Exercise Science Vol.27, No.4, November 2018: ISSN(Online) REVIEW ARTICLE 숏풋운동이발의안쪽세로활과균

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1 Exercise Science Vol.27, No.4, November 2018: ISSN(Online) REVIEW ARTICLE 숏풋운동이발의안쪽세로활과균형에미치는영향과효율적적용에대한연구 황룡 ¹, 최영준 ² ¹ 동남보건대학교물리치료과, ² 조은정형외과물리치료실 A Study on The Effects of Short Foot Exercise on Medial Longitudinal Arch and Balance in the Foot and Efficient Application: Literature Review Ryong Hwang¹, Young-Jun Choi² ¹Department of Physical Therapy, Dongnam Health University, Suwon; ²Department of Physical Therapy, Joeun Orthopedic Clinic, Bucheon, Korea PURPOSE: The purpose of this study was to analysis the effective short foot exercise methods and verify the effect of short foot exercise (SFE) on medial longitudinal arch (MLA) and balance in order to utilize it as foundation data for clinical fields. METHODS: In this study, research papers were collected by using RISS, KISS and PubMed as a search term for SFE, foot intrinsic muscle exercise (FIME) and MLA. RESULTS: A total of 30 research were gathered, and 16 papers of data were related effect of SFE, and 9 papers was related to effective exercise methods, and 5 papers was related to a comparison with other FIME. The collected data were classified into the influence of SFE on the MLA, balance, and the efficient exercise methods. CONCLUSIONS: The result of this study confirmed that SFE was very effective to maintain MLA and improve foot stability, dynamic balance and gait. In addition to, imagery training and biofeedback with SFE was efficient methods, and SFE applied with weight bearing, or windlass effect, or 30 ankle dorsiflexion strengthened abductor halluces muscle effectively. Therefore, SFE will be useful for rehabilitation of pes planus patients or athletes. Key words: Short foot exercise, Medial longitudinal arch, Intrinsic foot muscle exercise, Balance, Pes planus 서론 일반적으로발은인체의 5% 를구성하고발바닥의감각정보를통해자세의조절과균형을유지하는안정성을제공하며, 충격을흡수하는역할을한다 [1]. 여러인대와근육그리고뼈구조물로이루어져있는발은매우복잡하지만크게수동과능동의두가지구조물로분류된다. 수동적구조물은발바닥인대와발뼈로형성된세로활 (Medial Longitudinal Arch), 발바닥근막이있으며, 능동적구조물은발의외재 근건과내재근들이있다 [2]. 이두구조물은하체의운동사슬의기저면으로서역할을하고역동적인활동중하지의안정화에중요한역할을한다 [2,3]. 안쪽세로활은발의일차적인체중지지및충격흡수구조로, 낮은스트레스나정적인상황에서발을지지하는역할을한다 [4]. 발꿈치뼈, 목말뼈, 발배뼈, 그리고 3개의쐐기뼈와첫번째부터세번째발허리뼈가골격을구성하는안쪽세로활은발바닥근막, 긴발바닥인대와짧은발바닥인대, 용수철인대가수동적지지를제공하며, 앞정강근과뒤정강근, 발가락굽힘근과발가락벌림근이능동적지지 Corresponding author: Young-Jun Choi Tel Fax manse2010@naver.com * 이논문은동남보건대학교학술연구비지원을받아연구되었음. Keywords 단축발운동, 안쪽세로활, 발내재근운동, 균형, 편평발 Received 29 Jul 2018 Revised 22 Aug 2018 Accepted 10 Sep 2018 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. 252 Copyright 2018 Korean Society of Exercise Physiology

2 를제공한다. 안쪽세로활의구성요소중발의내재근, 특히엄지벌림근은체중지지활동동안활 (arch) 의안정성에기여하고발바닥근막, 발바닥인대및발의외재근과함께작용하여보행시발의목말밑관절의엎침을조절한다 [5-7]. 그러나여러이유로구조물들이충분한지지를하지못하여안쪽세로활이무너질경우편평발 (pes planus) 이발생한다. 편평발은만성적인증상으로안쪽세로활각도의감소, 뒤발의밖굽이, 뒷발에대한중간발의벌림이나타난다 [8]. 이러한발의과도한엎침은압박골절, 발허리뼈골절, 아킬레스건염등과사용손상이일어난다 [9-11]. 이러한문제를해결하기위해스포츠재활분야에서는발가락으로물건집기, 한쪽균형동작, 정강이굴곡과숏풋운동 (Short foot exercise) 등과같은중재들이사용되었다 [12,13]. 숏풋운동은발을앞쪽에서뒤쪽방향으로짧게만드는방법으로, 발가락굽힘없이첫번째발허리뼈머리를뒤꿈치방향으로끌어당기는운동이며, 종종발의내재근, 세로활과가로활의강화를위해스포츠및재활영역에서처방된다 [13]. Jung et al. [14] 에따르면, 숏풋운동은엄지벌림근을활성화하며, 안쪽세로활이낮아지는것을예방할뿐만아니라, 노인환자의낙상예방과보행동안의안정성을향상시키는데효과적이다 [15,16]. 숏풋운동은최근편평발환자에대한운동으로자주이용되고있다. 하지만평상시사용하는근육이아니고발내재근이약해져있어올바른운동의수행이어렵다 [17]. 이러한이유로숏풋운동에대한최근연구들은숏풋운동의다양한운동효과를검증하고효율적으로적용할방법을연구해왔으나자료가부족한실정이다. 따라서본연구는숏풋운동의다양한효과를분석하여효율적인적용을제시하고일반인, 스포츠선수및환자등의재활에기초자료로활용하는것을목표로한다. 연구방법 문헌검색은 2018년 3월 1일부터 6월 12일까지진행하였다. 문헌검토는 PRISMA 지침을기반으로, 인터넷을활용한국내및해외데이터베이스를이용하여첫번째단계에서는키워드를통한검색으로초록과전문을분석하여 2007년부터 2017년까지발표된사례연구및무작위대조군연구 38편을선별하였고고찰논문과본연구의목적에부합하지않는논문 8편은제외하여총 30편의논문을검토하였다. 국내논문의경우학술연구정보서비스 (RISS) 와한국학술정보서비스 (KISS) 를통해출판및완성된학술지및학위논문을검색하였으며, 외국학술자료의경우 PubMed를통하여확장검색하였다. 검색어는 단축발운동, 숏풋운동, Short foot exercise, Short-foot exercise, Foot intrinsic exercises 로검색하였다. 그중숏풋운동의다양한영향에대해연구한논문은 16편, 숏풋운동의효율적인운동방법에대해연구 한논문 9편, 숏풋운동과다른유사운동들과비교한논문은 5편으로분류하였다. 분류된연구자료를토대로숏풋운동이안쪽세로활에미치는영향과발목의안정성및보행에영향을미치는균형과숏풋운동의효율적운동방법을세부내용으로정리하고분석하였다. 본론 1. 숏풋운동이발안쪽세로활에미치는영향편평발은안쪽세로활이편평해지는것, 뒤발의밖굽이, 뒤발에대한중간발의벌림증상을포함하는만성적인징후이다 [8]. 안쪽세로활은걷거나달릴때발생하는충격을흡수하는역할을하며, 첫번째발허리뼈먼쪽및중간부분은신체의움직임시스프링과같이체중을지탱하여균형을유지한다 [18]. 발을구성하는근육들중엄지벌림근은안쪽세로활의상승과함께엄지굽힘근, 첫번째발허리뼈의뒤침근, 뒤꿈치뼈의번짐근, 정강근의바깥돌림근의기능을같이수행을한다 [19]. 또한선행연구에서는엄지발가락벌림근에피로가쌓이면발배뼈하강 (Navicular drop) 이증가하고, 정강신경을차단한 (Tibial nerve block) 상태에서엄지굽힘을시도했을때, 역시발배뼈하강의증가와엄지벌림근의근활성도가유의하게감소하는결과를언급하며, 엄지벌림근이안쪽세로활을지지하고정적인상태에서엎침을조절하는중요한역할을한다고주장했다 [5,7]. 따라서엄지벌림근의강화는과도하게엎침된발의안쪽세로활유지와편평발을가진사람들에게서발생할수있는과사용에따른문제를예방하는데필수적이다 [5,7,19]. 편평발과관련된병적문제는서있거나걷는동안의발이과도한엎침이되어이로인해흔한과사용손상이발생하고, 아킬레스힘줄염, 엄지발가락가쪽휨증, 뒤경골근기능부전그리고무릎뼈넙다리통증등의증상을유발한다 [20-24]. 이문제를해결하기위해처방되는운동으로는숏풋운동, 발가락오므리기운동, 발가락벌리기운동과발가락으로물건집기등이이용되었다 [12,13]. 숏풋운동은발바닥을바닥에붙인채로시행되는운동이며이를통해발바닥자극이활성화된다. 그뿐만아니라안쪽세로활을구성하는엄지벌림근과짧은엄지굽힘근의근활성을통해고유수용감각되먹임을적용한감각운동훈련이가능하다 [25]. Prentice [13] 는숏풋운동이세로활과가로활의강화와내재근의강화효과를나타낸다고하였다. 또한여러선행연구에서도숏풋운동이엄지벌림근을활성화시키는데효과적이며안쪽세로활이낮아지는것을예방한다고보고하였다 [14,26]. 2. 숏풋운동이균형에미치는영향발은인체의 5% 를차지하고있지만발바닥감각정보를통해자세를조절하고, 균형유지를위한안정성을제공하며, 충격을흡수한다 황룡외 숏풋운동의효과고찰 253

3 Vol.27, No.4, November 2018: Table 1. Various effects of short foot exercise Subject Effectiveness Result Reference Hyper-pronated foot adult Sensory feedback SE Moon [42] Normal feet adult Foot arch support strengthening SE Jung et al. [14] Normal feet adult AHM FHBM strengthening SE Heo et al. [26] Normal feet adult IM strengthening SE Heo et al. [50] Normal feet adult Dynamic balance SE Lynn et al. [3] Normal feet adult Static balance Non-SE Mulligan et al. [33] Hyper-pronated foot adult Gait ability SE Moon [42] APM, abductor hallucis muscle; FHBM, flexor hallucis brevis muscle; IM, intrinsic muscle; SE,significant effect. [1]. 안쪽세로활이낮아지거나구조적또는기능적변형이일어날정도로완전히무너질경우에충격을흡수하는능력은감소할것이고균형감각의소실로이어져걷거나뛰는동안안정성이감소하게된다. 이는보행의어려움과보행지구력의감소로나타나게된다 [27,28]. 이런문제를해결하기위해서는다양한요인의치료적접근이필요하다. 균형에영향을주는요인으로근골격계요소, 신경근연접, 개개의감각계, 감각전략, 선행기전, 적응기전그리고내적재현등이있는데 [29], 이들중발목불안정성의가장큰원인은고유수용성감각또는관절위치감각의감소라고보고되었고 [30], 고유수용성감각을향상시키기위한치료적방법으로발바닥자극은운동감각과자세유지능력을향상시킬수있다 [31]. Janda et al. [32] 은숏풋운동이신체분절을유지하고발바닥의체성감각을자극하여체간안정성까지향상시킨다고하며, 다른운동과함께적용시숏풋운동은고유수용감각훈련의첫단계로시행될수있다고언급하였다. 숏풋운동이균형과안정성에미치는영향을균형평가도구로분석한연구들을살펴보면, Lynn et al. [3] 은숏풋운동후동적균형평가에서내측에서외측으로의압력중심이유의하게감소하여동적균형능력향상을보고하였으나, 정적균형검사에서는유의한차이를보이지않았다. 또한 Mulligan et al. [33] 은동적균형평가에서앞쪽을제외한모든방향에서안정성이향상되었다고보고하였으며, 이와유사하게 Drewes et al. [34] 의연구는하지손상이있는환자에게숏풋운동적용시발내재근검사와계단내려오기항목에서향상을보였지만, 역시정적인평가에서는차이가없었다. Mignogna et al. [35] 은이러한정적검사와동적검사에서숏풋운동이차이를보이는결과에대하여발내재근의기능적인연관성에초점을두었다. 정적자세조절은동적자세조절과달리발내재근의영향보다는다른운동감각이나체성감각그리고중추신경계기전에의해더의존적일것이라판단하였다. 이를고려하면동적균형에서발내재근, 특히엄지벌림근의근활성은발의안정성을향상시키고근활성동안얻어지는고유수용성감각되먹임기전으로자세안정성에도향상을보인것으로사료된다. 선행연구를바탕으로 Chung et al. [36] 의연구에서안정성에대한척도로감각평가를시행하였다. 발내재근운동으로발가락오므리기 운동군과숏풋운동군으로나누어비교하였는데, 숏풋운동군에서감각평가에더유의한증가가있음을보고하였다. 이러한결과가나타난이유로두운동모두내재근근활성을통한고유수용감각의향상을야기했으나숏풋운동군에서수축동안더효과적인원심성감각정보가유입되었음을주장하였다. 하지만운동방법에서숏풋운동은발가락오므리기운동과달리, 바닥에발바닥을접촉시킨상태로시행하기때문에발바닥자극을통해감각평가에서더좋은결과가나올가능성이있다. 향후감각평가를분석하는숏풋운동연구에서는비교운동군간에발바닥자극정도를동일하게적용해야할것으로사료된다 (Table 1). 3. 숏풋운동의효율적적용 1) 관련운동및중재와의비교 Jung et al. [14] 은엄지벌림근의근전도와안쪽세로활각도를숏풋운동과발가락오므리기운동동안에비교를하였다. 이연구에서는숏풋운동이더큰근활성도를보인것으로나타났다. 이는발가락오므리기운동은발허리발가락관절의굽힘이발가락굽힘과함께발생하지만숏풋운동은발가락굽힘없이엄지벌림근의근활성이유발되기때문이다. 이연구와동일하게두운동적용시안쪽세로활과발목안정성을비교한논문에서도숏풋운동그룹에서더욱효과적인것으로보고되었다 [36]. Kim et al. [37] 의연구에서는엄지발가락가쪽휨증환자에게숏풋운동보다발가락벌리기운동 (Toe spread out exercise) 에서엄지벌림근의근활성도가더욱크고첫번째발허리발가락관절의각도가높아지는결과를나타내서더효율적인운동으로보고하였다. 하지만대상자가엄지발가락가쪽휨증을가진사람이기때문에숏풋운동을하는동안에첫번째발허리발가락관절이모음되어있어활시위효과를발생시켜엄지모음근보다엄지벌림근의근활성이낮게나타난것으로보고하였다. Goo et al. [38] 의연구에서는앉은자세와서있는자세에서숏풋운동과발가락벌리기운동의근활성도를비교하였다. 이연구에서는발가락벌리기운동그룹에서만앉은자세와선자세에서차이를나타냈다. 이는길이-장력관계에따라서엄지벌림근의길이가짧아지는숏풋운동보다길이를유지하는발가락벌 254 Ryong Hwang, et al. The Effect of Short Foot Exercise

4 리기운동에서효과가나타났음을보고하였다. 하지만정확한체중지지의양을정량화하지못하여실험자가각기다른부하를주었음을고려하여추후연구가필요함을보고하였다. Goo et al. [38] 의연구결과를고려해보면, 앞서분석한 Jung et al. [14] 과 Kim et al. [37] 의결과에서, 엄지벌림근은길이 -장력관계에의해활성화도에서차이가났음을가정해볼수있다. 발가락오므리기운동은첫번째발허리발가락관절의굽힘이일어나엄지벌림근의기시와정지지점이가까워진반면에숏풋운동은엄지발가락의굽힘이없기때문에더높은근활성도를낼수있는근육길이를유지했을것으로사료된다. 또한엄지발가락가쪽휨증환자의첫번째발허리뼈의모음된위치역시엄지벌림근의기시와정지지점의변화로근활성도가작게나타나발가락벌리기운동보다근활성도가적은것으로보고하였다. 근전도가아닌 MRI를이용한발내재근운동의근활성변화를연구한논문의결과를보면, 숏풋운동과발가락벌리기운동모두근활성도에변화가있었으나두운동간비교는하지않았다. 그럼에도불구하고두운동의근활성도가변화한평균차이는매우비슷하였고, Kim et al. [37] 의연구는엄지발가락가쪽휨증환자였음을이유로다른결과가나타났다. 그러므로숏풋운동이안쪽세로활을유지하게하는엄지벌림근강화에효과는있지만엄지발가락가쪽휨증과같은이차적인병적증상에서정상발의모양이아닐경우효율적이지않을수있다. 향후정상인을대상으로각각의발내재근강화운동을시행한근활성도비교연구를통해엄지벌림근의길이-장력관계에따른효율적인운동을알아보는연구가필요할것으로사료된다. 이전의연구들을바탕으로 Moon et al. [39] 의연구에서는동적균형을안정한계점 (limit of stability) 을이용하여검사하였다. 서있는자세와앉은자세에서숏풋운동후에동적균형변화를측정하였는데, 왼쪽, 앞, 뒤전체모든영역에서안정한계점이증가했다. 이역시발바닥에서의고유수용감각자극으로인한결과라고보고하였고, 신경계환자에게숏풋운동을적용한연구논문에서도동일한결과를얻을수있었다 [40]. Kim et al. [41] 도 Y-균형검사 (Y-Balance Test) 에서숏풋운동그룹이활지지보조기그룹과차이를보이고동적균형능력이향상되었음을보고하였다. 이들은숏풋운동이체중지지와보행시신체를앞으로미는역할을하는엄지벌림근과말기입각기에서안쪽세로활을유지하는짧은엄지굽힘근의활성화로인한결과로판단하였다. 숏풋운동의보행기능에대한효과분석논문에서는보행시좌우압력중심의이동거리와속도가감소하고, 운동을통해발목의안쪽번짐이증가, 가쪽번짐의감소, 무릎의안쪽돌림과수평면가동범위의감소하는결과를보인다 [42]. 이러한보행기능의향상은감각운동훈련과숏풋운동을결합하여적용했을때, 과도하게엎침된발을가진사람에게더욱효과적이었다. 또한 Lim [43] 은편평발을가진노인에게단축발을적용한연구사례에서보행시좌우변동성이유의하게 줄어들어노인의낙상예방에효과적이라고주장하였다. 이전의연구들을종합적으로검토해보면, 숏풋운동을통한발바닥자극과고유수용성감각자극을통해동적균형능력이향상되고, 발의내재근강화로안쪽세로활이유지되어보행에도긍정적인결과가있음을알수있었다. 그러나유연성편평발과중립발대상자간의숏풋운동을통한균형효과비교연구에서는압력중심동요면적과별표식균형검사 (Star Excursion Balance Test) 에서편평발운동군과중립위발운동군모두에서동적및정적균형이유의하게향상된결과를나타냈다 [44]. 이전의선행연구들은압력중심의이탈을동적균형의척도로선정한반면, 이연구에서는압력중심동요면적을정적균형의척도로선정하였다. 압력중심이탈의경우최대치와최소치의이상값에상당히영향을받을뿐만아니라, 발움직임의 3차원축을설명하기어려워오차를줄이고자압력중심동요면적을선택하였다. 그결과로유연성편평발을가진운동군은중립발운동군에비해압력중심동요면적이크게감소하였다. 이는유연성편평발을가진사람은정상인보다운동전압력중심영역이넓은상태였고, 운동을통해유의하게감소하였음을증명하였다. 하지만압력중심동요면적을측정한유일한연구이기때문에앞으로관련된연구가필요할것으로사료된다. Jung et al. [45] 의연구에서는편평발환자에게숏풋운동과함께안쪽세로활을높이는발보조기를적용하였다. 발보조기는편평발환자의정상적인발정렬을유지하게하여발내재근이적절한길이로복구되어근수축을할수있다. 연구결과로보조기만적용한대조군보다발보조기와숏풋운동을결합한실험군에서더효과적으로강화되어편평발환자에게는보조기를결합한운동을권고하였다. 그러나 Kim et al. [46] 의연구에서는앉은자세와한발로서있는자세에서발보조기와숏풋운동을적용한그룹보다권양기효과 (windlass effect) 를적용한숏풋운동그룹이근활성도가높은것으로나타났다. 권양기효과는발허리발가락관절을발등굽힘시키면발바닥근막의장력이증가하여안쪽세로활의높이를올리고발의안정성을제공해주는역할을하는것을말한다 [47]. 또한앉은자세보다한발로선자세에서근활성도가유의하게증가하여체중지지에의한지면반발력이발내재근에대한저항으로적용한것으로보았다. 이는 Kelly et al. [48] 의앉은자세와서있는자세, 한발로서있는자세를비교한논문에서체중지지가많을수록근활성도가크다는결과와동일하게나타났다. Koo [49] 의발목관절의각도에따른운동효과연구에서는숏풋운동과발가락벌리기운동그룹모두에서발목의 30 발등굽힘에서근활성도가크게나타났으며, Heo et al. [50] 의논문에서도이와동일하게일반적인숏풋운동보다 30 발목발등굽힘상태에서더높은근활성도를보인것으로나타났다. 이러한결과의이유로발목의 30 발등굽힘상태에서는아킬레스건이신장되어증가한장력이발바닥에영 황룡외 숏풋운동의효과고찰 255

5 Vol.27, No.4, November 2018: Table 2. Comparison with related exercise and intervention Exercise Comparison Subject Effectiveness Result Reference TC, SF Normal feet adult Pronated foot patient Proprioceptor facilitation TC<SF Jung et al. [14] Chung et al. [36] TCE, SF Normal feet adult Pronated foot patient AHM activity TC<SF Jung et al. [14] Chung et al. [36] TC, SF Normal feet adult Pronated foot patient MLA stability TC<SF Jung et al. [14] Chung et al. [36] TC, SF Normal feet adult Pronated foot patient Ankle stability TC< SF Jung et al. [14] Chung et al. [36] TSO, SF HV patients AHM activity TSO>SF Kim et al. [37] TSO, SF HV patients First MTPJ angle height increase TSO>SF Kim et al. [37] TC, toe curl; SF, short foot; TSO, toe spread out; HV, hallux valgus; AHM, abductor hallucis muscle; MLA, medial longitudinal arch; MTPJ, metatarsophalangeal joint. 향을준것으로보았다. 30 발등굽힘은권양기효과와마찬가지로발바닥장력을증가시켜엄지벌림근의근활성을향상시킨것으로생각된다 (Table 2). 앞서논의한연구들을종합해보면, 편평발에서늘어난엄지벌림근의길이는발보조기적용시정상길이로회복되어근활성도가높아지지만, 엄지벌림근이최대수축을할수있는근육의길이는정상적인발자세보다권양기효과가적용된, 즉엄지발가락의폄상태로나타났다. 이전에논의했던 Kim et al. [37] 과 Goo et al. [38] 의연구에서발가락벌리기운동이숏풋운동보다더효과적이었던이유도발가락벌리기의운동방법이발가락의폄상태에서시작했기때문에영향을미쳤을것으로사료된다. 그뿐만아니라권양기효과와마찬가지로발목의 30 발등굽힘자세역시발바닥장력증가로인해정상발자세보다높은근활성도를유도할수있다. 체중지지의여부에따라서도발바닥에미치는지면반발력이발내재근에저항으로작용하여한발로서있는자세에서근활성도가높았다. 하지만이모든요소가정상발이나편평발에적용되었을때엄지벌림근의근활성도가가장높다고할수는없다. 발목의 30 발등굽힘과권양기효과를중복적용시켰을때엄지벌림근의길이가비정상적으로길어져정상근수축을유발하지못할수있고, 더불어체중지지를부여할수록발바닥의지면반발력은발내재근에스트레스로적용되어손상을일으킬수도있다. 따라서향후에권양기효과, 발목의 30 발등굽힘그리고체중지지의여부에따른비교연구가필요할것으로사료된다. 2) 효율적적용방법숏풋운동은앞발과뒤꿈치는바닥에붙인상태로첫번째발허리뼈의머리를뒤꿈치쪽으로당기는근수축을유발하되발가락은굽히지않는운동이다 [13]. Janda et al. [51] 은숏풋운동을 1단계수동적모형화 (passive modeling), 2단계능동-보조모형화 (active-assistive modeling), 3 단계능동적모형화 (active modeling) 로시행하는것을제안하였는데, 운동중앞정강근과같은외재근들의과도한활성을피하며처음에는 부분적인체중부하상태에서중재자와함께수동적으로진행되며점차대상자가능동적으로완전한체중부하상태에서수행할수있도록하였다 [17]. Lee et al. [52] 은일반적인숏풋운동에추가로심상기법을이용하여발목불안정성에대한효과를연구하였다. 심상기법을적용한다른운동의선행논문과동일하게심상기법이숏풋운동에유의한효과가있음을보고하였다. 그러나발목불안정성에기인한결과를증명하였으므로추후근전도나 MRI를통한객관적인자료를제공해야함을제언하였다. 발목불안정성은앞서논의했던연구에서알아본바와같이, 숏풋운동시발바닥자극이나발의고유수용성감각자극을통해해결될수있다. 이전심상기법연구에서심상기법을통해운동학습능력이나근력강화에효과적이라주장했지만 Lee et al. [52] 의연구는심상기법을통한발목안정성향상을확인하였기에향후에엄지벌림근의근활성도에영향을미치는지에대한연구가진행되어야할것으로사료된다. Lee et al. [53] 은편평발환자의숏풋운동적용시엄지벌림근과앞정강근의근활성도비교연구를통해편평발환자의숏풋운동에서엄지벌림근과앞정강근의근활성비율이 1보다높아앞정강근의근활성도가더높은것으로나타냈다. 따라서숏풋운동시행시앞정강근의근활성도가높아지는것은안쪽세로활의각도를유지하기위한보상작용임을인식하고주의해야한다고보고하였다. 이러한문제를해결하기위해, 바이오피드백접근법은운동과접목하여적용시보상작용을감소시키고선택적수축이가능하여일반적인운동에비해운동의효과를극대화시킬수있다 [54]. Cha et al. [55] 은외재근과내재근의근활성도를제어하기위한방법으로, 근전도바이오피드백을이용한숏풋운동이앞정강근의근활성을억제하여안쪽세로활유지에효과가있음을보고하였으며, 서있는자세에서체중지지동안효과가극명히나타날것이라주장하였다. 마찬가지로, Jeong [56] 의연구에서는족저압의시각적피드백을이용한숏풋운동이더욱효과가있었다고보고하였다. Park et al. [57] 은핀치측정기 (Pinch gauge) 를첫번째발허리머리아래위치시키고시각피드백을적용한연구에서엄지벌 256 Ryong Hwang, et al. The Effect of Short Foot Exercise

6 Table 3. Effective application of short foot exercise Application Method Effectiveness Result Reference Phased approach Passive EFM activity decrease SE Page et al. [17] Active-assistive Active SFE+IT 5 sec/times Ankle stability SE Lee et al. [52] 3 times/week 6 weeks SFE+FO Custom-made FIM strengthening SE Jung et al. [45] Foot othosis SFE+WE MTPJ 30 DF MLA height increase AHM activity increase SE Kim et al. [46] Koo [49] SFE+BF EMG BF Compensation decrease Selective contraction increase MLA height increase SE Lee et al. [53] Cha et al. [55] Park et al. [57] SFE, short foot exercise; IT, imagery techniques; FO, foot orthosis; FIM, foot intrinsic muscle; WE, windlass effect; MTPJ, metatarsophalangeal joint; DF, dorsi flexion; EMG, electromyography; BF, bio feedback. 림근의근활성과핀치측정기수치의긍정적상관관계가있음을확인하며, 임상에서엄지벌림근의근활성을효과적으로확인할도구로추천하였다. 결과적으로이전의바이오피드백과운동을결합한연구들과마찬가지로숏풋운동에서도바이오피드백을결합시킬경우외재근의보상작용없이엄지벌림근의선택적수축이가능하며, 핀치측정기를이용하여간편하게엄지벌림근의활성을유도할것으로사료된다 (Table 3). 본연구는숏풋운동에대한전반적인적용방법과효과를연구한논문을분석하였다. 하지만각논문의운동방법의기간이나방식에서같지않았고, 대상자또한정상인, 운동선수, 편평발환자등다양하게구성되어있으며, 표본수가적은논문도포함되어있으므로일반화하지못하였다. 그럼에도숏풋운동은엄지벌림근의강화로안쪽세로활유지에효과적이며, 동적균형과발안정성, 보행에긍정적인영향을미치는것을확인하였다. 때문에본연구에서검토한효율적인숏풋운동방법을사용한다면임상에서안쪽세로활이무너진일반인, 운동선수와환자의재활에유용할것으로판단된다. 결론 본연구는숏풋운동이안쪽세로활과균형에미치는영향과효율적인적용방법등에관하여전반적인고찰과분석을통해임상에서기초자료로활용하고자실시하였다. 숏풋운동은발내재근중엄지벌림근의강화를주목적으로적용되며, 그결과로안쪽세로활이무너지지않고유지되게하는검증된운동이었다. 이는편평발을가진사람뿐만아니라정상인에게도효과적이며발목의안정성과동적균형을향상시켜보행기능을향상시키는것으로나타났다. 그러나엄지발가락가쪽휨증이있는환자의경우 는활시위효과로인해발가락벌리기운동이숏풋운동보다효과적이었으며, 정적균형에대한영향은검사항목에따라결과가달라서향후후속연구가필요한실정이다. 숏풋운동을더욱효율적으로적용하기위한방법으로는심상기법을운동후에적용했을때와운동중에는바이오피드백을결합한운동이었다. 운동환경의변화를통한효율적인운동방법으로는체중지지시, 발목을 30 발등굽힘을통한권양기효과가발내측세로활지지와엄지벌림근활성도에효과가있었으며, 숏풋운동과함께발안창보조기적용시발내재근강화에효과가뛰어났다. 하지만각각의변형된방법중어떠한방법이최적인지혹은모두적용했을때운동효과가효율적으로나타날것인지불분명한상태이므로향후더많은후속연구를통해검증해야할것이다. REFERENCES 1. Hillstrom HJ, Song J, Kraszewski AP, Hafer JF, Mootanah R, et al. Foot type biomechanics part 1: structure and function of the asymptomatic foot. Gait Posture. 2013;37(3): Mckeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49(5): Lynn SK, Padilla RA, Tsang KK. Differences in static- and dynamicbalance task performance after 4 weeks of intrinsic-foot-muscle training: the short foot exercise versus the towel-curl exercise. J Sport Rehabili. 2012;21(4): Neumann DA. Kinesiology of the musculoskeletal system: foundation for physical rehabilitation. St Louis: Mosby Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J. Fatigue of 황룡외 숏풋운동의효과고찰 257

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