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1 Original Article J Korean Orthop Assoc 2012; 47: 동결견환자에서의수면상태및삶의질평가 Sleep Status and Quality of Life in Patients with Frozen Shoulder 조철현 정성원 * 손은석 황일선계명대학교의과대학정형외과학교실통증연구소, * 정신과학교실 목적 : 동결견환자에서의수면상태및삶의질을평가하고, 동통과기능제한이수면및삶의질에미치는영향에대해알아보고자하였다. 대상및방법 : 특발성동결견으로진단된 30명의환자군과, 60명의건강대조군을대상으로하였다. 동통과기능정도를평가하기위해 visual analogue scale (VAS), American Shoulder and Elbow Surgeon's Score (ASES) 및 Korean Shoulder Score (KSS) 점수를측정하였고, 수면상태및삶의질을평가하기위해 Pittsburg Sleep Quality Index (PSQI) 및 World Health Organization Quality of Life Scale Abbreviated Version (WHOQOL-BREF) 점수를측정하였다. 결과 : 평균 PSQI 점수는환자군에서 8.6점으로대조군의 4.1점에비해통계학적으로의미있는차이를보였으며, 86.7% 의높은수면장애의발생률을보였다. WHOQOL-BLEF 점수는환자군에서 77.6점으로대조군의 93.6점에비해통계학적으로의미있는낮은점수를보였다. 증상기간, VAS, ASES, KSS 점수는 PSQI 및 WHOQOL-BLEF 점수와통계학적으로의미있는상관관계를보이지않았으나, ASES 점수는 WHOQOL-BLEF의하부척도인신체적건강과 KSS 점수는전반적인삶의질및신체적건강과양의상관관계를보였다. 결론 : 동결견환자들은심한통증과일상생활에서의기능제한을가지며, 높은수면장애의발생률과함께낮은삶의질수준을보였다. 색인단어 : 동결견, 수면장애, 삶의질 서론 동결견 (frozen shoulder) 은견관절의통증및운동제한을유발하고, 일반적으로보존적인치료에도비교적양호한결과를얻으며, 약 1-2년정도의기간을가지는자가치유질환 (self-limiting disease) 으로알려져있다. 1) 그러나적절한치료를하지않은다수의환자에서는 3년이상경과해야회복을얻을수있었으며, 또는영구히회복되지않았다는보고들도있다. 2) 아직까지기전은명확하지않으나동결견을가진환자에서특이적으로야간통 (night pain) 이흔한것으로알려져있다. 3) 이러한야간통을호소하는환자에대한부적절한치료는만성통증을야기하고, 결과적으로일상생활의어려움뿐만아니라삶의질을 접수일 2011 년 7 월 22 일수정일 2011 년 8 월 28 일게재확정일 2011 년 10 월 6 일교신저자조철현대구시중구달성로 56 번지, 계명대학교의과대학동산의료원정형외과학교실 TEL , FAX oscho5362@dsmc.or.kr 저하시킬수있다. 4) 골관절염, 류마티스관절염, 섬유근통등의만성근골격계질환을가진환자에대한수면상태및삶의질에대한연구는보고되어있으나, 5-11) 동결견환자들에대한수면상태및삶의질에대한연구는현재까지보고된바가없다. 이에저자들은특발성동결견환자에서의수면상태및삶의질을평가하고, 동통과기능제한이수면및삶의질에미치는영향에대해알아보고자하였다. 대상및방법 1. 연구대상 2009년 7월부터 2010년 2월까지본원정형외과외래를방문한 30 명의특발성동결견환자군과건강검진을위해본원건강증진센터를방문한 60명의건강대조군을대상으로하였다. 환자군은한명의정형외과전문의에의해병력청취, 진찰검사와함께자기공명영상또는초음파로회전근개질환, 석회화건염등의견관절통증을일으킬수있는질환들을배제한다음최종진단을 대한정형외과학회지 : 제 47권제 3호 2012 Copyright 2012 by The Korean Orthopaedic Association 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.

