JKPT pissn Vol. 28, No. 1, February 2016 J Kor Phys Ther 2016:28(1): eissn X Original Article The Effect of Exercise Using Gras

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1 pissn Vol. 28, No. 1, February eissn X Original Article The Effect of Exercise Using Grasping on Shoulder Muscle Activity and Muscle Thickness of Patients with Rotator Cuff Repair Eun-Young Choi 1, Hyun Choi 2 1 Department of Physical Therapy, Gwangyang Health College, Gwangyang; 2 Department of Physical Therapy, Mokpo Mirae Hosipital, Mokpo, Korea Purpose: This study intended to mediate shoulder exercise using grasping and investigate examine how its effects on affects activities of the shoulder surrounding muscles of the shoulder and thickness of shoulder muscle to suggest effective exercise for patients with rotator cuff repair to return to daily life. Methods: This study has been done targeteding male patients more than 6 weeks after having En-masse Suture Bridge Technique as rotator cuff repair of the right shoulder, aged 40 to 55 in a medical institution located in Jeollanam-do. Experimental group I (n=15) was selected for a conducting common exercise therapy program and Experimental group II (n=15) was selected for an conducting exercise therapy program using grasping. %RVC was measured by surface electromyography and muscle thickness was measured by ultrasound before mediation to for analysisze of before and after results within group and between groups. Results: In comparison of change of %RVC, Tthere were meaningful differences in only posterior deltoid and infra in comparing a change of %RVC within experimental group I (p< 0.001),. and Tthere were meaningful differences in both supra and infra in muscle thickness within experimental group I (p<0.001). In comparison of change of %RVC, Tthere were meaningful differences in anterior deltoid, posterior deltoid and infra in comparing a change of %RVC within experimental group II (p<0.05)(p< 0.01) (p< 0.001), and there were meaningful differences in both supra and infra in muscle thickness within experimental group II (p< 0.001). In comparison of change of %RVC between groups, Tthere was a meaningful difference in only posterior deltoid in comparing a change of %RVC between groups (p< 0.001). Conclusion: We found that exercise therapy using grasping has a positive effect on shoulder stability muscles such as supra muscle and infra muscle and activity of deltoid muscle. Keywords: Rotator cuff repair, Grasping, Shoulder muscle activity 서론인간의일상생활동작을수행하는데손의기능은반드시필요하며, 이와더불어일생생활동작을위해어깨관절의능동적관절운동범위와근력, 지구력, 피로에대한저항능력등이필요하다. 1 어깨관절이손상되면먹기, 씻기등과같은일상생활을수행하는데어려움을호소하게된다. 2 어깨관절손상은유착성어깨관절낭염, 어깨충돌증후군, 근막통증증후군, 어깨돌림근띠파열등이원인이되며, 특히어깨돌림근띠손상은근골격계질환및레져활동인구증가로그유병율이증가하고있는추세이고, 3 이렇게발생되는어깨돌림근띠파열들은일반적으로부분혹은완전손상으로발생되어기능적인측 면으로는 40세이후부터증가하기시작한다. 4 어깨돌림근띠의손상은어깨관절의벌림, 회전그리고위팔어깨의안정성을유지하는주된기능에악영향을미치며, 특히위팔어깨의힘줄염좌나움직임제한, 주변부위의액체유출, 그리고근부하의불균형등과같은특성들에의해다양한형태의역학적손상을보이고있다. 5 이렇게발생되는손상기전은독립적으로판단하기보다는다양한원인들로인해동시에발생되거나또는단계적으로작용하여병적인상태로진행되며, 6 이는어깨관절의고정이나약물등의치료로재생되거나자연경과로치유되기가어려워일시적으로통증이감소하더라도점진적인근력약화가동반되기도한다. 7 근례에들어어 Received Jan 18, 2016 Revised Feb 19, 2016 Accepted Feb 22, 2016 Corresponding author Hyun Choi enthusiasm74@naver.com Copylight 2016 The Korea Society of Physical Therapy This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License ( creativecommons.org/license/by-nc/3.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. 52

2 The Effect of Exercise Using Grasping 깨돌림근띠손상후발생하는관절증을치료하기위해관절경하최소간헐적봉합술및관절경하봉합술등의수술기법들이이용되고있으며, 8 통증을줄이고움직임과기능의회복에높은신뢰를보여주고있으나, 9 수술후관절낭의단축에서오는어깨관절의수동적움직임제한과근력의약화에서오는능동적움직임제한등이흔히발생된다. 10 이러한합병증을줄이고재파열을방지하기위해임상에서많은재활방법들이시행되고있지만, 관절경수술후에고전적재활지침에따라재활을수행해도수술환자 4.9% 에서는필연적으로관절경직이발생된다고보고하였다. 11 관절경직은점진적인기능감소를유발하고관절낭의구축으로인해어깨관절의모든관절가동범위에서나타나며특히머리위로손을가져가는업무나등뒤로손을가져가는활동들에있어서의어려움을나타낸다. 12 따라서기능적제한을회복시키기위해어깨에대한구조의이해를바탕으로기능제한에대한원인의탐구와이를기초로한치료를시행해야한다. 13 좋은재활프로그램은수술후환자가기능적활동과삶의질을빠른시간안에되돌릴수있는것이다. 14 이를위해어깨재활의치료지침은초기 6주동안은재건한힘줄의손상을줄이기위해능동적움직임을제한하고이후점차열린사슬과닫힌사슬을이용하여근육들의기능회복에초점을맞춰시행해야한다고권고하고있으며, 힘줄과뼈의확실한치유가확인되면시행해야한다는견해가일반적이다. 15 또한복원술후어깨돌림근띠근기능이약화됨으로움직임수행시근육작용의불균형이일어날수있고이를보상하기위하여이차적인압박이나장력이가해질수있기때문에이런현상을피하기위해근력강화의필요성또한제시되고있다. 16 복원술후운동중에서어깨의심부근육들의활성도를높일수있는방법으로쥐기 (hand grasp) 운동은수술부위에부하를크게전달하지않으며근육의긴장도를증가시킬수있는중재방법이다. 17 손에부하가가해질경우삼각근과같은어깨거상근육에비해어깨관절의안정성에관여하는어깨돌림띠근육, 특히가시아래근에서근활성도의변화가 더욱두드러진다고하였는데, 수의적인쥐기힘이증가하는동안세모근들의활성도가줄어드는반면가시아래근의참여도는증가한다고하였다. 18 본연구는이러한쥐기의특성을사용하여어깨운동을중재한후어깨주변근육의활성도와근두께에미치는영향을알아봄으로써향후어깨돌림근띠복원술환자의조기일상생활복귀를위한효율적인운동방법을제시하고자한다. 연구방법 1. 연구기간및대상본연구는 2014년 10월부터 2015년 5월까지 8개월간, 전라남도에소재한의료기관에서오른쪽어깨돌림근띠복원술을일체 (En-masse) 교량형봉합술로받은 40-55세연령범위의남성환자들로, 연구대상자선정기준은어깨돌림근띠부분파열 (3 cm 미만 ) 을진단받고어깨돌림근띠복원수술을받은지 6주가지난환자로, 본연구에영향을미칠수있는다른근골격계또는신경계질환이없는자로선정하였으며, 병원인근에거주하여퇴원후에도외래로꾸준히중재를받을수있는자, 본연구를충분히이해하고동의한 30명을표본추출하여실험군 Ⅰ과실험군 Ⅱ에각각 15명씩무작위로배치하였다. 2. 연구설계본연구는어깨돌림근띠복원술을받고 6주가지난남성환자들을대상으로일반적운동치료프로그램을중재한집단을실험군 Ⅰ로, 쥐기를활용한운동치료프로그램을중재한집단을실험군 Ⅱ로설정한후, 4주간, 주 4회, 1일 1회, 1회 40분간중재하여, 중재전표면근전도로 %RVC를측정하였고, 초음파로근두께를측정하였고 4주중재후다시 %RVC와근두께를재측정하여집단내전후비교와집단간분석을실시하였다. Table 1. General exercise program on 1-4 weeks General exercise program on 1-2 weeks General exercise program on 3-4 weeks Position Stretching Strengthening` Stretching Strengthening Standing Supine Sidelying Prone Pendulum Behind the back internal rotation Passive arm elevation with 90 abduction cross-chest stretch Horizontal arm raises, "t" rowing, scaption "y" Pendulum Behind the back internal rotation Wall slide stretch Passive arm elevation with 90 abduction Cross-chest stretch Forward flexion Sub-maximal isometric exercise: internal and external rotation at neutral 53

3 The Journal of Korean Physical Therapy Eun-Young Choi, et al. 3. 중재방법 1) 일반적운동치료일반적운동치료는미국스포츠의학협회에서제시한객관화된지침을사용하였으며, 1단계강화운동후실시하는 2단계강화운동단계로주로치료사나보조기구를이용한능동보조운동을실시하였고, 저항성견갑골강화운동과어깨돌림근띠와어깨세모근에대한운동을주로시행하였으며, 수행되는모든운동은통증이없는범위에서실시하였다 (Table 1). 신장운동은각동작간 1회씩 3set 로실시하였고, 근력운동은 1set 당 6회씩 3set 를 1주일에 4회실시하였다. 그리고운동간피로를방지하기위해휴식시간은 set 당 1-2분의휴식을갖게하였으며, 운동후에통증을조절하기위해 Icing 15분, TENS 15 분을적용하였다. 2) 쥐기를활용한운동치료대상자들의쥐기운동중량을결정하기위해악력계를사용하여파악력 1RM (Repeated maximum) 을측정한후, 측정값을토대로훈련중량은 1RM의 30% 로설정하였다. 일반적운동치료중재에서근력강화의동작전에악력계를사용하여쥐기를 1RM의 30% 중량으로쥔후일반적운동치료의운동과정을수행하였고, 19 운동을시행하는동안악력계의수치를지속적으로확인하여시각적 feedback을활용한운동을실시하였으며, 20 신장운동은각동작간 1회씩 3set 로실시하였고, 근력운동은 1set 당 6회씩 3set 를 1주일에 4회실시하였다. 그리고운동간피로를방지하기위해휴식시간은 set 당 1-2분의휴식을갖게하였으며, 운동후에통증을조절하기위해 Icing 15분, TENS 15분을적용하였다. 4. 측정방법 1) 어깨주변근활성도측정 (1) 표면근전도전극부착어깨주변근육의근활성도를측정하기위해표면근전도 MP 150 system (Biopac, USA) 5채널을사용하였으며, 근전도신호수집을위한표본추출율 (sampling rate) 은 1,000으로하였고, 주파수대역필터는 Hz로하였다. 앞어깨세모근, 뒤어깨세모근, 가시위근, 가시아래근그리고위등세모근의근전도신호를수집하기위한전극부착방법및부위는다음과같다. 근전도신호의피부저항을최소화하기위해대상자들의피부에서털을제거하고가는사포를이용하여각질을제거한뒤알코올솜으로문질러피부를청결히한후, Ag/Agcl 표면전극을사용하여앞어깨세모근은어깨봉우리에서손가락 2-3개정도아래근복위근섬유방향으로부착하였고, 뒤어깨세모근은어깨봉우리에서후부쪽으로손가락 2-3개정도뒤에부착하였다. 가시위근은어깨뼈가시돌기의 외측원위부를촉지하여어깨뼈가시위돌기에부착하였으며, 가시아래근은어깨뼈가시돌기를촉지하고이와평행하게외측연으로부터 4 cm 정도가시아래돌기에부착하되어깨세모근후부섬유를피해서부착하였다. 위등세모근은제7목뼈가시위돌기와빗장뼈원위부사이 1/3 지점에부착하였고, 접지전극은가까운돌출부위에부착하였으며, 모든전극은 2 cm 간격으로근섬유와평행하게부착하였다. (2) %RVC 측정 %RVC 측정은우선특정동작을기준으로정규화 (Normalizing) 하기위해기준동작시 RMS값과특정동작시 RMS를측정하였다. 기준동작시 Root Mean Square (RMS) 는악력계를자연스럽게쥐고, 어깨관절 90 팔꿉관절폄상태에서 5초동안유지할때앞어깨세모근, 뒤어깨세모근, 가시위근, 가시아래근그리고위등세모근의근전도신호를수집하여, 앞 1초구간과뒤 1초구간을제거하고 3초구간의 RMS 값을구하였고, 이를 3회반복측정하여평균값을측정하였다. 특정동작시 RMS는기준동작과동일한자세에서악력계를최대의힘으로 5초동안쥐게하여앞어깨세모근, 뒤어깨세모근, 가시위근, 가시아래근그리고위등세모근의근전도신호를수집하였으며, 앞 1초구간과뒤 1초구간을제거하고 3초구간의 RMS값을구하였고이를같은방법으로 3회반복측정하여평균값을측정하였다. 매측정마다충분한휴식을취한후측정하였으며, 동작시간의균일화를위해동작시메트로놈을켜놓고사전에충분한연습을통해시간내에동작을실시하도록하였다. 이렇게수집된근전도신호들은특정동작시 RMS 평균값을기준동작시 RMS 평균값으로나눠백분율하여 %RVC 값을구하였으며, 근전도신호분석은 Acqknowledge software program (Biopac, USA) 를사용하였다. 2) 가시위근과가시아래근의두께측정근육의구조변화를측정하기위해범용초음파영상촬영장치 (Acuson X300PE, Siemens Co., Germany) 를사용하여가시위근과가시아래근의두께를측정하였다. 사용된변환기는 VF1 선형변환기 (Liniear transducer) 로장치의주파수변조범위는 3-5 MHz이고 gain 범위는 20-80이다. gain (G50) 과 focus (4.5 cm) 는고정시켜모든검사에동일하게적용하였다. 측정자세는팔걸이의자에편하게앉아팔걸이에팔을올려놓아아래팔부위를고정하여상지를이완시킨후측정하였다. 가시위근을검사하기위해견갑가시에서상부 2.5 cm, 내측모서리에서 2.5 cm 에서횡주사 (transverse measurement) 를하였으며, 가시아래근을검사하기위해어깨가시에서하방 5 cm, 내측모서리에서 2.5 cm 에서횡주사로평면형프로브 (Linear Pro be) 를사용하여검사하였다. 21 획득한영상은컴퓨터영상저장및전송프로그램인 picture achiving and communication system (PACS) 의 caliper를사용하여두께 54

4 The Effect of Exercise Using Grasping 를분석하였다. 시위근, 가시아래근, 위등세모근등에서정규성을나타내었다 (Table 2). 5. 자료분석 자료분석방법은 Window 용 SPSS 18.0 을이용하여연구대상자의일 반적특성을 Shapiro-wilk 로정규성검정하였다. 어깨주위근활성도 와근두께의집단내변화비교는대응표본 t- 검정 (Paired t-test) 을사 용하였으며, 사전검사값을통제하기위해공변량을사전검사로설 정후집단간사후검사값으로공분산분석 (ANCOVA) 을시행하였 고, 유의수준은 α = 0.05 로설정하였다. 결과 1. 연구대상자들의일반적특성 실험집단간키, 나이, 몸무게, 그리고앞어깨세모근, 뒤어깨세모근, 가 Table 2. Characteristic of subjects Items Experimental groupⅠ (n=15) Experimental groupⅡ (n=15) t p * Age 52.5± ± Hight 166.5± ± Weight 64.2± ± Anterior %RVC 94.6± ± Posterior %RVC 100.0± ± spnatus %RVC 99.6± ± %RVC 122.4± ± Trapezius Upper %RVC 103.6± ± * Shapiro-wilk. Table 3. Change in %RVC and muscle thickness within experimental group I %RVC Muscle thickness * p< anterior posterior Trapezius upper Experimental group I (n=15) pre-test post-test 94.64± ± ± ± * 99.62± ± ± ± * ± ± ± ± * 14.17± ± * t p 2. 집단내실험군 I 의 %RVC 와근두께변화비교 실험군 I 의집단내 %RVC 변화비교에서는뒤어깨세모근과가시아래 근에서유의한차이가있었으며 (p < 0.001), 근두께에서는가시위근과 가시아래근모두에서유의한차이가있었다 (p< 0.001) (Table 3). 3. 집단내실험군 II 의 %RVC 와근두께변화비교 실험군 II 의집단내 %RVC 변화비교에서는앞어깨세모근, 뒤어깨세 모근그리고가시아래근에서유의한차이가있었으며 (p < 0.05, p < 0.01, p < 0.001), 근두께에서는가시위근과가시아래근모두에서유 의한차이가있었다 (p< 0.001) (Table 4). 4. 집단간 %RVC 와근두께변화비교 집단간 %RVC 의변화비교에서는뒤어깨세모근에서만유의한차이 가있었고 (p< 0.001), 근두께에서는유의한차이가없었다 (Table 5). 고찰 수술후재활의목적은질환의상태를이해하여추가손상을방지하 고, 교원질의회복을도모하며약해진근력을강화시켜유착, 구축등 에의해감소된관절운동을회복하는것이지만봉합부위와힘줄을 복원한부위를고려해서적용해야한다. 16 어깨돌림근띠복원술후 어깨돌림근띠의기능이소실된상태에서는어깨세모근의대상성흥 분으로인해어깨뼈의관절오목에대한위팔뼈의위쪽으로향하는 압력이발생하고이때문에정상적인움직임이어려워지게된다. 22 이 Table 4. Change in %RVC and muscle thickness within experimental group II %RVC Muscle thickness anterior posterior Trapezius upper Experimental group II (n=15) pre-test * p< 0.05, ** p< 0.01, *** p< post-test ± ± * ± ± ** ± ± ± ± *** ± ± ± ± *** 14.03± ± *** t p 55

5 The Journal of Korean Physical Therapy Eun-Young Choi, et al. Table 5. Change in %RVC and muscle thickness between experimental groups Group Pre Post F p %RVC anterior Experimental group I 94.64± ± Experimental group II ± ±22.71 posterior Experimental group I 99.97± ± * Experimental group II ± ±14.26 Experimental group I 99.62± ± Experimental group II ± ±18.49 Experimental group I ± ± Experimental group II ± ±12.23 Trapezius upper Experimental group I ± ± Experimental group II ± ±21.52 Muscle thickness Experimental group I 50.15± ± Experimental group II 50.12± ±3.89 Experimental group I 14.17± ± Experimental group II 14.03± ±3.47 * p< 는수술후기능이떨어진어깨돌림근띠에의해나타나는일반적인현상으로수술후근력의회복에미치는영향은파열정도에따라다른것으로인식되었지만, 최근엔수술후어떤관리를하느냐에따라회복정도는달라질것이라는의견이지배적이다. 23 본연구는어깨돌림근띠복원술후 6주가지난환자를대상으로 4 주간일반적운동치료중재와쥐기를활용한운동치료중재를적용하여어깨주변근육의활성도와근두께에미치는영향을알아보았으며, 결과를토대로다음과같이논의해보고자한다. McCully 등 24 은가시위근의기능이떨어진상태를재연하기위해 15명의남녀대상자로가시위신경을신경마취시키기전과후를비교하였는데, 가시위신경마취로인한가시위근의약화시어깨세모근들의근활성도증가를확인하였다. 어깨충돌증후군환자나어깨돌림근띠손상환자의운동치료는이러한대상성움직임을줄이고가동화단계에서나타나는불균형을정상적으로되돌리는데목적이있다. 25 또한 Worsley 등 15 은정상군 16명과어깨충돌증후군을가진환자 16명을대상으로 10주동안운동조절재훈련을시켜표면근전도와 Vicon 3차원동작분석기를사용하여관절기능과어깨주변근육의활성도및생역학적분석을한실험에서어깨뼈의운동학적측면과연관된어깨근육들이변화되는것을확인하였다. 그리고 Roy 등 26 의연구에서도 33명의어깨끼임증후군환자들에게뻗기동작을훈련시킨결과어깨에적용한운동중재가어깨의끼임증후군을완화시켰다고하였고, 이는운동중재가어깨의근육동원패턴을변화시켰기때문이라고하였다. 본연구에서도실험군집단내 %RVC의변화비교에서는실험군I의경우뒤어깨세모근은중재후증가하였고가시아래근은 %RVC 가감소하여유의한차이를나타냈으며, 실험군 II의경우앞어깨세모근, 뒤어깨세모근그리고가시아래근모두 %RVC가감소하여수술 후정상적인어깨움직임을방해하는대상성움직임이쥐기를활용한운동을통해서어느정도억제된것으로나타났다. 그러나실험군 I의뒤어깨세모근의증가는중재후여전히남아있는어깨세모근의대상성흥분을반영하는것이라할수있다. 어깨관절의초기움직임시에가시위근은특히 30 미만에서높은활성도를보인다. 27 가시위근은어깨돌림근띠손상중손상률이 95% 이상으로가장높은손상빈도를보이며, 가시아래근이나어깨밑근이다음으로높은손상빈도를보이고있다. 28 또한 Struyf 등 29 은어깨의끼임증후군환자들을대상으로연구된 12개의논문들을중심으로리뷰논문을작성하였는데, 위등세모근의활성도가비정상적으로높아져있음을보고하였다. 특히아래등세모근의활성도가떨어지는현상을보이는사람들에게서위등세모근은흔히지나친활성도를가지게된다. 위등세모근의높은활성도는가슴우리에서빗장뼈의지나친올림을야기하고어깨뼈의앞쪽기울기를발생시켜어깨위팔관절의올림시에어깨의충돌증상을만들어낸다. 30 위등세모근은어깨의기능장애가발생되어어깨관절의원할한움직임이일어나지않을때어깨세모근과더불어대상작용으로가장많이동원되는근육중하나이다. 22 Jang 등 31 은두가지팔의각도와네가지쥐기강도로어깨근육들의근활성도를알아본실험에서손쥐기자세를중립자세에서실시할경우가시아래근이활성화되고, 팔 70 거상자세에서는어깨세모근이억제된다는것을발견하였다. Antony 와 Keir18의연구에서도 16명의대상자로어깨의등척성수축과동적수축을하는동안에 30% 쥐기와손에 0.5 kg의무게를든상태, 그리고하중이손에없는경우로각각 8개근육의근활성도를측정한결과특히가시아래근의활성도가 2% 정도증가했으나아직정확한기전은밝혀진바없다고하였다. 또한 Sporrong 등 32 에따르면정적인쥐기를통해 56

6 The Effect of Exercise Using Grasping 세모근의최대근활성도가 4-14% 정도줄어든다고하였으며, Hodder 와 Keir 33 의연구에서도앞어깨세모근의경우쥐기를여러차례반복하면활성도가떨어진다는것을발견하였다. 본연구결과에서도실험군집단간 %RVC의변화비교에서실험군 Ⅱ의뒤어깨세모근만이통계학적으로유의한차이를보였으며, 쥐기를활용한운동치료그룹에서뒤어깨세모근의근활성도의감소가더많이나타나선행연구들을지지하였다. 이는쥐기를활용한운동치료가어깨세모근의대상성움직임을억제하는데좀더효과적이었다는것을나타내는결과라고할수있을것이다. 이처럼집단간비교에서유의한차이가뒤어깨세모근에서만나타난이유는집단내비교와마찬가지로 %RVC를측정하는자세가어깨관절 90 굽힘상태에서실시했기때문이라고사료된다. 19 또한본연구결과에서통계학적으로유의한차이는나타나지않았으나두집단모두에서전체적으로 %RVC가감소한양상을보였는데, 검사방법에서어깨의직접적인운동하에서의측정이아닌최대쥐기를시행하는동안측정된어깨근육들의간접적인 %RVC이기때문에나타난결과라고추측된다. Oschman 등 34 은 15명의어깨돌림근띠파열환자들을대상으로가시위근과등세모근을측정하였는데검사결과파열정도가증상이없는파열군보다파열정도가더컸음을발견하였고가시위근에위축이나타났다고제시하였다. Myung 35 의연구에서도어깨돌림근띠환자들을대상으로 8주간슬링을이용한운동치료와일반적운동치료를비교한실험에서두그룹모두 8주후에가시위근과가시아래근의유의한근두께변화를나타낸다고보고하였다. 본연구에서도실험군집단내근두께변화비교에서가시위근, 가시아래근은실험군모두에서통계학적으로유의한차이가나타나위의연구들을지지하였다. 그러나실험군집단간근두께변화비교에서가시아래근만이통계학적으로유의한차이가있었다. 가시아래근의경우실험군 Ⅱ 에서근두께가더커진것으로나타났는데이는쥐기를활용한운동이가시아래근의선택적강화에효과가있음을의미하는것이다. 17 본연구를통해서일반적운동치료중재와쥐기를활용한운동치료중재는어깨돌림근띠복원술환자들의어깨주변근활성도및근두께에영향을준다는것을알수있었다. 특히쥐기를활용한운동치료중재는가시위근과가시아래근같은어깨안정화근육들과수술후재활기간에나타나는어깨세모근의증가된근활성도를진정시켜긍정적인영향을미친다는것을알수있었다. 본연구의제한점으로는단일의료기관에서실험을진행했다는것과환자들의약물과일상생활을통제하지못하여결과에따른변수가발생될수있다는점이며, 근활성도측정동작이직접적인어깨움직임이아닌최대쥐기를통한간접적인측정방법이라는점과중재기간이짧고남자환자들만을대상으로하여일반화하기에는어려움이따른다. 하지만어깨재활에있어안정성에관계된어깨돌림근띠근육들의선택적근력강 화는기능적인어깨움직임에필요한임상적기초자료로써중요한 요소이고, 그렇기때문에앞으로도지속적으로연구되어야할과제 이며어깨관절움직임의다양성만큼다각적인시도가필요할것이다. REFERENCES 1. Sokk J, Gapeyeva H, Ereline J et al. Shoulder muscle function in frozen shoulder syndrome patients following manipulation under anesthesia: A 6-month follow-up study. Orthop Traumatol Surg Res. 2013;99(6): Song HS, Kim SY. Comparison of the rehabilitation program after rotator cuff repair by time closed chain exercise. J Korean Soc Phys Med. 2014;9(4): Wiliams GR, Rockwood CA, Bigliani LU et al. Rotator cuff tears: why do we repair them?. J Bone Joint Surg Am. 2004;86-A(12): Seitz AL, McClure PW, Finucane S et al. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both?. Clin Biomech, 2011;26(1): Maxwell CP, James ET, Thay QL. History, physical examination, radiographic anatomy, and biomechanics and physiological function of the rotator cuff. Oper Tech Sports Med. 2012;20(3): Kim YK. Controversy in pathophysiology of rotator cuff tear: degenerative tear. CiSE. 2008;11(2): Oliva F, Osti L, Padulo, J et al. Epidemiology of the rotator cuff tears: a new incidence related to thyroid disease. Muscles Ligaments Tendons J. 2014;4(3): Papadopoulos P, Karataglis D, Boutsiadis A et al. Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: a 3-5 year follow-up study. J Shoulder Elbow Surg. 2011;20(1): McKee MD, Yoo DJ. The effect of surgery for rotator cuff disease on general health status. Results of a prospective trial. J Bone Joint Surg Am, 2000;82-A(7): Namdari S, Green A. Range of motion limitation after rotator cuff repair. J Shoulder Elbow Surg, 2010;19(2): Huberty DP, Schoolfield JD, Brady PC et al. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy. 2009;25(8): Seo BD, Shin HS. The effect of self-stretching exercise in patients with shoulder adhesive capsulitis. J Kor Soc Phys Ther. 2010;22(1): Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthop Phys Ther Clin N Am. 2001;32(3): Yoon HY, Choi JD. Effects of Low-intensity Scapular Stabilization Exercise in Arthroscopic Shoulder Surgery Patients. J Kor Soc Phys Ther. 2012;24(3): Worsley P, Warner M, Mottram S et al. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. J Shoulder Elbow Surg. 2013;22(4): Kim jh. Rehabilitation of rotator cuff repair. The Korean Journal of Arthroscopy Soc. 2008;12(2): Kang JI, Moon YJ, Park sk et al. Effects of exercise program intervention on muscle activity in rotator cuff repair patient. J Kor Soc Phys Ther. 2013;25(2): Antony NT, Keir PJ. Effects of posture, movement and hand load on 57

7 The Journal of Korean Physical Therapy Eun-Young Choi, et al. shoulder muscle activity. J Electromyogr Kinesiol. 2010;20: Choi H. The effect of hand grip force on the activity of shoulder muscles in the patterns of arm position. Journal of Digital Convergence. 2012; 10(9): Smets MP, Potvin JR, Keir PJ. Constrained handgrip force decreases upper extremity muscle activation and arm strength. Ergonomics. 2009; 52(9): Juul-Kristensen B, Bojsen-Møller F, Holst E et al. Comparison of muscle sizes and moment arms of two rotator cuff muscles measured by ultrasonography and magnetic resonance imaging. Eur J Ultrasound. 2000; 11(3): Steenbrink F, Nelissen RG, Meskers CG et al. Teres major muscle activation relates to clinical outcome in tendon transfer surgery. Clin Biomech. 2010;25(3): Lee SY, Gong WT, Park MC et al. A study of shoulder stabilizer muscle exercise using the contraction of finger flexor muscle. J Phys Ther Sci. 2011;23: McCully SP, k DN, Kosek P et al. scapular nerve block results in a compensatory increase in deltoid muscle activity. J Biomech. 2007; 40(8): Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012;21(11): Roy JS, Moffet H, Hébert LJ et al. Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: a single-subject study design. Man Ther. 2009;14(2): Alpert SW, Pink MM, Jobe FW et al. Electromyographic analysis of deltoid and rotator cuff function under varying loads and speeds. J Shoulder Elbow Surg. 2000;9(1): Braddom RL, R.M. Buschbacher. Physical medicine and rehabilitation. 2nd, W.B. Saunders Company, Struyf F, Cagnie B, Cools A et al. Scapulothoracic muscle activity and recruitment timing in patients with shoulder impingement symptoms and glenohumeral instability. J Electromyogr Kinesiol. 2014;24(2): De Mey K, Danneels L, Cagnie B et al. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. 2013;16(1): Jang HJ, Kim JS, Choi JD et al. The effects of hand grip force on shoulder muscle activity in two arm posture. JKAIS. 2012;13(3): Sporrong H, Palmerud G, Herberts P. Hand grip increases shoulder muscle activity, An EMG analysis with static hand contractions in 9 subjects. Acta Orthop Scand Suppl. 1996;67(5): Hodder JN, Keir PJ. Targeted gripping reduces shoulder muscle activity and variability. Electromyogr Kinesiol. 2012;22(2): Oschman Z, Janse van Rensburg C, Maritz NGJ et al. Ultrasound study of the asymptomatic shoulder in patients with a confirmed rotator cuff tear in the opposite shoulder. South African Sports Medicine Assoc. 2007;19(1): Myung MS. The effect of sling exercises on increase muscles thickness, function, and range of motion in rotator cuff surgery patients. Junnam University. Dissertation of Master s Degree

CASE STUDY

CASE STUDY Biomechanics GACHON UNVERSITY Dept, of Physical Therapy Choi Won Ho Chapter3. Shoulder complex 학습목표 Q. 근육과관절의상호작용에대하여알아본다. 어깨근육들의작용 어깨가슴관절의근육들 팔을올림시키는근육들 어깨관절을모음시키고폄시키는근육들 어깨관절을안쪽돌림시키는근육들과가쪽돌림시키는근육들 3