사료된다.

7 지지면에따른호흡운동기법이배근육두께에미치는영향 39 Ⅴ. 결론본연구는건강한 20대성인 31명 ( 남자 11명, 여자 20명 ) 을대상으로지지면에따른호흡운동기법이배근육에미치는영향을알아보고자실시하였다. 드로잉- 인기법적용시안정지지면과불안정지지면모두에서배속빗근과배가로근의평균값이가장높았고, 교각운동적용시안정지지면과불안정지지면모두에서배바깥빗근의평균값이가장높았지만통계적유의성은보이지않았다. 또한지지면에따라서는각각의호흡운동방법에따른배근육의두께는유의한차이를보이지않았다. 본연구의결과를통하여보았을때드로잉-인기법이배속빗근과배가로근의두께증가에긍정적인효과가있었음을알수있었다. 따라서배깊은근육에약증이있는환자들에게는드로잉- 인기법을적용하는것이재활에효과적일것이라고사료된다. References Akuthota V, Nadler S. Core strengthening. Arch Phys Med Rehabil. 2003;85(suppl1): Bang HS. The effects of lumbar stabilization exercise on muscle activity and isokinetic muscle strength of female patients with chronic low back pain. J Korean Soc Phys Med. 2015;10(2): Beith I, Synnott RE, Newman SA. Abdominal muscle activity during the abdominal hollowing manoeuvre in the four point kneeling and prone positions. Man Ther. 2001;6(2):82-7. Bergmark A. Stability of the lumbar spine: a study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230: Chon SC. Combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults and patients with low back pain. Yonsei University Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007;88(1): Ha Y, Lee GC, Bae WS, et al. The effect of abdominal muscle drawing-in exercise during bridging exercise on abdominal muscle thickness, using for real-time ultrasound imaging. J Korean Soc Phys Med. 2013; 8(2): Imai A, Kaneoka K, Okubo Y, et al. Trunk muscle activity during lumbar stabilization exercises on both a stable and unstable surface. J Orthop Sports Phys Ther. 2010;40(6): Jull GA, Richardson CA. Motor control problems in patients with spinal pain: A new direction for therapeutic exercise. J Manipulative Physiol Ther. 2000;23(2): Kim TY. The Effects of Spinal Stability Exercise Using the Sling and Mat. Korea Sport Res. 2005;16(6): Kendall FP, McCreary EK, Provance PG. Muscles testing and function(4thed). Baltimore, Williams & Wilkins, Kisner C, Colby LA. Therapeutic exercise: foundations and techniques (5THed). Philadelphia, F.A. Davis, Lee GC, Bae WS, Kim CH. The effects of bridging exercise with contraction of hip adductor muscles on thickness of abdominal muscles. J Korean Soc Phys Med. 2014;9(2): Lee JM, Yi CH, Kwon OY et al. The effect of lumbar stabilization exercise for caregivers with chronic low back pain. Phys Ther Korea. 2011;18(2):9-17. Lee MH, Kim BK. Comparison of abdominal muscle activity after sling and swiss-ball exercises in asymptomatic adults. J Korean Soc Phys Med. 2014;9(3): Lehman GJ, Hoda W, Oliver S. Trunk muscle activity during bridging exercises on and off a Swiss ball. Chiropr Osteopat. 2005;30:14. Liebenson C. Functional stability training. Rehabilitation of the spine. A practitioner s manual (2NDed).

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80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization

80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization 1) 스위스볼을적용한교각자세변화에따른체간의근활성도비교 The Comparison of Trunk Muscles Activity During Bridging Stabilization Exercises on Swiss Ball According to Change of Position Sun-tae Son, Min-hye Kim, Hee-jin Kim, Ji-hye