pissn Vol. 31, No. 2, April 2019 J Kor Phys Ther 2019:31(2):122-128 1229-0475 eissn 2287-156X Original Article Effects of Sagittal Spinopelvic Alignment on Motor Symptom and Respiratory Function in Mild to Moderate Parkinson`s disease DongYeon Kang 1, SangMyung Cheon 2, MinJi Son 3, HyeRyun Sung 2, HyeYoung Lee 4 1 Department of Health Care and Science, College of Health Science, Dong-A University, Busan; 2 Parkinson s Disease Center, Dong-A University Hospital, Busan; 3 Graduate School of Medical, Dong-A University, Busan; 4 Department of Physical Therapy, Keimyung University Dongsan Medical Center, Daegu, Korea Purpose: This study examined the effects of sagittal spinopelvic alignment on the clinical parameters, motor symptoms, and respiratory function in patients with mild to moderate Parkinson s disease (PD). Methods: This study was a prospective assessment of treated patients (n=28, Hoehn and Yahr [H&Y] stage 2-3) in a PD center. Twentyeight subjects (68.5± 5.7 years) participated in this study. The clinical and demographic parameters, including age, sex, symptoms duration, treatment duration, and H&Y stage, were collected. Kinematic analysis was conducted in the upright standing posture with a motion capture system. A pulmonary function test (PFT) was performed in the sitting position using a spirometer. The motor symptoms were assessed on part III of the movement disorder society sponsored version of the unified Parkinson s disease rating scale (MDS-UPDRS). SPSS 18.0 was used to analyze the collected data. Results: The exceeding 12 degrees group of the lower trunk showed significantly higher on the clinical parameters than the below 12 degrees group. In addition, the exceeding 12 degrees group of the lower trunk showed a significantly lower forced expiratory volume at one second (FEV1) / forced vital capacity (FVC) (%) and 25-75% forced mid-expiratory flow (FEF) (L/sec) than in the below group. On the other hand, there was no difference in the upper trunk and the cervical pelvis between the groups. Conclusion: These findings suggest that the sagittal balance in the lower trunk is related to the clinical parameters and respiratory function, but not the motor symptoms in patients with mild to moderate PD. Keywords: Parkinson s disease, Spinopelvic alignment, Respiratory function 서론파킨슨병 (Parkinson s disease, PD) 의대표적인임상증상은경직 (rigidity), 안정시진전 (tremor of rest), 운동느림 (brady-kinesia) 그리고자세불안정 (postural instability) 과같은운동장애로소개되고있지만 1-4 다양한비운동장애뿐만아니라병의진행과함께환자의약 1/3 이상에서는머리, 목, 몸통그리고다리관절이앞으로굽은자세변형 (stooped or bent posture) 이나타난다. 5-7 그뿐만아니라약 2-12% 정도에서는피사증후군 (pisasyndrome), 몸통굽힘증 (camptocormia, bent syndrome) 및머리가앞으로숙여지는 (antecollis) 등의심한변형까지도나타난다. 5-8 이러한것의원인은움직임을조절하는기저핵, 시상핵및소뇌의손상또는앞이마엽기능이상 (frontal lobe dysfunction) 과관련이있는 것으로제시되고있지만 9,10 현재까지병리학적기전이명확하게밝혀진것은아니며이에대한약리반응또한연구마다다양하게나타나고있다. 5,11 그뿐만아니라파킨슨병환자의경우에는외과적척추교정술로인한합병증발생이높은것 9 으로알려져있다. 일반적으로지나치게앞으로굽은자세는환자의몸통움직임을제한하고허리통증, 균형및보행장애를초래해일상생활은물론사회생활에까지부정적인영향을미치며넘어짐 (falls) 의원인이되기도한다. 8,9 하지만파킨슨병환자의경우에몸통이앞으로구부러지는자세는운동느림, 불안정한자세와같은운동장애에대한보상작용 (compensation) 으로보행동결 (freezing of gait, FOG) 이나타나는환자의보행개시에도움이될수있는것으로제시되고있어 12 이들의자세와임상증상에대한올바른이해를돕기위해다양한연구가필요한부분이다. Received Mar 25, 2019 Revised Apr 29, 2019 Accepted Apr 29, 2019 Corresponding author DongYeon Kang E-mail dongyeon68@naver.com Copylight 2019 The Korean 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. 122 www.kptjournal.org
Sagittal Spinopelvic Balance in Patients with PD 자세변형은파킨슨병환자에서도시상면 (sagittal plane) 과관상면 (coronal plane) 에서복합적으로나타난다. 6 하지만척추질환관련치료에서시상면의균형원리를먼저이해하는것이우선이다. 13 따라서파킨슨병환자의적절한치료및관리를위해시상면자세변형에대한이해가필수적이다. 현재까지파킨슨병환자의자세와관련된연구는시상면자세변형과임상지표와의관련성, 7,12,13 자세평가방법, 7,9 자세관련된주요지표 13,14 및중재방법 15 등에대해진행되었다. 이중시상면자세변형과임상지표와관련성에관한결과를구체적으로살펴보면앞으로굽은자세를가진파킨슨병환자 190명 (m: 122, f: 68) 의나이, Hoehn and Yahr H&Y (stage), 질병기간, 허리통증및골다공증 (osteoporosis) 정도가 10-17개월전후자세변화에유의한영향을미치는것을확인하였다 (p < 0.05). 7 또한 Hoehn and Yahr H&Y stage 1-3 인환자 (n = 175) 를대상으로시상면자세균형과임상지표의관련성을분석한결과척추엉치각도 (spinosacral angle) 는진단기간, 나이, H&Y, UPDRS-motors와유의한음의상관관계를, 척추골반각도 (spinopelvic angle) 는 H&Y (stage) 와유의한양의상관관계가있음을실제로확인하였다 (p < 0.05). 13 하지만이러한연구는대상자의자세변형의진행정도에관계없이진행되어몸통굽힘증을보이는환자와그렇지않은환자의특성차이를이해하는데에는부족한부분이존재한다. 자세변형유발인자에는근병증, 골격계및연부조직변화뿐만아니라근긴장이상, 경직, 고유감각및감각운동이상등이제안되는데 14 자세불안정, 근경직, 근긴장이상, 근병증과고유감각손상등을겪는파킨슨병환자에게척추변형이동반되어나타날경우에는환자에게미치는임상적영향은더심각할수있다. 13 한편선행연구에서후만증 (kyphosis) 이있는여성을대상으로들숨량과허파활량을검사한결과등뼈의후만각도가클수록호흡기능이감소되어있는것과 16 전방머리자세 (forward head posture) 를가진대상자들은그렇지않은사람들보다 Forced vital capacity, FVC과 forced expiratory volume at one second, FEV 1 정도가낮다 17 는것을확인하였다. 그뿐만아니라전방머리자세는가로막수축과가슴및배의움직임감소와가슴우리의상승을유도한다고 18 하여비정상적인시상면의자세는호흡기능에부정적인영향을미치는것을제시하였다. 파킨슨병환자의경우에도몸통의굽은각도가클수록허파활량 (vital capacity, VC) 을제한하고이것이호흡곤란 (breathlessness) 까지유도한다면이들의독립적인일상생활의범위는더협소해질수밖에없다. 6,10 일반적으로건강한사람은자세에따른호흡능력의차이가있다. 그러나한연구에서몸통굽힘증이있는파킨슨병환자는누운자세와앉은자세에서노력성페활량 (Forced vital capacity, FVC) 과 1초간노력성호기량 (forced expiratory volume at one second, FEV 1) 등에서차 이를보이지않았다는결과 (p < 0.05) 19 에서이들의자세변형과호흡기 능의관련성은일반적인대상자와같지않다는것을예측할수있다. 특히, 파킨슨병환자의호흡기능장애가병의초기부터시작된다는 점을 20 생각한다면이들의자세변형과호흡기능의관련성을구명하 는것은임상에서이들의근골격및신경계뿐만아니라호흡재활치 료의전략수립측면에서도연구의필요성이제시된다. 따라서이연구는임상적으로파킨슨병환자의자세변형에대한 유용한정보와자세변형조기관리프로그램및개선중재프로그램 의기초자료를제공하는데에목적을두고몸통굽힘증이없는 H&Y stage 2-3 인파킨슨병환자의시상면척추골반정렬을등허리, 허리골 반및목골반으로분류하여선자세에서각부위의기울기와임상특 성, 주요운동증상및호흡기능과의상호관련성을분석하고이러한 요소에영향을미치는주요부위와그정도를구명하고자한다. 연구방법 1. 연구대상 D 의료원파킨슨병센터에내원하는 60 세이상환자중 UK Parkinson s disease society brain bank 임상기준에근거하여파킨슨병 (PD) H&Y Table 1. The characteristics of subjects Variable Subjects (n=28) Age (yr) 68.45±5.77 Height (cm) 158.97±9.43 Weight (kg) 59.81±7.93 Upper trunk ( ) 6.27±6.64 Lower trunk ( ) 12.16±5.86 Cervical-pelvis ( ) 7.58±3.85 Duration of treatment (yr) 5.91±6.08 Duration of symptom (yr) 6.82±5.06 Levodopa equivalent dose (mg) 577.08±353.62 H&Y (stage) 2.39±0.45 Freezing of gait (score) 0.58±0.93 Rigidity (score) 6.41±3.83 Posture (score) 0.98±0.21 Gait (score) 0.96±0.47 Total motor (score) 32.58±9.68 Total UPDRS (score) 46.3±14.5 VC (L/s) 2.33±0.99 FVC (L/s) 7.99±30.18 FEV 1 (L/s) 2.12±0.55 FEV 1/FVC (%) 91.72± 5.87 25-75% FEF (L/s) 3.05±0.92 PCF (L/s) 413.07±82.39 Values are presented as mean± standard deviation, Mean± SD. H&Y: Hoehn and Yahr, UPDRS: unified Parkinson s disease rating scale. www.kptjournal.org 123
The Journal of Korean Physical Therapy DongYeon Kang, et al. stage 2-3으로판정된 28명 ( 남 : 17, 여 : 11) 이다. 이들은자립보행으로일상생활이가능하고인지장애 (K-MMSE 24점 ) 가없으며최근 1년이내급 만성호흡기질환및심혈관질환을진단받지않았고근골격계질환이나척추관련질환으로외과적수술을받지않았다. 그리고 Movement disorder society unified parkinson`s disease rating scale (MDS-UPDRS) part III의자세항목에서 2 (score) 이하에해당되고시상면의목골반기울기가 15 이하인자 6 들이다. 그리고모두연구의목적을이해하고동의하였다. 이연구에서는표본집단의평균값과빈도분석에의해산출된중앙값을기준으로하여허리골반의시상면기울기가 12 이하집단 (n = 14) 과 12 초과집단 (n = 14) 으로분류하였다. 이들의일반적인신체적특성은다음과같다 (Table 1). 