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1 Journal of The Korean Society of Integrative Medicine, 2017, 5(3), 29~37 ISSN (Print) ISSN (Online) 고정아 1 박웅식 2 문세영 3 1 광주여자대학교물리치료학과대학원, 2 광주여자대학교작업치료학과, 3 광주중경한방병원 The Changes in the Ultrasound Imaging of Abdominal Muscles based on the Inspiratory Muscle Strengthening Training of Low Back Pain Patients Ko Jeongah, PT 1 Park Woongsik, PT, Ph.D 2 Moon Seyoung, PT 3 1 Dept. of Physical Therapy, Graduate School, Gwangju Womens University 2 Dept. of Occupational Therapy, Gwangju Womens University 3 Dept. of Physical Therapy, Gwangju Jungkeyoung Oriental Hospital Abstract Purpose: The purpose of this study was to classify patients with chronic back pain according to the degree of their back pain, and to compare the pain dysfunction index with the qualitative changes in abdominal muscles. Therefore, we aimed to provide a basis for the treatment intervention method for patients with back pain. Methods: Twenty patients with chronic back pain were purposive sample to a group of 10 patients with a back pain index of 60 % or more and a group with less than 60 % of back pain, and the subjects who voluntarily participated in the study After receiving the letter, I conducted the research the dysfunction of back pain was measured by the Korean version of the Oswestry Disability Index (KODI), and the ultrasonic wave (Ultrasound MyLabOne, ESAOTE, Italy) And the white area index, and the abdominal muscle movement was used as the exercise instrument POWER breathe K5 (Hab direct, UK), which strengthens the respiratory muscles through threshold-muscle traction. Result: In this study, patients with chronic back pain were subjected to breathing exercises, which led to the decrease in back pain dysfunction. The ultrasonographic analysis of abdominal muscles revealed that both the white area index and muscle image density in the skeletal muscle and in the outer muscle of the abdomen gradually decreased over time. Conclusion: It is thought that introducing back pain patients to abdominal muscle reinforcement training is effective in improving the functions of the patients muscles, thus increasing their quality of life. Key Words: pelvic muscle image, visual pain scale, back pain index, breathing training, pain 교신저자 : 박웅식, uspark@kwe.ac.kr 논문접수일 : 2017 년 4 월 26 일 수정일 : 2017 년 6 월 22 일 게재승인일 : 2017 년 7 월 28 일 29

2 대한통합의학회지제 5 권제 3 호 Ⅰ. 서론 1. 연구의배경및필요성허리통증은현대사회에서많이발생하고 % 이상한번은경험하게되는만성근골격계질환이다 (Cherkin 등, 1992). 만성허리통증환자들은통증으로일상생활에영향을미치고, 정상인에비하여근력과지구력이감소된다 (Van der Ploeg 등, 2000). 또한, 허리통증은환자의정서상태에도영향을주어우울증과불안감, 자신감, 생활만족도, 삶의질저하와같은심리적인문제를유발하며, 치료에대한의욕을감소시킨다 (Hsieh & Lee, 2002). 허리근육들은심부근육과표층근육으로구분되고, 심부근육은사지의움직임에서발생하는몸의흔들림, 걷기동작과같은움직임으로형성되며, 안정성에관여한다 (Hodges & Richardson, 1999). 몸통근육에서허리의안정화에기여하는근육으로배가로근, 배속빗근, 뭇갈래근을들수있으며, 골반바닥근육및배근육들또한몸통근육들과같이배압력을발생시켜허리안정화에기여한다 (Ko 등, 2012). 특히, 배가로근, 뭇갈래근, 배속빗근, 배바깥빗근, 허리네모근은척추안정성에중요한역할을하고고정근으로작용한다 (Kavcic 등, 2004). 하지만허리통증환자는정상인에비교하면심부근육이약하고불균형적일뿐아니라, 고유수용성감각도감소되어척추의안정성을유지하지못하고, 허리통증의재발을만든다 ( 정성수등, 2004). 허리통증환자에게운동요법은만성허리통증의악순환을끊을수있는대표적인치료방법으로허리근육을강화시키고, 유연성을증가시키며, 허리통증으로인한구조적인이상을대부분감소시켜준다 (Smith 등, 2000). 임상에서는심부근육을강화하기위해몸통안정화운동을실시하고, 그효과를위해운동시요가호흡, 강제호흡등의다양한호흡운동을함께사용하고있다 (Bach, 1993). Sutbeyaz 등 (2010) 은들숨근육훈련이근력향상과배근육의근력에영향을미친다고하였으며, Norman 등 (1998) 은배근육과등쪽부분의근력을향상시켜준다고 하였다. Sapsford(2004) 는골반바닥근육과배가로근의동시수축후, 심호흡을이용하여허리안정화를시켰고, 김경등 (2005) 은허리통증환자의가로막호흡운동후몸통근육활성화를통해근력증진의결과를보여주었으며, 최근에는그대상이허리통증환자에게로옮겨져비슷한주제들이연구되기시작했다. Wensel 등 (2000) 은들숨훈련시저항하여호흡하게함으로써최대정적들숨노력으로저항성호흡전략을할수있도록하는방법으로, 지구력훈련과들숨강화훈련이가능하다고하였다. Carter 등 (2009) 은날숨근훈련으로배가로근을강화시켜날숨과관련된허파기능을개선시켰고, 강효실 (2013) 은근력운동과호흡운동을병행하게되면호흡장애를감소시키고저항운동에대한불안과두려움을감소시킬수있다고하였다. 최근에는호흡물리치료를통해허리통증의접근에있어통증완화위주의보존적인물리치료방법을벗어난직접적으로허리주위근육의훈련을통한치료법이주목을받고있다 (Han 등, 2007). 그러나허리통증장애정도에따라호흡운동이얼마나효과적인지, 특히들숨근운동과배근육근에대한연구는미흡한실정이다. 2. 연구의목적본연구는만성허리통증환자들을허리통증기능장애지수에따라분류하여들숨근운동이통증기능장애지수와배근육의양적변화를비교하고, 허리통증환자들에통증정도에따른치료중재법에대한근거자료로제시하고자하였다. Ⅱ. 연구방법 1. 연구대상본연구는 2015년 6월 29일부터 8월 15일까지광주 H 병원물리치료실에내원중인디스크척추협착증등의관절에관련된진단명을받지않은단순허리통증환자를대상으로유병기간 6개월이상만성허리통증환자 20 30

3 명을허리통증기능장애지수 60 % 이상인군 10명, 60 % 미만인군 10명으로유의표집하였고, 연구에자발적으로참여한대상자모두에게실험동의서를받은후연구를진행하였다. 집단의분류기준은허리통증기능장애지수 60 % 를기준으로두그룹으로분류하였다 (Beaton 등, 2001). 선정기준은심폐질환자및흡연자는제외하였고, 실험기간내에다른운동은제한시켰다. 실험은 2015년 6월 29일부터 8월 15일까지진행되었다. 대상자의일반적인특성은다음과같다 ( 표 1). 표 1. 연구대상자의일반적특성 Ⅰ (n=10) Ⅱ (n=10) 연령 ( 세 ) 65(±11.34) 63(±12.25) 신장 (cm) 152(±10.43) 153(±11.23) 체중 (kg) 58(±12.21) 56(±14.34) (M±SD)Ⅰ: 만성허리통증기능장애지수 60% 이상그룹 Ⅱ: 만성허리통증기능장애지수 60% 미만그룹 * 두그룹모두유병기간 6개월이상만성허리통증환자 2. 측정기기및측정방법 1) 허리통증기능장애허리통증기능장애는한글판허리통증장애지수 (Korea version Oswestry disability index, KODI) 로측정하였으며, 항목은통증정도, 개인적관리, 들기, 걷기, 앉아있기, 서있기, 잠자기, 성생활 ( 적용될때 ), 사회생활그리고여행 10개의항목으로구성되어있으며, 환자의수행정도에따라불편함이없는것을 0점으로하고최악의상태를 5점까지부여하였다. 항목별응답한점수를합하여총점으로나눈후 100을곱하여백분율 (%) 로분석하였다. 2) 초음파측정초음파 (Ultrasound My Lab One, ESAOTE, Italy) 는 MHz의진단용초음파로근육의영상밀도및백색영역지수를측정하는데사용하였고, 탐촉자는선형탐촉자를사용하였다. 주파수는 13 MHz이고깊이는 6 cm로설정하였다. 초음파를사용하여운동전, 2주후, 4주후대상자의배곧은근, 배바깥빗근, 배속빗근, 배가로근의근육을상태를측정하였다. 초음파의영상획득시피부의압박을최소화하기위하여충분한양의겔을변환기와피부사이에도포하였고, 측정이일정하게되도록변환기는피부와직각을유지하게하였다. 또한측정의신 뢰도를높이기위해한검사자가 3회측정하였다. 배곧은근의측정자세는실험자에게누운자세를취하게한후배꼽에서가쪽으로 1 cm아래쪽으로 2 cm되는지점에서측정하였다. 배바깥빗근, 배속빗근, 배가로근은 12번째갈비와 ASIS 사이에서안쪽으로 2 cm, 아래쪽으로 2 cm되는부분으로실험자에게누운자세를취하게한후측정하였다. 수집된영상들은 Photoshop 7.0 (Photoshop7.0, Adobe, USA) 프로그램을통해 8 비트회색모드 ( pixels) 로변환시킨후, 이영상을 Image Pro Plus 4.1(Media Cybernetics, USA) 프로그램을사용하여분석하였다. 백색영역지수는가로단면으로영상을획득한후, 근막이포함되지않도록직사각형영역을선택하였다. 백색영역지수는선택된영역의영상에서백색으로보이는모든영역의화소수를전체화소수로나눈값이다. 근육의밀도는선택된영역의평균화소값 (pixel value) 을구하여, 이것을근육의영상밀도로정하였다. 화소가순수한검정색이면 0이고, 순수한흰색이면 255가된다. 검정색의분포가많을수록건강한근육이다 (Maurits 등, 2004). 3. 들숨근운동방법들숨근운동은두군모두동일하게실시되었으며역 31

4 대한통합의학회지제 5 권제 3 호 치-저항훈련을통해호흡근을강화시키는운동기구 POWER breathe K5 (Hab direct, UK) 를사용하였다. 개인용마우스피스를입에물고폐의잔기량을최대로빼낸후빠르고강하게숨을들이마시는것을훈련전 3회실시하여훈련방법을연습후, 똑같은방법으로훈련시 Auto mode- veryright ( 최대흡기력의 40 % 저항 ) 로편하게앉은자세에서 30회씩시행하였다. 중간에환자가힘들어할경우 2 3분간휴식을취한후실시하였고, 주 3 회씩 4주간총 12회시행되어졌다. 4. 물리치료중재 을실시하였다. 자극은맥동빈도 120 pps를사용하였고, 맥동기간은 100 μs로하였으며, 최소가시수축이유발되지않는범위의낮은강도로하였다. 주파수는 100 Hz로환부주위로 15분간적용하였다. 5. 자료분석통계분석은윈도우 SPSS version 12.0을사용하였다. 각측정항목들의기간에따른그룹간변화양상의차이를비교하기위해반복측정분산분석을사용하였으며, 유의수준 α=0.05로설정하였다. 대상자는주 3회씩 4주간총 12회의처치를받게하였으며, 두그룹에대한중재는다음과같다. Ⅲ. 연구결과 1) Hot Pack Hot Pack은바로누운자세에서수건으로겉을감싸고환부에 20분을적용하였다. 2) 전기치료경피신경자극치료 (IN-1200, Yeongin Medical, Korea) 는바로누운자세에서고빈도 - 저강도경피신경전기자극 1. 허리통증기능장애의변화허리통증기능장애의변화를분석한결과기간과그룹간교호작용이통계적으로유의한것으로나타나 (p<0.05) 운동기간에따른그룹간허리기능장애지수의변화양상이다른것으로나타났다 ( 표 2). 표 2. 허리통증기능장애변화 운동전 2 주후 4 주후기간그룹기간 * 그룹 Ⅰ (n=10) 75.50(±9.02) 67.80(±10.39) 62.90(±10.81) Ⅱ (n=10) 46.80(±7.39) 45.10(±6.28) 43.90(±6.55) *p<0.05 (M±SD)Ⅰ: 허리통증기능장애지수 60% 이상그룹 Ⅱ: 허리통증기능장애지수 60% 미만그룹 * 두그룹모두유병기간 6개월이상만성허리통증환자 0.000* 0.000* 0.000* 2. 배근육백색영역지수의변화배곧은근, 배바깥빗근, 배가로근의백색영역지수변화를분석한결과기간과그룹간교호작용이통계적으로유의하지않은것으로나타났으나, 시간에따른변화는유의한차이가있는것으로나타났다 (p<.05). 따라서운 동기간에따른그룹간백색영역지수의변화양상은비슷하나두그룹모두시간에따라서백색영역지수가감소하는것으로나타났다. 배속빗근의백색영역지수변화를분석한결과기간과그룹간교호작용및주효과검정모두에서통계적으로유의한차이가나타나지않았다 ( 표 3). 32

5 표 3. 배근육백색영역지수변화 ( 단위 : %) 운동전 2 주후 4 주후기간그룹기간 * 그룹 배곧은근 Ⅰ (n=10) 12.73(±10.90) 11.75(±10.35) 11.11(±10.09) 0.000* Ⅱ (n=10) 8.80(±7.23) 8.38(±7.00) 7.53(±6.30) 배바깥빗근 Ⅰ (n=10) 17.78(±15.05) 16.94(±14.91) 16.54(±14.36) 0.000* Ⅱ (n=10) 9.05(±5.78) 8.03(±5.72) 7.90(±5.68) 배속빗근 Ⅰ (n=10) 8.92(±7.98) 7.29(±6.36) 6.95(±6.29) Ⅱ (n=10) 15.20(±9.96) 14.66(±9.84) 13.96(±9.65) 배가로근 Ⅰ (n=10) 7.11(±6.13) 6.12(±5.97) 5.56(±6.04) Ⅱ (n=10) 14.26(±11.46) 13.24(±11.15) 12.66(±10.75) 0.000* *p< 배근육밀도의변화배곧은근, 배바깥빗근밀도변화를분석한결과기간과그룹간교호작용이통계적으로유의하지않은것으로나타났으나, 시간에따른변화는유의한차이가있는것으로나타났다 (p<.05). 따라서운동기간에따른그룹 간근육밀도의변화양상은비슷하나두그룹모두시간에따라서근육밀도가감소하는것으로나타났다. 배속빗근, 배가로근밀도변화를분석한결과기간과그룹간교호작용및주효과검정모두에서통계적으로유의한차이가나타나지않았다 ( 표 4). 표 4. 배근육밀도변화 운동전 2 주후 4 주후기간그룹기간 * 그룹 배곧은근 Ⅰ (n=10) (±19.60) (±16.85) (±11.86) 0.007* Ⅱ (n=10) (±16.33) (±9.53) (±14.28) 배바깥빗근 Ⅰ (n=10) (±16.75) (±12.03) (±22.18) 0.030* Ⅱ (n=10) (±8.15) (±12.61) (±21.21) 배속빗근 Ⅰ (n=10) (±14.98) (±27.28) (±24.03) Ⅱ (n=10) (±12.66) (±13.51) (±12.77) 배가로근 Ⅰ (n=10) (±17.20) (±14.32) (±13.99) Ⅱ (n=10) (±13.01) (±6.66) (±5.69) *p<0.05 Ⅳ. 고찰 Jeong 등 (2011) 은만성허리통증이허리부위의근력과근지구력의감소, 유연성소실등의신체적이상을초래하여근력이더욱약화된다고하였고, 손호희와오정림 (2014) 은통증의원인들로심부근육의기능감소와척추의안정성, 근육과운동조절능력손실을보고하였다. 이 러한허리통증의치료방법들로수술적치료와보존적치료방법이제시되고있으며, 보존적치료방법중특히심부근육들을활성화시킬수있는호흡운동을강조하고있다 (Moseley, 2002). 본연구에서는허리통증환자들의통증감소와배근육들의활성화정도를알아보기위해호흡운동중들숨근운동으로배근육들의초음파영상을알아보았다. Lehto 33

6 대한통합의학회지제 5 권제 3 호 등 (1989) 은허리통증이자세균형수행을방해하고, 균형유지능력에손상을일으켜비정상적인자세를유발시키며, 근골격계의생체역학적스트레스를증가시키는결과를초래한다고하였다. 몸통의안정성을유지하는데가장중요한근육으로밝혀진뭇갈래근과배가로근은 (O'Sullivan 등, 1997), 운동시작시먼저작용하여몸통의안정성을형성한다. 또한, 배속빗근, 배바깥빗근, 허리네모근이안정근과고정근으로작용하는역할을한다 (Sapsford 등, 2001). 배가로근은허리뼈근막의장력을증가시킴으로허리뼈분절의위치를조절하고안정성을제공하는역할을하며, 배속빗근과배바깥빗근은허리회전력을일으키고, 외부의부하와균형을유지하는역할을한다 (Byun 등, 1995). 허리통증은통증을줄이기위해활동을피하게되고, 운동량이감소하여, 허리폄근육이위축되고, 근력이약화되어통증이증가한다 ( 정연태, 2000). 따라서몸통근육의위축으로허리골반을불안정하게하여통증을발생시킨다 ( 김형수등, 2008). Hides 등 (2001) 은장기간의허리안정화운동을실시한그룹은 1년후만성허리통증의재발이낮게나타난다고하였다. Shaughnessy와 Caulfield(2004) 는 10주간의허리안정화운동이허리통증환자들의삶의질과기능적상태가개선되었다고하였다. Mehling 등 (2005) 은허리안정화운동과호흡운동을병행하면허리통증환자의통증감소에효과적이라고하였다. 국윤진등 (2013) 은유산소운동이허리통증장애, 허리근력및심부근활성화에미치는영향으로유산소운동을통한배근육강화가허리통증환자들의허리통증기능장애지수및통증에유의한감소가있다고보고하였다. Deyo 등 (1990) 의연구에서허리통증환자에게운동치료를수행한후환자가보고하는통증의호소횟수가호전된결과를보여주었다. 또한유종윤 (1994) 의연구에서도호흡운동을지속적으로시행한군이시행하지않은군보다통증감소효과를나타냈다. 본연구에서도들숨근강화운동을통하여허리통증환자들의허리통증기능장애지수및통증에서유의한감소를나타냈다. 이와같이호흡운동은허리통증에적극적이고능동적인치료이며, 통증은물론일상생활능력의향상까지가져온다할수있다. Richardson(2004) 는허리통증환자의호흡패턴변화와 배날숨전략의효과에서날숨시에배가로근, 배바깥빗근, 배곧은근에서밀도와백색영역지수가유의하게감소하였고, 배속빗근은유의한차이가없다고보고하였다. 또한김경등 (2005) 의연구에서는가로막호흡이허리통증환자들에게몸통근육을활성화시킨다고보고하였고, Sutbeyaz 등 (2010) 은들숨근육훈련이근력향상과배근육의근력에영향을미친다고하였으며, Norman 등 (1998) 은들숨근훈련이배근육과등쪽부분의근력을향상시켜준다고하였다. 본연구에서는들숨근을훈련한결과, 배속빗근은백색영역지수와배근육밀도에서유의한차이가없게나타났고, 배바깥빗근과배곧은근에서백색영역지수및배근육밀도는유의한차이가나타났으며, 배가로근은백색영역지수에서만유의한차이가나타났다. 이는호흡운동을실시하면배근육과심부근육의내부압력만이아닌가로막하강에따른배안내압력이발생하게되고이를지지하기위한몸통근육이효율적으로작용하게되어허리통증환자들의근활성패턴에변화를주게되는것으로생각된다. 따라서, 날숨시뿐만아니라들숨시에도배바깥빗근, 배곧은근, 배가로근이중요한역할을하며, 배속빗근은상대적으로역할이적다고할수있다. 근육을평가하는데유용한지침으로근밀도, 백색영역지수등이있는데, 근밀도는건강한근육조직일수록어둡게보인다 (Pillen & van Alfen, 2011). 뼈대근의질적특성에관련된초음파근육영상밀도와백색영역지수는당뇨병환자 ( 윤세원등, 2006) 와뇌졸중환자 ( 이정우등, 2007) 에서훈련된근육일수록, 나이가적을수록, 신경계손상질환이없는근육일수록근육의영상밀도와백색영역지수가감소되는것으로보고되었다. 근육의초음파이미지영상밀도의범위는 0 255인데, 0에가까울수록어둡게보인다. 백색영역지수는낮을수록더어두운것을의미하며, 어두운것은반사되지않는, 즉지방이나결합조직이아닌근육조직으로구성되면될수록더어둡게보이는것을나타낸다 (Pillen & van Alfen, 2011). Pillen 등 (2011) 등은근육두께가감소할수록흰색을띠게되어백색영역지수가증가한다고보고하였다. 본연구에서시간에따른배곧은근, 배바깥빗근, 허리네모근의백색영역지수와밀도가감소하였으며, 배가로근은백색영역지수에서만감소하였다. 또한배곧은근의밀도에서 34

7 허리통증기능장애지수 60 % 이상과비교해허리통증기능장애지수 60 % 미만에서더감소하였다. 이와같은결과는호흡운동이배곧은근, 배바깥빗근, 배가로근의근육량과근두께가증가하였다는것을나타내며, 들숨시더활성화되었다는것을의미한다. Loveridge 등 (1989) 과 Derrickson 등 (1992) 은환자들에게들숨근훈련을통해서호흡기능을증진시킬수없다고하였다. 하지만, 본연구결과들숨근강화훈련을통해서배곧은근, 배바깥빗근, 배가로근, 허리네모근등배근육들이시간에따른변화가나타났다. 연구결과가다르게나온이유는 Loveridge 등 (1989) 과 Derrickson 등 (1992) 의연구와비교하여, 본연구가허리통증환자들을대상자로운동을시켰고, 배곧은근, 배바깥빗근, 배가로근, 허리네모근등의근육의이미지영상만을보았기때문으로생각된다. 이러한연구들과같이들숨근강화훈련을통해배심부근육들의유의한변화가있었으나, 대부분의연구들이뇌졸중, 척수손상, COPD등신경계환자나호흡계환자들에국한되어져있다. 본연구에서는허리통증환자들을대상으로연구를하여, 통증과허리통증기능장애지수감소와, 배곧은근에서유의한변화를보였고, 배바깥빗근, 배가로근, 허리네모근등근육들이시간에따른변화가나타났으나, 대상자의수가적고, 중재기간이짧았기때문에연구결과를일반화하기는힘들다. 추후연구에서는이런부분을보안하여통증과초음파영상뿐만아니라근력과허파기능등을알아볼필요가있을것으로생각된다. Ⅴ. 결론 본연구에서는만성허리통증을가진환자들에게들숨근운동을적용하였으며, 그결과허리통증기능장애가감소하는것을알수있었다. 또한, 배근육의초음파영상분석결과배곧은근, 배바깥빗근에서백색영역지수와근육영상밀도모두시간에따라점차감소함을알수있었고, 배가로근에서는백색영역지수에서시간에따라점차감소함을알수있었다. 따라서요통환자에게들숨근강화훈련을시키는것은일상생활능력과배근육중특히배곧은근, 배바깥빗근의기능향상에도움이된다고볼수있으며, 이러한결과는향후물리치료의적용과중재방법에대한기초자료로활용될것이라생각된다. 참고문헌 강효실, 이석민, 전지경 (2013). 운동과학편 : 복합운동과유산소운동이뇌졸중환자의인지및기능적수행능력에미치는영향. 한국사회체육학회지, 53(2), 국윤진, 김창원, 임종훈등 (2013). 체간근력운동과심부근안정화운동이요통장애, 요부근력및심부근활성화에미치는영향. 한국체육학회지-자연과학, 52(2), 김경, 박래준, 배성수 (2005). 복식호흡운동이요통환자의체간근육활성화에미치는영향. 대한물리치료학회지, 17(3), 김형수, 이근희, 배성수 (2008). 몸통안정화운동이만성허리통증환자의허리통증기능장애지수에미치는영향. 대한물리의학회지, 3(3), 손호희, 오정림 (2014). 복식호흡을병행한척추안정화운동이요통환자의균형능력과오스웨스트리장애지수에미치는영향. 한국콘텐츠학회 2014 추계종합학술대회, 유종윤, 권도윤, 이수아등 (1994). 요추추간판탈출증환자의보존적치료후경과관찰. 대한재활의학회지, 18(3), 윤세원, 황태연, 김용남등 (2006). 제 2 형당뇨환자의말초신경기능및골격근의 Echogenicity 분석. 대한임상전기생리학회지, 4(1), 이정우, 서삼기, 윤세원 (2007). 뇌졸중환자의독립보행유무에따른하지근의질적특성에대한분석. 대한임상전기생리학회지, 5(1), 정성수, 이종서, 정광훈등 (2004). 환축추간경관절고정시후방나사못삽입을위한전산화단층촬영. 대한정형외과학회지, 39(3), 정연태 (2000). 허리뼈부안정성운동이허리통증환자의 35

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