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1 Journal of The Korean Society of Physical Medicine, 2013; 8(3): Online ISSN: Print ISSN: X Research Article Open Access 단기간의요부안정화운동이만성요통환자의근력과자세균형에미치는영향 조성학 김진희 최문희부산가톨릭대학교대학원물리치료학과 The Effect of Short-term Lumbar Stabilization Exercise for Lumbar Muscle Strength and Postural Balance on Chronic LBP Sung-Hak Cho, PT, MS, Jin-Hee Kim, PT, MS, Mun-Hee Choi, PT, MS Department of Physical Therapy, Graduate school, Catholic University of Pusan Received: February 28, 2013 / Revised: May 25, 2013 / Accepted: June 8, 2013 c 2013 Journal of the Korean Society of Physical Medicine Abstract PURPOSE: The purpose of this study was to investigate the effect of short-term lumbar stabilization exercise to patients suffering from chronic low back pain(clbp) on the strength of their lumbar flexor and extensor and the postural balance of them and to suggest effective treatment duration for them. METHODS: Study subjects were 20 patients with CLBP who s been reported the pain for more than 12 weeks. For these subjects, muscle strength of both extensor and flexor of lumbar and the balancing ability were measured before and after the intervention. Lumbar stabilization exercise was composed of matt, ball and sling exercise. The intervention was applied for total 12 sessions for 4 weeks (3 times a week) and each session was for 40 minutes. RESULT: For muscle strength of both extensor and flexor of lumbar, there was significant differences after the application of lumbar stabilization exercise(p<.05). For balancing ability, stabilization shows significant differences Corresponding Author : haebaejj@naver.com in all of the positions except PC(eyes closed on pillows)(p<.05). Distribution of weight shows no significant differences but it was generally distributed within normal range after the exercise and Fall index shows significant differences between before and after the exercise(p<.05). CONCLUSION: These results could have positive effect on deciding different periods of therapeutic intervention. Key Words: Chronic low back pain, Short-term, Lumbar stabilization, Strength, Postural balance Ⅰ. 서론요통으로인해야기되는문제는크다. 인간의약 80% 이상이일생을통해서적어도한번이상은요통을겪게되며 (Natvig와 Picavet, 2002; Wheeler, 1995), 통계청자료에따르면국내취업인구중 86.2% 가경험한적이있을정도로발생율이높은만성질환이기도하다 (Statistics Korea, 2011). 우리나라에서인구 100명당요통으로인한활동제한일수는남자의경우 81.5일, 여자

2 296 대한물리의학회지제 8 권제 3 호 의경우 129.7일로보고되었으며, 이로인한경제적손실액은 3,602억원으로국내총생산의 0.07% 에달하는것으로보고되었다 (Ministry of Health and Welfare, 2002). 요통을일으키는원인에는수많은요인이있지만, 이중에서도요추부의불안정성은다른여타의것보다더중요한원인인자로여겨지고있다 (Wallden, 2009). 대부분의척추기능부전은유연성이부족한분절에서보다는특정한분절에서상대적유연성이과도하기때문에일어나며, 어떤분절의유연성감소는가장유연한분절에보상운동을발생시키는데기여한다 (Sahrmann, 2002). 이로인한요통을방지하고경감시키는데중요한요점은척주와골반을최적정렬로안정화시킬수있는체간근육을갖는것이다 (Panjabi, 2003). 최근에는요통의접근에있어통증완화위주의보존적인물리치료방법을벗어난직접적으로요부주위근육의훈련을통한치료법이주목을받고있다. 특히요부안정화 (Lumbar stabilization) 와요통과의관련성은그중요성이과학적으로입증되었으며 (França 등, 2010), 최근에는다른그어떤운동법보다요통에대한가장과학적인치료적운동법으로받아들여지고있는분야이다. 그중에서도볼과슬링등을이용한불안정한면에서닫힌사슬운동방법의요부안정화운동이가장각광을받고있다 (Kim 등, 2008; Yu 등, 2011; Lee, 2008; Akuthota와 Nadler, 2004; Saliba 등, 2010). 요통환자의치료에있어근력의강화만큼중요한점은자세균형의유지이다. 요통환자는정상인에비해심부근육이약하고불균형적일뿐아니라, 고유수용성감각도감소되어있기에이것이다시척추의안정성을저해시키고, 이는다시요통의재발을야기시키기때문이다 (O'Sullivan 등, 2003). Alexander와 Lapier(1998) 는요통환자가정상인보다균형이저하되어있어균형을개선시킬수있는프로그램이추가되어야한다고보고하였다. 그러나이제까지의연구들을보면만성요통환자의균형능력에만초점을맞추거나근력에만초점을맞춘논문들이대부분이었으며, 근력과자세균형의변화를확인한연구들은그중재기간이 12주에서부터 6주까지 의기간을적용하여그증가치를확인하였다. 그러나비교적짧은기간인 4주를적용하여그관련성을입증한결과는찾기는어려웠다. 물론장기간의안정화운동이단기간의운동보다효과가있겠으나, 사실상요통환자에게치료접근법으로오랜기간의안정화운동을요구하는것은오히려그선택을주저하게하는요인이될수도있을것이다. 따라서본연구에서는만성요통환자에게타운동에비해이미효용성이검증된요부안정화운동을이전연구보다비교적단기간인 4주간의중재기간을선택하여그유의성을확인하려하였다. 본연구의목적은수술적치료가필요하지않은만성요통환자들을대상으로비교적짧은기간인주 3회씩 4주간의매트와볼, 슬링을이용한요부안정화운동을실시하여요부굴곡근, 신전근의근력과신체균형에미치는영향을알아보기위한것이다. Ⅱ. 연구방법 1. 연구대상이연구는부산에소재한 J병원에내원한 12주이상의요통을호소한만성요통환자 20명을대상으로실시하였다. 참여자들은만 30세이상의여성환자로서본연구의과정에대한충분한설명을듣고참가에동의하였으며, 척추분리증이나척추전방전위증으로인한요통환자, 임신한자, 신경학적으로감각이상이나근육마비가있는자, 정신적인문제나이해력이부족하여운동수행능력이어려운자는연구에서제외하였다. 2. 측정도구와방법요부굴곡근과신전근의근력측정에는 M3(Schnell, Germany) 를사용하였고, 자세균형측정에는 Tetrax(Sunlight, Israel) 를사용하였다. 1) 근력측정근력측정은 M3 장비를사용하였다. M3는근육의

단기간의요부안정화운동이만성요통환자의근력과자세균형에미치는영향 297 등척성및최대수축력까지측정할수있는장비로서피험자는 M3에앉아다리와골반을고정한채순수하게요부신전근과굴곡근만을사용하여 5초간최대등척성근력을측정하였다. 1회테스트시각각 3회씩측정이이루어졌고그평균값을사용하였다.

Lumbar extensor test(m3) 장비로서, 좌우전족부와후족부의체중변화로자세의흔들림을측정하기때문에다양한자세변인을측정할수있으며, 최근에는국내에서도 Tetrax를이용한균형능력평가연구가활발히이루어지고있다 (Kim, 2010; Choi, 2011).

체중분배지수는 4개의힘판에각각분배되어지는체중의분배정도를나타내는것으로서, 정상치는 4에서 6이다. 체중분배지수가높을수록병적인상태를의미한다. 낙상지수는안정성지수, 체중분배, 그리고다른변수들을이용하여분석하여낙상의위험정도를양적으로표현한것으로서그수치가높을수록낙상위험도가높음을나타낸다 (Kohen-Raz, 1991).

3 단기간의요부안정화운동이만성요통환자의근력과자세균형에미치는영향 297 등척성및최대수축력까지측정할수있는장비로서피험자는 M3에앉아다리와골반을고정한채순수하게요부신전근과굴곡근만을사용하여 5초간최대등척성근력을측정하였다. 1회테스트시각각 3회씩측정이이루어졌고그평균값을사용하였다. 각측정간 1분의휴식시간을제공하였고, 요부신전근 (Fig. 1) 과굴곡근 (Fig. 2) 각각별도로측정하였다. 테스트는실험전, 후총 2회를실시하였다. Fig 1. Lumbar extensor test(m3) 장비로서, 좌우전족부와후족부의체중변화로자세의흔들림을측정하기때문에다양한자세변인을측정할수있으며, 최근에는국내에서도 Tetrax를이용한균형능력평가연구가활발히이루어지고있다 (Kim, 2010; Choi, 2011). 자세변인들로는안정성지수 (stability index, ST), 체중분배지수 (weight distribution index, WDI), 낙상지수 (fall index, FI) 를측정하였다. 안정성지수는 4개의힘판에서자세의흔들림을수치화한것으로그값이높을수록불안정성이큰것을의미한다. 체중분배지수는 4개의힘판에각각분배되어지는체중의분배정도를나타내는것으로서, 정상치는 4에서 6이다. 체중분배지수가높을수록병적인상태를의미한다. 낙상지수는안정성지수, 체중분배, 그리고다른변수들을이용하여분석하여낙상의위험정도를양적으로표현한것으로서그수치가높을수록낙상위험도가높음을나타낸다 (Kohen-Raz, 1991). 균형평가는외부자극이적은곳에서총 8개의자세에서검사를시행하였으며, 각각의자세에서검사시간은각기 32초이다. 검사중에는움직임을최대한제한하도록하고, 자세를잡는초기안정화시기의자료를포함시키지않기위해 10초동안자세의안정화여부를확인하고검사를시작하였다. 테스트는실험전, 후총 2회를실시하였다 (Fig. 3). Fig 2. Lumbar flexor test(m3) 2) 자세균형측정자세균형측정에는 Tetrax를사용하였다. Tetrax는독립적인 4개의지면반력장치인힘판 (force plate) 으로 4영역측정방식을채택하여정확한진단을할수있는 Fig 3. Postural test(tetrax)

Marshall과 Murphy(2005) 이적용한방법의난이도를수정한볼을이용한안정화운동방법 5가지, Neurac(2007) 매뉴얼에소개된

안정화운동의방법으로는우선적으로관절에서크고미세한움직임을조절하여요천추의중립자세를찾는요령을익히게한다음, 숙달이되었다고판단이되면점진적으로매트에서부터볼을이용한방법,

별도로운동전, 후로각 5분씩가벼운몸풀기와스트레칭을적용하였다. 1) Matt exercise 매트위에서안정화운동을실시하였다.

2) 볼을이용한방법볼을이용하여불안정성을증가시켰으며자세는볼에서앉은자세유지하기, 한발씩교대로들기, 두발들고자세유지하기,

4 298 대한물리의학회지제 8 권제 3 호 3. 운동방법만성요통환자에게적용될안정화운동프로그램으로는 Koumantakis 등 (2005) 이적용한방법을기준으로난이도를수정한매트위에서의안정화운동방법네가지, Marshall과 Murphy(2005) 이적용한방법의난이도를수정한볼을이용한안정화운동방법 5가지, Neurac(2007) 매뉴얼에소개된 Sling을이용한안정화운동방법 5가지를교대로적용하였다. 1회에 40분씩, 주 3회 4주간총 12회의운동방법을적용하였다. 안정화운동의방법으로는우선적으로관절에서크고미세한움직임을조절하여요천추의중립자세를찾는요령을익히게한다음, 숙달이되었다고판단이되면점진적으로매트에서부터볼을이용한방법, Sling을이용한방법의순으로진행하였다. 모든운동은안정화자세에서회당 10초간유지, 5회 1세트로구성하여각기 5세트를실행하였다. 별도로운동전, 후로각 5분씩가벼운몸풀기와스트레칭을적용하였다. 1) Matt exercise 매트위에서안정화운동을실시하였다. 네발기기 자세에서배꼽끌어당기기, 매트위에서의교각자세, 네발기기자세에서자세를유지한채한다리들기, 네발기기자세에서한다리들고한팔들기등의네가지동작들이적용되었다. 2) 볼을이용한방법볼을이용하여불안정성을증가시켰으며자세는볼에서앉은자세유지하기, 한발씩교대로들기, 두발들고자세유지하기, 볼에서의바로누운자세와엎드린자세의허리교각운동등의다섯가지동작들이적용되었다. 3) sling을이용한방법가장불안정성이큰슬링을이용하여바로누운자세에서허리의중립자세를유지하는교각운동, 엎드려누운자세에서의교각운동, 옆으로누운자세에서의교각운동, 서서혹은무릎을꿇고요부세팅등의다섯가지동작들을적용하였으며, 환자의상태에따라슬링현수점, 탄력밴드적용등의변화를주어안정화운동을실시할수있도록하였다 (Fig. 4). Fig 4. Sling exercises

5 단기간의요부안정화운동이만성요통환자의근력과자세균형에미치는영향 자료분석자료분석은 SPSS 18.0 for window를이용하여연구대상자의운동전후근력과자세균형을비교하기위하여대응 T검정 (paired t-test) 을실시하였다. 모든분석에있어서통계학적유의수준은.05로설정하였다. Ⅲ. 연구결과 1. 연구대상자의일반적특성연구대상자들의일반적인특성은 Table 1과같다. 대상자는총 20명으로평균연령은 47.60세, 신장은 cm, 체중은 60.85kg이었다. Table 1. General characteristics of subjects (N=20) age(yr) height(cm) weight(kg) 47.60± ± ± 요부근력의변화 1) 안정화운동전ㆍ후요부굴곡근력의변화운동전, 후의굴곡근력을비교한결과운동후의근력이 28.18±11.59에서 44.50±16.20으로유의하게증가한것을확인할수있었다 (p<.05)(table 2). Table 2. Comparison of lumbar flexor and extensor (N=20) Flexion Strength (Nm) Extension Strength (Nm) pre post p 28.18± ± * 45.38± ± * 2) 안정화운동전ㆍ후요부신전근력의변화운동전, 후의신전근력을비교한결과운동후의근력이 45.38±19.55에서 60.02±19.71로유의하게증가한것을확인할수있었다 (p<.05)(table 2). 3. 자세균형요인의변화 1) 안정성지수운동전, 후안정성지수는눈을뜨고바로선상태인 NO(normal position with eyes open), 눈을감고바로선상태인 NC(normal position with eyes closed), 눈을뜨고필로우위에올라선상태인 PO(eyes open on pillows), 눈을감고머리를오른쪽으로회전한상태인 HR(head turned right and eyes closed), 눈을감고머리를왼쪽으로회전한상태인 HL(head turned left and eyes closed), 눈을감고머리를 30 뒤로젖힌상태인 HB(eyes closed with Table 3. Comparison of postural Stability Index and Weight Distribution Index (N=20) Position Stability Index Weight Distribution Index p pre post pre post p NO 15.88± ±2.13*.012* 6.42± ± NC 23.11± ±4.85*.014* 5.97± ± PO 20.53± ±4.37*.040* 5.83± ± PC 31.16± ± ± ± HR 21.51± ±5.67*.002* 6.03± ± HL 23.94± ±5.03*.002* 5.65± ± HB 25.62± ±5.84*.009* 5.46± ± HF 26.42± ±4.90*.012* 6.34± ± *: p<.05 NO: normal position with eyes open, NC: normal position with eyes closed, PO: eyes open on pillows, PC: eyes closed on pillows, HR: head turned right and eyes closed, HL: head turned left and eyes closed, HB: eyes closed with raising head backward by 30 degree, HF: eyes closed with head forward about 30 degree

6 300 대한물리의학회지제 8 권제 3 호 raising head backward by 30 degree), 눈을감고머리를 30 앞으로숙인상태인 HF(eyes closed with head forward about 30 degree) 의 7가지자세에서감소를나타내안정성지수의유의한차이를확인할수있었다 (p<.05). 다만눈을감고필로우위에선상태인 PC(eyes closed on pillows) 자세에서는유의한차이를확인할수없었다 (p.05)(table 3). 2) 체중분배지수운동전, 후체중분배지수는유의한차이는확인할수없었으나, 운동전과비교해운동후모든수치가정상범위에근접해모든자세에서정상수치인 4에서 6범위의내에분포하는것을확인할수있었다 (Table 3). 3) 낙상지수운동전, 후낙상지수를비교한결과낙상지수가운동후에 41.60±28.24에서 28.95±22.64으로유의하게감소하여낙상위험도의유의한감소를확인할수있었다 (p<.05)(table 4). Table 4. Comparison of Fall Index (N=20) pre post p Fall Index 41.60± ± * *: p<.05 Ⅳ. 고찰최근에지지를받고있는요부안정화운동 (Lumbar stabilization) 은코어안정화운동 (Core stabilization), 동적안정화운동 (Dynamic stabilization), 중립척추조절운동 (Neutral spine control) 등여러비슷한이름들로도언급되고있는데 (Akuthota와 Nadler, 2004), 그핵심개념은척추분절을잡아주는국소근육 (local muscle) 과체간을움직이는큰근육 (global muscle) 들의상호조절 (control) 과조화 (coordination) 에있다 (Behm 등, 2002; Hodges, 2003). 만성요통환자의요부안정화운동과근력의연관성 을확인한 Cho 등 (2012) 의연구에서폐경전, 후여성을대상으로 8주간의요부안정화운동을적용하였더니, 폐경여부와관계없이요부근력의유의한증가를확인할수있었다. 또한, Kim 등 (2007) 의요통환자를대상으로기구를사용한 8주간의요부안정화운동에서도운동강도와관계없이요부근력의유의한증가를확인할수있었고, Lee(2008) 의연구에서요통환자를대상으로공을이용한 12주간의요부안정화운동에서도요부근력의증가를확인할수있었는데, 본연구에서도 4 주간의요부안정화운동후요부근력의증가를확인할수있었다. 또한본연구에서는별도로요부굴곡근력의증가도확인할수있었는데, 이러한굴곡근력의증가는보다허리의안정성을증가시키는것에역할을할것이다. 그리고만성요통환자에게요부안정화운동을적용하여균형능력의증가를확인한다른연구들을살펴보면, 최근의연구에서 Park 등 (2012) 도만성요통환자에게코어운동과근력운동을병합한복합재활운동을 12 주간적용한결과균형능력의증가를확인할수있었고, Ha 등 (2008) 의연구에서도안정화운동을통해양하지의체중분배능력의증가를확인할수있었다고하였는데본연구의단기간의중재에서도균형능력의증가를확인할수있었다. 본연구에서자세안정지수는거의모든자세에서유의한감소를보여자세안정성의유의한증가를보였다. 다만 PC자세에서만유의성을발견할정도까지향상될수없었던이유는필로우에올라눈을감는자세가시각정보와체성감각을제한하는가장불안정한자세이기에그향상이단기간에는어려웠던것으로여겨진다. 이는정상인을대상으로 6주간안정화운동을실시한 Kaya 등 (2012) 의연구에서도유사한결과를확인할수있었다. 그리고낙상지수에서도유의한감소를보여낙상위험도도감소한것을할수있었지만, 체중분배지수에선유의한감소를확인할수없었는데, 그이유는운동후모든체중분배지수가정상치에도달했음에도불구하고, 운동전체중분배지수가이미정상치에상당히근접해있었기에통계적유의한차이를발견할수없었던것으로판단된다.

7 단기간의요부안정화운동이만성요통환자의근력과자세균형에미치는영향 301 근력의증가와자세균형의향상을모두살펴본 Ko 등 (2009) 은여성노인에게 8주간요부안정화운동후균형능력의증가와근단면적의변화를통해근력의증가를확인할수있었고, 6주간의볼을이용한요부안정화운동에서요부신전근력의강화와균형의증가를확인하였다 (Kang, 2006). 본연구에서는 4주간의단기간을통해굴곡근력의증가까지함께확인할수있었다. 많은선행연구들은요부안정화운동이만성요통환자에게가장효율적이라고주장하고있지만, 효율성이란측면에서서잊지말아야할중요한요점은시간이다. 치료의기간을예측할수있다는것은치료계획의수립에있어서중요한의미를갖는다. 본연구에서는 4주라는비교적단기간의요부안정화운동기간도요부근력의증가와자세균형의증가에효과가있는것을확인할수있었다. 따라서단기간일지라도요부안정화운동이만성요통환자의요부근력과자세균형의향상에긍정적인영향을미칠것으로판단된다. Ⅴ. 결론본연구는만성요통환자를대상으로단기간의요부안정화운동이요부근력과자세균형에효과를줄수있는지에대해설정하였으며그결과는긍정적이었다. 매트와볼, 슬링을이용한요부안정화운동이요부신전근력과굴곡근력을증가시켰으며, 자세균형의향상에도영향을주었다. 따라서단기간일지라도만성요통환자에게요부안정화운동을적용하는것이효과적일것이라고생각된다. Acknowledgment 본연구는미간행된조성학석사학위의일부를발췌하였습니다. References Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85: Alexander KM, LaPier TL. Differences in static balance and weight distribution between normal subjects and subjects with chronic unilateral low back pain. J Orthop Sports Phys Ther. 1998;28(6): Behm DG, Anderson K, Curnew RS. Muscle force and activation under stable and unstable conditions. J Strength Cond Res. 2002;16(3): Choi SH. Balance control according to the severity of knee osteoarthritis. Graduate School Kyung Hee University. Master's thesis Choi SJ, Park KM. The relationship between menopause management practice and low back pain in climacteric women by menopausal stage. J of the Korean Society of Maternal and Child Health. 2000;4(1): Cho SY, Kim SS, Cha HJ et al. The effect of 8weeks of lumbar stabilization exercise on lumbar strength in premenopausal & postmenopausal women with chronic low back pain. Journal of sport and leisure studies. 2012;47(2): França FR, Burke TN, Hanada ES, et al. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics (Sao Paulo). 2010; 65(10): Ha MS, Hyoung IH. The effects of the modalities treatment and lumbar stabilizing exercise on the difference of weight-bearing distribution. Journal of sport and leisure studies. 2008;33(2): Hodges PW. Core stability exercise in chronic low back pain. Orthop Clin North Am. 2003;34(2): Kang MS. Effects of swiss ball lumbar satabilization exercise on lumbar extensor strengthㆍbalance and flexibility in office workers with chronic low back pain. Korea sport research. 2006;17(6): Kaya DO, Ergun N, Hayran M. Effects of different segmental

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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