2 206 조철현 정성원 손은석외 1 인 하였으며, 견관절통증을제외한다른근골격계질환, 정신과적질환, 전신질환이있는경우는제외하였다. 건강대조군은견관절통증을포함한근골격계질환, 정신과적질환및전신질환이없는경우를대상으로하였다. 2. 연구방법및평가도구통증과기능정도를평가하기위해 visual analogue scale (VAS), American Shoulder and Elbow Surgeon's Score (ASES), Korean Shoulder Score (KSS) 점수를측정하였고, 수면상태및삶의질을평가하기위해 Pittsburg Sleep Quality Index (PSQI), World Health Organization Quality of Life Scale Abbreviated Version (WHO- QOL-BREF) 점수를측정하였다. 본연구는본원의학연구윤리심의위원회의승인을거쳐진행되었으며, 연구에참여하는모든대상자에게연구및검사의목적과방법에대해자세히설명한후서면으로동의서를받은후평가를시행하였다. 1) PSQI 이척도는수면의질을평가하기위해 Buysse 등 12) 이개발한자기보고식검사이다. 주관적수면의질, 수면지속시간, 수면시간, 습관적수면효율성, 수면장애, 수면제사용, 주간기능장애와같은다양한영역에서수면의질을평가하기위한 17개항목으로구성되어있다. 각문항은 0-3점 (0: 어려움이없음, 3: 매우어려움 ) 으로 4점척도로되어있으며, 절단점은 5점으로, 5점이상인경우의미있는수면장애가존재함을시사한다. 2) WHOQOL-BREF 이삶의질척도는세계보건기구에서개발한것을국내에서 Min 등 13) 이표준화한것으로, 신체적건강, 심리적건강, 사회적관계, 환경영역등 4개의영역에속하는 24개의하부척도와전반적인삶의질에대한 2개의문항을포함하여총 26개의문항으로이루어져있다. 각문항의점수는 5점척도로구성되었으며, 점수의범 Table 1. Demographic Characteristics Demographics Patient group (n=30) Control group (n=60) p-value Age (yr) 52.0± ± Gender Female 21 (70.0) 38 (63.3) 0.53 Male 9 (30.0) 22 (36.7) Education < Elementary school 1 (3.3) 2 (3.3) 0.91 Elementary school 3 (10.0) 14 (23.3) Middle school 3 (10.0) 8 (13.3) High school 13 (43.3) 17 (28.3) > College 5 (16.7) 19 (31.7) Working status Full time 5 (16.7) 15 (25.9) 0.04* Part time 0 (0) 7 (12.1) None 9 (30.0) 24 (41.4) Others 13 (43.3) 12 (20.7) Marital status Single 0 (0) 1 (1.7) 0.19 Married 24 (80.0) 52 (86.7) Divorced/Separated 1 (3.3) 5 (8.4) Widowed 4 (13.3) 2 (3.3) Alcohol Yes 11 (36.7) 25 (41.7) 0.74 No 18 (60.0) 35 (58.3) Smoking Yes 3 (10.0) 18 (30.0) 0.04* No 26 (86.7) 42 (70.0) Symptom duration (mo) 8.1±5.5 VAS 6.5±2.2 ASES 40.3±20.7 KSS 45.1±16.1 Values are presented as mean±standard deviation or n (%). *The difference was statistically significant (p<0.05); Missing data excluded. VAS, visual analogue scale; ASES, American Shoulder and Elbow Surgeon s Score; KSS, Korean Shoulder Score.

