Original Article J Health Info Stat 2017;42(3):269-275 https://doi.org/10.21032/jhis.2017.42.3.269 pissn 2465-8014 eissn 2465-8022 일부여고생과여대생에서의월경곤란증및허리통증과체간근지구력및가동범위 두영택, 정연우 광주여자대학교물리치료학과 Dysmenorrhea, Back Pain, and Muscular Endurance, Angle of the Trunk in High School Girl Students and Women University Students Young Taek Doo, Yeon Woo Jeong Department of Physical Therapy, Kwangju Women s University, Gwangju, Korea Objectives: This study was conducted to investigate the association of dysmenorrhea and back pain during menstruation with muscular endurance and angle of trunk in high school girl students and women university students. Methods: The current study assessed data collected from 49 high school girl students and 50 women university students who participated in self-administered questionnaire survey on dysmenorrhea and back pain and test for measurement of muscular endurance and angle of trunk. A path analysis model was designed. Results: Menstrual distress questionnaire (MDQ) scores on dysmenorrhea and visual analog scale (VAS) scores on back pain were higher in high school girl students than that of women university students. For high school girl students, a path analysis model was designed to evaluate effects of MDQ, VAS on muscular endurance and angle of trunk. When VAS was higher, MDQ was higher and MDQ affected on muscular endurance of trunk negatively. For women university students, the effects of MDQ on VAS was statistically significant (p < 0.05) and when VAS was higher, angle of trunk was smaller. Conclusions: Considering the present result, dysmenorrhea and back pain during menstruation will affect muscular endurance and angle of trunk. Therefore, a proper approach is required to alleviate dysmenorrhea and back pain during menstruation for high school girl students and women university students. Key words: Dysmenorrhea, Back pain, Muscular endurance, Trunk angle 서론 월경은여성에게생물학적, 문화적, 사회적그리고개인적으로중요한의미를갖는총체적인사건으로 [1], 가임기간매달마다주기적으로일어나는자궁출혈을말한다. 월경동안여성들은다양한증상을경험하는데, 이중월경곤란증은개인마다차이가있다. 월경전증후군의정서적증상으로는정서불안, 긴장, 우울, 통제력상실등이있으며, 행 동적증상에는수면장애, 식욕변화, 주의집중곤란, 흥미저하등이있고 [2], 피곤, 오심, 두통, 설사를동반하는쥐어짜는듯심한복통과같은증상이포함된다 [3]. 월경증상발현시기와증상의내용과같은월경의특성은개인의연령에따라다른경향이있다고보고있는데 [4], 15-20세의여성에게서흔히나타나는월경전후기증상은대체로배란주기존재와관련되며월경전증상등을수반하지않는특징을가진다. 반면 35세이후여성 Corresponding author: Yeon Woo Jeong 201 Yeodae-gil, Gwangsan-gu, Gwangju 62396, Korea Tel: +82-62-950-3773, E-mail: pt10335@kwu.ac.kr Received: July 25, 2017 Revised: August 28, 2017 Accepted: August 28, 2017 No potential conflict of interest relevant to this article was reported. How to cite this article: Doo YT, Jeong YW. Dysmenorrhea, back pain, and muscular endurance, angle of the trunk in high school girl students and women university students. J Health Info Stat 2017;42(3):269-275. Doi: https://doi. org/10.21032/jhis.2017.42.3.269 It is identical to the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) whichpermit sunrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 2017 http://www.e-jhis.org 269
Young Taek Doo and Yeon Woo Jeong 들이경험하는증상은월경전에시작해서하복부, 허리및유방에그통증의특징은무거우면서, 끌어들이는것같은둔한그리고지속적인것으로설명하고있다 [5]. 그러나우리나라여성의연령과월경전후기증상정도및유형에관한연구에서 10대여성은생리시작전에복부불편감을호소하는것이가장높았고, 20대여성은생리시작일에허리통증을느낀다고하는것이가장높았으며, 20대여성이다른연령층에비해전반적으로월경증상호소가많고정도도더심한것으로나타났다 [6]. 우리나라여대생을대상으로한연구에서는월경곤란증 13개항목중 증상이매우심하다 고한경우가하복부동통 22.3%, 허리통증 15.9% 로허리통증에대한불편함이높았다 [7]. 우리나라 20세이상성인여성을대상으로월경곤란증을조사한연구에서통증에대한점수가가장높았으며, 통증은 20-24세에서다른연령에비해가장높았다 [4]. 허리통증과허리근력과의관계를알아보기위하여복부근력과허리근력을측정한외국의연구에서는허리통증이허리근력의약화와밀접한관련이있다는사실을발견하였다 [8]. 인간의신체활동은주로굽힘과폄의수축작용에의해서이루어지고있는데그중요통과밀접한관련을갖고있는배근력 [9] 은허리통증이심해지면신체활동에제한을받게되고만성화가될수록척추주변근육의단면적이감소되며 [10], 허리구조및주위조직의변화를가져와체간과복부근력약화와통증및기능제한을가져온다고하였다 [11]. 이와같이여성의월경곤란증은허리통증을유발할수있고, 허리통증은신체활동에제한을가져오게되며만성화될수록체간과복부근력약화와기능제한을가져오게된다. 우리나라연구에서 10대여성은생리시작전에불편감을호소하고 20대여성은생리시작일에허리통증을느끼고증상이심한등월경증상정도및유형이다른것으로보고되고있으나이들을대상으로월경곤란증및허리통증과체간근지구력및가동범위와의관계를체계적으로연구한것은별로없는실정이다. 이에본연구에서는월경곤란증증상의내용과양상이다르다고보고되고있는 10대에속하는여고생과 20대에속하는여대생을대상으로월경곤란증의정도및허리통증, 그리고체간근지구력및가동범위와의관계를알아보고자하였다. 연구방법 연구대상본연구는호남권에소재하는 1개여자고등학교와여자대학교의 3 학년학생을대상으로 2016년 7-8월두달에걸쳐월경곤란증, 허리통증등에대한설문조사와체간근지구력및체간의관절가동범위를 측정하였다. 연구대상자의선정은여고생 60명과여대생 60명을대상으로본연구에대한설명을하고연구참여를동의하였으며설문지를통하여연구조건에충족한여고생, 여대생각각 50명씩총 100명을설문조사시부여한순서대로선정하였고이들을대상으로체간근지구력과체간의관절가동범위를측정하였다. 본연구에서연구조건을충족하는대상자는통증을줄이기위해약물을주기적으로복용하는자, 분만시제왕절개의경험이있는자, 최근교통사고경험이있는자, 자궁질환을진단받았거나질환을갖고있는여성은제외한여고생과여대생이었다. 체간근지구력및가동범위측정에서측정이불완전한여고생 1명을제외하고최종분석대상은여고생 49명, 여대생 50명으로총 99명이었다. 연구의틀우리나라여성의연령과월경전후기증상정도및유형에관한연구에서월경증상은 생리시작전이삼일동안복부팽만감이있다 와 생리가시작되는날에는허리가아프다 가높았고 [6], 우리나라여대생을대상으로한연구에서는월경곤란증 13개항목중 증상이매우심하다 고한경우가하복부동통 22.3%, 허리통증 15.9% 로하복부동통과허리통증에대한불편함이높았고 [7], 20세이상성인여성을대상으로월경곤란증을조사한연구에서통증에대한점수가가장높았으며, 통증은 20-24세에서다른연령에비해가장높았다 [4]. 허리통증은허리근력의약화와밀접한관련이있는데, 요통과밀접한관련을갖고있는배근력 [9] 은허리통증이심해지면신체활동에제한을받게되고만성화가될수록척추주변근육의단면적이감소되며 [10], 허리구조및주위조직의변화를가져와체간과복부근력약화와통증및기능제한을가져온다고하였다 [11]. 이에본연구에서는여성의평소월경곤란증과허리통증은관련이있고, 평소느끼는월경곤란증과허리통증은신체활동에제한을가져오게되며만성화될수록체간과복부근력약화와기능제한에영향을미칠수있는것으로경로를설정하였다. 이때우리나라 10대여성은생리시작전에불편감등의동통을가장호소하였고, 20대여성은생리시작일에허리통증을가장많이느낀다는보고 [6] 가있어월경곤란증의정도가허리통증에영향을미칠수있고, 허리등의체간통증이월경곤란증에영향을미칠수도있는쌍방경로를설정하였다 (Figure 1). 측정방법월경곤란증월경곤란증은월경곤란증척도 (Menstrual Distress Questionnaire, MDQ) 를이용하여 2개월에걸쳐대상자들의생리주기별로월경곤란 270 http://www.e-jhis.org
Dysmenorrhea, Back Pain, Muscular Endurance and Angle of the Trunk in Girl Students Figure 2. Posture of trunk flexor endurance measurement. Figure 1. Structural equation model in current study. 증정도를측정하였다. 측정시기는생리통증이가장심할때하였다. MDQ는신체적통증, 집중력저하, 행동변화, 자율신경계반응, 수분축정, 부정적정서의 6개범주로구성되고 6점척도, 35문항으로된것으로최저 35점에서최고 210점으로점수가높을수록월경곤란증이심한것을의미한다 [12]. 허리통증허리통증은시각적통증척도 (Visual Analog Scale, VAS) 를이용하여평소월경시허리통증의정도를측정하였다. 전혀통증없음의 0 에서극한의통증 10까지의척도를그림으로제시한후해당하는통증정도에표시를하는방법으로측정하는데, 점수가높을수록통증이높은것을의미한다. 근지구력측정굽힘근근지구력측정대상자는바로누운자세에서체간굽힘근검사를실시하였으며, 대상자에게무릎을엉덩이가까이에굽히고턱을앞으로당기고몸통을구부려팔을핀후무릎까지닿는자세를취하게한후부터시작하여최대한으로유지할수있는만큼유지하게한후바닥에닿는시간까지초를측정하였으며근피로방지를위해회당 1분휴식을취하였으며신뢰도를높이기위해서 3번의반복측정후측정값들의평균값을사용하였다 (Figure 2). 폄근근지구력측정대상자는엎드린자세에서체간폄근검사를실시하였으며, 대상자의발목을고정시키고양손을머리뒤로하게하고몸통을편자세를취하게한후부터시작하여최대한으로유지할수있는만큼유지하게한후바닥에닿는시간까지초를측정하였으며근피로방지를위해회당 1분휴식을취하였으며신뢰도를높이기위해서 3번의반복 Figure 3. Posture of trunk extensor endurance measurement. 측정후측정값들의평균값을사용하였다 (Figure 3). 체간의관절가동범위체간의굽힘과폄의관절가동범위는경사계 (Universal Inclinometer, Performance Attainment Associates, Lindstrom, USA) 를이용하였다. 이경사계의검사자내신뢰도의 ICC값은 0.97로 [13], 검사자간신뢰도의 ICC값은 0.89 [14] 로제시되어있다. 체간의관절가동범위는각도기를등뼈 12번높이에고정한후대상자에게앞으로교차하여팔을모으게하고앞으로최대한굽히고펼수있을만큼한후각도를측정하였다 (Figures 4, 5). 자료분석여고생과여대생별로신장, 체중, 월경곤란증, 허리통증, 근지구력과관절가동범위에대하여평균과표준편차를산출하였으며, 이들변수들간인과관계에대한이론적모형에대하여구조방정식모형 (structural equation model) 을이용하여검정하였다. 구조방정식모형의모형적합도는절대적합지수를나타내는카이제곱통계량을자유도로나눈 Q통계량, 적합지수 (goodness of fit index, GFI), 조정된적합지수 (adjusted goodness of fit index, AGFI) 와표준화평균제곱잔차제곱근 (standardized root mean square residual, srmr) 으로평가하였고측정 http://www.e-jhis.org 271
Young Taek Doo and Yeon Woo Jeong Table 1. General characteristics, MDQ score, VAS score of study subjects High school girl students (n=49) Women university students (n=50) Age (y)** 18.2±0.5 21.0±0.9 Height (cm) 161.0±6.0 162.0±4.6 Weight (kg) 55.1±7.4 55.7±7.3 MDQ (dysmenorrhea)** 105.0±32.3 156.7±13.4 VAS (back pain)** 6.6±2.0 8.3±0.7 SD, standard deviation; MDQ, menstrual distress questionnaire; VAS, visual analog scale. **p<0.01. Table 2. Muscular endurance and angle of trunk in study subjects Figure 4. Measurement of trunk flexion angle. High school girl students Women university students Muscular endurance of trunk TFE 58.3 ± 29.4 48.4 ± 33.7 TEE** 53.8 ± 22.5 38.9 ± 24.4 Angle of trunk TF** 80.0 ± 15.3 71.7 ± 10.8 TE** 71.7 ± 11.9 50.6 ± 13.3 SD, standard deviation; TFE, trunk flexor endurance; TEE, trunk extensor endurance; TF, trunk flexion; TE, trunk extension. **p<0.01. Corp., Armonk, NY, USA) 을사용하였고, 나머지는 IBM SPSS Statitics 23.0 프로그램 (IBM Corp., Armonk, NY, USA) 을사용하였다. 모든통 계학적검정의유의수준은 5% 로설정하였다. 연구결과 Figure 5. Measurement of trunk extension angle. 모형의척도가동일하지않은점을고려하여경로계수는표준화경로계수를사용하였다. 표본크기가작아검정력 (test of power) 이낮은관계로통계적유의성에근거를두지않고이론모형에서표준화경로계수가 0.1 이상이면경로를살려서모형적합도를최대화하였다. 통계분석은구조방정식모형은 IBM SPSS Amos 21.0 프로그램 (IBM 대상자의연령은여고생이 18.2세, 여대생이 21.0 세이었고, 신장은여고생이 161.0 cm, 여대생이 162.0 cm, 체중은여고생이 55.1 kg, 여대생이 55.7 kg이었다. 월경곤란증점수는여고생이 105.0점, 여대생이 156.7 점으로여대생이높았고 (p < 0.01), 허리통증점수도여고생이 6.57점, 여대생이 8.3점으로여대생이높았다 (p < 0.01)(Table 1). 체간굽힘근근지구력은여고생이 58.3, 여대생이 48.4로여고생이컸으나유의하지는않았고, 폄근근지구력은여고생 53.8, 여대생 38.9 으로여고생이근지구력이유의하게컸다 (p < 0.01). 체간의관절가동범위는굽힘의관절가동범위는여고생이 80.0도, 여대생이 71.7도, 폄의관절가동범위는여고생 71.7도, 여대생 50.6도로여고생의관절가동범위가컸다 (p < 0.01) (Table 2). 이론모형을근거로여고생을대상으로한구조방정식모형에적합한최적모형에서신체적조건은월경곤란증과허리통증의경로계수가 272 http://www.e-jhis.org
Dysmenorrhea, Back Pain, Muscular Endurance and Angle of the Trunk in Girl Students Figure 6. Structural equation model in high school girl students. (Q=0.785, GFI=0.943, AGFI=0.879, srmr=0.077). 각각 b = 0.17 과 b = 0.11로양의영향이있었으나유의하지않았다. 허리통증이높을수록월경곤란증이높아지는관계가있어경로계수는 b = 0.25이었으며유의확률은경계수준에놓여있었다 (p = 0.07). 월경곤란증은근지구력에음의영향력이있어 b = -0.18이었고근지구력은높을수록관절가동범위도높아지는관계가있어 b = 0.34로추정되었으나유의하지는않았다. 결과적으로키가크거나체중이무거우면근지구력과관절가동범위는낮아지는경향이있었고허리통증이커지면월경곤란증은커져서근지구력과관정가동범위가낮아지는관계를보였다. 모형적합도는 Q=0.785로 3보다작았으며 GFI = 0.943로 0.9 보다높았으나 AGFI = 0.879로 0.9에미치지못하였고 srmr = 0.077로 0.1미만수준으로전반적으로모형적합도적절한편이었다 (Figure 6). 이론모형을근거로여대생의적합된구조방정식모형은신체적조건은허리통증과근지구력에직접적인영향력이있었으며허리통증에로의경로계수는 b = 0.11로양의영향력을근지구력으로는 b = -0.23으로음의영향력이있었고근지구력이높으면관절가동범위가높아져 b = 0.67로추정되어키가크고체중이무거울수록결과적으로관절기동범위는낮아지는경향이있었다. 월경곤란증이크면허리통증이커지는영향이있어 b = 0.30으로유의하였으며 (p = 0.03) 허리통증이크면관절가동범위는작아지는영향이있어추정경로계수 b = -0.32로음의영향이있었으나유의하지는않았다. 모형적합도는 Q =1.361로 3보다작았으며, GFI = 0.909로 0.9보다높았으나 AGFI = 0.808로 0.9에미치지못하였지만, srmr = 0.096로 0.1 미만수준으로전반적으로모형적합도적절한편이었다 (Figure 7). 고찰및결론 월경동안여성들은다양한증상을경험하는데, 약 75% 의여성이월경관련증상을경험하고있으며, 심한경우일상활동이나개인적, 사회적혹은직업적활동에방해를받는다 [15]. 본연구에서여고생에비해여대생이월경곤란증점수가유의하게높았고허리통증점수도유의하게높았다. 우리나라여성의연령과월경전후기증상정도에대한연구 [6] 에서도 20대여성이다른연령층에비해전반적으로월경증상호소가많고정도도더심하다고하였는데이와같은결과였다. 폄근지구력과체간의굽힘과폄의관절가동범위는여고생이여대생에비해컸는데, 이는허리통증이여대생이여고생에비해큰것과발달과정상여고생이더유연한것과관련이있는것으로생각된다. 우리나라여성의월경증상의정도에대한연구 [6] 에서 생리가시작되는날에는허리가아프다 가두번째로많이경험하는증상이었고, 여대생을대상으로한연구에서는월경곤란증 13개항목중 증상이매우심하다 고한경우가하복부동통 22.3%, 허리통증 15.9% 순으로체간의통증에대한불편함이높았고 [7], 20세이상성인여성을대상으로월경곤란증을조사한연구에서통증에대한점수가가장높았으며, 통증은 20-24세에서다른연령에비해가장높았다 [4]. 허리통증이허리근력의약화와밀접한관련이있는데 [8], 인간의신체활동은주로굽힘과폄의수축작용에의해서이루어지고있는데그중요통과밀접한관련을갖고있는배근력 [9] 은허리통증이심해지면신체활동에 http://www.e-jhis.org 273
Young Taek Doo and Yeon Woo Jeong Figure 7. Structural equation model in women university students. (Q=1.361, GFI=0.909, AGFI=0.808, srmr=0.096). 제한을받게되고만성화가될수록척추주변근육의단면적이감소되며 [10] 허리구조및주위조직의변화를가져와체간과복부근력약화와통증및기능제한을가져온다고하였다 [11]. 본연구에서경로분석결과, 여고생에있어서는허리통증이높을수록월경곤란증이높아지는관계가있었는데, 이는우리나라 10대여성은생리시작전에복부불편감등의통동을호소한다고보고한연구 [6] 와관련하여유추하면, 여고생의경우생리시작전에통증을인지하고이것이월경곤란증에영향을미치는것으로생각할수있다. 향후전향적인연구로이의관계를밝히는연구가필요할것이다. 여고생에있어서허리통증은월경곤란증에영향을미치고월경곤란증은근지구력에부정적인영향을미치고있었으며, 근지구력이낮으면관절가동범위가낮아지는관계를보였다. 이는요통과밀접한관련을갖고있는배근력 [9] 은허리통증이심해지면신체활동에제한을받게되고만성화가될수록척추주변근육의단면적이감소되며 [10] 허리구조및주위조직의변화를가져와체간과복부근력약화와통증및기능제한을가져온다고한연구결과 [11] 와부합하고있었다. 여대생의경우월경곤란증이크면허리통증이커지는영향이있었고허리통증이커지면관절가동범위는작아지는영향이있었다. 여대생의경우는경로가월경곤란증이허리통증에영향을미치는것으로유의하였는데, 본연구와같은여대생을대상으로한연구에서도월경곤란증으로인한통증이심할수록허리통증이더유발된다고하여동일한결과였다 [16]. 본연구에서여고생은경로가허리통증이월경곤란증에영향을미치는것으로나타난것과는달리여대생은월경곤란증이허리통증에영향을미치는것으로타나났다. 이는월경증상발현 시기와내용은연령에따라달라지는것을볼수있는데, 20대의경우생리시작일에허리통증을느낀다는한결과 [6] 와부합되고있었다. 허리통증은통증뿐만아니라근력, 지구력, 운동성과협응성을저하시켜일상생활동작의제한과장애를유발한다 [17]. 요통을일으키는원인에는수많은요인이있지만, 이중에서도허리뼈부의불안정성은다른어떤것보다더중요한원인인자로여겨지고있고 [18], 대부분의척추기능부전은유연성이부족한분절에서보다는특정한분절에서상대적유연성이과도하기때문에일어나며, 어떤분절의유연성감소는가장유연한분절에보상운동을발생시키는데기여하고 [19], 허리통증이심해지면신체활동에제한을받게된다 [10]. 본연구의제한점으로는연령을 10대와 20대로국한하여연령별차이를알아보고자하였는데, 연령의편차가크지않았으며, 체간의근지구력과체간관절가동범위에는다양한요인이영향을미칠것이나이를고려하지못했다는것이다. 또한한지역의 1개고등학교와여자대학교의 3학년여학생을대상으로하여대표성에한계가있을수있는것과단면연구라는한계가있다. 이런제한점에도불구하고월경증상발현시기와내용이다르다고알려지고있는 10대여고생과 20대여대생을대상으로월경곤란증과허리통증, 체간의근지구력과관절가동범위의관계를파악한의의가있는것으로생각한다. 향후다양한연령층의더많은여성을대상으로체간의근지구력과관절가동범위에영향을미칠수있는다양한요인들을고려한횡단적인연구가필요할것으로생각한다. 이상의결과, 월경곤란증과허리통증은관계가있었으며, 월경곤란증과허리통증은체간의근지구력과관절가동범위에부정적인영향 274 http://www.e-jhis.org
Dysmenorrhea, Back Pain, Muscular Endurance and Angle of the Trunk in Girl Students 을미치고있었다. 따라서월경곤란증과월경과관련된허리통증을완화할수있는방안들이강구되어야할것이다. 스트레스가월경증상의위험요인으로밝혀짐에따라스트레스를낮추기위한다양한중재법들이사용되고있으며, 그중의하나가아로마테라피 (aromatherapie) 이다. 아로마테라피는식물에서추출한정유를증상이나질병을완화시키기위해제공하는처치인데 [20], 우리나라여대생을대상으로한연구에서복부마사지로제공한아로마테라피는생리통이있는여대생의월경중스트레스반응을낮추는데효과적이었다 [21]. 또한월경곤란증시나타나는요통을방지하고경감시키는데중요한요점은척주와골반을최적정렬로안정화시킬수있는요부근육을갖게해주는것인데 [22], 우리나라여대생을대상으로한연구 [16] 에서체간안정화운동이월경곤란증으로인한허리통증감소뿐만아니라월경곤란증에도도움을주고있었으므로이런운동프로그램을개발하여중재하는것이좋을것으로생각한다. REFERENCES 1. Motiff TE, Caspi A, Belsky J, Silva PA. Childhood experience and the onset of menarchy: a test of a sociological model. Child Develop 1992; 63:47-58. 2. Freeman EW. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology 2003; 28:25-37. 3. Granot M, Yarnitsky D, Itskovitz-Eldor J, Granovsky Y, Peer E, Zimmer EZ. Pain perception in women with dysmenorrhea. Obstet Gynecol 2001;98(3):407-411. 4. Lee EH, Kim JI, Kim HW, Lee HK, Lee SH, Kang NM, et al. Dysmenorrhea and menstrual attitudes in adult women. Korean J Women Health Nurs 2003;9(2):105-112 (Korean). 5. Woods NF, Lentz MJ, Mitchell ES, Heitkemper M, Shaver J. PMS after 40: persistence of a stress-related symptom pattern. Res Nurs Health 1997;20:329-340. 6. Park YJ. The severity levels and patterns of perimenstrual symptoms among Korean women in relation to their ages. Korean J Women Health Nurs 1999;5(2):145-156 (Korean). 7. Han SH, Hur MH. A study on the menstrual pain and dysmenorrhea, factors influenced to theam, and self-management method for theam of college students. J Korean Acad Soc Nurs Educ 1999;5(2):359-375 (Korean). 8. Nachemson A, Lindh M. Measurement of abdominal and back muscle strength with and without low back pain. Scand J Rehabil Med 1969;1:60 9. Risch SV, Norvell NK, Pollock ML, Risch ED, Langer H, Fulton M, et al. Lumbar strengthening in chronic low back pain patients. Physilogical and psycosocial benefits. Spine 1993;18:232-238. 10. Yoshihara K, Shirai Y, Nakayama Y, Uesaka S. Histochemical changes in the multifidus muscle in patients with lumbar intervertebral disc herniation. Spine 2001;26(6):622-626. 11. França FR, Burke TN, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics 2010;65(10):1013-1017. 12. Moss RH. The development of a menstrual distress questionnaire. Psychosom Med 1968;30(6):853-967. 13. Mayer T, Brady S, Bovasso E, Pope P, Gatchel RJ. Non invasive measurement of cervical tri-planar motion in normal subjects. Spine 1993;18(15):2191-2195. 14. Bush KW, Collins N, Portman L, et al. Validity and intertester reliability of cervical range of motion using inclinometer measurement. J Man Manip Ther 2000;8(2):52-61. 15. Campbell MA, Mcgrath PJ. Use of medication by adolescents for the management of menstrual discomfort. Arch Pediatr Adolesc Med 1997;151(9):905-913. 16. Kim YJ. The effect of trunk stability exercise on dysmenorrhea back pain of women university students [dissertation]. Graduate school of Kwangju women s university, 2015 (Korean). 17. Hasenbring MI, Hallne, D, Rusu AC. Fear avoidance and endurancerelated responses to pain: Development and validation of the Avoidance Endurance Questionnaire (AEQ). Eur J Pain 2009;13(6):620-628. 18. Wallden M. The neutral spine principle. J Bodyw Mov Ther 2009;13 (4):350-361. 19. Sahrmann S. Diagnosis and treatment of movement impairment syndromes. Mosby; 2002. 20. Price S. Practical aromatherapy. 2nd eds. London, England: Thorsons; 1987. 21. Han SH, Hur MH, Kang JY. Effects of aromatherapy on the stress response of college women with dysmenorrhea during menstruation. J Korean Acad Nurs 2002;32(3):317-326 (Korean). 22. Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol 2003;13(4):371-379. http://www.e-jhis.org 275