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1 J Korean Soc Phys Med, 2017; 12(2): Online ISSN: Print ISSN: X Research Article Open Access 운동트레이닝과카이로프랙틱의복합처치가전방머리자세와거북목대상자의악력과경추부근력에미치는영향 김영환 길재호경희대학교체육대학원스포츠의학과 Effects of Exercise Training and Chiropractic on Grip Strength and Cervical Muscle Strength of Subjects with Forward Head Posture and Turtle Neck Young-Hwan Kim, PhD Jae-Ho Khil, PhD Dept. of Sports Medicine, Graduate School Physical Education, Kyung Hee University Received: April 26, 2017 / Revised: May 1, 2017 / Accepted: May 8, 2017 c 2017 J Korean Soc Phys Med Abstract 1) PURPOSE: Forward head posture and turtle neck are common musculoskeletal disorders of the cervical vertebrae. The purpose of this study was to investigate the effects of combined exercise training and chiropractic on the grip strength and cervical muscle strength of subjects with forward head posture and turtle neck. METHODS: The subjects were divided into two groups: forward head posture (n=9) and turtle neck (n=9). Both groups performed combined exercise training and chiropractic. The subjects were instructed about the exercise training once a week. This training was performed for 30 minutes every day for 8 weeks, and the chiropractic was performed for 15 minutes once a week. The cervical muscle strength and grip strength were measured. Two-way repeated measured ANOVA was Corresponding Author : hwarang297@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. performed for statistical analysis. RESULTS: In changes to the left grip strength, the main effect over time was significant, but the interaction effect and the main effect in the groups were not significant. In changes to the right grip strength, no difference was found to be statistically significant. In changes to the cervical muscle strength, no difference was found to be statistically significant. CONCLUSION: The increases of grips strengths and cervical muscle strength in forward head posture group were greater than turtle neck group but there were not found to be statistically significant. Key Words: Cervical muscle strength, Forward head posture, Grip strength, Turtle neck syndrome Ⅰ. 서론척추의정상적인만곡 (Curve) 은태아때부터시작된다. 이시기에흉추후만 (Thoracic kyphosis) 을통해내부장기를보호하게되고, 출생후걷게되는과정을통해요추전만 (Lumbar Lordosis) 이이루어지며직립자세를

2 122 J Korean Soc Phys Med Vol. 12, No. 2 유지하고자보상적만곡을유지하게된다. 즉, 태어난후 8~10년동안의성장과정을거치면서성인과비슷한척추의만곡이형성되는것이다 (Korean Society of Oriental Rehabilitation Medicine, 2011). 이렇게형성된척추만곡은축성압력에대항하며척추에가해지는체중의무게중심을잡고, 탄성을부과하는기능을가지게된다 (Pal와 Sherk, 1988). 반면하부경추의과굴곡 (Hyperflexion) 과상부경추의과신전 (Hyperextension) 등에의하여목부위에근골격계스트레스가전달될수있으며이것은여러가지병증으로나타날수있다 (Garrett 등, 1993). 목과어깨및상지의신체구조물들은체중의약 1/7을차지하는머리의무게를지탱하기위해서항상일정한긴장도를유지하고있지만전방머리자세 (Forward head posture, FHP) 에서는정상적인자세보다중력의수직방향으로약 3.6배의압력이경부에가해지기때문에 (Sauter 등, 1991) 머리와목주변연결부위의구조적변화가진행되며 (Harrison 등, 2003), 상지교차증후군 (Upper Crossed Syndrome) 과같은근ㆍ골격계의균형장애를유발한다 (Moore, 2014). 앉은자세로하루에 4시간이상의집중적인영상단말기를사용하는작업을가진사무직근로자들은정상적인척추자세의유지가어려워지고, 무의식적으로머리를앞으로향한채장시간구부정한자세를취하면서경추의전만을증가시키고, 이는 VDT 증후군 (Visual display terminal syndrome) 과같이근골격계질환의주원인이다 (Kim, 2003). 컴퓨터사용시간이증가할수록두개척추각이유의하게증가하며 (Lee와 Jung, 2009), 체간과책상사이거리의증가는전방머리자세를유발한다 (Lee, 2013). 인체의가장이상적인자세는시상면 (Sagittal plane) 에서보았을때인체수직선이복사뼈 (Malleolus) 약간안쪽을지나서무릎중앙선을거치고고관절중앙의약간후방을지나면서어깨관절을통과하게될때외이도 (External auditory canal) 선상에연결되는자세이다 (Haughie 등, 1995). 이렇게전방머리자세로부터발생하는경추질환이있는환자에게서흔히나타나는대표적인자세변형 (Hickey 등, 2000) 이거북목증후군 (turtle neck syndrome) 이다. 경추의정상적인전만의감소때문에변형된전방 머리자세는근골격계를원인으로인하여경추의후만곡이형성된거북목과구분된다. 즉, 경추의부정렬이이루어지는과정으로정상적인경추의만곡에서전만이상실되는전방머리자세를거쳐서거북목이되며이것은경증과중증으로나눌수있다. 이러한경추의부정렬을신경학적으로분석하면신경학적인근육분절 (Myotome) 의경추부 7번과 8번신경은손가락과손목의굴근력을관장하며 (Khill와 Gong, 2005), 악력은체력요인중근력측정을대표로가늠할수있는요소로팔근력 ( 완력, r=.84), 다리근력 ( 각력, r=.76), 등허리근력 ( 배근력, r=.75) 과높은상관관계가있다 (Yoo 등, 2006). 이러한근골격계의균형장애를해소하기위한방법으로써카이로프랙틱 (Chiropractic) 과운동트레이닝 (Exercise training) 은효과적인방법론이다. 특히카이로프랙틱은병의증상치료에얽매이기보다는의과학적으로근본적인원인을찾아서인체를한부분이아닌, 전체적인관점으로접근하는의학적학문이기때문이다 (Dishman 등, 2002). 따라서본연구는거북목증상을보이는대상자들에게경추부신경전달충동에영향을줄수있는동일한측정기준을적용하여전방머리자세와거북목으로분류한후, 두그룹에게정상적인경추정렬회복에효과적인운동트레이닝과카이로프랙틱을 8주동안복합처치하였다. 경추정렬의차이로인한악력과경추부근력의변화를비교분석함으로써경추의정렬상태가경추부근력과악력에미치는영향을분석하여경추의정렬에따른증상의차이를확인하고명확한연구의필요성을제시하고자하였다. Ⅱ. 연구방법 1. 연구대상본연구대상자는경기도소재 K대학에재학중이거나인근에거주하고있는남녀로서전방머리자세증상을보이는 20대 18명으로선정하였다. 실험참가를희망하는자는연구목적, 연구방법, 측정과평가에대한

3 운동트레이닝과카이로프랙틱의복합처치가전방머리자세와거북목대상자의악력과경추부근력에미치는영향 123 설명을듣고, 충분히이해하였음을확인한후에실험참가동의서와개인정보활용에동의한자들을 1차대상자로선정하였다. 1차참가희망자들을대상으로인근정형외과를방문하여, X-ray를촬영한후정형외과전문의의진단결과거북목에포함되며경추의정렬상태가전방머리자세와거북목에해당되는경우를 2차선별하였다. 본실험에참가를희망하였지만경추 (Cervical) 의정렬상태가정상이거나만성질환, 약물복용, 척추질환, 최근 6개월이내의사고경력이있는경우, 정형외과전문의의진단소견을참고하여카이로프랙틱이나운동트레이닝의처치에위험성이있거나개인의사정으로참석이어려운경우는대상자에서제외하였다. 대상자의일반적인특성은 Table 1과같다. Table 1. Participant Characteristics (N=18) (M±SD) Group Year (age) Height (cm) Weight (kg) FHP (n=9) 28.33± ± ±11.98 TN (n=9) 25.78± ± ±17.65 FHP: Forward head posture, TN: Turtle neck 2. 측정장비대상자의일반적특성을파악하기위해체성분분석기 (X-scan plus, JAWON medical, Korea) 를이용하였으며, 대상자의악력을측정하기위해디지털악력기 (T.K.K. 5101, TAKEI, JAPAN) 를이용하였다. 대상자의경추부근력을측정하기위해바이오피드백스테빌라이져 (Stabilizer Pressure Biofeedback Muscle testing Device, Chattanooga Inc., USA) 를이용하였다. 3. 실험방법참가전촬영장비및제원은진단용 X선발생장치 (DXG-325R-RS 형식 ) 이며검사대상자의안정을위해최소한의 X선량을이용하여촬영하였다. 촬영방식은 C-spine AP로 70kVP, 30mAs, 거리 100cm, 촬영테이블에눕혀서경추의전후를촬영하였으며 C-spine Lateral 방식으로는 80kVP, 30mAs, 거리 180cm 조건으로촬영테이블에서서경추측면을촬영하였다. 전문의의진단과평가를기준으로전방머리전위 (Forward head displacement) 와경추전만각 (Cervical lordosis angle: CLA) 을분석하여전방머리자세 (FHP, n=9) 와거북목 (TN, n=9) 그룹으로나누어 8주동안진행되었다. 운동트레이닝전대상자들은체성분, 신장, 체중을측정하였다. 준비운동 (Warm-up exercise) 은발목을돌려서풀어주는것으로시작해서무릎과허리, 목과어깨의유연성을유연성을증가시킬수있도록 10분동안실시되었다. 정적스트레칭 (Static stretching) 을천천히 6~60초정도유지하고 (Beaulieu, 1981; Peterson과 Renstrom, 1986), 근긴장을천천히진행시켜뻗침반사를억제하고근육을이완시킬수있도록하였다 (Anderson과 Burke, 1991). 본운동 (Main exercise) 은로카바도운동 (Rocabado exercise) 을응용하여실시하였다. 양발을모으고두엄지를세운채주먹을쥔상태로바로선시작자세에서숨을내쉬면서두엄지가외측으로향하도록팔을돌려어깨와가슴을펴고턱은살짝아래로당겨내리며복부에힘을주어척추쪽으로밀어넣고엉덩이근육에도힘을준상태에서 5초간유지한후시작자세로돌아오게하는동작을 5회반복하였다 (Go, 2016). 마지막 10분동안은동적스트레칭 (Dynamic stretching) 으로근육을늘어나게한자세에서반동 (Bouncing movement) 을반복적으로시행하여근긴장이발생하고근육이늘어나는범위를축소할수있도록하였다 (Beaulieu와 John, 1981; Ciullo와 Zarins, 1983). 운동자각도 (Rate of Perceived Exertion: RPE) 를기준으로저강도운동을실시하였으며, 실험시작에서는 4주까지는 Moderate (13-14) 로실시하였고, 5주에서 8주까지는 Vigorous (15-16) 한단계높여서대상자들에게동기부여와성취감으로실험에대한지속적인참여가가능과함께운동트레이닝의효과가높아질수있도록하였다. 정리운동 (Cool-down exercise) 으로정적스트레칭을 10분동안실시하였다. 운동트레이닝은주 1회 30분동안교육하였으며, 매일 1회씩반복실시할수있도록권고하였다. 카이로프랙틱교정방법은 Palmer Gonstead Technique 중하나로피검자를틀어진가시돌기가위로향하게엎드려눕게한후시술자의접촉손을틀어진경추의횡돌기에접촉후시계방향또는반시계방향으로낮은진폭과빠르게회전시키는척추교정방법을택하여실시하였다. 대상자의악력은카이로프랙틱적용후 30분의안정

4 124 J Korean Soc Phys Med Vol. 12, No. 2 시간을두었으며 1회측정후 3분휴식하며 3회측정하였고파악력을높이기위해구령 (Oral facilitation) 을붙였다. 악력검사자세는 1981년미국수부치료사협회 (America Society of Hand Therapists, ASHT) 에서제시한파악력검사를위한표준화된피검자의측정자세인똑바로선자세에서견관절을내전하고중립으로회전한상태에서주관절을굴곡시키고손목관절을중위로한자세를채택하였다. 경추부근력측정시, 대상자가바로누운상태에서머리를자연스럽게유지하도록하고경추부의하부공간에압력바이오피드백장비를설치하였다. 경추부와장비사이의공간을줄이고밀착시킬수있도록 20mmHg 의압력에서시작하였고 (Kim 등, 2005), 대상자가머리를들지않은상태에서턱을당기며머리를끄덕이며 3초간유지한때압력을측정하였다. 1회측정후 3분휴식하였고총 3회측정하여평균을구하였다. 4. 자료처리방법연구대상자의수는 G*Power 3.1 프로그램을사용하여 Repeated measures, within -between interaction 측정을위하여유의수준.05, 집단수 2, 검정력 80% 를구하였을때필요한표본수를구하였고, 탈락자를고려해서각그룹별 9명으로총 18명을선정하였다. SPSS 23.0 for Windows 프로그램을이용하여각변인별로평균과표준편차를산출하였으며반복측정에의한이원분산 분석 (Repeated measures two-way ANOVA) 을실시하였다. 그룹간상호작용을검증하고, 상호작용이있을경우집단간의차이에대한검증을위해독립표본 t-검사, 집단내시기에따른변화검증을위해대응표본 t-검사를실시하였다. 모든분석의통계적유의수준 (α) 은.05로설정하였다. Ⅲ. 연구결과 1. 복합처치적용에따른좌우측악력변화비교결과 FHP 그룹과 TN그룹의복합처치전후좌측악력비교결과, 그룹과시기의상호작용효과, 그룹간의주효과가유의한차이가나타나지않았으나, 시기간주효과에서유의한차이가나타났다. 우측악력비교분석결과, 그룹과시기의상호작용효과, 그룹의주효과, 시기의주효과모두유의한차이가나타나지않았다 (Table 2). FHP 그룹에서운동트레이닝과카이로프랙틱복합처치결과, 좌측의악력은적용전 36.23±10.51에서적용후측정결과 38.55±12.63으로 6.40 % 만큼향상되었으며, 우측의악력은적용전 36.28±11.85에서적용후 38.57±13.80으로 6.31 % 향상되었으나좌측과우측모두통계적으로유의한차이가나타나지는않았다. TN 그룹에서운동트레이닝과카이로프랙틱복합 Table 2. The changes of grip strength according to combined exercise Item group pre post % p Left-GS (kg) FHP 36.23± ± Group.422 Time.030* TN 32.52± ± Group*Time.586 FHP 36.28± ± Group.895 Right-GS Time.125 (kg) TN 36.09± ± Group*Time p <.05: Primaryeffectorinteraction, % = (post-pre)/pre*100, GS: Grip strength, FHP: Forward head posture, TN: Turtle neck

5 운동트레이닝과카이로프랙틱의복합처치가전방머리자세와거북목대상자의악력과경추부근력에미치는영향 125 Table 3. The changes of cervical muscle strength according to combined exercise Item group pre post % p FHP 26.11± ± Group.353 Time.294 CMS (kg) TN 33.41± ± Group*Time.417 % = (post-pre)/pre*100, CMS: Cervical muscle strength, FHP: Forward head posture, TN: Turtle neck 처치결과, 좌측의악력은적용전 32.52±10.29에서적용후측정결과 33.97±9.52으로 4.46 % 향상되었으며, 우측의악력은적용전 36.09±12.08에서적용후 37.24±10.96으로 3.19 % 향상되었으나통계적으로유의한차이가나타나지는않았다. 2. 복합운동적용에따른경추부근력비교결과 FHP 그룹과 TN그룹의복합처치전후경추부근력비교분석결과, 그룹과시기의상호작용효과, 그룹의주효과, 시기의주효과모두유의한차이가나타나지않았다 (Table 3). FHP 그룹에서운동트레이닝과카이로프랙틱복합처치결과, 경추부근력은적용전 26.11±12.87에서적용후 31.74±13.62으로 % 향상되었으나통계적으로유의한차이가나타나지않았다. TN 그룹에서운동트레이닝과카이로프랙틱복합처치결과, 경추부근력은적용전 33.41±14.11에서적용후 34.15±8.26으로 2.21 % 향상되었으나통계적으로유의한차이가나타나지않았다. Ⅳ. 고찰본연구는경추만곡의정도를기준으로경추의경증변형인전방머리자세그룹과중증변형인거북목그룹으로나누어두그룹에게카이로프랙틱과운동프로그램을복합처치적용후, 좌우측악력과경추부근력의변화를알아보았다. 전방머리자세에서좌측과우측의악력은운동전측정에서비슷한수준을보였으며, 복합처치후측 정결과에서도각각좌측 6.40 % 과우측 6.31 % 향상되었다. 복합처치에따른악력비교결과, 좌측의악력은상호작용효과, 그룹의주효과에서유의한차이가나타나지않았으나시기의주과에서유의한차이가나타났다. 우측의악력은상호작용효과, 그룹의주효과, 시기의주효과모두유의한차이가나타나지않았다. 반면거북목의복합처치전측정에서우측의악력이좌측의악력보다높게나타났으며, 복합처치후측정결과좌측은 4.46 % 향상되었고우측악력은 3.19 % 향상되었다. 좌측의악력이우측의악력보다향상되면서좌우측의악력이우측의악력에균형을맞추려는경향을보였다. 두그룹의경추정렬이보이는차이는좌측악력만시기의주효과에서유의한차이가나타났고경증의전방머리자세에서는좌우측악력이균형을나타냈지만중증의거북목은좌측악력이우측악력에비하여낮게나타났다. 경추의정렬이변화는전방머리자세에서악력의향상이비슷한수준에서나타났지만거북목은좌측악력의변화가조금더증가하였다. 결국경추의전만이감소된그룹은좌우측의악력이비교적균형을이루며비슷한수준의향상을보였지만경추의후만이생성된그룹은좌측의악력이우측의악력보다낮게나타났지만우측보다조금더향상되는경향을보였다. 이는통계적으로유의한차이가나타나지는않았지만, 운동트레이닝과카이로프랙틱의복합처치가경추의후만이생성된그룹의우측악력보다좌측악력을향상시키면서악력의균형을향상시키는데기여했다고사료된다. 복합처치에따른경추부근력비교결과, 두그룹모두그룹과시기간상호작용, 그룹의주효과, 시기의

6 126 J Korean Soc Phys Med Vol. 12, No. 2 주효과에서유의한차이가나타나지않았다. 전방머리자세에서경추부근력이 % 의변화를보이는반면거북목에서는 2.21 % 의변화를보였다. 이는유의한차이는없었으나, 운동트레이닝과카이로프랙틱의복합처치는전방머리자세의경추부근력을향상시키는데도움을준것으로사료된다. 결국경추의전만이상실된전방머리자세와후만이생성된거북목의경추정렬은통계적인상호작용을보이면서유의미한효과를보이지는않았지만경추정렬의전만과후만의차이는경추부근력의차이로나타난것으로보인다. 본연구의가설과같이거북목증상을보이는실험참가자들의경추정렬의차이는악력과경추부근력의차이를보인다. 따라서거북목증후군, 전방머리자세, 거북목등의용어를혼용하는연구보다는거북목증후군증상을보이는이들을전방머리자세와거북목으로구분하여연구할필요성이있다고할것이다. 다만실험참가자가적었고대조군과비교가없는것은본연구의제한점으로향후대조군과의비교를필요로하며많은참가자들을대상으로다양한연구가필요할것으로보인다. Ⅴ. 결론정상적인경추의전만이작아지는전방머리자세는좌우측악력의차이를보이지않았고복합처치후좌우측악력이균형있게향상되었지만경추의후만이생성되는거북목은좌측악력이우측악력에비하여낮게나타났으며복합처치후좌측의악력이우측에비하여조금더향상되면서좌우의균형이맞춰지려는경향이나타났다. 거북목증상을보이는전방머리자세와거북목에대한복합처치전후비교결과경추의만곡변화에따라서악력과경추부근력은차이를보였다. 또한, 경추부근력은경추의전만이상실되는일자목과후만이형성된거북목에서차이가나타났다. 따라서전방머리자세와거북목은경추정렬의차이에의한만곡을기준으로구분하여연구해야할필요성이있다. References Anderson B, Burke ER. Scientific, medical, and practical aspects of stretching. Clin sports med. 1991;10(1):63. Beaulieu JE. Developing a stretching program. Phys Sportsmed. 1981;9(11): Ciullo JV, Zarins B. Biomechanics of the musculotendinous unit: relation to athletic performance and injury. Clin sports med. 1983;2(1):71. Dishman DJ, BallKA, Burke J. Central motor excitability changes after spinal manipulation, a trans cranial magnetic simulation study. JMPT. 2002;25(1):1-9. Garrett TR, Youdas JW, Madson TJ. Reliability of measuring forward head posture in a clinical setting. JOSPT. 1993;17(3): Go DI. Cervical disc conquest. Republic of Korea. Prunsol Harrison DE, Harrison DD, Bets JT, et al. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003;26(3): Haughie LJ, Fiebert IM, Roach KE. Relationship of forward head posture and cervical backward bending to neck pain. J Man Manip Ther. 1995;3(3):91-7. Hickey ER, Romndeau MJ, Corrente JR, et al. Reliability of the cervical range of motion (CROM) device and plumb line techniques in measuring resting head posture (RHP). J Man Manip Ther. 2000;8(1):10-7. Khill JH, Gong MS. Sports chiropractic. Republic of Korea. Happy and Books. 2005;52-3. Kim HG. The effect of ankle muscle strengthening exercise on the balance adjustment ability of the elderly using elastic band. Master's Degree. Dankook University Kim KB, Chie EK, Wu HG, et al. Treatment outcome of metastatic carcinoma of cervical lymph node from

7 운동트레이닝과카이로프랙틱의복합처치가전방머리자세와거북목대상자의악력과경추부근력에미치는영향 127 an unknown primary. J Korean Soc Ther Radiol Oncol. 2005;23(3): Korean Society of Oriental Rehabilitation Medicine. Department of Oriental Rehabilitation Medicine. Republic of Korea. Gunja Publishing Company Lee KS, Jung HY. Analysis of the Change of the Forward Head Posture According to Computer Using Time. J Korean soc phys med. 2009;4(2): Lee WH. Effect of Distance Between Trunk and Desk on Forward Head Posture and Muscle Activity of Neck and Shoulder Muscles During Computer Work. J Korean soc phys med. 2013;8(4): Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J Manipulative Physiol Ther. 2014;27(6): Pal GP, Sherk HH. The vertical stability of the cervical spine. Spine. 1988;13(5): Peterson L. Renstrom P. Sports injuries: their treatment and prevention. UK. Martin Dunitz Sauter SL, Schleifer LM, Knutson SJ. Work posture, workstation design, and musculoskeletal discomfort in a VDT data entry task. Hum Factors. 1991;33(2): Yoo SH, Kim HD, Song JK, et al. New physical measurement assessment. Republic of Korea. Daekyung Books

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