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1 ㄴ J Korean Soc Phys Med, 2016; 11(2): Online ISSN: Print ISSN: X Research Article Open Access 상지림프부종환자의견갑골안정화운동이안정시견갑골위치에미치는영향 안소윤 김좌준 하해정 1 춘해보건대학교물리치료과, 1 부산가톨릭대학교물리치료학과 Effects of Scapular Stabilizing Exercise on Resting Scapular Position of Breast Cancer-related Lymphedema Patients So-Youn Ahn Jwa-Jun Kim Hae-Jung Ha 1 Dept. of Physical Therapy, Choonhae College of Health Sciences 1 Dept. of Physical Therapy, College of Health Sciences, Catholic University of Pusan Received: May 11, 2016 / Revised: May 11, 2016 / Accepted: May 11, 2016 c 2016 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this study was to confirm the effect of exercise combined with scapular stabilizing on resting scapular position (RSP) in breast cancer-related lymphedema patients. METHODS: A total of 20 patients with lymphedema after mastectomy participated in the study. All assessments of the patients edema sides (ES) and non-edema sides (NES) were evaluated. The assessment tools used wad RSP. RSP are; 1) scapular index, 2) 8th thoracic spines process (T8S) to inferior angle of scapular (IA) distance, 3) standing pectoralis minor (PM) distance, and 4) PM index (PMI). All patients carried out a scapular stabilizing exercise seven times a week for 8 weeks. The collected data were analyzed with PASW The statistical significance (α) was Corresponding Author : hj @hanmail.net 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. RESULTS: According to the results, all the variable between the ES and NES for RSP were statistically significant (p<0.05) in the pre-test. After the exercise, the differences in T8S to IA distance and the PMI between the ES and NES weren't statistically significant. The results of the RSP showed a significant improvement in T8S to IA distance, standing PM distance, and PMI. CONCLUSION: The results of this study showed that, performing the scapular stabilizing exercise had a significant effect on improving RPS in breast cancer-related lymphedema patients. Key Words: Lymphedema, Resting scapular position, Scapular stabilizing exercise Ⅰ. 서론림프부종은피부및피하공간에혈장단백질과지방등의림프액이비정상적으로축적되는것으로림프관발달이부적절하거나암치료를위한림프절절제술과

2 132 J Korean Soc Phys Med Vol. 11, No. 2 방사선치료또는감염으로인해림프계손상시에초래된다. 이로인해림프액수송에기능적결함이유발되면조직내의단백질축적, 부종, 섬유화, 만성염증이복합적으로나타난다 (Brennan 등, 1992; Casley-Smith, 1992). 림프부종이진행되면환자는어깨통증과상지의저린감, 무거운감, 열감을느끼고상지둘레또는부피가증가한다. 또한환측흉벽하부의조직이제한되는흉곽유착으로인해전거근과견관절수평내전근의근력약화, 견관절관절가동범위의감소, 자세의비대칭과부정렬이나타난다. 또한전거근과견관절수평내전근의근력약화로인한견갑골내전근의구축 (tightness) 은견갑골을전인, 하강된상태로지속시켜정상적인견갑골과흉곽의움직임이제한되는전방으로나온어깨를만든다 (Blomqvist 등, 2004; Cho 등, 2015; Kibler, 1998; Sahrmann, 2002). 상지가움직일때견갑골은승모근, 견갑거근, 능형근, 전거근등에의하여움직이면서동시에고정자로서의역할을수행하게되는데견갑골이이상적인위치에있어야견관절의움직임이증가되고견관절에안정성을주는회전근개가적절한힘을발휘하여상지의움직임을원활하게하기때문에중요하다. 견갑골이비정상적인위치를가지게되면견갑골과상지에관절가동범위가제한되고견관절의안정성이떨어진다 (Kibler, 1998; Kevin, 2007). 따라서어깨의기능이상은견갑골안정시위치와비정상적인움직임에연관이있고, 임상적인관점에서견갑골위치에대한평가를하는것은필수적이다 (Nijs 등, 2007). 비정상적인견갑골위치를가진환자의견갑골움직임재교육을위해서는상완골두가관절와의중심부에유지되면서견갑골은흉곽의중립위치에고정하는것이목적인견갑골안정화운동이많이사용되어진다. 최근의연구에서근육군의동원순서, 근육길이의차이, 근육군의짝힘의불균형을견갑골주변근육의등척성운동과견갑골움직임의재교육을통해개선하여견갑골의정상적인위치를회복하고견갑골안정성을증진시켜야한다고제시하였다 (Junsang 등, 2007). 림프부종환자를대상으로시행한연구에서는림프부종을개선하기위한운동방법에대한여러연구 (Box 등, 2002; Erickson 등, 2001; Christodoulakis 등, 2002; Margaret 등, 2004; Gosselink 등, 2003; Lim과 Han, 2011) 가있었다. 림프부종환자의운동치료방법은근수축을통하여림프관내에압력을유발시켜림프액을배출시키고림프흐름을저하시킬수있는연부조직과관절의가동성을증가시킨다. 또한환측상지의근력을강화시키고근위축을예방하며림프의펌프작용의효율을증진시키기위해서도중요하다. 따라서최근에는유산소운동, 순환운동등의운동을통해부종이완화되고상지기능이개선되는가에대한연구 (Lee, 2008; Lee, 2010; Lee 등, 2013) 가활발히진행되고있지만견갑골의비대칭이나부정렬을개선하기위한운동방법에대한연구는부족한실정이다. 이에본연구는상지림프부종환자에게견갑골안정화운동이안정시견갑골위치에미치는영향을알아보고자하였다. 이러한자료는치료사가림프부종환자에게견갑골안정화운동을시행하는데보다구체적이고정확한평가와치료를제공할수있는논리적근거를제시하는데기여할수있을것으로기대한다. Ⅱ. 연구방법 1. 연구대상본연구는부산광역시 K대학병원에서물리치료를받는상지림프부종환자중실험전연구목적과연구방법에대하여충분히설명한후실험참여에동의한 20명을대상으로하였다. 선정기준은유방절제술을시행하고방사선치료와항암치료를모두끝내고한쪽팔에만림프부종이발병하여기본적인림프부종관리를하고있는자로, 이뇨제를사용하거나정형외과적문제가있는자는제외하였다. 2. 연구절차본연구는견갑골안정화운동이림프부종환자의안정시견갑골위치에미치는영향을알아보기위해유방절제술후상지림프부종으로진단을받은연구대상자에게견갑골안정화운동을함께실시하였다. 견갑골비대칭이있는지알아보기위해실험전에부종이없는

3 상지림프부종환자의견갑골안정화운동이안정시견갑골위치에미치는영향 133 팔과부종이있는팔의견갑골위치를비교하였고실험 8주후에도부종이없는팔과부종이있는팔의견갑골위치를비교하였다. 또한견갑골비대칭의변화를알아보기위해실험전과실험 8주후의안정시견간골위치의변화량을비교하였다. 3. 측정방법 1) 견갑골지수 (scupaular index; SI) 견갑골거리를일반화하기위한목적을가지고값이작을수록견갑골이외회전혹은외전된것이다 (Borstad 와 Ludewig, 2005). 견갑골지수 =[( 흉골절흔에서오훼돌기까지의거리 ) / ( 세번째흉추에서견봉후외측각까지의거리 ) 100] (1) 흉골절흔 (sternal notch; SN) 에서오훼돌기 (coracoid process; CP) 까지의거리환자의손을 3번흔들어고관절옆에나란히위치시키고, 목을 3번굴곡, 신전하여정면을응시하게한다. 검사자는표시용테이프를이용하여흉골절흔의중간과오훼돌기의내측면을표시하고줄자를사용하여거리를측정한다 (Borstad, 2006). 이는견갑골의전인 (protraction) 이나내회전 (internal ratation) 을측정하기위하여사용하는방법이다 (Nijs 등, 2007). (2) 세번째흉추 (3rd thoracic spine; T3S) 에서견봉후외측각 (Posterolateral angle of acromion; PLA) 까지의거리 (T3S to PLA distance) 환자의손을 3번흔들어고관절옆에나란히위치시키고, 목을 3번굴곡, 신전하여정면을응시하게한다. 검사자는표시용테이프를사용하여견봉의후외측각과세번째흉추극돌기중간부위의거리를측정한다. 이는견갑골의후인 (retraction) 이나외회전을측정하기위하여사용하는방법이다 (Nijs 등, 2007). 측정자내신뢰도는 0.94이다 (Gibon 등, 1994). 2) 8번째흉추 (8th thoracic spine; T8S) 에서견갈골하각 (inferior angle; IA) 까지의거리 (T8S to IA distance) 환자의손을세번흔들어고관절옆에나란히위치시키고, 정면을바라보고선자세로표시용테이프를사용하여견갑골하각과 8번째흉추의극돌기를표시하고줄자를이용하여두표시점사이를측정한다. 이는견갑골의비대칭을평가하기위하여사용하는방법이다. 측정자내신뢰도는 0.90이다 (Gibon 등, 1994). 3) 선자세에서의소흉근 (pectoralis minor; PM) 거리 (standing PM distance) 환자의손을세번흔들어고관절옆에나란히위치시키고, 정면을바라보고선자세로표시용테이프를사용하여오훼돌기하내측면과 4번째늑골과흉골이만나는부위에각각표시하고줄자로거리를측정한다. 이는소흉근의근길이혹은전방기울기를평가하기위하여사용하는방법이다. 측정자내신뢰도는 0.96이다 (Borstad와 Ludewig, 2005). 4) 소흉근지수 (PM index; PMI) 환자의키를사용하여소흉근의길이를일반화시키는방법으로그값이클수록견갑골의전방기울기가커진다 (Borstad, 2005). 소흉근지수 =[( 선자세에서의소흉근의거리 ) / 환자의키 100] 4. 중재방법 1) 견갑골안정화운동본연구에서는견갑골세팅 (Scapular setting) 운동과열린사슬 (Open kinetic chain) 운동으로구성된견갑골안정화 (Scapular setting) 운동을실시하였다 (Odom과 Taylor, 2001). 견갑골안정화운동은정적최대근력에서 8초간자세유지를한후 2초휴식으로 6회반복하였고, 열린사슬운동을각각정적최대근력에서 8초간자세유지후 2초

4 134 J Korean Soc Phys Med Vol. 11, No. 2 휴식으로 6회반복하였으며견갑골세팅운동후 1분, 열린사슬운동후 2분간휴식하여 1일 1세트, 20분씩주 7일, 8주간실시하였다. 대상자가피로감을호소할경우휴식시간을추가적으로충분히제공하였다. 열린사슬운동시행시저항강도는맨손에서 0.5kg, 1kg 덤벨을사용하여점진적으로무게를증가시켜적용하였다. 훈련기간동안정확한운동을실시할수있도록충분한설명과시범을보여주었고, 2주간연구자의감독하에운동을수행하였다. 운동프로그램을정확하게할수있도록운동매뉴얼과운동일지를나누어주어운동시행상태를표시하도록하였고, 주기적으로운동을잘시행하고있는지확인하였다. (1) 견갑골세팅운동견갑골세팅 (Scapular setting) 운동은대상자가옆으로누운자세에서견갑골을내전, 후인, 하강, 하방회전의상태로귀볼과견봉이같은수평선상에일치하도록하는자세로대상자에게 당신의어깨를척추쪽으로가지고가세요 라고지시한다. 8초간이자세를유지하고시작자세로돌아온다. (2) 열린사슬운동 1 견갑골후인운동견갑골후인운동은견갑골안정에필요한능형근을촉진하는운동으로대상자가엎드려누운자세로림프부종이있는팔을침대옆으로떨어뜨리고점차견갑골을등쪽으로당기어 8초간이자세를유지하고시작자세로돌아온다. 이때대상작용이일어나지않도록이마를중앙으로고정한다. 2 견관절굴곡운동 1 견관절굴곡운동은견관절굴곡근과상승모근을촉진하며견관절의움직임패턴을만드는운동으로대상자가엎드려누운자세로림프부종이있는팔을아래로내리고견관절은중립자세를취하고주관절은신전하여견갑골을따라서움직이도록수평면에서전방 135 도까지들어올린후 8초간이자세를유지하고시작자세로돌아온다. 3 견관절굴곡운동 2 견관절굴곡운동은상승모근의과도한수축을억제하고중승모근의운동을촉진하는동작으로견갑골안정을유지하는데필요한운동이며대상자는옆으로누운자세로림프부종이있는팔은차렷자세에서머리방향으로천천히들어올린상태로 8초간이자세를유지하고시작자세로돌아온다. 4 견관절신전운동견관절신전운동은견관절신전근을촉진하며견관절의움직임패턴을만드는운동으로대상자가엎드려누운자세로침대가장자리에림프부종이있는팔을떨어뜨린후견갑골을따라서움직이는느낌으로견관절을신전시켜 8초간이자세를유지하고시작자세로돌아온다. 5 견관절외전운동견관절외전운동은견관절외전근과중승모근을촉진하며견관절의움직임패턴을만드는운동으로대상자가엎드려누운자세로림프부종이있는팔을아래로내린상태에서견갑골을따라서움직이는느낌으로옆으로팔을들어 8초간이자세를유지하고시작자세로돌아온다. 6 견갑골외회전운동견갑골외회전운동은견관절외회전근을촉진하는운동으로대상자가엎드려누운자세로림프부종이있는팔을옆으로벌리고주관절은구부린상태로전완을돌리고올린후 8초간이자세를유지하고시작자세로돌아온다. 7 견관절당기기운동견관절당기기운동은광배근을촉진하며어깨의움직임패턴을만드는운동으로대상자가엎드려누운자세로림프부종이있는팔을당기듯이들어올리는느낌으로올리고 8초간이자세를유지한후시작자세로돌아온다.

5 상지림프부종환자의견갑골안정화운동이안정시견갑골위치에미치는영향 견관절대각선운동견관절대각선운동은하승모근을촉진하며견관절의움직임패턴을만드는운동으로대상자가엎드려누운자세로림프부종이있는팔을아래로내려서견갑골을따라서움직이는느낌으로대각선방향으로팔을들어 8초간이자세를유지하고시작자세로돌아온다. 5. 자료처리본연구는견갑골안정화운동에참여한 20명의측정결과를 PASW 18.0 ver. (SPSS Inc, USA) 을사용하여분석하였고모든통계에대한유의수준 (α) 은 0.05로하였다. 연구대상자의일반적특성에대하여평균과표준편차를산출하였다. 실험전에부종이있는팔과없는팔사이의안정시견갑골위치를대응표본 t-검정 (Paired t-test) 을통해비교하였고, 실험후에부종이있는팔과없는팔사이의안정시견갑골위치변화를대응표본 t-검정 (Paired t-test) 을통해비교하였다. 또한실험전과실험후에안정시견갑골위치의변화량비교를대응표본 t-검정 (Paired t-test) 을통해비교하였다. 으며평균체중은 55.60±3.90kg이었다. 평균 BMI는 22.17±1.60이었고평균발병기간은 7.13±1.13개월이었다 (Table 1). Table 1. Physical characteristics of subjects Mean±SD Age (years) 50.70±4.90 Height ( cm ) ±0.03 Body weight ( kg ) 55.60±3.90 BMI ( kg / m2 ) 22.17±1.60 Onset (month) 7.13± 안정시견갑골위치측정시측정자내신뢰도안정시견갑골위치측정시측정자내검사-재검사신뢰도를확인하기위하여 20명의연구대상자를대상으로급간내상관계수를구하였다. 급간내상관계수 (ICC) 값은 0.99, 95% CI는 0.98에서 0.99로아주높은신뢰도가나타났다. Ⅲ. 연구결과 1. 연구대상자의일반적인특성본연구의대상자는총 20명이었고평균연령은 50.70±4.90세이었으며평균신장은 ±0.03cm이었 3. 실험전안정시견갑골위치견갑골안정화운동을시행하기전부종이있는팔과없는팔사이의안정시견갑골위치를측정한결과를보면견갑골지수, 제 8흉추에서견갑골하각사이의거리, 서있는자세에서의소흉근거리, 소흉근지수에서유의한차이가있었다 (p<0.05)(table 2). Table 2. Resting scapular position in the pre-test NES ES t p Scapular index 67.45± ± * T8S to IA distance ( cm ) 14.60± ± * Standing PM distance ( cm ) 13.22± ± * PMI 7.80± ± * NES; non-edema side, ES; edema side, T8S; 8th thoracic spine, IA; inferior angle, PM; pectoralis minor * p<0.05

6 136 J Korean Soc Phys Med Vol. 11, No. 2 Table 3. Resting scapular position in the post-test NES ES Scapular index 67.45± ± * T8S to IA distance ( cm ) 14.60± ± Standing PM distance ( cm ) 13.22± ± * PMI 7.80± ± NES; non-edema side, ES; edema side, T8S; 8th thoracic spine, IA; inferior angle, PM; pectoralis minor * p<0.05 t p Table 4. Differences in resting scapular position between NES and ES in pre and post-test Pre-test Post-test Scapular index 23.65± ± T8S to IA distance ( cm ) 1.40± ± * Standing PM distance ( cm ) 2.82± ± * PMI 1.90± ± * T8S; 8th thoracic spine, IA; inferior angle, PM; pectoralis minor * p<0.05 t p 4. 실험후안정시견갑골위치의변화견갑골안정화운동을 8주간시행한후부종이있는팔과없는팔사이의안정시견갑골위치를측정한결과를보면견갑골지수와소흉근거리에서유의한차이가있었으나제 8흉추에서견갑골하각사이의거리, 소흉근지수에서유의한차이가없었다 (p<0.05)(table 3). 5. 안정시견갑골위치의변화량비교부종이있는팔과없는팔의안정시견갑골위치차이를실험전과후에비교한결과를보면제 8흉추에서견갑골하각사이의거리, 서있는자세에서의소흉근거리, 소흉근지수에서유의한차이가있었으나견갑골지수에서유의한차이가없었다 (p<0.05)(table 4). Ⅳ. 고찰본연구는상지에림프부종환자에게견갑골안정화 운동이안정시견갑골위치에미치는효과를알아보고자시행하였다. 림프부종은일차성과이차성으로구분되며일차성림프부종은선천적으로림프관의수가적거나림프관이좁은사람에게서나타날수있다. 이차성림프부종은림프절과림프관을암또는전이성질병의치료를위해수술적인방법으로제거한경우에나타날수있다. 상지림프부종은유방암환자의수술중전이를막기위해액와림프절절개를시행하는것과연관되어많이발생한다 (Rockson 등, 1998). 상지림프부종환자의문제점은상지부종으로인해팔의둘레가정상에비해평균 2~10cm정도두꺼워지게되어활동시움직임의제한이있다는것이다. 또한일상생활을하기위하여팔을지속적으로사용하기때문에근육의변형, 견관절기능의장애가동반되기도한다 (Devoogdt 등, 2009). 림프부종을개선하기위해사용되고있는복합림프부종물리치료 (Complete Decongestive Therapy: C.D.T) 는림프부종마사지, 압박요법, 피부관리, 림프순환운

7 상지림프부종환자의견갑골안정화운동이안정시견갑골위치에미치는영향 137 동을포함하며이는림프부종을완화시키는데효과를준다고하였다 (Charles 등, 2003; Damstra와 Partsch, 2009; Haghighat 등, 2010; Huang 등, 2013). 본연구에서도견갑골안정화운동을시행하는동안림프부종이악화되는것을막기위해복합림프부종물리치료를함께시행하였다. 림프부종환자를대상으로시행한연구에서복합림프부종물리치료와유산소운동, 근력운동이포함된복합운동치료를함께시행하였을때복합림프부종물리치료만시행한대조군에비해견관절가동범위가더큰향상을보였다 (Lee 등, 2013). 또한복합림프부종물리치료와유산소운동을함께시행한연구에서도실험군의견관절가동범위가대조군에비해굴곡, 외전, 외회전에서유의하게큰향상을보인것으로보고하였으며 (Lee, 2010) Ha 등 (2013) 은한쪽팔에만림프부종이발생한환자 20명을대상으로부종이있는팔과없는팔사이의견갑골기능이상을측정였을때견갑골지수, 8번째늑골에서견갑골하각까지의거리, 선자세에서의소흉근거리, 소흉근지수에서유의한차이를보여견갑골기능이상이나타난다고보고하였다. 본연구에서도복합림프부종물리치료와견갑골안정화운동을함께시행하였을때실험전에비해안정시견갑골위치의차이가줄어들어견갑골비대칭이완화되었다. 또한실험전실시한안정시견갑골위치측정에서부종이없는팔과부종이있는팔사이에모든항목에서유의한차이를보여견갑골비대칭을보였으나실험후안정시견갑골위치측정을다시시행한결과부종이없는팔과부종이있는팔사이에 8번째흉추에서견갈골하각까지의거리와소흉근지수항목에서유의한차이를보이지않아견갑골비대칭이개선된다는것을알수있었다. 이와같은연구결과는상지림프부종이발생한이후환측흉벽하부에있는조직이제한되는흉곽유착으로인해나타나는전거근, 견관절내전근의약화와유방절제술후대흉근, 소흉근의단축으로전방어깨와견갑골후방기울기가감소된것을알수있다. 이러한문제를해결하기위해올바른어깨의움직임과자세의회복을위한중재가필요하며, 견갑골안정화운동이견갑골 비대칭과부정렬을개선시키는데효과적인영향을미치는것을확인할수있었다. 따라서향후림프부종환자의치료에견갑골안정화운동을포함하는것이림프부종환자의견갑골비대칭과부정렬의개선에도움이될것이라고사료된다. 본연구는림프부종이발병한지평균 6개월이지난환자를대상으로하였기때문에다양한발병시기의환자들을조사하지못하였고, 중재이후효과가얼마나지속되는지에대한결과를확인하지못하였다. 따라서향후연구에서는다양한발병시기의환자들을대상으로견갑골안정화운동이견갑골비대칭과부정렬에미치는영향과그효과가얼마나지속되는가에대한연구가이루어져야될것이다. Ⅴ. 결론본연구는 20명의상지림프부종환자를대상으로견갑골안정화운동을실시하여견갑골비대칭과부정렬에미치는영향을알아보고자하였다. 연구대상자는복합림프부종물리치료와견갑골안정화운동을주 7회, 8주동안시행하였다. 그결과실험전에안정시견갑골위치를측정한결과부종이있는팔과부종이없는팔에서연구대상자는견갑골비대칭을보였으나실험 8주후에안정시견갑골위치를다시측정한결과견갑골비대칭이감소되었다. 또한실험전과실험 8주후에안정시견갑골위치의차이가감소하여견갑골비대칭과견갑골의과도한전인이개선을보였다. 본연구의결과를토대로복합림프부종물리치료와견갑골안정화운동을함께적용하는것은상지림프부종환자에게견갑골비대칭을개선시키는데보다효과적일것으로사료된다. Acknowledgements 본논문은 2015년도부산가톨릭대학교교내학술연구비지원에의하여수행된것임.

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Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical