NEUROTHERAPY 대한신경치료학회지김찬규제20, 권이은상제3호 전방머리자세를동반한긴장성두통환자의자세개선에따른두통의변화 김찬규, 이은상 * 광주보건대학교물리치료과 The Changes of in Headache due to Postural Improv

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1 NEUROTHERAPY 대한신경치료학회지김찬규제20, 권이은상제3호 전방머리자세를동반한긴장성두통환자의자세개선에따른두통의변화 김찬규, 이은상 * 광주보건대학교물리치료과 The Changes of in Headache due to Postural Improvement in Patients with Tension Headache with Forward Head Posturl Chan-Kyu Kim, Eun-Snag Lee* Department of Physical Therapy, Gwang-ju Health University Purpose Forward head posture is the most found disease in today's people. Most patients with forward head posture suffer tension type headache. The purpose of this study is to apply physical therapy intervention to the patients and investigate how the tension type headache alleviated by treatment methods for forward head posture influences their Pressure-pain the sholds and Henry Ford Headache disability Inventory. Methods Twenty-nine patients with tension type head ache participated in this study. According to intervention methods of stretching group(n=14), and bio feedback group(n=15) were designed. On the basis of lottery draws of 29 patients were assigned to each group randomly. After the application of each intervention three times a week for four weeks, measurements before and after intervention were made to analyze headache influence index, pressure pain threshold of the headache region, pressure pain threshold of soft tissues(ppts), Henry Ford Headache disability Inventory(HDI). A blind measurement was made for evaluation. Results After completion of the exercise, there was a significant difference in Craniovertebral angle, PPTs, and HDI in the stretching exercise group (p<0.05). Craniovertebral angle, PPTs, and HDI were more improved in the biofeedback exercise group than stretching exercise. forward head posture correction group with bio feedback is considered to have better effects overall(p<0.05). Conclusion Forward head posture correction exercise with biofeedback based forward head posture correction is a more effective intervention method. Key words Forward head posture, Tension type headache, Biofeedback, Pressure-pain thesholds, Henry Ford Headache disability Inventory 책임저자 Eun-Snag Lee (lespt0430@gmail.com) 논문접수일 2016 년 8 월 16 일수정접수일 2016 년 9 월 27 일논문게재일 2016 년 10 월 28 일 I. 서론 두통은삶에있어서누구나한번쯤경험하게되는아주흔한증상이며, 안면, 목과머리부위에불쾌감을동반한통증을이야기한다. 1) 두통환자의약 80% 가두통으로인해일상생활을하는데어려움을겪고있으며, 수면장애와우울, 불안을동반하는경우가많아지고있다, 2) 대표적인두통중긴장성두통 (tension-type headache, TTH) 은성인에게있어서두통장애중가장흔한두통으로알려져있다. 3) TTH는한달에한번이상의빈도로양측성으로통증이짧게는 30분길게는 7일간지속될뿐아니라, 중등도이하의강도로조이거나누르는듯한통증이나타나고, 오심이나구토 가동반되지않는삽간성또는만성적인두통을이야기한다. 4) TTH의기전으로여러요인이관여할것으로보이지만근육인자에의한병태생리학적인기전에서중요한역할을하는것으로추측되어지며 5), TTH환자의 80% 이상에서두개골및목주변에비정상적수축이있는것으로보고되었다. 6) 비정상적인근수축은자세이상이나자세조절이상에따라발생할수있으며 5), 이러한자세는목의근골격계에비정상적인근수축을유발한다. 대표적인자세이상으로우리는전방머리자세를 (forward head posture, FHP) 를들수있다. 7) FHP는상부목뼈가굽힘되고하부목뼈가폄되어머리가체간에비해앞으로나오는자세로 8), 폄근육 ( 뒤통수밑근, 반가시근, 널판근, 그리고위등세모근 ) 과더불어목빗근의단축과목굽힘근의약증을동반하고있다. 9) 이로인해목의척추사 전방머리자세를동반한긴장성두통환자의자세개선에따른두통의변화 27

2 NEUROTHERAPY NEUROTHERAPY 2016;20(3):27-32 이관절의압박이증가하고, 다양한목주변의압통점을유발할수있다. 10) 특히, TTH환자들은공통적으로뒤통수밑근의압통점을보유하고있으며 11), Falla 등 12) 은그이유로뒤통수밑근에대부분의근방추가집중되어있으며, 뒤통수밑근의기능저하에따른 TTH 환자의상부목뼈기능부전과함께깊은목굽힘근의기능장애가나타난다고하였다. 대부분의연구들은 FHP에따른단축된근육에신장방법이나도수치료등을적용하여압통점을제거하여 TTH를치료하는 1차적인방법에초점을맞추고있다. 3,13,14) 하지만그러한방법들은일시적인통증제거에이용될뿐근본적인자세개선에따른장기적인 TTH를치료하는데제한점이있을것이다. 따라서, 본연구에서는 TTH를개선하기위해두통에만집중했던일시적인치료법과달리 FHP를가진환자들에게자세개선을통한근본적인 TTH치료방법을알아보고, 긴장성두통의증상에대한임상적인변수와함께 FHP와 TTH에미치는효과를연구하고자한다. II. 연구방법 1. 연구대상대상자는 G광역시소재의대학생 451명을대상으로두통관련설문지를실시하였고 15), 두통을가지고있으면서 FHP에해당하는환자를선별하기위하여 Nemmers et al. 16) 이실시한두개척추각 (Craniovertebral angle, CVA, ICC=0.88) 을측정하여 49 미만인자는 FHP로간주하였다. 긴장성두통에대한선정기준은국제두통학회 4) 의분류범위에따라다음과같이설정하였다. 1) 양측성두통, 누르거나조이는통증, 약하거나중간정도의통증강도, 일상적인신체활동에의해유발되지않는 4개의항목중 2개이상을충족한자, 2) 구토증상이없는자, 3) 광공포증이나소리공포증이없는자로선정하였다. 제외기준은 1) 두통이발생하지 6개월미만인자, 2) 최근 1년이내에두통이나목관련치료를받은자, 3) 3개월이내두통약이나진통제를투약한자, 4) 치료에영향을미칠수있는주사치료, 외과적수술, 심한추간판탈출증, 골절환자등 을제외하였다. 그중실험에참여를동의한실험대상자 29명 ( 남자15명, 여자14명, 평균연령 22.07±2.31) 을선정하였다. 본연구대상자의일반적특성은 Table 1과같다. 2. 연구방법선정된 29명의대상자를일반적으로압통점을해소하기위해사용하는스트레칭군 (stretching exercise group, STG) 과자세개선을위한바이오피드백훈련군 (Biofeedback group, BFG) 으로 2개의집단과성별을고려하여제비뽑기를통해무작위로나누어배정하였다. 본실험은 2개그룹에사전검사후주3회 20~25분으로실시하였고, 4주간중재후사후검사를실시하였다. 사전검사와사후검사는두개척추각을측정하여 FHP의변화를알아보고, 그에따른두통관련임상적변수인압통역치, Henry Ford Headache disability Inventory (HDI) 를측정하였다. 3. 중재방법 (1) 스트레칭운동스트레칭기법은이명효등 17) 의기본신장운동을사용하여수정보완하였다. 가슴스트레칭 3가지목스트레칭 3가지각운동별로 10 초. 지속후 5초. 휴식을기본으로하며, 목부위신장운동은좌, 우모두실시하였다. 6가지동작을한번하는것을 1세트로하여 1일 10세트총 25분간실시하였다주 3회를기본으로하여대상자가할수있는최대한의범위까지하였다. 스트레칭방법은 Table 2와같다. (2) 바이오피드백훈련바이오피드백훈련은 Fernández-de-las-Peñas 등 3) 의훈련을기반으로수정보완하여단계별로설정하였으며, 1~2주는 20-24mmHG로실시하였고 3~4주는 25-30mmHG의강도로실시하였다. 공기를채운에어백을뒤통수뼈밑에놓는다. 놓여진에어백의압력을 20mmHg로맞추고에어백을부풀린다. 환자에게턱을당기면서에어백을누르라고지시함과동 Table 1. Demographic characteristics of the subjects SEG(n1=14) BFG(n2=15) t/x2(p) Age (year) 22.21± ± (0.750) Gender (male/female) 6 / 8 9 / (0.374) Height (cm) ± ± (0.328) Weight (kg) 60.84± ± (0.331) SEG= Stretchingexercise group, BFG= Biofeedback group. 28 The Changes of in Headache due to Postural Improvement in Patients with Tension Headache with Forward Head Posturl

3 김찬규, 이은상 Table 2. Stretching exercise Put both hands on the back of the trunk and lift both arms slowly upward as far as possible. Chest stretching Cervical stretching One hand passes over the back of the shoulder, the other hand holds the elbow over the head, and pulls it as far inward as possible. Perform both left and right. Raise the tips of your hands on your shoulders, stretch your chest, and turn your head backward. Throw your head forward and slowly turn in a circle.. With your head tilted backward, slowly turn your head forward in a circle, then stop at the maximum pulled-out position. After looking at the front, slowly turn your head horizontally in one direction to stop at the maximum range. Table 3. Biofeedback exercise Term Intensity 1~2 weeks 20mmHG ~ 24mmHG 3~4 weeks 25mmHG ~ 30mmHG 시에환자들로하여금압력눈금을보고스스로압력을찾아가맞추도록하였다 (Table 2). 3. 측정방법 (1) 두개척추각 (Craniovertebral angle) CVA를측정하기위하여각도기 (Goniometer) 를사용하였다. CVA를측정은대상자가고정된의자에앉아시선을정면을바라보도록하고팔을자연스럽게무릎위에놓고목은자신이가장편하게유지하는자세를취하게한후, 귀의이주에서제 7 목뼈를연결한선과수평선이이루는각도를측정하였다 (ICC=0.88). CVA이작으면작을수록두부전방자세가많이진행된것으로볼수있으며선행연구에따라본연구에서는 49 미만을 FHP로간주하였다. 16) (2) 압통역치 (Pressure-pain thesholds) 본연구에서는 Commander Algometer TM((JTech Medical Industries, USA) 를사용하여압통역치 (Pressure pain thesholds: PPTs) 를측정하였다, 제품은탐색자, 손잡이그리고기록계로이루어져있으며, 손잡이끝에탐색자가있고표면의크기는 10 10mm이다. 측정방법은 Fischer와 Andrew 18) 가제시한방법을이용하여측정시대상자는편안하게앉은자세를취하였으며, 검사하고자한부위를확인후압통각계를안정적으로잡기위하여압통각계의중간부위를가볍게잡고느린속도로압력을점차증가시켰다. 측정근육은뒤통수밑근과어깨올림근에측정하였으며, 측정하기에앞서대상자에게 제가이기구를이용하여당신의압통점을누르는과정에서만약누르는느낌이처음과다르게아픔이느껴지면 아! 라고소리쳐주십시오 라고설명하여실험의오차를줄이기위해 3번측정후평균값을산출하였다. 압력의단위는파운드 (lb.) 를사용하였고, 평균pearson상관계수 r=0.990으로높은상관계수를보였다. 19) (3) Henry Ford Headache disability Inventory(HDI) HDI는두통의영향과치료의효과그리고두통이일상생활에미치는영향을평가하는데유용한척도이다. 20) HDI는총 25 문항으로이루어져있고, 두통으로인한기능적, 감각적면을평가한다. yes 경우 4점, sometimes 일경우 2점, no 의경우 0점이주어지며세단계의척도로평가가이루어진다, 점수는문항점수의총합으로계산하게되고점수가높을수록두통이심각한것을의미한다. 20) HDI는높은내적일치도 (Cronbach s alpha : 0.94) 와검사- 재검사신뢰도 (Pearson correlation coefficients : 0.83) 를가지고있다. 21) 4. 통계방법연구의모든작업과통계는 SPSS Ver (SPSS Inc., Chicago, USA) 을이용하여평균과표준편차를산출하였다. 전체대상자는동질성검정과정규성검증방법중 Kolmogorov-Smirnov test를이용하였으며 (p>0.05), 모든측정자료들이정규분포를보였기때문에, 모수적검정법을이용하여평균값들의비교를실시하였다. 대상자의일반적특성은기술통계를사용하였고, 집단간차이를알아보기위해독립표본 t검정을실시하였다. 단축발훈련과고유수용성감각훈련을적용전 후간의유의성을비교하기위하여대응표본 t검 전방머리자세를동반한긴장성두통환자의자세개선에따른두통의변화 29

4 NEUROTHERAPY NEUROTHERAPY 2016;20(3):27-32 Table 4. Comparison of the CVA CVA( ) SEG: Stretchingexercise group, BFG: Biofeedback group. CVA: Craniovertebral angle. *p<0.05; **p<0.01 SEG(n1=14) BFG(n2=15) t(p) Pre-test 47.79± ± (0.869) Post-test 50.57± ±1.53 Change value 3.50± ± (0.014) * t(p) 6.686(0.000) ** (0.000) ** Table 5. Comparison of the PPTs PPTs(lb.) SEG: Stretchingexercise group, BFG: Biofeedback group. PPTs: Pressure-pain thesholds. *p<0.05; **p<0.01 SEG(n1=14) BFG(n2=15) t(p) Pre-test 17.64± ± (0.145) Post-test 19.15± ±2.08 Change value 1.51± ± (0.045) * t(p) 3.220(0.007) ** (0.000) ** Table 6. Comparison of the HDI HDI(Score) SEG: Stretchingexercise group, BFG: Biofeedback group. HDI: Henry Ford Headache disability Inventory. *p<0.05; **p<0.01 SEG(n1=14) BFG(n2=15) t(p) Pre-test 77.29± ± (0.827) Post-test 73.79± ±5.70 Change value -3.50± ± (0.002) * t(p) (0.005) ** (0.000) ** 정을실시하였다. 자료의모든통계학적유의수준은 α=0.05 이하로설정하였다. III. 결과 1. 척추두개각의변화 CVA의변화는 SEG이 47.79±0.98에서 50.57±2.14로 3.50만큼, BFG이 46.73±0.70에서 52.27±1.53로두그룹모두유의한감소를보였으며 (p<0.05), BEG가 SEG보다더욱유의한증가를보였다 (p<0.05)(table 4). (1) 압통역치의변화 PPTs의변화를비교해본결과 SEG는 17.64±1.55에서 19.15±2.11로 1.51만큼유의한증가를보였고 (p<0.05), BFG 에서 18.56±1.73에서 21.17±2.08로 2.61만큼유의한증가를보였다 (p<0.05). SEG과 BFG사이에 BFG에서증가에따른더욱유의한증가를보였다 (p<0.05)(table 5). (2) Henry Ford Headache disability Inventory의변화 HDI의변화를비교해본결과 SEG는 77.29±3.23에서 73.79±4.28로 3.50만큼유의한감소를보였으며 (p<0.05), BFG는 76.93±4.77에서 67.77±5.70로유의한감소를보였다 (p<0.05). 그중 BFG가 SEG에비해더욱유의한감소를보였다 (p<0.05)(table 6). 30 The Changes of in Headache due to Postural Improvement in Patients with Tension Headache with Forward Head Posturl

5 김찬규, 이은상 IV. 고찰 긴장성두통은직장인들과학생들에게흔히발병하는질환으로 써업무나공부, 일상생활에여러가지해를가하며, 신체적으 로는둥근어깨, 목의관절가동범위감소와통증 3,12), 그에따른 많은연구들이진행이루어지고있다. FHP 는목주변에많은 부하와근골격계의통증을유발하는원인이되며, 목의근골격계비정상긴장성두통과연관있다고제시되고있다. 5,13) 하여본연구에서는 FHP 를가진 TTH 환자를대상으로자 세개선에따른 TTH 의변화를알아보기위해 FHP 에대한두 그룹에스트레칭과바이오피드백을실시하여경추정렬을바로 잡고 FHP 의변화양상을측정분석하였다. Fernández-de-las-Peñas 등 3) 의연구에의하면 FHP 환자 에게 Stabilizer 를이용하여총 5 단계 (22,24,26,28,30 mmhg) 로나눠 4 주간적용한결과앉은자세 (p<0.01) 에서유의한 FHP 의자세개선이나타났고, 본연구에서또한두그룹모두 유의한감소가있었지만, Biofeedback 훈련에서더욱유의한 자세개선이나타났다 (p=0.014). 이는스트레칭에의한일시적 으로짧아진근육은늘려일시적인자세개선은일어날수있 지만, FHP 의근본적인자세개선에필요한인지적요소를같 이훈련하지않을때장기적인측면에서 FHP 에근본적인치 료가이루어지지않은것이라생각할수있다. 채윤원과이현민 13) 에따르면 FHP 는머리의무게중심이앞 으로배치됨으로써뒤통수밑근과같은목의폄근육의단축에 기여하고목긴근및머리긴근과같은목앞의깊은목굽힘근의약화를초래하여 FHP에따른근단축과함께근막통증증후군이발생한다고하였다. 본연구에서또한 FHP의자세개선에따른근막통증점의통증감소를알아보기위해뒤통수밑근과어깨올림근에압통역치를측정하였으며, 그결과에서또한 Biofeedback을통해훈련한그룹에서조금더유의한효과를보였다 (t=2.104, p=0.045). 또한정확한두통양상인 HDI를통해더욱정확한 TTH에대한결과를봤을때, 압통역치의실험결과와같은 biofeddback훈련이더욱효과적인양상을보였다 (t=-3.530, p=0.002). 이는위에서설명한바와같이 FHP의자세개선에따라단축된근육의신장으로인한근막통증점의해소를근본적인해결방법으로볼수있으며, Bendsten 22) 는머리와목영역에서근막통증점은 TTH의말초기전에관여하게되고계속적인근막조직으로부터유해수용성정보입력을가져와삼차신경꼬리핵의유해수용성활성을증가시키고중추감각에의한긴장성두통의중추기전에기여하게된다고하였다. 또한채윤원과이현민 13) 은이런근막통증점의활성은두통의임상적변수인빈도, 강도그리고지속시간에영향을미친다고하였다. 이러한결과들을해석해봤을때, Biofeedback 훈련은 FHP자세개선에탁월한효과를보인것을알수있으며, FHP 에따른 TTH발생환자들에게 Biofeedback훈련은뒤통수밑근의신장을유도하여압통과함께두통에도움이되었을것으로사료된다. 22) V. 결론 본연구에서는 FHP를가진자중 TTH를가지고있는환자를대상으로 Biofeedback 훈련과기존두통치료인스트레칭을적용하여 FHP의자세개선에따른 TTH의임상적변수들의변화에대해연구하였다. 4주간의중재후 FHP의개선과함께 biofeedback 훈련이압통역치와두통에모두유의한효과를보였음을알수있었다. 이러한연구결과를바탕으로 FHP의자세개선과함께두통환자들의더욱효과적인치료방법을제시할수있을것이며, 나아가두통환자물리치료시 biofeedback 훈련의적용은더욱의미있는치료적효과를얻을수있을것으로사료된다. 참고문헌 1. Lee BI. Headache. J Korean Pain Assoc. 1992;5(1): Sahota RK, Dexter J. Sleep and headache syndromes: a clinical review. Headache: The Journal of Head and Face Pain. 1990;30(2): Fernández-de-las-Peñas C, Pérez-de-Heredia M, Molero-Sánchez A, et al. Performance of the craniocervical flexion test, forward head posture, and headache clinical parameters in patients with chronic tension-type headache: a pilot study. J Orthop Sports Phys Ther. 2007;37(2): Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. Cephalalgia. 2004;24(1): Lee GH. Postural Control in the Patients with Chronic Tension-Type Headache. J Korean Neurol Assoc. 2004;25(3): Lipchik GL, Holroyd KA, France CR, et al. Central and peripheral mechanisms in chronic tension-type headache. Pain. 1996;64(3): Griegel-Morris P, Larson K, Mueller-Klaus K, et al. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther. 1992;72(6): 전방머리자세를동반한긴장성두통환자의자세개선에따른두통의변화 31

6 NEUROTHERAPY NEUROTHERAPY 2016;20(3): Raine S, Twomey LT. Head and shoulder posture variations in 160 asymptomatic women and men. Arch Phys Med Rehabil. 1997;78(11): Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual: Lippincott Williams & Wilkins; van Duijn J, van Duijn AJ, Nitsch W. Orthopaedic manual physical therapy including thrust manipulation and exercise in the management of a patient with cervicogenic headache: a case report. J Man Manip Ther. 2007;15(1): Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, et al. Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache. Headache: The Journal of Head and Face Pain. 2006;46(3): Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004;29(19): Chae YW, Lee HM. The Effect of Craniocervical Exercise on Tension-Type Headache. The Journal Korean Society of Physical Therapy. 2009;21(4): McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipital muscle atrophy--a pilot study. J Manipulative Physiol ther. 1997;20(1): Park HJ. Relationship between addict and use of application that teenagers use smartphone. Jeonju: chonbuk national university; Nemmers TM, Miller JW, Hartman MD. Variability of the Forward Head Posture in Healthy Communitydwelling Older Women. J Geriatr Phys ther. 2009;32(1) : Lee MH, Song JM, Kim JS. The Effect of Neck Exercises on Neck and Shoulder Posture and Pain in High School Students. The journal of Korean Society of Physical Therapy. 2011;23(1): Fischer AA. Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain. 1987;30(1): Kinser AM, Sands WA, Stone MH. Reliability and validity of a pressure algometer. The Journal of Strength & Conditioning Research. 2009;23(1): Cottrell D. Handbook of Neurologic Rating Scales. Springer Science & Business Media; Jacobson GP, Ramadan NM, Aggarwal SK, et al. The Henry Ford hospital headache disability inventory (HDI). Neurol. 1994;44(5): Bendtsen L. Central sensitization in tension-type headache-possible pathophysiological mechanisms. Cephalalgia. 2000;20(5): The Changes of in Headache due to Postural Improvement in Patients with Tension Headache with Forward Head Posturl

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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