대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) J Korean Oriental Med 2012;33(1):79-89 Original Article 動態損傷症候群에관한연구현황고찰 김정균 1, 김현호 2, 서재호 2, 김동원 3, 박영재 1,2, 박영배 1,2

대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) J Korean Oriental Med 2012;33(1):79-89 Original Article 動態損傷症候群에관한연구현황고찰 김정균 1, 김현호 2, 서재호 2, 김동원 3, 박영재 1,2, 박영배 1,2 1 경희대학교학과간협동과정한방인체정보의학과, 2 경희대학교한의과대학진단생기능의학과학교실, 3 우당한의원 A Review Study on Movement System Impairment Syndromes Jeong-Kyun Kim 1, Hyunho Kim 2, Jae-Ho Seo 2, Dong-Won Kim 3 Young-Jae Park 1,2 Young-Bae Park 1,2 1 Department of Human Informatics of Oriental Medicine, Interdisciplinary Programs, Kyung Hee University 2 Department of Biofunctional Medicine & Diagnostics, College of Oriental Medicine, Kyung Hee University 3 Woo-Dang Oriental Medicine Clinic Objectives: Sahrmann, an American physical therapist, has developed a set of movement-related diagnoses on musculoskeletal pain syndromes (MPS). We reviewed articles for studies of objectification and quantification of Oriental medicine diagnosis system about MPS. Methods: The authors reviewed a total of 12 studies found on PubMed to obtain movement system impairment (MSI)-based classification categories. Results: The MSI system has been developed for objectification and quantification of physical therapists' MPS diagnoses. The MSI system of classification is based on the basic premise that loss of precise movement is the result of specific repetitive movements and positions in everyday life. The MSI system defines 8 categories in the shoulder region, 5 in the lumbar region, and 7 in the knee region. Treatment involves (1) educating the person about the specific directions of alignment and movement that appear to be contributing to the musculoskeletal problem, (2) modifying the direction - specific alignment and movement patterns during daily activities, and (3) exercises to address the impairments. Conclusions: The authors propose that MSI studies could help to advance an Oriental medical diagnosis system on musculoskeletal pain syndromes, because MSI shares similarity with Oriental medicine in terms of holism, views of constant motion, and mi-byung (subhealth) treatment. Key Words : classification, Sahrmann, movement system impairment syndromes (MSIS), shoulder pain, low back pain, knee pain 서론최근한방의료이용양상에관한연구에서입원과외래모두신경계질환과근골격계질환에대한진료비지출이가장많은것으로연구되었다 1,2). 박등 2) 은통증치료를목적으로내원한환자의비율이 50% 이상이라고응답한한의원이 84.8% 를차지한 다고보고하였다. 또한이전의연구에서도한의원내원환자를대상으로한연구에서전체응답자의 60% 이상이 근골격계및결합조직과관련된질환 인것으로조사된바가있다 3). 그러나한방의료이용환자의상당수가근골격계질환환자임에도불구하고, 객관적이고정량적으로진단할수있는체계 Received:15 December 2011 Revised:21 February 2012 Accepted:6 March 2012 Correspondence to: 박영재 (Young-Jae Park) 경희대학교한의과대학진단생기능의학교실 Tel:+82-2-440-7229, Fax:+82-2-440-7242, E-mail:bmpomd@paran.com 79

(80) 대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) 가미비한실정이다. 미국의물리치료사인 Shirley A. Sahrmann은근육의작용으로인한관절의움직임을관찰하고통증의원인이 Movement system impairments(msi) 4,5) 에있다는것을발견하여역학적인부분에서발생하는근골격계의기계적통증 (Mechanical pain) 에대한진단과치료법개발에공헌하였다. 특히근골격계통증과관련된의사의진단은통증을일으키는원인이특정한해부학적조직의염증과관련이있으며이를해결하기위한치료방법을결정하는것이기때문에보존적관리 (Conservative management) 를위한진단과는차이가있다고보고하였다. MSI의관점에서바라보는기계적인통증은일상생활동작중특정한방향으로의운동 (Movements) 및자세 (Positions) 가반복되어정확한관절의움직임이변형된결과라는전제를바탕으로하고있다 4,6,7). 이러한반복은운동계 (Movement system) 의생역학 (Biomechanical) 및운동조절 (Motor control) 요소들을변형시킨다고알려져있다 4). 예를들면, 특정한방향으로의운동및자세의반복은조직의뻣뻣함 (Stiffness) 과신장성 (Extensibility) 을증가시키거나감소시킬수있고, 다양한근육활동의발생시간순서 (Timing) 나규모의변화를유발할수도있다. 정확한관절움직임의변형은조직에작은규모 (Low magnitude) 의스트레스를가할수있으며, 이러한특정한스트레스의누적은미세외상 (Microtrauma) 을유발하여결과적으로통증을유발하게된다. 또한이러한생역학및운동조절요소들의변화가교정되기전에는증상이지속되거나재발할가능성이있다고말하고있다 4,5,9,17-20). 이러한 Sahrmann의근골격계통증에대한진단과치료법은첫째는증상이나타나는국소부위에만국한하지않고전신의상태를살펴서근본원인을치료한다는전일개념, 둘째는건강과질병의중간단계로서방치할경우질병으로이환될수있는건강저하상태를의미하는 미병 ( 未病 ) 8), 셋째는기능적문제가장기간치료되지않고방치될경우구조의변화를가져올수있다는 形質기능실조 라는한의 학적개념과유사하다고판단된다. 그러므로동태손상증후군 ( Movement system impairment syndrome ; MSIS ) 에관한연구가한의학근골격계진단시스템의정량화와객관화를위한연구에도움이된다고판단하여문헌적고찰을시행해보고자한다. 연구방법 MSI가지금까지어떤경향으로연구가이루어져왔으며, 현재어떤연구가진행되고있는지에대해알아보기위하여발표된문헌을검색하였다. National center for biotechnology information 의 Pubmed 에서검색하였다. 우선 MSIS, classification, Sahrmann, movement system impairment 등을 keyword로한문헌을검색한결과총 38편의논문이검색되었다. 허리와관련된논문은 8편, 어깨와관련된논문은 2 편, 무릎과관련된논문 1편과 MSIS의개발배경과개념을설명하고예증하기위한논문은 3편, 그외부위가 24편이었다. 그중에서허리, 어깨, 무릎등의세부위에대한진단분류가논문중에기재되어있었으므로, 검색된논문중에서허리, 어깨, 무릎과관련된논문을위주로분류및분석하였다. 연구결과 1. 동태손상증후군 (MSIS) 의개발배경근골격계통증을치료하기위해병원에찾는사람들중의대부분은보존적치료를받는데 11-13), 그중한가지방법이물리치료이다. 하지만근골격계통증 (Musculoskeletal pain syndromes ; MPS) 에대한의사가내리는진단은약물이나수술적치료를위한병태생리학적상태 (Pathophysiology) 와관련되어있기때문에, 생역학적인원인에대한치료를기술하거나선택하는물리치료사에게는치료행위를하는데있어서실질적으로적당하지않다 4,10). 이에물리치료사에게적합한 MPS의진단체계개발을위한많은노력들이있었다. 대표적으로 1983년물 80

김정균외 5 명 : 動態損傷症候群에관한연구현황고찰 (81) 리치료사들은물리치료중재의초점 (Focus of physical therapy intervention) 을 운동 (Movement) 으로정하는철학적인표현에합의를보았으며 14), Jette 15) 와 Guccione16) 는 World Health Organization(WHO) 의 International Classification of Impairments, Disabilities, and Handicaps와 Nagi Model of Disablement(Nagi) 를우리업무분야의임상적현상을분류하는근거로사용하는것에대한이해와제안을제시한바있다. Sahrmann 은손상 (Impairment) 을해부학적, 생리학적, 심리학적구조나기능의변화로어떤비정상 (abnormality) 이발생하는것으로정의한 Nagi의장애모델에동의하며, 통증의원인이 Movement system impairments(msi) 4,5) 에있다는것을발견하여역학적인부분에서발생하는근골격계통증 (mechanical pain) 에대한진단과치료법을개발하였다 10). 2. MSI에기반한진단분류방법동태손상증후군의진단분류체계는정확한관절움직임의변형이일상생활동작중특정한방향으로의운동과자세의반복에의한결과라는전제를 바탕으로하고있다. 이러한반복은운동계 (Movement system) 의생역학 (Biomechanical) 및운동조절 (Motor control) 요소들을변형시킨다고알려져있다 4). 그리고반복운동과지속적인자세 (Sustained posture) 는어떤특정한해부학적방향으로운동이쉽게일어나는관절을만든다 4,5,9,17-20). 이러한관절은부수적운동 (Accessory movement) 과생리적운동 (Physiological movement) 의빈도가증가되며, 연부조직을손상시키는원인으로여겨진다. 관절에서운동이쉽게발생하는방향 (Directional susceptability to movement; DSM) 을찾는것이진단적분류의명칭을붙이고조직화하는데초점이된다 4). 3. 어깨, 허리, 무릎부위의진단분류 1) 어깨부위 (Shoulder) MSI에기반을둔어깨부위의진단분류는 table 1과같다 17). 진단명은환자의증상양상과연관이있다고판단되는정렬및움직임에근거하여명명되었으며, 진단의초점은통증의병리해부학적인근원보다는통증을유발하는움직임에두었다. Table 2 는견갑골의운동 (Scapular movements) 에대한정의 Scapular Humeral Category Definition Downward rotation Insufficient upward rotation Depression Insufficient elevation Abduction Excessive abduction Winging/tilting Anterior glide Superior glide Shoulder medial rotation Winging and tilting during the return from arm elevation, or Insufficient posterior tilt at the end range of arm elevation, or Winging during arm elevation, and/or Alignment of winging and/or anterior tilt Excessive anterior or insufficient posterior glide, and/or Alignment of humeral head excessively anterior Excessive superior or insufficient inferior Alignment of humeral head excessively Insufficient lateral rotation, and/or Alignment of excessive medial rotation Glenohumeral hypomobility Decreased range of motion in all directions glide, and/or superior * The diagnoses are named for the alignment and/or movement impairment that when corrected decrease or abolishes the symptoms. The following combinations may occur: (1) normal alignment and movement impairment, (2) impaired alignment and normal movement, and (3) impaired alignment and impaired movement. 81

(82) 대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) Terms Scapular adduction/ abducion Scapular upward/ downward rotation Scapular anterior/ posterior tilt/tipping Scapular winging Definitions The scapula translates along the rib cage medially toward (adduction), or laterally away from (abduction), the vertebral column A movement of the scapula (about an axis perpenducular to the scapula at the acromioclavicular joint) in which the inferior angle moves laterally and the glenoid fossa rotates to face cranially (upward rotation) or the inferior angle moves medially and the glenoid fossa rotates to face caudally(downward rotation) A movement of the scapula (about an axis parallel to the scapular spine at the acromioclavicular joint) in which the coracoid moves anteriorly and caudally while the inferior angle moves posteriorly and cranially (anterior tilt) or the coracoid moves posteriorly and cranially and the inferior angle moves anteriorly and caudally(posterior tilt) Abnormal movement of the scapula about a vertical axis at the acromioclavicular joint in which the vertebral border moves in a posterior and lateral direction away from the ribcage 를기술하고있다. 임상검사는병력청취와운동및자세에대한몇가지임상테스트 (Clinical tests) 를포함하고있다 4). 검사는개인의어깨증상에대한각각검사의결과가모두모니터된다는점에서매우독특하다. 환자는각각의검사를선호하는전략 (Strategy) 을이용하여시행하고, 검사자는증상을평가하고방향과관련된운동이나정렬패턴에대한판단을내리게된다. 만약어떤운동이나자세가증상을유발하면해당검사는환자가정상적인운동패턴이나자세를가질수있도록선호전략을교정하여재평가한다. 교정이후의증상은선호된패턴을이용했을때의증상과비교하여평가된다 4,17). 어깨부위의분류는총 8가지로분류되는데, 견갑골의문제로발생하는분류가 4가지이고, 상완견관절 (Glenohumeral joint) 의문제로발생하는분류가 4 가지이다. Cheryl caldwell et al. 17) 은어깨통증환자를상대로한임상례에서 movement-related diagnosis set를소개하였으며, 어깨통증을호소하는환자에게 MSI 에기반을둔진단체계사용을제시하고, 그것이어떻게치료처방을안내하였는지를설명하였다. 또한어깨충돌증후군으로진단을받은환자를견갑골하방회전 (scapular downward rotation) 을동반한상완골전방활주 (humeral anterior glide) 라는 MSI 적인진단을통하여물리치료를지도하였으며긍정적인단기및장기결과를보고하였다. 권등 21) 은양측견갑골하방회전증후군 (bilateral scapular downward-rotation syndrome) 이라는 MSI 에기반을둔진단을받은환자들을상대로하여통증, 고유감각 (Proprioception), 운동범위에대한견갑골위치수동교정 (passive correction of scapular position ; PCSPT) 의효과에대해서보고하였다. 결과는 PCSPT 가능동적인경추회전 (active neck rotation) 동안에유의하게관절위치오류 (joint-position error; JPE), 경부 ( 頸部 ) 통증을감소시켰으며, 경추회전가동범위 (neck-rotation ROM) 을유의하게증가시켰다 (P<0.05). 이러한결과는양측견갑골하방회전증후군 (bilateral scapular downward-rotation syndrome) 을가진경부통증환자들에게서능동적인경추회전 (active neck rotation) 동안에경부통증을감소시키고경추회전가동범위 (neck-rotation ROM), 고유감각기능을증가시킨다는것을보고하였다. 2) 허리부위 (Lumbar) MSI에기반을둔허리부위의진단분류는 table 3과같다 9). 허리통증 (Low back pain ; LBP) 에대한 MSI 접근의바탕에있는이론은기계적허리통증 (mechanical low back pain ; MLBP) 이체간이나사지의움직임에따라특정한방향으로움직이려는척추 (Lumbar spine) 의성향에서비롯된다고보고하였다. 이러한성향은기능적활동과더불어특정한방향으로이루어지는정렬및운동전략의반복된사 82

김정균외 5 명 : 動態損傷症候群에관한연구현황고찰 (83) Category Extension Associated signs and symptom behavior Tendency for the lumbar spine to move in the direction of extension with movement of the spine and extremities. Lumbar spine alignment tends to be extended relative to neutral a with the assumption of posture (i.e. standing, sitting, supine, side lying, prone, quadruped). Symptoms increase or are produced with the lumbar spine positioned or moved into extension. Symptoms decrease or are eliminated with restriction of lumbar extension. b Flexion Sings and symptoms are similar to those described for extension except that they occur with flexion Rotation Rotation with flexion Rotation with extension Tendency for the lumbar spine to move in the direction of rotation with movement of the spine and extremities. Lumbar spine alignment tends to be rotated relative to neutral with the assumption of postures. Symptoms(often unilateral) increase or are produced with the lumbar spine positioned or moved into rotation. Symptoms decrease or are eliminated with restriction of lumbar rotation. Tendency for the lumbar spine to move in the direction of rotation and flexion with movement of the spine and extremities. Lumbar spine alignment tends to be flexed and rotated relative to neutral with the assumption of postures. Symptom(often unilateral) increase or are produced with the lumbar spine positioned or moved into rotation and flexion. Symptoms decrease or are eliminated with restriction of lumbar rotation and flexion. Signs and symptoms are similar to those described for rotation with flexion except that they occur with rotation and extension. a: Neutral is defined as the position of the lumbar spine at which an inclinometer centered over each lumbar spinous process would result in a measure of 0, without rotation or side bending of any of the lumbar vertebrae. b: Restriction of spinal motions and alignments is accomplished using verbal cues, active stabilization by the patient, and manual stabilization by the examiner. 용의결과로볼수있다. 특정방향전력의반복은근육조직 (Muscle tissue) 과같은수동적요소 (Passive element) 와타이밍과근육의힘생산 (Force production) 과같은능동적요소 (Active element) 의변화에기여하게된다. 이러한변화는검사상에서신체손상 (Physical impairment) 으로나타난다. 척추조직이같은방향으로반복된부하에노출되게되면누적조직스트레스 (Cumulative tissue stress) 및미세외상에기여하게되고, 결국에는 LBP로이어지게된다 4,9,18,20). Linda R. Van Dillen et al. 은기계적허리통증 (MLBP) 환자들에대한횡단적연구 (Cross-sectional study) 를통하여 MSI-based classification 의 3범주 (Lumbar rotation with extension, lumbar rotation, lumbar extension) 에대한구성타당도를증명하였다 9). 또한요추굴곡 회전증후군 (lumbar flexion with rotation syndrome) 으로진단을내린환자를대상으로한임상례에서는일상동작에서척추가회전과굴곡방향으로운동과정렬이일어나도록하는인자 (Contributing factor) 를조정하고운동처방을통하여환자의증상, 장애, 재발율이감소하였음을보고하였다 20). 그리고 Marcie Harris-Hayes et al.18) 은요추신전증후군 (lumbar extension syndrome) 으로진단된 MLBP 환자를대상으로한임상례에서 MSI 진단방법을통한치료적접근은단기와장기간의손상및기능적단계결과에서개선을보이는것을보고하였다. 권등 22) 은요추신전 회전증후군 (lumbar rotation with extension syndrome) 으로진단된환자들을대상으로하여능동복와위무릎굴곡 (active prone knee flexion) 동안에 abdominal drawing-in maneuver (ADIM) 이슬건근 (Hamstring) 과척추세움근 (Erector spinae) 의활동성과골반의움직임및무릎굴곡의정도, 골반움직임의발생에미치는영향을조사하였다. 결과에서좌 우척추세움근의 EMG activity상의유의한감소와내 외측슬건근의활동성 (Medial and lateral hamstrings activity) 에서 EMG activity 상의유의한증가가보였다. 게다가많은양의골반 83

(84) 대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) 전방경사, 골반회전, 무릎굴곡, 인지된통증이동일한방법의 non-adim condition 과비교하여 ADIM condition에서의복와위무릎굴곡 (prone knee flexion) 동안에유의하게감소하는것으로나타났다. 즉, 요추신전 회전증후군을가지고있는환자들에서복와위무릎굴곡동안에 ADIM은무릎굴곡근들의활성화를효과적으로증가시키고, 요추신전근의활성화를감소시키며, 골반의움직임과요통을감소시킨다는것을보고하였다. 3) 무릎부위 (Knee) MSI에기반을둔무릎부위의진단분류는 table 4와같다 19). 진단은환자의통증과연관되어있으면서교정후통증이감소또는소실되는일관적인운동패턴의확인을바탕으로한다. 횡단면및전두면 (Transverse and frontal planes) 상에서의하지 (Lower extremity) 의운동손상 (Movement impairments) 은무릎의통증 23-25) 과조직손상 26-30) 에기여하는것으로알려져있다. 운동손상은검사항목및기능적활동의수행중비정상적인정렬과하지의운동이상으로나타날수있다. 무릎 의외반 (Knee valgus), 무릎의내반 (Knee varus) 또는대퇴골에대한경골의상대적인회전 (Rotation) 과같은비정상적인정렬은슬부전면부통증 (Anterior knee pain) 29,31) 과골관절염 (Osteoarthritis) 26,32,33) 의진행과연관이있다고밝혀진바있다. 만약하지의운동손상이무릎의통증및손상과연관이있다면운동손상교정의목적을지닌치료법이유용할것이다. Marcie Harris-Hayes et al. 19) 은경대퇴골회전증후군 (tibiofemoral rotation syndrome) 으로진단된환자를대상으로한임상례에서무릎부위에관한 movement system impairment classification categories 를소개하였다. 그리고경대퇴골회전증후군으로진단된환자를상대로하여무릎의정렬및운동패턴의교정후기능적활동의개선과통증소실을보고하여, MSI에기반을둔진단과특화된치료는환자통증해소와기능적활동수행에있어개선된능력을제공한다는것을보고하였다. 4. MSI 진단분류를통한치료방법 Sahrmann 4) 은증상의근원 (Source) 을밝히는것보 Category Description Pain Tibiofemoral rotation Tibiofemoral hypomobility Knee extension Knee hyperextension Patellar tracking Tibiofemoral accessory hypermobility Tissue impairment Impaired motion at the tibiofemoral joint, transverse or frontal plane Physiological loss of ROM Associated with dominance of quadriceps muscle Associated with dominance of hamstrings Impaired alignment or tracking of the patella in the trochlear groove Excessive motion at the tibiofemoral joint No MSI diagnosis or unable to perform a movement examination as in cases of acute trauma or postsurgery Pain along the joint line Pain associated with tibiofemoral rotaion(wb or NWB) Pain with WB that decreases with rest Pain is located deep in joint Stiffness Pain located at suprapatellar or infrapatellar tendon Pain located along the anterior or posterior joint line of the tibiofemoral joint or peripatellar pain Pain is peripatellar or retropatellar Instability or giving way May or may not have pain associated with instability Pain is associated with trauma or surgery Abbreviations : MSI, movement system impairment; NWB, non-weight bearing; ROM, range of motion; WB, weight bearing 84

김정균외 5 명 : 動態損傷症候群에관한연구현황고찰 (85) 다원인을찾는것을더강조한다. 이접근법은관절의운동에통증과제한이발생하기전에운동의패턴들이손상을받기때문에근골격계문제가발생한다는전제를기초로하고있다. 그러므로 MSI 진단분류를통한치료 4,10,17-20) 는 (1) 근골격계문제에기여하는것으로보이는특정한방향으로의정렬및운동에대한환자교육, (2) 일상생활속의방향특징적인정렬및운동패턴의교정, 그리고 (3) 방향과연관된정렬및운동패턴에기여하는것으로판단되는손상을교정할수있는운동요법등이있다. 고찰미국의물리치료사인 Sahrmann이개발한 MSI를기반으로하는근골격계의진단체계는한의학의개념과몇가지측면에서유사성이있다. 첫째, 전일관념 ( 全一觀念 )34) 이다. 즉, 인체는유기적인전체이므로질병이발생하면국소의병변이전신에영향을미칠수있고전신의병변이일정한국소에반영되기도하며외부에있던병이내부로전입되는가하면내장 ( 內臟 ) 의병이외부로나타난다는의미이다. 그러므로증상이나타나는국소에만집중하기보다는오장육부및경락의상태, 정신상태, 생활습관 (Life style), 자세등의전체적인부분을고려하여질병을진단하고치료한다는것이한의학의전일개념이다. 운동은근육과골격계로구성되는기본요소 (Base), 신경계로구성되는조절기요소 (Modulator), 정역학 (Statics) 과동역학 (Dynamics) 으로구성되는생체역학요소 (Biomechanical), 심호흡 (Cardiac and pulmonary) 과신진대사 (Metabolic) 로구성되는지지요소 (Support) 등의네가지 4,5) 가상호작용하여만들어진다. Sahrmann은이요소들중의한곳또는그이상이손상되면근골격계통증증후군을발생시킬수있으므로, 근골격계문제를진단할때증상이나타나는국소부위만을봐서는안되고해부학적그리고생리학적시스템전체를고려해야한다는개념을중요하게생각한다 (Fig. 1). 이러한부분에서한의학의전일관념과의미가일맥상통한다고 볼수있다. 둘째, 항동관념 ( 恒動觀念 ) 35) 이다. 恒動觀念이란자연계와모든인체를포함한모든물질들은영구적으로운동하며쉬지않는다고보는것인데, 동태적관점에서생명현상의규율을파악하고이것을치료에적용한다는뜻이다. Sahrmann 4,5) 은증상을진단하고치료하는데있어서, 정적인상태와동적인상태모두를관찰하였다. 즉, 일상생활동작중정확한관절움직임의변형이미세외상을유발하며, 이것이누적되어통증으로이어질수있으므로, 생역학 (Biomechanic) 및운동조절요소 (Motor control) 라는동적인부분까지치료해야한다고보고있다. 사람은정적인상태에존재하는것이아니고, 항상움직이는상태에놓여있으므로동적인부분의치료에많은비중을두고있다는뜻이다. 이것은한의학에서말하는항동관념과일치한다고볼수있다. 셋째, 한의학에서강조하는미병 ( 未病 ) 8,36) 의개념과유사하다고볼수있다. 미병이란건강과질병의중간단계로서방치할경우질병으로이환될수있는일종의건강저하상태를의미한다. 미병의病因중不內外因에해당하는생활습관병은직업, 취미, 운동, 수면습관등의부적절이장기간방치될경우근골격계의통증으로이어질수있는데, 근골격계의관점에서는이러한미병의상태를통증이발생하기이전의단계이므로통증잠복단계 (Pain latent stage) 라고부를수있을것이다. 만약건강저하상태가장기간개선되지않을경우비만, 굽은등, 허리통증, 무릎통증, 목통증, 발목통증, 어깨통증등체중및체형변화와관련된형질기능실조의증상들이나타날수있다 36). 그러므로미병에서는환자의기능부조화를적극조절함으로써더이상의질병진행을억제하고보다빠른회복을도모하는관리방법을중요시한다. 이는운동을만들어내는구성요소인기본요소 (Base), 조절기요소 (Modulator), 생체역학요소 (Biomechanical), 지지요소 (Support) 중어떤한요소에바람직하지못한기능이있다면손상 (Impairment) 이발생하게되고, 만약손상이교정되지않고반복운동이계속된다면통증을유발하게되므로, 비 85

(86) 대한한의학회지제 33 권제 1 호 (2012 년 3 월 ) Base Musculoskeletal Modulator Nervous Biomechanics Static/dynamics Support cardio/pulmon Metabolic Movement and Postures Abnormality or Injury Components Impairment Precise Movement Movement Impairment Functional Limitation Good Musculoskeletal Health Disability 정상적인요소를찾아내고교정하여근골격계통증예방을중요하게여기는 MSI의개념과내용과일치한다고볼수있다. 또한 Sahrmann의 MSI 연구방법은근골격계에대한정량적이고객관화된한방진단시스템을연구하는데참고가될수있다. 한방의료는임상적측면에서양방의료에비하여전인적인접근이라는긍정적인측면을가지고있다. 하지만진단, 치료및결과에있어객관적이고, 표준화된기준이나통계적연구가결여되어있다고평가되고있다. 이는환자나의사가느끼는치료의효과와효능성의계량화가어려워한방의료인이외의전문가들에게한방의료효능에대한비판의여지를제공하고있다고볼수있다 1). 의사의진단이물리치료사의치료행위에부합하지않는다고판단한 Sahrmann은 MSI-based diagnosis system을개발한후임상례 10,17-20) 와타당도 9) 에대한논문을통해서객관성을입증하고있다. 이것은다음과같은이유에서중요성을갖는다 9). 첫째, 제안된분류체계는임상의들에게 MPS의하위범주들을일관되게정의할수있도록함으로써향상된결과를도출할수있는특정한치료법을도입할수있도록해준다. 둘째, 환자의 MPS의분류에기초한통일된용어는임상적으로비슷한그룹인환자들의예후를결정할수있는기준을제공한다. 셋째, MPS를가진환자들을 MSI에근거하여하위그룹으로분류할수있는점은치료의효과를시험하기위한임상실험의파워를증가시킬수있다. 이러한관점에서 Sahrmann이제안한 MSI-based diagnosis system은근골격계질환환자에대한객관적이고정량적인한방진료시스템을위한연구에도움을줄 86

김정균외 5 명 : 動態損傷症候群에관한연구현황고찰 (87) 수있다고생각한다. 마지막으로 MSI 진단분류를통한치료방법은기존의근골격계치료법과비교해볼때, 증상이발생하게되는과정을이해하고이에대한부분을교정하여증상을치료할뿐만아니라재발까지예방하는것을목표로한다는점에서차이가있다. 예를들면, 시리악스 (Cyriax) 34) 는일련의검사를통하여병변이있는국소부위를찾아내고해당부위에심부횡마찰법, 주사주입법등을시행하여증상을감소시키거나없앤다. 카이로프랙틱 (Chiropractic) 요법 37) 은신경계에영향을주는척추변위상태인아탈구 (Subluxation) 을찾아내고, 교정 (Adjustment) 라고하는방법을통하여증상을치료한다. 근에너지기법 (Muscle energy technique; MET) 은긴장되고단축된근육이나인대성구조물을찾아내어등장성 / 등축성수축및신장법을적용하여부드럽게회복시켜주는방법이다 38). 위의진단과치료방법들은결정론적진단과결과를중요하게여기는 치료중심의학 인반면, Sahrmann의동태손상증후군은진단과치료의개념자체가질병상태에이르게된과정을중요하게여기는 과정중심의학 이라고말할수있다. 그러므로 MSI를기반으로한진단분류체계는이론배경과치료목적의면에서한의학과유사한면을많이가지고있기때문에, MSI의연구는근골격계질환환자에대한객관적이고정량적인한방진료시스템구축을위한연구에도움을줄수있다고판단이된다. 결론본논문에서는 Sahrmann이개발한근골격계진단시스템인 MSI-based diagnosis system과관련된논문을연구하였다. 그중에서도특히발생빈도가높은부위인어깨, 허리, 무릎부위에대한논문을고찰하였다. 미국의 physical therapist인 Sahrmann 은기존의근골격계진단체계가보존치료를위주로 하는물리치료사를위한진단체계가될수없다고판단하여 MSI-based diagnosis system을개발하였는데, 다음과같은점에서한의학의개념과유사하다고볼수있다. 첫째, 근골격계문제를진단할때증상이나타나는국소부위만을봐서는안되고시스템전체를고려해야한다는개념을중요하게여기는데한의학의 全一觀念 과유사하다. 둘째, 근골격계문제를진단하고치료할때정적인상태뿐만아니라생역학 (Biomechanic) 및운동조절요소 (Motor control) 라는동적인부분까지고려하는것을중요하게여기는데한의학의 恒動觀念 과유사하다. 셋째, 운동을만들어내는구성요소중어떤한성분에바람직하지못한기능이있다면손상 (Impairment) 이발생하게되고, 만약손상이교정되지않고반복운동이계속된다면통증을유발하게되므로, 비정상적인요소를찾아내고교정하여근골격계통증을예방하는것을중요하게여기는데한의학의 未病 의개념과유사하다. 그러므로동태손상증후군 (MSIS) 의연구는근골격계질환환자에대한객관적이고정량적인한방진료시스템구축을위한연구에도움을줄수있다고판단이된다. 참고문헌 1. Han DW, Kim HJ, Yoon TH, Woo HK. Current Circumstance and Issues in Traditional Korean Healthcare Sector: What are Public Policy Options for Future Society?. Kor. J. Oriental Preventive Medical Society. 2005; 9(1): 77-89 2. Park JE, Jung HJ, Kim AR, Jung SY, Hwang HS, Choi SM. Current state of pain treatment in oriental medicine. J Korean Oriental Med. 2011; 32(2): 23-41. 3. Lee KS, Cho KS. A Study on Utilization Patterns of Oriental Medical Care. Korean J. of Health 87

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