untitled

Transcription

1 Journal of Korean Medicine Rehabilitation Vol. 28 No. 1, January 2018 pissn eissn Review Article 이건영 조희근 * 설재욱 김신애청연한방병원, 청연의학연구소 * A Review of the Pain and Function Assessment Instruments for Shoulder Disease Patients in Korean Medicine Clinical Studies Published in South Korea Geon-Yeong Lee, K.M.D., Hee-Geun Jo, K.M.D.*, Jae-Uk Seol, K.M.D., Shin-Ae Kim, K.M.D. Chung-Yeon Korean Medical Hospital, Chung-Yeon Medical Institute* 본연구는청연의학연구소연구프로그램지원에따라수행되었습니다. RECEIVED November 6, 2017 REVISED November 18, 2017 ACCEPTED November 22, 2017 CORRESPONDING TO Hee-Geun Jo, Chung-Yeon Medical Institute, 64 Sangmujungang-ro, Seo-gu, Gwangju 61949, Korea TEL (062) FAX (062) jho3366@hanmail.net Copyright 2018 The Society of Korean Medicine Rehabilitation Objectives The purpose of this study is to analyze the current status of measurement instruments used to evaluate and function for shoulder disease patients in Korean Medicine clinical studies published in South Korea. Methods 5 Korean online databases from January 2007 to July 2017 were used to source articles for the review. Data of and function assessment instruments, measurement methods, time point and frequency for shoulder assessment were extracted. And it was analyzed by investigating the frequency of use for each item. Results A total of 78 studies met the selection criteria. There were many studies with no description for assessment instruments or inconsistent measurement methods. In the function assessment, the frequency of use was low and there were a lot of use of instruments with low validity and reliability. Conclusions To develop the objectivity of clinical research, further clinical studies, active use of measurement instruments, and standardization of measurement methods are needed. (J Korean Med Rehabil 2018;28(1):33-51) Key words Pain, Pain Measurement, Shoulder Pain, Korean Medicine, Measurement Instrument, Review 서론»»» 어깨관절은인체에서가장복잡한해부학적구조를갖고있기때문에, 다양한요인과상황에영향을받을수있다. 이때문에어깨질환에서는급, 만성의통증은물론이며, 상지의기능장애및약화소견등이다양하게발생한다 1). 한코호트연구에서는새로발생한어깨통증으로진단받은근로자의 30% 이상이병가를사용할것으로예 측된다는보고가있으며, 이같은어깨질환으로인한사회적손실액은일개국가의조사에서연간약 70억달러로조사되기도하였다 2,3). 이처럼어깨질환이개인과사회에엄청난부담을안기기때문에, 관련의학적문제를신속하게해결하고업무에조기복귀할수있도록하기위한임상연구가지속적으로요구된다. 임상연구수행의가장중요한조건으로신뢰도와타당도를갖춘측정도구 (measurement instrument) 를바탕으 33

2 이건영 조희근 설재욱 김신애 로건강상태를객관적으로측정하여야한다는점을들수있다. 그러나어깨질환과관련된상태를잘반영하는양질의측정도구가충분하게갖춰졌다고보기는어려운형편이다 4). 또한, 어깨질환관련다수의임상시험을분석한코크란체계적문헌고찰들에서도동일질환의연구에서채택한측정도구의연구간이질성이대단히크다는점을지적하고있다 5,6). 이러한선행연구들의견해는어깨질환의통증과기능및정신적문제등다양한측정대상을포괄적으로반영해낼수있는측정도구관련연구가지속적으로필요한상황임을시사한다 7). 경험적데이터 (empiric data) 를양적결과물로전환하여후속연구의기반이될수있도록하는것이측정도구의역할이라는점을감안한다면, 한의학연구에있어서도양질의측정도구도입은필수적이라고볼수있다. 최근에는어깨질환을포함하는통증질환영역에있어침등을비롯한한의치료의유효성이뚜렷하게규명되고있는데, 이는전적으로적절한측정도구의사용을바탕으로한객관적설득이있었기에가능한성과이다 8,9). 따라서각종질환에대한한의치료의효과를확인하기위한양질의측정도구에관한논의는앞으로보다관심을기울여야할주제로생각된다. 저자들은이와같은문제인식하에국내한의임상연구에서사용되고있는어깨질환관련측정도구의현황을조사하고, 현황에따른향후어깨질환관련한의임상연구측정도구사용에대한지견을얻을목적으로본연구를수행하였다. 대상및방법»»» 1. 연구대상본연구는 2007년 1월 1일부터 2017년 7월 31일까지국내데이터베이스에등록되거나발간된연구의원본및초록을대상으로시행하였다. 한국전통지식포탈 (Oriental Medicine Advance Searching Integrated System, OASIS), 학술연구정보서비스 (RISS), 한국학술정보원 (KISS), 과학기술정보통합서비스 (NDSL), DBpia의데이터베이스에서 ʻ견통ʼ, ʻ견비통ʼ, ʻ견관절통증ʼ, ʻʼ, ʻshoulder functionʼ을포함한논문및해당결과로찾은주요어깨질환명을재검색하여결과를종합하였다. 이중체계적문 헌고찰을비롯한 2차문헌, 임상연구가아닌실험연구, 어깨특이적인증상이아닌경우, 측정도구를사용하지않은경우, 경제성연구, 안전성연구, 변증연구등기타연구주제와맞지않는경우를제외하였고, 어깨특이적인질환은아니지만주요증상이어깨통증에해당하는경우는연구에포함시켰다. 측정도구의경우통증과기능측정이외에근력측정, 삶의질, 치료만족도등을측정하는도구는제외하였다. 2명의연구자가각각검색하여결과를취합하였으며, 의견이불일치할경우논의를통한합의에의하여결정하였다. 2. 연구방법검색된논문들을연도별로연구형태, 진단명, 사용한통증및기능측정도구, 측정방법, 측정시간및횟수등으로분류하여추출하였다. 그리고각각의항목별로사용된빈도를조사하여분석하였다. 이후에일정한기준에따라권장될만한어깨질환통증및기능측정도구를선정하였다. 결과»»» 1. 문헌조사및선별결과최초로검색된연구 316편중중복연구를제외한후 129편의연구를수집하였다. 이후에전문을확인하여체계적문헌고찰 3편, 기존문헌을대상으로한연구 14편, 어깨특이적인증상과관련되어있지않은연구 21편, 연구주제와맞지않는연구 13편을제외하였다. 총 78편의연구가선정되었다. 연구선정및과정은다음과같다 (Fig. 1). 2. 연구의특성및분석선별된연구들은 2007년 7편, 2008년 7편, 2009년 9편, 2010년 10편, 2011년 11편, 2012년 8편, 2013년 2편, 2014년 14편, 2015년 3편, 2016년 7편이발표되었다. 연구형태는무작위대조임상연구 3편, 환자-대조군연구 8편, 증례군연구 10편, 증례보고 57편으로나타났다. 어깨질환에대한주요한진단은비특이적인어깨통증 13 편, 유착성관절낭염 ( 오십견 ) 10편, 뇌졸중후유증으로인 34 J Korean Med Rehabil 2018;28(1):33-51

3 Fig. 1. Flow chart of study selection process. 한어깨통증 9편, 회전근개파열 6편, 수술후통증 5편, 어깨충돌증후군 4편, 석회화건염 4편, 상부관절와순전후방병변 (Superior Labrum from Anterior to Posterior lesion, SLAP) 3편, 극상근건염과삼각근하점액낭염이동반된경우 3편, 극상근건염, 근막동통증후군, 극상근건파열, 복합부위통증증후군 (Complex Regional Pain Syndrome, CRPS) 각각 2편, 견관절아탈구, 견갑골골절, VDT 증후군 (Visual Display Terminal Syndrome), 어깨충돌증후군과삼각근하점액낭염이동반된경우, 관절와순파열, 이두근건염, 회전근개질환, 베체트병, 삼각근하점액낭염, 외상성어깨통증, 흉곽출구증후군, 다양한질환을조사한연구각각 1편으로분류되었다. 측정시점은치료전과치료후 2회측정한경우가 17 편으로가장높은빈도를보였고, 측정횟수는최소 2회부터최대 24회까지다양하게나타났다. 각연구의측정시점및측정횟수는표에언급하였다 (Table I). 통증측정도구가사용된연구는총 75편이었고 7개의측정도구가언급되었다. 시각상사척도 (Visual Analog Scale, VAS) 가 48건으로가장많은비중을차지하였다. 그다음으로는숫자평정척도 (Numerical Rating Scale, NRS) 12건, 통증평가척도 (Pain Rating Scale) 5건등이었고 VAS나 NRS가사용되었으나측정방법에대한기술이없는경우는 12건으로전체의 15% 에해당하였다. VAS 나 NRS를사용한연구에서 10이나 100에해당하는숫자가의미하는통증에대한기술을살펴보면 ʻ참을수없는통증ʼ이 21건으로가장많았고, ʻ가장심한통증ʼ 15건, ʻ상상가능한가장심한통증ʼ, ʻ심한통증ʼ 순이었다. 내원당시의통증을 10으로설정한경우가 3건이었고, 보고되지않은경우는 23건이었다. 어떤시점에서의통증을측정했는지에대한언급이있는연구는총 8편이었다. 현재의통증이 4건으로가장많았고이전 2 3 일동안의통증이 2건, 하루동안의가장심한통증, 최근의통증이각각 1건이었다. 기능측정도구가사용된연구는총 35편이었고 8개의측정도구가언급되었다. Shoulder Pain And Disability Index () 가 24건으로가장많이사용되었고, 그다음으로견통자각증상설문 6건, UCLA shoulder rating scale 4건등이었다. 어깨관절운동범위 (Range Of Movement, ) 를측정한연구는총 62건이었고능동, 수동 35

4 이건영 조희근 설재욱 김신애 Table I. Pain and Function Assessment Tools and Measurement Methods, Time Point and Frequency from the Articles Author Type of study Diagnosis Pain Function Measurement methods Measurement time point and frequency Ko 10) et al, 2007 Randomizedcontrolled trial Kim 11) et al, 2007 Randomizedcontrolled trial Nam 12) et al, 2007 Case-control study Post-stroke Nonspecific Adhesive Hur 13) et al, 2007 Case series Nonspecific Lee 14) et al, 2007 Case series Nonspecific Kim 15) et al, 2007 Case-control study Lee 16) et al, 2008 Case-control study Post-stroke Nonspecific Lee 17) et al, 2008 Case report Supraspinatus Han 18) et al, 2008 Case report Shoulder subluxation Lee 19) et al, 2008 Case report Post-stroke Kim 20) et al, 2008 Case report Calcific VAS* VAS: 10-severe 0-no, PRS FMMA, recent : passive ext. rot FMMA: use upper limb subscale Baseline, after 2 weeks VAS CSA score Not reported Baseline, after 4 weeks VAS CSA score VAS: not reported Baseline, after 1, 2, 3 weeks, : abd***, add, flx, ext after every treatment 5 times 4-grade scale Not reported Not reported VAS VAS: 10-unbearable 0-no, : active abd, add, flx, ext, eversion, inversion VAS VAS: : passive abd, add, flx, ext, med. rot, lat. rot VAS Shoulder subjective symptom tool VAS Shoulder subjective symptom tool VAS: 10-most severe 0-no, : use subscale VAS: 10-unbearable 0-no, : active abd, add, flx, ext, int. rot, ext. rot Shoulder subjective symptom tool: use musculoskeletal subscale VAS VAS: 10-most severe 0-no, VAS VAS: 10-baseline 0-no, : passive abd, add, flx, ext, int. rot, ext. rot Baseline, after 2 weeks Baseline, after 1, 2, 4 weeks 4 times VAS: Baseline, after 4, 8, 12, 16, 21, 25 days 7 times : Baseline, after 2, 4 weeks/ 3 times Baseline, every day 7 times Baseline, every 2 days 14 times VAS Not reported Baseline, every day 7 times 36 J Korean Med Rehabil 2018;28(1):33-51

5 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Measurement time point and frequency Lee 21) et al, 2008 Case report Nonspecific Kim 22) et al, 2008 Case report Nonspecific Jeong 23) et al, 2009 Case report Rotator cuff tear Yang 24) et al, 2009 Case report Shoulder impingement syndrome Ahn 25) et al, 2009 Case report Adhesive Kim 26) et al, 2009 Case report Supraspinatus Subdeltoid bursitis VAS VAS: not reported : abd, add, flx, ext, int. rot, ext. rot VAS VAS: not reported : abd, add, flx, ext, int. rot, ext. rot VAS VAS: not reported : abd, flx VAS VAS: 10-unbearable 0-no, rest : abd, add, int. rot, ext. rot VAS VAS: 10- as bad as it could be 0-no, : abd, flx, ext VAS VAS: 10-unbearable 0-no, overall : passive abd, add, flx, ext, int. rot, ext. rot Lee 27) et al, 2009 Case report CRPS VAS VAS: 10-unbearable 0-no, overall : abd, add, flx, ext, int. rot, ext. rot Kim 28) et al, 2009 Case-control study Nonspecific Moon 29) et al, 2009 Case report Shoulder impingement syndrome Kim 30) et al, 2009 Case series Adhesive Lee 31) et al, 2009 Case report Scapular fracture VAS Shoulder subjective symptom tool VAS VAS: pressure of 5 acupoints (GB21, LI16, SI11, BL12, LI14) Baseline, every treatment 2 4 times Unclear 9 10 times Baseline, after 1, 2, 3 weeks 4 times Baseline, every treatment, discharge after 1, 2 months VAS, : 11 times : 4 times VAS: baseline, every day 1 : baseline, after 6, 11 days / 3 times VAS: baseline, every 5 days / 9 times : baseline, every 10 days / 5 times : abd, add, flx, ext, int. rot, ext. rot Baseline, after 3, 6, 9 treatments 4 times VAS: 10-most severe 0-no, : abd, add, flx, ext, int. rot, ext. rot NRS NRS: 10-unbearable 0-no, : abd, add, flx, ext, int. rot, ext. rot Baseline, after 3, 6 treatments, after treatment 4 times 37

6 이건영 조희근 설재욱 김신애 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Measurement time point and frequency Lim 32) et al, 2010 Case report Shoulder impingement syndrome Subdeltoid bursitis Jang 33) et al, 2010 Case report Post-stroke Kim 34) et al, 2010 Case report Post-stroke VAS VAS: 10-unbearable 0-no, overall : abd, add, flx, ext, int. rot, ext. rot VAS VAS: 10-unbearable 0-no, on movement : passive abd, flx VAS You 35) et al, 2010 Case report VDT VAS WOSI** syndrome UCLA scale Lim 36) et al, 2010 Case report Biceps Kwon 37) et al, 2010 Case report Postoperative Park 38) et al, 2010 Case series Nonspecific Choi 39) et al, 2010 Case report Postoperative Yeom 40) et al, 2010 Case report Calcific VAS: 10-most severe 0-no, overall, current : use subscale : passive abd, flx, ext, ext. rot VAS: 10-most severe 0-no, overall, current VAS VAS: 10-worst 0-no,, SF-MPQ current VAS: baseline, after 5, 11, 13, 19, 22 days / 6 times : baseline, after 1, 2, 3 weeks / 4 times Baseline, every week (unclear) 5 6 times Baseline, every day 7 times VAS: baseline, every day 7 times WOSI, UCLA scale, : baseline, after 2, 4, 6 days 4 times, discharge day 3 times VAS Not reported VAS: baseline, every day 9 times : baseline, after 3, 6, 9, 12 days / 5 times Shoulder subjective symptom tool Shoulder subjective symptom tool: use musculoskeletal subscale VAS VAS: 10-most severe 0-no, rest : abd VAS VAS: not reported : abd, flx, int. rot, ext. rot Baseline, after 4, 8 treatments 3 times VAS: baseline, after 2, 4, 6, 8, discharge day 6 times : baseline, discharge day / VAS: baseline, every treatment / 2 7 times : baseline, after treatment / 38 J Korean Med Rehabil 2018;28(1):33-51

7 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Measurement time point and frequency Jin 41) et al, 2010 Case report SLAP VAS Park 42) et al, 2011 Case-control study Post-stroke Sohn 43) et al, 2011 Case series Nonspecific Kim 44) et al, 2011 Case report Post-stroke Kweon 45) et al, Case report Adhesive 2011 Kim 46) et al, 2011 Case report Supraspinatus Choi 47) et al, 2011 Case-control study Subdeltoid bursitis Nonspecific VAS PRS FMMA VAS: on movement : physical examination VAS: 10-most severe 0-no, overall, average in the previous 2 3 days : abd, add, flx, ext, average of 3 times measurements FMMA: use upper limb subscale Baseline, after 4, 8, 12, 15, 19 treatments 6 times Baseline, after 2, 4 treatments 3 times VAS VAS: Before treatment, after treatment (unclear) 5 times PRS : sagittal, frontal, transverse plane VAS VAS: Baseline, every day 4-grade scale : abd, flx, ext 6 times NRS NRS: : active abd, add, flx, ext, int. rot, ext. rot VAS Shoulder subjective symptom tool Park 48) et al, 2011 Case report SLAP VAS UCLA scale Kim 49) et al, 2011 Case report Calcific Lee 50), 2011 Case series Adhesive VAS VAS: 10-unbearable 0-no, overall VAS: 10-unbearable 0-no, rest : abd, add, flx, ext, int. rot, ext. rot UCLA scale VAS: 10-most severe 0-no, overall : use subscale VAS VAS: 10-unbearable 0-no, overall : abd, add, flx, ext NRS: Baseline, every 1 2 days / 8 13 times : Baseline, every 3 7 days / 3 times Baseline, after 1, 2, 3 weeks 4 times VAS: unclear / 6 7 times : unclear / 3 times UCLA scale: baseline, after treatment / Baseline, after 3, 6, 9, 12 days 5 times 39

8 이건영 조희근 설재욱 김신애 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Lee 51) et al, 2011 Case report Rotator cuff tear Oh 52), 2011 Case report Subdeltoid bursitis Jo 53) et al, 2012 Case report Postoperative VAS UCLA scale VAS: 10-unbearable 0-no, overall : abd, flx, ext, int. rot, ext. rot VAS VAS: 10-unbearable 0-no, overall : abd, add, flx, ext NRS NRS: 10-worst imaginable 0-no, : abd, add, flx, ext, int. rot, ext. rot Jeong 54) et al, 2012 Case report Rotator cuff tear Yoo 55) et al, 2012 Case report Rotator cuff tear NRS Pressure NRS: 10-most severe 0-no, rest : active abd, flx Pressure of humerus: greater, lesser tubercle tenderness (4-likert scale) VAS VAS: 10-unbearable 0-no, overall SDQ, current : abd, add, flx, ext, int. rot, ext. rot Kim 56) et al, 2012 Case report Labrum tear VAS VAS: not reported : active abd, flx, int. rot, ext. rot Park 57) et al, 2012 Case report Rotator cuff tear Jung 58) et al, 2012 Case report Shoulder impingement syndrome VAS VAS: 10-unbearable 0-no, overall, on movement : abd, add, flx, ext NRS NRS: : abd, add, flx, ext, int. rot, ext. rot Cho 59) et al, 2012 Case-control study Post-stroke VAS FMMA VAS: 10-most severe 0-no, overall, average in the previous 2 3 days FMMA: use upper limb subscale : passive ext. rot Measurement time point and frequency After 2, 3, 4, 5, 6, 7 months 6 times VAS: baseline, every 3 days / 9 times : unclear NRS: baseline, after 4, 11, 18, 25, 33 days / 6 times : baseline, every 3 4 days / 11 times : baseline, after 2, 4 weeks / 3 times Baseline, every 2 days 8 times VAS, : Baseline, every day / 9 times SDQ: Baseline, every 2 days / 5 times Baseline, every 1 2 weeks (various) 7 times Unclear VAS: 8 times : 7 times NRS: Unclear / 5 6 times : baseline, after 4 days, discharge day 3 times 40 J Korean Med Rehabil 2018;28(1):33-51

9 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Measurement time point and frequency Cho 60) et al, 2012 Case report CRPS VAS VAS: 10-most severe 0-no, overall : abd, flx, ext, int. rot, ext. rot Lee 61) et al, 2013 Case report Behcet Disease VAS VAS: 10-unbearable 0-no, rest : abd, add, flx, ext, int. rot, ext. rot Lee 62) et al, 2013 Case report Calcific Ji 63) et al, 2014 Case-control study Traumatic Lee 64) et al, 2014 Case report Supraspinatus tendon tear Kim 65) et al, 2014 Case report Supraspinatus tendon tear Jo 66) et al, 2014 Randomizedcontrolled trial Nonspecific Jeong 67) et al, 2014 Case report Adhesive Park 68) et al, 2014 Case report Adhesive Hong 69), 2014 Case report Adhesive Heo 70) et al, 2014 Case report Post-stroke PRS : int. rot, length from C7 level to thumb-reachable level VAS VAS: 10-baseline, 0-no, : abd, int. rot VAS VAS: 10-most severe 0-no, overall : abd, add, flx, ext, int. rot, ext. rot VAS VAS: 10-unbearable 0-no, overall : abd, flx VAS VAS: 100-unbearable 0-no (0 100 scale), VAS Constant-murley score PRS VAS 4-grade scale VAS: 10-worst imaginable 0-no,, most severe in the previous 24 hours Constant-murley score: use subscale : abd, int. rot test (location of the end of thumb) Baseline, after 13, 19, 22, 27, 35, 45 weeks 7 times Baseline, after 1, 2, 3, 4 weeks, discharge day 6 times PRS, : baseline, every 2 days / 6 times : baseline, every day 11 times Baseline, after 2, 3, 4 weeks, discharge day 5 times Baseline, every 5 14 days (various) 3 5 times Baseline, every day VAS: 1, constant-murley score, : 10 times : abd, flx, int. rot, ext. rot Baseline, every day 13 times VAS: : abd, add, flx, ext VAS VAS: not reported : active, passive abd, add, flx, ext Baseline, OPD treatment (unclear) 3 times Baseline, every 5 days, discharge day 14 times 41

10 이건영 조희근 설재욱 김신애 Table I. Continued Author Type of study Diagnosis Pain Function Measurement methods Son 71) et al, 2014 Case report Postoperative NRS NRS: 10-worst imaginable 0-no, : abd, length from C7 level to thumbreachable level Lim 72) et al, 2014 Case series Various NRS NRS: : abd, flx, int. rot, ext. rot Kim 73) et al, 2014 Case report Postoperative Lee 74) et al, 2014 Case report Thoracic outlet syndrome Park 75) et al, 2014 Case report Supraspinatus NRS NRS: 10-baseline 0-no, rest : passive abd, add, flx, ext, int. rot, ext. rot NRS NRS: 7 10-severe 5 6-moderate 1 4-mild 0-no, rest VAS VAS: 10-severe 0-no, rest : abd, int. rot, length from C7 level to thumb-reachable level Jo 76) et al, 2014 Case series Adhesive Lee 77) et al, 2015 Case report Myofascial syndrome VAS VAS: 10-most severe 0-no, overall : passive abd, add, flx, ext, pro, sup VAS Shoulder subjective symptom tool VAS: 10-severe 0-no,, on movement Shoulder subjective symptom tool: use musculoskeletal subscale Yang 78) et al, 2015 Case report Shoulder impingement syndrome VAS VAS: 10-unbearable 0-no, overall : active abd, flx, ext. rot Jo 79) et al, 2015 Case series Adhesive Yun 80) et al, 2015 Case report Supraspinatus Subdeltoid bursitis VAS VAS: not reported : abd, add, flx, ext, int. rot, ext. rot NRS NRS: : abd, add, flx, ext Measurement time point and frequency Baseline, every day 1 Baseline, discharge day Baseline, every 2 days 1 Baseline, after 4, 7, 14, 20 days 5 times VAS, : baseline, every day / 11 times : baseline, after 3, 6, 9 days, discharge day 5 times VAS: baseline, every twice a day / 24 times Shoulder subjective symptom tool: baseline, every day / 1 VAS, : baseline, every day / 11 times : baseline, after 2, 5, 8, 10 days / 5 times Baseline, every treatment (unclear) 9 times 42 J Korean Med Rehabil 2018;28(1):33-51

11 Table I. Continued Author Type of study Diagnosis Pain assessment tools Function Measurement methods Measurement time point and frequency Oh 81), 2016 Case report Rotator cuff tear Kim 82) et al, 2016 Case series Nonspecific Choi 83) et al, 2016 Case report Supraspinatus tendon tear Lee 84) et al, 2016 Case report Nonspecific VAS VAS: 10-unbearable 0-no, overall NRS Yoon 85) et al, 2016 Case report SLAP Jun 86) et al, 2016 Case report Myofascial syndrome Jeong 87) et al, 2016 Case report Rotator cuff disease NRS: 10-worst imaginable 0-no, : abd, add, flx, ext, int. rot, ext. rot VAS VAS: 10-most severe 0-no, overall : abd, add, flx, ext, int. rot, ext. rot NRS NRS: not reported : abd VAS NRS Baseline, after 6, 7, 8 treatments 4 times Unclear 4 times : abd, add, flx, ext, int. rot, ext. rot Baseline, after 9, 18 days, discharge day 4 times VAS: 10-unbearable severe 0-no, on movement : active, passive int. rot, length from inferior angle of scapula to thumb NRS: 10-most severe 0-no, rest : abd, add, flx, ext, int. rot, ext. rot Baseline, every day 1 *VAS: Visual Analog Scale, PRS: Pain Rating Scale, FMMA: Fugl-Meyer Motor Assessment, CSA score: Constant Shoulder Assessment score, : Shoulder Pain And Disability Index, NRS: Numerical Rating Scale, **WOSI: Western Ontario Shoulder Instability Index, SF-MPQ: Short-Form McGill Pain Questionnaire, SDQ: Shoulder Disability Questionnaire, CRPS: Complex Regional Pain Syndrome, VDT syndrome: Visual Display Terminal syndrome, SLAP: Superior Labrum from Anterior to Posterior lesion, ***abd: abduction, add: adduction, flx: flexion, ext: extension, int. rot: internal rotation, ext. rot: external rotation. 43

12 이건영 조희근 설재욱 김신애 Table II. Number of Measurement Instruments and Methods from the Articles Measurement instruments and characteristics Number (%) of trials, n=78 Pain 75 (96) Total number of measure instruments=7 Overall (VAS) 38 (49) Pain on movement (VAS) 5 (6) Rest (VAS) 5 (6) Overall (NRS) 8 (10) Rest (NRS) 4 (5) Pain Rating Scale 5 (6) Shoulder Pain And Disability Index subscale 3 (4) 4-Grade scale 3 (4) Other (instrument reported in 3% of trials)* 2 (3) No description reported (VAS or NRS) 12 (15) Function/disability 42 (54) Total number of measure instruments=8 Shoulder Pain And Disability Index 24 (31) Shoulder subjective symptom tool 6 (8) University of California-Los Angeles shoulder rating scale 4 (5) Fugl-Meyer Motor Assessment 3 (4) Constant Shoulder Assessment score 2 (3) Other (instrument reported in 3% of trials) 3 (4) Range of movement 62 (79) Active range of movement via goniometer or tape measure (any movement) 8 (10) Passive range of movement via goniometer or tape measure (any movement) 11 (14) Range of movement via goniometer or tape measure (unclear if active or passive) 45 (58) Abduction 55 (71) Adduction 35 (45) Flexion 48 (62) Extension 40 (51) Internal rotation 35 (45) External rotation 33 (42) Other (eg, inversion, eversion, pronation, supination etc.) 13 (17) Wording of anchor levels in the measurement instrument 10-unbearable 0-no 21 (27) 10-most severe 0-no 15 (19) 10-worst imaginable 0-no 4 (5) 10-baseline 0-no 3 (4) 10-severe 0-no 3 (4) Other (reported in 3% of trials) 3 (4) Not reported 23 (29) Time interval incorporated in the measurement instrument Current 4 (5) Average in the previous 2 3 days 2 (3) Most severe in the previous 24 hours 1 (1) Recent 1 (1) Not specified 63 (81) *Other measurement instruments: Short-Form McGill Pain Questionnaire, Pressure, Other function measurement instruments: Western Ontario Shoulder Instability Index, Shoulder Disability Questionnaire, Constant-Murley Score subscale, Other wording of anchor levels: 10- as bad as it could be 0-no, 10-worst 0-no, 7 10-severe 5 6-moderate 1 4-mild 0-no. 44 J Korean Med Rehabil 2018;28(1):33-51

13 운동범위에대한기술이있는연구가 19건으로각각 8건, 11건으로나타났다. 운동동작별로분류했을때가장다빈도동작은외전으로전체연구의 71% 에서시행되었다. 그다음으로굴곡, 신전, 내전, 내회전, 외회전순이었다. 기타사용된측정도구및사용된빈도, 측정방법에대한자세한내용은표에정리하였다 (Table II). 3. 권장될만한어깨질환통증및기능측정도구타당도와신뢰도가충분하게검증되어있고, 측정방법이간편하며, 해외연구에서사용빈도가높은도구들을선정하였다 88). 1) Numerical rating scale (NRS) 통증의정도를숫자로표현하는대표적인일차적통증측정도구로서다양한변형형태가있지만일반적으로 0 부터 10까지의통증강도를측정하는 NRS-11 이가장많이사용된다. 비슷한측정도구인 VAS에비해측정이간편하고반응성이뛰어나다는장점이있다. 따라서급성통증보단만성통증이다수를차지하고뇌졸중후유증이후의어깨통증같이인지장애를동반하는환자가많은국내어깨질환연구의특성을고려했을때우선적으로응용할수있다 89). 2) Short-form McGill questionnaire (SF-MPQ) McGill Pain Questionnaire의간소화된버전으로 11가지의통증감각설문과 4가지의감정설문으로이루어져있다. 환자가보다직관적으로통증의경도, 중등도, 중증의증상을이해할수있고단순통증의강도뿐만아닌통증의다양한유형을반영하는점이특징이다. 어깨통증의경우상지의방사통이나이상감각을동반하는경우가많기때문에이러한증상에사용하기에적합하다 90). 3) Brief inventory (BPI) 통증의강도와통증으로인한일상생활에서의신체적, 심리적장애 ( 활동, 기분, 보행, 업무, 수면, 삶의질 ) 등을종합적으로측정하는 15가지의항목으로이루어진다면적통증측정도구이다. 근골격계질환이나수술이후의통증에서나타날수있는여러가지활동제한이나심리적인요소를같이반영할수있기때문에근로자를대상으로 하거나관찰연구시에특히효율적인측정방법이다 91,92). 4) Multidimensional inventory (MPI) MPI는만성통증을주로측정하는도구로써통증의정도와주변구성원의지지, 일상활동장애의 3가지항목으로나누어져있다. 주변구성원의지지같은사회적인항목을중요한요소로삼고있는점이특징이다. 임상연구에서는장기간치료를받는환자의다면적요인을측정하는데사용한다 93,94). 5) Disabilities of the arm, shoulder and hand score (DASH) 6가지의증상관련항목과 24가지의신체, 사회적기능관련항목으로이루어진측정도구이다. 이것의간소화된도구인 QuickDASH 역시타당도, 신뢰도가검증되어있으며 DASH에비해서사용이간편하다. 다수의관절에통증이있을때나어깨통증에팔꿈치와손의증상이동반되는등상지전체의증상과기능을종합적으로측정할수있는가장좋은도구이다 95). 6) Shoulder and disability index () 5가지의통증관련항목과 8가지의기능관련항목으로이루어진측정도구이다. 어깨통증과기능을측정하는도구중에가장쉽고, 짧기때문에반응성이높다. 또한분석하기간편하여연구에사용하기매우유용하며모든어깨질환에동일하게적용이가능하다는장점을가지고있다 96). 7) Oxford shoulder score (OSS) 4가지의통증관련항목과 8가지의일상기능관련항목으로이루어진측정도구이다. 항목들이매우짧고반응성이좋다. 어깨수술후평가를위해제작된도구이기때문에회전근개질환이나관절와순손상으로인한수술이후의환자에게적용하기에유용하다 97). 8) American shoulder and elbow surgeons standardized shoulder assessment form (ASES) 환자관련항목 3가지 ( 통증, 불안정성, 일상활동 ) 와검사자관련항목 4가지 ( 관절가동범위, 징후, 근력, 불안정성 ) 로이루어진측정도구이다. 검사자가직접객관적인항목을측정할수있고, 높은수준의구성타당도, 신뢰 45

14 이건영 조희근 설재욱 김신애 도, 반응성을나타내어범용성있게사용이가능하다 98). 고찰»»» 본연구는어깨질환에대한통증및기능측정도구에대한국내의현황파악과동시에후속적인체계적문헌고찰을위한분석을목표로수행하였다. 이미 2007년도에어깨관절의임상적측정도구사용에대한선행연구가존재하지만 10년이전의임상연구를대상으로하여최근의연구들을반영하지못하고있고침구치료만을대상으로하여표본이부족했다는한계점이존재했다 99). 이후국내외의후속연구가지속적으로진행되어어깨질환측정도구를사용한임상연구가점차늘어나고있을뿐만아니라, 기존에침구치료에국한되었던중재가한의치료전반으로범위가넓어지는경향을보이고있다. 본연구는단순히기존연구에서사용된측정도구들의종류와빈도에대한조사이외에도각연구의측정방법및측정시점, 측정빈도를추가적으로분석하였다는점, 과거 2007년의선행연구이후현재까지의추가적연구결과물들의현황을반영하였다는점에서의의를갖는다. 통증의측정도구로서대다수연구에서 VAS가활용되었다. VAS는사용이간편하며이미타당도와신뢰도가충분히입증되어있는도구이다 100). 그러나시각척도이기때문에노인이나인지장애환자처럼정확한측정이힘든경우에는 NRS에비해반응성이떨어지게되고, 결과측정이부정확할수있다는단점이있다. 또한 VAS나 NRS를사용한통증측정에있어서모든연구가 0에해당하는통증을 ʻ통증없음ʼ으로일관성있게표현했으나 10이나 100 에해당하는통증에대한설명은각연구마다다양하게나타났다. 이에관한체계적문헌고찰에따르면 ʻ상상할수있는최악의통증ʼ이가장높은빈도로사용되고있다고보고하였다 101). 문화권에따른표현의차이때문에아직까지표준화된표현은존재하지않지만, 다수의연구사이에일정한수준의통일성을갖춘사용형태를보이고있기때문에아직까지연구간결과비교에있어서가장유용한도구로볼수있다. 통증의측정에있어서다면적측정도구의사용은조사대상연구중 6건에그쳤다. 국제적으로합의가이루어진통증의정의는 실제또는잠재적인조직손상이나이러 한손상의표현과관련된불쾌한감각적및정서적경험 이다 102). 이는통증의관리에심리사회적요인의고려가중요한요소임을시사하는것이다. 본연구에서포함된질환의경우에도비교적양호한예후를보여주는단순통증상태이외에도뇌졸중후유증에의한어깨질환, 어깨수술후통증, 유착성관절낭염등장기간의경과를갖는질환관련보고도적지않았다. 이처럼만성의경과를보이는질환의경우환자의기존증상이외에도사회적역할및일상생활에문제가발생하기때문에다양한심리적문제가발생하게된다. 따라서, 향후한의임상연구에서이러한영역의평가에있어서통증과동반된심리적요인을반영할수있는 SF-MPQ 나 BPI 등측정도구의적극적활용이필요할것이다. 또한, 어떤시점에서의통증을측정했는지에관한선행연구에서는 ʻ지난 24시간동안의평균통증ʼ을가장잘묘사한수치를사용하도록권고하고있으며다만임상연구가갖는구체적인목표에따라 ʻ지난주동안의통증ʼ 등으로유동적으로설계할수있다고하였다 103). 그러나본연구의조사대상문헌에서는이에관한언급이없는경우가전체의 81% 였다. 이러한문제점을보완하기위하여이후연구에서는통증측정시점의명확한기술에대해서도주의를기울일필요가있다. 전체조사대상연구의 54% 정도에서기능장애에대한측정이이루어졌다. 특징적인점은기능장애에대한측정을시행한거의대부분의연구에서 를채택하였다는점이다. 이외에소수의연구에서견통자각증상설문과같은타당도, 신뢰도검증이이루어지지않았거나, 한국어판이없는측정도구를사용한경우들이있었다. 개별적목적에따른어깨의기능장애측정도구로는 이외에도 DASH나 SDQ, OSS 등의한국어판이마련되어있다. 이들도구들은해외의어깨질환관련임상연구에서는다빈도로사용될뿐만아니라타당도와신뢰도가잘입증되어있다. 이러한조사결과는향후임상연구의질을재고하기위하여어깨의기능장애관련측정도구가보다적극적으로활용되어야할것임을시사한다. 또한, 측정도구를선택하기전에신뢰도와타당도가입증된도구인지여부를검토하는절차도중요할것으로보인다. 이와관련하여한국어판의마련과정에서신뢰도와타당도를별도로확인하지않는다면언어의차이로인하여연구의신뢰성에문제가생길수있다. 따라서, 해외유래측정도구인경우한국어판관련별도연구가있는지확인할필요 46 J Korean Med Rehabil 2018;28(1):33-51

15 가있을것으로보인다. 또한, 보다다양한도구를활용하여연구대상질환에특이적인측정도구를선택하려는노력도요구된다. 이와는별도로어깨의기능장애를위한별도의측정도구를선택하지않은연구에서는대부분어깨관절 만을이용하여평가하였다. 이와관련하여능동및수동가동범위에대한별도의기술이존재하는연구또한 을측정한연구의중 24% 에그쳤고동일질환에대한연구사이에도측정과정사이의상당한이질성이있었다. 한편, 여러가지이학적검사들을보조적으로사용하여양성, 음성반응을통해호전도를측정하는연구들이조사되었다. 그러나 을포함한어깨관절의전반적인이학적검사에대한체계적문헌고찰에의하면, 흔히사용되는어떠한이학적검사도질환의회복에대한확고한신뢰도를확보하지는못하였음을보고하고있다 104). 이에따르면 이나이학적검사의경우 1차측정도구를보조하는 2차측정도구로서채택하는것이적절할것이다. 본연구는다음과같은한계점을갖는다. 먼저, 본연구는제한된기간내국내의어깨관련임상연구의현황만을살필목적으로설계되었다. 따라서메타분석양적분석의방법론을채택하지않았으며, 검색의범위도제한적이다. 그러므로상기에서확인한어깨질환측정도구관련지견을일반화된결론으로전환할수는없다. 또한, 어깨질환측정도구에대하여신뢰도와타당도가입증된양질의참조표준 (reference standard) 역할을할수있는도구와그렇지못한도구의차이는분명하게존재한다. 그러나본연구에서는그러한도구간의질적차이를구체적으로비교분석할수있는설계를채택하지않았다. 따라서잠재적으로어깨질환측정도구사이의차이점이있음을파악할수있지만, 보다개별질환에특이적으로적용할수있는어깨질환측정도구의추천을본연구를통하여이끌어낼수도없다. 저자들은이러한한계점을각각개별적으로보완한후속추가연구를시행할예정이다. 결론»»» 결론적으로, 본연구에서는 2007년이후의국내에서발표된한의임상연구에사용된어깨질환의통증및기능측정도구에대한현황을검토하여사용도구가점차다양 화되는추세와함께사용되는도구의종류및특성을일부확인하였다. 본연구에서확인한국내한의임상연구에서는현재까지제한적인숫자의어깨질환측정도구만이활용되고있으며, 타당도와신뢰도가입증되지않은도구가사용되고있지않을뿐아니라측정방법이해당도구의표준적인측정기준에부합하지않는문제점도발견되었다. 이러한문제점은향후한의임상연구에서보완해나가야할점으로써엄격한방법론을사용한보다구체적인어깨질환도구관련분석연구및아직한국어판이나오지않은측정도구의도입연구등이지속적으로필요하다는점을시사한다. 본연구에서파악된현황및문제점을해결할수있는후속연구가지속적으로이루어질때보다객관적인한의어깨질환임상연구의성과평가가이루어질수있을것으로생각된다. References»»» 1. Whittle S, Buchbinder R. In The Clinic. Rotator Cuff Disease. Ann Intern Med. 2015;162(1):ITC Kuijpers T, van der Windt DA, van der Heijden GJ, et al. A Prediction Rule for Shoulder Pain Related Sick Leave: A Prospective Cohort Study. BMC Musculoskelet Disord Dec 6;7: Meislin RJ, Sperling JW, Stitik TP. Persistent Shoulder Pain: Epidemiology, Pathophysiology, and Diagnosis. Am J Orthop (Belle Mead NJ). 2005;34(12 Suppl): Wright RW, Baumgarten KM. Shoulder Outcomes Measures. J Am Acad Orthop Surg. 2010;18(7): Page MJ, Green S, Kramer S, et al. Manual Therapy and Exercise for Adhesive Capsulitis (Frozen Shoulder). Cochrane Database Syst Rev. 2014;(8):CD Page MJ, Green S, Kramer S, et al. Electrotherapy Modalities for Adhesive Capsulitis (Frozen Shoulder). Cochrane Database Syst Rev. 2014;(10):CD Page MJ, Huang H, Verhagen AP, et al. Outcome Reporting in Randomized Trials for Shoulder Disorders: Literature Review to Inform the Development of a Core Outcome Set. Arthritis Care Res (Hoboken) Apr Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Individual Patient Data Meta-Analysis. Arch Intern Med. 2012;172(19): Yuan QL, Guo TM, Liu L, et al. Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One. 2015; 10(2):e

16 이건영 조희근 설재욱 김신애 10. Ko CN, Min IK, Park SW, et al. Effectiveness of Bee Venom Acupuncture on Shoulder Pain after Stroke. J Korean Oriental Med. 2007;28(1): Kim CY, Kwon NH, Shin YJ, et al. Randomized Controlled Trial: Effect of Master Dong s Acupuncture in Chronic Shoulder Pain Patients. J Korean Acupuncture & Moxibustion Society. 2007;24(6): Nam DW, Lim S, Kim JI, et al. Clinical Observation of Acupuncture and Nerve Block Treatment for Adhesive Capsulitis Patients. J Korean Acupuncture & Moxibustion Society. 2007;24(4): Hur B, Yim YK. Study on Clinical Effects of Indirect Moxibustion at Geogol (LI16) on the Shoulder Pain. J Korean Medical Research Institute, Daejeon University. 2007;16(2): Lee JS, Song KH, Lee SN, et al. Clinical Study of Different Effect between Trigger Point Needling and Remote Acupuncture Point Needling on Shoulder Pain Patient. J Korean Acupuncture & Moxibustion Society. 2007;24(5): Kim MB, Chung SH, Kim SS. The Influences of Chuna(Shoulder Traction) Therapy for Shoulder Pain and Range of Movement in Hemiplegic Patients After Stoke. J Oriental Rehab Med. 2007;17(2): Lee HY, Youn HM, Kim WI. Clinical Study about Shoulder Pain by Oriental Medical Treatment and Oriental-Western Medical Treatment. J Phamacopuncture. 2008;11(2): Lee GJ, Lee BY, Song YK, et al. The Case Report of Chuna Treatment on Supraspinatus Tendinitis with Kyphotic Cervical Curvature. J Korea CHUNA Manual Medicine for Spine & Nerves. 2008;3(2): Han JW, Oh MS. A Clinical cases Study of Shoulder Dislocation in Patients Undergoing Stroke. J Korean Medical Research Institute, Daejeon University. 2008; 17(1): Lee YK, Lee YK, Kim JS, et al. The Effects of Bee Venom Acupunture Therapy on Shoulder Pain Patients in Stroke Sequelae. J Meridian & Acupoint. 2008;25(2): Kim SH, Ko KM, Lee YK, et al. A Case Report of the Patient with Calcified Tendinitis Treated by Oriental Medicine. J Spine & Joint Korean Medicine. 2008;5(1): Lee IS, Kim BH, Kim MK. The Effects of Intervention on Thoracic Vertebral Region s Du Mai( 督脈 ) and Jia Ji Xue( 夾脊穴 ) for Shoulder Pain; 4 Clinical Case Report. J Oriental Rehab Med. 2008;18(1): Kim YM, Hong KE. Case Reports : The Clinical Study on the Effect of Acupotomy in Shoulder Disease. J Korean Acupuncture & Moxibustion Society. 2008;25(4): Jeong DU, Song SC, Yeo KC, et al. Report of Two Cases of Shoulder Pain Diagnosed through MRI as Partial Tear of Supraspinatus Tendon Treated by Oriental Medical Treatment. J Korean Oriental Med. 2009;30(1): Yang MS, Chu MG, Cho HG, et al. Case Study of Shoulder Impingement Syndrome with Synovial Joint Effusion Improved as Sweet BV Acupuncture. Korean J Oriental Physiology & Pathology. 2009;23(4): Ahn MS, Park JS, Jung JH, et al. A Case Report of Frozen Shoulder with Muscular Acupuncture and Muscle Energy Technique. J Korea CHUNA Manual Medicine for Spine & Nerves. 2009;4(2): Kim EH, Oh MS. The Clinical Observation of 1 Case of Supraspinatus Tendinosis and Subdeltoid Bursitis. J Korean Medical Research Institute, Daejeon University. 2009;18(1): Lee EJ, Yoon IJ. The Clinical Observation of 1 Case of the Complex Regional Pain Syndrome. J Korean Medical Research Institute, Daejeon University. 2009; 18(1): Kim YS, Kim KB, Kim GC, et al. Effects of the BUDDEUMI Therapy on the Relief of Shoulder Pain among Middle Aged Women. Korean J Oriental Physiology & Pathology. 2009;23(5): Moon TW, Eom TW, Chung YH. The Clinical Report on 3 Cases of Patients with Shoulder Impingement Syndrome Improved by Chuna Treatment and Burning Acupuncture Therapy. J Korea CHUNA Manual Medicine for Spine & Nerves. 2009;4(1): Kim DH, Kim HW, Lee GH, et al. Effect of Scolopendrid Pharmacupuncture Therapy on Frozen Shoulder Patients. J Korean Acupuncture & Moxibustion Society. 2009;26(1): Lee KM, Lim SH, Yoon DY, et al. Two Clinical Cases on Patients with Pain and Limited Range of Motion about Shoulder Subsequent to Scapular Fracture by Oriental Medical Treatments and Chuna Treatment. J Korea CHUNA Manual Medicine for Spine & Nerves. 2009;4(2): Lim DW, Lee KJ, Jung TS, et al. Case Study of Shoulder Impingement Syndrome with Subacromial Bursitis Improved as Sweet BV Herbal Acupuncture. Korean J Oriental Medical Prescription. 2010;18(2): Jang YH, Lim HW, Kim JY, et al. 3 Case Reports of Trigger Point Needling and Oriental Medical Treatment to Shoulder Pain Patients in Stroke Sequelae. Korean J Joongpoong. 2010;11(1): Kim DH, Kim BH, Kim YJ, et al. A Clinical Study of Burning Acupuncture Therapy on SI11 in Post-Stroke Patient with Shoulder Pain. J Spine & Joint Korean Medicine. 2010;7(1): J Korean Med Rehabil 2018;28(1):33-51

17 35. You JH, Kim DH, Kim JH, et al. A Case Report on Shoulder Pain and Dysfunction of Visual Display Terminal Syndrome Patient Treated with Dong-Shi Acupuncture Therapy. J Spine & Joint Korean Medicine. 2010;7(1): Lim GM, Kwon YH, Kim JH. A Case Report on the Biceps Tendinitis Treatment with Fire Needling Therapy. Korean J Acupuncture. 2010;27(3): Kwon JM, Kim DC. Traditional Korean Medicine Management of Complications of Breast Surgery-A Case Report of Complications After Breast Surgery. J Oriental Obstetrics & Gynecology. 2010;23(4): Park KM, Lee GJ, Song YK, et al. The Clinical Effects of Low Level Laser Therapy on Shoulder Pain. J Oriental Rehab Med. 2010;20(1): Choi KH, Bang JH, Kim JH, et al. A Clinical Case Report of a Lung Cancer Patient with Shoulder Pain after Lobectomy. J Korean Traditional Oncology. 2010; 15(1): Yeom SR, Song JH. Calcific Tendinitis of the Shoulder by Oriental Medical Treatments: 4 Cases Report. J Oriental Rehab Med. 2010;20(1): Jin ES, Yeon SK, Kim S, et al. A Case Report of Conservative Treatment for the Amatuer Baseball Player Diagnosis with Type 2 Superior Labral Anterior Posterior Lesion. J Korea CHUNA Manual Medicine for Spine & Nerves. 2010;5(2): Park JA, Lee CH, Kwon GS, et al. The Effects of Sweet Bee Venom Pharmacopuncture on the Post-Stroke Hemiplegic Shoulder Pain. J Korean Acupuncture & Moxibustion Society. 2011;28(4): Sohn D, Yoon HM, Jung HM. The Effects of Dry Cupping Therapy on the Shoulder Pain and Fatigue of Nurses. J Pharmacopuncture. 2011;14(2): Kim JH. Kwak HY, Kwon YJ, et al. A Case Report on the Effect of Electroacupuncture at LI15 and TE14 for the Treatment of Shoulder Pain in Post-stroke Hemiplegia Patients. J Korean Acupuncture & Moxibustion Society. 2011;28(6): Kweon JJ, Yeom DS, Lim HH, et al. A Clinical Study on Patient with Frozen Shoulder Treated by Oriental Medicine Treatment in Combination with Carthmi-Flos Herbal Acupuncture. J Oriental Sports Med. 2011;11(1): Kim MY, Choi YI, Choi HS, et al. The Clinical Observation of Oriental Medicine Treatment and Hominis Placenta Pharmacopuncture in 4 Cases of Supraspinatus Tendinosis and Subdeltoid Bursitis. J Korea Institute of Oriental Medical Informatics. 2011;17(2): Choi HN, Lee SW, Kim CH, et al. Clinical Study of the Effects of Juglandis Semen Pharmacopuncture Therapy on Shoulder Pain. J Pharmacopuncture. 2011;14(4): Park SH, Ro HR. The Case Report of Prescribing Kamiseokyong-tang(Nam) for the Two Patients with Superior Labral Anterior Posterior Lesion. J Korea CHUNA Manual Medicine for Spine & Nerves. 2011; 6(1): Kim NH, Jang HJ, Kim JH, et al. A Clinical Study on the Case of Right Shoulder Pain Occurred in Calcific Tendinitis. J Oriental Medical Thermology. 2011;9(1): Lee CK. Effect of Oriental Medicine Public-health Program on Frozen Shoulder Patients. J Korean Acupuncture & Moxibustion Society. 2011;28(6): Lee JH, Ko MK, Yoon KS, et al. Case Report of Acute Traumatic Rotator Cuff Tear Treatment in Traditional Korean Medicine. J Pharmacopuncture. 2011;14(4): Oh WK. Pharmacopuncture and Autohemo-Seperated Regeneration Pharmacopuncture for Acute Traumatic Subdeltoid Bursitis with Patial Tear of Subscapularis Tendon After Bongchuna Treatment A Case Report. J Pharmacopuncture. 2011;14(2): Jo DC, Moon SJ, Kong JC, et al. Case Report about Postoperative Rehabilitation of Oriental Medicine for the Distal Clavicular Fracture. Korean J Oriental Physiology & Pathology. 2012;26(1): Jeong JY, Kim JH, Song CH, et al. Case Reports : 1 Case of Shoulder Pain Treated with Oriental Treatment Including Pharmacopuncture in Rotator Cuff Surgery. J Korean Acupuncture & Moxibustion Society. 2012;29(6): Yoo DJ, Lee MJ, Kim ES, et al. A Case of a Rotator Cuff Tear Patient Suffering with Right Shoulder Pain and Limitation of Range of Movement Treated with Warm Needling Acupuncture. J Spine & Joint Korean Medicine. 2012;9(1): Kim SJ, Lee HJ, Choi YJ, et al. Case Report on the Case of Patient with Labral Tear. J Korean Acupuncture & Moxibustion Society. 2012;29(5): Park MJ, Min SJ, You KG, et al. A Clinical Case of the Oriental Medical Treatment for the Patient with Partial Tear of Rotator Cuff. J Oriental Rehab Med. 2012;22(2): Jung YG, Kim MY, Kim JS, et al. A Case Report of Prescribing Geumchuldodam-tang for the Three Patients with Shoulder Impingement Syndrome. J Korea CHUNA Manual Medicine for Spine & Nerves. 2012;7(1): Cho SH, Cho HS, Lee KY, et al. The Comparative Study of Effectiveness of Cotreatment with Samgieum-gagam, Acupuncture and Sweet Bee Venom Acupuncture on Post-Stroke Shoulder Pain. The Acupuncture. 2012; 29(2): Cho TH, Park KM. Effect of Placental Extract on Immobilization of Shoulder Joint in a Complex Regional 49

18 이건영 조희근 설재욱 김신애 Pain Syndrome Patient. The Acupuncture. 2012;29(2): Lee SM, Ji YS, Jeon JH, et al. Effect of Needle- Embedding & Acupuncture Therapy on Shoulder Pain in Behcet Disease Patient: A Case Report. The Acupuncture. 2013;30(4): Lee JN, Lee SM, Yoon KH, et al. A Case Report of Left Shoulder Pain from Calcific Tendinitis Located at Supraspinatus Treated with Sa-Am Acupuncture Sojangjeounggyeok. J Spine & Joint Korean Medicine. 2013;10(1): Ji MJ, Lim SC, Kim JS, et al. Case Report : The Comparative Study on Effect of Jungsongouhyul Phamacopuncture and Electroacupuncture in Patients with Acute Traumatic Shoulder Pain. The Acupuncture. 2014; 31(4): Lee SJ, Park JH, Nam SH, et al. Two Clinical Cases of Active Release Technique with Korean Medicine Treatment for Supraspinatus Tendon Partial Tear. J Korea CHUNA Manual Medicine for Spine & Nerves. 2014;9(1): Kim HS, Heo WY, Hyun MK, et al. Case Report : Four Case of Partial Tear of Supraspinatus Tendon Treated by Acupotomy Combined Oriental Medical Treatments. The Acupuncture. 2014;31(1): Jo SJ, Choi YD, Jang JT, et al. A Randomized Controlled Clinical Trial of Topical Herbal Gel Treatment for Chronic Shoulder Pain. The Acupuncture. 2014;31(4): Jeong YK, Choi JE, Han JS, et al. A Case Report of Right Shoulder Pain from Frozen Shoulder Treated with Extra Point Acupuncture and Dong-Qi Therapy. J Spine & Joint Korean Medicine. 2014;11(1): Park JH, Han JS, Kwon MS, et al. A Case Report on the Effects of Balanced Acupuncture Treatment and Jin s Three Acupuncture Treatment on Right Shoulder Pain and Limitation of Range of Movement in a Frozen Shoulder Patient. J Spine & Joint Korean Medicine. 2014;11(1): Hong SW. Case Report Combined Therapy of Acupuncture and Fire Needling is Effective to Treat Frozen Shoulder. Korean J Oriental Physiology & Pathology. 2014;28(1): Heo WY, Kim HO, Kang IA. A Case Report on Shoulder Pain Caused by Sequela of Cerebral Infarction Treated with Placenta Pharmacopuncture. J Spine & Joint Korean Medicine. 2014;11(1): Son JH, Kim JH, Jo DH, et al. A Case of Arthroscopically Repaired Left Rotator Cuff Tear Treated Kyun-Tong Acupoint of Pyung-Hyung Acupuncture. J Spine & Joint Korean Medicine. 2014;11(1): Lim SJ, Jun JY, Lee CW, et al. Clinical Characteristics and Treatment Effects of Shoulder Pain Patients Admitted to a Korean Medicine Hospital Based on MRI Findings. The Acupuncture. 2014;31(4): Kim YJ, Won JH, Ahn HD, et al. A Clinical Case of Korean Rehabilitation Treatment for Rotator Cuff Tear. J East-West Medicine. 2014;39(3): Lee DG, Lee OJ, Lee JH, et al. A Case Report of Thoracic Outlet Syndrome Improved by Integrated Korean Medical Treatment. The Acupuncture. 2014;31(2): Park YE, Kwon MS, Kim JH, et al. A Case Report of Shoulder Pain Caused by Supraspinatus Tendinitis Treated with Warm Needling. J Spine & Joint Korean Medicine. 2014;11(1): Jo NY, Yeo IH, Jung SH, et al. Effect of Chuna (Shoulder Traction) Treatment on Frozen Shoulder During Korean Medical Treatment. The Acupuncture. 2014;31(2): Lee SJ, Kim SY, Jo JJ, et al. A Case Report of Myofascial Pain Syndrome Patient with Rounded Shoulder and Chronic Shoulder Pain Treated with Acupuncture. J Spine & Joint Korean Medicine. 2015;12(1): Yang SP, Ahn JH, Park JH, et al. A Case Report of Shoulder Impingement Syndrome with Limited Range of Movement Treated with Electroacupuncture. J Spine & Joint Korean Medicine. 2015;12(1): Jo NY, Roh JD. Effects of Embedding Therapy on Frozen Shoulder. J Korean Med. 2015;36(4): Yun YU, Chung JH, Cheong SH, et al. A Case Report of Supraspinatus Tendinitis and Subdeltoid Bursitis Patient Improved by Korean Medicine Treatment with Shinbaro3 Pharmacopuncture. J Oriental Rehab Med. 2015;25(4): Oh MJ. Effect of Bee Venom Pharmacopuncture Complex Therapy on Rotator Cuff Tear without Range of Motion Limitation. J Sports Korean Med. 2016;16(1): Kim SM, Lee SH, Shin YB, et al. Effects of Korean Medical Combination Treatment for Shoulder Pain Patients: An Observational Study. J Sports Korean Med. 2016;15(2): Choi BS, Oh MS. Two cases Report of Supraspinatus Tendon Tear Treated with The Daoyin Exercise Program Combined with Korean Medicine Treatment. J Korean Medical Research Institute, Daejeon University. 2016; 25(1): Lee HJ, Lee NH, Son CG, et al. Acupuncture Stimulation on LR3 Reduced Shoulder Pain Caused by Upper Trapezius Rigidity: A Case Report. Korean Medical Research Institute, Daejeon University. 2016;25(1): Yoon TK, Lee SJ, Lee EJ, et al. A Case Report of Patients with Labrum Tear in Shoulder Treated by 50 J Korean Med Rehabil 2018;28(1):33-51

19 Oriental Therapy, Including Sinbaro3 Pharmacopuncture. The Acupuncture. 2016;33(4): Jun HJ, Boo JY, Lee HH, et al. A Case Report on Limited Range of Motion of Right Shoulder and Right Brachial Pain with Myofascial Pain Syndrome Treated with Complex Therapy Including Flash-Fire Cupping Method. J Spine & Joint Korean Medicine. 2016;13(1): Jeong JK, Park GN, Kim KM, et al. The Effectiveness of Ultrasound-Guided Bee Venom Pharmacopuncture Combined with Integrative Korean Medical Treatment for Rotator Cuff Diseases: A Retrospective Case Series. The Acupuncture. 2016;33(4): Hawker GA, Mian S, Kendzerska T, et al. Measures of Adult Pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) Nov;63 Suppl 11:S Farrar JT, Troxel AB, Stott C, et al. Validity, Reliability, and Clinical Importance of Change in a 0-10 Numeric Rating Scale Measure of Spasticity: A Post Hoc Analysis of a Randomized, Double-Blind, Placebo-Controlled Trial. Clin Ther May;30(5): Main CJ. Pain Assessment in Context: A State of the Science Review of the McGill Pain Questionnaire 40 Years on. Pain Jul;157(7): Song CY, Lin SF, Huang CY, et al. Validation of the Brief Pain Inventory in Patients with Low Back Pain. Spine (Phila Pa 1976) Aug 1;41(15):E Erdemoglu AK, Koc R. Brief Pain Inventory Score Identifying and Discriminating Neuropathic and Nociceptive Pain. Acta Neurol Scand Nov;128(5): Verra ML, Angst F, Staal JB, et al. Reliability of the Multidimensional Pain Inventory and Stability of the MPI Classification System in Chronic Back Pain. BMC Musculoskelet Disord Aug 24;13: Choi Y, Mayer TG, Williams M, et al. The Clinical Utility of the Multidimensional Pain Inventory (MPI) in Characterizing Chronic Disabling Occupational Musculoskeletal Disorders. J Occup Rehabil Jun;23(2): Ochi K, Iwamoto T, Saito A, et al. Construct Validity, Reliability, Response Rate, and Association with Disease Activity of the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire in the Assessment of Rheumatoid Arthritis. Mod Rheumatol Mar;25(2): Breckenridge JD, McAuley JH. Shoulder Pain and Disability Index (). J Physiother. 2011;57(3): Younis F, Sultan J, Dix S, et al. The Range of the Oxford Shoulder Score in the Asymptomatic Population: A Marker for Post-Operative Improvement. Ann R Coll Surg Engl Nov;93(8): Kocher MS, Horan MP, Briggs KK, et al. Reliability, Validity, and Responsiveness of the American Shoulder and Elbow Surgeons Subjective Shoulder Scale in Patients with Shoulder Instability, Rotator Cuff Disease, and Glenohumeral Arthritis. J Bone Joint Surg Am Sep;87(9): Yang DH, Kim KH, KIM HB, et al. A Review of Clinical Shoulder Assessment Scales. J Korean Acu. 2007;24(6): Boonstra AM, Schiphorst Preuper HR, Reneman MF, et al. Reliability and Validity of the Visual Analogue Scale for Disability in Patients with Chronic Musculoskeletal Pain. Int J Rehabil Res Jun;31(2): Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies Comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for Assessment of Pain Intensity in Adults: A Systematic Literature Review. J Pain Symptom Manage Jun;41(6): van Boekel RLM, Vissers KCP, van der Sande R, et al. Moving Beyond Pain Scores: Multidimensional Pain Assessment is Essential for Adequate Pain Management after Surgery. PLoS One May 10;12(5):e Dworkin RH, Turk DC, Farrar JT, et al. Core Outcome Measures for Chronic Pain Clinical Trials: IMMPACT Recommendations. Pain Jan;113(1-2): May S, Chance-Larsen K, Littlewood C, et al. Reliability of Physical Examination Tests Used in the Assessment of Patients with Shoulder Problems: A Systematic Review. Physiotherapy Sep;96(3):