대한재활의학회지 : 제 33 권제 1 호 29 경직성뇌성마비환아에서흔하게나타나는하지관절의보행이상 연세대학교의과대학재활의학교실및재활의학연구소박은숙ㆍ나동욱ㆍ김형빈ㆍ김민준 Common Gait Abnormalities of Each Joint in Children with Spastic Cerebral Palsy Eun Sook Park, M.D., Dong-Wook Rha, M.D., Hyoung Bin Kim, M.D. and Min June Kim, M.D. Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine Objective: To investigate the prevalence of gait abnormalities of each joint of lower legs in children with spastic cerebral palsy (CP) and to find out the influences of subtype of CP, age, previous surgery and motor function on the gait abnormalities. Method: The gait analysis and foot scan from 32 children with CP were reviewed. Types of gait abnormalities were classified into 5 types for hip joint, 4 types for knee joint and 8 types for foot and ankle joint. The prevalence of gait abnormalities was assessed and the influence of subtype of CP, age, previous surgery and GMFCS (gross motor function classification system) level were also investigated. Results: In foot and ankle joint, intoeing (63.8%) was the most common in all CP. In knee joint, jumping knee (32.8%) was the most common in diplegic and hemiplegic CP but crouch (47.6%) was the most common in quadriplegic CP. The likelihood of having planovalgus and crouch significantly increased with age and pes calcaneus increased after orthopaedic surgery. The children with lower functional level on GMFCS tended to show stiff and recurvatum knee pattern. Conclusion: Predominent gait abnormalities in each joint were assessed. Age, previous surgery, motor function and subtype of children with CP had a significant effect on the prevalence of gait abnormalities in each joint. (J Korean Acad Rehab Med 29; 33: 64-71) Key Words: Spastic cerebral palsy, Gait analysis, F-scan system, Foot deformities 서 뇌성마비환자하지의경직성및근위약, 근육수축들의부조화, 관절변형등으로인하여, 보행시다양한형태의비정상적인보행양상을보인다. 1-5 다양한보행양상을적절히분류하는것은서로다른보행이상을보이는환자군에서원인이되는근육들을밝혀내고적절한치료방법을결정하며, 치료효과를좀더객관적으로평가할수있는바탕이되기때문에매우중요하다. 뇌성마비환자의보행이상소견을객관적으로측정하고그원인을분석하기위하여컴퓨터를이용한 3차원보행분석이시행된이래로, 이러한분석결과를이용하여뇌성마비환자의보행이상을분류하고자하는많은노력들이있었다. 3,4,6-9 하지만이렇게분류된각각의보행이상소견의유병률및이에영향을미치는요소에대한체계적인연구는매우부족한실정이며, 국내 접수일 : 28 년 2 월 25 일, 게재승인일 : 28 년 8 월 21 일교신저자 : 김민준, 서울시서대문구신촌동 134 번지 12-752, 연세의료원재활병원재활의학과 Tel: 2-2228-373, Fax: 2-363-2795 E-mail: anaphylaxis@naver.com 론 에서는아직보고된바가없다. 이러한유병률에대한연구는의사나연구자들이어디에그들의노력을집중해야되는지알려주고또한뇌성마비환자들이나이가들어감에따라혹은수술이후생길수있는문제들에대해예측하여대비할수있게하기에중요하다. 9 따라서본연구에서는독립적보행이가능한경직성뇌성마비환자를대상으로보행분석및족저압측정결과를분석하여고관절, 슬관절, 발목및족부에서나타나는보행이상소견을정의하고이들의유병률을살펴보고자하였으며각각의보행이상소견과나이, 정형외과적수술여부그리고전신운동기능분류 (gross motor function classification system, GMFCS) 상기능수준과의연관성을알아보고자하였다. 1) 연구대상 연구대상및방법 2년 1월부터 26년 6월까지연세의료원재활병원동작분석실에서보행분석검사를시행받은환자중경직성뇌성마비로진단받은 32명의보행분석결과를후향적으로분석하였으며, 226명은양지마비, 73명은편마비, 13명 64
박은숙외 3 인 : 경직성뇌성마비환아에서흔하게나타나는하지관절의보행이상 65 은사지마비였다 (Table 1). 이중근건연장술등의정형외과적수술을 1회이상시행받은환아는모두 49명 (15.3%) 이었다. Number of subjects Percent of total subjects Age (years)(mean±sd) Sex (male:female) GMFCS (I:II:III) Table 1. Patients Demographics Diplegia 226 7.6% 7.46±3.84 141:85 29:114:83 Hemiplegia Quadriplegia 73 22.8% 7.64±4.54 52:21 31:41:1 21 6.5% 11.38±4.74 16:5 1:12:8 SD: Standard deviation, GMFCS: Gross motor function classification system 2) 방법보행분석검사는 VICON 37 Motion Analysis System (Oxford Metrics Inc., Oxford, UK) 을이용하여보행선형지표와운동형상학적지표를측정하였다. VICON 프로토콜에따라기립정지상태에서천골표시자, 양측골반표식자, 양측대퇴표식자, 양측슬관절표식자, 양측경골표식자, 양측족관절표식자, 양측전족부표식자등총 13개의표식자를부착하여검사를시행하였다. 검사대상자의신체부위에표지를부착하는작업은항상한명의숙련된검사자가시행하여오차를줄이도록하였다. 검사는맨발인상태에서시행되었고우선 8미터길이의보도를수차례걷게하여평상시의자연스러운보행을유도하였으며, 검사하는동안은최소한 6차례이상의보행을시도하여측정치의평균값을사용하였다. Foot & Ankle Knee Hip Gait abnormlity Equinus Equinovarus Equinovalgus Planovalgus Calcaneus Normal foot Intoeing Out-toeing Jump knee Crouch knee Stiff knee Recurvatum knee Scissoring Excessive hip flexion Excessive internal rotation Table 2. Definitions of Gait Abnormalities Definition Ankle plantarflexion >1 SD more than mean for normal during stance phase & no varus or valgus on foot scan Ankle plantarflexion >1 SD more than mean for normal during stance phase & varus on foot scan (COPI >1 SD more than mean for normal) Ankle plantarflexion >1 SD more than mean for normal during stance phase & valgus on foot scan (COPI <1 SD less than mean for normal) Without equinus & valgus on on foot scan (COPI <1 SD less than mean for normal) Ankle dorsiflexion >1 SD more than mean for normal during significant portion of stance phase (5% of stance phase) Normal kinematics of ankle & within 1 SD of mean for normal COPI Internal foot progression >1 SD more than mean for normal External foot progression >1 SD more than mean for normal Knee flexion at least 3 during early stance phase and incomplete knee extension during late swing phase, but, nearly normal (1 2 ) extension during mid or terminal stance phase Knee flexion at least 3 throughout the stance phase & incomplete knee extension during late swing phase Peak knee flexion in the swing phase less than 45 & delay of peak knee flexion after 72% of the gait cycle Knee extension in stance phase beyond Knee adduction >1SD more than mean for normal during significant portion of swing phase (5% of swing phase) Knee adduction >1SD more than mean for normal during significant portion of stance phase (5% of stance phase) Peak hip extension during stance phase >1SD less than mean for normal Internal hip rotation >1SD more than mean for normal during significant portion of stance phase (5% of stance phase) Excessive internal hip rotation with excessive external foot progression (>1SD more than mean for normal, regardless of cause, tibial torsion versus foot deformity) SD: Standard deviation, COPI: Center of pressure index Center of pressure index=(area in lateral column of foot scan)/(area in medial column of foot scan) COPI of normal control group=1.3±.2
66 대한재활의학회지 : 제 33 권제 1 호 29 족저압은 F-scan (Tekscan Inc., South Boston, MA) 을이용하여측정하였다. 96개의압력감지점이 5 mm 간격의격자형식으로균일하게분포되어있는, 두께가.15 mm인압력탐색자를연구대상자의발크기에맞게잘라서굽이 1 cm인실내화에부착시켜 1분간보행적응을시킨후검사를하였다. 환자는자연스럽게원하는속도로보행하도록하였고, 보행중간의 5 걸음동안의족저압의평균값을측정하였다. 측정된족저압은 FSCAN version 4.19 F 프로그램으로분석하였으며, 족부의내반및외반여부를결정하기위하여측정된족저압을외측과내측으로나누어입각기의전기간에걸쳐발바닥이지면과접촉되는외측면적을내측면적으로나눈값인 center of pressure index (COPI) 를계산하였다. 1 족부의내반및외반여부를결정하기위하여 12명의정상소아 ( 여아 5명, 남아 7명 ) 의 24족부에서측정된족저압을대조군으로모집하였다. 대조군의나이는 7.75±1.54세였으며실험군의평균나이 7.73±4.19세와통계적으로유의한차이는없었다. 대조군에서측정된 COPI 값은 1.3±.2이었으며, 이를이용하여족부를관상면상에서내반변형을보이는경우 ( 대조군에비해 COPI 값이 1 표준편차를초과하여큰경우 ) 와외반변형을보이는경우 ( 대조군에비해 COPI 값이 1 표준편차미만으로작은경우 ) 로분류하였다. 상기보행분석과족저압측정을통하여측정한운동형상학적지표와 COPI 측정값을이용하여각환자의보행이상소견을고관절부위 5가지, 슬관절부위 4가지, 발목및족부 8가지로분류하였다 (Table 2). SPSS 11, for window을이용하여나이, 수술여부, 기능적인양상에따른보행이상소견과의상관관계를로지스틱회귀분석으로분석하였으며 p 값이.5 미만인경우의미있는것으로하였다. 결과 1) 보행이상의유병률발목및족부에서가장흔한보행이상소견은양지마비, 편마비, 사지마비환자군모두에서발가락내향보행 (intoeing) 이었다. 다음으로흔한것은양지마비군과사지마비환자군에서는외반편평족 (planovalgus foot) 이었고, 편마비환자군에서는내반첨족 (equinovarus) 이었다. 슬관절에서가장흔한보행이상소견은양지마비, 편마비환자군에서는도약보행 (jumping knee), 웅크림보행 (crouch knee) 순이었던반면에사지마비환자군에서는웅크림보행, 도약보행순이었다. 고관절에서가장흔한보행이상은모든환자군에서고관절의과도한굴곡 (excessive hip flexion) 이었으며다음으로양지마비군과편마비환자군에서는고관절의과도한내전 (excessive hip adduction) 이었고, 사지마비환자군에서는고관절의과도한내회전 (excessive internal rotation) 이었다 (Table 3). 정형외과적수술을받은환자군에서는발목및족부에서발가락내향보행의유병률이 43% 로가장흔한보행이상소견이었으나, 수술받지않은환자군의 66% 에비해그유병률이낮았다. 또한수술을받은환자군에서정상족 Table 3. Prevalence of Gait Abnormalities in Children with Spastic Cerebral Palsy Total patients Diplegia Hemiplegia Quadriplegia Foot & ankle Knee Hip Intoeing (63.8%) Planovalgus (3.3%) Equinovalgus (19.7%) Out-toeing (17.8%) Equinovarus (16.9%) Equinus (14.1%) Normal (1.9%) Calcanus (5.3%) Jumping knee (32.8%) Crouch (28.8%) Recurvatum (18.8%) Stiff knee (16.9%) Excessive hip flexion (6.6%) Excessice hip adduction (18.4%) rotation (15.6%) (15.3%) Scissoring (6.9%) Intoeing (63.3%) Planovalgus (31.9%) Equinovalgus (22.1%) Out-toeing (18.1%) Equinus (13.3%) Normal foot (11.1%) Equinovarus (1.6%) Calcanus (6.6%) Jumping knee (3.5%) Crouch (29.2%) Recurvatum (19.9%) Stiff knee (18.1%) Excessive hip flexion (65.%) (17.7%) rotation (14.6%) (14.6%) Scissoring (8.%) Intoeing (65.8%) Equinovarus (35.6%) Planovalgus (2.5%) Equinus (17.8%) Out-toeing (16.4%) Equinovalgus (13.7%) Normal foot (12.3%) Calcanus (1.4%) Jumping knee (42.5%) Crouch (21.9%) Recuvatum (15.1%) Stiff knee (13.7%) Excessive hip flexion (46.8%) (17.8%) rotation (12.3%) (9.6%) Scissoring (1.4%) Intoeing (61.9%) Planovalgus (47.6%) Out-toeing (19.%) Equinovarus (19.%) Equinovalgus (14.3%) Equinus (9.5%) Normal foot (4.8%) Calcanus (4.8%) Croch (47.6%) Jumping knee (23.8%) Recurvatum (19.%) Stiff knee (14.3%) Excessive hip flexion (61.9%) rotation (38.1%) Rotational alignment (28.6%) (28.6%) Scissoring (14.3%)
박은숙외 3 인 : 경직성뇌성마비환아에서흔하게나타나는하지관절의보행이상 67 부 (normal foot), 종족보행 (calcaneus gait) 의유병률이높았던반면첨족 (equinus), 내반첨족 (equinovarus), 외반첨족 (equinovalgus) 소견은드물었다. 슬관절에서는수술여부와상관없이도약보행과웅크림보행이가장흔하였다. 고관절에서도수술여부와상관없이고관절의과도한굴곡이가장흔하였으나, 수술후고관절의과도한내회전의유병률이 2.% 로수술받지않은환자군의 18.3% 에비해그유병률이낮았다 (Table 4). 2) 보행이상의유병률에영향을미치는요소 정형외과적수술여부와 GMFCS상기능수준을보정하면, 환아의나이가증가할수록발목및족부에서첨족, 내반첨족, 외반첨족소견을보이는빈도는낮아지고외반편평족발생이증가하였으며, 슬부에서는뻗정다리보행 (stiff knee) 및도약보행의빈도는낮아지고웅크림보행의발생이증가하였다. 또한고관절에서는나이가증가할수록하지의회전부정열 (rotational malalignment), 고관절의과도한내전및내회전, 고관절의과도한굴곡등이모두증가하였다 (Table 5). 환아의나이와 GMFCS상기능수준을보정하면, 정형외과적수술후에는발목및족부에서내반첨족및외반첨족변형의빈도는감소하고종족보행과정상족부소견을보이 Table 4. Most Prevalent Gait Abnormalities for Cerebral Palsy with or without Previous Surgery Previous surgery (n=271) No previous surgery (n=49) Prevalence of foot and ankle gait abnormalities Intoeing (42.9%) Intoeing (66.1%) Planovalgus (26.5%) Planovalgus (3.7%) Out-toeing (24.5%) Equinovarus (21.2%) Normal foot (22.4%) Equinovalgus (2.2%) Calcaneus (2.4%) Out-toeing (16.5%) Equinus (6.1%) Equinus (15.1%) Equinovalgus (4.1%) Normal foot (1.6%) Equinovarus (4.1%) Calcaneus (1.8%) Prevalence of knee gait abnormalities Jumping knee (32.7%) Jumping knee (38.1%) Crouch (26.5%) Crouch (27.5%) Stiff knee (2.4%) Recurvatum (15.1%) Recurvatum (16.3%) Stiff knee (14.7%) Prevalence of hip gait abnormalities Excessive hip flexion Excessive hip flexion (59.2%) (56.4%) (16.3%) rotation (18.3%) (1.2%) (13.8%) rotation (2.%) (13.3%) Scissoring (2.%) Scissoring (4.6%) 는빈도가크게증가하였으며, 발가락내향보행의발생이감소하였다. 슬관절에서는수술이후에의미있는발생빈 Table 5. Adjusted Odd Ratios for Gait Abnormalities with Age (Adjusted for Previous Surgery and GMFCS) Gait abnormality Odd ratio 95.% C.I Significance Planovalgus Crouch rotation Excessive hip flexion Calcanus Out-toeing Intoeing Scissoring Normal foot Recurvatum Jumping knee Equinovalgus Equinovarus Stiff knee Equinus Table 6. Adjusted Odd Ratios for Gait Abnormalities with Previous Surgery (Adjusted for Age and GMFCS) Gait abnormality Odd ratio 95.% C.I Significance Calcanus Normal foot Out-toeing Stiff knee Recurvatum Jumping knee Excessive hip flexion Crouch Planovalgus Equinus Intoeing Scissoring Equinovarus Equinovalgus rotation 1.296 1.15 1.8 1.77 1.72 1.6 1.35 1.29.965.957.931.93.914.99.95.94.66 12.273 2.936 1.32 1.289 1.82 1.41.954.949.887.661.512.475.46.369.181.177.91 1.25 1.84 1.8 1.7 1.2 1.1.915.962.913.835.845.856.858.835.83.823.547 4.8 1.32.67.551.467.444.485.499.43.243.734.133.215.47.42.41.12 1.394 1.22 1.158 1.151 1.147 1.122 1.171 1.1 1.2 1.96 1.26 1.11.973.989.987.992.796 36.916 6.62 2.869 3.18 2.511 2.437 1.876 1.86 1.833 1.82 2.853 1.695.767 2.895.778.757.683.7.31.43.44.584.49.27.523.152.9.5.26.24.34 C.I: Confiden index *p-value<.5, the odd ratio differs significantly from 1..9.484.558.854.927.892.874.747.419.19.251.5.369.22.2.2 C.I: Confiden index *p-value<.5, the odd ratio differs significantly from 1.
68 대한재활의학회지 : 제 33 권제 1 호 29 Table 7. Adjusted Odd Ratios for Gait Abnormalities with GMFCS (Adjusted for Age and Previous Surgery) Gait abnormality Odd ratio 95.% C.I Significance Stiff knee Scissoring Recurvatum Excessive hip flexion Calcanus rotation Crouch Equinus Intoeing Planovalgus Equinovalgus Out-toeing Normal foot Equinovarus Jumping knee 2.583 2.347 2.28 1.948 1.765 1.568 1.465 1.461 1.423 1.319 1.262 1.253 1.181.856.667.65.525 1.57 1.159 1.34 1.381.828.988.931.956.991.825.93.881.787.564.399.422.368 4.12 4.753 3.155 2.746 3.763 2.488 2.37 2.234 2.43 2.18 1.762 1.782 1.772 1.3 1.115.999.749.18.2.141.56.99.8.56.247.172.29.422.467.123.49 C.I: Confiden index *p-value<.5, the odd ratio differs significantly from 1. 도의변화는관찰되지않았으나, 고관절에서는과도한내회전의발생빈도가의미있게감소하였다 (Table 6). 정형외과적수술여부와환아의나이를보정하면, GMFCS 로측정한환아의기능수준이낮을수록발목및족부에서내반첨족의발생빈도가감소하였다. 슬관절에서도약보행의발생빈도는감소하고뻗정다리보행이나반장슬 (recurvatum knee) 의빈도가증가하였으며고관절에서는가위보행 (scissoring) 이나과도한고관절굴곡의발생빈도가증가하였다 (Table 7). 고 현재까지경직성뇌성마비에서발목및족부에서나타나는비정상보행은다양하나주로첨족이가장흔한것으로알려져있다. 2,11,12 하지만본연구에서는발목및족부의가장흔한비정상보행은보행시족부의전진이횡단면상에서내측을향하게되는발가락내향보행 (63.8%) 이었고이는양지마비, 사지마비, 편마비모두에서가장흔히관찰되었다. 첨족의유병률은관상면상의이상이동반된내반첨족과외반첨족을모두포함했을때 5.7% 로두번째로흔히관찰되었다. Wren 등 9 의연구에서도발가락내향보행을뇌성마비의족부에서가장흔한보행이상으로보고하였으며그유병률도 64% 로본연구와거의같은결과를보였다. 하지만발가락내향보행은중족골내전이나내반족과 찰 같은족부이상외에도고관절내전근과내회전근그리고슬와부근육의경직에의한대퇴골전경의증가, 경골내측회전의증가등에의해발생할수있다. 13 따라서발가락내향보행은족부의보행이상소견이라기보다는고관절, 슬관절, 발목및족부에걸친하지전체의복합적인이상소견의결과이기때문에순수하게발목및족부에서발생하는보행이상은하퇴삼두근의경직에의한첨족이가장흔하다고할수있다. 발가락내향보행다음으로흔한보행이상은양지마비와사지마비환아군에서는외반편평족이었으며편마비환아군에서는내반첨족이었다. 편마비환아군에서다른환아군에비해내반첨족이 2.6:1 정도로더많이관찰되었다. 양지마비환자나사지마비환자의경우첨족또는내반첨족소견을보였던족부에체중이지속적으로부하되면중족부 (mid-foot) 와후족부 (hindfoot) 에스트레스가가해지게되고후경골근의기능이저하되면점차세로발궁 (longitudinal arch of foot) 이무너지면서발목및족부에서외반변형이발생하게된다. 14,15 하지만편마비환자의경우에는건측에주로체중부하를하고환측에체중부하를하지않는보행패턴을보이는경우가많기때문에양지마비나사지마비환자에비해외반변형이적은것으로생각한다. 이환부위에따른내반과외반변형의빈도를분석한이전연구들에서도양지마비환자나사지마비환자의경우외반변형이상대적으로많았고편마비환자군에서는타환자군에비해내반변형이 16:1 1:1 정도로많거나 16 거의같은빈도를보였다. 11 본연구에서도편마비환아군에서다른환아군에비해내반첨족이 2.6:1 정도로더많이관찰되었다. 경직성뇌성마비환자의슬관절에서나타나는보행이상은양지마비와편마비환자군에서도약보행이가장흔하였으며사지마비환자군에서는웅크림보행이흔하였다. Wren 등 9 의연구에서는뻗정다리보행 (8%) 이가장흔한것으로보고하였는데이는전술한바와같이 Surtherland와 Davids 4 의분류와달리도약보행을빼고슬관절의보행이상을웅크림보행, 뻗정다리보행및반장슬보행의 3가지로분류하여, 유각기시에슬관절의신전이정상에가깝게되지만지체되어나타나는도약보행이뻗정다리보행으로편입되었기때문이다. 또한사지마비환아들의경우웅크림보행이가장흔한것으로나타났는데, 이는양지마비환아와편마비환아 ( 평균나이 7.54±4.56세 ) 에비해사지마비환아의나이 ( 평균나이 11.38±4.74세 ) 가통계적으로유의하게많은사실을고려해볼때 (p<.5), 이환부위에따른차이보다는연령차이에따른현상으로생각한다. 그이유는도약보행은주로고관절내전근과굴근그리고슬와부근육의과도한수축및경직에의해나타나는데 4 연령이증가할수록이근육들에구축이나타나고하퇴삼두근의구축또는위약이동반되어 4,7 점차웅크림보행으로진행하기때문이다. 본연구의나이에따른유병률의회귀분석에서도
박은숙외 3 인 : 경직성뇌성마비환아에서흔하게나타나는하지관절의보행이상 69 연령이증가함에따라관절에서웅크림보행을보일확률이증가함을보여준다. 고관절에서는모든환자군에서과도한굴곡이가장흔하였다. 고관절의과도한굴곡은흔히요굴근의구축에의해발생하고이것은앞서언급한것처럼웅크림보행의원인이되기도한다. 본연구에서는나이가증가할수록, 전신운동기능이저하될수록고관절의과도한굴곡을보이는빈도가증가되는것이관찰되었다. Bell 등 17 의연구에서도좀더기능적인보행을하는환아의경우과도한굴곡의정도가연령이증가함에따라호전되고, 그렇지못한환아의경우굴곡의정도에변화가없거나악화되는추세를보인다고보고된바있다. 본연구에서는앞서기술한뇌성마비환아의보행이상발생에영향을미치는요소로서연령, 수술적치료여부그리고기능적수준등을분석하였다. 그동안뇌성마비환아들의연령이증가함에따라보행이상이어떻게변화되는지관찰한연구가있었으나주로보장과보행속도, 균형등의변화를분석한것이었다. 17,18 이에따르면환아의성장에따른다리길이변화가없다고가정한다면대체적으로나이가증가함에따라보행속도와보장이감소하게되며보행시관절운동범위가줄어들게된다. 하지만이러한연구들에서는나이와운동형상학적수치간의산술적연관성만을분석하였기때문에, 보행양상의분류상어떤변화가생기게되는지를파악하는데어려움이있었다. 본연구에서연령과가장밀접한상관관계를가지는보행양상의변화는족부에서외반편평족을가질확률이증가하고내반첨족과외반첨족을포함한첨족의비율이감소하는것이었다. Bell 등 17 의연구에서도연령이증가한후측정한보행분석에서유각기의족부배굴및입각기의최대족부배굴의각도가증가하는등첨족변형의감소를보고하였다. 이는전술한바와같이연령이증가함에따른지속적인체중부하가첨족변형을보이는뇌성마비아동의족부의중족부와후족부에스트레스를가하여세로발궁이무너지면서외반편평족으로변화하기때문인것으로생각한다. 슬관절에서는웅크림보행이, 고관절에서는고관절의과도한굴곡이차지하는비율이증가하였다. 경직성뇌성마비환자에서경직을보이는근육의성장이골격의성장보다지체되는것으로알려져있는데, 이러한이유로연령이증가함에따라경직으로인한과도한수축을보이던슬와부근육및고관절굴곡근의구축이발생 5,19 하고관절가동범위가점차감소 17,2 하여고관절의과도한굴곡과슬관절의웅크림보행이상이증가하는것으로생각한다. 정형외과적인수술이후발목및족부에서는여전히발가락내향보행이가장흔하였으나 66.1% 에서 42.9% 로감소된양상을보였으며시상면상의첨족변형이감소하고종족보행과정상족부의비율이증가하였다. 이는첨족보행이임상에서가장흔히관찰되고관심의대상이되는보 행이상이며이를교정하기위한수술도가장광범위하게이루어지고있기때문이다. 본연구에서도정형외과적수술을시행한 49명의환자중 45명 (92%) 에서첨족의교정술이시행되었다. 하퇴삼두근의구축으로인한첨족의교정을위한수술적방법으로아킬레스건연장술과비복근연장술등이있는데술후많은환자에서보행분석검사상운동형상학적, 운동역학적지표가정상에가깝게개선되었다고보고된바있으며 12,21-23 족저압검사를이용한본저자들의이전연구에서도시상면뿐만아니라관상면상의지표들도호전되는결과를관찰할수있었다. 24 하지만수술후첨족의과도한교정으로인한종족보행의발생이 3 36% 까지보고 12,23 되고있다. 본연구에서도수술후종족보행의증가가뚜렷한것으로분석되었다 (Table 6). 발목및족부와는달리슬관절및고관절에서는고관절내회전의유병률이수술한경우 (2.%) 에서수술하지않은경우 (18.3%) 보다감소된것을제외하고는수술여부에따른보행이상유병률의차이가거의없었다 (Table 4). 많은이전연구에서정형외과적인수술이후슬관절이나고관절모두에서관절의운동범위가증가 21,22 하고웅크림보행과고관절의과도한굴곡이호전된다 25-27 고보고하였는데이번연구에서는이런변화가뚜렷하지않았다. 이러한결과의원인으로는하퇴삼두근연장술을포함한복합적인정형외과적인수술이후족부배굴의정도는정상화되지만슬관절이나고관절의신전에필요한족저굴곡근육의긴장도는오히려감소하고, 21 또한슬와부근육의연장술을한경우에도슬관절의관절범위운동은좋아지나고관절의신전에필요한근력이저하됨으로써과도한굴곡이지속되는것 26 등을고려해볼수있다. 뇌성마비환아의대운동기능발달상더기능적인환아일수록보행속도도빠르고보장거리도길며시상면상에서관절의운동범위도더크다. 17,28 그렇지만보행이상을분류하여기능수준과의연관성에대한연구는아직없는상태이다. 이번연구에서는뇌성마비환아들의운동기능을비교적간단히분류할수있는전신운동기능분류법을사용하여보행이상과의상관성을조사하였다. 전신운동기능분류법과보행이상과의로지스틱회귀분석에서슬관절의보행이상의연관성이다른관절보다높게나왔는데특히전신운동기능이떨어질수록슬관절의뻗정다리보행이나반장슬보행을가질확률이유의하게높았다. 슬관절의뻗정다리보행은대퇴직근의비정상적인활동에의해주로발생 4,7 하고반장슬보행은대부분하퇴삼두근의구축및경직, 그리고슬와부근육의위약에의해발생 4,7 하는것으로알려져있다. 최근의연구에의하면이러한슬와부근육과대퇴직근의경직이나근력이운동기능과높은연관성이있다고 29-31 보고된바있어슬관절의보행이상과운동기능과의연관성이높은이번연구결과를뒷받침하고있다. 또한고관절에서는전신운동기능이낮을수록가위
7 대한재활의학회지 : 제 33 권제 1 호 29 보행의빈도가증가되었다. 가위보행은고관절내전근의경직과외전근의위약에의한동적불균형에의해주로발생하게되는데 32,33 최근에 Ross 등 3 이고관절외전근의근력이다른근육들보다보행기능과연관성이가장높다고보고하여본연구와유사한결과를보였다. 따라서경직성뇌성마비환아에서대퇴직근, 슬와부근육, 하퇴삼두근, 고관절외전근의근력이나경직으로인한각관절의보행이상이전신운동기능에주로영향을미치는것으로생각한다. 결 경직성뇌성마비환아의발목및족부에서관찰되는가장흔한보행이상은발가락내향보행이었다. 이환부위에따른비교시양지마비와사지마비환자에서는외반편평족이, 편마비환자에서는내반첨족이관찰되는경우가많았다. 슬관절에서는도약보행이가장흔한보행이상이었는데비교적연령대가높은사지마비환자군에서는웅크림보행이보다많이관찰되었다. 고관절에서가장흔한보행이상은이환부위에상관없이과도한굴곡이었다. 환자의연령이증가함에따라발목및족부에서는내반첨족과외반첨족을포함한첨족변형의빈도가감소되고외반편평족이많이발생하며, 슬관절에서는뻗정다리나도약보행이감소하고웅크림보행이증가하였다. 또한고관절에서는과도한내전, 내회전및굴곡이많이관찰되었다. 정형외과적인수술후에는내반첨족이나외반첨족이교정되어정상족부소견을보이는경우가증가하는반면에종족보행의발생도증가하였다. 뇌성마비환아의운동기능이낮을수록슬관절에서는뻗정다리보행이나반장슬보행이, 고관절에서가위보행을보일확률이높아진다. 론 참고문헌 1) Gabriella E. Molnar MMAA, MD. Pediatric rehabilitation, 3rd ed, Philadelphia: HANLEY & BELFUS, INC., 1999, 193-218 2) Banks HH. The management of spastic deformities of the foot and ankle. Clin Orthop Relat Res 1977; 122: 7-76 3) Winters TF Jr, Gage JR, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am 1987; 69: 437-441 4) Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res 1993; 288: 139-147 5) Crenna P. Spasticity and spastic' gait in children with cerebral palsy. Neurosci Biobehav Rev 1998; 22: 571-578 6) Hullin MG, Robb JE, Loudon IR. Gait patterns in children with hemiplegic spastic cerebral palsy. J Pediatr Orthop B 1996; 5: 247-251 7) Lin CJ, Guo LY, Su FC, Chou YL, Cherng RJ. Common abnormal kinetic patterns of the knee in gait in spastic diplegia of cerebral palsy. Gait Posture 2; 11: 224-232 8) Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br 24; 86: 251-258 9) Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop 25; 25: 79-83 1) Oeffinger DJ, Pectol RW Jr, Tylkowski CM. Foot pressure and radiographic outcome measures of lateral column lengthening for pes planovalgus deformity. Gait Posture 2; 12: 189-195 11) Bennet GC, Rang M, Jones D. Varus and valgus deformities of the foot in cerebral palsy. Dev Med Child Neurol 1982; 24: 499-53 12) Borton DC, Walker K, Pirpiris M, Nattrass GR, Graham HK. Isolated calf lengthening in cerebral palsy. Outcome analysis of risk factors. J Bone Joint Surg Br 21; 83: 364-37 13) Rethlefsen SA, Healy BS, Wren TA, Skaggs DL, Kay RM. Causes of intoeing gait in children with cerebral palsy. J Bone Joint Surg Am 26; 88: 2175-218 14) Reimers J, Pedersen B, Brodersen A. Foot deformity and the length of the triceps surae in Danish children between 3 and 17 years old. J Pediatr Orthop B 1995; 4: 71-73 15) Staheli LT. Planovalgus foot deformity. Current status. J Am Podiatr Med Assoc 1999; 89: 94-99 16) O'Connell PA, D'Souza L, Dudeney S, Stephens M. Foot deformities in children with cerebral palsy. J Pediatr Orthop 1998; 18: 743-747 17) Bell KJ, Ounpuu S, DeLuca PA, Romness MJ. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop 22; 22: 677-682 18) Johnson DC, Damiano DL, Abel MF. The evolution of gait in childhood and adolescent cerebral palsy. J Pediatr Orthop 1997; 17: 392-396 19) O'Byrne JM, Jenkinson A, O'Brien TM. Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyzer. J Child Neurol 1998; 13: 11-18 2) Wright J, Rang M. The spastic mouse. And the search for an animal model of spasticity in human beings. Clin Orthop Relat Res 199; 253: 12-19 21) Lyon R, Liu X, Schwab J, Harris G. Kinematic and kinetic evaluation of the ankle joint before and after tendo achilles lengthening in patients with spastic diplegia. J Pediatr Orthop 25; 25: 479-483 22) Park CI, Park ES, Kim HW, Rha DW. Soft tissue surgery for equinus deformity in spastic hemiplegic cerebral palsy: effects on kinematic and kinetic parameters. Yonsei Med J 26; 47: 657-666
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