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1 J Korean Soc Phys Med, 2015; 10(1): Online ISSN: Print ISSN: X Research Article Open Access 복식호흡을병행한척추안정화운동이요통환자의균형능력과오스웨스트리장애지수에미치는영향 손호희 부산가톨릭대학교보건과학대학물리치료학과 The Effects of Stabilization Exercise with Abdominal Breath on Balance and Oswestry Disability Index for Low Back Pain Patients Ho-Hee Son, PT, PhD Department of Physical Therapy, College of Health Sciences, Catholic University of Pusan Received: January 23, 2015 / Revised: February 5, 2015 / Accepted: February 9, 2015 c 2015 J Korean Soc Phys Med Abstract 1) PURPOSE: This study was to investigate the effect of stabilization exercise with abdominal breath on Balance and Oswestry Disability Index for Low Back Pain Patients. METHODS: The subjects were 18 low back pain patients in their twenties. The subjects were randomly assigned into experimental group and control group. Control group and experimental group both participated in 30 minutes of stabilization exercise for 8 weeks(5 times/week), and experimental group participated in stabilization exercise with abdominal breath. The subjects were tested balance and pain using BioRescue and Oswestry Diability Index respectively, before and after intervention. RESULTS: The experimental group showed a statistical significance in movement areas of the body's center(p<.05), but there was no significant differences between groups (p>.05). The experimental group showed a statistical significance in movement distances of the body's center with eyes open(p<.05), and there was significant differences between groups(p<.05). Both groups showed a statistical significance in ODI between pre and post test(p<.05) but there was no significant differences between groups(p>.05). CONCLUSION: As a result, the group participating in stabilization exercise with abdominal breath had a more effective improvement than the control group. Therefore, the stabilization exercise with abdominal breath may be used improving balance and pain in low back pain patients. Key Words: Stabilization exercise with abdominal breath, Balance, Oswestry Disability Index Corresponding Author : sonhh@cup.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. 서론 요통환자들은통증으로인해자세의변화가발생하고이로인해근육의길이, 신체질량중심과압력중심의

2 위치가변화되어있다. 이러한변화들로인해요통환자들은근육의수축속도및수축강도가변화하게되는데, 심부분절의근육수축속도와강도가감소되고대단위분절의근육의과도한활동과긴장성수축이일어나게되어결국요통환자들의움직임은정상인들과는달라지게된다 (Hodges 와 Richardson 1999, Selles 등, 2001). 몸의균형과평형을유지하기위해서는많은근육이기능적으로잘조화된패턴으로작용해야하며이를위해서는정상적인운동제어능력을통한근육동원패턴이지속적으로일어나야한다. 그러나요통환자들은정상적인운동제어능력이감소하여비정상적분절움직임이과도한범위로일어나는임상적불안정성이발달된다. 그러므로요통환자들에게는심부분절의근육안정화가매우중요한데, 특히횡경막과복횡근의근긴장은심부안정화를제공하기위한가장중요한요소이다.(Chaitow, 2004). 최근많은연구에서급성, 아급성및만성요통의예방과치료를위해척추안정화운동을시행하고있다 (Moseley, 2002; Niemisto 등, 2003). 척추안정화운동은척추분절조절, 동적안정성, 허리의근력, 지구력을증가시켜허리의통증을줄이고기능을향상시켜기능장애를교정하고신경근조절시스템을강화하기위해실시한다 (Rasmussen-Barr 등, 2003; Arokoski 등, 2004). 여러무작위임상연구를통해척추안정화운동의효과를평가하고있으며척추안정화운동을통해통증을감소시키며요통의재발을막고건강관리에장기간의효과가있는것으로밝혀졌다 (O sullivan 등, 1997; Koumantakis 등, 2001; Hides 등, 2001). 이처럼요통환자에게척추안정화운동의효과가있는것이알려지면서임상에서요통환자를위한안정화운동을실시하고있으며그효과를더하기위해운동시복부할로잉기법을적용하거나요가호흡, 강제호흡등의다양한호흡기법을함께사용하고있다. 복부할로잉기법은복횡근, 내복사근, 다열근, 횡경막등의심부근육을우선수축시키기는것으로복횡근이골반저근및횡경막과함께작용하면복부내압을상승시켜심부안정성을제공하는데도움이된다고알려져있다 (Allison 등, 1998; Matthijs 등, 2014). 척추안정화운동과 함께적용하는호흡기법으로는강제호흡, 요가호흡등이활용되고있다. 강제호흡 (forced breath) 은호흡장비를사용하여들숨과날숨을조절하여복부근육을자극시키는방법으로흉요부의안정화에도움을준다 (Ki, 2011). 복식호흡은횡격막을주로사용하는호흡방법으로, 숨을깊이들이마셔폐바로아래에위치한횡격막이아래로내려오면서복강의내압이상승하게되고심부근육의활성에도움을주게된다. 이러한장점을이용하여복부부위의통증이완, 분만시호흡조절및스트레스관리의목적으로이용되고있다 (Kim 등, 2005a). 지금까지의연구에서요통환자에게복부할로잉, 강제호흡운동, 복식호흡등의다양한호흡형태를적용한연구는있어왔다. 그러나복부할로잉운동은대상자가정확하게운동을수행하기위해서는생체피드백시스템을사용하는등충분한훈련이필요하며강제호흡운동또한호흡장비를사용해야하는등의단점이있다. 이에비해복식호흡은기법이단순하고일상생활이나운동중자연스럽게통합할수있어 (Yu와 Song, 2001) 유용하다. 지금까지복식호흡을하는동안직접적으로요부근육의활성도에미치는영향에대한연구는많이있어왔으나이러한복식호흡을안정화운동과병행했을때요통환자의균형능력과기능에미치는영향에대한연구는매우부족한실정이다. 따라서본연구는요통환자에게안정화운동과복식호흡을병행하여적용하였을때균형능력과허리통증으로인한장애지수에미치는영향을알아보고자하였다. Ⅱ. 연구방법 1. 연구대상및연구기간본연구는 B광역시에거주하는 20대의요통환자 18 명을대상자로선정하였다. 선정조건은 6개월이상의간헐적만성요통 (intermittent chronic low back pain) 을가지고있으며연구종료시까지정해진운동프로그램을수행할수있는자로하였으며본연구에서의운동프

3 Table 1. Exercise Program warm up main ex. cool down exercise number of times muscle side reach 10times 1set(both side) rectus abdominis, Abdominal external oblique, Abdominal internal oblique forward bending 10times 1set rectus abdominis crunch(with towel) criss cross exercise (with towel) 10times 1set 10times 1set(both side) transversus abdominis, rectus abdominis rectus abdominis, Abdominal external oblique, Abdominal internal oblique bridge 5times 1set erector spinae, multifidus quad arm leg reach shoulder pull down (with towel) 10times 1set(both side) 10times 1set rectus abdominis, erector spinae abdominal muscle stretching 로그램이외의도수치료를받은자, 척추수술의병력을가진자, 신경학적손상으로신경근압박이심한자, 염증성관절병변으로진단된자는제외하였다. 모든대상자는연구에대한설명을듣고이해를구하여자발적동의를얻은후실험에참여하였다. 연구기간은 2012년 7월부터 2012년 9월까지총 8주간운동을실시하였다. 2. 연구절차연구대상자들을무작위로두그룹으로배정하여실험군은요부안정화운동을실시하는동안복식호흡을함께적용하였고대조군은요부안정화운동만시행하였다. 운동시작전과 8주간운동을실시한후, 균형증진정도와요통장애지수를비교하였다. 체간안정화운동은외부저항없이심부수축에서시작하여등척성운동에서동적운동으로변화하고체중을부하하지않은자세에서체중부하자세로지지면의변화를주도록설정하였다. 운동은준비운동 2가지, 본운동 3가지, 정리운동 2가지로이루어졌다. 실험군은운동을하면서동작을하는동안배가볼록나오도록들숨을하고준비자세로돌아오는동안배를집어넣으면서날숨을한다. 대조군은호흡을신경쓰지않고동작을시행한다. 운동은주 5회, 1세트에 20분, 총 8주 간시행하였다. 대상자들의상태를고려하여첫째주에는운동을 1세트씩만하였고, 둘째주에는 2세트씩하였고, 셋째주부터는 3세트씩하였다. 운동방법은표 1과같다 (Table 1). 3. 측정도구 1) 균형검사 : 연구대상자들의균형능력을측정하기위해 Bio-rescue(RM INGENIERIE, Rodez, France) 장비의롬버그테스트 (Romberg test eye open/close) 를사용하였다. 측정시시작자세는측정장비위에올라서서발판위의사선을두번째발가락으로밟도록발뒤꿈치를붙이고발의앞쪽부분은 30 간격을유지하도록하였다. 롬버그테스트는측정장비위에올라눈을뜬상태와눈을감은상태로각각 60초씩측정하였다. 측정전, 대상자에게측정과정을설명하였으며 2회측정하여평균값을사용하였다. 2) 오스웨스트리허리통증장애지수 (Oswestry Disability Index : ODI) : 허리통증으로인한일상생활에서의신체적불편함을정량화하기위해 Oswestry 장애지수한국어판설문지를이용하여측정하였다 (Fairbank 등, 1980; Kim 등, 2005b). 0-5점단위의 10개항목으로점수가

4 높을수록장애가심한것을뜻하는설문지이나, 한국어판설문지에서는한국문화의특성을고려하여성생활에대한항목을제외하여 0-5점단위의 9개항목으로구성되어 45점이최고점수이다. 본연구에서는총점을항목 *5로나눈값을백분율로환산하여표시하였다. 4. 자료분석실험후수집된자료의분석을위해통계처리프로그램인 SPSS statistics 21.0을사용하여통계처리하였으며정규성검정을만족하여모수적접근방법을사용하였다. 실험군과대조군의균형능력과오스웨스트리장애지수의전 후비교를위하여짝비교 t 검정 (paired t test) 을, 그룹간평균차이를비교하기위하여독립표본 t 검정 (independent t-test) 을사용하였다. 통계학적유의수준을검증하기위한유의수준 (α) 은.05로설정하였다. 연령은 26.33±4.55세, 평균신장은 ±5.33cm, 평균몸무게는 51.11±7.20kg 그리고대조군의평균연령은 22.00±0.86세, 평균신장은 ±4.91cm, 평균몸무게는 54.00±4.89kg이었다 (Tabel 2). 2. 운동전후신체중심이동면적비교눈을뜬상태에서신체중심이동면적을비교한결과, 복식호흡과복근운동을함께적용한그룹에서는운동전과후의유의한차이가있었으나 (p<.05) 복근운동만을적용한그룹에서는유의한차이가없었다 (p>.05). 눈을감은상태에서도복식호흡과복근운동을함께적용한그룹에서는운동전과후의유의한차이가있었으나 (p<.05) 복근운동만을적용한그룹에서는유의한차이가없었다 (p>.05). 그룹간차이에서는눈을뜬상태와감은상태모두신체중심이동면적에서차이가없었다 (p>.05)(table 3). Ⅲ. 연구결과 1. 연구대상자의일반적특성연구에참여한전체대상자의일반적특성은다음과같다. 실험군의평균 Table 2. General characteristics of the subjects (values are mean±sd) group A B p age(yrs) 23.31± ± height(cm) ± ± weight(kg) 51.11± ± A: exercise with abdominal breath, B: exercise only 3. 운동전 후신체중심이동길이비교눈을뜬상태에서의신체중심이동길이비교에서운동전과후, 두그룹모두유의한차이가없었다 (p>.05). 눈을감은상태에서의비교에서복식호흡과복근운동을함께적용한그룹에서는운동전과후의유의한차이가있었으나 (p<.05) 복근운동만을적용한그룹에서는유의한차이가없었다 (p>.05). 그룹간차이에서눈을뜬상태는차이가없었으나 (p>.05) 눈을감은상태에서는유의한차이가있었다 (p>.05)(table 3). 4. 운동전후오스웨스트리요통장애지수비교운동전과후의오스웨스트리요통장애지수에서 Table 3. A comparison of surface of area and length (values are mean±se) group pre post pre-post p (within group) p (between group) surface area length eyes closed eyes open eyes open eyes closed A 63.89± ± ± * B 57.88± ± ± A 47.44± ± ± * B 35.86± ± ± A 23.19± ± ± B 21.94± ± ± A 26.91± ± ± * B 20.21± ± ± * A: exercise with abdominal breath, B: exercise only

5 Table 4. A comparison of Oswestry Disability Index (values are mean±se) Oswestry Disability Index group pre post pre-post p(within group) p(between group) A 9.88± ± ± *.47 B 10.06± ± ± * A: exercise with abdominal breath, B: exercise only 두그룹모두유의한차이를보였으나 (p<.05), 그룹간의유의한차이는나타나지않았다 (p>.05)(table 4). Ⅳ. 고찰본연구는요통환자를대상으로척추안정화운동을실시할때복식호흡을병행할경우균형능력과허리통증으로인한장애지수에미치는영향을알아보기위해실시하였다. 척추안정화운동은요통환자의심부근육을활성화시켜척추의안정성과고유수용성감각을증진시키고이를통해근육과운동조절능력을회복하기위해적용하며최근요통환자치료에필수적인접근방법으로이용되고있다. Hides 등 (2001) 에의하면장기간의척추안정화운동을실시한그룹은 1년후만성요통의재발율이 30% 로대조군의 84% 에비해낮게나타났으며 2~3 년의추적연구에서대조군의재발율은 75% 인것에비해 35% 로매우낮게나타났다고보고하였다. 또한 Shaughnessy와 Caulfield(2004) 에의하면만성요통환자들에게 10주간의척추안정화운동을적용한이후삶의질과기능적상태가모두개선되었다고하였다. 본연구의결과에서도척추안정화운동을 8주간실시한결과실험군과대조군모두에서오스웨스트리장애지수의유의한감소가나타났다. 본연구에서는이러한척추안정화운동의효과를높이기위해임상에서적용하고있는여러가지호흡방법중특정장비의도움없이가장쉽게적용할수있는복식호흡을함께적용하여그효과를알아보고자하였다. 균형능력평가를위한신체중심이동면적측정에서실험군에서는눈을감은상태와눈을뜬상태모두에서운동전과후의유의한차이가있었으며척추안정화 운동만을실시한대조군에서는이동면적의감소는있었으나유의한차이는나타나지않았다. 이는척추안정화운동을실시할때복식호흡을함께실시할경우, 복식호흡의원리에따라복강의압력이발생하게되고주변의체간근육의활성에영향을미침에따라추체의안정을유지하는데도움을주어균형능력에영향을미친것으로사료된다. 이는복식호흡을실시하면복근과심부근육의내부압력만이아닌횡격막하강에따른복강내압력이발생하게되고이를지지하기위한체간근육이효율적으로작용하게되어요통환자들의근활성패턴에변화를주게된다는 Frank 등 (2013) 과 Nouwen 등 (1987) 의연구와일치한다. Ki(2011) 의연구에서만성요통환자의치료에강제호흡운동을함께적용한실험군에서척추안정화운동만을실시한대조군에비해흉추부의유연성과척추관절의안정화가유의하게증가하였다고하였다. 그에비해본연구에서는운동전과후에두그룹모두장애지수와신체중심이동거리및면적의감소가있었으나눈을뜬상태의신체중심이동길이변수이외에는그룹간의차이가유의하게나타나지는않았는데, 이는본연구에서적용한복식호흡은안정호흡 (quiet breathing) 의형태인것에비해강제호흡운동을적용하게되면, 요추부위뿐만아니라흉추부의운동성이증가되어요추의보상작용의감소가더욱크게나타나허리안정화에기여하였을것으로사료된다. Kim(2006) 은정상인을대상으로동적및정적자세를실시하는동안복식호흡을적용하여요부근육의활성도를측정하였으며정적, 동적자세에서복식호흡흡기시요부근육의최대자발적수축력이유의하게증가하였다고보고하였다. 또한 Kim 등 (2005a) 은요통환자에게복식호흡운동만을적용하였을때에도체간근육의활성도가유의하게증가하였다고보고하였다. 이

6 는복식호흡이복강내압의증가를통해요부근육의활성에영향을미치기때문으로해석할수있으며이러한결과를바탕으로복식호흡을통해체간근육의활성화를유도하고척추안정화운동을함께적용한다면그효과가더욱클것으로사료된다. 본연구의결과에서복식호흡을척추안정화운동과병행하여실시한실험군에서대조군에비해균형능력이유의하게향상되어이를뒷받침하는결과라볼수있다. 횡경막의활동을통해복압이상승하게되면골반저근이활성화되어동시수축할수있으며 (Talasz 등, 2011), 호흡을하는동안일어나는복부의수축을통해복횡근을쉽게활성화시킬수있다 (Urquhart 등, 2005). 따라서복식호흡을통해횡경막의작용을강화하면척추의안정성에기여하는골반저근의활성화를촉진하고복횡근이활성화되어흉곽과요부의안정화에도움을줄수있을것이라생각된다. 앞서기술한여러선행연구들의결과와본연구의결과를종합해볼때복식호흡은특별한훈련이나장비가필요없이누구나쉽게적용할수있다는장점이있으며특별한부작용없이복강내압의상승과체간근육의활성도를높여척추의안정성을증가시킬수있어향후요통환자를위한운동프로그램에복식호흡을적절히적용한다면더욱좋은효과를나타낼것으로사료된다. 본연구는대상자의연령이 20대의젊은성인이고연구대상자의수가적어향후연구대상자의수를늘리고급성및만성요통에복식호흡이미치는영향을세분화하여추가적인연구가필요할것이라고생각된다. Ⅴ. 결론본연구는척추안정화운동시복식호흡을병행할때균형능력과오스웨스트리장애지수에미치는영향에대해알아보기위해시행되었다. 연구결과, 균형능력평가를위한신체중심이동면적변수에서실험군은눈을뜬상태와감은상태모두운동전후유의한감소가있었으며신체중심이동거리변수에서도실험군의눈을감은상태에서유의한차이가나타났다. 오스웨스트리장애지수는두그룹모두유의하게감소하였다. 이를통해척추안정화운동을할때복식호흡을적용하면더욱좋은효과가있는것을확인할수있었다. 현재임상에서요통환자에게안정화운동을적용할때그효과를높이기위해다양한방법을활용하고있으며그중방법이간단하고일상생활에서가장쉽게활용할수있는복식호흡을적절히적용한다면요통환자의치료에더욱효과적일것으로생각된다. Acknowledgements 이논문은 2013년도부산가톨릭대학교교내연구비에의하여연구되었음. References Allison G, Kendle K, Roll S et al. The role of the diaphragm during abdominal hollowing exercises. Aust J of Physiother. 1998;44(2): Arokoski JP, Valta T, Kankaanpaa M et al. Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients. Arch Phys Med Rehabil. 2004;85(5): Chaitow L. Maintaining body balance, flexibility, and stability : a practical guide to the prevention and treatment of musculoskeletal pain and dysfunction. New York, Churchill Livingstone, Fairbank JC, Couper J, Davies JB et al. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66(8): Frank C, Kobesova AKolar P. DYNAMIC NEUROMUSCULAR STABILIZATION & SPORTS REHABILITATION. Int J of Sports Phys Ther. 2013;8(1): Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine (Phila Pa 1976). 2001;26(11):E Hodges PW, Richardson CA. Altered trunk muscle recruitment

7 in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil. 1999;80(9): Ki C. Effects of Forced Breathing Exercise on the Trunk Functions of Chronic Low Back Pain Patients. Master s Degree. Daegu University Kim DY, Lee SH, Lee HY et al. Validation of the Korean version of the oswestry disability index. Spine (Phila Pa 1976). 2005b;30(5):E Kim K. Effect of Diaphragmatic Breathing Exercise on Activation of Lumbar Paraspinal Muscles of Healthy people. J Korean soc phys med. 2006;1(1): Kim K, Park RJ, Bae SS. Effect of diaphragmatic breathing exercise on Activation of trunk muscle of patients with low back pain. J Korean soc phys med. 2005a;17(3): Koumantakis GA, Oldham JA,Winstanley J. Intermittent isometric fatigue study of the lumbar multifidus muscle in four-point kneeling: an intra-rater reliability investigation. Man Ther. 2001;6(2): Matthijs OC, Dedrick GS, James CR et al. Co-contractive activation of the superficial multifidus during volitional preemptive abdominal contraction. PM R. 2014;6(1): Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): Niemisto L, Lahtinen-Suopanki T, Rissanen P et al. A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine (Phila Pa 1976). 2003;28(19): Nouwen A, Van Akkerveeken PF,Versloot JM. Patterns of muscular activity during movement in patients with chronic low-back pain. Spine (Phila Pa 1976). 1987; 12(8): O'Sullivan P, Twomey L, Allison G et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain. Aust J Physiother. 1997;43(2): Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Man Ther. 2003;8(4): Selles RW, Wagenaar RC, Smit TH et al. Disorders in trunk rotation during walking in patients with low back pain: a dynamical systems approach. Clin Biomech (Bristol, Avon). 2001;16(3): Shaughnessy M, Caulfield B. A pilot study to investigate the effect of lumbar stabilisation exercise training on functional ability and quality of life in patients with chronic low back pain. Int J Rehabil Res. 2004; 27(4): Yu SJ, Song MS. The Effects of Abdominal Relaxed Breathing Training on Stress response and Blood Pressure for Elderly Hypertensionve Patient. Journal of Korean Academy of Nursing. 2001;31(6): Talasz H, Kremser C, Kofler M et al. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-8.

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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