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1 Clinical Article The Korean Journal of Sports Medicine 2015;33(1):1-5 pissn eissn 체외충격파치료를이용한견관절석회화건염의치료효과 국민건강보험일산병원정형외과 1, 연세대학교의과대학정형외과학교실 2 이윤태 1 ㆍ박준영 2 ㆍ성사현 2 ㆍ박상훈 1 The Effect of Extracorporeal Shock Wave Therapy for Calcific Tendinitis of the Shoulder Yun-Tae Lee 1, Jun-Young Park 2, Sa-Hyun Soung 2, Sang-Hoon Park 1 1 Department of Orthopedic Surgery, National Health Insurance Service, Ilsan Hospital, Ilsan, 2 Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea To evaluate the functional and radiologic outcomes of extracorporeal shock wave therapy (ESWT) in shoulders with chronic calcific tendinitis. We report a retrospective study to compare the outcome after ESWT (group l, 15 cases) with the effect of medication treatment (group 2, 15 cases) in patients with chronic calcific tendinitis. Patients were aged 42 to 58 years, mean of 48 years and treated with extracorporeal shock waves or medication from September 2012 to May The ESWT was performed six cycles of shock waves, weekly treatment for the three cycles and the rest cycles after 2 weeks of pause. In the same period, there were 12 women and 3 men treated with medication treatment for calcific tendinitis. The clinical outcomes were evaluated according to Constant and Murley score and pain visual analogue scale. Radiologic evaluation was performed to confirm disintegration of calcific deposits 3 months and 6 months after treatment. Clinical outcomes were significantly improved in ESWT group, and there was significant difference between ESWT group and medication group. In radiographic evaluation, the calcific deposit was significantly decreased in ESWT group. ESWT therapy is more effective to achieve functional improvement and to alleviate pain in the patients with calcific tendinitis of the shoulder. Keywords: Shoulder, Calcific tendinitis, Extracorporeal shock wave therapy 서 론 Received: October 23, 2014 Revised: March 19, 2015 Accepted: May 27, 2015 Correspondence: Sang-Hoon Park Department of Orthopedic Surgery, National Health Insurance Service, Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang , Korea Tel: , Fax: orthomania@gmail.com Copyright 2015 The Korean Society of Sports Medicine CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 견관절의석회화건염은회전근개내의칼슘염침착에의한반응성석회화질환으로견관절통증과운동제한을초래하는흔한질환이다 1,2). 칼슘염침착은극상근이상완골에부착하는부위에서가장흔하게발견되며극하근, 소원형근, 견갑하근의순으로관찰된다 3). 석회화건염의원인은명확하지않으며, 40 50대의여성에서더흔한것으로보고된다. 석회화건염의발생률은초음파, 자기공명영상 (magnetic resonance imaging), X-ray 등의진단방법, 무증상환자의포함여부에따라서 2.7% 에서 63% 까지다양하게보고된다 1,4-6). 석회화건염은석 제 33 권제 1 호

YT Lee, et al. The Effect of Extracorporeal Shock Wave Therapy for Calcific Tendinitis of the Shoulder 회화침착물의자발적인용해로증상이자연호전된다고하나 7), 석회침착의용해기간이길며통증을유발하기때문에환자의일상생활에불편을초래한다.

2 YT Lee, et al. The Effect of Extracorporeal Shock Wave Therapy for Calcific Tendinitis of the Shoulder 회화침착물의자발적인용해로증상이자연호전된다고하나 7), 석회침착의용해기간이길며통증을유발하기때문에환자의일상생활에불편을초래한다. 석회화건염의치료는질환의자연경과를앞당기거나증상을완화시키는목적으로이루어지며현재다양한방법을이용한보존적치료를시행하고있다. 비스테로이드성소염제의경구투여나견봉하간격으로스테로이드주사, 주사침을이용한석회침착제거 8), 수동적견관절관절운동을포함하는물리치료등의방법이있으나 9), 그효과에한계가있는것으로보고되고있다 10-12). 보존적치료에반응하지않는환자에서는개방적술식또는관절경을이용한수술적제거술이증상호전에도움이되기도한다 2,13). 본연구는견관절석회화건염환자에대한체외충격파치료의임상적, 방사선학적효과에대해알아보고자한다. 연구방법 mj/mm 2 의강도로분당 120회, 총 1,200회시행하였다. 1주간격으로 3회치료를시행한뒤 2주간의휴지기를두고다시 3회의치료를시행하였다. 휴지기는환자의치료준수 (compliance) 를높이고, 회전근개부위의손상을막기위해 2주간시행하였다. 체외충격파는동일한시술자에의해시행되었고, 석회성건염의위치는체외충격파조사전초음파를통하여확인하였다. 모든환자는앉은자세에서체외충격파를시행받도록하였다 (Fig. 1). 약물치료는비스테로이드성소염제 (aceclofenac) 를하루 2회씩 2개월간투여하였고, 위장관계부작용예방을위하여 H2 차단제 (H2-blocker) 를같이투여하였다. 3. 치료후분석방법견관절의기능회복을평가하기위해두군의환자들에게치료전과치료후 6개월뒤 Constant and Murley Scale (CMS) 을계산하였고동통의정도를파악하기위해 pain visual analog scale (VAS) 를측정하였다. CMS는견관절의기능을평가하는표준화된임상방법으로총 100점만점으로통증정도, 일상 1. 환자선정견관절의석회화건염주소로본원외래를내원한환자중 2013년 9월부터 2014년 5월까지체외충격파치료또는약물치료를받은 30명을후향적으로분석하였다. 연구대상으로선정된환자들은체외충격파치료를시행한제1군과약물치료를시행한제2군으로분류하였다. 제1군은 15명 ( 남자 3명, 여자 12명 ) 으로 42세에서 58세까지의연령분포로평균연령은 48.1세였다. 제2군은 15명 ( 남자 3명, 여자 12명 ) 으로 43세에서 59세까지연령분포를보이고, 평균연령은 49.1세였다. 최소 3개월이상 1년이내의이환기간을갖는환자를대상으로하였으며, 제1군은 6.9개월 ( 범위, 3 12개월 ), 제2군은 7.5개월 ( 범위, 3 12개월 ) 이었다 (Table 1). 2. 치료방법 체외충격파치료는 6 회에걸쳐진행되었다. 충격파는 0.03 Fig. 1. Extracorporeal shock wave therapy. Table 1. Demnographic factors Parameter Group 1 (n=15) (ESWT therapy) Group 2 (n=15) (conservative treatment) p-value* Age (y) 48.1±4.2 (42 58) 49.1±4.5 (43 59) Gender (male/female) 3/12 3/12 - Morbidity period (mo) 6.9± ± ESWT: extracorporeal shock wave therapy. *Mann-Whitney test. 2 대한스포츠의학회지

이윤태외. 체외충격파치료를이용한견관절석회화건염의치료효과 생활수행능력의주관적요소 (35점) 과운동범위, 근력의객관적요소 (65점) 으로구성된다. VAS는동통을주관적인평가에기초하여나타내며통증이없는경우를 0점으로하고극심한통증을 10점으로정하였고, 치료전과치료이후 6개월에조사하였다.

05인변수는유의한차이가있는것으로분석하였다. 결과 CMS 점수는체외충격파치료를시행한제1군에서치료전평균 26점에서치료후평균 72점 ( 범위, 47 92점 ) 으로증가하였고약물치료를시행한제2군에서는치료전평균 29점에서치료후평균 45점 ( 범위, 23 78점 ) 으로호전되어체외충격파치료를시행한경우더월등한견관절기능의회복을보였 다.

3 이윤태외. 체외충격파치료를이용한견관절석회화건염의치료효과 생활수행능력의주관적요소 (35점) 과운동범위, 근력의객관적요소 (65점) 으로구성된다. VAS는동통을주관적인평가에기초하여나타내며통증이없는경우를 0점으로하고극심한통증을 10점으로정하였고, 치료전과치료이후 6개월에조사하였다. 방사선학적치료평가를위하여치료전과치료후 3개월및 6개월에단순방사선촬영을시행하여석회화결절의크기를확인하였다. 통계적검증은 SPSS ver.17.0 (SPSS Inc., Chicago, IL, USA) 를이용하였다. Demographic factor는 Mann- Whitney test로, 치료전후결과는 paired t-test를이용하여 p-value<0.05인변수는유의한차이가있는것으로분석하였다. 결과 CMS 점수는체외충격파치료를시행한제1군에서치료전평균 26점에서치료후평균 72점 ( 범위, 47 92점 ) 으로증가하였고약물치료를시행한제2군에서는치료전평균 29점에서치료후평균 45점 ( 범위, 23 78점 ) 으로호전되어체외충격파치료를시행한경우더월등한견관절기능의회복을보였 다. VAS 점수도두군에서모두감소하였으나제1군에서치료전평균 8.8점 ( 범위, 6 10점 ) 에서치료후평균 2.3점 ( 범위, 0 5점 ) 으로감소하였고제2군에서는치료전평균 8.3점 ( 범위, 5 10점 ) 에서치료후평균 5.2점 ( 범위, 2 10점 ) 으로체외충격파치료시행시더나은통증의감소를보였다. 이는모두통계학적으로유의하였다 (Table 2). 방사선학적평가에서제2군에서는총 15명의환자중약물치료 3개월뒤 3명, 6개월뒤 7명이방사선촬영에서석회화결절의감소가관찰된것에비해제1군에서는총 15명중체외충격파치료 3개월뒤 7명, 6개월뒤 13명에서석회화결절의감소가관찰되었다. 체외충격파치료시방사선학적석회화결절의감소도더뚜렷한것으로나타났다 (Fig. 2). 체외충격파치료이후건파열이나골부종과같은심각한임상적부작용은없었다. Table 2. Clinical outcomes between ESWT therapy and conservative treatment Outcome Group 1 (n=15) (ESWT therapy) Group 2 (n=15) (conservative treatment) Preop Last F/U Preop Last F/U p-value CMS score (47 92) (23 78) <0.05 VAS score <0.05 ESWT: extracorporeal shock wave therapy, Preop: preoperative, F/U: follow up, CMS: Constant and Murley Scale, VAS: visual analog scale. Fig. 2. (A) Initial plain X-ray of calcific tendinitis patient. (B) After 6 months, follow-up X-ray of extracorporeal shock ave therapy therapy patient for calcific tendinitis. 제 33 권제 1 호

4 YT Lee, et al. The Effect of Extracorporeal Shock Wave Therapy for Calcific Tendinitis of the Shoulder 고찰석회화건염은퇴행성이아닌반응성석회화과정으로석회침착의형성과용해의진행에따라석회화전기, 석회화기, 석회화후기로구분한다 2,3,7). 통증이나운동제한등의증상은주로석회화기에서발생하는것으로알려져있다. 견관절통증은팔을거의움직일수없을정도로극심할수있으며야간에악화되는양상을보인다. 석회침착은수년이지나면저절로흡수되어사라지게된다. Gartner와 Simons 14) 는견관절방사선에서경계가뚜렷한석회침착이 3년뒤 33% 에서자발적으로사라졌음을보고하였으며, Bosworth 1) 는석회침착의 6.4% 가자발적인용해과정을거쳤음을보고하였다. 본연구에서는석회화건염환자에게체외충격파요법을시행한군에서약물치료를시행한군보다증상의완화와기능의개선이더월등하며, 석회화침착의소실도더많은것으로나타났다. 그동안의증례보고, 코호트연구및임상실험을포함한다양한보고에서도석회화건염환자에있어체외충격파요법이좋은치료결과를보고하였다 15). 수술적치료에비해서도체외충격파요법은비침습적이고안정성이보장되어있어더효과적인치료로알려져있다 16). 이연구역시이러한경향을뒷받침한다. 체외충격파쇄석술 (extracorporeal shock wave therapy) 은 1980년부터요석제거목적으로임상에서사용되었고최근에는비뇨기과영역에서요석치료의가장많이이용되고있다. 90년대초반부터체외충격파쇄석술은골절의불유합, 족저근막염과외측상과염등의만성건염에대한치료에되었다 17-19). Loew 등 20) 은견관절의석회화병변에체외충격파치료의효과에대해기술한바있으며, 이후에도다양한보고가이루어졌다 16,21). 체외충격파치료의성공률은 30% 에서 85% 로다양하게보고되며, 각각의경우마다다른횟수, 용량, 시술방법으로시행되기때문에결과에대해논란이많다 22,23). 체외충격파요법의효과에대한정확한생체내기전은알려져있지않다. 신생혈관생성, 조직의재분화, 과잉자극에따른마비효과가조직회복에중요한역할을한다고알려져있으며 7,14), 체외충격파는직접적으로조직자극을통해분자수준에서이러한반응을유도한다는가설도제기되고있다 24). 또한체외충격파는인접점액낭으로의석회침착물의흡수를촉진시키며국소염증반응을통해침착물의파괴를돕는다고알려져있다 25,26). 체외충격파요법을시행한후국소발적이나피하혈종의 발생등의부작용이보고된바있다 27). 또한고에너지의충격파를조사하였을경우시술중통증을호소하는경우가있으며이러한통증감소를위해시술전국소마취를시행하는경우도있다. 그러나그동안체외충격파요법에의해건파열이나골부종과같은심각한임상적부작용이발생되었다는보고는없다. 본연구에서도이러한부작용은발생하지않았다. 본연구의제한점은후향적연구로진행되었으며, 체외충격파의용량에따른차이를분석하지않은점이다. 또한석회성건염의자연사로인해증상이호전된것인지, 체외충격파나약물치료로인해증상이호전된것인지명확하지않다. 그렇지만저용량의체외충격파치료로도, 초음파를통해정확한부위에시행을할경우에석회화건염의치료에효과적임을알수있다. 견관절석회화건염에있어체외충격파치료는약물치료보다더유의미한관절기능의향상과통증의감소및방사선학적소견의호전을보인다. References 1. Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12,122 shoulders. JAMA 1941;116: Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8: Uhthoff HK. Calcifying tendinitis. Ann Chir Gynaecol 1996; 85: Refior HJ, Krodel A, Melzer C. Examinations of the pathology of the rotator cuff. Arch Orthop Trauma Surg 1987; 106: Milone FP, Copeland MM. Calcific tendinitis of the shoulder joint. Presentatin of 136 cases treated by irradiation. Am J Roentgenol Radium Ther Nucl Med 1961;85: Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA 2003;290: Moseley HF. The natural history and clinical syndromes produced by calcified deposits in the rotator cuff. Surg Clin North Am 1963;43: Parlier-Cuau C, Champsaur P, Nizard R, Wybier M, Bacque MC, Laredo JD. Percutaneous treatments of painful shoulder. Radiol Clin North Am 1998;36: Gimblett PA, Saville J, Ebrall P. A conservative management 4 대한스포츠의학회지

5 이윤태외. 체외충격파치료를이용한견관절석회화건염의치료효과 protocol for calcific tendinitis of the shoulder. J Manipulative Physiol Ther 1999;22: Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998;316: Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Phys Ther 2001;81: Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999;340: Ogden JA, Alvarez RG, Levitt R, Marlow M. Shock wave therapy (Orthotripsy) in musculoskeletal disorders. Clin Orthop Relat Res 2001;(387): Gartner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res 1990;(254): Rompe JD, Hope C, Kullmer K, Heine J, Burger R. Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. J Bone Joint Surg Br 1996;78: Rompe JD, Zoellner J, Nafe B. Shock wave therapy versus conventional surgery in the treatment of calcifying tendinitis of the shoulder. Clin Orthop Relat Res 2001;(387): Birnbaum K, Wirtz DC, Siebert CH, Heller KD. Use of extracorporeal shock-wave therapy (ESWT) in the treatment of nonunions: a review of the literature. Arch Orthop Trauma Surg 2002;122: Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am 2002;84: Wang CJ, Chen HS. Shock wave therapy for patients with lateral epicondylitis of the elbow: a one- to two-year follow-up study. Am J Sports Med 2002;30: Loew M, Daecke W, Kusnierczak D. The effects of extracorporeal shock wave application (ESWA) in treatment of calcifying tendinitis of the shoulder. J Bone Joint Surg Br 1997; 79(Suppl 2): Schmitt J, Haake M, Tosch A, Hildebrand R, Deike B, Griss P. Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus: a prospective, randomised study. J Bone Joint Surg Br 2001;83: Speed CA, Richards C, Nichols D, et al. Extracorporeal shockwave therapy for tendonitis of the rotator cuff: a doubleblind, randomised, controlled trial. J Bone Joint Surg Br 2002;84: Haake M, Deike B, Thon A, Schmitt J. Exact focusing of extracorporeal shock wave therapy for calcifying tendinopathy. Clin Orthop Relat Res 2002;(397): Wang CJ. An overview of shock wave therapy in musculoskeletal disorders. Chang Gung Med J 2003;26: Wang CJ, Wang FS, Yang KD. Biological effects of extracorporeal shockwave in bone healing: a study in rabbits. Arch Orthop Trauma Surg 2008;128: Delius M, Draenert K, Al Diek Y, Draenert Y. Biological effects of shock waves: in vivo effect of high energy pulses on rabbit bone. Ultrasound Med Biol 1995;21: Seil R, Wilmes P, Nuhrenborger C. Extracorporeal shock wave therapy for tendinopathies. Expert Rev Med Devices 2006;3: 제 33 권제 1 호

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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