3 207 동결견환자에서의수면상태및삶의질평가 위는 점으로점수가높을수록삶의질이좋음을의미한다. 든분석의통계적유의수준은 p 값이 0.05 미만인경우로하였다. 3. 통계분석 통계분석은 SPSS ver for Windows (SPSS Inc., Chicago, IL, USA) 를이용하였으며, 연구대상자의인구통계학적특성을파악하기위해빈도분석과기술분석을시행하였다. 연구대상자의수면장애, 삶의질의차이를파악하기위해다변량분산분석을시행하였다. 통증및기능제한정도와수면장애및삶의질과의연관성을평가하기위해피어슨상관분석을사용하였다. 모 Table 2. Comparison of Sleep Status and QOL between Patient Group and Control Group Instruments Patient group (N=30) Control group (N=60) F p-value PSQI 8.6± ± * WHOQOL-BLEF (total) 77.6± ± * Overall QOL 5.4± ± * Physical health 19.6± ± Psychological health 17.3± ± <0.001* Social relationships 10.5± ± Environmental 24.8± ± Values are presented as mean±standard deviation. *The difference was statistically significant (p<0.05). QOL, quality of life; PQSI, Pittsburg Sleep Quality Index; WHOQOL-BLEF, World Health Organization Quality of Life Scale Abbreviated Version. Table 3. Comparison of Sleep Disturbance between Patient Group and Control Group Sleep disturbance Patient group (N=30) Control group (N=60) Yes 26 (86.7) 15 (25.0) No 4 (13.3) 45 (75.0) Values are presented as n (%). 결과 환자군의평균증상기간은 8.1개월이었으며, 평균 VAS, ASES, KSS 점수는각각 6.5점, 40.3점, 45.1점이었다. 두군간의직업과흡연여부는통계학적으로유의한차이가있었으나, 그이외의연구통계학적변수에서는유의한차이가없었다 (Table 1). 평균 PSQI 점수는환자군에서 8.6점으로대조군의 4.1점에비해통계학적으로의미있는높은점수를보였다. 총 30명중 26 명에서수면장애가있었으며, 86.7% 의높은발생률을보였다. WHOQOL-BLEF 점수는환자군에서 77.6점으로대조군의 93.6 점에비해통계학적으로의미있는낮은점수를보였다. WHO- QOL-BLEF 하부척도에서는전반적삶의질과신체적건강에서환자군이대조군보다통계적으로유의하게낮은점수를보였다 (p<0.05) (Table 2, 3). Table 4. Correlations of Various Parameters with PSQI, and WHOQOL- BLEF Parameters PSQI WHOQOL-BLEF Symptom duration Coefficient p VAS score Coefficient p ASES score Coefficient p KSS score Coefficient p PSQI, Pittsburg Sleep Quality Index; WHOQOL-BLEF, World Health Organization Quality of Life Scale Abbreviated Version; VAS, visual analogue scale; ASES, American Shoulder and Elbow Surgeon s Score; KSS, Korean Shoulder Score. Table 5. Correlations of Various Parameters with WHOQOL-BLEF Domains Parameters Overall QOL Physical health Psychological health Social relationships Environmental Symptom duration Coefficient p VAS score Coefficient p ASES score Coefficient * p KSS score Coefficient 0.437* 0.419* p *The difference was statistically significant (p<0.05). WHOQOL-BLEF, World Health Organization Quality of Life Scale Abbreviated Version; QOL, quality of life; VAS, visual analogue scale; ASES, American Shoulder and Elbow Surgeon s Score; KSS, Korean Shoulder Score.

4 208 조철현 정성원 손은석외 1 인 증상기간, VAS, ASES, KSS 점수는 PSQI 및 WHOQOL-BLEF 점수와통계학적으로의미있는상관관계를보이지않았으나 (p>0.05) (Table 4), ASES 점수는 WHOQOL-BLEF의하부척도인신체적건강과 KSS 점수는전반적인삶의질및신체적건강과양의상관관계를보였다 (p<0.05) (Table 5). 고찰 동결견은유착성관절막염 (adhesive capsulitis) 또는견관절주위염 (periarthritis of shoulder) 이라고도하며, 회전근개질환과더불어견관절통증을유발하는가장흔한원인중의하나로알려져있다. 흔히야간에악화되는견관절통증과운동제한이점진적으로진행하는것이특징적이다. 1,3,4) 아직까지정확한기전은밝혀진바가없으나동결견환자에서특징적인증상인야간통으로인해정상적인수면에방해를받을수있고, 심한운동제한으로인해일상생활의어려움뿐만아니라삶의질에심각한영향을미칠수있다. 4) 일반인구에서수면장애의유병률은약 27% 로알려져있으며, 통증이존재하면수면장애가더빈번하게발생하여그유병률이약 51-70% 에이른다. 9) 통증이감정적각성을초래하고, 이러한각성은수면을취하기어렵게만드는것으로알려져있다. 9,11) 이처럼만성통증을가진환자는우울증과불안증, 그리고수면장애와연관되어있는경우가많으며지속적인통증지각이수면장애를초래하고, 이는낮동안의기능장애를야기함으로써삶의질을악화시키는악순환을가져올수도있다. 