Ⅰ. 서론 15세에서 64세에해당하는생산가능인구의약 1/3은주기적인목통증 (neck pain) 을호소하며 (Andersen et al., 2011), 사무직근로자의 50% 이상은목및어깨의통증을경험한다고보고하였다 (Blangsted et al., 2008). 또한사무직근

Transcription

1 J Korean Soc Phys Med, 2016; 11(1): Online ISSN: Print ISSN: X Research Article Open Access 치료적운동이전방두부자세환자의자세, 통증및비대칭적근육활성에미치는영향 : 증례보고 유경태 1 이호성 2 1 남서울대학교물리치료학과, 2 단국대학교대학원운동의과학과 Effects of Therapeutic Exercise on Posture, Pain and Asymmetric Muscle Activity in a Patient with Forward Head Posture: case report Kyung-Tae Yoo, PhD, PT 1 Ho-Seong Lee, PhD 2 1 Department of Physical Therapy, Namseoul University 2 Department of Kinesiologic Medical Science, Graduate, Dankook University Received: November 29, 2015 / Revised: December 01, 2015 / Accepted: December 24, 2015 c 2015 J Korean Soc Phys Med Abstract 1) PURPOSE: The purpose of this case report was to determine the effect of therapeutic exercise on posture, pain, and muscle activity in two patients with forward head posture (FHP). METHODS: A-31-year-old male (patient A) and a 19-year-old women (patient B) presented with FHP, neck pain, and headache. The therapeutic exercise program consisted of cervical mobilization, deep cervical flexors strengthening, and cervical extensors stretching, for 40 min/d, 2 d/week, for 8 weeks. Neck pain (VAS), neck disability (NDI), cervical range of motion (CROM), lateral view of cervical spine X-ray (indicating the FHP), and asymmetrical neck and shoulder muscular activity ratio were measured before, after 4 weeks, and after 8 weeks of corrective exercise. RESULTS: VAS and NDI decreased in patients A and B after exercise compared to before the program. CROM increased in patients A and B at flexion, extension, side bending, and rotation after exercise compared to before the program. FHP decreased in patients A and B at distance after exercise compared to before the program. In addition, asymmetrical neck and shoulder muscles activity ratio improved in patients A and B after exercise compared to before the program. CONCLUSION: We demonstrated in a case report that therapeutic exercise increases ROM, decreases pain and disability of neck, FHP, and asymmetry muscle activity ratio in patients with FHP. These finding have clinical implications for therapeutic exercise in patients with FHP. Corresponding Author : hoseh28@dankook.ac.kr 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. Key Words: Neck pain, Strengthening exercise, Radiography, Electromyography

2 Ⅰ. 서론 15세에서 64세에해당하는생산가능인구의약 1/3은주기적인목통증 (neck pain) 을호소하며 (Andersen et al., 2011), 사무직근로자의 50% 이상은목및어깨의통증을경험한다고보고하였다 (Blangsted et al., 2008). 또한사무직근로자의목및어깨관련근골격계장애는장시간정적으로일하는자세에기인하여 (van der Windt et al., 2000), 두부의위치를앞으로움직이게한다고보고하였다 (Sun et al., 2014). 이러한시상면에서두부의위치가신체의중력선앞으로편위되는상태를전방두부자세 (forward head posture; FHP) 혹은거북목증후군 (testudinate syndrome) 으로정의할수있다 (Salahzadeh et al., 2014;Harman et al., 2005;Mostamand et al., 2013). FHP 는가장흔히발생하는자세장애중하나로, 목빗근 (sternoclenoidomastoid; SCM), 앞목갈비근 (scalenus anterior) 및상부등세모근 (upper trapezius; UT) 의단축과어깨올림근 (levator scapulae; LS) 및머리반가시근 (semispinalis capitis posterior major) 의신장을야기하여목뼈굽힘근및폄근의비정상적인근활성을초래한다고하였다 (Finley and Lee, 2003). 또한 FHP는근육의고유수용체 (Lee et al., 2014) 및목근육의근방추민감도의변화를발생시켜목움직임의정밀도를저하시키며 (Cheng et al., 2010), 목및어깨주변근육의긴장및부하를증가시켜결과적으로통증, 저림 (numbness), 기능소실및팔 (upper limb) 에다양한신경근증상을발생시킨다 (Kang et al., 2012;Hwang et al., 2012). FHP의치료를위해서는단축된상부의 UT 및 SCM 의스트레칭과 LS 및심부목뼈굽힘근 (deep cervical spine flexor) 의근력강화에초점을맞출필요가있으며 (Lynch et al., 2010), 여러선행연구에서 FHP 환자를대상으로유연성및근력강화를이용한치료적운동의효과를보고하였다 (Lynch et al., 2010;Roddey et al., 2002;Wang et al., 1999). Jull 등 (2002) 은치료적운동이목통증및목부위에기인한긴장성두통을감소시켰다고하였으며, Evans 등 (2002) 은 191명의목부위통증환자를대상으로 11주간의치료적운동을적용한결과, 통증및목의장애가감소되었으며운동종료 2년후까 지긍정적인효과가있었다고보고하였다. 또한 Cunha 등 (2008) 은 31명의만성목부위통증을가진환자 31명을대상으로치료적운동을적용한결과, 통증의감소, 목부위관절가동범위의증가와더불어삶의질을향상시켰다고보고하였다. 한편, 선행연구에의하면, 장시간시야높이보다낮게위치한모니터주시 (Sun et al., 2014) 및장시간의무거운배낭착용 (Kim et al., 2008) 은머리를과도하게앞으로위치하는잘못된자세를야기하며, 이에기인한 FHP와같은목의자세장애는양쪽어깨의비대칭및머리의옆으로기울임 (lateral tilt) 을동반하여비대칭적 (asymmetrical) 근육활성, 척주의옆편위및골반옆경사를발생시킨다고보고하였다 (Corrêa and Bérzin, 2007;Johnston et al., 2008). 특히비대칭적근육활성은목통증의중요한지표로 (Cibulka et al., 2010), Szeto 등 (2005) 은척추의비대칭적근육활성은기능적활동을제한하며, 척추구조물에변화를발생시켜척추움직임및반발력에대한보호작용을감소시킨다고하였고, Ning 등 (2011) 은비대칭적근육활성은옆굽힘과같은관상면에서의움직임뿐만아니라굽힘및폄과같은시상면의움직임에도부정적인영향을미치며, 이는굽힘과폄동작시양측근육중어느한쪽근육의활성도가높아짐에따라반대측근육의수동조직 (passive tissue) 에장력을발생시켜대칭적움직임을저해한다고하였다. 또한, Yoo (2014) 는목부위에서기인한비대칭적근육활성은 ROM의감소및신경근의부정적변화를초래하며, 비대칭적자세정렬과이를통한비대칭성움직임을발생시킨다고보고하였다. 이와같이자세장애를통한비대칭적근육활성의문제점을검토한연구는많이있지만, 가장흔한자세장애중하나인 FHP 환자를대상으로치료적운동이 FHP 및비대칭적근육활성의변화를검토한연구는미비한실정이다. 이에이사례연구에서는 FHP 환자를대상으로치료적운동이 FHP, 통증및비대칭적근육활성도에미치는영향을확인하고, FHP 환자의치료적운동의기초자료를제공하는데그목적이있다.

3 73 Ⅱ. 연구방법 1. 연구대상이사례연구의대상은 C지역소재 M센터에내원한환자를대상으로방사선검사상목뒤쪽부위의연직선 (plump line) 과어깨관절뒤쪽부위와의수평거리가 50 mm 이상이며 (Sun et al., 2014), 목장애지수 (neck disability index; NDI) 가 24점이하인 FHP 환자 2명으로선정하였다. 환자 A는사무직으로재직중인 30세남성으로 ( 신장 cm, 체중 kg) 2015년 2월에 C지역소재 J병원에서 FHP 및목뼈에기인한긴장성두통진단을받은후본센터에내원하였으며, 목통증, 두통및피로감을호소하였다. 환자 B는 19세여성대학생으로 ( 신장 158 cm, 체중 kg) 2015년 7월에 S지역 소재 S병원에서목뼈에기인한긴장성두통진단을받은후본센터에내원하였으며, 목통증및목뼈주변근육의피로감을호소하였다. 대상자에게는사례연구의취지내용을충분히설명한후자발적으로참가동의를얻었다. 2. 치료적운동프로그램이사례연구에서사용한치료적운동프로그램은 Diab와 Moustafa (2011) 의연구에서진행된운동프로그램을수정및보완하여수행하였다. 본운동시작전준비운동으로 5 분간몸통및상지의대근육군스트레칭을실시하였다. 본운동은목뼈의움직임향상, 목뼈주변근육근력강화및스트레칭을위한프로그램으로구성하여 1 명의치료사의감독하에진행하였다. 목뼈 Fig. 1. Therapeutic exercise program. A: Strengthening deep cervical flexors; B: Stretching cervical extensors through a chin drop in sitting; C: Strengthen shoulder retractors; D: Unilateral and bilateral pectoralis stretches.

4 움직임향상을위한목뼈관절가동술을 5 분간실시하였으며, 심부목뼈굴곡근의근력강화, 턱당기기를통한목뼈폄근의스트레칭, 어깨뒤당김근 (retractors) 의근력강화및큰가슴근의스트레칭을 1회 2초간수축및신장을유지하도록지시하면서 12회씩 3세트실시하였다 (Fig. 1). 세트간휴식시간은 30 초간및운동간휴식시간은 60 초로설정하였다. 본운동후에정리운동은 5분간의스트레칭을실시하였다. 치료적운동은 1 일 40 분, 주 2 회및 8 주간에걸쳐서실시하였다. 3. 측정항목 1) 신체조성신체조성은신장계 (Inbody BSM 330, Biospace, Korea) 를이용하여신장을측정하였으며, 체성분분석기 (Inbody 770, Biospace, Korea) 를이용하여체중, 체지방률및근육량을운동전, 운동 4 주및 8 주후에각각측정하였다. 각피험자는몸에부착된금속성물질을제거한후측정장치에올라서서발전극을밟은후손잡이를들고직립자세로팔과다리를약간벌린자세에서양손에전극을누른자세로측정하였다. 신체조성은치료적운동전에측정하였다. 이어느정도인지를직접표시하게하였다. 0mm 의위치를통증이전혀없는상태, 100mm 의위치를참을수없을정도의극심한통증을나타내고거리를측정하여점수화하였다 (Iizuka, 2015). 3) 목뼈관절가동범위목뼈관절가동범위 (cervical range of motion; CROM) 는목뼈관절가동범위측정도구 (CROM, Performance Attainment Associates, Roseville, USA) 을이용하여편안한의자에앉은후엉덩관절및무릎관절을 90 굽힘상태에서굽힘, 폄, 옆굽힘및회전가동범위를측정하였다. 목뼈관절가동범위측정도구중각도측정기는머리위에고정시켰으며, 자기고리 (magnetic collar) 는어깨에위치시켜독립적인목부위의관절가동범위만을측정하였다. 목부위의굽힘, 폄, 옆굽힘및회전의측정전머리는각도계상 0 를중립자세로설정하였으며, 각방향간최대수축상태에서 5초간유지한값을사용하였다 (Tousignant et al., 2006),. 관절가동범위는모든방향에서각각 3 회측정하여평균값을사용하였다 (Law and Chiu, 2013). 모든측정은운동전, 운동 4 주및 8 주후에동일한방법으로동일한치료사에의해측정하였다. 2) 목통증관련지표목통증환자의일상생활수행능력을평가하기위하여개발된자기기입식설문지인 NDI를사용하여목의기능장애수준을평가하였다. 통증정도, 물건들기, 집중, 독서, 두통, 자기관리, 운전, 작업, 수면및여가활동을포함한 10 개의문항으로구성되어있으며, 각문항당점수는 0~5 점으로, 모든문항의점수를합하여총점을기록하였다. 총점은 50점이며, 0~4점은장애없음, 5~14 점은약간의장애, 15~24 점은중등도의장애, 25~34 점은심한장애, 그리고 35 점이상은완전한장애로평가하였다 (Vernon and Mior, 1991). 목통증은시각상사척도 (visual analogue scale; VAS) 를이용하여측정하였다. VAS는환자가느끼고있는통증의수준을시각적인형태로나타내는방법으로대상자는눈금이표시되어있는 100mm 선에통증의수준 4) 전방두부자세전방두부자세 (forward head posture; FHP) 는목뼈부 X선을이용하여측정하였다. 목뼈부 X선촬영은피험자가편안히앉은자세에서목뼈부의측면을촬영하였으며, Sun 등 (2014) 이사용한측면 X선을이용한 FHP 분석방법을사용하여수평거리를측정하였다 (Fig. 1). 수평거리 1 (D 1) 은목뒤쪽부위의연직선 (plump line) 과어깨관절뒤쪽부위와의수평거리를측정하였으며, 수평거리 2 (D 2) 는 1 번목뼈의전면가장자리 (margin) 과 7번목뼈가시돌기의후면가장자리와의거리를측정하였고, 수평거리 3 (D 3) 은귓구멍 (earhole) 과 7번목뼈아래가장자리의거리를측정하였다. 일반적으로 FHP환자는 D 1에서 5.00cm, D 2에서 8.50cm 및 D 3에서 1.10cm 이상의거리를보인다 (Sun et al., 2014). 모든측정은운동전, 운동 4 주및 8 주후에동일한방법으로

5 75 동일한치료사에의해각각측정하였다. 5) 근활성도근전도신호는 Delsys trigno 무선근전도 (Delsys trigon wireless EMG system, Delsys Inc., Boston, MA, USA) 를이용하여수집하였다. 근전도의표본수집률 (sampling rate) 은 1,000 Hz로하였으며, 주파수대역폭은 20~45 Hz의대역통과필터 (bandpass filter) 를적용하고, 동상제거비율 (common mode rejection ratio) 은 100 db이상, 초기잡음 (baseline noise) 은 1 mv이하및입력저항값 (input impedance) 은 100mOhms이상으로설정하였다. 각근육에서수집된표면근전도신호는 Delsys EMG 분석소프트웨어 (Delsys EMG Works Acqusition, Delsys Inc., Boston, MA, USA) 을사용하여실효치 (root mean square; RMS) 를수집하여분석하였다. 근전도신호는양측 SCM, UT, LS 및척추세움근 (erector spinae; ES) 을대상으로측정하였다. 전극은 SENIAM (1999) 에따라 UT의전극은어깨뼈봉우리 (acromion) 와 7번목뼈사이중앙에부착하였으며, SCM의전극은유돌기 (mastoid process) 와흉골절흔 (sternal notch) 중앙부에부착하였다. 또한 LS의전극은 SCM 뒤모서리와 UT 앞모서리의중앙에부착하였으며, ES의전극은 1번요추에서 3cm 측면에부착하였다. 피부저항으로생기는오차를줄이기위하여제모를시행한후에알코올솜으로소독하여근육섬유방향과평행하게부착하였다. 근활성도의정량화를위해서근활성도측정전목굽힘과폄, 어깨들어올리기및허리폄동작에서치료사에저항을이용하여최대수의적등척성수축 (maximal voluntary isometric contraction; MVIC) 을우세 측및비우세측에서각각측정하였다. 근활성도의측정은목굽힘과폄, 어깨들어올리기및허리폄동작에서저항없이 10회측정하여평균값을사용하였으며, 수집된근전도자료를이용하여우세측및비우세측의근활성도발현의차이를비교하였다. 근활성도는운동전, 운동 4주및 8주후에동일한방법으로각각측정하였다 (SENIAM, 1999). Ⅲ. 연구결과 1. 목통증관련지표의변화목통증관련지표의변화는 <Table 1> 에제시한바와같다. VAS는환자 A의경우운동전과비교해서운동 8주후에 % 감소하였으며, 환자 B의경우는운동전과비교해서운동 8주후에 73.68% 감소하였다. NDI 는환자 A의경우운동전과비교해서운동 8주후에 85.71% 감소하였으며, 환자 B의경우는운동전과비교해서운동 8주후에 77.78% 감소하였다. 2. 목뼈관절가동범위의변화목뼈관절가동범위 (CROM) 의변화는 <Table 2> 에제시한바와같다. 환자 A에서굽힘, 폄, 오른쪽옆굽힘, 왼쪽옆굽힘, 오른쪽회전및왼쪽회전의 CROM은운동전과비교해서운동 8주후에 33.51%, 12.10%, 52.43%, 15.79%, 27.07% 및 11.41% 각각향상하였으며, 환자 B에서굽힘, 폄, 오른쪽옆굽힘, 왼쪽옆굽힘, 오른쪽회전및왼쪽회전의 CROM은운동전과비교해서운동 8주후에 44.37%, 8.42%, 53.52%, 18.18%, 44.65% Table 1. Changes in pain and disability before (pre), after 4- (post) and 8- week (post 1) therapeutic exercise VAS (mm) NDI (score) Patient A Decrease Patient B Decrease VAS = Visual analogue scale; NDI = Neck disability index; Decrease = the ratio of pre to post 2

6 Table 2. Changes in cervical range of motion before (pre), after 4- (post) and 8- week (post 1) therapeutic exercise Flx ( ) Ext ( ) Rt LB ( ) Lt LB ( ) Rt AR ( ) Lt AR ( ) Patient A pre Post 1 Post 1 Increase Patient B Increase Flx = flexion; Ext = Extension; Rt = right; Lt = left; LB = lateral bending; AR = axial rotation; Increase = the ratio of pre to post 2 및 11.96% 각각향상하였다. 3. 전방두부자세의변화전방두부자세 (FHP) 의변화는 <Table 3> 및 (Fig. 3) 에제시한바와같다. 환자 A에서 D 1, D 2 및 D 3는운동전과비교해서운동 8주후에 28.43%, 22.65% 및 60.94% 각각감소하였으며, 환자 B에서에서 D 1, D 2 및 D 3는운동전과비교해서운동 8주후에 19.03%, 12.06% 및 34.97% 감소하였다. 4. 근활성도의변화근활성도비율의변화는 <Table 4> 에제시한바와같다. 환자 A에서 SCM, UT, LS 및 ES의우세측대비비우세측근활성도비율은운동전과비교해서운동 8주후에 54.52%, 12.57%, 27.25% 및 66.06% 로각각개선되었으며, 환자 B에서 SCM, UT, LS 및 ES의우세측대비비우세측근활성도비율은운동전과비교해서운동 8주후에 57.95%, 37.73%, 25.92% 및 36.13% 로각각개선되었다. Table 3. Changes in FHP before (pre), after 4- (post) and 8- week (post 1) therapeutic exercise D 1 (cm) D 2 (cm) D 3 (cm) Patient A Decrease Patient B Decrease Decrease = the ratio of pre to post 2; D 1 = the horizontal distance between plump line of posterior neck and posterior shoulder; D 2 = the horizontal distance between the anterior margin of C1 body and the posterior margin of C7 spinous process; D 3 = the horizontal distance between the earhole and midline of C7 lower margin.

7 77 Table 4. Changes in asymmetrical muscle activity before (pre), after 4- (post) and 8- week (post 1) therapeutic exercise SCM (%MVIC) UT (%MVIC) LS (%MVIC) ES (%MVIC) Patient A Increase Patient B Increase SCM = sternocleidomastoid; UT = upper trapezius; LS = levator scapulae; ES = erector spinae; Increase = the ratio of pre to post 2 Ⅳ. 고찰 Fig. 2. The horizontal distance 1, 2 and 3 were measured by using the lateral view of cervical spine X-ray. Distant 1 was the horizontal distance between plump line of posterior neck and posterior shoulder. Distant 2 was the horizontal distance between the anterior margin of C1 body and the posterior margin of C7 spinous process. Distant 3 was the horizontal distance between the earhole and midline of C7 lower margin. 이사례연구에서는 FHP 환자를대상으로 8주간의치료적운동이통증관련지표, 목뼈 ROM, FHP 및근활성도에미치는영향을검토한결과, 치료적운동이목뼈의통증및장애를감소시켰으며, ROM의증가및 FHP와비대칭적근육활동비율을개선시키는것으로확인하였다. 이상의결과를통해이연구에서의치료적운동은전방두부자세환자의임상적인효과가있는것으로생각된다. 심부목뼈굽힘근은목뼈굽이 (curvature) 의받침대역할을하는중요한자세유지근육중하나로머리목부분의자세이상이심부목뼈굽힘근의약화를야기하며 (Yun and Kim, 2013), 이러한심부목뼈굽힘근의약화는목통증을발생시킨다고보고하였다 (Jull et al., 2009). Gupta 등 (2013) 은 30명의 FHP 환자를대상으로 4주간의심부목뼈굽힘근강화운동을실시한결과, FHP, 통증및목의장애정도가감소하였다고보고하였으며, Diab과 Moustafa(2011) 은 48명의 FHP 환자를대상으로 10주간의심부목뼈굽힘근강화운동을적용한결과, 통증의감소와더불어 FHP의개선이이루어졌다고보고하였다. 심부목뼈굽힘근강화를통한통증의감소및 FHP의개선은목뼈의통증이상부목뼈굽힘시주로나타나며, 심부목뼈굽힘근이상부목뼈에기인한통증민감성구조들에직접적으로영향을주었

8 Fig. 3. Lateral view of cervical spine pre, after 4- and 8-week therapeutic exercise in a patient A 기때문이라고보고하였다 (O Leary et al., 2003). 이사례연구에서 VAS 및 NDI는환자 A와 B 모두에서운동전과비교하여운동 8주후에각각감소하는것으로나타났다. 따라서이사례연구에서 FHP 환자에게심부목뼈굽힘근강화를포함한치료적운동이목의통증및장애정도를감소시켰다고생각된다. Fernández-de-las-Peñas 등 (2005) 에따르면 FHP는척추체 (vertebral body) 의후관절 (facet joint) 및후면에과도한압력을발생시켜두부및목뼈부위의움직임을감소시킨다고보고하였으며, Morningstar 등 (2003) 은 FHP 환자는상부목뼈에서과도한폄이나타나지만, 하부목뼈의저운동 (hypomobility) 에의해굽힘, 옆굽힘및회전뿐만아니라폄의 ROM도감소시킨다고보고하였다. 이사례연구에서환자A의굽힘, 폄, 오른쪽및왼쪽옆굽힘과오른쪽및왼쪽회전 CROM은치료적운동 8주후에 51.80, 83.40, 31.40, 35.20, 및 로향상하였으며, 환자 B의굽힘, 폄, 오른쪽및왼쪽옆굽힘과오른쪽및왼쪽회전 CROM은치료적운동 8주후에 42.30, 70.80, 32.70, 35.10, 및 로향상하였다. Chen 등 (1999) 의메타분석에의하면건강한성인의목뼈 ROM의정상범위는굽힘이 48 ~69, 폄이 61 ~93, 옆굽힘이 38 ~49 및회전이 70 ~93 라고보고하였다. 선행연구와비교한결과, 이연구에서환자 A는목굽힘, 폄, 오른쪽및왼쪽회전 ROM이정상범위로개선하였으며, 환자 B는목폄, 오른쪽및왼쪽회전 ROM이정상범위로개선하였다는사실을확인하였다. 한편, 목뼈관절가동술은기능부전이있는척추에 ROM의증가및통증을감소시키기위하여주로사용하고있으며 (Lee et al., 2015), 목통증을동반한 ROM의제한환자에게효과적이라고보고하였지만 (Gong et al., 2010;Ganesh et al., 2015), Bronfort 등 (2001) 은 191명의 ROM에제한이있는목통증환자를대상으로 11주간목뼈관절가동술집단및근력강화운동과관절가동술을복합적으로적용한집단과비교한결과, 관절가동술과근력강화를복합적으로적용한집단에서근력, 근지구력, 통증및 ROM의향상이크게나타났고, 운동종료 1년후까지지속적으로유지되었다고보고하면서, FHP 환자의빠른치료및장기간의효과를유지하기위해서는관절가동술과근력강화운동을복합적으로적용할필요가있다고하였다. 이사례연구에서도목뼈관절가동술, 근력강화운동및스트레칭의복합적인치료적운동이통증의감소와 ROM의증가를초래하였다고생각된다. FHP는후관절 (facet joint) 의과도한압박, 목부위연부조직의신장및후부근육길이의단축과같은생리학적제한을야기하여관절주머니인대 (capsular ligament) 의과도한긴장으로통증을유발시키며 (Silva et al.,

9 ; Pearson et al., 2004), 특히후관절의과도한압박은물질 P(substance P) 와칼시토닌유전자관련펩티드 (calcitonin gene-related peptide) 의통각수용성신경종말을포함하는윤활주름 (synovial folds) 을손상시켜통증을더욱증가시킨다고보고하였다 (Inami et al., 2001). Diab (2012) 는 FHP의감소를위해서는심부목뼈굽힘근의강화와목뼈폄근의스트레칭이필수적이라고보고하였으며, Paris (1990) 는 FHP의개선은후관절주머니의압박및관절주머니인대의긴장으로인한손상의위험성을감소시킨다고보고하였다. 이사례연구에서 FHP는환자 A와 B의 D 1, D 2 및 D 3 모두에서운동전과비교하여운동 8주후에각각감소하였다. 이사례연구에서는 FHP 환자에게심부목뼈굽힘근의강화와목뼈폄근의스트레칭으로구성된치료적운동이 FHP 를감소시켰으며, FHP 의감소를통한후관절의과도한압박등생리학적제한의개선을통해통증이감소되었을가능성이시사되었다. 하지만이사례연구에서는 FHP 환자에게치료적운동이생리학적제한에미치는효과에대해서는검토하지않았기때문에이점에관해서는향후추가연구가필요하다고생각된다. 비대칭적근육활성은 FHP와같은경부의자세장애로인해나타나는증상중하나로오른쪽및왼쪽근육단면적의차이 (Fernández-de-las-Peñas et al., 2008), 통증, 근육긴장도와근육피로증가, 협응력과근육신경세포전위 (electric potentials) 의감소를야기한다고보고하였으며 (Ferrario et al., 2007; Kogawa et al., 2006), 턱관절의운동장애및삼차신경통 (trigeminal neuralgia) 등을포함한측두하악관절 (TM joint) 의문제를발생시키는주요원인으로보고하였다 (Schroeder et al., 1991). Ries 등 (2008) 은 SCM을포함한목뼈부근육의비대칭적근육활성은두부의불안정성을증가시키며, 목뼈운동의제한을야기시켜신경근압박등의이차적손상의위험성이증가한다고하였다. 이사례연구에서 SCM, UT, LS 및 ES의우세측대비비우세측근활성도의비율은환자 A와환자 B 모두에서운동전과비교해서운동 8주후에각각개선한것으로나타났다. Boyle (2012) 는척추주변근근력강화를포함한치료적운동이신경근의재교육효과를통해운동조절능력과오른쪽및왼쪽 의양측정렬을향상시킨다고하였다. 또한 Lee 등 (2015) 은치료적운동이목뼈부위근육의비대칭적근육활성및근육긴장도를개선시켰으며, 이는 1번및 2번목뼈의위치변화에기인하여발생하였다고보고하였다. 이사례연구에서는근력강화를포함한치료적운동이 FHP의감소즉, 목뼈위치의변화및근력향상을통한양축정렬의향상으로인해비대칭적근육활성을개선시켰으며, 두부의불안정성을감소시켜이차적손상을예방할가능성이있다고생각된다. Ⅴ. 결론이사례연구에서는 FHP 환자를대상으로 8주간의치료적운동이통증관련지표, 목뼈 ROM, FHP 및근활성도에미치는영향을검토한결과, 치료적운동이목뼈의통증및장애를감소시켰으며, ROM의증가및 FHP와비대칭적근육활동비율을개선시키는것으로확인하였다. 이상의결과를통해이연구에서의치료적운동은전방두부자세환자의임상적인효과가있는것으로생각된다. 향후에는 FHP 환자를대상으로치료적운동의일반화를위해서는보다많은피험자를대상으로통증, 자세및근육활성등에미치는상세한효과를검토할필요가있다고생각된다. References Andersen LL, Hansen K, Mortensen OS, et al. Prevalence and anatomical location of muscle tenderness in adults with nonspecific neck/shoulder pain. BMC Musculoskelet Disord. 2011;12:169. Blangsted AK, Søgaard K, Hansen EA, et al. One-year randomized controlled trial with different physicalactivity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers. Scand J Work Environ Health. 2008;34(1): Boyle K. Conservative Management for Patients with Sacroiliac

10 Joint Dysfunction. In: Norasteh AA, editor. Low Back Pain. Rijeka, Croatia: InTech; 2012: Bronfort G, Evans R, Nelson B. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine (Phila Pa 1976). 2001;26(7): Chen J, Solinger AB, Poncet JF, et al. Meta-analysis of normative cervical motion. Spine (Phila Pa 1976). 1999;24(15): Cheng CH., Wang JL., Lin JJ., et al. Position accuracy and electromyographic responses during head reposition in young adults with chronic neck pain. Journal of Electromyography and Kinesiology. 2010;20(5): Cibulka MT, Strube MJ, Meier D, et al. Symmetrical and asymmetrical hip rotation and its relationship to hip rotator muscle strength. Clin Bio mech (Bristol, Avon). 2010;25: Corrêa EC, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10): Diab AA, Moustafa IM. The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial. Clin Rehabil. 2012;26(4): Diab AA. The role of forward head correction in management of adolescent idiopathic scoliotic patients: a randomized controlled trial. Clin Rehabil. 2012; 26(12): Evans R, Bronfort G, Nelson B, Goldsmith CH. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine (Phila Pa 1976). 2002;27(21): Fernández-de-las-Peñas C, Albert-Sanchís JC, Buil M, Benitez JC, Alburquerque-Sendín F. Cross-sectional area of cervical multifidus muscle in females with chronic bilateral neck pain compared to controls. J Orthop Sports Phys Ther. 2008;38(4): Fernández-de-las-Peñas C, Downey C, Miangolarra-Page JC. Validity of the lateral gliding test as tool for the diagnosis of intervertebral joint dysfunction in the lower cervical spine. J Manipulative Physiol Ther. 2005;28(8): Ferrario VF, Tartaglia GM, Luraghi FE. The use of surface electromyography as a tool in differentiating temporomandibular disorders from neck disorders. Man Ther. 2007;12(4): Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84: Ganesh GS, Mohanty P, Pattnaik M. Effectiveness of mobilization therapy and exercises in mechanical neck pain. Physiother Theory Pract. 2015;31(2): Gong WT, Lee SY, Lee YM. The Effects of Cervical ROM and Muscle Endurance on Cervical Joint Mobilization of Normal Adults J Korean Soc Phys Med. 2010;5(1):7-13. Gupta BD, Aggarwal S, Gupta B, et al. Effect of Deep Cervical Flexor Training vs. Conventional Isometric Training on Forward Head Posture, Pain, Neck Disability Index In Dentists Suffering from Chronic Neck Pain. J Clin Diagn Res. 2013;7(10): Harman K, Hubley-Kozey CL, Butler H. Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial. J Manual Manip Ther. 2005;13: Hwang BG, Kim GC, Park YK. Effects of Self-stretching Exercise and Upper Thoracic Joint Mobilization on Range of Motion and Pain of the Patients with Chronic Neck Pain. J Korean Soc Phys Med. 2012;7(4): Iizuka Y, Iizuka H, Mieda T. Association between neck and shoulder pain, back pain, low back pain and body composition parameters among the Japanese general

11 81 population. BMC Musculoskelet Disord. 2015;16(1): 333. Inami S, Shiga T, Tsujino A, et al. Immunohistochemical demonstration of nerve fibers in the synovial fold of the human cervical facet joint. J Orthop Res. 2001;19: Johnston V, Jull G, Souvlis T. Neck movement and muscle activity characteristics in female office workers with neck pain. Spine (Phila Pa 1976). 2008;33(5): Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976). 2002;27(17): Jull GA, Falla D, Vicenzino B, et al. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009;14(6): Kang JH, Park RY, Lee SJ, et al. The effect of the forward head posture on postural balance in long time computer based worker. Ann Rehabil Med. 2012;36: Kim MH, Yi CH, Kwon OY, et al. Changes in neck muscle electromyography and forward head posture of children when carrying schoolbags. Ergonomics. 2008;51(6): Kogawa EM, Calderon PS, Lauris JR. Evaluation of maximal bite force in temporomandibular disorders patients. J Oral Rehabil. 2006;33(8): Law EY, Chiu TT. Measurement of cervical range of motion (CROM) by electronic CROM goniometer: a test of reliability and validity. J Back Musculoskelet Rehabil. 2013;26(2): Lee B, Lee J, Yang J. The effects of stretching exercise for upper trapezius on the asymmetric rate of bite force. J Phys Ther Sci. 2015;27(7): Lee KJ, Roh JS, Choi HS, et al. Effect of Active Intervention after Kaltenborn s Cervical Joint Mobilization on The Cervical Spine Alignment and Muscle Activity in Patients with Forward Head Posture. J Korean Soc Phys Med. 2015;10(2): Lee MY., Lee HY., Yong MS. Characteristics of cervical position sense in subjects with forward head posture. J Phys Ther Sci. 2014;26(11): Lynch SS, Thigpen CA, Mihalik JP, et al. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Internet Br J Sports Med. 2010;44(5): Morningstar MW, Strauchman MN, Weeks DA. Spinal manipulation and anterior headweighting for the correction of forward head posture and cervical hypolordosis: A pilot study. J Chiropr Med. 2003; 2(2):51-4. Mostamand J, Lotfi H, Safi N. Evaluating the head posture of dentists with no neck pain. J Bodyw Mov Ther. 2013;17(4): Nam SH, Son SM, Kwon JW, et al. The intra- and inter-rater reliabilities of the forward head posture assessment of normal healthy subjects. J Phys Ther Sci. 2013; 25: Ning X, Haddad O, Jin S. Influence of asymmetry on the flexion relaxation response of the low back musculature. Clin Biomech (Bristol, Avon). 2011; 26(1):35-9. O Leary s, Falla D. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J Pain. 2007;8(11): Paris SV. Cervical symptoms of forward head posture. Top Geriatr Rehabil. 1990;5(4):11-20 Pearson AM, Ivancic PC, Ito S, et al. Facet joint kinematics and injury mechanisms during simulated whiplash. Spine (Phila Pa 1976). 2004;29: Ries LG, Alves MC, Bérzin F. Asymmetric activation of temporalis, masseter, and sternocleidomastoid muscles in temporomandibular disorder patients. Cranio. 2008;26(1): Roddey T, Olson S, Grant S. The effects of pectoralis muscle

12 stretching on the resting position of the scapula in persons with varying degrees of forward head/rounded shoulder posture. J Man Manip Ther. 2002;10: Salahzadeh Z, Maroufi N, Ahmadi A, et al. Assessment of forward head posture in females: observational and photogrammetry methods. J Back Musculoskelet Rehabil. 2014;27(2): Schroeder H, Siegmund H, Santibáñez G. Causes and signs of temporomandibular joint pain and dysfunction: an electromyographical investigation. J Oral Rehabil. 1991;18(4): SENIAM. European Recommendations for Surface ElectroMyoGraphy, results of the SENIAM project. SENIAM project. Roessingh Research and Development Silva AG, Punt TD, Sharples P, et al. Head posture and neck pain of chronic nontraumatic origin: a comparison between patients and pain-free persons. Arch Phys Med Rehabil. 2009;90: Sun A, Yeo H, Kim T, et al. Radiologic Assessment of Forward Head Posture and Its Relation to Myofascial Pain Syndrome. Ann Rehabil Med. 2014;38(6):821-6 Szeto GP, Straker LM, O Sullivan PB. EMG median frequency changes in the neck-shoulder stabilizers of symptomatic office workers when challenged by different physical stressors. J Electromyogr Kinesiol. 2005;15: Tousignant M, Smeesters C, Breton AM, Breton E, Corriveau H. Criterion validity study of the cervical range of motion (CROM) device for rotational range of motion on healthy adults. J Orthop Sports Phys Ther. 2006;36(4): van der Windt DA, Thomas E, Pope DP, et al. Occupational risk factors for shoulder pain: a systematic review. Occup Environ Med. 2000;57(7): Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7): Wang CH, McClure P, Pratt NE, et al. Stretching and strengthening exercises: their effect on threedimensional scapular kinematics. Arch Phys Med Rehabil 1999;80:923 9 Yang NY, Oh JS. Effects of Visual Biofeedback on Movement Patterns of Neck Lateral Bending and Muscle Activation of Sternocleidomastoid during Neck Rotation in Adults with Forward Head Posture. J Korean Soc Phys Med. 2014;9(4): Yoo WG. Comparison of Orbicularis Oculi Muscle Activity during Computer Work with Single and Dual Monitors. J Phys Ther Sci. 2014;26(11): Yun KH, Kim K. Effect of CranioCervical Flexion Exercise Using Sling on Thickness of Sternocleidomastoid Muscle and Deep Cervical Flexor Muscle. J Korean Soc Phys Med. 2013;8(2):