JKPT pissn Vol. 29, No. 2, April 2017 J Kor Phys Ther 2017:29(2):85-90 1229-0475 eissn 2287-156X Original Article Effects of Manual Therapy on Pain and Function of Patients with Chronic Low Back Pain Kyoung Kim 1, Kwan-sub Lee 2, Seok-Joo Choi 3, Chun-Bae Jeon 4, Gook-Joo Kim 1 1 Department of Physical Therapy, College of Rehabilitation Science, Daegu University, Daegu; 2 Department of Physical Therapy, Kang Hospital; 3 Department of Physical Therapy, Daegu Science University, Daegu; 4 Department of Physical Therapy, The Most Holy Trinity Hospital, Daegu, Korea Purpose: This study was conducted to determine how a manual therapy (joint mobilization and flexion-distraction technique) would affect pain and function with the chronic low back pain. Methods: Thirty patients were assigned to either the experimental group (n= 15) or the control group (n= 15). Patients in the experimental group performed joint mobilization and flexion-distraction technique. Patients in the control group performed spinal decompression therapy. Both exercises were performed for three days per week, for a period of six weeks. Pain was measured by the visual analogue scale (VAS) and functional disability was measured using the Oswestry disability index (ODI). A paired t-test was used for identify differences before and after treatment, and an independent t-test was used to identify differences between treatment groups. Results: In the within group comparison, the experimental group and control group differed significantly for all variables (p<0.05). However, no significant differences were observed in any variables between groups (p> 0.05). Conclusion: The above results confirmed that it is necessary to confirm the various benefits of therapy with the joint mobilization and the flexion-distraction technique. The findings of the concerned study will be useful to doctors applying therapy to treat patients with the chronic low back pain. Keywords: Manual therapy, Chronic low back pain, VAS, ODI 서론여러근골격계질환중요통은일상에서흔히발생하는질환이고일상생활의지장과함께치료를위한비용의증가로이어져삶의질에큰영향을미치는요인중하나이다. 1 요통을일으키는원인은척추자체병변으로생기는구조적원인과스트레스에의한심리적요인, 복강내장기나생식기질환, 그리고근골격계의기능저하때문에생기는생체역학적요인등이있으며, 그중에서도대부분이체간의연부조직손상이나근력약화에따른요부의불안정성같은역학적원인에의한것이다. 이러한원인으로발생한통증은활동의제한과관절사용의감소, 이차적근력약화를초래하며신체기능과생산활동을저하시키는악순환으로이어진다. 2-5 만성요통이란요통의원인이사라졌음에도불구하고, 통증이 3-6개월이상지속되면만성요통으로분류한다. 6 만성요통은치료의예후도나쁘고통증의지속성으로인하여환자개인의사회적, 심리적안정에도지대한영향을끼치 고있다. 7 요통환자들은일반적으로보존적인치료와운동치료를강조하고, 이러한치료에효과가없거나상태가심각한경우수술을시행하게되지만무엇보다요통을치료하는데중요한부분은신체적인문제와사회심리적인문제를포함한포괄적인치료방법을선택하는것이다. 8-10 Bae 등 11 은통증, 제한된움직임그리고나쁜자세로인한문제를치료하는데있어도수치료가이용된다고하였으며, 도수치료기법의핵심원리는기능부전의척추와사지의근육, 관절을다양한도수교정치료기법을이용해근육의신장, 관절가동범위와변위의정상화, 유착을제거등으로근골격계적증상과신경을회복시킨다. 도수치료기법의범주에는근골격계의관절이나연부조직의가동술, 도수교정, 정골요법, 결합조직마사지, 근막이완술, 굴곡신연기법, 근에너지기법등이포함될수있다. 12 척추도수치료중에서관절가동기법은동통이나근방호또는근경련등에신경생리학적그리고기계적인측면에영향을주며, 가역성 (reversible) 이있는저가동성 (hypomobili- Received Mar 2, 2017 Revised Apr 27, 2017 Accepted Apr 27, 2017 Corresponding author Gook-Joo Kim E-mail ptk8911@hanmail.net Copylight 2017 The Korea Society of Physical Therapy This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License (Http:// creativecommons.org/license/by-nc/4.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. www.kptjournal.org 85
JKPT The Journal of Korean Physical Therapy Kyoung Kim, et al. ty) 관절이나점진적으로가동성에제한이나타나고있는관절그리고기능적으로고정된관절의치료에효과적이다. 13 또한기능부전이있는척추의가동범위를증가시키고통증을경감시키기위하여척주에많이사용되고있으며, 관절의자유로운동작을허용하기위해신연 (distraction), 활주 (gliding), 압박 (compression), 구르기 (rolling), 회전 (spinning) 등의방법을적절하게적용하여뻣뻣한조직을스트레칭시켜관절가동범위를증가시킬수있다. 14 도수치료방법중굴곡- 신연기법치료는척추주위인대의협착감소, 디스크내의대사물질의이동증가, 척추후관절개방을통한후방디스크에가해지는스트레스및내압감소, 그리고추간공확장등을통해손상된척추신경과주위구조물을회복시킬목적으로사용하는치료기술이다. 15 또한척추후관절의변위를복귀시켜후방척추운동의정상범위유지, 운동기능향상과자세교정을통한통증감소로신체기능을향상시킬뿐만아니라, 단순한염좌와타박상에서부터심각한추간판탈출증으로인한다양한요통에적용된다고보고하였다. 16 요통환자의보존적치료로최근에는견인치료의단점을보완한척추감압치료 (spinal decompression therapy) 가적용되고있다. 척추감압치료는미항공우주국 (NASA) 우주인들이실험중우주여행의무중력상태에서추간판높이가증가되어요통이해소되고키가커지는현상에착안하여개발된치료방식으로, 탈출되어있는추간판에음압을가해튀어나와있는추간판이제자리로돌아가게만드는치료원리로수핵의돌출과근경직을줄여주고척추의안정과길이신장에도효과적이다. 17 척추감압치료는일반적인견인의사용이어려운부분에대한 3차원적인견인, 심리적안정감, 인대및근육에무리를주지않는범위내에서의효과등의장점이있으나, 값비싼장비가격과치료비용, 사전에계산되어진셋팅으로인한치료중변수발생에대한조절의어려움이있다. 현재까지만성요통환자를위한다양한치료효과에관한연구는지속적으로이루어져왔고, 관절가동기법과굴곡-신연기법을병행한치료와척추감압치료에대한각각의치료법들이다른보존적인치료방법들보다효과적이라는점이인정되고있지만, 두치료법에관해비교한연구는부족한실정이다. 따라서본연구의목적은만성적인요통을호소하는환자들에대해관절가동기법과굴곡-신연기법을통한치료방법이통증과기능에어떠한영향을미치는지에대해척추감압치료와비교분석하여만성요통에대한치료방법의방향성을제시하여효과적인처치방법을제공하고자한다. 연구방법 1. 연구대상본연구는 2016년 10월 31일부터 12월 10일까지 6주동안대구소재 S 정형외과에입원한환자와외래로내원한환자중임신이나생리, 비뇨기계등의감염으로인한통증을제외한근골격계의문제로인한만성요통으로진단받고통증이지속된지 3개월이상된 30세에서 60세사이의성인 30명을대상으로척추감압치료를실시한대조군 15명 ( 남자 4명, 여자 11명 ) 과도수치료인관절가동기법과굴곡-신연기법을실시한실험군 15명 ( 남자 4명, 여자 11명 ) 을무작위로두그룹으로나누어실시하였다. 본연구의의도와실험전과정에대한내용을충분히설명한후자발적동의를얻어실시하였으며요통을제외한근골격계질환이나특이한병력이없는자로선정하였다. 2. 실험방법 1) 측정도구 ⑴ 통증통증정도를알아보기위해시각적상사척도 (visual analogue scale, VAS) 방법을이용하였다. 100 mm의수평자에왼쪽끝은통증이없는아주편안한상태, 오른쪽끝은대상자가생각하기에극심한통증으로참을수없는통증으로정의되도록하여그선상에검사자의질문을듣고통증의정도를수평자위에표시하도록하였다. VAS는다양한증상, 특히통증의강도와주기를측정하기위해역학및임상연구에흔히사용되고, 다른심리현상이나증상의정도, 기능이나삶의질등을측정하는데에도광범위하게이용되고있다. 18 또한다양한환경에서쉽게사용할수있으며적용에필요한연습시간이적게걸릴뿐만아니라, 측정된자료의변수는통계처리가가능한특징을가지고있다. 19 (2) 기능장애요통으로인한기능장애정도를평가하기위해오스웨스트리요통장애지수 (Oswestry disability index, ODI) 를이용하였다. ODI는장애변화에가장민감한자가인지도구이며, 척추질환의관리에이용되는주요한조건별결과측정법의하나이다. 20 10개의문항 ( 통증정도, 자기관리, 들기, 걷기, 앉아있기, 서있기, 잠자기, 성생활, 사회생활, 여행 ) 은기능적수행능력에따라 0점에서 5점까지점수로측정하며, 점수가높을수록장애가심한것을뜻한다. 본연구에서는배우자가없는대상자를고려하여성생활항목을제외한 9개항목을적용하였다. 9개항목은각각 6개의문항으로되어있고각항목을측정한점수를합하여항목의총점인 45점으로나눈값을 % 로하여 0-20% 는경증장애 (minimal disability), 21-40% 는중등도장애 (moderate disability), 40-60% 는중증장애 (severe disability), 60% 이상은생활전반의장애 (severely disabled life) 로구분한다. 점수의계산은답한문항의총점수를백분율로환산하여표시하였다. 21,22 86 www.kptjournal.org
The Effects of Manual Therapy with Chronic Low Back Pain JKPT 2) 연구방법 (1) 관절가동기법관절가동기법은적용하는분절에서대상자를옆으로누운자세에서엉덩관절과무릎관절을굴곡시킨후실시하였으며, 관절가동기법은각각 10회씩적용하여총 20분을다음과같이실시하였다. 23 1 허리뼈분절의굽힘가동기법 (lumbar segmental flexion mobilization) 연구자의한손은대상자의허리뼈후방에놓고동시에손가락을치료하고자하는분절의머리쪽에위치한추골의가로돌기나가시돌기를고정시키고, 다른쪽손은대상자의엉치뼈에놓고손가락을치료하고자하는분절의꼬리쪽에위치한추골의가로돌기나가시돌기에놓고골반을꼬리쪽 -배쪽(caudal-ventral direction) 으로움직여분절에서굴곡시킨다. 2 허리뼈분절의폄가동기법 (lumbar segmental extension mobilization) 연구자의한손은대상자의허리뼈에놓고동시에시지를치료하고자하는분절의머리쪽에위치한추골의가시돌기후방에위치시켜고정시키고, 다른쪽손은대상자의양쪽하퇴와무릎관절의후방을감싸쥐고대상자의양쪽다리와골반을후방으로움직이게하여허리뼈분절을신전시킨다. 3 허리뼈분절의견인가동기법 (lumbar segmental traction mobilization) 연구자의한쪽아래팔과손을대상자의허리뼈에밀착시키고시지와중지는치료하고자하는분절의머리쪽에위치한추골을고정시킨후, 다른쪽팔과손을대상자의엉치뼈에밀착시키고시지와중지로치료하고자하는분절의꼬리쪽에위치한추골에놓고가슴부위를대상자의넓적다리와골반앞부분에밀착시켜치료하고자하는분절에서견인이일어나도록팔과몸통을하나의단위처럼사용하여움직인다. (2) 굴곡신연방법굴곡-신연기법은 Zenith-Cox flexion table(zenith-100, USA) 을이용하였다. 대상자는엎드려누운자세에서연구자의한손은치료하고자하는허리뼈가시돌기에모지구 (thenar) 로접촉해고정하고다른손은말미부분의손잡이를잡고테이블의꼬리측골반분절 (caudal pelvic section) 을아래로내려 4-5초씩 5회의굴곡-신연동작을가해총 20초간의신연이가해지도록하였으며, 꼬리측분절을아래쪽으로움직일때는 5 cm정도까지만내려전체적용횟수는 20초적용, 5회반복을 1 set로하여 3 set까지실시하였다. 굴곡-신연기법을적용한후한손으로대상자의머리를연구자의손으로고정시키고테이블의하단를아래로내려굴곡-신연동작을적용하는큰구멍펌프 (foramen magnum pump) 기법을 10회반복하였다. 24 (3) 척추감압치료척추감압치료기 (MID 4 M Serise, WIZ medical, KOR) 를이용하여대상자는치료기위에바로누운자세로눕고공기압견착방식 (air grip extension) 을이용하여골반, 가슴부위, 머리에벨트로고정하고요추의전만을유지하기위하여공기압펌프엉치뼈고정보드 (sacrum extension) 장치를적용하였다. 견인력은처음강도 4-5에서시작하여점차강도를한단계씩일정비율로증가시켰으며견인력증가에따른통증발생시견인력을낮추거나유지시켰다. 견인치료시간은 20분이며유지시간 (hold time) 10초와휴지시간 (rest time) 5초로설정하여표준감압방식과분할감압방식을동시에적용하였다. 본연구에서실험군은관절가동기법과굴곡-신연기법을적용하였고, 대조군은척추감압치료를적용하였다. 실험군과대조군의모든대상자에게먼저온열치료 20분, 간섭파치료 100 bps 15분, 초음파치료 5분을통증부위에동일하게적용하였다. 각대상자들은주 3회, 총 6주동안실시하였다. 3. 자료분석본연구의목적을위하여수집된자료는 SPSS /PC Ver.13.0 을이용하여분석하였으며, Shapiro-Wilk 검정방법을이용하여정규분포임을확인하였다. 대상자들의일반적인특성은기술통계방법을사용하였고, 각군의실험전과후의유의성검정은대응표본 t-검증 (paired t- test) 을실시하였으며, 각군간실험전과후의변화량차이의유의성검정은독립표본 t-검증 (independent t-test) 을실시하였다. 통계학적유의수준은 0.05로하였다. 결과 1. 연구대상자의일반적특성실험군의평균연령은 48.6 ± 9.4세, 평균신장은 160.2 ± 6.0 cm, 평균체중은 62.3 ± 12.0 kg이었다. 대조군의평균연령은 46.1 ± 8.5세, 평균신장은 162.7± 9.1 cm 평균체중은 59.3 ± 11.9 kg이었다. 연구대상자의일반적특성에대한두집단간의유의한차이는없었다 (p> 0.05)(Table 1). 2. 시각적상사척도비교실험전, 후 VAS의변화에서, 실험군은 6.40 ± 0.34에서 4.53 ± 0.39로감소하여유의한차이가있었고 (p < 0.05), 대조군도 6.27± 0.42에서 4.27 ± 0.36로감소하여유의한차이가있었다 (p < 0.05). 각군의실험전, 후의집단간의비교에서는유의한차이가없었다 (p> 0.05)(Table 2). www.kptjournal.org 87
JKPT The Journal of Korean Physical Therapy Kyoung Kim, et al. Table 1. General characteristics of subjects Group EG (n=15) CG (n=15) p Age (year) 48.6±9.4 46.1±8.5 0.440 Height (cm) 160.2±6.0 162.7±9.1 0.525 Weight (kg) 62.3±12.0 59.3±11.9 0.453 Mean± SD: mean± standard deviation, CG: control group, EG: experimental group. Table 2. Comparison of VAS in inner-groups and between groups Group Pre Post t p EG 6.40±0.34 4.53±0.39 6.424 0.000 * CG 6.27±0.42 4.27±0.36 4.830 0.000 * t -0.248-0.505 p 0.806 0.618 CG: control group, EG: experimental group, VAS: visual analogue scale. Table 3. Comparison of ODI in inner-groups and between groups Group Pre Post t p EG 33.75±18.40 21.94±13.48 3.676 0.002 * CG 29.72±12.25 18.89±9.80 4.581 0.000 * t 0.729 0.733 p 0.473 0.470 CG: control group, EG: experimental group, ODI: Oswestry disability index. 3. 오스웨스트리요통장애지수비교 실험전, 후 ODI 의변화에서, 실험군은 33.75 ± 18.40 에서 21.94 ± 13.48 로 감소하여유의한차이가있었고 (p < 0.05), 대조군도 29.72 ± 12.25 에서 18.89 ± 9.80 로감소하여유의한차이가있었다 (p < 0.05). 각군의실험 전, 후의집단간의비교에서는유의한차이가없었다 (p> 0.05)(Table 3). 고찰 본연구는 3 개월이상지속된만성요통환자 30 명을대상으로효과적 인치료방법과치료방향을제시하기위하여관절가동기법과굴곡 - 신연기법의효과를척추감압치료와비교, 분석하였다. 본연구에서는통증정도를측정하기위해 VAS 검사를실시하였 다. VAS 의변화는도수치료방법중하나인관절가동기법과굴곡 - 신 연기법을실시한실험군과척추감압치료를실시한대조군모두에서 실험전에비해실험후유의한통증감소를보였다. Ferreira 등 25 의연 구에서도만성요통환자를대상으로척추도수치료를시행한결과, VAS 가치료전 6.2 에서치료후 4.1 로통계학적으로유의한차이가있 다고보고하였다. 또한 Giles 등 26 은만성요통환자를대상으로척추 도수치료를실시하여 VAS 가통계학적으로유의하게감소하여본연 구와유사한결과를보였다. 관절가동기법과굴곡 - 신연기법으로인 한통증감소의원인은척수와뇌간단계에서통증자극의전달을억 제하는기계적수용기를자극하고관절을가동시키는척추도수치료가관절의움직임을통한척추의통증민감성조직인인대와관절낭의자극전달을감소시켜통증감소가나타났고, 고유수용성감각이유해성자극인식에선행하여정상신경발화를자극함으로써통증을감소시키는것으로보고하였다. 27,28 Ramos와 Martin 29 은척추감압치료후통증감소에유의한효과가있다고보고하였다. 또한요추추간판탈출증환자에게척추감압치료를적용하여탈출된디스크의축소와디스크의재생에긍정적인영향, 통증과유연성및근활성도에서유의한효과가있다고보고하였다. 30 본연구에서도척추감압치료후 VAS 검사를통한통증감소를보였으며그원인으로는통증의원인이되는척추디스크부위를조준하여감압을반복함으로써추간판내의압력을부분무중력상태로만들고이런환경에서탈출되었던디스크가정상위치로되돌아오기도하고수분, 혈액, 그리고여러영양소들의원활한소통을도와통증을해결하며자연치유력증진을도와준것으로사료된다. 본연구에서기능장애를측정하기위해 ODI를실시하였다. ODI 의변화는관절가동기법과굴곡-신연기법을실시한실험군과척추감압치료를실시한대조군모두에서실험전에비해실험후에유의한기능장애감소를보였다. Sutlive 등 31 은요추와골반에도수치료를한그룹과요추척추후관절에척추도수치료를실시한그룹을비교하였을때두그룹모두 ODI 점수에서의변화에통계학적으로유의하게감소하였으며, 요추신경병증을지닌 L4-5, L5-S1 추간판탈출증환자에게 Cox 신연치료를 6주실시한후통증과 ODI가약 90% 개선되었다고보고하였다. 32 Ghroubi 등 33 은 64명의만성요통환자를대상으로 4주간척추도수치료를실시한결과 ODI에서통계학적으로유의한효과를나타내었다고보고하여본연구와유사한결과를보였다. 본연구에서도척추도수치료를만성요통환자에게 6주간실시한결과 ODI가통계학적으로유의하게감소한결과를보였으며중등도장애에서경증장애에가까운향상을보였다. 이러한결과는제한된관절운동이원할해지면서관절강내운동기능의향상으로인한결과로사료된다. 또한, 굴곡-신연기법 (flexion-distraction manipulation) 으로인해척추관안에서시상직경의확장, 후부의운동단위개방, 추간판내의압력을감소, 추간판사이에공간확장, 전종인대와후종인대가신전되어추간판이스스로재배열됨으로써고착되었던후관절열림과요추자세의재배열로통증감소, 운동기능향상, 자세교정을통해다양한일상생활동작의증진이된다고보고하였다. 34,35 Gose 등 36 은감압치료가통증을감소시키고가동성을증가시키며 MRI영상의변화에서유의한효과가있었다고하였다. Ma 등 37 도요추신경뿌리병증환자에게척추감압치료를적용하여 ODI와근력개선의증진을보여본연구와유사한결과를보였다. 특히본연구에서 ODI에서는중등도장애에서경증장애로향상을보였다. 이러한결과는척추 88 www.kptjournal.org
The Effects of Manual Therapy with Chronic Low Back Pain JKPT 감압치료가추체의분리를통해추간공의직경을증가시키고, 신경 조직에대한압력을완화시킴으로써방사통과신경학적결손을줄 일수있었고, 척추사이원반의스트레스감소, 척추사이원반의공간 확보로신경자극을완화시켜움직임의방해가줄어든것으로예상 할수있다. 38 각군의측정전과측정후의집단간 VAS 와 ODI 는측정전과측정 후모두통계학적으로유의한차이가없었다. 이러한결과는관절가 동기법과굴곡 - 신연기법을적용한실험군과척추감압치료를실시한 대조군모두에서추간판내의압력을감소시킬뿐만아니라추간판 의간격을넓혀주고후부의운동단위가활성화가된것으로사료된 다. 또한제한된관절운동이원활해지고관절낭내운동기능의향상 으로고착된후관절이열림으로인해요추자체의재배열향상, 압박 된신경과긴장된근육의감소로요추부위의통증과기능에서동반 향상된것으로볼수있다. 본연구의결과로관절가동기법과굴곡 - 신연기법을이용한도수 치료와척추감압치료는임상에서만성요통환자에게적용시통증 감소와기능증진에있어서유사한효과가있을것으로사료된다. 그 러나, 비교적높은장비가격과치료비용의발생, 치료중에유발할 수있는다양한변수로인한재셋팅으로인한시간지연및불편함을 주는척추감압치료의단점을대신할수있는도수치료가임상적으 로볼때효율성이높을것이다. 본연구의제한점은 6 주동안의비교적짧은기간과대상자수의 부족으로일반화하여해석하기에는부족함이있고, 대상자들의완전 한일상생활통제에한계가있었던점, 각치료방법에대한장단점을 확인하지못한점을볼수있다. 향후연구에서는다양한요통의원인 에따른적합한치료방법에관한장기적인연구가필요할것이다. 참고문헌 1. Kim SB. Effect of manual adjustment and gym-ball exercise on semg, Cobb s angle, VAS, flexibility, and strength in elderly women with low back pain symptom. Kyung-hee University. Dissertation of Doctorate Degree. 2012. 2. Kang SS, Goo BO. The effects of yoga low back pain exercise and lumbar extensor muscle endurance exercise on chronic low back pain patients. J Kor Phys Ther. 2012;24(2):107-12. 3. Fordyce WE, Brockway JA, Bergman JA et al. Acute back pain: a controlgroup comparison of behavioral vs traditional management methods. J Behav Med. 1986;9(2):127-40. 4. Lee WJ, Park SI. The effect of cigarette smoking on physical fitness and depression of patients with chronic low back pain. J Kor Phys Ther. 2015;27(4):275-80. 5. Song GB, Park EC. Effects of neck and trunk stabilization exercise on balance in older adults. J Kor Phys Ther. 2016;28(4):221-6. 6. Seo JK, Kim SY. The Relationship between hip abductor muscle strength and lumbar instability in patients with chronic low back pain. J Kor Phys Ther. 2011;23(4):15-22. 7. Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(9178):581-5. 8. Yuk GC, Park SH, Kim CS. Kinematics analysis of lumbar spine during breathing in lying position purpose. J Kor Phys Ther. 2011;23(5):15-21. 9. Kim K, Kim EK, Lee DK. Effects of PNF patterns exercise on pain, functional disability and fear avoidance belief in chronic low back pain patients. J Kor Phys Ther. 2014;6(2):110-6. 10. Kong YS, Hwang YT. Comparison of the activity and proprioception of trunk muscles according to different types of bridge exercises in subjects with and without chronic low back pain. J Kor Phys Ther. 2015;27(6): 400-6. 11. Bae SS, Kim SY, Kim TY et al. Orthopedic physical therapy. 3th ed. Seoul, Dae-Hag, 2009. 12. Kim HB, Kim SY, Kim YM. The comparison about a evaluation and treatment concept of the manual therapy techniques. J Kor Aca Ortho Manu Ther. 2005;11(1):49-64. 13. Kisner C, Colb LA. Therapeutic exercise: foundation and techniques. 2nd ed. Philadelphia, FA Davis, 1990. 14. Godges JJ, Mattson-Bell, Shah 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):713-8. 15. Onel D, Tuzlaci M, Sari H et al. Computed tomographic investigation of the effect of traction on lumbar disc herniations. Spine. 1989;14(1):82-90. 16. Gudavalli MR, Cambron JA, McGregor M et al. A randomized clinical trial and subgroup analysis to compare flexion distraction with active exercise for chronic low back pain. Eur Spine J. 2006;15(7):1070-82. 17. Gionis, Thomas A, Groteke E. Spinal decompression. Orthopedic technology review. 2003;5:36-9. 18. Paul-Dauphin A, Guillemin F, Virion JM et al. Bias and precision in visual analogue scales: a randomized controlled trial. Am J Epidemiol. 1999;150(10):1117-27. 19. Philip BK. Parametric statistics for evaluation of the visual analog scale. Anesth Analg. 1990;71(6):710. 20. Fairbank JCT, Pynsent PB. The Oswestry disability index. Spine. 2000;25(22):2940-52. 21. Lee HJ, Song JM. Analysis of the characteristics of patients with chronic low back pain using the ICF concept. J Kor Phys Ther. 2013;25(5):282-7. 22. Lee HJ, Song JM. Mapping items of functioning questionnaires into the international classification of functioning, disability and health: low back pain. J Kor Phys Ther. 2016;28(5):321-7. 23. Kaltenborn FM, Evjenth O, Kaltenborn TB et al. The spine: basic evaluation and mobilization techniques. 3rd ed. Oslo, Olaf Norlis Bokhandel, 1993. 24. Kwon WA, Ryu Y-Sa, Ma SY. The effects of Cox distraction manipulation on functional assessment measures and disc herniation index in patients with L4-5 herniated disc. J Kor Data and Info Sci Soc. 2012;23(4): 727-38. 25. Ferreira ML, Ferreira PH, Latimer J et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain. 2007;131(1-2):31-7. www.kptjournal.org 89
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