5-11) 골관절염, 류마티스관절염, 섬유근통, 요통과같은근골격계질환을가진환자들을대상으로심리적상태에대한연구들이최근많이이루어지고있지만, 5-11) 동결견환자들에대한수면상태를포함한심리적상태및삶의질에관한연구는현재까지보고된것이없다. 만성요통이있는환자의 51% 에서수면장애가있었으며, 9) 섬유근통환자에서는 75%, 5) 류마티스관절염에서는 54-70% 의수면장애를보고하였다. 6) 본연구에서동결견환자의수면장애의발생률은 86.7% 로대조군의 25.0% 보다통계학적으로의미있게높았으며, 다른만성통증을가진질환에대한연구결과들보다높은수면장애의발생률을확인할수있었다. 이처럼동결견환자에서수면장애의빈도가높은것은야간통이동반되는질병의특성이영향을미친것으로보인다. 동결견환자에서의야간통이생기는이유에대해서는아직까지정확히밝혀진것이없으며, 앞으로발병원인및병리기전을밝히기위한기초연구가필요하다고생각한다. 동결견환자에서의 WHOQOL-BLEF 점수는 77.6점으로 93.6 점의대조군과비교해서통계학적으로의미있게낮았으며, WHOQOL-BLEF 하부척도점수는전반적인삶의질과신체적건강영역에서대조군보다낮게나타났다. Kim 등 14) 이보고한암 환자에서 WHOQOL-BLEF 점수가 71.1점이었던것보다는높았지만, 상당한삶의질의저하가있음을보여주었다. 여러연구에서만성통증을가진환자는통증과기능장애가심할수록수면장애의발생률이증가하고삶의질또한저하되는상관관계를보고하였다. 15,16) 본연구에서는통증을반영하는 VAS 점수와, 통증과더불어전반적인일상생활에대한기능제한정도를평가한 ASES 점수와 KSS 점수는 PSQI 및 WHOQOL- BLEF와통계학적으로유의한상관관계를보이지않았다. 그러나 WHOQOL-BLEF 하부척도와의상관관계에서 ASES 점수는신체적건강과 KSS 점수는전반적인삶의질및신체적건강과양의상관관계를보였다. 현대사회가발달하고삶의질에보다관심이많아지면서질환의평가와치료에있어심리적접근이강조되고있다. 암이나신장질환, 심장질환등의환자에서는이러한연구가비교적활발하게이루어지고있으나, 14,17) 근골격계질환특히만성견관절통증을가진환자에서는보고된것이매우드문실정이다. 따라서본연구는동결견환자에서수면장애의발생률을알아보고견관절통증과기능제한이삶의질에미치는영향을알아본최초의연구라는데의의가있다. 본연구의제한점으로는첫째표본수가적고단일삼차의료기관에서이루어진연구로결과를일반화하기에는어려움이있다. 둘째연구대상자들의자기보고식심리평가를토대로평가가이루어져응답편견이있을수있으며, 실제임상에서 Diagnostic and Statistical Manual of Mental Disorders-IV-TR에기초하여정신과전문의의면담과평가를통해진단된수면장애와는다소차이가있을수있다는것이다. 따라서동결견을포함한만성견관절통증을가진환자에서의정신심리학적상태, 수면장애및삶의질에대한대규모의체계적인전향적연구들이필요하다. 또한동결견환자의치료에있어통증조절, 기능장애회복을위한재활프로그램, 그리고공존된수면장애에대한적절하고적극적인치료가포괄적으로이루어져야겠다. 결론 동결견환자들은심한동통과일상생활에서의기능제한을가지며, 높은수면장애의발생률과함께낮은삶의질수준을보였다. 참고문헌 1. Park TS, Na JU, Kim SI, Kim TS. Arthroscopic management and manipulation of chronic idiopathic adhesive capsulitis of the shoulder. J Korean Orthop Assoc. 2001;36:

5 209 동결견환자에서의수면상태및삶의질평가 2. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A longterm follow-up. J Bone Joint Surg Am. 1992;74: Yoo JC, Ahn JH, Kim JH, Chang MJ, Seo HS, Sul EJ. Pathology of the rotator cuff in adhesive capsulitis patients. J Korean Arthrosc Soc. 2007;11: Cho KH, Song JY, Lee H, Kim JS, Rhee YG. The effect of subacromial bursa injection of hyaluronate in patients with adhesive capsulitis of shoulder joint: multicenter, prospective Study. J Korean Acad Rehabil Med. 2002;26: Celiker R, Borman P, Oktem F, Gökçe-Kutsal Y, Başgöze O. Psychological disturbance in fibromyalgia: relation to pain severity. Clin Rheumatol. 1997;16: Onen SH, Onen F, Courpron P, Dubray C. How pain and analgesics disturb sleep. Clin J Pain. 2005;21: Power JD, Perruccio AV, Badley EM. Pain as a mediator of sleep problems in arthritis and other chronic conditions. Arthritis Rheum. 2005;53: Scopaz KA, Piva SR, Wisniewski S, Fitzgerald GK. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Arch Phys Med Rehabil. 2009;90: Stiefel F, Stagno D. Management of insomnia in patients with chronic pain conditions. CNS Drugs. 2004;18: VanDyke MM, Parker JC, Smarr KL, et al. Anxiety in rheumatoid arthritis. Arthritis Rheum. 