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1 대한수부외과학회지제 14 권제 2 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 14, NUMBER 2, June 2009 고강도레이저와체외충격파를이용한외상과염치료의임상적결과비교 연세대학교의과대학정형외과학교실 Comparison of the Clinical Results of HILT Versus ESWT in the Lateral Epicondylitis Ho Jung Kang, MD, Man Seung Her, MD, Seung Yeup Lee, MD, Soo-Bong Hahn, MD Department of Orthopaedic Surgery Yonsei University, College of Medicine Seoul, Korea Purpose: To compare the clinical results of High intensity laser therapy (HILT) versus Extracorporeal shock wave therapy (ESWT) in the lateral epicondylitis. Materials and Methods: Fifty patients who suffer from lateral epicondylitis for more than six month duration were randomly assigned two treatment groups. Group 1 (n=25) was treated with HILT using a HIRO 3.0 laser(asa srl, Arcugnano, Italy) and total energy was administered approximately 1200J following a standard protocol for each session; Group 2 (n=25) recieved with ESWT treatment using an EvoTron(Switech Medical AG, Kreuzlingen, Switzerland) for a total of 1000 shocks for each session. The patients were evaluated by assessment of pain using visual analog scale (VAS) and simple elbow test (SET). Comparision of overall clinical outcomes were evaluated by Roles and Maudsley score at 9 months. Results: Average VAS and SET scores were significantly improved in two groups, also achieved significant improvement of symptoms at 9 months follow up Address reprint requests to: Ho Jung Kang, MD Department of Orthpedic Surgery, College of Medicine, Yonsei University Yondong Severance Hospital, Yondong P.O.Box 1217, Seoul, Korea TEL: , FAX: kangho56@yumc.yonsei.ac.kr according to Roles and Maudesley scores(p<0.05). The success rate in the HILT group was 76 % and in the ESWT group was 72 %. Conclusions: This study suggests that HILT could be considered as effective and noninvasive treatment modality for lateral epicondylitis. (J Korean Soc Hand Surg 2009;14:61-6) Key Words: Lateral epicondylitis, High intensity laser therapy (HILT), Extracorporeal shock wave therapy (ESWT) 서 론 일명테니스주관절이라불리우는주관절외상과염은신근의외측상과기시부에국한된동통이나국소압통을보이는질환으로서주관절통증을유발하는대표적인질환이다. 이질환은 1873년 Runge 1 에의해 writer s cramp 로최초로기술되었지만아직까지도그동통의원인과병리가명확히밝혀지지않았으며다만외상과에서기시하는수근관절신건의반복된스트레스에의해발생하는과사용증후근정도로생각되고있다 2-7. 이러한이유로치료방법또한정확히규명되어있지않고있으나대부분보존적치료에잘반응하며약 3.3%~8% 의환자에있어서수술이필요하다고알려져있다 4,8-10. 지금까지소개된보존적치료로는휴식, 약물요법, 국소스테로이드주입, 보조기, 저강도레이저치료, 체외충격파치료등이있다. 이중저강도레이저를이용한치료결과는 1990년대초기부터많이발표되었지만결과가다양하여아직까지논의의여지가남아있는상태이며 체외충격파를이용한치료는 1996년 Heller와 Niethard 20 가좋은결과를보고한이래높은성공률이보고되고있으나다양한치료결과또한보고되어왔다 체외충격파는치료시발생하는통증으로약 5% 정도의환자들이 61

2 치료를중단하거나국소마취를필요로하는단점이지적되고있다. 이러한보존적치료이외에도최근들어정형외과영역의근골격계질환에서레이저의침투깊이를깊게하여세포대사증진및염증반응의감소를통한동통과종창감소의효과를볼수있는고강도레이저치료에대한관심이증가하고있다. 본연구의목적은주관절외상과염의치료로서고강도레이저치료와체외충격파치료에대한임상적결과를비교함에있다. 연구대상및방법 1. 연구대상 연구대상은 2005년 3월부터 2008년 3월까지본원에내원한주관절외상과부위의압통및단요수근신건긴장검사에서양성을보이면서휴식, 약물요법, 국소스테로이드주입, 보조기치료를포함한보존적치료에 6개월이상반응하지않은주관절외상과염으로진단받은환자중고강도레이저혹은체외충격파치료를받고최소 6개월이상경과관찰한 50예였으며국소감염및종양, 임신, 혈액응고장애질환및신경학적질환, 동통을유발할수있는전신질환을가진환자들은대상에서제외하였다. 총 50예의대상은치료방법에따라고강도레이저군과체외충격파군으로나누어비교분석하였으며두군의대상은표1과같다 (Table 1). 두군간에평균나이, 성별의차이, 질환의이환기간에있어서통계적으로의미있는차이는보이지않았다 (P>0.05). 2. 치료방법 1) 고강도레이저치료고강도레이저치료는외래에서 HIRO 3.0 laser(asa srl, Italy) 를이용하여주관절외상과부위에레이저를조사하였다. 조사된레이저는고강도 Nd:YAG 레이저로파장은 1064 nm, 최대강도는 3kW, 레이저조사간격은 120 μs미만으로매회최대에너지는 350 mj로써레이저의출력에너지는 1780 mj/cm 2 이다. 일정거리를유지할수있는 Standard handpiece를이용하여조사하였으며레이저의직경은 5 mm였다. 레이저치료시환자는편안한자세로앉거나누워서시행하였으며치료부위를알코올솜으로소독하였으며시술자는레이저로인한시력보호를위해보호안경을착용하도록하였다. 치료는정해져있는기본치료방침에준하여치료부위를빠르게조사 (100 cm 2 /30sec) 하는초기단계와느리게조사 (100 cm 2 /60sec) 하면서초기단계의치료효과를안정화시키고증진시키는최종단계로나누어시행하였다. 두단계는각각 25 Hz 주파수, 510 mj/cm 2 에너지를조사하는 1단계부터 20 Hz 주파수, 610 mj/cm 2 에너지를조사하는 2단계, 19 Hz 주파수, 710 mj/cm 2 에너지를조사하는 3단계로세분하였으며조사된총에너지는초기단계와최종단계모두에서각단계별 200J씩조사함으로써 1200J의레이저를조사하였다. 2) 체외충격파치료체외충격파치료또한외래에서시행하였고 EvoTron (Switech Medical AG, Kreuzlingen, Switzerland) 을이용하여주관절외상과부위에집중화하였다. 시술전국소마취는시행하지않았으며충격파는외과용윤활제를접촉면적에바른후 5 mm~30 mm까지의투과깊이가가능한 EvoTrode R05의제어가이드를이용하여 0.10 mj/mm 2 energy flux density의충격파 1000회를가하였다. 두군모두에서치료후집에서냉찜질을하도록교육하였고비마약성의진통제를복용하도록하였으며비스테로이드성소염제는처방하지않았다. 3. 치료후임상적평가치료의평가는휴식시와일상활동시동통의정도를 Table 1. Comparison of baseline characteristics and various scores across compared groups. Values are numbers of participants and their gender, dominant side, and means±sd of age and duration Group 1 (HILT) Group 2 (ESWT) Number Male/Female 11/14 10/15 Dominant side Mean Age 45.56±8.24 years (range: 23~62) 42.84±9.01 years (range: 25~61) Mean Duration 12.16±5.29 months (range: 6~26) 14.92±5.94 months (range: 6~24) HILT: high intensity laser therapy, ESWT: extracorporeal shock wave therapy. 62

3 고강도레이저와체외충격파를이용한외상과염치료의임상적결과비교 Table 2. Comparison of different scores across HILT and ESWT groups at different time periods. Baseline 1 month 3 month 6 month HILT ESWT HILT ESWT HILT ESWT HILT ESWT VAS score at rest at work SET score VAS: Visual Analog Scale, SET: Simple Elbow Test Visual Analog Scale (VAS) 을이용하여나타내었으며동통이없는경우 10부터극심한동통 0까지로정하였다. 또한주관절의기능회복을알기위해 Simple Elbow Test (SET, questionnaire of the University of Washington) 를이용한평가를치료전, 치료후 1, 3, 6개월에각각실시하여비교분석하였다. 전체적인치료평가를위해최종추시 9개월에는 Roles와 Maudsley의평가방법을이용하여결과를 4가지로구분하였다. 이중우수와양호인경우는성공으로판단하였으며치료를중단하고수술을받은대상에대하여는불량으로판단하였다. 결과에대한통계학적분석은 Statistical Product and Service Solution(SPSS, version10) 의 paired t- test로시행하였으며 p값이 0.05 보다작은경우유의한것으로평가하였다. 결과 고강도레이저군의환자들에서치료전휴식시동통을평가한 VAS 평균점수는 3.05 이었다. 치료후 1개월의 VAS 평균점수는 6.24, 3개월의 VAS 평균점수는 7.51, 6개월의 VAS 평균점수는 7.84로나타났으며, 일상활동시동통을평가한 VAS 평균점수또한치료전에는 2.57이었으나치료 1개월뒤에는 5.97, 3개월에는 7.48, 6개월의 VAS 평균점수는 7.81로나타났다. SET의치료전평균점수는 4.85, 1개월뒤에는 8.25, 3개월뒤에는 9.75, 6개월뒤에는 10.32를나타내어고강도레이저치료후평가기준모두에서통계학적으로유의한통증의완화및주관절기능의향상을볼수있었다 (p<0.05)(table 2). 체외충격파군의환자들에서도 VAS 의평균점수가치료전휴식및일상활동시평가한경우가각각 3.12, 2.76 치료 6개월에 7.90, 7.82로나타났으며 SET 평가항목또한치료전 4.90 치료후 6개월뒤에는 10.94로나타나두평가기준모두에서통계학적으로유의한호전양상을볼수있었다 (p<0.05)(table 2). 두군모두에서치료를시행한첫한달동안많은호전을보였으며그후최종추시인 6개월까지꾸준한호전양상을보였으며두군간의치료효과에대한유의한차이는없었다 (p>0.05)(table 2). 치료 6개월뒤시행한 Roles와 Maudsley의평가방법에의하면고강도레이저군의경우, 우수 8예 (32%), 양호 11 예 (44%), 보통 4예 (16%), 불량 2예 (8%) 였으며체외충격파군의경우우수 7예 (28%), 양호 11예 (44%), 보통 3예 (12%), 불량 4예 (16%) 이었다 (Table 3). 즉치료의성공인우수와양호는고강도레이저군 19예 (76%), 체외충격파군 18예 (72%) 를차지하였다. 고강도레이저군의경우치료직후환부에약간의열감을호소한 2예 (8%) 외에는화상등을포함한별다른합병증은없었으나체외충격파군중 3예 (12%) 에서치료시외상과부위통증으로국소마취를필요로하거나치료를중단하였다. 고찰 주관절의외상과염 (lateral epicondylitis) 은 1873 년 Runge 1 에의해 Writer s cramp 로최초로기술되었으며주관절외상과주위의동통및수근신전건이작동할때유발되는동통을주증상으로하는증후군으로서주관절동통의가장흔한원인중하나이다. 이질환은테니스골프등팔을머리위로많이사용하는운동이과도하거나반복적인팔운동으로인해발생하며, 손상건, 특히단요수근신건의치유과정에이상 63

4 Table 3. Comparison of overall clinical outcomes evaluated by Roles and Maudsley score in HILT and ESWT groups at 9 months after treatments Roles and Maudsley score Group 1:HILT (n=25) Group 2:ESWT (n=25) Excellent 8(32%) 7(28%) Good 11(44%) 11(44%) Acceptable 4(16%) 3(12%) Poor 3(12%) 4(16%) Table 4. Characteristic difference between LLLT and HILT LLLT HILT Mean Power 1W 6 ~ 60W Peak Power 27 ~ 250W 500 ~ 60,000W Duty Cycle 10 ~ 100% 0.01 ~ 0.1% Pulse Repetition Frequency 100 ~ 5,000Hz 0.5 ~ 40Hz LLLT: low level laser therapy 이생겨서발생하는것으로알려져있다 2-7. 대부분은소염진통제, 물리치료, 보조기, 스테로이드혹은 botulinum toxin 주사요법, 체외충격파치료, 저강도레이저등의보존적요법에약 92%~97% 의환자에서효과를보인다고알려져있다 4,8-10. 체외충격파치료는 1976년신장과담관의결석을분해하는데사용된이래 1990년대초부터독일에서다양한영역의정형외과질환에서새로운치료방법으로서시도되었으며 1996년 Heller와 Niethard 20 에의해최초로보고된이래여러저자에의해다양한성공률이보고되고있다. Rompe등 24 은테니스운동후발생한주관절외상과염환자들을대상으로시행한체외충격파치료로 65% 의환자에서최소 50% 이상의통증감소효과를볼수있었다고보고한바있으며 Pettrone등 23 은주관절외상과염환자들을대상으로국소마취제를사용하지않고저에너지체외충격파 (0.06 mj/mm 2 energy flux density) 를이용하여 61% 의환자에서최소 50% 이상의통증감소, 기능회복등의우수한치료효과를보고하였다. 본연구에서도 25예중 18예 (72%) 에서통증회복뿐아니라기능회복면에서도우수한결과를볼수있었다. 그러나 Haake 28, Speed 26, Melikyan등 29 에의하면주관절외상과염에있어서체외충격파의치료는위약치료군과비교하여의미있는호전도를보이지않는다고하였으며다른보고에의해서도치료시발생하는외상과부위의통증발생에대한단점을지적하고있다. 본연구에서도 3예 (12%) 에서치료시외상과부위의심한통증으로국소마취를필요로하거나치료를중단하고수술적치료를받았다. 레이저는 1917년 Albert Einstein의 The stimulated emission of radiation 라는가정을시작으 로 1958년 Shawlow와 Townes가 Light amplication 이라는원리를제안함으로써개발되었고치료를목적으로하는의료용레이저는조사된레이저의파장과해당조직의특성에따라다른여러효과를가져올수있는비이온화된전자기장고밀도광원이라할수있다. 이러한의료용레이저는크게저강도레이저 (Low Intensity Laser Therapy, LILT), 고강도레이저 (High Intensity Laser Therapy, HILT), 선택적레이저 (Selective Laser Therapy, SLAT), 세가지로나눌수있다. 저강도레이저는흔히저레벨레이저 (Low Level Laser Therapy, LLLT) 로알려져있으며세포대사, 상처치유촉진, 통증및종창감소등의효과에대해많이보고하고있다. Stergioulas 30 는주관절외상과염환자에게서저레벨레이저치료와플리오메트릭운동 (Plyometric exercise) 으로효과가있다고하며 Lam 등 31 또한운동요법을병행한저레벨레이저치료는주관절외상과염환자에서통증감소및악력증가등의효과가있다고하였다. 그러나이보고들은저레벨레이저치료의단독효과를입증하기어려우며 Basford 등 11 은주관절외상과염환자에서 Nd:YAG 레이저를이용한저레벨레이저치료는위약치료군과의미있는치료성적차이를보이지않는다고하였다. 따라서깊은조직에많은양의레이저에너지를전달하여보다효과적인치료를얻기위해 2005년 HIRO (ASA srl, Arcugnano, Italy) 기기를이용한고강도레이저치료가미국식약청의인증을받았다. HIRO (ASA srl, Arcugnano, Italy) 기기는 1064 nm Nd:YAG 레이저를이용하며기존의저레벨레이저와비교하여보다높은전력, 짧은레이저조사시간및긴레이저조사간격 (low duty cycle : 레이저한펄스의조사시간 / 두번째펄스가조사되기까지의시간 ) 을특징으로하여 (Table 4) 기존의 Nd:YAG 레이저로는피부화상의합병증으로인하여불가능하였던깊은조직내에많은양의레이저조사가가능하게하였다. 고강도레이저치료는광물리 (photomechanical) 효과, 광열 (photothermal) 효과, 광화학 (photochemical) 효과로통증감소와손상된조직의치유가가능하였다. 광물리및광열효과는조직내로전달된 64

5 고강도레이저와체외충격파를이용한외상과염치료의임상적결과비교 양성자들이발생시키는물리적충격과직접적으로전달된열에너지로림프액의순환을원활하게하여조직내의부종을감소시키고삼투액의흡수를증가하여염증유발물질들의제거를도우며광화학효과는양성자의에너지가 ATP 생산을증가시키고칼슘분비를억제하여결국통증역치를높인다고하였다. 본연구에서는 HIRO(ASA srl, Arcugnano, Italy) 기기를이용한고강도레이저치료로대상 25예중 19예 (76%) 에서우수및양호의치료성적을얻을수있었으며시술부위통증및화상등의합병증은없었다. 결론 주관절외상과염의치료에있어서고강도레이져치료는안전하며효과적인비침습적치료방법으로특히적용시에통증을유발하지않는다는점에서외래치료나보존적요법으로수술전실시해볼수있는치료방법이라생각한다. 참고문헌 01) Runge F. Zur Genese und Behandlung des Schreibekrampfes. BerKlin Wchnschr, 1873;10: Cited from Boyd, HB, Mcleod AC Jr. Tennis elbow. J Bone Joint Surg Am. 1973;55: ) Coonard RW, Hooper WR. Tennis elbow: It s course, natural history, conservative and surgical management. J Bone Joint Surg Am. 1973;55: ) Gellman H. Tennis elbow: lateral Epicondylitis. Orthop Clin North Am. 1992;23: ) Kamien M. A Rational management of tennis elbow. Sports Med, 1990;9: ) Nagy L. The treatment of therapy-resistant lateral epicondylitis. Swiss Surg 1997;3: ) Nirschl RP. Elbow tendinosis/tennis Elbow. Clin Sports Med. 1992;11: ) Noteboom T, Cruver R, Keller J, Kellogg B, Nitz AJ. Tennis elbow: a review. J Orthop Sports Phys Ther. 1994;19: ) Boyd HB, Mcleod AC. Tennis elbow. J bone Joint Surg Am. 1973;55: ) Friedlander HL, Reid RL, Cape RF. Tennis elbow. Clin Orthop Relat Res. 1967;51: ) Nirschl RP, Pettrone FA. Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone Joint Surg. 1979;61: ) Basford JR, Sheffield CG, Cieslak KR. Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis. Arch Phys Med Rehabil. 2000;81: ) Ferrell WR, Balint PV, Sturrock RD. Novel use of laser Doppler imaging for investigating epicondylitis. Rheumatology Oxford. 2000;39: ) Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002;1:CD ) Hoens AM. Low intensity Nd:YAG laser irradiation for lateral epicondylits. Clin J Sport Med. 2002;12:55. 15) Sevier TL, Wilson JK. Treating lateral epicondylitis. Sports Med. 1999;28: ) Simunovic Z, Trobonjaca T, Trobonjaca Z. Treatment of medial and lateral epicondylitis tennis and golfer elbow with low level laser therapy: a multicenter double blind, placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg. 1998;16: ) Stasinopoulos DI. The use of polarized polychromatic noncoherent light as therapy for acute tennis elbow/lateral epicondylalgia: a pilot study. Photomed Laser Surg. 2005;23: ) Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23: ) Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004;17: ) Heller KD, Neithard FU. Using extracorporeal shockwave therapy in orthopedics- a metaanalysis. German Z Orthop Ihre Grenzgeb. 1998;136; ) Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004;32: ) Lebrun CM. Low-dose extracorporeal shock wave therapy for previously untreated lateral epicondylitis. Clin J Sport Med. 2005;15, ) Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005;87: ) Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004;32: ) Rompe JD, Schoellner C, Nafe B. Evaluation of low-ener- 65

6 gy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J. Bone Joint Surg Am. 2002;84: ) Speed CA, Nichols D, Richards C, Humphreys H, Wies JT, Burnet S et al. Extracorporeal shock wave therapy for lateral epicondylitis a double blind randomised controlled trial. J Orthop Res. 2002;20: ) Weil LS, Roukis TS, Weil LS, Borrelli AH. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg. 2002;41: ) Haake M, Konig IR, Decker T, Riedel C, Buch M, Muller HH. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am. 2002;84: ) Melikyan EY, Shahin E, Miles J, Bainbridge LC. Extracorporeal shock-wave treatment for tennis elbow: A randomised double-blind study. J Bone Joint Surg Br. 2003;85: ) Stergioulas A. Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis. Photomed Laser Surg. 2007;25: ) Lam LK, Cheing GL. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomed Laser Surg. 2007;25:

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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