Journal of Korean Medicine Rehabilitation Vol. 27 No. 2, April 2017 pissn 1229-1854 eissn 2288-4114 https://doi.org/10.18325/jkmr.2017.27.2.55 Review Article 섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 이정민대전대학교한의과대학한방재활의학과교실 Literature Review of Korean Medicine Studies for Fibromyalgia Syndrome (FMS) Jung-Min Lee, K.M.D. Department of Korean Medicine Rehabilitation, College of Korean Medicine, Dae-Jeon University RECEIVED March 16, 2017 REVISED April 4, 2017 ACCEPTED April 12, 2017 CORRESPONDING TO Jung-Min Lee, Department of Korean Medicine Rehabilitation, College of Korean Medicine, Dae-Jeon University, 75 Daedukdaero 176bun-gil, Seo-gu, Daejeon 35235, Korea TEL (042) 470-9424 FAX (042) 470-9005 E-mail mogli01@hanmail.net Objectives This study aimed to review studies in Korean medicine for fibromyalgia syndrome (FMS). Methods We conducted search across 3 electronic databases (Korean traditional knowledge portal, RISS, Oasis) to find studies for FMS in Korean medicine. Studies of Korean medicine for FMS were included and analysed. Results 15 studies were included. 2 studies were reviews and 13 studies were case reports. Total numbers of patients in case studies were 15. In case studies, acupuncture (100%), herbal medicine (76.9%), Korean physical therapy (69.2%), pharmacopuncture (53.8%), Chuna (46.1%) and moxibustion (30.7%) etc. were used. BL23 in acupuncture and CV12 in moxibustion were most frequently used. Gamisoyo-san in herbal medicine and visual analogue scale (VAS) in outcome measure were most frequently used. Conclusions This systematic review found encouraging but limited evidence of Korean medicine for FMS. I expect various trials such as randomized clinical trial or animal experimentation and more case reports. And systemic review for FMS in other national journals is needed. (J Korean Med Rehabil 2017;27(2):55-66) Copyright 2017 The Society of Korean Medicine Rehabilitation Key words Fibromyalgia, Fibromyalgia syndrome, FMS, Korean medicine, Systemic review 서론»»» 섬유근통증후군 (fibromyalgia syndrome, FMS) 이란근육과결합조직통증을의미하는것으로, 만성적으로전신에걸쳐넓게나타나는통증과피로, 압진에의해증가되는통증등을특징으로한다. 만성적인수면장애, 우울증, 불안, 두통, 근육경련, 사지의위약감, 피부지각장애, 심계항진등을호소하며이외에도기립성현훈, 배변장애, 과민성장및방광증상, 집중력감소등의다양한증상이 나타난다. 아직까지정확한원인은알려지지않았지만정신적, 유전적, 신경생물학적, 환경적인자등의요인에의한것으로추정하고있다 1). 섬유근통증후군은장기적인경과를보이며, 3차의료기관을내원한대다수의환자들이일생동안증상을가지고있다. 이로인해취업이나삶의질에부정적인영향을받는다. 그러나현재뚜렷이효과를보이는보편적인치료방법은없으며, 현재의치료방법은증상에대한관리가치료의주를이룬다. 일반적인치료법으로소염진통제및 www.e-jkmr.org 55
이정민 항우울제등의약물요법과인지행동요법, 운동요법, 최면요법, 수치료, 마사지등의비약물요법이있다. 환자들중약 90% 가한번이상보완대체의학적치료를받은경험이있다고알려져있다 1-3). 국민건강보험공단이건강보험진료비지급자료를분석한내용에따르면, 국내에서섬유근통으로진료를받은사람은 2009년 41,008명에서 2014년 72,756명으로연평균 12.2% 증가하였으며, 건강보험에서섬유근통진료에지급된총진료비는 2009년약 51억원에서 2014년약 143억원으로증가하여연평균 23.0% 증가하였다 4). 한의학에서는침, 약침, 추나, 한약등다양한치료를활용하고있으며, 국내한의계에서는 2004년이후섬유근통증후군에대한연구가발표되었다. 총 15개의논문중이등 5) 과이등 6) 의연구를제외한 13개의논문이증례논문이었다. 모든증례논문은단독요법이아닌복합적치료를시행하였으며, 그치료법또한다양하다. 보고된논문에대한한의학중재법사용에대한동향조사나체계적문헌고찰은보고되지않았다. 이에저자는향후섬유근통증후군의임상치료에서그간보고된중재법및평가도구를활용하고, 향후섬유근통증후군에대한연구설계에도움이되고자하는목적으로국내에서발표된섬유근통증후군관련한의학논문을조사하였다. 수집한논문을종류에따라분류및분석하고, 증례논문에대해중재법, 평가도구등을중심으로분석한내용을보고하고자한다. 2. 자료추출 1차선정시에는검색된논문들의제목과초록을통해검토하였으며, 2차배제시에는원문을모두검토하여선정하였다. 자료추출은 1명의저자에의해수행되었고, 국내에서발간된논문중한의학과관련된논문을모두선정하였다. 3. 포함연구자료분석최종선정된각논문들의원문을검토한뒤핵심정보를추출하였다. 선정된논문들을연구종류에따라분류하고, 증례논문에대하여환자, 적용된중재, 평가도구, 주요결과등을각논문별로정리하여서술적인분석을하고, 이를표로정리하였다 (Table I). 결과»»» 1. 검색과정및결과 3개의데이터베이스에서섬유근통, 섬유근육통으로검색된논문은총 125편이었으며, 한의학과의관련성이없는논문을제외한후총 26편이남았다. 이후중복되는논문을제외하여총 15편이선정되었다. 선정된논문중 2편은종설논문이었고, 13편은증례논문이었다 (Fig. 1). 대상및방법»»» 1. 데이터베이스선택및검색국내에발표된모든논문을대상으로한국전통지식포탈 (http://www.koreantk.com), 학술연구정보서비스 (http:// www.riss.kr), 오아시스 (http://oasis.kiom.re.kr) 의 3가지온라인데이터베이스를활용하여섬유근통 (fibromyalgia) 에대한연구를검색하였다. 각데이터베이스의자료는기간제한없이학위논문과국내학술지논문을대상으로하였으며, 검색어는 섬유근통, 섬유근육통 으로하였다. 2. 연도별논문과증례수섬유근통관련한의학논문은총 15편으로 2004년에 2 편이발표된이후 2008년을제외하고매년꾸준히발표되었으며, 2014년에 3편으로가장많이발표되었다. 그중종설논문은논문 5편에대한연구로 섬유근육통의중의학적치료에대한문헌적연구 가 2004년에발표되었고, 2007년에는논문 6편에대한 섬유근통증후군에대한침치료의연구동향 이발표되었다. 13편의증례논문의총환자수는총 15명으로, 2006년과 2014년에발표된논문이각 2명의환자를보고하였으며, 나머지논문은각 1명의환자를보고하였다 (Fig. 2). 56 J Korean Med Rehabil 2017;27(2):55-66
섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 Table I. Characteristics of Case Studies of Fibromyalgia First author (year) Number of cases, patient(s) (gender/age), treatment period Intervention Acupuncture Moxibustion Herbal medicine etc. Outcome measures Main result Kim 7) (2004) Cho 8) (2005) Lee 9) (2006) Jeong 10) (2009) Yim 11) (2010) Lee 12) (2011) Kim 13) (2012) n=1, F/61, 8 days n=1, F/46, 28 days n=2 1. M/21, 54 days (11 times) 2. M/22, 57 days (12 times) 1. GV5, GV4, GV3, GV2, BL22, BL23, BL25, BL24, GB30, Palyo, Yoan 2. Electroacupuncture 1. BL23, GV3, BL60, KI3, GB30, ST36, BL40, GB41, etc. 1. BL23, BL24, BL25, GB30, BL40, GB34, BL60, ST36, GB20, GV16, BL1, GV14, TE17, quadratus lumborum TP, iliopsoas muscle TP 2. Ohaeng acupuncture: HT7 (tonification), HT3 (sedetion) None None 1. Physical therapy: TENS, micro wave 2. Chuna 3. Traction CV12, ST25 1. Gamisoyo-san 2. Hyangsayukgunja-tang 1. Physical therapy: Iontophoresis (Aconiti ciliare tuber, Plantaginis asiatica L.) None None 1. Physical therapy: cupping, TENS, hot pack 2. Chuna 3. Psychology consultation n=1, F/60, n.r. n.r. n.r. 1. Keuibi-tang 2. Cheongsimhwadam-jeon+ Keuibi-tang 3. Chungsanggyuntong-tang 4. Jeongkicheonhyang-tang n=1, F/46, 31 days n=1, F/43, 1) 19 days, 2) 12 days n=1, F/46, 1) about 3 weeks 2) about 3 weeks 1. Low pack and leg 2. Warming acupuncture: neck, low back etc. 1. Hwa acupuncture: GV20, GV26, CV24, HT8, KI10, GB41, BL66, ST36, SP3, LR1, LI1, etc. LR3, PC6, Gyunjung, Knee point (Seuljum), SP3, LI11 None 1. Gamisamul-tang 2. Daeyoung-jeon gami 3. PRN: Gamisoyo-san, Jebyungtongchi-wan, Mahaenggamseok-tang, etc. None 1. Shihogyejikungang-tang 2. Jisilhaebaekgyeji-tang 3. Buja-tang None 1. Dokhwal-tang gami 2. Insampaedok-san 3. Gyejigagalgeun-tang gami 4. Hyangso-san gami 2. Other symptoms 2. ROM 3. Physical test 2. FMS tender point 1. Physical therapy 1. Symptom 1. ND 1. Physical therapy: cupping, IFC, TDP, Ultra sound, special thermal sand bed 2. Isolytic MET 1. Pharmacopuncture: Ginseng, Samgihwalryeok, Hominis placenta, SBV 1. Physical therapy: hot pack, TENS 2. Pharmacopuncture: SBV, Soyeom, Sciatic 3. Burning acupuncture 1. Symptom (pain) 2. SF-MPQ 3. PRS 3. Improved www.e-jkmr.org 57
