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1 J Korean Soc Phys Med, 2017; 12(2): Online ISSN: Print ISSN: X Research Article Open Access 분절별등뼈관절가동술이만성허리통증환자의통증과관절가동범위에미치는즉시적효과 심재헌 정의철 최희양 김철용 1 재 ) 자생의료재단울산자생한방병원, 1 울산과학대학교물리치료과 The Immediately Effects of Thoracic Mobilization by Segment on Pain and Range of Motion in Chronic Low Back Pain Patients Jae-Heon Sim, PT, MSc Ui-Cheol Jeong, PT, PhD Hee-Yang Choi, PT Cheol-Yong Kim, PT, PhD 1 Dept. of Physical Therapy, Ulsan Jaseng Hospital of Korean Medicine, Jaseng Medical Foundation 1 Dept. of Physical Therapy, Ulsan College Received: February 3, 2017 / Revised: February 19, 2017 / Accepted: April 19, 2017 c 2017 J Korean Soc Phys Med Abstract 1) PURPOSE: This study aims to identify the immediate effects of thoracic mobilization according to segment on disabling low-back pain and the range of motion in patients with chronic low-back pain. METHODS: The participants were divided randomly into two groups: a group (N=12) with pain and disability between the 5th and 9th thoracic vertebrae (T5-T9) and a group (N=12) with pain and disability between the 10th and 12th thoracic vertebrae (T10-T12). The same experiment was conducted in both groups: 10 minutes of thoracic mobilization and 10 minutes of functional massage. The visual analogue scale (VAS) and range of motion measurements were applied to the Corresponding Author : uspt9599@naver.com 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. participants in both groups. All participants were measured again immediately after the program was completed. RESULTS: In both groups, the VAS and range of motion measurements showed statistically significant improvement after the experiment (p<.05). No statistically significant difference was revealed between the two groups (p>.05). CONCLUSION: The results of this study confirmed positive and immediate effects of thoracic mobilization of patients with chronic low-back pain. But, no significant difference in the thoracic mobilization by segment between the two groups. Based on these results, thoracic mobilization could help to improve pain control and functional activity in patients with chronic low-back pain. Key Words: Chronic low back pain, Range of motion, Thoracic mobilization

2 34 J Korean Soc Phys Med Vol. 12, No. 2 Ⅰ. 서론허리통증은현대사회에서많은사람들에게흔히나타나는가장일반적인질환중에하나이며, 갈비뼈하부와골반의윗부분및허리분절을포함한부분에서나타나는통증을표현하는용어로 (Haynes와 Williams, 2008), 일반대중의 60 80% 정도가일생의어느시점에허리통증을경험한다 (Nachemson 등, 2000). 허리통증의발생빈도는남녀모두에서 30 50대사이에가장빈번히발생하며, 주로 40대이후에중년여성에게많이발생한다 (Hicks 등, 2005). 허리통증은통증지속기간에따라 6주이하는급성, 6주에서 3개월사이는아급성, 3개월이상이면만성허리통증으로분류되는데 (Koes 등, 2006), 증상에따라비특이성허리통증, 신경병증또는척추관협착증과관련된허리통증, 다리방사통및다른척추원인과관련된허리통증이있다 (Last 와 Hulbert, 2009). 만성허리통증의여러원인중에서허리분절의불안정성이만성허리통증과관련이있는데, 척추의정상관절가동범위를넘어선불안정성이가장중요한요소로여겨지고있다 (Jeong, 2000; Wallden, 2009). 허리분절불안정성이란, 허리뼈추체사이에서의중립위치를생리적한계범위내로유지하지못하는상태로 (Panjabi, 1992), 허리분절심부근육들의약화와재위치능력저하및고유수용성감각기능의결함으로허리분절불안정성이발생하게되는데이로인해, 허리통증이만성화되면체성감각에다양한문제를발생시켜그중에서허리분절의가동성과안정성의감소가발생하고, 근력및협응력의저하와고유수용기의변화가나타나게된다 (Koumantakis 등, 2005). 허리통증환자는통증, 구조적손상, 반사적근수축기전억제등으로인해몸통의활동성이감소되며, 장기간동안몸통의활동성감소와불사용으로인해근위축및근력저하를유발하여, 이는허리통증을더악화시키고이차적인허리분절손상및신체장애를유발하게된다 (Kader 등, 2000). 만성허리통증환자에게서는등뼈분절의제한된움직임을볼수있는데, 이렇게줄어든등뼈분절의움직임으로오는구조적, 기능적이상이척추사이의움 직임을증가시키고이로인해, 허리분절사이에서후관절 (facet joint) 의불안정성을야기하며허리통증의주된원인이된다 (Edmondston과 Singer, 1997; Singer, 1997; Kim과 Baek, 2003). 또한, Richardson 등 (2004) 은허리통증환자와건강한사람을비교하였을때, 허리통증환자의몸통굽힘과폄시에불균형이일어나고, 바깥굽힘시에는비정상적인짝동작 (couple motion) 이일어난다고하였다. 이러한척추의불안정성은인접한주변관절움직임을제한시키는데 (O'Sullivan 등, 2003), 후관절의연결성에의한척추의움직임은상대적으로인접해있는관절들의움직임에영향을주게되어, 만성허리통증환자의경우에는등뼈의관절가동범위에제한을일으킨다 (Lee와 Kim, 2010; Levangie와 Norkin, 2011). 이감소된등뼈의움직임은허리분절과목분절에영향을주어더많은움직임을유발시키고, 많아진움직임에의해추체사이의구조적및기능적인문제를일으켜서허리분절후관절의불안정성과만성허리통증의원인을제공하게된다 (Edmondston와 Singer, 1997; McConnell, 2002). 이러한문제를해결하기위해 Kaltenborn 등 (1993) 은움직임이감소된인접한관절의움직임을증가시켜불안정한관절의안정성을유도하는방법으로치료를접근해야한다고하였다. Cleland 등 (2007) 은등뼈관절가동술을적용한간접적인중재는목분절또는허리분절에직접적으로적용하는것보다부작용이적다고하였으며또한, 간접적중재인윗등뼈관절가동술을만성목통증환자에게적용한후목통증및관절가동범위증진에효과적이었다 (Hwangbo 등, 2012; Lee 등, 2015). 최근, 선행연구에서는만성허리통증환자에게등뼈관절가동술을적용하여허리통증을완화시키고허리분절의관절가동범위증진에효과적이었다고보고하였다 (Baek, 2015; Jeong, 2015; Ko 등, 2009; Yang, 2016). 관절가동술 (joint mobilization) 은통증감소와관절가동범위향상으로자주사용되고있는데, 관절가동술은관절면에서신연 (distraction), 미끄러짐 (sliding), 압박 (compression), 구름 (rolling), 축회전 (spinning) 과같은접근방법으로수동적견인과활주를향상시키고, 관절이자유롭게움직일수있게회복시키며보호한다 (Godges

3 분절별등뼈관절가동술이만성허리통증환자의통증과관절가동범위에미치는즉시적효과 35 등, 2003). 또한, 관절가동술은뻣뻣한조직 (stiffness tissue) 의관절가동범위를증가시키고, 손상된관절의정상적인움직임을촉진하며, 관절움직임이일어날때증상이악화되는것을예방하게한다 (Godges 등, 2003). Kaltenborn 등 (1993) 은등뼈는윗등뼈 (T1-T4), 아랫등뼈 (T5-T12) 로분류하여윗등뼈는목뼈와연관성이있고아랫등뼈는허리뼈와연관성이있다고하였다. 하지만, 최근에는더세분화하여위등뼈 (T1-T4), 중간등뼈 (T5-T9), 아랫등뼈 (T10-T12) 로분류하고있다 (Tawackoli 등, 2004). 윗등뼈는목뼈의움직임과유사하고, 중간등뼈는갈비뼈관절로인해움직임이가장적으며, 아랫등뼈는 T11과 T12에부유갈비뼈 (floating rib) 가부착되어갈비뼈앞면부가완전하게결합하지않아움직임이많이일어난다 (Park 등, 2013). 이처럼등뼈의각분절에따라특성이있어, 본연구에서는등뼈를더세분화하여중간등뼈와아랫등뼈에각각관절가동술을적용하여어느분절이만성허리통증환자의통증과허리관절가동범위에더즉시적으로영향을미치는지를확인하고자한다. Ⅱ. 연구방법 1. 연구대상본연구는 2016년 10월부터 2016년 12월까지 U시소재 J한방병원에서만성허리통증진단을받고증상이 3개월이상지속된여성환자들 (30세 ~50세 ) 로, 중등도의시각적통증사상척도 (4점 ~6점 ) 와중등도의허리통증장애지수 (21~41%) 를가진만성허리통증환자 (Mousavi 등, 2006) 를대상으로하였다. 연구대상자중허리통증이외의다른근골격계질환이있는환자, 신경학적징후 ( 근약화, 마비, 심부건반사소실등 ) 가있는환자, 허리뼈및등뼈에골절이나, 신경등에구조적이상이있는환자, 허리뼈및등뼈에수술경험또는염증성질환이있는환자는제외하였다. 모든대상자들은본연구의실험과정에대한설명을듣고, 연구목적을이해하였으며, 자발적으로동의한대 상자총 24 명을대상으로진행하였다. 사전검사후, 제비뽑기를하여무작위로각각, 통증과기능장애가있는중간등뼈군 (12명) 과아랫등뼈군 (12명) 등 2개의군으로분류하고, 단순눈가림법 (single blinding) 을이용하여등뼈 5-9번 (T5-T9) 분절과등뼈 10-12번 (T10-T12) 분절에서총 20분동안, 각각등뼈관절가동술 (10분) 및기능적마사지 (10분) 을적용한후바로사후검사를실시하여즉시적결과를얻었다 (Fig. 1). 2. 연구설계 T5-T9 group (N=12) Subject select (N=24) Randomized, Single blinding T10-T12 group (N=12) Pre test (Visual Analogue Scale, Range of Motion) T5-T9 Thoracic Mobilization + Functional Massage (N=12) T10-T12 Thoracic Mobilization + Functional Massage (N=12) Immediately post test (Visual Analogue Scale, Range of Motion) Statistical analysis (SPSS for window ver. 18.0) Fig. 1. Flow chart of study 3. 실험도구 1) 시각적통증사상척도 (Visual Analogue Scale : VAS) 환자가느끼는주관적인통증의정도로 10cm 길이의눈금없는직선위에환자가느끼는통증정도를표시한후시작점에서거리를측정하여점수화하는방법이다. 전체 0점에서 10점까지점수를부여하여통증이없는상태는 0점, 가장심한통증상태를 10점으로

4 36 J Korean Soc Phys Med Vol. 12, No. 2 정의한다 (Gong 등, 2010). VAS가 3점이하면낮은통증, 4~6점은중등도통증, 7~10점은심각한통증으로분류한다 (Jensen 등, 2001). 검사-재검사간신뢰도 (r=1) 와검사자간신뢰도 (r=.99) 가매우높은평가도구이다 (Wagner 등, 2007). 2) 관절가동범위 (Range of Motion : ROM) T5-T12와 L1-L5의굽힘및폄자세에서의길이를각각줄자로측정하였다 (Yun, 2003). 4. 실험방법본연구에서는 T5-T9 그룹과 T10-T12 그룹으로분류하여, 등뼈관절가동술 (10분) 과기능적마사지 (10분) 으로총 20분동안치료를실시하였다. 1) 등뼈관절가동술 (Thoracic mobilization) 환자는엎드린자세에서가동하고자하는분절의바로윗분절전방에모래주머니를놓고윗분절을고정한뒤등뼈관절가동술을시작한다. 한손을이용하여선택한등뼈분절의극돌기사이를촉지하여윗분절과아래분절을확인한뒤, 다른한손으로아래분절의횡돌기에쐐기 (wedge) 를위치시킨다. 쐐기의상단은척추궁 (lamina arcus) 및선택된분절의횡돌기가장아래부분에놓는다. 쐐기에압박을주어선택된분절의극돌기사이가분리되면, 2번째손가락 을사용하여분절의움직임을평가한다. 인접하는조직신장을위해쐐기를가압하여 Kaltenborn 등 (1993) 이분류한 3단계강도로적용하였다 (Ko 등, 2009). 등뼈관절가동술은각분절마다휴식을포함한 2세트로, 30초동안 3회를적용하였고, 관절가동술사이의간격은 3초로설정하였다. 분절간이동및휴식은 15초, 세트간휴식은 30초로적용하였다 (Cleland 등, 2007; Kaltenborn 등, 1993)(Fig. 2). 2) 기능적마사지 (Functional massage) 기능적마사지는연부조직의이완과원활한혈액순환을가져오고, 관절가동과관절수용기의기능적인부분을증가시킨다 (Weerapong 등, 2005). 본연구에서는 T5-9 그룹과 T10-12 그룹모두에똑같이관절가동술을적용하기전에등뼈부위의이완을유도하기위해서 T5-12에기능적마사지 (10분) 를실시하였다 (Fig 2). 4. 자료분석본연구에서통계처리는연구의목적을위하여수집된자료를 SPSS 18.0 for window를이용하여측정된모든변인에대하여평균과표준편차를산출하였다. 수집된자료의정규성검정을위해 Kolmogorov- Smirnov검정을시행하였으며, 각집단내실험전, 후에통증수준과허리관절가동범위의변화를알아보기위하여대응표본 t-test를실시하였고, 집단간의동질성 Warm up (FM) Main therapy (TM) T5-T9 group T10-T12 group 10min Fig. 2. Thoracic mobilization and functional massage 10min

5 분절별등뼈관절가동술이만성허리통증환자의통증과관절가동범위에미치는즉시적효과 37 검정과변화량비교는독립표본 t-test 를실시하였다. 통계학적유의수준 (α) 은.05 로설정하였다. 통증사상척도및관절가동범위의초기값에유의한차이가없었다 (Table 1). Ⅲ. 연구결과 1. 대상자의일반적특성본연구에참여한연구대상자는총 24명의여성만성허리통증환자로두집단간에나이, 신장, 체중, 통증및장애지수에서유의한차이가없었고, 시각적 2. 집단내통증수준및관절가동범위의변화비교 T5-T9 그룹에서의 VAS는실험전후에서유의하게감소하였고 (p<.05), TFR은실험전후에서유의하게증가하였고 (p<.05), TER은실험전후에서유의하게감소하였고 (p<.05), LFR은실험전후에서유의하게증가하였고 (p<.05), LER은실험전후에서유의하게감소하였다 (p<.05)(table 2). Table 1. General characteristics of Subjects T5-T9 Group (N=12) T10-T12 Group (N=12) t p Age (year) ± ± Height (cm) ± ± weight (kg) ± ± ODI ± ± VAS 6.05 ± ± TFR ± ± TER ± ± LFR ± ± LER ± ± TFR : Thoracic Flexion Range of motion TER : Thoracic Extension Range of motion LFR : Lumbar Flexion Range of motion LER : Lumbar Extension Range of motion Table 2. Comparison of T5-T9 group on VAS and ROM T5-T9 Group (N=12) t p VAS pre 6.05 ± 1.80 post 3.53 ± * TFR pre ± 4.00 post ± * TER pre ± 2.52 post ± * LFR pre ± 3.19 post ± * LER pre ± 2.02 post 9.33 ± * * p<.05 TFR : Thoracic Flexion Range of motion TER : Thoracic Extension Range of motion LFR : Lumbar Flexion Range of motion LER : Lumbar Extension Range of motion

6 38 J Korean Soc Phys Med Vol. 12, No. 2 Table 3. Comparison of T10-T12 group on VAS and ROM T10-T12 Group (N=12) VAS pre 6.33 ± 1.55 post 4.55 ± 1.78 TFR pre ± 4.59 post ± 4.43 TER pre ± 3.61 post ± 4.21 LFR pre ± 2.98 post ± 2.95 LER pre ± 1.26 post ± 1.41 * p<.05 TFR : Thoracic Flexion Range of motion TER : Thoracic Extension Range of motion LFR : Lumbar Flexion Range of motion LER : Lumbar Extension Range of motion t p * * * * * T10-T12 그룹에서의 VAS는실험전후에서유의하게감소하였고 (p<.05), TFR은실험전후에서유의하게증가하였고 (p<.05), TER은실험전후에서유의하게감소하였고 (p<.05), LFR은실험전후에서유의하게증가하였고 (p<.05), LER은실험전후에서유의하게감소하였다 (p<.05)(table 3). 차이가없었고 (p>.05), TER에서실험전후변화에서는두집단간유의한차이가있었다 (p<.05). LFR에서실험전후의변화에서는두집단간유의한차이가없었고 (p>.05), LER에서실험전후변화에서는두집단간유의한차이가없었다 (p>.05)(table 4). 3. 집단간통증수준및관절가동범위의변화비교 VAS에서실험전후의변화에서는두집단간유의한차이가없었다 (p>.05). TFR에서실험전후의변화에서는두집단간유의한 Ⅳ. 고찰 본연구에서는만성허리통증환자들에게분절에따라 T5-T9와 T10-T12에등뼈관절가동술을각각적용하 Table 4. Comparison of VAS and ROM change between the groups T5-T9 Group (N=12) (Post Pre) T10-T12 Group (N=12) (Post Pre) VAS ± ± * TFR 2.41 ± ± * TER ± ± * LFR 1.80 ± ± * LER -.99 ± ± * * p<.05 TFR : Thoracic Flexion Range of motion TER : Thoracic Extension Range of motion LFR : Lumbar Flexion Range of motion LER : Lumbar Extension Range of motion t p

7 분절별등뼈관절가동술이만성허리통증환자의통증과관절가동범위에미치는즉시적효과 39 여통증및등뼈와허리의관절가동범위의즉시적인변화에대해알아보았다. 각각의분절에따른등뼈관절가동술시행후, VAS는두집단에서모두유의하게감소하였다 (p<.05). 이결과는만성허리통증환자에게등뼈관절가동술을적용하여허리통증을감소시켰다고보고한연구들과같은결과를나타냈다 (Baek, 2015; Jeong, 2015; Ko 등, 2009; Yang, 2016). 본연구에서의등뼈관절가동술은, 전단부하 (shearing loading) 즉, 회전과함께조직섬유의압박과신장의복합적패턴을제공하여관절조직의섬유에영향을주고수동적인신장을만든다 (Lederman, 1997). 두그룹에적용한관절가동술이관절을구성하는근육, 관절낭, 인대등에지속적인수동적자극을주어관절과연부조직의역학적변화를일으키고척추의운동성을회복하게하여관절움직임이일어날때증상이악화되는것을예방하게하였고 (Cleland 등, 2007), 관절움직임을통해향상된고유수용성감각은유해성자극에응답하여정상적인신경발화자극으로통증인식을억제하게하여 (Godges 등, 2003), 등뼈관절가동술이 T5-9 그룹과 T10-12 그룹의 VAS를감소시키는즉시적효과를가져왔다고사료된다. 만성허리통증환자들은정상인에비해척추가굽힘과폄시바깥굽힘및축회전, 즉짝운동 (couple motion) 의제한과불균형이관찰되었고 (Lund 등, 2002), 몸통근육의단축, 유연성감소로인한척추의제한된움직임은등뼈회전움직임패턴의변화를일으킬수있다 (Sharpe 등, 2008). 등뼈후만의증가는기립자세에서현저히높은척추의하중및몸통근육의힘에영향을주고이러한부하는척추분절의빠른퇴행과기능이상및통증을증가시킨다 (Briggs 등, 2007). 증가된등뼈후만은해부학적변화와운동성감소로현저하게등뼈의폄을제한시킨다 (Ko 등, 2009). 결국, 등뼈후만의증가와등뼈운동성의감소는보상작용에의해허리뼈의운동성을증가시켜허리의과다사용으로인한허리분절의불안정성을발생시키므로결과적으로허리통증을유발시키게된다 (Hur, 2005). 이러한만성허리통증환자들의감소된유연성과제한된등뼈의움직임개선에어떠한영향을미치는지알아보기위해본연구에서는분절별관절가동술을적용하였고, T5-T12 사이에 관절가동술을적용하여 T5-T12 및 L1-L5의관절가동범위의변화를알아보았다. T5-T9 그룹과 T10-T12 그룹에각각관절가동술을적용한후그결과, 두그룹에서허리의관절가동범위가개선되는것을볼수있었다. 이것은등뼈후관절견인 (traction of thoracic facet joint) 을만성허리통증환자에게적용하여증가된등뼈운동성은통증의감소와척주의운동성을개선하는데도움을주었다는연구 (Ko 등, 2009), 만성허리통증환자에게허리분절안정화운동후등뼈관절가동술을추가적으로적용한치료적접근방법이관절가동범위증진을위해효과적이라는연구 (Baek, 2015), 만성허리통증환자에게등-허리뼈면관절견인기법과몸통안정화운동은즉각적으로등-허리뼈의움직임성을증가시킴으로써허리분절을안정화시킨다는연구 (Jeong, 2015), 만성허리통증환자에게등뼈가동술을통해등뼈의움직임을증가시킨다면통증의감소와척추운동성을개선하는데효과적일것이라는연구 (Yang, 2016) 들과같은결과로, 본연구에서의등뼈관절가동술을적용한후허리의관절가동범위가즉시적으로증가되는것을볼수있었다. 등뼈관절가동술에의해등뼈분절의인대가신장함에따른관절가동범위의증가 (Debski 등, 1999) 와등뼈분절의관절움직임을제한하는주변연부조직의신장과관절내압력의감소가관절가동범위의증가 (Hoeksma 등, 2004) 를유도하여본연구에서처럼등뼈의관절가동범위가증가함에따라이로인해허리의관절가동범위가증가한것이라고사료된다. 선행연구들에서는 T5-T9와 T10-T12를각각구분없이, T5-T12를전체적으로관절가동술을적용하여그효과를알아보는연구들이많았고, T5-T9와 T10-T12에각각의관절가동술이허리에어떤영향을주는지명확히구별할수있는연구는없었다. 이러한부분을보완하여본연구에서는 T5-T9와 T10-T12를세분하여각각관절가동술을적용하였다. T5-9에서는갈비뼈에의해복장뼈와연결되어가슴우리를이루고, 이로인하여시상면에서의안정성을얻는특성이있어서 (Watkins 등, 2005), 상대적으로 T10-12 보다척추의움직임이적다. 반대로, T10-12에서는불완전한가슴우리의보호, 증가된척추의운동성, 후관절의방향전환및등뼈

8 40 J Korean Soc Phys Med Vol. 12, No. 2 후만에서허리전만으로이행등으로외상과퇴행성변화등이호발되는상대적으로불안정한부위이다 (Kang 등, 2016). 이러한등뼈분절의구조적인특성으로등뼈관절가동술을적용하여각각의허리관절가동범위의변화를알아보았다. 하지만, T5-9 그룹과 T10-12 그룹에서의허리관절가동범위의변화량을비교해보았을때, 관절가동범위의양은 T5-9 그룹이 T10-12 그룹보다더증가한것을볼수있었으나, 통계적으로유의한차이를나타내지는않았다. 결론적으로, 본연구에서분절별등뼈관절가동술을적용하였더니각그룹에서통증, 등뼈및허리의관절가동범위의개선을볼수있었으나그룹간비교에서는 T10-T12 그룹이등뼈폄가동범위에서만효과적개선을보였다. 이는본연구에서알아보고자했던, 분절별등뼈관절가동술의적용에따른즉시적효과의차이를명확히밝히지는못하였으나등뼈의폄가동범위가증가되어허리의움직임에대한스트레스를감소시키는긍정적인영향을줄수있지않을까사료된다. 본연구의제한점으로는, 연구대상자의인원이많지않았고, 기간이부족한점과 30~50대여성으로남녀및다른연령층과의일반화하여해석하기에는제한이있다는점이다. 추후의연구에서는보다많은연구대상자와다양한연령층에서의연구가필요할것이다. Ⅴ. 결론본연구는분절별등뼈관절가동술이만성허리통증환자의통증과관절가동범위에미치는즉시적효과를알아보았다. 그결과, 집단내변화는통증과관절가동범위에서유의한효과가있었으나, 집단간변화비교에서는 T10-T12 그룹이등뼈폄관절가동범위에서유의한효과를보였다. 결과적으로, 본연구에서는분절별등뼈관절가동술을적용이등뼈의관절가동범위개선됨에따라즉시적으로허리통증의감소와허리관절가동범위의증가에긍정적인영향을미친다고볼수없었으나등뼈관절가동술을통한등뼈의가동성증진과유지는만성허리통 증환자에게있어통증조절과허리의기능적활동성향상에영향을미친다고할수있을것이다. References Baek IH. The Effects of Indirect Thoracic Joint Mobilization on Thoracolumbar Proprioception, Active Range of Motion, Pain, and Disability in Patients with Chronic Low Back Pain. Master s Degree. Konyang university Briggs AM, Van Dieen JH, Wrigley TV, et al. Thoracic kyphosis affects spinal loads and trunk muscle force. Phys Ther. 2007;87(5): Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007; 87(4):431. Debski RE, Sakane M, Woo SL, et al. Contribution of the passive properties of the rotator cuff to glenohumeral stability during anterior-posterior loading. J Shoulder Elbow Surg. 1999;8(4): Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3): Godges JJ, Mattson-Bell M, Thorpe D, et al. The immediate effects of soft tissue mobilization with proprioceptive neuromuscular facilitation on glenohumeral external rotation and overhead reach. J Orthop Sports Phys Ther. 2003;33(12): Gong WT, Cheun HJ, Lee KM. The effect of cervical stabilized exercise and joint mobilization on maximum muscle strength and static muscle endurance of cervical region. Journal of the Korean Data and Information Science Society. 2010;21(1): Haynes S, Williams K. Impact of seating posture on user comfort and typing performance for people with

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Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical