대한정형외과초음파학회지제 4 권제 2 호 2011 J Korean Orthop US Soc 2011; 2: 101-110 종 설 정형외과영역에서의증식치료 성균관대학교의과대학삼성서울병원정형외과 손민수 유재철 Prolotherapy in Orthopedic Field Min Soo Shon, M.D., Jae Chul Yoo, M.D. From the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea To describe the background, mechanism, clinical results and complications of prolotheapy based on the literature review. Prolotherapy is a minimally invasive injection-based treatment of chronic musculoskeletal pain, including ligament and joint laxity. The mechanism of this injection-based technique is to initiate a local inflammatory response with resultant tissue healing. The used proliferants are classified by bio-mechanism to act in three different ways as osmotic, irritants, and chemotatics. The most commonly used proliferant is hyperosmolar (10~25%) dextrose to act by osmotic rupture of cells. High resolution ultrasound imaging of musculoskeletal structure provide a more accurate diagnosis. Also ultrasound-guided intervention provides a more high efficacy and low rate of complications. The most common complication is local pain at the injected site, that is self-limited and good responsive to anti-inflammatory agents. Other complications are rare. It is reported that prolotherapy appears safe when performed by an experienced clinician. Prolotherapy has grown in popularity and has received significant recent attention. However there are limited evidence-based data supporting the indication and efficacy of prolotherapy in the treatment of chronic musculoskeletal pain or soft tissue injuries. Future studies are necessary to determine whether prolotherapy can play an independent and definitive role in a treatment for chronic musculoskeletal pain Key Words: Musculoskeletal, Prolotherapy, Ultrasound imaging 서 론 최근정형외과영역에서관심을받고있는증식치료 (prolotherapy) 는전통적으로건혹은인대이완으로인한통증의치료법중하나로써만성적으로손상된건혹은인대를강화하기위해인체의정상적인치유기전 (natural healing mechanism) 을자 통신저자 : 유재철서울특별시강남구일원동 50 성균관대학교의과대학삼성서울병원정형외과 Tel: 02-3410-3501, Fax: 02-3410-0061 E-mail: shoulderyoo@gmail.com 극하는최소침습적주사요법 (minimally invasive injection procedure) 이다. 1937년 Gedney 1) 가과도하게움직이는천장관절의인대에주사요법을실시하고경화요법 (scleolotherapy) 라명명하면서유사한치료법이시도되었으며 1953년 Hackett 등 19) 이처음으로증식치료 (prolotherapy) 라명명하였다. 이연구에서는 30년이상의임상경험을바탕으로근-골격계에증식치료를적용하였고증식 (prolo-) 을새로운세포의증식을의미한다고하였다. 이후증식치료는근-골격계질환의치료에새로운방법으로자리잡게되었다. 최근에는증식치료의작용기전에서성장인자조절을강조하는의미로 101
대한정형외과초음파학회지 : 제 4 권제 2 호 2011 Regenerative Injection Therapy (RIT) 로서표현하기도하였다. 3,4) 하지만아직까지증식치료에대한근거-중심의연구 (Evidence based study) 의부족 (Fig. 1), 인대의이완혹은불안정에대한진단기준의부족및건증 (tendinosis) 와건염 (tendinitis) 의정확한구분이안되어있어지금까지널리보급되지않고그성과역시엇갈리는보고들을하고있다. 이에근거-중심의문헌고찰을통하여증식치료의이론적배경과기전, 시술방법, 결과및합병증등에대하여논의하고자한다. 1. 증식치료의이론적배경과기전증식치료는증식치료제 (proliferants) 을주사하여부분적으로조직에상처를입혀염증을일으키는중간물질 (inflammatory mediators) 을방출하게함으로써상처치유 (wound healing) 를유도하는치료방법이다. Reeves 등 5) 은 성장인자또는성장인자자극제의주사요법 (injection of growth factors or growth factor stimulants) 혹은 정상적인세포혹은조직의성장을유도하는주사요법 (injection that causes growth of normal cells or tissues). 라고표현하여증식치료에대하여보다구체적인정의를내리기도하였으며, 사용되는증식치료제와여러성장인자들과연관성은여러연구들에의해보고된바있다. 6-9) 주입된증식치료제에의해조직이손상을받게되면세포가손상되고개방되어세포내의내용물들이삼출된다. 이결과과립구 (granulocyte) 와대식세포 (macrophage) 가 나타나게하여염증반응을일으키게되며이러한염증성삼출은증식치료제의주사이후 24시간후에두드러지게되고 48시간정도지난뒤진정되게된다. 결과적으로섬유아세포 (fibroblast) 가활성화되어콜라겐 (collagen) 을침착시키고, 콜라겐은인대를강화시키고수축시키게되는것이다. 증식치료제의주사이후 3일째섬유아세포의증식이두드러지고 7일째에는새로운콜라겐이시작되며치밀한섬유조직은 8주가지나야그증거를볼수있다. 이후기질 (matrix) 형성과재형성 (remodeling) 과정을통해손상된인대혹은건을치유하게된다. 이러한일련의과정은인체의정상적인치유기전 (natural healing mechanism) 과유사하다 (Fig. 2). 증식치료이후인대혹은건의생역학 (biomechanical) 과형태학적 (morphologic) 특성의변화는여러동물실험 10-13) 및사체실험 14) 에서보고된바있고, Fullerton 15) 은증식치료이후고해상도초음파와자기공명영상장치를이용하여조직회복의정도를확인하기도하였다. 2. 증식치료제의종류 증식치료에사용되고있는증식치료제는작용기전에따라크게 3가지종류가흔하게사용되고있다. 16,17) 1) 세포의삼투성파괴 (Osmotic rupture of local cells) Hyperosmolar dextrose, Glycerin 등이이에 Fig. 1. Number of published clinical studies on prolotherapy since 1937. 102
손민수외 : 정형외과영역에서의증식치료 속하는증식치료제이다. 이러한증식치료제는주입된주위조직의세포에대하여탈수화반응을일으켜세포파괴를유도하게된다. 2) 세포자극 (Local cellular irritation) Phenolglycerine-glucose (P2G), Guaiacol, tannic acid가포함된다. 이러한증식액은 phenol hydroxyl group을포함하고있으며, 이들은쉽게 reactive quinine compounds로산화되고이러한 quinine derivatives는 direct oxidation으로세포손상을초래하여염증반응을일으키게되는것으로알려져있다. 3) 염증매개체에대한화학주성유도 (Chemotactic attraction of inflammatory mediators) Sodium morrhuate (sodium salt of a fatty acid derived from cod liver oil) 가포함되며 prostaglandin, thromboxane과 leukotrienes 등과같은염증성매개체들에대한전구체로써작용하게된다. 4) 기타 (Others) 건증 (tendinopathy) 과관련된것으로알려진병적인신생혈관에대한경화요법 18-20) 에사용되는경화액 (sclerosing agents) 이있으며, Polidocanol 이이에속한다. 그외여러성장인자들을직접주사하거나성장인자를포함한혈액제제를사용하는치료가증식치료의일환으로시도되고있으나, 아직까지임상적결과는거의없는실정이다. 21,22) 3. 증식치료의기법확실히정립되어있는지침은없지만, 일반적으로주사치료제를기능부전이발생된연부조직내혹은근처에주사하게되며, 주로섬유-골접합부에바늘을삽입하지만근-건이나인대, 근육과건의접합부등에주사할수도있다. 16,17) 피부천자횟수는가능한적게하고바늘을피부밖으로빠지지않도록주의하며방향을바꾸어가능한넓은부위에주사한다. 증식치료제는한번에많은양을주사하지말고 0.5~1 ml씩나누어여러부위에주사한다. 증식치료제는주로바늘의끝이뼈와접촉할때주사한다. 이렇게함으로써위험한조직의손상을피할수있고피하나근육내로주사되는것을방지할수있다. 인대가두꺼운경우는바늘을빼면서증식치료제일부를주사한다. 근-건이나인대가깊지않은견갑주위근의경우바늘을제거한후압박하며마사지를하여증식제가잘퍼지도록한다. 부위가넓을때는 1~3일에나누어하거나며칠간격을두고나머지부위를한다. 주사간격은매주, 격주, 매 Fig. 2. Healing response cascade. 103
대한정형외과초음파학회지 : 제 4 권제 2 호 2011 월, 6~8주등다양한주장이있으나새로운조직의증식작용이 4~8주에있음을고려해야할것이며주사빈도는대개총 3~6회를시행한다. 주사를할때방사선투시를사용하여확인해보면의외로의도하지않은곳에주사하는경우가많아정확한부위의주사를위해서는방사선투시의사용이권장된다. 최근초음파기술의발달로인하여많은분야에서초음파의이용이증가하고있으며, 증식치료에있어서도유용하게이용되고있다. 외래에서간단히시행할수있으며, 진단뿐아니라초음파중재하증식치료 (Ultrasound-guided intervention) 를가능하게해준다. 따라서시술전정확한주사부위를설정하고주사시바늘의경로를실시간으로확인하면서시행할수있어증식치료의효율을높이고합병증을줄일수있어증식치료에큰진전을이루게되었다. 또한시술후추적조사를통하여시술전상태와비교함으로써조직의회복및형태변화여부를직접관찰하면서객관화시킬수있게되었다. 19,20,23-26) 투시 (fluoroscopy) 나초음파의사용이권장된다. 포도당을사용하는경우특히감염을주의해야하고약제에대한과민반응과여러부위에주사하므로예상하지못한신경및혈관손상도발생할수있다. 또한피하지방층혹은근육내주입되는경우위축 (atrophy) 를야기시켜기능상과미용상의문제를일으킬수있으므로주의하도록한다. 급성골절이동반되어있는경우, 치료부위의국소적인혹은관절내감염이나혈관염이동반되어있는경우, 알레르기반응이있을시, 심한신장병이나간기능에이상이있는경우증식치료의금기증에해당된다. 또한임산부, 자가면역질환을가지고있거나면역능력이떨어져있는경우, 조절이되지않는제 1형당뇨, 인공관절을넣은경우, 출혈경향이있는경우에서증식치료를시행할경우에는주의를요한다. 5. 증식치료의실제와근거중심의연구들 (Evidencebased studies) 4. 증식치료의합병증현재까지보고되고있는증식치료의합병증은드물다. 16,17,27,28) 가장흔한합병증은증식치료제주사이후 2~7일간지속될수있는주사부위의통증이며이러한통증은대개자기한정적 (self-limited) 이고 acetaminophen과같은진통제에잘반응한다. 하지만이러한시기를지나서도통증이지속되면서압통점이존재한다면증식치료제의과도한용량혹은부작용을고려해야할것이다. 또한시술과정에서발생가능한통증에대하여사전에충분히설명하여환자를이완시키고시행하게된다. 출혈및치료기전을생각하여치료전 2일및치료후 2~3주정도비스테로이성소염제 (NSAIDs) 를사용하지않는것이좋을수있으며, 주사부위는충분한압박을하여붓거나출혈이되지않도록한다. 통증을다시유발할수있는동작은하지않는것이좋으며주사후 2~3개월동안은심한운동이나도수치료는피하는것이좋고가벼운운동으로유지하다가서서히운동의강도를올려야한다. 척추부위에시술하는경우드물지만척수성두통이발생할수있다고보고되고있다. 해부학적으로중요한구조물을손상시킬수있는부위에대하여증식치료를시행할때는방사선 1) 관절에서의손상및관절염 (Injuries and Osteoarthritis in the joint) (Table 1) 인대혹은건의손상에의한관절불안정증에서의증식치료는통증완화와관절운동범위를포함한관절의기능회복을위하여시행되며퇴행성변화로의악화를방지하고하기위해사용되고있다. 1,29-31) Reeves와 Hassanein 32,33) 은수지관절과슬관절의퇴행성관절염환자에대하여증식치료 (10% dextrose/lidocaine) 를시행하여퇴행성변화가이미존재함에도불구하고증식치료로인해통증완화와기능개선의효과를확인할수있었고, 12개월이후시행한단순방사선촬영상퇴행성변화의정도가개선되었다고보고하였다. 2) 주관절의외측상과염 (Lateral epicondylitis) (Table 2) Lyftogt 등 34) 은다른보존적치료에반응하지않는 20명의외측상과염을대상으로증식치료 (20% glucose/0.1% lidocaine) 를시행하였으며평균 19 개월을추적관찰하였을때통증이유의하게감소되었고 90% 이상에서만족하였다고보고하면서증식치료의간편함, 비용절감및효과의지속성등에대하여강조하였다. Scarpone 등 35) 은 24명의휴식, 104
손민수외 : 정형외과영역에서의증식치료 비스테로이드성소염진통제및스테로이드주사에도효과가없는만성외측상과염환자에대한증식치료의결과를보고하였다. 이연구에서는 Saline을사용한 control 군에비하여증식치료를시행한군에서유의하게통증완화와근력개선의효과가있었으며이러한효과는 52주정도유지되었다고보고하였다. 2009년 Rabago 등 36) 은비수술적치료에실패한외측상과염에대한 4가지치료법 (prolotherapy, polidocanol, whole blood 와 platelet-rich plasma) 에대하여문헌고찰을통한 비교에관한보고를하였다. 이연구에서 4가지치료법모두통증감소및기능개선에효과적으로보고한바있다. 3) 족저근막염 (Plantar fasciitis) Ryan 등 37) 은보존적치료에반응이없는 20명의만성족저근염환자에대하여초음파유도하증식치료 (25% dextrose/lidocaine) 을 6주간격으로평균 3회시술하였을때 80% 에서치료에만족을보였으며휴식시통증과운동시통증이모두개선 Table 1. Randomized controlled trial data of prolotherapy for Osteoarthritis Subjects Methods F/U Outcomes Reeves 32) 68 (M39/F29) Proliferants 12 mo Reported improved pain, swelling, 2000 Mean age:63y 10% Dextrose and 0.075% buckling, and knee flexion compared Knee OA pain Lidocaine in bacteriostatic H 2O to control (p=.015) Placebo Decreased laxity (p=.025), increased H 2O/lidocaine flexion (p=.005) in uncontrolled follow-up compared to baseline. Reeves 33) 27 (M11/F16) Proliferants 12 mo Improvement in pain with finger 2000 Mean age:64y 10% Dextrose and 0.075% movement compared to controls Finger OA pain Lidocaine in bacteriostatic H 2O (p=.027) Placebo Improved flexion range compared to H 2O/lidocaine controls (p=.003) Non-significant (p=.096) improvement in multiple pain scores compared to controls. Improved joint space narrowing compared to controls at 1 yr (p=.006) Table 2. Randomized controlled trial data of prolotherapy for Lateral epicondylitis Subjects Methods F/U Outcomes Glick 48) 8 (M6/F2) Proliferants 9 wks McGill score improved (p=0.086) by 2006 Mean age:50y 15% Dextrose/1% lidocaine/ 7.75 points compared with baseline > 3 mo of Placebo and 7 points compared with control. Lateral 0.9% Saline/1% dextrose Physical Composite score improved epicondylitis (p=0.05) by 8.4 points compared with baseline and control. Scarpone 35) 24 Proliferants 12 mo Differences in pain scores were 2008 Lateral 5% sodium morrhuate/ significant compared to baseline epicondylitis 50%Dextrose/4% lidocaine/ scores within and between groups 0.5% sensorcaine/ saline (p<.001). Placebo Prolotherapy subjects also reported Saline improvement extension strength compared to Controls (p<0.01) and grip strength compared to baseline (p<0.05). 105
대한정형외과초음파학회지 : 제 4 권제 2 호 2011 되었음을보고하였다. 4) 아킬레스건증 (Achilles tendinopathy) (Table 3) 만성아킬레스건증에대한증식치료는좋은효과를보이는것으로알려져있다. 2011년 Yelland 등 38) 은동통성중심부아킬레스건증 (painful midportion achilles tendinosis) 을가진 43명의환자를대상으로한연구의결과를보고하였다. 편심성운동요법 (Eccentric loading exercise) 을시행받 은 15명의환자군, 증식치료제 (hypertonic glucose/lignocaine alongside) 를사용한증식치료를시행받은 14명의환자군및두치료를병합하여시행받은 14명의환자군으로나누어 12개월후의임상적결과를비교하였으며증식치료를시행받은환자군, 특히증식치료와함께편심성운동요법을병합하여치료받은군에서증식치료없이편심성운동요법만시행받은군보다더빠른증상의호전을보였다고보고하였다. Table 3. Randomized controlled trial data of prolotherapy for Achilles tendinosis Subjects Methods F/U Outcomes Yelland 38) 43 (n=15) 12 weeks program of 12 mo For Achilles tendinosis, prolotherapy 2011 Achilles eccentric loading exercise and particularly ELE combined with tendinosis (n=14) prolotherapy with prolotherapy give more rapid 20% hypertonic glucose/ improvements in symptoms than ELE 0.1% lidocaine/ alone but long-term VISA-A scores 0.1% ropivacaine are similar. (n=14) combined treatment Table 4. Randomized controlled trial data of prolotherapy for Low Back Pain or Sacroiliac dysfunction Subjects Methods F/U Outcomes Ongley 30) 81 (M38/F43) Proliferants 6 mo 88% of intervention subjects achieved 1987 Mean age:44y P2G >50% pain reduction vs. 39% in Mean 10y of LBP Placebo control group (p=.03) Saline/lidocaine Klein 39) 79 (M47/F 32) Proliferants 6 mo 77% of intervention subjects achieved 1993 Mean age:44y P2G >50% pain reduction vs. 53% in Mean 11y of LBP Placebo control group (p, 0.05) Saline/lidocaine Dechow 40) 74 (M36/F38) Proliferants 6 mo No significant improvement in 1999 Mean age:46y P2G primary or secondary outcome scores >10y of LBP Placebo between groups Saline/lidocaine 50% pain or disability reduction Yelland 28) 110 (M63/F 47) Proliferants 24 mo No significant improvement in 2004 Mean age:50y 20% Dextrose/0.2% lidocaine primary or secondary outcome scores Mean 14y of LBP Placebo between groups Saline 50% pain or disability reduction Kim 43) 48 (n=23) 15 mo The cumulative incidence of >50% pain 2010 > 3 mo of Intraarticular prolotherapy relief at 15 months was 58.7% SI joint pain with 50% Dextrose/ (95% confidence interval [CI] 0.25 levobupivacain 37.9%-79.5%) in the prolotherapy (n=25) group and 10.2% (95% CI Intraarticular Steroid injection 6.7%-27.1%) in the steroid group, with 40 mg Triamcinolone/ as determined by Kaplan-Meier 0.125% levobupivacaine analysis; there was a statistically significant difference between the groups (log-rank p<0.005). 106
손민수외 : 정형외과영역에서의증식치료 5) 하부요통및천장관절부전 (Low Back Pain or Sacroiliac dysfunction) (Table 4) 만성비특이적요통혹은천장관절증후군에대한증식치료는가장오래전부터시행되어왔으며현재까지가장많이보고되고있는증식치료의적응증중하나이다. 28,30,39-43) 많은연구들에서는이러한증식치료가효과적이라는결과를보여주었고증식치료제를천장관절관절강내로직접주입하는관절강내증식치료가효과적이었다고보고하기도하였다. 하지만상반된결과를보고하는연구도있으며 2004년 Yelland 등 28) 은만성비특이적하부요통에대한증식치료의체계적문헌고찰 (systemic review) 을실시한결과증식치료단독으로는효과가없다고보고한바있다. 2010년 Cusi 등 41) 은 25명의천장관절의통증 (SI joint pain, deficient stability of the SI joint) 를가진환자를대상으로한증식치료 (50% Dextrose/ 1% bupivicaine/isovue (iopamidol)) 의전향적연구에서모든환자에서좋은임상적결과를보였다고하였으며, 대상환자의정확한선택, 주입부위와용량등정확한시술방법을강조하였다. 6) 그외건증혹은관절불안정성 (Other tendiopathies or joint instabilities) 견관절주위의건증 (Rotator cuff tendinopathy), 견관절및견관절주위관절의불안정증등에대하여적응이되어왔고임상적결과가보고되었다. 5,34,44) 2004년 Jo 등 45) 은견관절주위인대손상이의심되면서 3개월이상의보존적치료에도반응이없는 29명의환자를대상으로시행한증식치료 (15% dextrose) 를시행하였으며 83% 에서만족스러운결과를보였다고하였다. 또한 Topol 등 46,47) 은고관절내전근 (Hip adductor) 의건증에의한통증을호소하는운동선수들을대상으로증식치료 (12.5% dextrose) 를시행하여통증완화를보였고스포츠경기로의복귀가가능하였다고하였다. 결 론 증식치료 (Prolotherapy) 는근-골격계통증및관절이완의치료방법으로써최근재조명되고있으나, 현재까지보고된결과들은대조군 (Control group) 의결여, 대상환자에대한진단의혼란, 다양하게주 입된주사치료제, 적은대상환자의수등으로아직까지는그효과에대한확실한자료가부족한실정이다. 또한저자마다다양한임상적결과를보이면서시술자의경험과숙련도에따른차이를극복하지못하고있다. 이에증식치료는확실한진단기술및적응이되는환자의적절한선택이필수적이며, 향후적응이되는대상의선택을확실히할수있는신체검진혹은진단기술등에대한연구혹은주사요법과다른보존적치료와의비교연구등을통하여증식치료에대한근-골격계에서의독립적이면서효과적인역할에대하여명확히해야할것이다. 참고문헌 01. Gedney E. Special technic hypermobile joint: a preliminary report. Osteopath Prof. 1937;4:30-1. 02. Hackett GS. Joint stabilization through induced ligament sclerosis. Ohio Med. 1953;49:877-84. 03. Linetsky FS, Botwin K, Gorfin L, et al. Regeneration injection therapy (RIT): effectiveness and appropriate usage. Florida Academy of Pain Medicine [Internet]. 2001;1-12 Available at: http://www.gracermedicalgroup.com/resources/ articles/rf_file_0025.pdf 04. Linetsky FS, Frafael M, Saberski L. Pain management with regenerative injection therapy (RIT). In: Weiner RS, ed. Pain management. Boca Raton (FL): CRC Press;2002. 381-402. 05. Reeves KD. Basic Science, Clinical Studies, and Technique. In: Lennard TA, ed. Pain procedures in Clinical Practice 2nd Ed. Hanley and Belfus. Philadelphia; 2000. 172-90. 06. Di Paolo S, Gesualdo L, Ranieri E, Grandaliano G, Schena FP. High glucose concentration induces the overexpression of transforming growth factor-beta through the activation of a platelet-derived growth factor loop in human mesangial cells. Am J Pathol. 1996;149: 2095-106. 07. Fukuda K, Kawata S, Inui Y, et al. High concentration of glucose increases mitogenic responsiveness to heparin-binding epidermal growth factor-like growth factor in rat vascular smooth muscle cells. Arterioscler Thromb Vasc Biol. 1997;17: 1962-8. 08. Oh JH, Ha H, Yu MR, Lee HB. Sequential 107
대한정형외과초음파학회지 : 제 4 권제 2 호 2011 effects of high glucose on mesangial cell transforming growth factor-beta 1 and fibronectin synthesis. Kidney Int. 1998; 54: 1872-8. 09. Murphy M, Godson C, Cannon S, et al. Suppression subtractive hybridization identifies high glucose levels as a stimulus for expression of connective tissue growth factor and other genes in human mesangial cells. J Biol Chem. 1999;274: 5830-4. 10. Liu YK, Tipton CM, Matthes RD, Bedford TG, Maynard JA, Walmer HC. An in situ study of the infuence of a sclerosing solution in rabbit medial collateral ligaments and its junctional strength. Connec Tissue Res.1983;11:95-102. 11. Maynard JA, Pedrini VA, Pedrini-Mille A, Romanus B, Ohlerking F. Morphologic and biochemical effects of sodium morrhuate on tendons. J Orthop Res.1985;3:236-48. 12. Forslund C, Aspenberg P. Tendon healing stimulated by injected CDMP. Med Sci Sports Exerc. 2001;33:685-7. 13. Jensen KT, Rabago DP, Best TM, Patterson JJ, Vanderby R Jr. Response of knee ligaments to prolotherapy in a rat injury model. Am J Sports Med. 2008; 36:1347-57. 14. Klein RG, Dorman TA, Johnson CE. Proliferant injections for low back pain: Histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment. J Neurol Orthop Med Surg.1989;10:141-4. 15. Fullerton BD. High-resolution ultrasound and magnetic resonance imaging to document tissue repair after prolotherapy: a report of 3 cases. Arch Phys Med Rehabil.2008;89:377-85. 16. Banks AR. A Rationale for Prolotherapy. Journal of Orthopaedic Medicine.1991;12(3):54-9. 17. Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Prim Care. 2010;37:65-80. 18. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of Randomised controlled trials. Lancet. 2010; Nov 203:76(9754):1751-67. 19. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med. 2006; 34:1738-46. 20. Zeisig E, Fahlström M, Ohberg L, Alfredson H. A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow. Br J Sports Med. 2010;44:584-7. 21. Taylor MA, Norman TL, Clovis NB, Blaha JD. The response of rabbit patellar tendons after autologous blood injection. Med Sci Sports Exerc. 2002;34:70-3. 22. Ravin T. The use of Testosterone and Growth Hormone for Prolotherapy. Journal of Prolotherapy. 2010;2:495-503. 23. Fullerton BD, Reeves KD. Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma, and other injectants. Phys Med Rehabil Clin N Am. 2010;21:585-605. 24. Davidson J, Jayaraman S. Guided interventions in musculoskeletal ultrasound: what s the evidence?. Clin Radiol. 2011;66:140-52. 25. Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am. 2008;46:515-33. 26. Ryan M, Wong A, Taunton J. Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional and midportion achilles tendinosis. Am J Roentgenol. 2010;194:1047-53. 27. Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: A physiatric perspective. Am J Phys Med Rehabil. 2004;83:379-89. 28. Yelland MJ, Del Mar C, Pirozzo S, Schoene ML. Prolotherapy injections for chronic low back pain: a systematic review. Spine. 2004;29:2126-33. 29. Kim YU. Prolotherapy for the Lower Extremities. J Korean Orthop US Soc. 2009;1:37-44. 30. Ongley MJ, Dorman TA, Eek BC, Lundgren D, Klein RG. Ligament Instability of Knees: a New Approach to Treatment. Manual Med. 1988;3:152-4. 31. Reeves KD, Hassanein K. Long-term effects of dextrose prolotherapy for anterior cruciate liga- 108
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대한정형외과초음파학회지 : 제 4 권제 2 호 2011 국문초록증식치료의이론적배경과기전, 시술방법, 결과및합병증등에대하여근거-중심의문헌고찰을토대로논의하고자한다. 증식치료는전통적으로건혹은인대이완으로인한통증을포함한만성적인근-골격계통증의치료법중하나로써증식치료제를주사하여염증반응을유도하여인체의정상적인치유기전을자극하는최소침습적주사요법이다. 증식치료제는크게세가지기전에의하여작용하며, 가장흔히사용되는증식치료제는 10~25% 포도당이다. 최근초음파기기의발달과함께증식치료에있어서도유용하게이용되고있어진단뿐아니라초음파중재하시술을통해효율을높이고합병증을줄일수있게되었다. 가장흔한합병증은주사부위의통증으로대개자기한정적이고진통제에잘반응한다. 그외합병증은드물며경험이많은임상의에의해시행되었을경우비교적안전한것으로보고되고있다. 증식치료는근-골격계통증및관절이완의치료방법으로써최근재조명되고있으나, 현재까지보고된결과들은아직까지는그적응과효과에대한확실한자료가부족한실정이다. 이에향후적응이되는대상의선택을확실히할수있는신체검진혹은진단기술등에대한연구혹은주사요법과다른보존적치료와의비교연구등을통하여증식치료에대한근-골격계에있어서의독립적이면서효과적인역할에대하여명확히해야할것이다. 색인단어 : 근 - 골격계, 증식치료, 초음파 110