이정민 Table I. Continued First author (year) Number of cases, patient(s) (gender/age), treatment period Kim 14) (2013) n=1, F/38, about 30 days Bae 15) (2014) Lee 16) (2014) n=2 1. F/23, 21 days 2. F/39, 59 days n=1, M/31, 20 days Jang 17) (2014) n=1, F/47, 84 days Kim 18) (2015) n=1, F/44, 1) 21 days (ADM) 2) 32 days (OPD) Intervention Acupuncture Moxibustion Herbal medicine etc. 1. LI4, LR3, GV20, Taeyang, 4 points around GV20 (Sasinchong), ST36 and abdominal area 2. Electroacupuncture: both ST36, ST37 ST36, CV4, GB21, SP6, LI11, BL23, LR3 1. Baesu spots of Joktaeyang-bangkwang-kyeong and acupoints around pain area 2. Electroacupuncture 1. (1 62 days) GV16, GV14, SI11, G21, BL23, GV3, GB30 2. (1 62 days) Sa-am acupuncture: Stomach-tonification, Lung sedating acupuncture, Gall bladder-tonification, Samcho-tonification etc. 3. (63 84 days) Pyung-hyung acupuncture: nuchal pain (Gyungtong), shoulder pain (Gyuntong), low back pain (Yotong), gluteal pain (Duntong), knee pain (Seultong), wrist pain (Wantong), ankle pain (Gwatong), hemiplegia (Pyuntan) 1. n.r. 2. Electroacupuncture 1. Direct: CV13, CV12, CV10, ST21, CV3, CV4 2. Indirect: CV12, CV4 1. Gyeji-tang gami 2. Sungyangikgibuja-tang gami 3. Sipimikwanjung-tang gami 4. YoungsunJaetong-em 5. YoungsunJaetong-em gami 6. Yangyigongjin-dan None 1. Ohyaksungi-san 2. Samhab-tang 1. Physical therapy: TENS 2. Pharmacopuncture: HN, HO, CS 25% 1. Pharmacopuncture: Muscle relaxation 2. Chuna None None 1. Physical therapy: cupping, TENS 2. Chuna 1. Artemisia vulgaris: CV4, CV6, CV12 2. Bamboo salt: both wrist and ankle joint 1. Gamdu-tang 2. Sopunghwalhyeal-tang 3. YoungsunJaetong-em 4. Gamisoyo-san 5. Cheunggansoyo-san 6. Cheongsimbohyul-tang 7. Bunsimgi-eum 8. Sobokchukeo-tang 9. Sabaeck-san 10. Gamiondam-tang 11. Pyungwisangabuja-tang 12. Pyungwi-san gami None 1. Hyungtonghaeul-tang 2. PRN: Galgeun-tang, Macmundong-tang, Jakyakgamcho-tang 1. Physical therapy: cupping 2. Pharmacopuncture: bee venom 25% 3. Chuna 4. Burning acupuncture: sacroiliac-joint, gluteus maximus, quadratus lumborum 1. Physical therapy: cupping, hot pack, ICT, micro wave 2. Pharmacopuncture: bee venom 3. Chuna 4. Aroma therapy Outcome measures 1. NRS 2. Symptom 1) sleep 2) digestion 1. NRS 2. ACR 2. Pain area 2. PRS 1. ACR 1990 2. ACR 2010 3. DITI 4. Yangdorak 5. VAS 6. FIQ 7. BDI Main result 2. 1) Improved 2) ND 3. Improved 4. Improved 5. Improved 6. Improved 7. Improved 58 J Korean Med Rehabil 2017;27(2):55-66
섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 Table I. Continued Intervention Main result Outcome measures Acupuncture Moxibustion Herbal medicine etc. Number of cases, patient(s) (gender/age), treatment period First author (year) 3. Improved 4. Improved 2. ACR 2010 3. DITI 4. FIQ 1. Physical therapy: cupping, ICT, micro wave, infra red, TDP 2. Pharmacopuncture 1) Bee venom 10%, Hwangryunhaedok-tang 2) Hwangryunhaedok-tang, Hominis placenta 3. Aroma therapy None 1. Samchulkunbi-tang gami 2. Daikangwhal-tang gami 1. GB21, SI15, BL41, SI11, BL23, BL24, BL25, GV3, GB30, GB29, BL56, BL57, KI6, BL62 2. Electroacupuncture: both BL23, GB21 3. Acupotomy: erector spinae n=1, F/42, 1) 18 days, 2) 17 days Lee 19) (2016) F: female, TENS: Transcutaneous electrical nerve stimulation, VAS: visual analogue scale, ROM: range of motion, M: male, TP: trigger point, FMS: fibromyalgia syndrome, n.r.: not reported, ND: No difference between before and after treatment, PRN: pro re nata, IFC: interferential current, TDP: tending diancibo pu, MET: muscle energy technique, SBV: sweet bee venom, SF-MPQ: short form McGill pain questionnaire, PRS: pain rating scale, NRS: numeric rating scale, ACR: american college of rheumatology preliminary diagnostic criteria, ADM: admission, OPD: out patient department, ICT: interferential current therapy, DITI: digital infrared thermal imaging, FIQ: fibromyalgia impact questionnaire, BDI: Beck depression inventory. 3. 증례논문에서사용된중재방법 13편의증례논문에서총 11종류의중재법이사용되었으며, 침이 13편 (100%), 한약이 10편 (76.9%), 한방물리요법이 9편 (69.2%), 약침요법이 7편 (53.8%), 추나요법이 6편 (46.1%), 뜸이 4편 (30.7%), 아로마요법이 2편 (15.3%), 견인요법, 심리상담, 등분성근에너지기법 (muscle energy technique, MET) 이각각 1편 (7.6%) 에서사용되었다 (Table II). 침치료에온침치료와도침치료가각각 1편 (7.6%), 가열식화침치료가 2편 (15.3%) 에서병행하여시행되었고, 5 편 (38.4%) 에서침전기자극술이사용되었다. 한방물리요법에는 10종류의요법이사용되었으며, 부항요법이 6편 (46.1%), 경피전기자극요법 (transcutaneous electrical nerve stimulation, TENS) 이 5편 (38.4%), 경근중주파요법 (interferential current therapy, ICT; interferential current, IFC) 과혈위극초단파 (micro-wave, M/W), 온열요법 (hot pack) 이각각 3편 (23%), 특정전자파치료 (tending diancibo pu, TDP) 가 2편 (15.3%), 한방통전약물요법, 경피적외선조사요법 (infra red, IR), 혈위초음파요법 (ultra-sound, U/S), 특수보온모래침대가각각 1편 (7.6%) 에서사용되었다. Jeong(2009) 의연구에서는물리치료의구체적인방법은언급되지않았다. 약침요법에는 11종류의약침이사용되었으며, 봉약침이 5편 (38.4%), 자하거약침이 2편 (15.3%) 이사용되었고, 산삼약침, 삼기활력, 소염약침, 좌골약침, 근이완약침, 황련해독약침이각각 1편 (7.6%), 대한면역약침학회에서제조한 HN약침, HO약침, CS약침이각각 1편 (7.6%) 에서사용되었다. 4. 증례논문에서침구치료에사용된혈위 (acupoint) 13편의논문에서침치료에총 63개의혈위가사용되었으며, 2편이상의논문에서사용된혈위는 8개로腎兪 (BL23) 가 5편 (38.4%), 環跳 (GB30) 가 4편 (30.7%), 腰陽關 (GV3) 이 3편 (23%) 에서사용되었고, 大腸兪 (BL25), 氣海兪 (BL24), 足三里 (ST36), 太衝 (LR3), 肩井 (GB21) 이각각 2편 (15.3%) 에서사용되었다 (Table III). Lee(2006) 는요방형근과장요근의 TP (trigger point) 에자침하고오행침법을사용하였고, Lee(2011) 는和鍼에따른迎受補瀉法을, Jang(2014) 은사암침법과평형침법을사용하였다. Jeong(2009) 과 www.e-jkmr.org 59
이정민 Fig. 1. A flow chart of study selection process. Fig. 2. The number of papers and cases of Korean medicine for fibromyalgia. This figure includes 2 literature reviews (2004, 2007). Table II. Intervention Reported in Case Studies of Korean Medicine for Fibromyalgia Intervention Number of papers n (%) Acupuncture 13 (100) Herbal medicine 10 (76.9) Korean physical therapy 9 (69.2) Pharmacopuncture 7 (53.8) Chuna 6 (46.1) Moxibustion 4 (30.7) Aroma therapy 2 (15.3) Traction 1 (7.6) Psychology consultation 1 (7.6) Isolytic MET 1 (7.6) MET: muscle energy technique. Table III. Acupoint in Case Studies of Korean Medicine for Fibromyalgia Intervention Acupoint Number of papers n (%) Acupuncture 腎兪 (BL23) 5 (38.4) 環跳 (GB30) 4 (30.7) 腰陽關 (GV3) 3 (23.0) 大腸兪 (BL25) 2 (15.3) 氣海兪 (BL24) 2 (15.3) 足三里 (ST36) 2 (15.3) 太衝 (LR3) 2 (15.3) 肩井 (GB21) 2 (15.3) Moxibustion 中脘 (CV12) 3 (23.0) 關元 (CV4) 2 (15.3) 60 J Korean Med Rehabil 2017;27(2):55-66
섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 Yim(2010), Lee(2014) 는자침한혈위를보고하지않았다. 13편의논문에서뜸치료에총 8개의혈위가사용되었으며, 中脘 (CV12) 이 3편 (23%), 關元 (CV4) 이 2편 (15.3%) 에서사용되었고, 天樞 (ST25), 上脘 (CV13), 下脘 (CV10), 梁門 (ST21), 中極 (CV3), 氣海 (CV6) 가각각 1편 (7.6%) 에서사용되었다. 5. 증례논문에서사용된처방 13편의논문에서총 40개의처방이사용되었으며, 2편이상의논문에서사용된처방은 3개로加味逍遙散이 3편 (23%), 歸脾湯과靈仙除痛飮이각각 2편 (15.3%) 에서사용되었다 (Table IV). 6. 증례논문에서양약병용치료여부 13 편의논문중 8 개의연구에서한의학적치료와더불 Table IV. Herbal Medicine in Case Studies of Korean Medicine for Fibromyalgia Herbal Medicine Number of papers n (%) 加味逍遙散 (Gamisoyo-san) 3 (23.0) 歸脾湯 (Keuibi-tang) 2 (15.3) 靈仙除痛飮 (YoungsunJaetong-em) 2 (15.3) 어양약을복용하였으며, 나머지 5편의연구에서는양약복용여부를기록하지않았다. 양약을복용한 8개의논문에서총 42개의약물이사용되었다. 단, 동일성분으로구성된약물은동일약물로처리하였다. Jeong(2009) 의논문에서는약물명이나구성에대한언급없이필요에따라수면유도제와비스테로이드성소염진통제를사용하여약물의수에서는제외하였으며, 식품의약품안전처분류에서는각각정신신경용제와해열소염진통제로분류하였다. 42개의약물중 2편이상의논문에서사용된약물성분은총 6개로 Acetaminophen 과 Tramadol HCl가 3편 (23%), Amitriptuline HCl, Cyclobenzaprine, Sodium tianeptine, Hydroxychloroquine sulfate, Zolpidem tratrate 가각각 2편 (15.3%) 에서사용되었다. 식품의약품안전처분류에따라분류하였을때, 정신신경용제가 14건으로가장많이사용되었고, 해열소염진통제와소화성궤양용제가각 5건, 골격근이완제, 기타의소화기관용약, 기타의알레르기용약, 기타의중추신경용약이각 3건, 부신호르몬제, 최면진정제, 항원충제가각 2건사용되었다 (Table V). 7. 증례논문에서사용된평가도구 13편의논문에서총 13개의평가도구가사용되었으며, 시각통증척도 (visual analogue scale, VAS) 가 9편 (69.2%), 2010년미국류마티스학회섬유근통진단기준 (American Table V. Western Medicine in Case Studies of Korean Medicine for Fibromyalgia Classification Component Number of use Psychotropic agents Duloxetine HCl, Etizolam, Amitriptyline, Fluoxetine HCl, Sodium 14 tianeptine, Trazodone HCl, Diazepam, Amitriptuline HCl, Venlafaxine HCl, Milnacipran HCl, Trazodone HCl, Alprozolam Antipyretic-antiinflammatory-analgesics Acetaminophen + Tramadol HCl, Mefenamic acid, Diclophenac 5 sodium Peptic ulcer medications Esomeprazole, Omeprazole, Rebamipide, Ranitidine HCl, 5 Rebeprazole sodium Skeletal muscle relaxant Cyclobenzaprine, Eperisone HCl, 3 Other gastrointestinal medications Metoclopramide, Trimebutine maleate, Domperidone maleate 3 Other anti-allergy medications Olopatadine HCl, Pranlukast hydrate, Azelastine HCl 3 Other central nerve medications Oxiracetam, Pregabalin, Afloqualone 3 Hormone preparations for adrenal gland Prednisolone, Deflazacort, 2 Hypnotics sedatives Zolpidem tratrate 2 Anti-protozoal Hydroxychloroquine sulfate 2 HCl: hydrochloride. www.e-jkmr.org 61
이정민 Table VI. Outcome Measures in Case Studies of Korean Medicine for Fibromyalgia Outcome Measures Number of papers n (%) VAS (visual analogue scale) 9 (69.2) ACR 2010 (American college of rheumatology 3 (23.0) preliminary diagnostic criteria) ROM (range of motion) 2 (15.3) Physical examination 2 (15.3) PRS. (pain rating scale) 2 (15.3) NRS (numeric rating scale) 2 (15.3) DITI (digital infrared thermal imaging) 2 (15.3) FIQ (fibromyalgia impact questionnaire) 2 (15.3) college of rheumatology preliminary diagnostic criteria, ACR 2010) 이 3편 (23%), 관절가동범위 (range of motion, ROM), 이학적검사, 통증척도 (pain rating scale, PRS), 수치통증척도 (numeric rating scale, NRS), 적외선체열진단 (digital infrared thermal imaging, DITI), 섬유근통증후군영향척도 (fibromyalgia impact questionnaire, FIQ) 가각각 2편 (15.3%), 섬유근통증후군압통점검사, SF-MPQ (short form McGill pain questionnaire), 양도락검사, 1990 미국류마티스학회섬유근통진단기준 (American college of rheumatology preliminary diagnostic criteria, ACR 1990), 벡우울척도 (Beck depression inventory, BDI) 가각각 1편 (7.6%) 에서사용되었다 (Table VI). 2편의논문에서는별도의평가도구없이증상의경과를서술형으로나열하였다. 고찰»»» 섬유근통증후군은전신적근육통과피로감을특징으로하는흔한비염증성, 비관절성근골격계질환이다. 강직과수면장애가흔하고, 불안, 우울등의심리적증상이동반되기도하고, 편두통, 후두통, 월경곤란증, 이상감각, 심계항진, 어지러움, 과민성장증후군, 과민성방광이나소화기장애등의증상도나타나기도한다 1,20). 전체인구의약 2 4% 가앓고있으며, 여성과남성의비율이 9:1로여성이압도적이고, 어느연령층에서나나타나지만주로 30 50 세사이에호발한다. 류마티스내과에내원하는환자의 10 20% 가섬유근통증후군환자 로알려져있다 1,2). 국민건강보험공단의분석에따르면, 국내에서섬유근통으로진료를받은환자는 2014년을기준으로 50 70대여성이전체환자의약 40% 를차지하였으며, 50 70대여성중에서섬유근통으로진료받은사람은인구천명당 3 4명인것으로분석되었다 4). 이러한섬유근통증후군의진단기준으로는 1990년미국류마티스학회의분류기준 (ACR) 이가장널리사용되어왔다. 1990 ACR은 3개월이상지속된광범위한통증과함께 18개의압통점중 11개이상에서압통점이있을때섬유근통증후군으로진단한다. 최근 2010 년에발표된미국류마티스학회의진단기준은전신통증지수 (widerspread pain index, WPI) 와증상심각도점수 (symptom severity scale score, SS scale score) 로진단하게되는데, 압통점검사없이설문만으로도진단할수있게되어상당수의만성전신통증환자들을섬유근통으로진단할수있게되었으나, 이기준은환자스스로증상을평가하기때문에증상자체가과대평가될가능성이있다. 최근섬유근통증후군은성향진단 (trait diagnosis) 이라는것이대다수의전문가들의의견이다. 임상에서조직손상이나염증으로설명되지않는다발성통증을호소하는환자들중피로, 수면장애, 집중력및기억력장애등과같은비통증성증상을같이호소할때고려해야하는진단이섬유근통증후군이다 21-23). 현재일반적인치료법으로는진통제나진정제등의약물요법을주로사용하며, 최면요법, 침또는전침, 프롤로테라피, 인지행위요법, 스트레스조절과이완반응훈련등의광범위한치료법이사용되고있다. 그예후는각증례와진료기관및초진상태에따라서상당한차이가있는것으로알려져있으며, 만성질환의일종으로재발이반복되기도한다 24,25). 이에저자는증가하고있는섬유근통증후군환자의치료및삶의질개선을위해국내한의학분야에서발표된섬유근통증후군관련논문을수집하여분석하였다. 본연구에서섬유근통증후군에대한한의학치료법관련논문을수집하여총 15편의논문을최종분석대상으로선정하였다. 그중 2편의논문은종설논문이었고, 13 편의논문이증례논문이었으며, 증례논문의총환자수는 15명이었다. 국외에서는많은환자에대한증례보고 26), 무작위대조군연구 27), 동물실험연구 28) 등의연구들이보고 62 J Korean Med Rehabil 2017;27(2):55-66
섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 되는것이비해다각적접근이이루어지지않고있으며, 그증례의수또한적은편이다. 향후국내연구뿐아니라, 국외에서발표된논문들을토대로보다많고다양한연구가필요할것으로사료된다. 섬유근통증후군에사용된한의학중재법은총 13편의증례논문에서침이 13편 (100%), 한약이 10편 (76.9%), 한방물리요법이 9편 (69.2%), 약침요법이 7편 (53.8%), 추나요법이 6편 (46.1%), 뜸이 4편 (30.7%), 아로마요법이 2편 (15.3%), 견인요법, 심리상담, 등분성근에너지기법 (muscle energy technique, MET) 이각각 1편 (7.6%) 에서사용되었다 (Table II). 섬유근통증후군의치료에매우다양한치료법이사용되었다. 이는국소부위가아닌여러부위에통증이나타나며, 자율신경계부조와관련된증상이나정신의학적증상등비통증성증상또한다양하게나타나는섬유근통의특성에따라그치료에있어여러방향에서의다양한접근이시도되었음을보여준다. 모든증례논문에서단일치료법이아닌복합치료법을사용하였다. 이에따라각중재법의효과에대한개별적평가가어려우나, 복합치료의결과로는양호한치료효과를나타내었다. 향후이러한논문결과들을바탕으로각각의단일치료법에대한효과를입증하고, 나아가환자의상태및변증등에따라각단일치료법들의효과까지입증한다면, 보다효율적이고개개인에게가장적합한세부적분석에의한치료를시행할수있을것으로생각된다. 증례논문에서사용된중재법중한방물리요법은부항요법이 6편 (46.1%), 경피전기자극요법 (TENS) 이 5편 (38.4%), 경근중주파요법 (ICT, IFC) 과혈위극초단파 (M/W), 온열요법 (hot pack) 이각각 3편 (23%), 특정전자파치료 (TDP) 가 2편 (15.3%), 한방통전약물요법, 경피적외선조사요법 (IR), 혈위초음파요법 (U/S), 특수보온모래침대가각각 1 편 (7.6%) 에서사용되었다. 한방물리요법이섬유근통증후군치료의중재법중세번째로많이사용되었으며, 그종류도매우다양하게사용되었음을알수있다. 현재한방물리요법중극히일부의요법만급여해당항목으로지정되어있다. 실제적으로한방치료에서한방물리요법이매우많이그리고다양하게사용되어있지만, 환자에게급여해택을주지못하고있다는점이아쉬움으로생각된다. 약침요법은네번째로많이사용된중재법으로, 이에 11종류의약침이사용되었다. 이러한결과를통해한의학에서섬유근통증후군의치료에침치료, 한약치료가가장보편적으로사용되었으며, 한방물리요법과약침요법의활용이적극적이고다양하게이루어지고있음을나타낸다. 섬유근통증후군의침치료에사용된혈위는腎兪 (BL23) 가 5편 (38.4%), 環跳 (GB30) 가 4편 (30.7%), 腰陽關 (GV3) 이 3편 (23%) 에서사용되었고, 大腸兪 (BL25), 氣海兪 (BL24), 足三里 (ST36), 太衝 (LR3), 肩井 (GB21) 이각각 2편 (15.3%) 에서사용되었다. 또한요방형근과장요근의 TP에자침을하거나, 오행침법, 화침, 사암침법, 평형침법을활용한증례들이보고되었다. 가장많이활용된혈위들을보면, 통증이있는부위의혈위를활용한경우가가장많았고, 다양한침법이활용되었다. 다양한침법이활용된증례의수가적으나, 모든증례에서좋은경과를나타내었다. 이러한증례보고를바탕으로향후다각적시각으로다양한침법에대한보다적극적이고많은연구가이루어지기를기대한다. 뜸치료에사용된혈위는中脘 (CV12) 이 3편 (23%), 關元 (CV4) 이 2편 (15.3%) 에서사용되었고, 天樞 (ST25), 上脘 (CV13), 下脘 (CV10), 梁門 (ST21), 中極 (CV3), 氣海 (CV6) 가각각 1편 (7.6%) 에서사용되었다. 이는통증부위의혈위를주로활용한침치료와는차이를나타낸다. 중완혈은和胃氣, 化濕滯, 理中焦, 調升降의작용이있어제반소화기질환, 허로와같은소모성질환, 불면등과같은신경질환, 고혈압, 중풍등과같은순환기질환에응용할수있으며 29), 관원혈은기혈의조정, 신장의기능강화를통한수분대사의조절, 전신의기능향상을통한질병의치료와예방및자양강장의혈성을가지고있다 30). 이러한혈위를사용한것은음양의부조화와기혈의불균형을조절하여경락을소통시키고질병을예방하고치료하는데효과가있으며 31), 진통효과, 신경의억제또는흥분, 작용혈행의촉진작용, 영양상태증진, 흡수능력의활성, 각종분비선의기능조절, 자연치유능력증진의효능등이있는 32) 뜸치료의특성과관련이있을것으로생각된다. 섬유근통증후군의한약치료에사용된처방은매우다양하였으나, 그중가미소요산이 3편 (23%), 귀비탕과영선제통음이각각 2편 (15.3%) 에서사용되었다 (Table IV). 가미소요산은鬱症에사용하는대표방으로七情鬱結로인하여발생되는寒熱, 上氣, 頭暈, 脇痛, 倦怠, 女子經水不調, 心悸, 口苦등의증에활용되고있는처방이며 33), www.e-jkmr.org 63
이정민 그간의연구를통하여항우울작용, 항불안작용의효과를나타내었으며 34,35), 스트레스에의한여성울증환자의치험례에서양호한효과가보고된바있다 36). 귀비탕은精氣益血, 養心健脾하는작용으로思慮過度, 勞傷心脾로인한健忘, 怔忡, 不眠, 發熱등貞神過渡로인한제반증상에두루응용되는처방으로, 스트레스에의한뇌손상에대한신경보호효과와항스트레스및항우울효과가보고된바있다 37-39), 영선제통음은동통의치료에빈용되는처방으로, 진통및소염작용이보고되었다 40). 섬유근통증후군의한약치료에서스트레스및울증등신경정신과적접근이이루어졌으며, 주증상인통증에대한직접적인처방이사용되었음을알수있다. 섬유근통증후군의치료에양약을병용하여치료한경우, 정신신경용제가 14건으로가장많이사용되었고, 해열소염진통제와소화성궤양용제가각 5건, 골격근이완제, 기타의소화기관용약, 기타의알레르기용약, 기타의중추신경용약이각 3건, 부신호르몬제, 최면진정제, 항원충제가각 2건사용되었다 (Table V). 이는서양의학의약물치료에서도신경정신과적접근과통증에대한직접적치료가우선되어시행되고있음을보여준다. 이러한약물사용은섬유근통증후군의병태생리학적기전에대한연구결과로생각된다. 연구에따르면섬유근통증후군은주로중추통증전달기전의변화가원인인것으로알려지고있다. 명확한기전은밝혀지지않았지만, Serotonin transporter gene과 Catechol-O-methytransferase 효소에서특이다형현상이섬유근통과연관되어있다고보고되었다 41,42). 또한섬유근통증후군환자들중에서시상하부-뇌하수체-부신축의항진과교감신경계의항진을포함한신체의다양한스트레스반응체계에이상이있음도보고되고있다 43). 섬유근통증후군의경과에대한평가도구로시각통증척도 (VAS) 가 9편 (69.2%), 2010년미국류마티스학회섬유근통진단기준 (ACR 2010) 이 3편 (23%), 관절가동범위 (ROM), 이학적검사, 통증척도 (PRS), 수치통증척도 (NRS), 적외선체열진단 (DITI), 섬유근통증후군영향척도 (FIQ) 가각각 2편 (15.3%), 섬유근통증후군압통점검사, SF-MPQ, 양도락검사, 1990 미국류마티스학회섬유근통진단기준 (ACR 1990), 벡우울척도 (BDI) 가각각 1편 (7.6%) 에서사용되었다 (Table VI). 통증이주증상인증후군으로 VAS, PRS, NRS 등의통증에대한주관적평가가주를이루었 고, 이를객관화하기위한방법으로 ACR, 압통점검사등이사용되었다. 또한전신건강상태및신경정신과적평가를위해 DITI, 양도락검사, BDI 등의검사가사용되었다. 향후연구에서세로토닌검사, 심박변이도검사 (heart rate variability, HRV) 등을활용하는것도섬유근통증후군의기전연구및평가에도움이되리라생각된다. 섬유근통증후군에대해국내한의계에서발표된논문에대해위와같은분석결과를얻었다. 2004년이후지속적으로섬유근통증후군에대한연구가진행되고있다. 그러나대부분이증례논문에국한되어있고, 그증례또한부족한실정이다. 증례보고의경우, 단독치료법이아닌복합치료법에대한보고만이루어져각각의치료에대한효과를알아보기에부족한점이있다. 이문헌고찰이향후보다다양하고많은연구의기초자료로활용되고, 임상에서중재법및평가도구를활용하는데도움이되기를기대한다. 또한향후해외에서발표된섬유근통증후군의한의학적치료에대한연구들에대한고찰또한지속적으로이루어져야할것으로생각된다. 결론»»» 1. 선정된 15편의논문은 2004년이후꾸준히발표되었으며, 그중 2편은종설논문이었고, 13편은증례논문이었다. 2. 13편의증례논문에서 15명의증례가보고되었다. 3. 13편의증례논문에서총 11종류의중재법이사용되었으며, 침이 13편 (100%), 한약이 10편 (76.9%), 한방물리요법이 9편 (69.2%), 약침요법이 7편 (53.8%), 추나요법이 6편 (46.1%), 뜸이 4편 (30.7%), 아로마요법이 2편 (15.3%), 견인요법, 심리상담, 등분성근에너지기법 (muscle energy technique, MET) 이각각 1편 (7.6%) 에서사용되었다. 4. 13편의증례논문에서침치료에총 63개의혈위가사용되었으며, 2편이상의논문에서사용된혈위는 8개로腎兪 (BL23) 가 5편 (38.4%), 環跳 (GB30) 가 4편 (30.7%), 腰陽關 (GV3) 이 3편 (23%) 에서사용되었고, 大腸兪 (BL25), 氣海兪 (BL24), 足三里 (ST36), 太衝 (LR3), 肩井 (GB21) 이각각 2편 (15.3%) 에서사용되었다. 5. 13편의증례논문에서총 40개의처방이사용되었으며, 2편이상의논문에서사용된처방은 3개로加味逍遙 64 J Korean Med Rehabil 2017;27(2):55-66
섬유근통증후군의한의학적연구에대한문헌조사 : 국내논문을대상으로 散이 3편 (23%), 歸脾湯과靈仙除痛飮이각각 2편 (15.3%) 에서사용되었다. 6. 13편의증례논문중 8개의연구에서양약복용을병행하였으며, 약물성분은 Acetaminophen 과 Tramadol HCl이가장많이사용되었고, 식품의약품안전처분류에따른정신신경용제가가장많이사용되었다. 7. 13편의논문에서총 13개의평가도구가사용되었으며, 시각통증척도 (VAS) 가 9편 (69.2%), 2010년미국류마티스학회섬유근통진단기준 (ACR 2010) 이 3편 (23%), 관절가동범위 (range of motion, ROM), 이학적검사, 통증척도 (PRS), 수치통증척도 (NRS), 적외선체열진단 (DITI), 섬유근통증후군영향척도 (FIQ) 가각각 2편 (15.3%), 섬유근통증후군압통점검사, SF-MPQ, 양도락검사, 1990 미국류마티스학회섬유근통진단기준 (ACR 1990), 벡우울척도 (BDI) 가각각 1편 (7.6%) 에서사용되었다. References»»» 1. Rehabilitation medicine of Korean medicine. Korean rehabilitaion medicine. 4th ed. Seoul:Koonja publishing Co. 2015:122-6. 2. Wall PD, Melzack R. Textbook of pain I. Seoul:Jungdam. 2002:679-97. 3. Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, McIntosh MJ, et al. A meta-analysis of fibromyalgia treatment interventions. Annals of behavioral medicine. 1999; 21(2):180-91. 4. The ministry of health and welfare. http://www.mohw. go.kr/front_new/al/sal0301vw.jsp?par_menu_id=04&me NU_ID=0403&CONT_SEQ=327592&page=1. 5. Lee JJ, Cho HC, Song YK, Lim HH. The study on literature review of Chinese medical treatment for fibromyalgia. The journal of Korea Chuna manual medicine. 2004;5(1):169-81. 6. Lee SY, Lee YH. Study trends on acupuncture treatment of fibromyalgia. The journal of Korea spine and joints. 2007;4(1):27-35. 7. Kim WY, Park JS, Paek ST, Lee SD. Clinical study on 1 case of fibromyalgia syndromes. The journal of Korea spine and joints. 2004;1(1):13-8. 8. Cho HC, Jang G, Song YK, Lim HH, Cho TY. Clinical research on 1 case of fibromyalgia treated by iontophoresis. Journal of Korea Chuna manual medicine. 2005;6(1):137-46. 9. Lee CH, Lee MJ. Two case report on the patient with fibromyalgia syndrome(fms) with Chuna and acupuncture. The journal of Korea Chuna manual medicine for spine & nerves. 2006;1(1):91-103. 10. Jeong TY, Cho JH, Park BK, Son CG. A case report of symptomatic character and diagnosis of fibromyalgia. The society of Korean medicine. 2009;30(4):162-8. 11. Yim JH, Cho NG. A case report of a patient who has fibromyalgia and received the isolytic MET therapy. The journal of Korea spine and joints. 2010;7(1):43-9. 12. Lee YH, Kim JH, Lee CH, Kim CH, Youn HM. The clinical study on a case of fibromyalgia syndrome(fms) patient case report. Journal of pharmacopuncture. 2011; 14(1):97-104. 13. Kim MC, Kim SH. One case report of fibromyalgia syndrome(fms) patient improved by Korean medical combined treatment. Herbal formula science. 2012;20(1): 149-58. 14. Kim MJ, Kim SK, Ko SJ, Park JW. A case study of Korean medicine treatment for fibromyalgia syndrome(fms). Korea immuno-yakchim society. 2013;2(2): 47-55. 15. Bae YH, Jeon JY, Lim SJ, Lee CH, Kim HS, Kim HS, Song JH, Yeom SC, Kim MH. The case reports of muscle relaxation pharmacopuncture for the two patients with fibromyalgia. The journal of Korea Chuna manual medicine for spine & nerves. 2014;9(2):57-68. 16. Lee EJ, Bang SP, Jo HJ, Kim KY, Kim ST, Park JS, Choi YM, Kim MS, Hwang CH, Chiang SY. A clinical study on one case of a patient with fibromyalgia by Chuna therapy and traditional Korean medicine treatment. The journal of Korea Chuna manual medicine for spine & nerves. 2014;9(1):67-75. 17. Jang HG, Woo CH, Ahn HD. A clinical case study on fibromyalgia syndrome treatd by Pyung-hyung acupunture. The journal of east-west medicines. 2014;39(2):45-58. 18. Kim ES, Shin MK, Kim TR, Oh JS, Ma YH, Lee YS. Fibromyalgia syndrome combined with insomnia and depression 야 sorder managed with Korean medical treatment: a case report. The journal of Korean oriental internal medicine. 2015;36(3):400-9. 19. Lee JY, Kim MS, Yeom SR, Kwon YD. The clinical study on a case of fibromyalgia syndrome patient by Korean medicine treatment. Journal of oriental rehabilitation medicine. 2016;26(4):127-36. 20. Park W. Fibromyalgia. The journal of Korean medicine. 1998;55(4):812-25. 21. Lee SS. Newer diagnostic criteria of fibromyalgia and its clinical implications. Journal of rheumatic diseases. 2011; 18(3):153-60. 22. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katzet RS, Mease P, et al. The American college of rheu- www.e-jkmr.org 65
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