2004;51: Wilson KG, Eriksson MY, D'Eon JL, Mikail SF, Emery PC. Major depression and insomnia in chronic pain. Clin J Pain. 2002;18: Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28: Min SK, Lee CI, Kim KI, Seo SY, Kim DK. Development of Korean version of WHO quality of life scale abbreviated version (WHOQOL-BLEF). J Korean Neuropsychiatr Assoc. 2000;39: Kim KI, Soh HS, Min SK. A study on quality of life of cancer patients. J Korean Assoc Soc Psychiatry. 2002;7: Badcock LJ, Lewis M, Hay EM, McCarney R, Croft PR. Chronic shoulder pain in the community: a syndrome of disability or distress? Ann Rheum Dis. 2002;61: Kundermann B, Krieg JC, Schreiber W, Lautenbacher S. The effect of sleep deprivation on pain. Pain Res Manag. 2004;9: Davison SN, Jhangri GS. The impact of chronic pain on depression, sleep, and the desire to withdraw from dialysis in hemodialysis patients. J Pain Symptom Manage. 2005;30:

6 210 조철현 정성원 손은석외 1 인 Sleep Status and Quality of Life in Patients with Frozen Shoulder Chul-Hyun Cho, M.D., Ph.D., Sung-Won Jung, M.D.*, Eun-Seok Son, M.D., and Il-Seon Hwang, M.D. Department of Orthopedic Surgery, Pain Research Center, *Department of Psychiatry, Keimyung University School of Medicine, Daegu, Korea Purpose: The aims of this study were to assess sleep status and quality of life (QOL) in patients with frozen shoulder and to evaluate correlations between pain, disability, sleep disturbance and QOL. Materials and Methods: Thirty patients with idiopathic frozen shoulder and 60 healthy controls were enrolled into this study. Participants were evaluated using the following: visual analogue scale (VAS), American Shoulder and Elbow Surgeon s Score (ASES), Korean Shoulder Score (KSS), Pittsburg Sleep Quality Index (PSQI), and World Health Organization Quality of Life Scale Abbreviated Version (WHOQOL-BREF). Results: The mean VAS, ASES, and KSS scores in patient groups were 6.5, 40.3, and 45.1, respectively. The mean PSQI score was 8.6 in the patient group and 4.1 in the control group. Patient groups had significantly higher scores than the control group for the PSQI score (p<0.05). The incidence of sleep disturbance was 86.7%. The mean WHOQOL-BLEF score was 77.6 in the patient group and 93.6 in the control group. The patient group was signifi cantly lower than the control group in the WHOQOL-BLEF score (p<0.05). There were no statistically significant correlations with PSQI and WHOQOL-BLEF scores regarding duration of symptoms, VAS, ASES, and KSS scores (p>0.05). The ASES score had a positive correlation with physical health domain and KSS score had a positive correlation with overall QOL and physical health domain of the WHOQOL-BLEF (p<0.05). Conclusion: Patients with frozen shoulder had noticeable pain and functional disability. Furthermore, they had significant incidence of sleep disturbance and had a significantly lower QOL. Key words: frozen shoulder, sleep disturbance, quality of life Received July 22, 2011 Revised August 28, 2011 Accepted October 6, 2011 Correspondence to: Chul-Hyun Cho, M.D., Ph.D. Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, 56, Dalseong-ro, Jung-gu, Daegu , Korea TEL: FAX: oscho5362@dsmc.or.kr

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar