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1 J Korean Soc Phys Med, 2014; 9(4): Online ISSN: Print ISSN: X Research Article Open Access 회전근개봉합술후닫힌사슬운동적용시점에따른효과비교 송현승 김선엽 1 대전대학교대학원물리치료학과, 1 대전대학교자연과학대학물리치료학과 Comparison of the Rehabilitation Program after Rotator Cuff Repair by Time Closed Chain Exercise Hyun-Seung Song, PT, MS, Suhn-Yeop Kim, PT, PhD 1 Department of Physical Therapy, The Graduate School of Daejeon University 1 Department of Physical Therapy, College of Natural Science, Daejeon University Received: September 15, 2014 / Revised: November 7, 2014 / Accepted: November 14, 2014 c 2014 J Korean Soc Phys Med Abstract 1) PURPOSE: This study aimed to examine the pain, range of motion (ROM), upper extremity task performance, and functional levels of patients after rotator cuff repair according to the timing of a closed chain exercise thereby presenting basic data for an effective rehabilitation program. METHODS: The intervention was applied three times per week, one hour per day, for four weeks to 40 participants, 78 of whom had undergone rotator cuff repair. The participants were divided into four groups and assigned to usual general physical therapy and an open chain exercise. Group I consisted of the open chain exercise only. The closed chain exercise was applied to group II after the 4 times, group III after the 7 times, group IV after the 10 times. Measurement were used ROM, visual analogue scale (VAS), box and block test (BBT), and shoulder pain and disability index (SPADI).A one-way analysis of variance was conducted to test differences. RESULTS: There were significant differences in the internal/external rotation between group I and group II. The VAS significantly differed between group II and group I, group III, and group IV. The BBT results of group II and group I were significantly different compared to those of group IV. The SPADI significantly differed between group II and group I and between group II and group IV. CONCLUSION: The closed chain exercise was effective for patients following rotator cuff repair from the second week after active exercise was prescribed, verifying its applicability in rehabilitation programs. Key Words: Close chain exercise, Rotator cuff repair, Rehabilitation Corresponding Author : kimsy@dju.ac.kr 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. Ⅰ. 서론견관절통증은흔한근골격계질환으로 (Ministry of Labor, 2007), 성인인구의 20% 이상이평생에한번이상경험하고있으며, 이로인해수면장애, 먹기, 씻기, 같은

2 486 J Korean Soc Phys Med Vol. 9, No. 4 일상생활을어렵게한다 (Burbank, 2008). 견관절통증의원인은충돌증후군, 유착성견관절낭염, 근막통증증후군, 관절염, 회전근개파열같은질환이있다 (Ostor 등, 2005). 이중회전근개파열은최근산업체근골격계질환및레져활동인구증가로발생이증가하고있으며 (Williams 등, 2007), 점차적인퇴행성변화로인한내적원인과외상에의한갑작스런큰부하같은외적요인에의해발생한다 (Boes 등, 2005). 회전근파열에대한치료방법은보존적방법과수술적인방법이있으며, 영상진단방법과의료기술발전으로인하여수술적처치빈도가증가하고있다 (Williams 등, 2007). 회전근개봉합술후초기에보조기착용으로석화화가진행되어관절의운동기능이감소되는특성과통증으로인해, 환자는심리적불안감으로부동자세를취해기능감소와통증이증가되는악순환이반복된다 (Lee 등, 2012). 따라서통증감소와관절가동범위증진, 근력및지구력에대한관리가필요하다 (Kim, 2008). 회전근개봉합술후재활프로그램을강조하고있으나, 개개의근력강화와관절가동범위증진에초점을두고있다 (Kim, 2008). 견관절기능회복을위한효과적인재활프로그램을제공하기위해서는견관절안정근들사이의균형적인조절능력회복에초점을두어야하며 (Ludewig와 Cook, 2000), 이를위해개개의근력강화보다는짝힘을통한균형개선이견관절의기능회복에필요하다 (Newman, 2013; William 등, 2007). 그러나기존의재활프로그램은근력강화에초점을맞춘열린사슬운동에맞춰져있다 (Cohen 등, 2002). 열 린사슬운동은근위부는고정된상태에서원위부는자유롭게움직이며관절가동범위가제한된환자의근력강화를위해중요한역할을한다 (Prentice와 Voight, 2001). 반면, 닫힌사슬운동은원위부는고정시킨상태에서근위부와원위부에서저항을동시에적용할수있는운동으로근력강화, 지구력증진뿐만아니라관절면의기계적인압박을통해여러근육의협응수축을일으키며관절주위의구심성수용체를자극하여더많은고유감각을제공하므로관절의동적안정성과자세유지에효과적이다 (Prentice와 Voight, 2001). 최근닫힌사슬운동을이용한재활프로그램을사용하고있다 (Ellenbecker 등, 2006). 하지만기존연구들에서수술후재활프로그램에서는열린사슬운동과닫힌사슬운동방법을회복기간에맞춰복합적으로만제시하고있어견관절기능회복을위해효과적인닫힌사슬운동의적용시점이필요하다. 이에본연구의목적은회전근개봉합술후환자를대상으로한재활과정에서닫힌사슬운동적용시점에따른통증과관절가동범위, 상지과제수행력과기능수준의차이를확인하고이를통해효과적인재활프로그램을위한기초자료를제시하고자한다. Ⅱ. 연구방법 1. 연구대상및연구기간본연구는진단방사선과전문의에회전근개파열 Table 1. Application period to exercise between groups EXP1 EXP2 EXP3 EXP : Open chain exercise applied : Closed chain exercise applied EXP 1: Open chain exercise applied group EXP 2: Closed chain exercise applied group from 4 times EXP 3: Closed chain exercise applied group from 7 times EXP 4: Closed chain exercise applied group from 10 times

3 회전근개봉합술후닫힌사슬운동적용시점에따른효과비교 487 진단을받고수술한외래환자 78명중중도탈락자 13명, 선정기준미달자 20명, 참여거부 15명을제외한 40명을대상으로하였다. 대상자선정은회전근개파열진단을받은자, 수술후 6주가경과하고주치의의능동운동처방을받은자로하였으며, 경추부와상지에신경학적증상이있는자와견관절골절로인한처치를받은자는제외하였다. 모든참여자는설명을받고자발적으로동의한자로하였다. 본연구는대전대학교인간생명연구윤리위원회의연구심의를받고진행하였다. 대상자들은제비뽑기를통해무작위로 10명씩실험군 1, 실험군 2, 실험군 3, 실험군 4로배정하여 4주간주 3회, 1일 60분씩총 12회진행하였다. 모든실험군은동일하게일반적인물리치료 ( 온습포 30분, 경피신경자극치료 15분, 심부열치료 3분 ) 를적용하였다. 실험군 1은열린사슬운동을적용하였으며, 닫힌사슬운동적용을실험군 2는 4회부터그리고실험군 3은 7회부터그리고실험군 4는 10회부터적용하였다 (Table 1). 2. 평가도구 1) 견관절관절가동범위견관절의관절가동범위 (range of motion; ROM) 는측 각기 (gonoimeter) 를사용하여굴곡과신전, 외회전과내회전, 외전과내전에대한능동가동범위를측정하였다. ROM 측정시통증이발현되지않는범위에서 3회측정후평균값을사용하였다. 측정순서에의한영향을최소화하기위해무작위로진행하였다. 2) 통증수준통증수준은시각적상사척도 (visual analogue scale; VAS) 를사용하여측정하였으며, VAS는환자가느끼는통증의정도를시각적인형태로나타내는방법으로 10cm자를이용하여통증이전혀없는상태가 0cm이고매우극심한통증으로참을수없는상태를 10cm에표시한다. VAS의검사-재검사신뢰도 (r=.99) 와측정자간신뢰도 (r=1.00) 는매우높다 (Tashjian 등, 2009). 3) 상지과제수행력상지과제수행력을알아보기위해상자와나무토막검사 (box & block test; BBT) 를사용하였다. BBT는성인이나소아모두에게적용가능한도구로써, 60초동안정사각형의블록을한쪽상자에서다른쪽상자로옮긴개수를점수로산정하였다 (Desrosiers 등, 1994). 1회연습후 1회측정하여점수화하였다. Table 2. Rehabilitation Program Classification Warming up (5 min) Main Exercises (40 min) Cool down (5 min) Methods 1. Stretching the shoulder joint front section and rear portion in a standing position 2. Walking in place moving arms 3. Deep breathing Resting time (5 min) Open chain exercise Closed chain exercise 1. External rotation muscle strengthening exercise with a dumbbell in the side-lying position. 2. Scapular protraction and distraction, upward rotation and downward rotation, elevation and depression exercise using dumbbell. 3. Flexion and abduction, extension, internal rotation, external rotation exercises using dumbbells and elastic band (performed with isotonic). 1. External rotation strengthening exercises in a standing position using the wall 2. Push-up plus exercise using wall 3. Push-up plus exercise in quadri position 4. Lifting buttock with both hands in a sitting position in chair Resting time (5 min) 1. Stretching the shoulder joint front section and rear portion in a standing position 2. Walking in place moving arms 3. Deep breathing

4 488 J Korean Soc Phys Med Vol. 9, No. 4 Table 3. General characteristics of subjects Exp 1 (n=10) Exp 2 (n=10) Exp 3 (n=10) Exp 4 (n=10) F Sex (Male/Female) 6/4 7/3 5/5 5/5.38 Age (yrs) 46.30±7.04 a 54.00± ± ± Weight (kg) 64.60± ± ± ± Height (cm) ± ± ± ± Transitional Period (weeks) 7.00± ± ± ± Surgery Side (Left/Right) 4/6 4/6 3/7 7/ a Mean±SD Exp1: Open chain exercise applied group Exp2: Closed chain exercise applied group from 4 times Exp3: Closed chain exercise applied group from 7 times Exp4: Closed chain exercise applied group from 10 times Table 4. Comparison of range of motion change between groups in accordance with the applicable time of closed chain exercise Flexion/ Extension Abduction/ Adduction Rotation Exp 1 (n=10) Exp 2 (n=10) Exp 3 (n=10) Exp 4 (n=10) F Post Hoc pre ±12.80 a ± ± ± post ± ± ± ± Dif 14.74± ± ± ± pre ± ± ± ± post ± ± ± ± Dif 9.79± ± ± ± pre 91.70± ± ± ± post 99.60± ± ± ± Dif 7.50± ± ± ± >1 * a Mean±SD, * p<.05 Exp1: Open chain exercise applied group Exp2: Closed chain exercise applied group from 4 times Exp3: Closed chain exercise applied group from 7 times Exp4: Closed chain exercise applied group from 10 times 4) 견관절통증과기능수준견관절의통증과기능수준을알아보기위하여견관절통증과장애지수 (shoulder pain and disability index; SPADI, ICC=.64.66) 를사용하였다. SPADI는자가설문방식으로통증지수 5개, 장애지수 8개문항으로구성되어있으며각문항은어려움없음 0점에서전혀할수없음 10점으로총점과백분율로환산하여사용할수있다 (Williams 등, 1995). 3. 중재방법본연구에서재활프로그램은 Cohen (2002) 이제시한회전근개파열후재활프로그램을본연구목적에맞게수정하여사용하였다 (Table 2). 15회 /3세트로시행하였고모든운동은통증이유발되지않는범위에서대상자의상태에맞췄으며, 능력증진에따라난이도를조절하였다. 난이도조절방법으로아령은 kg으로 0.5kg 단위로향상시켰으며, 탄력밴드 (Thera-band, The Hygenic Corp, USA) 는색상에따라적용하였다. 모든운동은 3년이상의경력을가진물리치료사의감독하에시행하였다.

5 회전근개봉합술후닫힌사슬운동적용시점에따른효과비교 자료분석수집된자료는윈도우용 SPSS Ver 17.0 프로그램을사용하였으며, 그룹간측정항목들차이에대한검정은일요인분산분석 (one-way ANOVA) 을사용하였다. 사후검정은 Bonferroni 검정을실시하였다. 측정항목에대한통계학적유의수준은 α=.05로하였다. Ⅲ. 연구결과 1. 연구대상자특성연구에참여한그룹내대상자들의특성은 Table 3과같으며, 동질성검정에서모든항목에서그룹간유의한차이는없었다. 2. 견관절관절가동범위차이비교관절가동범위는중재전후그룹간차이비교에서외회전 / 내회전은실험군 2가실험군 1보다유의하게향상되었다 (p<.05). 굴곡 / 신전과외전 / 내전은그룹간유의한차이가없었다 (Table 4). 3. 통증수준의차이비교 VAS는중재전후차이비교에서실험군 2가실험군 1(p<.01) 과실험군 3(p<.05), 실험군 4(p<.05) 보다유의하게감소되었다. 다른그룹에서는유의한차이가없었다 (Table 5). 4. 상지과제수행력의차이비교 BBT는중재전후그룹간차이비교에서실험군 2가실험군 1(p<.01) 과실험군 4(p<.01) 보다유의하게향상되었다. 다른그룹에서는유의한차이가없었다 (Table 5). 5. 견관절통증과기능수준차이비교 SPADI는중재전후그룹간차이비교에서실험군 2와실험군 1(p<.05) 그리고실험군 2와실험군 4(p<.05) 에서각각유의하게감소하였다. 다른그룹에서는유의한차이가없었다 (Table 5). Table 5. Comparison of VAS and BBT, SPADI change between groups in accordance with the applicable time of closed chain exercises Exp 1 (n=10) Exp 2 (n=10) Exp 3 (n=10) Exp 4 (n=10) F Post hoc VAS b post 3.01± ± ± ± pre 6.00±0.75a 6.10± ± ± Dif 2.90± ± ± ± >1**, 3*, 4* BBT c post 23.43± ± ± ± pre 20.30± ± ± ± Dif 3.10± ± ± ± >1*, 4* SPADI d post 73.90± ± ± ± pre ± ± ± ± Dif 35.70± ± ± ± >1*, 4* a Mean±SD, b Visual analogue scale, c Box & black test, d Shoulder pain and disability index Exp1: Open chain exercise applied group Exp2: Closed chain exercise applied group from 4 times Exp3: Closed chain exercise applied group from 7 times Exp4: Closed chain exercise applied group from 10 times *p<.05, **p<.01

6 490 J Korean Soc Phys Med Vol. 9, No. 4 Ⅳ. 고찰본연구는회전근개봉합술후환자를대상으로재활프로그램에서닫힌사슬운동적용시점에따른차이를알아본결과, 열린사슬운동보다닫힌사슬운동에서견관절관절가동범위, 통증, 상지과제수행력과기능에서차이가있었고 2주차에서시작하는것이기능개선에효과적인것으로나타났다. 회전근개봉합술에있어회전근개파열의크기와파열의정도에따라수술후기능과만족도, 기능에영향을미친다 (Ellman, 1991) 고하였으나, 이후연구에서 Burkhart 등 (2001) 은파열의크기가결과에영향을주지않으며, 국내에서도전층파열과부분파열에있어기능의차이는없다고하였다 (Park, 2003). 이에본연구에서는파열의크기가결과에영향을주지않는다고판단하여대상자선정시파열크기를구분하지않았으며통증조절및기능회복을위한재활프로그램이중요하다고생각하였다. ROM은외회전과내회전만실험군 2에서실험군 1보다유의한향상이있었으나다른가동범위에서는유의한향상이없었다. Ellenbecker 등 (2006) 은봉합술후 12주경과환자를대상으로근력강화훈련을적용한연구에서가동범위와근력의유의한향상을보고하였다. 본연구에서도열린사슬운동과닫힌사슬운동모두에서가동범위증가가나타났다. 이는모든그룹에적용한 ROM운동이관절연골에영양분을공급하고, 콜라겐조직의정렬및재합성에도움 (Wilk와 Arrigo, 1993) 을준것으로생각된다. 그리고 Matthew 등 (2005) 은회전근개불균형원인이외회전과내회전의근력의차이, 근육크기등으로제시하였는데외회전과내회전에서유의한차이가있는것은본연구에서사용한재활프로그램이기능향상을위한외회전과내회전운동에초점이맞춰진것으로생각되며의미가있다고하겠다. VAS는실험군 2는실험군 1과실험군 3, 실험군 4에서유의한차이가있었다. 이는닫힌사슬운동방법으로적용한푸쉬업플러스운동이 (push-up plus) 견갑골의안정화에중요한전거근의활성화에영향을주었고중 승모근과하승모근의작용을촉진해견갑골의안정화와상방회전을원활하게이루어지도록한결과 4회차적용그룹이다른그룹에비해통증감소에긍정적영향을준것으로생각된다. BBT는실험군 2는실험군 1과실험군 4에서유의한차이가있었고, SPADI는실험군 2와실험군 1과실험군 4에서유의한차이가있었다. 회전근개수술후환자 37명을대상으로 ROM과등척성근력, 미국견주관절외과학회평가도구 (American shoulder elbow surgeons rating scale) 를사용하여 6주와 12주후비교에서유의한향상을보고한 Ellenbecker 등 (2006) 의연구결과와같았다. 회전근개는견관절안정화에중요한작용을하는근육으로기능회복을위한운동은상지의기능적움직임회복을위해반드시필요하며 (Ginn와 Cohen, 2005), 이러한어깨관절근육들은여러관절들을통해협응된활동을생산해내는복합적작용들로운동성이제공되며조절된다 (Neumann, 2013). 본연구에서닫힌사슬에바탕을둔푸쉬업플러스 (push-up plus) 운동을선자세와네발기기자세에서시행하여안정화작용에필요한견갑골주변근육의촉진과상호작용증진으로수행력과기능을향상시킨것으로생각된다. 회전근개봉합술후단순한증상회복을위함이아니라적극적인재활을통해통증조절과기능증진을이루어야한다. 이를위해닫힌사슬과열린사슬안정화운동 (Kisner와 Colby, 2012), 회전근개강화운동시견갑골안정화운동과결합 (Kibler 등, 2006) 하여재활프로그램을체계적으로시행하는것이중요하다. 또한 Dodson 등 (2010) 은회전근개봉합술후재파열의위험성을경고하였는데이역시재활의필요성을강조한것으로생각된다. 본연구의제한점은연구대상자수가적어모든회전근개수술후환자에게적용하기어려우며, 프로그램의효과의지속여부를확인하지못하였다. 이를보완한재활프로그램효과를알아보는연구가필요할것으로생각된다.

7 회전근개봉합술후닫힌사슬운동적용시점에따른효과비교 491 Ⅴ. 결론본연구는회전근개봉합술후환자를대상으로닫힌사슬운동적용시점에따른재활프로그램을실시하였고, 중재전후차이비교를통해관절가동범위와통증, 상지과제수행력, 기능수준을평가하였다. 분석한결과관절가동범위는실험군 2가실험군 1보다외회전 / 내회전에서 (p<.05) 유의하게향상되었다. VAS는실험군 2 가실험군 1(p<.01) 과실험군 3(p<.05), 실험군 4(p<.05) 보다더유의하게감소하였다. 그리고 BBT는실험군 2가실험군 1과실험군 4(p<.01) 에서유의한향상을, SPADI에서는실험군 1과실험군 4(p<.05) 에서유의하게감소하였다. 이러한결과는회전근개수술후환자가능동운동처방을받은후 2주차가되는시점부터닫힌사슬운동을적용하는것이효과적임을알수있었고, 이를통해재활프로그램으로적용가능성을확인하였다. References Boes MT. McCann PD. Dines DM. Diagnosis and management of massive rotator cuff tears: the surgeon s dilemma. Instructional course lectures. 2005;55: BurbanK KM. StevenSon JH. Czarnecki GR. et al. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008;77(4): Burkhart SS. Danaceau SM. Pearce Jr CE. Arthroscopic rotator cuff repair: analysis of results by tear size and by repair technique margin convergence versus direct tendon-to-bone repair. Arthroscopy: 2001;17(9): Cohen BB. Romeo AA. Bach Jr B. Rehabilitation of the shoulder after rotator-cuff repair. Operative Techniques in Orthopaedics. 2002;12(3): Desrosiers J. Bravo G. Hebert R. et al. Validation of the Box and Block Test as a measure of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil. 1994;75(7): Dodson CC. Kitay A. Verma NN. et al. The long-term outcome of recurrent defects after rotator cuff repair. Am J Sports Med. 2010;38(1):35-9. Ellenbecker TS. Elmore E. Bailie DS. Descriptive report of shoulder range of motion and rotational strength 6 and 12 weeks following rotator cuff repair using a mini-open deltoid splitting technique. J Orthop Sports PhysTher. 2006;36(5): Ellman H. Surgical treatment of rotator cuff rupture.in Watson Med. Surgical Disorders of the Shoulder. 1991: Ginn KA. Cohen, ML. Exercise therapy for shoulder pain aimed at restoring neuromuscular control: a randomized comparative clinical trial. J Rehabil Med. 2005;37(2): Kibler WB. Sciascia A. Dome D. Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med. 2006;34(10): Kim JH. Rehabilitation of Rotator Cuff Repair.The Journal of Korean Arthroscopy. 2008;12(2):82-6. Kisner C. Colby, L.A. Therapeutic exercise: foundations and techniques. FA Davis Lee BG. Cho N.S. Rhee, YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy: Arthroscopy. 2012;28(1): Ludewig PM. Cook T.M. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. PhysTher. 2000;80(3): Mattew AC. Michael CC. Michael GC. Orthipaedic sports medicine board review manual: Rotator cuff injury. Orthop Sports Med. 2005;2(2):1-13. Ministry of Labor.Analysis of the current state of work-related accidents Neumann DA. Kinesiology of the musculoskeletal system: Foundations for rehabilitation: Elsevier Health

8 492 J Korean Soc Phys Med Vol. 9, No. 4 Sciences Östör A. Richards C. PrevostA. et al. Diagnosis and relation to general health of shoulder disorders presenting to primary care.rheumatology. 2005;44(6): Park JY. Pathology of impingement syndrome and anatomy of the shoulder joint. Orthopedics classroom of DankookMedical University Prentice WE. Voight ML. Techniques in musculoskeletal rehabilitation: McGraw Hill Professional Tashjian RZ. Deloach J. Porucznik CA. et al. Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg. 2009;18(6): Wilk KE. Arrigo C. Current concepts in the rehabilitation of the athletic shoulder.j Orthop Sports PhysTher. 1993;18(1): William GB. Mary BB. Michael J. et al. Patient outcome following rehabilitation for rotator cuff repair surgery.j Orthop Sports PhysTher. 2007;37(6): Williams Jr JW. Holleman Jr DR. Simel D. Measuring shoulder function with the Shoulder Pain and Disability Index. J Rheumatol. 1995;22(4):

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar