Symposium J Korean Orthop Assoc 2018; 53: Non-Operative Regenerative Therapy for Muscu

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1 Symposium J Korean Orthop Assoc 2018; 53: Non-Operative Regenerative Therapy for Musculoskeletal Disorders 400 근골격계질환에대한체외충격파치료 염재광 안상준 인제대학교상계백병원정형외과 pissn : , eissn : Jae-Kwang Yum, M.D., Ph.D. and Sang-Jun Ahn, M.D. Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles, and extracorporeal shock wave therapy (ESWT) appears to have mechanical and biological effects on tissue healing. The application of ESWT to musculoskeletal disorders has been around for more than a decade and is used primarily in the treatment of calcific or non-calcific tendinitis of the shoulder, lateral and medial epicondylitis of the elbow, patellar tendinopathy, Achilles tendinitis or proximal plantar fasciitis of the heel, myofascial pain syndrome, etc. ESWT is also used in the treatment of delayed union or non-union of long bone fractures, avascular necrosis of the femoral head, and chronic diabetic ulcers. The vast majority of papers have reported positive and beneficial effects with few complications. The clinical application of ESWT has increased steadily. This article reviews the current status of ESWT in musculoskeletal disorders. Key words: extracorporeal shockwave therapy, musculoskeletal disease 서론 충격파는물과같은매질을통해고전압폭발이나증발로발생하 는고에너지음파다. 1) 충격파를만드는법은전기수력, 전자기, 압전기등의원리로만들어지며, 방사형과초점형으로나뉜다. 2,3) 방사형은퍼져나가기때문에충격파의에너지를조직의한곳에 집중할수없으나조직에전반적으로체외충격파를전달하는효 과가있기때문에근육질환에많이사용된다. 초점형은조직의 한부위에충격파에너지가집중되는효과가있지만이로인하 여통증이상대적으로더심할수있다. 따라서최근에는충격파 에너지가한점에해당하는부위에집중되지않고동전크기만한 부위에충격파에너지가골고루영향을줄수있는, 따라서통증 을경감할수있는스마트초점형이개발되었다. 체외충격파치 Received October 30, 2017 Revised January 30, 2018 Accepted June 20, 2018 Correspondence to: Jae-Kwang Yum, M.D., Ph.D. Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea TEL: FAX: yumccf@hanmail.net ORCID: 료는기계적인힘으로목표조직에에너지를집중시키는효과와조직치유를촉진하는생물학적효과가있는것으로알려져있다. 4,5) 체외충격파치료를시행할수있는분야는석회성또는비석회성건염, 주관절의외상과염또는내상과염, 슬개건염, 아킬레스건병증, 근위부족저근막염등이다. 또한골절의지연유합이나불유합, 그리고대퇴골두의무혈성괴사, 당뇨병에의한피부괴사등이다. 이러한질환에대한체외충격파치료의효과가좋아비수술적치료방법으로유용하다고많이보고되고있다. 1-18) 체외충격파를만드는원리 방사형체외충격파는공기압을이용해압력파 (pressure wave) 를만드는방식으로발사체 (projectile) 에서압축공기를가속화시킨후 applicator에서피부에운동에너지를전달한다 (Fig. 1). 3,19) 퍼져나가기때문에충격파의에너지를조직의한곳에집중할수없으나조직에전반적으로체외충격파를전달하는효과가있기때문에근육질환에많이사용된다. 3) 초점형체외충격파는전기에너지를기계적에너지로전환시켜충격파를만든뒤반사판을이 The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 by The Korean Orthopaedic Association 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.

2 401 용해특정부위에충격파를집중시키는방식이다. 사람의몸이 물과비슷한음향임피던스 (acoustic impedance) 를갖추고있어사 람의몸이매질이되어충격파를전달하는원리이다. 조직의한 부위에충격파에너지가집중되는효과가있지만이로인하여통 증이상대적으로더심할수있다. 초점형충격파를만드는방법 으로는전기수력 (electrohydraulic), 전자기 (electromagnetic), 압 전기 (piezoelectric) 등의원리가있다 (Fig. 2). 2,19) 전기수력의원리 로만들어진체외충격파기계는 1 세대로서고압의전기를이용 한수중폭발을일으켜발생한충격파를반사체를이용하여하나 의초점에모이게하는장치이다. 전자기나압전기등의원리로 만든기계보다상대적으로더큰에너지를내는장점이있다. 전 자기원리를이용한장치는전류를코일을통과시키면서강한전 기장이형성되면서충격파를만들어이를렌즈를이용하여초점 을형성한다. 압전기를이용한장치는전류공급에따라부피가 수축과팽창을하는압전금속 (piezoelectric crystals) 이주변의수 중에서충격파를발생시킨다. 형성된충격파가바로초점을형성 (selffocus) 할수있게압전금속이기하학적으로정렬되어있다. 2) 충격파는단상성 (uniphasic) 으로초음파의이상성 (biphasic) 과 Compressed air Air inlet Projectile Applicator Radial pressure waves Figure 1. Schematic illustration of a radial shock wave. Cited from the article of Moya et al. (J Bone Joint Surg Am. 2018;100:251-63). 19) 차이가있다. 충격파의최고압력은 500 bar 정도이고초음파의최고압력은 0.5 bar 정도로, 충격파가 1,000배이상더큰특징이있다. 충격파의효과는두가지로나뉘는데, 하나는기계적인힘으로목표조직에에너지를집중시켜치료효과를나타내는것이고, 다른하나는공동화 (cavitation) 현상으로간접적인기계적힘때문에조직에부정적인효과또는손상을주는것이다. 1) 체외충격파의치료기전과동물실험 체외충격파의명확한치료기전은아직밝혀지지않았다. 쇄석술에서는결석을분해하는효과가있는반면, 근골격계충격파는조직을분해하는것이아니고간질조직에미세한반응을일으켜치유를촉진하는것으로생각된다. 1) 1. 골절치유뼈에충격파를가하면미세골절을만들어혈종을형성하고조골세포 (osteoblast) 의골형성을유도하며골절을치유하는것으로생각된다. Wang 등 20) 은개를이용한체외충격파실험에서골절의신생골형성과피질골형성이대조군에비해더형성되었고체외충격파치료의효과는시간의존도가있다고보고하였으나, Forriol 등 21) 은골절에대한체외충격파치료가골절치유를지연시킨다고보고하였다. 이러한정반대의결과는다른동물에서시행되었고다른용량의충격파때문인것으로생각된다. Wang 등 22) 은토끼의대퇴골골절에고용량의체외충격파를가했을때신생골형성이대조군에비해더많았으며뼈도더강하게변했다고보고하였고, 저용량의체외충격파보다효과가좋다고보고한것등을볼때뼈에대한체외충격파치료의효과는용량과시간의의존도가높다고생각된다. Second focus Coupling fluid First focus 6 db focal region Ellipsoidal reflector Coupling fluid 6dB focal region Metallic membrane Piezo-ceramic elements 6dB focal region Coupling fluid Spark-plug Parabolic reflector Spherical aluminum backing A Cylindrical coil B C Figure 2. Three main techniques through which shock waves are generated. (A) Electrohydraulic. (B) Electromagnetic. (C) Piezoelectric. Cited from the article of Moya et al. (J Bone Joint Surg Am. 2018;100:251-63). 19)

3 402 Jae-Kwang Yum and Sang-Jun Ahn 2. 건 - 뼈접점부위의건병증 (insertional tendinopathy) 에서조직치유 개의아킬레스건 - 뼈접점부위에체외충격파를가했을경우신 생혈관이증가하는것으로보고되었고 2) 토끼의아킬레스건 - 뼈 접점부위에체외충격파를가했을경우혈관내피산화질소합성 효소 (endothelial nitric oxide synthase), 혈관내피성장인자 (vessel endothelial growth factor), 증식성세포핵항원 (proliferative cell nuclear antigen) 등의혈관신생인자및치유인자가많아짐을확 인하였다. 5) 따라서체외충격파가가해지면혈관신생이활발해지 고건 - 뼈접점부위에혈액공급이많아져서조직치유에도움을 주는것으로생각된다 (Fig. 3). 1) 이외에도과자극진통 (hyperstimulation analgesia) 으로통증역 치를높여통증이조절된다는이론도제기되고있다. 1) Bone repair Physical energy Biological response enos VEGF PCNA Improved blood supply Tissue regeneration Neovascularization Tendon repair Figure 3. The mechanism of shock wave therapy appears to involve a cascade of interactions between the physical shock wave energy and biological responses. enos, endothelial nitric oxide synthase; VEGF, vessel endothelial growth factor; PCNA, proliferative cell nuclear antigen. Cited from the article of Wang (Chang Gung Med J. 2003;26:220-32). 1) 체외충격파의합병증과금기사항 체외충격파치료의합병증으로는통증, 어지럼증, 국소출혈등이있으나치료중에충격파의강도를조절하면해결되며, 어지럼증을호소하는환자에서는즉시눕히고다리를높여주면수분내에회복된다. 또한큰혈관이나신경에직접적으로충격파가가해지면혈관및신경의손상이생길수있으므로주의를요한다. 체외충격파의금기증으로는출혈성질환이있거나항혈전약물을복용하는경우등이며머리부위, 소아의성장판에사용하는것은금기이다. 또한폐에충격파가직접전달되면폐포 (alveoli) 가손상될수있으므로주의를요한다. 석회성건염 석회성건염에서의체외충격파치료는통증과석회제거효과에유의한치료효과를얻었다는보고가많으며다양한방식으로체외충격파치료를시도하여효과적인치료결과도얻었다는보고도있다 (Table 1). Wang 등 6) 은견관절의석회성건염에대한체외충격파치료로 57.6% 에서석회가완전히제거되었으며 15.1% 에서는석회가부분적으로제거되었고 27.3% 에서는석회에변화가없었다고보고하였다. 또한치료후 2년추시결과석회성건염의재발은없었다고하였다. Maier 등 7) 은치료후자기공명영상검사결과조직손상등의체외충격파에의한부작용은나타나지않았다고보고하였다. 석회성건염에대한고용량의체외충격파치료가저용량의체외충격파치료보다우수한효과가있다는메타분석결과가있으며, 23) 체외충격파치료시투시장치를이용하여석회침착이되어있는부위에초점을맞추는방법, 침착부위에침을놓는방법, 어깨의자세를과신전, 내회전상태에서치료하는방법등이보다효과적인방법이라는보고도있다 ) 외상과염및내상과염 외상과염또는내상과염에대한체외충격파치료의효과는논란 Table 1. Studies Comparing ESWT with Other Treatment Modalities for Calcific Tendinitis of the Shoulder Reference Krasny et al. 25) (2005) Haake et al. 24) (2002) Tornese et al. 26) (2011) Case (n) Treatment Outcome measure Conclusion 80 ESWT vs. USG guided needling followed by ESWT 49 ESWT focusing at calcific deposit vs. tuberculum majus 35 ESWT neutral position vs. hyperextension & IR ESWT, extracorporeal shock wave therapy; USG, ultrasonography. Pain, function, calcification, resolution Pain, function, calcification, resolution Pain, function, calcification, resolution USG guided needling+eswt was more effective than ESWT alone with high rates of calcification resolution, better clinical result. Focusing at calcification rather than tuberculum majus was more effective for pain and function. Shoulder positioned in hyperextension showed better outcomes for calcification resolution and strength.

4 403 Table 2. ESWT for Lateral Epicondylitis Reference Rompe et al. 8) (1996) Pettrone and McCall 9) (2005) Spacca et al. 10) (2005) Chung and Wiley 27) (2004) Haake et al. 28) (2002) Staples et al. 29) (2008) Crowther et al. 30) (2002) Case (n) ESWT, extracorporeal shock wave therapy. Treatment Outcome measure Conclusion 100 ESWT vs. sham Pain, function, grip strength, global improvement ESWT was more effective than sham therapy at 114 ESWT vs. sham Pain ESWT was more effective than sham therapy at 62 ESWT vs. sham Pain, grip strength ESWT was more effective than sham therapy at 60 ESWT vs. sham Pain No difference at the end of treatment and at the follow-ups. 271 ESWT vs. sham Pain, function, grip strength, global improvement 68 ESWT vs. sham Pain, function, grip strength, global improvement No difference at the end of treatment and at the follow-ups. No difference at the end of treatment and at the follow-ups. 93 ESWT vs. steroid injection Pain Steroid injection was more effective than ESWT at 이있다 (Table 2). Rompe 등 8) 은만성외상과염에 3,000 회의충격 파를가했을때, 30 회의충격파를가한대조군에비해좋은임상 적결과를보였다고하였다. 이외에도외상과염에대한체외충격 파치료가효과가있다는보고가많다. 9,10) 그러나체외충격파치 료의결과가유의하지않다는보고도있으며 27-29) 체외충격파치 료보다는스테로이드주사치료가더효과적이라는보고도있 다. 30) Dingemanse 등 31) 은외상과염에대한여러가지전기물리치 료방법들의효과에대해서분석하였는데체외충격파치료의효 과에대해서는논란이있으며초음파나레이저치료는유의한효 과가있다고보고하였다. 슬개건염 (Jumper s Knee) 및아킬레스건병증 Wang 등 11) 은슬개건염에대한체외충격파치료후초음파검사상 보존적치료를시행받은군에비해충격파치료군에서혈관재생 이더많았고슬개건이얇아지며치유되는현상을보였다고보고 하였으며, Peers 등 12) 은만성슬개건염에대한수술적치료군과체 외충격파치료군의결과를비교분석하여체외충격파치료군에 서기능적결과가좋았다고보고하였다. 아킬레스건병증에대한 체외충격파치료도좋은결과를보고하고있다. 13) Rompe 등 32) 은 만성아킬레스건병증환자에서스트레칭치료군과체외충격파 치료군을비교하여스트레칭치료군의결과가더나빴다고보고 하였다. 근위부족저근막염 족저근막염에대한체외충격파치료로좋은결과를얻었다는보고는많으며치료성공률은 88% 까지보고되고있다. 14) Rompe 등 15) 은족저근막염환자에 0.16 mj/mm 2 용량으로 1주마다 6,300회의충격파를 3번에걸쳐치료한결과좋은결과를얻었다고보고하였다. 또한 Wang 등 16) 은족저근막염에체외충격파를시행한결과효과가없거나나빠진환자는없었고, 재발률은 5% 였다고보고하였다. 그러나족저근막염에체외충격파치료의효과가없었다는보고도있다. 33) Aqil 등 17) 이시행한메타분석에따르면체외충격파치료는대조군에비해유의한치료효과를보여 3개월이상비수술적치료에효과가없는만성족저근막염환자군에서체외충격파치료를사용할것을권하였다. 근막통증증후군 근막통증증후군은골격근에통증유발점이생겨심한통증및기능장애를나타내는질환으로서여러가지치료가시행되고있으나체외충격파치료를통증유발점에시행함으로써좋은임상적결과를보였다는보고가최근에늘어나고있다. 34) 저자도후견갑부의만성근막통증증후군에서체외충격파치료로좋은결과를얻고있다. 35) 결론 근골격계질환에대한체외충격파치료의많은보고들을볼때,

5 404 Jae-Kwang Yum and Sang-Jun Ahn 이치료는비침습적이고적응증을잘선택하면치료효과가좋으며합병증의예방이가능하고생겨도심하지않아서안전한치료로볼수있고수술적치료방법을선택하기전에시행될수있기때문에유용하다고할수있다. 체외충격파치료의원리인기계적인에너지집중효과와생물학적효과의적응증을잘선택해서시행한다면좋은임상결과를얻을수있을것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Wang CJ. An overview of shock wave therapy in musculoskeletal disorders. Chang Gung Med J. 2003;26: Ogden JA, Toth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clin Orthop Relat Res. 2001;387: Gerdesmeyer L, Gollwitzer H, Diehl P, Wagner K. Radial extracorporeal shockwave therapy (reswt) in orthopaedics. J Miner Stoffwechs. 2004;11: Wang CJ, Huang HY, Pai CH. Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs. J Foot Ankle Surg. 2002;41: Wang CJ, Wang FS, Yang KD, et al. Shock wave therapy induces neovascularization at the tendon-bone junction: a study in rabbits. J Orthop Res. 2003;21: Wang CJ, Yang KD, Wang FS, Chen HH, Wang JW. Shock wave therapy for calcific tendinitis of the shoulder: a prospective clinical study with two-year follow-up. Am J Sports Med. 2003;31: Maier M, Stäbler A, Lienemann A, et al. Shockwave application in calcifying tendinitis of the shoulder: prediction of outcome by imaging. Arch Orthop Trauma Surg. 2000;120: Rompe JD, Hope C, Küllmer K, Heine J, Bürger R. Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. J Bone Joint Surg Br. 1996;78: Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005;87: Spacca G, Necozione S, Cacchio A. Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Eura Medicophys. 2005;41: Wang CJ, Ko JY, Chan YS, Weng LH, Hsu SL. Extracorporeal shockwave for chronic patellar tendinopathy. Am J Sports Med. 2007;35: Peers KH, Lysens RJ, Brys P, Bellemans J. Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy. Clin J Sport Med. 2003;13: Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop. 2008;79: Metzner G, Dohnalek C, Aigner E. High-energy extracorporeal shock-wave therapy (ESWT) for the treatment of chronic plantar fasciitis. Foot Ankle Int. 2010;31: Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. 2003;31: Wang CJ, Chen HS, Huang TW. Shockwave therapy for patients with plantar fasciitis: a one-year follow-up study. Foot Ankle Int. 2002;23: Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013;471: Omar MT, Alghadir A, Al-Wahhabi KK, Al-Askar AB. Efficacy of shock wave therapy on chronic diabetic foot ulcer: a single-blinded randomized controlled clinical trial. Diabetes Res Clin Pract. 2014;106: Moya D, Ramón S, Schaden W, Wang CJ, Guiloff L, Cheng JH. The role of extracorporeal shockwave treatment in musculoskeletal disorders. J Bone Joint Surg Am. 2018;100: Wang CJ, Huang HY, Chen HH, Pai CH, Yang KD. Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model. Clin Orthop Relat Res. 2001;387: Forriol F, Solchaga L, Moreno JL, Canãdell J. The effect of shockwaves on mature and healing cortical bone. Int Orthop. 1994;18: Wang CJ, Yang KD, Wang FS, Hsu CC, Chen HH. Shock wave treatment shows dose-dependent enhancement of bone mass and bone strength after fracture of the femur. Bone. 2004;34: Verstraelen FU, In den Kleef NJ, Jansen L, Morrenhof JW. High-energy versus low-energy extracorporeal shock wave

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7 406 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: 근골격계질환의비수술적재생치료 근골격계질환에대한체외충격파치료 염재광 안상준 인제대학교상계백병원정형외과 충격파를만드는방법은전기수력 (electrohydraulic), 전자기 (electromagnetic), 압전기 (piezoelectric) 등의원리로만들어진다. 체외충격파치료는기계적인힘으로목표조직에에너지를집중시키는효과와조직치유를촉진하는생물학적효과가있는것으로알려져있다. 체외충격파치료는오랜기간시행되어왔으며, 체외충격파치료를시행하는분야는석회성또는비석회성건염, 주관절의외상과염또는내상과염, 슬개건염, 아킬레스건병증 (achilles tendinosis), 근위부족저근막염, 근막통증증후군등이다. 또한골절의지연유합이나불유합, 그리고대퇴골두의무혈성괴사, 당뇨병에의한피부괴사등에시도되고있다. 근골격계질환에대한체외충격파치료의결과가좋고합병증도경미하다는보고가많아근골격계질환에체외충격파치료의사용이증가하고있다. 따라서저자는근골격계질환에대한체외충격파치료에대하여논문고찰과함께정리해보고자한다. 색인단어 : 체외충격파치료, 근골격계질환 접수일 2017 년 10 월 30 일수정일 2018 년 1 월 30 일게재확정일 2018 년 6 월 20 일책임저자염재광 01757, 서울시노원구동일로 1342, 인제대학교상계백병원정형외과 TEL , FAX , yumccf@hanmail.net, ORCID 대한정형외과학회지 : 제 53 권제 5 호 2018 Copyright 2018 by The Korean Orthopaedic Association 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.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic