Original Article J Korean Geriatr Soc 2015;19(3): Print ISSN On-line ISSN 자기공명

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1 Original Article J Korean Geriatr Soc 2015;19(3): Print ISSN On-line ISSN 자기공명영상과수압팽창술효과의비교를통해알아본노인환자의유착성관절낭염의특징 성균관대학교의과대학삼성창원병원재활의학교실 박영숙 박윤희 Adhesive Capsulitis in the Elderly: Comparison of Magnetic Resonance Imaging Findings with Effectiveness of Hydrodilatation Treatment Young Sook Park, MD, Yun Hee Park, MD Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea Background: Shoulder pain and disability are common problems in the elderly, and adhesive capsulitis is one of the main causes. To identify the characteristics of adhesive capsulitis in elderly patients, we compared magnetic resonance imaging (MRI) findings of treatment effect between two age groups. Methods: We enrolled 54 adult patients with adhesive capsulitis who underwent shoulder MRI and hydrodilatation treatment, and divided them into the elderly and the control groups. Capsular thickness in the axillary pouch, presence of subcoracoid fat obliteration in the rotator interval and accompanying lesions in the rotator cuff were evaluated on the shoulder MRI. The constant score and range of motion of the shoulder joints were measured three times-baseline, week 2, and week 12. Results: The elderly group showed significantly higher frequencies of subcoracoid fat obliteration (p=0.04) and rotator cuff lesion (p=0.003). Constant scores (p=0.006) and range of motion (forward flexion, p=0.012; external rotation, p=0.001; internal rotation, p=0.007) at week 12 were better in the control group. The control group showed significant increases in the scores at all 3 assessments (p<0.001), whereas the elderly group did not show significant improvement between weeks 2 and 12. Neither the elderly nor the control patients with rotator cuff tears showed a significant increase in the constant score at all 3 assessments. Conclusion: Elderly patients showed more frequent rates of secondary adhesive capsulitis caused by rotator cuff injuries. Also, these rotator cuff injuries, especially tendon tears, might be related to a lack in long-term effect of hydrodilatation treatment. Key Words: Geriatrics, Adhesive capsulitis, Magnetic resonance imaging, Treatment Received: July 10, 2015, Revised: August 17, 2015 Accepted: August 18, 2015 Address for correspondence: Yun Hee Park, MD Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Paryong-ro, Masanhoewon-gu, Changwon 51353, Korea Tel: , Fax: yh0316.park@samsung.com 서론 노인에서어깨통증은매우흔한증상으로, 국내코호트연구에서 65세이상노인의 62.6% 가상지통증, 45.5% 가어깨통증을경험하는것으로나타났다 1). 노인에서어깨통증의원인으로유착성관절낭염 (adhesive capsulitis), 회전근개손상 Copyright 2015 Korean Geriatric Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (

2 Young Sook Park and Yun Hee Park: Adhesive Capsulitis in the Elderly (rotator cuff injury), 골관절염 (osteoarthritis) 등이대표적인데 2), 이중유착성관절낭염은어깨통증과운동제한을동반하는대표적인근골격계질환이다. 유착성관절낭염의발병에있어상완와관절 (glenohumeral joint) 주변연부조직의염증성반응또는섬유화변성이관여하는것으로알려지고있으나정확환원인과시작에대해서아직잘밝혀지지않고있다 3-5). 진단은대부분병력및신체검진소견을바탕으로임상적으로이루어지며, 단순방사선검사는어깨의다른병변을배제하기위해사용되기도한다 6). 자기공명영상검사 (magnetic resonance imaging) 및자기공명관절조영술 (magnetic resonance arthrography) 은일차진단으로적용되지는않지만, 이전의연구에서액와관절낭 (axillary pouch) 의비후, 회전근개간격 (rotator interval) 의변화등이유착성관절낭염에특이적인소견으로보고되었다 6-9). 유착성관절낭염의치료에있어 gold standard 는정립되어있지않지만, 물리치료, 경구소염제, 관절강내스테로이드주사 (intra-articular corticosteroid injection), 수압팽창술 (hydrodilatation) 등의보존적치료를 1차로시행하고, 충분한보존적치료에도호전이없을때는전신마취하도수치료 (manipulation under general anesthesia), 윤활막절제술 (synovectomy), 관절낭박리 (capsular release) 등수술적치료를시행하는것을원칙으로한다 4,6). 유착성관절낭염은주로 대에발생하는것으로알려져있어, 노인에서어깨통증의원인으로간과되기쉽다 5,10,11). 또한 18개월에서 3년이내에특별한치료없이도호전되는경향을보여적절한치료를받지않고지내는경우도있다 4,6,12). 특히노인들은통증을노화의일부과정으로생각하고참고수용해야하는문제로치부하여적절한치료로이어지지않는경우가있다 12,13). 하지만유착성관절낭염환자들중 7-15% 는영구적인관절운동제한이남고, 일부는이로인해장애를가지고살아가게된다 14). 또한유착성관절낭염뿐만아니라, 노인의어깨질환과관련된연구자체가매우드물다. 이에저자들은유착성관절낭염의진단및치료에있어노인환자의특징을알아보고자, 임상적으로유착성관절낭염을진단받은환자들을연령에따라구분하고견관절자기공명영상검사결과및수압팽창술치료효과를비교분석하고자한다. 대상및방법 1. 대상 2011 년 1 월부터 2014 년 12 월까지어깨통증을주소로본원 재활의학과를방문한 18세이상의성인환자중견관절단순방사선검사와자기공명영상검사및수압팽창술치료를시행한환자를전수조사하여후향적의무기록분석을시행하였고, 이들중유착성관절낭염의임상적진단기준을모두만족하는환자를연구대상으로선정하였다 15-17) : (1) 3개월이상점진적으로진행하는일측성견관절통증 ; (2) 수동, 능동관절운동에의한통증악화 ; (3) 전방굴곡 (forward flexion), 외전 0 에서외회전 (external rotation in 0 of abduction), 내회전 (internal rotation) 등세방향의수동관절운동범위 (range of motion, ROM) 중하나이상에서건측대비 50% 이상의감소 ; (4) 견관절단순방사선검사상정상소견, 견관절의외상및골절, 수술등의병력이있는환자, 견관절통증및기능에영향을줄수있는근골격계및신경학적질환의병력이있는환자 ( 예 : 류마티스관절염, 뇌졸중 ), 견관절단순방사선검사상이상소견을보이는환자는연구대상에서제외하였다. 2. 방법 1) 견관절자기공명영상검사대상환자들은 3.0-Tesla scanner (Ingenia, Philips, DA Best, The Netherlands) 를이용하여견관절자기공명영상검사를시행하였다. 획득영상및검사조건은다음과같다. T1-강조고속스핀에코 (T1-weighted turbo spin echo sequence) 영상 : 경사관상면 (oblique coronal), 경사시상면 (oblique sagittal); repetition time (TR)/echo time (TE)= /10 ms. T2- 강조고속스핀에코영상 : 경사관상면 ; TR/TE=2,098-2,480/80 ms. T1- 강조지방억제 (fat-suppressed) 영상 : 축면 (axial); TR/ TE= /10 ms. T2- 강조지방억제영상 : 경사관상면, 경사시상면, 축면 ; TR/TE=2,500-3,639/60-77 ms. Field of view= mm, matrix size= 으로검사를시행하였고, 모든영상은 3 mm의단면두께 (section thickness) 와 mm의단면간격 (intersection gap) 으로획득하였다. 획득한영상은 10년이상의근골격계영상판독경력을보유한본원영상의학과전문의 1인이분석하였고, 액와관절낭의두께, 회전근개간격의지방소실 (fat 148 J Korean Geriatr Soc 19(3) September 2015

3 박영숙과박윤희 : 노인환자의유착성관절낭염의특징 obliteration) 소견의유무, 회전근개병변의유무에대한평가가이루어졌다. 관절낭의두께는 T2- 강조지방억제경사관상면에서액와오목 (axillary recess) 의가장넓은부분을찾아고신호강도의관절액과관절낭의가장바깥쪽경계사이의거리를관절낭면에수직으로측정하였다 8,15) (Fig. 1). 회전근개간격은 T1- 강조경사시상면에서오구상완인대 (coracohumeral ligament) 와상부상완관절인대 (superior glenohumeral ligament) 를둘러싸고있는오구돌기하지방 (subcoracoid fat) 내에균일한저신호강도 (low signal intensity) 가관찰되는경 Fig. 1. Joint capsule thickness measurement on T2-weighted fat-suppressed oblique coronal imaging. Capsular and synovial thickness of axillary recess was measured by the distance between the high signal fluid and the outer border of the capsule in perpendicular direction to the capsular configuration (arrow). Fig. 2. Subcoracoid fat obliteration with homogenous low signal intensity (A) and normal high signal intensity of the fat tissue (B) are visible on T1-weighted oblique sagittal imaging. 우지방소실로평가하였다 9,15) (Fig. 2). 또한극상근건 (supraspinatus tendon) 을포함한회전근개에서건증 (tendinosis) 및파열 (tear) 소견이관찰될경우회전근개병변으로평가하였다. 2) 견관절수압팽창술앙와위에서시술부위의무균처리후 C-arm (Fluorostar 7900, GE Healthcare, Wendelstein, Germany) 유도하에 23- guage 척추바늘을상완와관절의중간 1/3에위치시키고방사선비투과조영제 (radiopaque contrast) 1 ml를주입하여바늘위치를확인하였다. 이후 2% lidocaine (5 ml), 조영제 (5 ml), triamcinolone (40 mg), 생리식염수 (9 ml) 를혼합하여총 20 ml의주사액을주입하였다. 수압팽창술은유착성관절낭염의보존적치료로서의효과가여러연구를통해입증되었으며 18-20), 일반적으로영상유도하에상완와관절내로다량의주사액을주입하여관절낭의확장및파열을유도하는시술로, 환자마다관절용적이다르기때문에주입되는주사액의용적이달라질수있고, 유착된관절낭의기계적확장을목표로하는시술이므로주사액에스테로이드를포함하지않는다. 그러나이번연구에서는모든환자에게동일한시술을시행하여그효과를평가하고자관절낭파열여부와관계없이 20 ml 의주사액을주입하였고, 충분한치료효과를기대하기위해주사액에스테로이드를포함하였다. 모든환자에서시술후이상반응은보고되지않았다. 모든환자에서수압팽창술치료후견관절운동교육을시행하였고, 통증조절을위한비스테로이드소염제는시술전과동일하게복용하도록허용하였다. 3) 결과측정이번연구에서수압팽창술의치료효과를평가하는일차결과 (primary outcome) 로대상환자에서 constant score 를측정하였고, 그외에견관절의수동운동범위를측정하였다. Constant score 는유착성관절낭염환자의평가에적합성이입증된 100점점수체계로, 통증 (15점 ), 일상생활동작 (activities of daily living, 20점 ), 관절운동범위 (40점 ), 근력 (25점 ) 항목으로구성되어있으며, 100점에가까울수록통증과기능이호전됨을의미한다 21). 관절운동범위는각도계 (goniometer) 를이용해전방굴곡 (0-180 ), 외회전 (0-90 ), 내회전의 J Korean Geriatr Soc 19(3) September

4 Young Sook Park and Yun Hee Park: Adhesive Capsulitis in the Elderly 세방향의운동범위를측정하였다. 전방굴곡은앙와위측면에서팔과몸통이이루는최대각도를측정하였고, 외회전은앙와위축면에서상완을 0 외전, 팔꿈치관절을 90 굴곡상태로고정한후바닥과수직을이루는가상의선과전완이이루는최대각도를측정하였다. 내회전은등받이가없는의자에허리를펴고앉은상태에서손등을척추에밀착시키고척추를따라최대한머리방향으로손등을올린후엄지손가락이위치하는척추높이를측정하여다음과같이 4단계로부호화 (coding) 하였다 : 0, 엉덩이 (buttock) 이하 ; 1, 제5요추이하 ; 2, 제1-5 요추 ; 3. 제12흉추이상. Constant score 및관절운동범위측정은수압팽창술치료전, 치료후 2주, 치료후 12주에시행하였다. 4) 자료수집및통계분석대상환자의의무기록에서나이, 성별, 수압팽창술시행까지의증상기간, 이환된견관절의우성또는비우성측여부, 당뇨및갑상선질환의유무등일반적특성에관한자료를수집하였다. 견관절자기공명영상검사에서관절낭의두께, 회전근개간격의지방소실소견및회전근개병변의유무를수집하였다. 또한치료전, 치료후 2주, 치료후 12주에측정한 constant score 및세방향의견관절운동범위를수집하였다. 이번연구의일차분석으로대상환자를나이에따라 61세이상의고령군과 60세이하의대조군으로분류하였고, 두군의일반적특성과자기공명영상검사소견을군간비교하고, constant score 와관절운동범위를군간, 평가시기간비교하였다. 이차분석으로대상환자를자기공명영상검사소견에따라분류하였는데, 먼저회전근개간격의지방소실소견의유무에따라분류하여 constant score 를군간, 평가시기간비교하였고, 회전근개병변에따라병변없음, 건증, 파열의세군으로분류하여 constant score 를군간, 평가시기간비교하였다. 마지막으로회전근개병변에따라분류된환자군을나이에따라다시분류하여 constant score 를군간, 평가시기간비교하였다. 치료후 12주에측정한 constant score 를일차평가변수 (primary endpoint) 로하는검정력분석에서 의충분한검정력이확인되었다. 연속형변수 ( 나이, 증상기간, 관절낭의두께, constant score, 관절운동범위중전방굴곡및외회전 ) 는평균 ± 표준편차로제시하였고, Mann Whitney U-test 와 Kruskall-Wallis test 를이용해군간비교하였다. 범주형변수중순위변수 ( 관절운동범위중내회전 ) 는중앙값과사분위수범위로, 명목변수 ( 성별, 우성또는비우성측, 당뇨및갑상선질환의유무, 지방소실소견의유무, 건증및파열등회전근개병변의유무 ) 는표본수와비율로제시하였으며, 각각 Mann- Whitney U-test 와 Fisher exact test를이용해군간비교하였다. Constant score 및관절운동범위의평가시기간비교에는 Wilcoxon signed rank test 및 Bonferroni correction을이용하였다. 통계분석은 PASW Statistics ver (SPSS Inc., Chicago, IL, USA) 을이용하였고, 0.05 이하의 p값은통계적으로유의한것으로판정하였다. 이번연구는본원연구윤리심의위원회의승인하에시행되었다. 결과 연구기간중유착성관절낭염으로본원재활의학과를방문하여견관절단순방사선검사및자기공명영상검사, 수압팽창술치료를받은환자는총 137 명이었고, 연구대상기준을적용하여 54명의환자가이번연구에포함되었다. 이중 61세이상의고령군은 13명이었고, 60세이하의대조군은 41명이었다. 두군의일반적특성에관한비교에서연령 (p<0.001) 을제외한다른변수는통계적유의성이관찰되지않았다 (Table 1). 견관절자기공명영상검사에대한평가에서, 관절낭두께는두군사이에유의한차이를보이지않았다. 그러나, 회전근개간격의지방소실소견은고령군의 92%, 대조군의 59% 에서관찰되었고 (p=0.04), 회전근개병변중건증의빈도는통계적유의성을보이지않았으나, 파열 (46% vs. 15%, p=0.027) 및회전근개병변전체 (92% vs. 44%, p=0.003) 의빈도는두군간에유의한차이를보였다 (Table 2). 일차분석결과에서 constant score 와세방향의관절운동범위는치료전, 치료후 2주에는고령군과대조군사이에유의한차이를보이지않았으나, 치료후 12주의점수 (p=0.006) 및전방굴곡 (p=0.012), 외회전 (p=0.001), 내회전 (p=0.007) 범위는모두대조군에서유의하게높았다. 평가시기간비교에서대조군은 4개의항목모두치료전- 치료후 2주, 치료후 2주-12 주, 치료전- 치료후 12주사이에유의한호전이관찰되었지만 (p< 0.001), 고령군은 constant score, 전방굴곡, 외회전이치료전-치료후 2주 (constant score, p=0.003; 전방굴곡, p=0.003; 150 J Korean Geriatr Soc 19(3) September 2015

5 박영숙과박윤희 : 노인환자의유착성관절낭염의특징 외회전, p=0.003), 치료전-치료후 12주 (constant score, p= 0.006; 전방굴곡, p=0.009; 외회전, p=0.006) 사이에서만, 내 회전이치료전-치료후 2주 (p=0.033) 사이에서만유의하게호전되었다 (Table 3). Table 1. Comparison of general characteristics Characteristic Elderly (n=13) Control (n=41) p-value * Age (yr) 66.3± ±6.3 <0.001 Sex Male:female 5:8 18: Duration (mo) 7.6± ± Side Dominant:Nondominant 7:6 23: Past medical history Diabetes 0 (0) 2 (5) Thyroid disease 0 (0) 2 (5) Values are presented as mean±standard deviation, ratio, or number (%). * p-values obtained by Mann-Whitney U-test and Fisher exact test. Table 2. Comparison of magnetic resonance imaging findings Variable Elderly (n=13) Control (n=41) p-value * Thickness of axillary pouch (mm) 4.91± ± Fat obliteration of rotator interval 12 (92) 24 (59) Pathologic finding of rotator cuff Tendinosis 6 (46) 11 (27) Tear 6(46) 7(17) Total 12 (92) 18 (44) Values are presented as mean±standard deviation or number (%). * p-values obtained by Mann-Whitney U-test and Fisher exact test. Table 3. Between-group and between-assessment comparisons of treatment outcomes Variable Baseline Week 2 Week 12 Constant score Elderly (n=13) 31.92± ± ±16.01 Control (n=41) 39.15± ± ±18.04 *,, ROM (FF, degree) Elderly 75.00± ± ±33.33 Control 84.76± ± ±31.45 *,, ROM (ER, degree) Elderly 31.15± ± ±15.46 Control 37.56± ± ±16.13 *,, ROM (IR, score ) Elderly 1 (0 1) 2 (1 2) 1(1 2) Control 1 (0 1) 1 (1 2) 2(1 2.5) *,, Values are presented as mean±standard deviation or median (interquartile range). ROM, range of motion; FF, forward flexion; ER, external rotation; IR, internal rotation. * p<0.05 compared to the elderly group by Mann-Whitney U-test. p<0.05 compared to baseline score by Wilcoxon signed rank test and Bonferroni correction. p<0.05 compared to the score at week 2 by Wilcoxon signed rank test and Bonferroni correction. transformation of ROM landmarks to a score (0-3). J Korean Geriatr Soc 19(3) September

6 Young Sook Park and Yun Hee Park: Adhesive Capsulitis in the Elderly 이차분석결과에서지방소실소견의유무에따라환자군을분류했을때, 두군의 constant score 는치료전, 치료후 2주, 치료후 12주모두에서유의한차이를보이지않았고, 두군모두평가시기간비교에서치료전-치료후 2주 ( 없음, p<0.001; 있음, p<0.001), 치료후 2주-12주 ( 없음, p=0.009; 있음, p<0.001), 치료전-치료후 12주 ( 없음, p<0.001; 있음, p<0.001) 사이에모두 constant score의유의한호전이관찰되었다. 회전근개병변에따라병변없음, 건증, 파열로환자군을분류했을때, 세군의 constant score 는치료전, 치료후 2주, 치료후 12주모두에서유의한차이를보이지않았다. 평가시기간비교에서회전근개병변이없는환자는치료전- 치료후 2주, 치료후 2-12주, 치료전- 치료후 12주사이에모두 constant score 의유의한호전이관찰되었고 (p<0.001), 건증환자및파열환자는치료전-치료후 2주 ( 건증, p<0.001; 파열, p=0.006), 치료전-치료후 12주 ( 건증, p<0.001; 파열, p= 0.009) 사이에유의한호전이관찰되었지만, 치료후 2주- 12 주의점수는통계적유의성을보이지않았다 (Table 4). 회전근개병변에따른환자군을나이에따라다시분류하였을때, 회전근개병변이없는환자중고령군은 1명이었기때문에군간비교는시행하지않았고, 건증환자와파열환자는모두치료전, 치료후 2주, 치료후 12주의 constant score 가고령군과대조군사이에유의한차이를보이지않았다. 평가시기간비교에서회전근개병변이없는대조군은치료전-치료후 2주, 치료후 2주-12 주, 치료전-치료후 12주사이에모두 constant score 의유의한호전이관찰되었고 (p<0.001), 건증대조군은치료전-치료후 2주 (p=0.015), 치료전-치료후 12 주 (p=0.009) 사이에서유의한호전이관찰되었지만, 건증고령군, 파열고령군, 파열대조군은세평가시기사이에 constant score의유의한호전이관찰되지않았다 (Table 5). Table 4. Between-group and between-assessment comparisons of the constant score according to magnetic resonance imaging findings Variable Baseline Week 2 Week 12 Fat obliteration of rotator interval Absence (n=18) 40.50± ± ±18.97, Presence (n=36) 35.86± ± ±18.95, Pathologic finding of rotator cuff Absence (n=24) 38.79± ± ±18.81, Tendinosis (n=17) 37.12± ± ±20.98 Tear (n=13) 35.23± ± ±14.32 Values are presented as mean±standard deviation. p<0.05 compared to baseline score by Wilcoxon signed rank test and Bonferroni correction. p<0.05 compared to the score at week 2 by Wilcoxon signed rank test and Bonferroni correction. Table 5. Between-group and between-assessment comparisons of the constant score according to age and rotator cuff pathology Variable Baseline Week 2 Week 12 Absence Elderly (n=1) Control (n=23) 39.48± ± ±19.62, Tendinosis Elderly (n=6) 34.50± ± ±10.95 Control (n=12) 39.92± ± ±17.64 Tear Elderly (n=6) 29.17± ± ±21.63 Control (n=6) 36.33± ± ±10.97 Values are presented as mean±standard deviation. p<0.05 compared to baseline score by Wilcoxon signed rank test and Bonferroni correction. p<0.05 compared to the score at week 2 by Wilcoxon signed rank test and Bonferroni correction. 152 J Korean Geriatr Soc 19(3) September 2015

7 박영숙과박윤희 : 노인환자의유착성관절낭염의특징 고찰 이번연구는유착성관절낭염의진단과치료에있어노인환자들의특징을알아보고자대상환자를연령에따라고령군과대조군으로구분하여견관절자기공명영상검사소견과수압팽창술치료효과를비교하였다. 그결과고령군은대조군에비해자기공명영상검사상회전근개병변이더높은빈도로동반되어있었고, 특히건파열의빈도가유의하게높았다 (Table 2). 또한 constant score 및관절운동범위의군간비교에서고령군은치료후 12주의점수및범위가대조군에비해유의하게작았고, 평가시기간비교에서도대조군의치료효과가치료후 12주까지지속된반면, 고령군의치료효과는치료후 2주-12주사이에유의한호전을보이지않았다 (Table 3). 유착성관절낭염은한국및일본에서는오십견으로불리기도하는데, 이는주로 50대에나타나저절로호전되는어깨통증이라는뜻을내포하고있으며 22), 실제로 세사이에서최대발병률을보인다 5,10,11). 하지만임상에서는다양한연령대의환자를경험할수있는데, 한지역사회연구에서노인인구의 25% 이상이어깨의통증및운동장애를가지고있고, 회전근개손상, 충돌증후군 (impingement syndrome), 유착성관절낭염, 골관절염등이노인어깨통증의흔한원인으로보고되었다 2). 노인견관절질환환자에대한장기추적연구에서 74% 가지속적인관절운동범위제한을보였고, 21% 는자기관리장애, 27% 는집안일장애가지속되었는데 23), 유착성관절낭염은통증과더불어심한운동범위제한을동반하기때문에노인에서독립적인일상생활의어려움을가져올가능성이높을것으로예상된다. 유착성관절낭염은임상적진단이므로병력과신체검진소견으로진단이가능하다. 수개월에걸쳐서서히진행하는어깨통증과운동범위제한 ( 전방거상, 외회전및내회전 ) 이진단에있어가장중요한소견이다 11,24). 영상검사에의한유착성관절낭염의진단은이전부터연구되어왔으나주로고식적관절조영술 (conventional arthrography) 에관한것이었으며 25,26), 최근에는자기공명영상검사에대한연구가활발히이루어지고있다. Emig 등 8) 은액와부에서윤활막 (synovium) 을포함한관절낭의두께가 4 mm 이상일경우유착성관절낭염의진단에 95% 의특이도를보인다고보고하였고, Sofka 등 27) 은유착성관절낭염의임상적병기가진행할수록관절낭의두께가두 꺼워짐을보고하였다. 이번연구에서고령군의액와부관절낭두께는 4.91±0.48 mm, 대조군은 4.54±0.78 mm로측정되어두군모두평균적으로유착성관절낭염에합당하였고, 비록고령군이약간더두꺼웠지만통계적으로유의한차이를보이지는않아유착성관절낭염의진행정도는두군에서큰차이를보이지않음을알수있었다 (Table 2). Ahn 등 15) 은임상적으로유착성관절낭염을진단받은 97명의환자를대상으로후향적자기공명영상검사연구를시행하였고, 이들중 81명 (83.5%) 의환자에서회전근개병변이동반되어있음을보고하였다. Yoo 등 22) 역시임상적으로유착성관절낭염을진단받은 81명의환자를대상으로전향적자기공명관절조영술연구를시행하였고, 이들중 50명 (61.7%) 의환자에서회전근개병변이동반되어있음을보고하였는데, 나이에따라두군으로나누어비교하였을때 60세미만은 53.1%, 60세이상은 73.3% 의회전근개병변빈도를보였으며, 특히회전근개파열소견은 60세미만에서 23.7%, 60세이상에서 60% 의빈도를보여통계적으로유의한차이를보였다. 이번연구에서도전체환자의 56% 에서회전근개병변이관찰되었고, 고령군은 92%, 대조군은 44% 의빈도를보였으며, 특히건파열소견은고령군의 46%, 대조군의 15% 에서동반되어유의한빈도차이를보였다 (Table 2). 각연구의대상환자기준이일치하지않아회전근개병변의빈도가다르게나타났지만, 이결과를통해상당수의유착성관절낭염환자가건파열을포함한회전근개병변을동반하고있으며, 그빈도가고령군에서더빈번함을알수있었다. 유착성관절낭염은그원인에따라특발성혹은이차성으로분류되는데 3), 회전근개병변이동반된유착성관절낭염은견봉하 (subacromial) 병변이일차질환이되고, 회전근개손상에의해발생하는견봉하윤활낭 (bursa) 의염증성변화가원인이되어이차적으로유착성관절낭염이발생하는것으로볼수있다 28,29). 이번연구에서대상환자들은견관절수압팽창술치료를받았고, constant score 및관절운동범위측정을통해치료효과를평가하였다. 군간비교에서고령군의점수및운동범위는치료후 12주에대조군보다유의하게낮았고, 평가시기간비교에서대조군은치료후 12주까지유의한호전이지속된반면, 고령군은치료후 2주-12 주사이에점수및운동범위의유의한호전이나타나지않았다 (Table 3). 이결과는고령군이치료후호전을보였지만, 치료효과가대조군에비해 J Korean Geriatr Soc 19(3) September

8 Young Sook Park and Yun Hee Park: Adhesive Capsulitis in the Elderly 작았고, 치료후호전이장기적으로지속되지않았음을보여준다. Lim 등 17) 의연구에서상완와관절의스테로이드주사치료를받은유착성관절낭염환자들은 constant score 의호전이치료후 12주까지지속되었는데, 이연구가자기공명영상검사상회전근개손상이배제된환자를대상으로하였음을고려할때, 이번연구에서고령군의치료효과가지속되지못한이유는회전근개손상이높은빈도로동반되어있었기때문으로추측할수있을것이다. 이번연구의이차분석결과에서회전근개병변이없는환자는치료후 12주까지호전이지속된반면, 건증및파열환자는치료후 2주 -12 주사이에 constant score 의유의한호전이나타나지않은것 (Table 4), 이들을나이에따라재분류했을때건파열환자는나이에관계없이모든평가시기간유의한호전을보이지않은것 (Table 5) 역시이를뒷받침해주는결과로해석할수있을것이다. 한편이번연구에서고령군은자기공명영상검사상회전근개간격의지방소실소견이대조군에비해유의하게더높은빈도로관찰되었다 (Table 2). Mengiardi 등 9) 의연구에서자기공명영상검사상회전근개간격에서관찰되는오구상완인대및상완와관절낭의비후, 지방삼각 (fat triangle) 의소실등은유착성관절낭염과관련성을보였으며, 특히지방삼각의소실은유착성관절낭염의진단에있어우수한특이도 (100%) 를보였으나민감도는낮았다 (32%). 회전근개간격의지방소실은염증반응에의한결과로볼수있으며, 이경우오구상완인대의비후및상완와관절낭의조영증강소견이있는지함께관찰할필요가있다. 다만이를위해서는조영제를직접관절강내로주입하거나, 정맥내로주입하는자기공명관절조영술을시행해야하는데, 이번연구에서는조영제를사용하지않은자기공명영상검사를시행하여이에대한평가가불가능하였다. Jost 등 30) 은오구상완인대를포함한회전근개간격이견관절의외회전에핵심적인역할을한다고보고한반면, Ahn 등 15) 은유착성관절낭염환자의자기공명영상과임상증상의상관관계에관한연구에서회전근개간격내오구돌기하지방소실소견이견관절운동범위및통증과상관관계를보이지않는다고보고하였다. 이번연구의이차분석결과에서도 constant score 를군간, 평가시기간비교했을때지방소실소견의유무에따른유의한차이는관찰되지않아 (Table 4) 지방소실소견이증상및견관절기능과직접적인관련성을가지지는않을것으로생각하며, 회전근개간격부위의이상 소견과임상양상사이의상관관계를연구하기위해서는조영증강자기공명영상및세분화된관절운동범위평가를이용한후속연구가필요할것으로생각한다. 이번연구는몇가지제한점을가지고있다. 첫째, 고령군과대조군의환자수가큰차이를보였는데, 이는 대에서가장많이발병하는유착성관절낭염의역학적특징을보여주는결과로생각되며, 일정기간내원한환자를전수조사하였기에선택오차 (selection bias) 를피할수있었을것으로생각한다. 또한회전근개파열환자전체는치료후 2-12 주사이에서만 constant score 의유의한호전이관찰되지않은반면, 이들을나이에따라다시분류했을때에는고령군과대조군모두모든치료기간에서유의한호전이관찰되지않았는데, 환자군을세분하여분석하기위해서는충분한환자수가필요할것으로생각한다. 둘째, 견관절병력 ( 외상, 골절, 수술 ) 과일부신경학적질환 ( 뇌졸중, 파킨슨병 ) 은이전연구에서이차성유착성관절낭염과의관련성이보고되었다 27,31-34). 그러나이러한질병들은그자체로견관절의통증및기능에영향을줄수있기때문에저자들은이를연구대상에서제외하였고, 이로인해고령군과대조군사이에어떤차이가있는지비교할수없었다. 그러나당뇨, 갑상선질환에대한비교는가능하였으며, 두군사이에유의한차이는없었다 (Table 1). 제1 형및 2형당뇨는유착성관절낭염의발병과가장흔한관련성을보이고, 당뇨의유병기간이길어질수록유착성관절낭염의유병률또한증가하며, 당뇨환자의유착성관절낭염은치료가더어려운것으로알려져있다 35-38). 갑상선질환또한유착성관절낭염과의관련성이보고된바있다 39). 마지막으로, 모든환자들에게일정한용적의주사액을주입하고주사액에스테로이드를포함하는등, 저자들은이번연구에서변형된방법의수압팽창술치료를시행하였고, 이로인해치료효과자체를이전의연구들과직접비교하기에는무리가있을것으로생각한다. 그러나이번연구의목적은치료방법을평가하는것이아니라, 노인환자의특징을평가하는것으로, 고령군과대조군에동일한치료를시행하였고, 두가지치료 ( 수압팽창술과관절강내스테로이드주사 ) 를동시에시행하여충분한치료효과를기대할수있기때문에연구목적을훼손하지는않을것으로생각한다. 또한저자들은이전의연구 4,8,40,41) 에서정상상완와관절용적은 ml, 유착성관절낭염에서의용적은 10 ml 이하로보고되었기때문에 20 ml 154 J Korean Geriatr Soc 19(3) September 2015

9 박영숙과박윤희 : 노인환자의유착성관절낭염의특징 의주사액을관절강의기계적확장을기대하기에충분한용적으로판단하였고, Tveita 등 42) 의연구에서스테로이드주사와수압팽창술의복합치료가스테로이드주사단독치료보다더큰효과를보였기때문에충분한치료효과를위해서적합한치료방법으로판단하였다. 하지만심하지않은유착성관절낭염에서 20 ml의주사액용적이관절낭의확장을위해충분하지않을가능성이있으며, 이를보완하는후속연구가필요할것으로생각한다. 유착성관절낭염의진단과치료에있어노인환자들의특징을알아보고자자기공명영상검사결과와수압팽창술치료효과에대한후향적분석을시행한이번연구에서, 고령군과대조군의관절낭두께는유의한차이를보이지않았고, 건파열등의회전근개병변은고령군에서유의하게더높은빈도를보였으며, 고령군및회전근개파열이동반된환자군은장기치료효과가불량함을알수있었다. 노인환자의유착성관절낭염은회전근개손상에의해이차적으로발생할가능성이있고, 일반적인유착성관절낭염의치료방법으로그효과가지속되지않을경우자기공명영상검사를통해다른이상소견이동반되어있는지확인해볼필요가있을것이다. 추후조영증강자기공명영상검사, 세분화된견관절통증및기능평가, 충분한대상환자수및전향적대조군설계등을이용한후속연구를통해노인환자의유착성관절낭염에대한더많은이해가필요할것으로생각한다. 요약 연구배경 : 노인인구에서어깨통증및운동장애는흔한증상이지만, 다수의환자들이적절한치료를받지못하고통증과장애를참고지낸다. 유착성관절낭염은노인인구에서도드물지않게발생하는어깨통증의원인이지만, 40-50대에호발한다고알려져있어간과되기쉬우므로진단및치료에있어노인인구의특징을이해하고적절한관리를제공해야할것이다. 방법 : 2011 년 1월부터 2014 년 12월까지유착성관절낭염으로본원재활의학과를방문한환자의의무기록, 견관절자기공명영상검사결과, 수압팽창술치료효과를후향적으로수집하였고, 대상환자를 61세이상의고령군과 60세이하의대조군으로분류하여두군을비교분석하였다. 결과 : 총 54명이대상환자로포함된이번연구에서, 고령군은견관절자기공명영상검사상회전근개간격의지방소실 (p=0.04) 및회전근개병변 (p=0.003) 이대조군에비해유의하게높은빈도로관찰되었다. Constant score 와관절운동범위를이용한수압팽창술치료효과평가에서치료후 12주에대조군이고령군에비해유의하게높은점수및넓은운동범위를보였고 (constant score, p=0.006; 전방굴곡, p=0.012; 외회전, p=0.001; 내회전, p=0.007), 대조군은치료전-치료후 2주, 치료후 2-12 주, 치료전-치료후 12주사이에점수와운동범위모두유의한호전을보였으나 (p<0.001), 고령군은치료후 2-12 주사이에유의한치료효과를보이지않았다. 또한자기공명영상검사결과에따라대상환자를분류했을때회전근개파열이동반된환자는고령군및대조군모두치료후유의한호전이관찰되지않았다. 결론 : 노인환자의유착성관절낭염은건파열등회전근개손상에의해이차적으로발생할가능성이높고, 이로인해수압팽창술치료효과가장기적으로지속하지않는것으로생각한다. 이해관계명시 (Conflict of Interest Disclosures) : 저자 ( 들 ) 은본논문과관련하여이해관계의충돌이없음을천명합니다. REFERENCES 1. Baek SR, Lim JY, Lim JY, Park JH, Lee JJ, Lee SB, et al. Prevalence of musculoskeletal pain in an elderly Korean population: results from the Korean Longitudinal Study on Health and Aging (KLoSHA). Arch Gerontol Geriatr 2010;51:e O Reilly D, Bernstein RM. Shoulder pain in the elderly. BMJ 1990;301: Hannafin JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clin Orthop Relat Res 2000;372: Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011;19: Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc 2007;15: Harris G, Bou-Haidar P, Harris C. Adhesive capsulitis: review of imaging and treatment. J Med Imaging Radiat Oncol 2013;57: Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: role of MR imaging in differential diagnosis. Eur Radiol 2002;12: Emig EW, Schweitzer ME, Karasick D, Lubowitz J. Adhesive J Korean Geriatr Soc 19(3) September

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11 박영숙과박윤희 : 노인환자의유착성관절낭염의특징 manifestations in patients with thyroid disease. Clin Endocrinol (Oxf) 2003;59: Choi ES, Kim JS, Lee YS, Shin BS, Ko YJ, Park SH. Arthrographic findings of frozen shoulder and therapeutic effect of distension arthrography. J Korean Acad Rehabil Med 2001;25: Park KD, Nam HS, Kim TK, Kang SH, Lim MH, Park Y. Comparison of sono-guided capsular distension with fluoroscopically capsular distension in adhesive capsulitis of shoulder. Ann Rehabil Med 2012;36: Tveita EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord 2008;9:53. J Korean Geriatr Soc 19(3) September