2. 실험방법 1) 측정도구 ⑴ MDS-UPDRS 이연구에서는 I. 정신, 행동및정서, II. 일상생활활동, III. 운동기능검사, IV. 약물치료에서나타나는부작용 ( 이상운동유무 ), V. modified H&Y, VI. 일상생활평가척도 (modified schwab and england activities of daily living, SEADL) 로구성된 MDS-UPDRS 21 를사용하였고신경과전문의에의해평가되었다. 6개항목중장애정도를나타내는 V. modified H&Y stage III, 운동기능검사의총점과세부항목중보행동결, 경직, 자세, 보행점수를사용하였다. 모든항목의점수가높을수록증상이심한것을나타낸다. 용하였고영상자료의샘플링주파수는 100 Hz로하였으며수집된자료는 Butterworth low-pass filter 2차, 차단주파수 6 Hz로필터링하였다. 22 모든대상자들은실험을위해 12시간동안약물복용을금지하였고밀착된상하의복장을착용하였다. 모든절차는선행연구 23 를참고하였다. 신체모델은 Vicon plug-in-gait model에기반하였고 14 mm 반사마커를부착하고해부학적자세로서서정면의표식을주시하였다. 자료는시작음이울리고 5초동안수집하였다. 각부위의중앙점은목 (cervical point) 은쇄골과 C7 마커를이은선의중간, 등허리 (thoracic point) 은흉골과 Th10 마커를이은선의중간그리고골반 (pelvic point) 은좌우 ASIS 마커와 PSIS 마커의중간지점으로하였다. 또한기저면은좌우측발가락과뒤꿈치마커의중간지점으로하였고질량중심점은 Vicon plug-in-gait model의중심점을신체에적용하여산출하였다. 이연구에서는이것을토대로하여등허리 (upper trunk) 의내측각도는목과몸통의중앙점을이어서, 허리골반 (lower trunk) 은몸통과골반의중앙점을이어서벡터와벡터의내적을산출하였다. 또한목골반 (cervical-pelvis) 기울기는몸통이광역좌표계의수직축에서전방으로기운정도를산출하였고전방으로기울때값을양 (+), 후방으로기울때값을음 (-) 으로나타낸다 (Figure 1). 3. 자료처리모든자료처리는 SPSS 18.0 Ver. 을이용하여각항목의평균 (M) 과표 (2) 폐기능검사 (pulmonary function test, PFT) PFT는선행연구 1 를참고하였다. PFT 측정은 spirometer (SP 205 spirometer, Schiller, USA) 를이용하여폐활량 (VC)(L/s), 노력성폐활량 (FVC)(L/s), 1초간노력성호기량 (FEV 1)(L/s), 최고호기유량 (peak cough flow, PCF)(L/s) 그리고 25-75% 강제호기유량 (25-75% forced mid-expiratory flow, 25-75% FEF)(L/sec) 을측정하였다. 의자에서 10분동안안정을취한상태에서실시하였고검사자는환자에게측정에대한자세한설명을하여측정의신뢰성을높일수있도록하였다. 측정치는미국흉부학회의가이드라인에따라 3회이상반복측정한후가장큰값을사용하였다. (3) 시상면척추정렬평가이연구의시상면의척추정렬은 6대의적외선카메라로구성된 3D motion capture system (Vicon, MX-T10, Oxford Metrics, Oxford, UK) 을이용하여분석하였다. 영상자료수집및분석은 Nexus software (Vicon, Oxford, UK) 를이 Figure 1. Definitions of points and angles used for postural measurements in patients with Parkinson's disease. 124 www.kptjournal.org
Sagittal Spinopelvic Balance in Patients with PD 준편차 (SD) 를구하였고항목간상호관련성검증을위해상관분석을실시하여 Pearson s correlation coefficient를산출하였고허리골반기울기가 12 이하집단과 12 초과집단의각항목을비교하기위하여 Independent t-test 를실시하였다. 모든통계적유의수준은 p < 0.05 로설정하였다. 결과 H&Y stage 2-3인파킨슨병환자 (PD)(n =28) 의시상면척추정렬, 운동증상및호흡기능의관련성을분석한결과는다음과같다 (Table 2). 허리골반 (lower trunk) 의시상면기울기는이들의치료기간 (r= 0.45), Table 2. Pearson s correlation coefficients among motor symptom and respiratory function related to sagittal alignment in subjects Variable Upper trunk (6.27 ±6.64 ) Lower trunk (12.16 ±5.86 ) Cervical-pelvis (7.58 ±3.85 ) Age (yr) 0.36 0.32 0.02 Duration of treatment (yr) 0.27 0.45 * -0.01 Duration of symptom (yr) 0.34 0.35-0.03 Levodopa equivalent dose (mg) 0.08 0.23-0.14 H&Y (stage) 0.29 0.35 0.15 Freezing of gait (score) 0.04 0.39 * -0.30 Rigidity (score) 0.18-0.09 0.17 Posture (score) -0.23 0.35 * -0.15 Gait (score) 0.25-0.06 0.15 Total motor (score) 0.33-0.02 0.30 Total UPDRS (score) 0.19 0.35 0.06 Upper trunk (score) 1.00-0.06 0.50 * Lower trunk ( ) -0.06 1.00-0.17 Cervical-pelvis ( ) 0.50 * -0.17 1.00 VC (L/s) 0.02-0.16-0.02 FVC (L/s) 0.22-0.23-0.88 FEV 1 (L/s) -0.03-0.29-0.20 FEV 1/FVC (L/s) 0.00-0.15-0.43 25-75% FEF (L/s) 0.00-0.32-0.12 PCF (L/s) -0.16-0.28-0.14 Mean±SD. H&Y: Hoehn and Yahr, UPDRS: unified parkinson s disease rating scale. * p<0.05. Table 3. Comparisons of motor symptom and respiratory function related to degrees of the lower trunk in subjects variable Below 12 degrees group (n=14, m: 9, f: 5 ) Excess 12 degrees group (n=14, m: 8, f: 6) p-value Lower trunk angle ( ) 7.81±3.63 16.52±4.18 <0.001 Age (yr) 66.27±4.96 70.64±5.85 0.043 Duration of treatment (yr) 2.70±2.86 7.37±5.43 0.013 Duration of symptom (yr) 4.872±4.32 8.69±5.28 0.049 Levodopa equivalent dose (mg) 467.03±303.32 687.14±376.34 0.100 H&Y (stage) 2.21±0.37 2.57±0.47 0.037 Freezing of gait (score) 0.28±0.46 0.89±1.17 0.085 Rigidity (score) 6.92±3.79 5.89±3.95 0.486 Posture (score) 0.92±0.26 1.03±0.13 0.191 Gait (score) 1.00±0.33 0.92±0.58 0.696 total motor (score) 33.35±8.56 31.82±10.96 0.683 total UPDRS (score) 46.67±13.09 45.92±16.28 0.894 Upper trunk angle ( ) 5.31±7.37 7.37±4.36 0.455 Cervical-pelvis angle ( ) 7.86±3.42 7.30±4.36 0.707 VC (L/s) 2.56±0.59 2.11±1.00 0.235 FVC (L/s) 2.34±0.59 2.22±0.64 0.627 FEV 1 (L/s) 2.23±0.54 1.99±0.57 0.299 FEV 1/FVC (%) 94.46± 3.59 88.75± 6.52 0.012 25-75% FEF (L/s) 3.48±0.85 2.63±0.80 0.012 PCF (L/s) 439.58±13.09 390.35±84.63 0.131 Mean±SD. H&Y: Hoehn and Yahr, UPDRS: unified parkinson s disease rating scale. www.kptjournal.org 125
The Journal of Korean Physical Therapy DongYeon Kang, et al. 보행동결 (r = 0.39) 및자세 (r = 0.35) 와유의한양의상관을보였다 (p< 0.05). 그러나등허리 (upper trunk) 과목골반 (cervical-pelvis) 의시상면기울기는운동증상과호흡기능의모든항목과유의한상관이없었다 (p< 0.05). 임상증상과양의상관을보인허리골반의시상면기울기를 12 초과집단과 12 이하집단으로분류하여운동증상과호흡기능을비교한결과는 12 초과집단이 12 이하집단보다나이 (years), 치료기간 (years), 증상기간 (years) 및 H&Y (stage) 가유의하게높았다 (p< 0.05). 그리고 12 이하집단은 12 초과집단보다 FEV 1/FVC (%) 와 25-75% FEF (L/s) 에서유의하게높게나타났다 (p < 0.05)(Table 3). 고찰파킨슨병환자의임상진료에서시상면자세변형이중요한이유는임상지표와의관련성뿐만아니라척추골반과시상면균형이자세조절과하지의보상메커니즘에도영향을미치는이유때문이다. 13,14 이들의자세변형에대한발생메커니즘에대해서는현재까지명확히알려져있지는않다. 그러나자세안정이척추주변의굽힘근과폄근의적절한동시수축에의해이루어진다는측면에서설명한다면환자의자세가앞으로굽어지는것은바닥핵의과잉반응에의한몸통굽힘근의기능항진때문이며또한운동장애에대한보상반응의하나로이해될수있다. 7 이연구에서파킨슨병 H&Y (stage) 2-3 의 28명 (68.45 years) 을대상으로시상면척추골반정렬을등허리, 허리골반및목골반으로분류하여임상특성, 주요운동증상및호흡기능과관련성을분석하였다. 그리고그결과에서상호관련성을보인허리골반기울기를 12 이하집단 (n=14, 7.810± 3.63 ) 과 12 초과집단 (n=14, 16.520± 4.18 ) 으로분류하여각항목을비교하였다. 이러한분류기준은파킨슨병환자를대상으로이연구에서동작분석기를통해측정하여산출한방법과유사한선행연구를참고할수없어표본집단의평균값과빈도분석에의해산출된중앙값을기준으로임의로정하였다. 선행연구 6,8 에서는파킨슨병이진행되면서나타나는앞으로굽은자세의기준을약 25 를초과하지않는것으로제시하고있지만몸통굽힘증은약 15-45 의불수의적인등허리굽힘으로정의하고있다. 20 현재까지파킨슨병환자의자세와임상특성, 주요운동증상과관련된대부분의선행연구는이러한환자의구분없이다양한측정도구 (X-ray 10,13, SpinalMouse 7, 줄자 12 ) 를사용하여진행되었다. 그러나이연구에서는몸통굽힘증이나타나지않은파킨슨병환자의자연스러운일상생활에서서있는자세에대한자료를수집하기위해동작분석기 (motion analysis) 를사용하였다. 그러므로선행연구결과와구체적으로비교및논의하는데에많은제한점이있다. 이연구에서는허리골반기울기가치료기간 (r= 0.45), 보행동결 (r = 0.39) 및자세 (r = 0.35) 와양의관련성을보였다. 따라서이러한주요결과에대해선행연구를참고하여다음과같이논의하였다. 먼저대상자의치료기간은상관분석뿐만아니라허리골반기울기가 12 초과한집단 (n =14) 과 12 이하인집단 (n =14) 의비교분석에서도큰허리골반기울기가상대적으로작은것보다치료기간이긴것으로나타났다. 이러한결과는몸통전체기울기와치료기간의양의관련성을보인연구를 7,15 참고할때비정상적인자세변화가시작되면서나타나는초중기파킨슨병환자의자세특성으로생각된다. 이러한것은이연구의대상자들의치료기간과다음에서제시할자세에대한허리골반기울기의관련성을종합적으로생각해보면더욱그렇다. 이연구의대상자는몸통굽힘증을동반하지않은병의초중기에해당하는경증자세장애대상자로서이들의치료기간이길어질수록허리골반이앞으로기울어진다는것을생각해보면초중기파킨슨병환자의자세변형은허리골반부에서시작된다는가능성을제시할수있다. 자세변화와비정상적인근긴장은요추디스크및연부조직과요추의골격구조에스트레스를증가시킬수있다. 따라서몸통굽힘증이나피사증후군과같은몸통의근긴장이상은파킨슨병환자의척추위치이상의원인이될수있으며 24,25 그리고기본적으로시상면척추정렬의주요요소는골반이다. 13 이러한측면에서본다면파킨슨병환자의자세변화와허리기울기의관련성은충분히제시될수있고이연구의결과는몸통굽힘증을동반하지않은초중기환자자세변형의특성으로생각될수있다. 그리고이연구에서이연구의대상자의허리골반기울기가클수록 FOG정도가심하다는결과에대한설명은선행연구에서는환자가스스로자세교정이가능한단계라면이들의앞으로굽은자세는 FOG를겪는환자의보행개시에도움이된다고하였다. 그이유는자세가앞으로굽어지면서질량중심 (center of mass, COM) 이앞으로이동하게되어보행을시작하기위한자세조절이용이하기때문이다. 12,26,27 이러한관점에서본다면허리골반기울기만으로복잡한발생메커니즘에서비롯되는 FOG를설명할수는없지만, 이연구의결과에대한설명이가능하다. 대상자 (n = 28) 의허리골반기울기는 MDS- UPDRS의 III. 운동기능검사중자세 (score)(r= 0.35) 와유의한관련성을, 환자의자세를측정하여얻은실측치에서는목골반기울기와등허리기울기가유의한상관 (r = 0.50) 을보였다 (Table 2). 이러한결과는환자의운동기능과관련된자세평가와정적인자세만의평가결과의차이점에서비롯된것으로생각된다. 이들의자세평가는파킨슨병환자의치료반응을평가하기위한임상척도로사용 1 되는 MDS-UPDRS의 III. 운동기능검사에포함된자세항목의점수를적용하였다. 이항목은 0-4척도로이연구의대상자는 0-2 (score) 에해당되며 0 (score) 은정상, 2 (score) 는검사자요구 126 www.kptjournal.org
Sagittal Spinopelvic Balance in Patients with PD 에따라자세를수정할수있는경증정도의자세장애를나타낸다. 따라서대상자의자세는전문의소견상정상에서경증정도의자세장애에해당한다. 그리고실제자세평가는위에서제시하였듯이동작분석기 (motion analysis) 를사용하였다. 따라서이러한평가방법차이에따른결과라고생각한다. 하지만목골반기울기와등허리기울기가유의한상관 (r = 0.50) 을보인것에대해서는분명한설명이어렵다. H&Y (stage) 1-3 인환자 (n=175) 의척추엉치각도 (spinosacral angle, SSA) 는 L1-S1의기울기와상관 (r= 0.78, p < 0.05) 이있는것 13 으로나타났다는것을볼때더욱그렇다. 한편이연구에서허리골반기울기가 12 초과한집단 (n = 14) 은 12 이하인집단 (n =14) 보다나이 (years), 치료기간 (years), 증상발현기간 (years), H&Y (stage) 에서유의하게높았고 FEV 1/FVC (%) 및 25-75% FEF (L/s) 에서는유의하게낮은것으로나타났다 (p < 0.05)(Table 3). 이러한결과는다른연구 8,13,15 에서도자세변화에따른나이, 치료기간및증상발현기간, H&Y (stage) 의상관에대한결과와유사한맥락이다. 그리고 10-17 개월동안파킨슨병환자 190명 (m: 122, f: 68) 의자세변화를나이, H&Y (stage) 및기간, 허리통증과의관련성 (p < 0.05) 을구명한연구 7 에서도참고할수있다. 또한파킨슨병환자의자세와호흡기능에관한연구 19 를살펴보면 60세이상의몸통굽힘증을동반한파킨슨병 (H&Y stage 1-5) 환자 11 명과동일연령대의건강한 10명의호흡기능을바로누운자세와 45 앞으로굽힌자세에따라비교하였다. 그결과파킨슨병환자의자세에따른 FEV 1/FVC (L) 에는변화가없었다 (p < 0.05). 하지만이연구에서는허리골반기울기에따른 FEV 1/FVC (%) 및 25-75% FEF (L/s) 의차이를확인하였다. 일반적으로몸통구힘증과같은앞으로숙이는자세는가슴확장을제한하여폐기능을저하시키는원인이된다고하였다. 이연구에서 28명의몸통굽힘증이없는파킨슨병 (H&Y stage 2-3) 환자의시상면자세와임상특성, 주요운동장애및호흡기능의관련성에대해분석하여첫째, 몸통굽힘증이없는파킨슨병초중기환자의시상면균형에서의미있는것은허리골반기울기이며이것이증가할수록 MDS-UPDRS 의 III. 운동기능검사항목중자세및보행동결장애정도가심하다. 둘째, 이연구에서허리골반기울기가큰사람은기울기가상대적으로작은사람보다나이가많고증상발현및치료기간이길었고호흡기능이저하되어있다는결론을얻었다. 이연구의흥미로운점은몸통굽힘증이없는파킨슨병초중기환자의허리골반기울기의중요성을새롭게제시함으로써초중기파킨슨병환자의자세변형에대한유용한정보를제공하였다는것이다. 그러나이연구에는대상자수가적고 X-ray 촬영등을통해산출된임상적파라미터를구체적으로분석하지않았고파킨슨병환자에서발생률이비교적높은만성요통과의관련성을제시하지못해이연 구의결과를다른연구결과와충분히비교및분석하여이해하지못 하는아쉬움이존재한다. 따라서초중기파킨슨병환자의자세균형 에서허리골반기울기의의미를재확인하고이들의자세변형에대한 조기관리프로그램및개선중재프로그램의신뢰도높은기초자료 를제공하기위해서임상파라미터사용과효과크기 (effect size) 등을 고려한향후연구가계획되어야할것으로생각된다. REFERENCES 1. Kang DY, Cheon SM, Lee KS et al, Correlations amang respiratoty function, UPDRS and senior fitness in Parkinson s disease patients. J Kor Phys Ther. 2014;26(2):48-55. 2. Bang DH, Noh HJ. Effects of aerobic exercise on disease severity and walking ability in patients with Parkinson s disease. J Kor Phys Ther. 2016;28(4):227-31. 3. Song HS, Kim JY. Clinical feasibility of mental practice for gait ability improvement of Parkinson disease patients: ABA single subject design. J Kor Phys Ther. 2014;26(6):398-402. 4. Lee DK, Kim EK, Kim YN et al. Effects of a virtual reality training program on balance and lower muscular strength of Parkinson s disease patients. J Kor Phys Ther. 2013;25(2):96-102. 5. Capecci M, Serpicelli C, Fiorentini L et al. Postural rehabilitation and Kinesio taping for axial postural disorders in Parkinson s disease. Arch Phys Med Rehabil. 2014;95(6):1067-75. 6. Doherty KM, van de Warrenburg BP, Peralta MC et al. Postural deformitiesin Parkinson s disease. Lancet Neurol. 2011;10(6):538-49. 7. Khlebtovsky A, Djaldetti R, Rodity et al. Progression of postural changes in Parkinson s disease: quantitative assessment. J Neurol. 2017;264(4): 675-83. 8. Benninger F, Khlebtovsky A, Roditi Y et al. Beneficial effect of levodopa therapy on stooped posture in Parkinson s disease. Gait Posture. 2015; 42(3):263-8. 9. Nair P, Bohannon RW, Devaney L et al. Reliability and validity of nonradiologic measures of forward flexed posture in Parkinson disease. Arch Phys Med Rehabil. 2017;98(3):508-16. 10. Bissolotti L, Gobbo M, Villafañe JH et al. Spinopelvic balance: new biomechanical insights with clinical implications for Parkinson s disease. Eur Spine J. 2014;23(3):576-83. 11. WilczyNski J, Pedrycz A, Mucha D et al. Body posture, postural stability, and metabolic age in patients with Parkinson s disease. Biomed Res Int. 2017;2017:1-9. 12. Mikami K, Shiraishi M, Kawasaki T et al. Forward flexion of trunkin Parkinson s disease patients is affected by subjective vertical position. PLoS One. 2017;12(7):1-9. 13. Bissolotti L, Berjano P, Zuccher P et al. Sagittal balance is correlated with Parkinson s disease clinical parameters: an overview of spinopelvic alignment on 175 consecutive cases. Eur Spine J. 2017;26(4):471-8. 14. Forsyth AL, Paul SS, Allen NE et al. Flexed truncal posturein Parkinson disease: measurement reliability and relationship with physical and cognitive impairments, mobility, and balance. J Neurol Phys Ther. 2017; 41(2):107-13. www.kptjournal.org 127
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