Original Article 대한침구의학회지제 30 권제 2 호 (2013 년 4 월 ) : 9-15 Journal of Korean Acupuncture & Moxibustion Medicine Society Vol. 30. No. 2. April 2013 : 9-15 ISSN 1229-1137(Print) ISSN 2287-7797(Online) 퇴행성슬관절염환자의뜸치료가양도락점수에미치는영향 오명진, 송호섭 * 가천대학교한의과대학침구의학교실 [Abstract] Effect of Moxibustion Therapy on Ryodoraku Score of the Patients with Degenerative Arthritis of Knee Joint Myung Jin Oh and Ho Sueb Song* Department of Acupuncture & Moxibustion Medicine, College of Oriental Medicine, Gachon University Key words : Degenerative arthritis; Knee joint; Moxibustion therapy; Ryodoraku score(f1, F6) Objectives : This study was done for reporting the effect of moxibustion therapy on Ryodoraku score of the patients with degenerative arthritis of knee joint Methods : We investigated 65 cases of patients with degenerative arthritis of knee joint, and devided patients into two groups : One group treated by moxibustion therapy, which was not applied to the other group we analyzed of each group the Ryodoraku score(f1, F6) of each group before and after moxibustion therapy and compared it. Results : 1. In moxibustion therapy group compared with baseline, at final, Ryodoraku score(f1, F6) was significantly increased. 2. At final, moxibustion therapy group showed significant increase on Ryodoraku score(f1, F6) score compared with non moxibustion therapy group. Conclusions : It is suggested that Ryodoraku score(f1, F6) should be available for diagnosing degenerative arthritis of knee joint. Received : 2013. 03. 05. Revised : 2013. 03. 28. Accepted : 2013. 03. 28. On-line : 2013. 04. 20. This research was supported by the Gachon University Research Fund in 2013(GCU-2013-R043) * Corresponding author : Department of Acupuncture & Moxibustion Medicine, Gil Oriental Medicine Hospital of Gachon Univercity, 1200-1, Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea Tel : +82-70-7120-5012 E-mail : hssong70@gachon.ac.kr This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2013 KAMMS. Korean Acupuncture & Moxibustion Medicine Society. All rights reserved. 9
Journal of Korean Acupuncture & Moxibustion Medicine Society Vol. 30 No. 2 April 2013 Ⅰ. 서론 퇴행성관절염은일차적으로관절연골이닳아없어지면서국소적인퇴행성변화가나타나는질환이다 1). 퇴행성관절염은가장흔한관절질환으로 10~20대에무증상으로시작하여 70세에이르면매우높은빈도를보인다. 비교적소수에서증상이나타나긴하지만 40세가되면체중부하로인해關節軟骨에병적인변화가나타난다. 유병률은남녀가비슷하지만남자에서보다빨리발병한다 2). 슬관절은퇴행성관절염의호발부위이다. 관절연골의퇴행성변화는고령에기인한것외에도슬관절의병변이나손상 ( 반월상연골손상, 골절, 탈구, 관절내유리체 ), 비만증, 내반슬, 외반슬등기계적부하축의이상, 감염증또는여러가지관절염등에의해서도촉진된다. 슬관절의동통과이상음 (cracking) 이초기증상으로나타나며질환이진행하면서계단오르내리기기립하기가힘들게된다 3). 한의학적으로슬관절은 黃帝內經ㆍ素問ㆍ脈要精微論 4) 에 膝者筋之府屈伸不能行則僂附筋將憊矣 라하였고, 黃帝內經ㆍ靈樞ㆍ經脈 5) 에 胃足陽明之脈, 以下髀關, 扺伏兎, 下膝臏中, 下循脛外廉, 脾足太陰之脈, 上膝股內前廉入腹 이라하여, 膝部가足陽明胃經과足太陰脾經에속하여있음을나타내었다. 또한슬관절질환의경우 黃帝內經ㆍ靈樞ㆍ經脈 5) 에 膝臏腫痛, 膝內腫厥 이라고記述되어있으며 鍼灸大成 6) 에서는 膝紅腫疼痛 이라고하였다. 퇴행성슬관절염의원인은노년에腎衰한데만성허손으로傷骨한것과氣血운행이風寒濕의邪氣로인해閉阻된것으로보는데, 대부분노쇠현상으로생긴것이라고볼수있다 7). 灸 란문자가가장먼저기재된것은 莊子ㆍ盜跖篇 8) 으로 無病自灸 라고하였고, 灸法은 醫學入門 9) 에 藥之不及, 針之不到, 必須灸之 라하여깊은病所에있는질병일수록灸法이효과적임을나타내었다. 良導絡은 1950년일본의中谷義雄박사가신장염환자의다리에직류전류통전측정법을시행하던중발견한것이다. 12 良導絡양측각각 1부위의대표측정점을측정하여총 24부위의측정점값으로病所와病性을예측하고체력의성쇠와허실을파악하며질병의예후와경과를판단하는지표이다 10). 지금까지의良導絡의임상연구는 Park et al 11), Jang et al 12), Bang et al 13), Lee et al 14) 등의기능성소화불량, 특발성안면신경마비, 파킨슨병, 요통등과良導絡의상관성연구가있었지만良導絡과퇴행성슬관절염에관한국내연구에대한보고는없었다. 이에저자는슬부가足陽明胃經과足太陰脾經에속하여있으므로퇴행성슬관절염에있어서足陽明胃經과足太陰脾經에灸法을시행하였을때해당경락의양도락수치인 F1, F6에미치는영향이있을것으로사료되어 2011년 7월부터 2012년 2월까지가천대학교부속길한방병원침구의학과에퇴행성슬관절염으로내원한환자중수술력이있는환자와염증성질환이나슬관절부위의심한변형이있는경우를제외한 65명을대상으로足太陰脾經과足陽明胃經의양도점의양도락검사측정치를분석하여다음의결과를보고하는바이다. 1. 연구대상 Ⅱ. 대상및방법 2011년 7월부터 2012년 2월까지가천대학교부속길한방병원침구의학과에퇴행성슬관절炎으로내원한환자중수술력이있는환자와염증성질환이나슬관절부위의심한변형이있는경우를제외한 65명을대상으로하였다. 치료기간은 4주이며, 치료횟수는 12회로하여灸法시술한군 ( 灸法시술군, 34명 ) 과시술하지않은군 ( 대조군, 31명 ) 으로무작위로분류하여성적을비교하였다. 2. 연구방법 1) 양도락측정 환측의足太陰脾經의양도점 (F1, 太白 ) 과足陽明胃經의양도점 (F6, 衝陽 ) 에서측정하였는데, 좌우양측의슬관절통증을호소하는경우는보다심한쪽을환측으로보고측정하였다. 측정전환자는몸에있는금속성물질을제거하였고, 침치료및물리치료를받지않았으며, 실온에적응하고, 5분간안정을취한상태에서측정하였다. 측정부위는땀의영향을최소화하기위해측정전과측정중에계속노출된상태를유지하였다. 측정부위에접촉할때에는직각으로하여일정한압력이되도록하였다. 정확히측정부위를 10
퇴행성슬관절염환자의뜸치료가양도락점수에미치는영향 취혈하고, 측정위치에변동이없도록하였다. 灸法시술군은치료전과 12회치료후에측정하였으며, 대조군은첫내원시와灸法시술없이 6주후내원하게하여측정하였다. 2) 灸치료방법뜸은햇님에서제작한마니나환부경혈용뜸 ( 강 ) 을사용하였으며, 1일 3회 5~7분씩시행하였으며 1주일에 3회씩 4주간총 12회를시행하였다. 選穴은슬관절주위혈중에서足陽明胃經ㆍ足太陰脾經의穴인犢鼻ㆍ足三里ㆍ梁丘ㆍ陰陵泉ㆍ血海의穴과가장통증이심한阿是穴 1~2 穴을더하여시행하였다. 3. 자료분석방법 실험결과는 SPSS 12.0 for Windows program 을이용하여통계처리를하였다. 도출된자료는 Mann- Whitney U test를통해치료성적에있어灸法시술군과대조군의유의성을검정하였고, Wilcoxon signed rank test로각군의치료기간동안유의성을검정하였다. 유의수준은 0.05 이하로하였다. Ⅲ. 결과 1. 대상자의일반적특성 총 65례중에서灸法시술군은남자 4례여자 30례이며, 평균연령 60.06±6.339세였다. 대조군은남자 4례여자 27례이며, 평균연령 59.48±5.870세였다. 일반적특성의동질성검증에서두군간의차이는없었다 (Table 1). Table 1. General Characteristics Moxibustion therapy(n : 34) Nonmoxibustion therapy(n : 31) p-value Age 60.06±6.339a 59.48±5.870 0.290 * Sex (male/female) 4/30 4/27 a : mean±standard deviation. * : p-value of Levene test>0.05. Table 2. Improvement of Moxibustion Therapy (n : 34) Group According to a Period of Treatment (F1s- F1f, F6s-F6f) F1s-F1f F6s-F6f Z -4.940-5.033 p-value 0.000 * 0.000 * F1s : F1 score at baseline. F1f : F1 score at final. F6s : F6 score at baseline. F6f : F6 score at final. * : Wilcoxon signed rank test p<0.01. (2) 대조군 Wilcoxon signed rank test의결과 F1과 F6의 Z가각각 -0.159와 -0.092로치료전을기준으로치료종결후유의한 (p>0.01) 감소를나타내지못하였다 (Table 3). Table 3. Improvement of Non Moxibustion Therapy (n : 31) Group According to a Period of Treatment (F1s-F1f, F6s-F6f) F1s-F1f F6s-F6f Z -0.159-0.092 p-value 0.873 * 0.926 * F1s : F1 score at baseline. F1f : F1 score at final. F6s : F6 score at baseline. F6f : F6 score at final. * : Wilcoxon signed rank test p<0.01. 2. 치료성적 1) 각군의치료전후비교 (1) 灸法시술군 Wilcoxon signed rank test의결과 F1과 F6의 Z가각각 -4.940과 -5.033으로치료전을기준으로치료종결후유의한 (p<0.01) 감소를나타내었다 (Table 2). 2) 두군간의치료전후비교 F1에서치료전灸法시술군의평균과표준편차는 11.15±12.033, 대조군의평균과표준편차는 12.55± 9.106이었으며, 치료종결후灸法시술군의평균과표준편차는 19.26±14.264, 대조군의평균과표준편차는 12.39±9.010으로, 灸法시술군의足太陰脾經양도점수치의유의한 (p<0.05) 증가를나타내었다 (Table 4). F6에서치료전灸法시술군의평균과표준편차는 11
Journal of Korean Acupuncture & Moxibustion Medicine Society Vol. 30 No. 2 April 2013 9.26±9.265, 대조군의평균과표준편차는 10.16±6.807 이었으며, 치료종결후灸法시술군의평균과표준편차는 17.56±15.490, 대조군의평균과표준편차는 10.13± 6.622로, 灸法시술군의足陽明胃經양도점수치의유의한 (p<0.05) 증가를나타내었다 (Table 5). Table 4. Comparison of Ryodoraku Score(F1) between Two Groups Before treatment After final treatment Moxibustion therapy(n : 34) Non-moxibust ion therapy (n : 31) p-value 11.15±12.033 a 12.55±9.106 0.087 19.26±14.264 12.39±9.010 0.042 * a : mean±standard deviation. * : p-value of Mann Whitney U test<0.05. Table 5. Comparison of Ryodoraku Score(F6) between Two Groups Before Treatment After final treatment Moxibustion therapy(n : 34) Non-moxibust ion therapy (n : 31) p-value 9.26±9.265 a 10.16±6.807 0.241 17.56±15.490 10.13±6.622 0.039 * a : mean±standard deviation. * : p-value of Mann Whitney U test<0.05. Ⅳ. 고찰 퇴행성관절염은관절연골의변성, 마모와관절변연의골극형성이나연골하골의골경화와같은골연골증식성변화가동반되어발생하는관절질환으로, 발생빈도는 55세이상의약 80 % 이며, 75세이상에서는거의전인구에서나타난다. 퇴행성요통은급성요추염좌나변형성요통, 요부의근육피로등여러가지원인으로일어난다 15). 슬관절은인체의가장큰관절로대퇴골, 경골, 슬개골로구성되어있는경첩관절이다. 또한슬관절에는세개의관절면이있는데두개는대퇴골과경골사이이고한개는슬개골과대퇴골사이이다 16). 그런 데슬관절은평평한경골 (tibia) 상단관절면에둥근모양의대퇴골 (femur) 원위단이접촉하므로골구조상매우불안정한상태에서주위인대나근육에의하여안정성을유지하고있기때문에사람이직립자세로생활하는데서발생하는체중의부하를가장많이받아퇴행성관절염이흔히발생된다 15,17). 이러한퇴행성슬관절염의발병원인에대해서는정확히규명되어있지않으나노쇠현상이나반복적인스트레스및지속적으로무릎을구부리고있는것등과도연관되어작용하는것으로이해되고있다. 주로중년또는노년에주로발생되고체중부하관절을많이침범하여관절연골의국소적인퇴행성변화, 연골하골의비대, 주변골연골부의과잉골형성을특징으로하며염증변화는소수에서나타난다 7). 임상적으로초기에는경도의동통및이상음이가장흔히나타나며관절의운동장애나경도의종창및관절주위의압통등을호소하며, 서서히진행되어계단오르내리기, 기립하기가힘들며, 활액막의비후, 관절액의증가, 근경련등이나타나고결국근위축, 운동제한, 관절잠김과같은소견이나타난다 18). 서양의학적인치료로는 simple analgesics(opioids 등 ), NSAIDs, COX-2 selective inhibitors 등을이용한약물요법을많이사용하나이러한약물의만성적인사용은상부위장관합병증과같은현저한부작용을일으킨다는보고도있다 19). 한의학적으로膝部는경락상足太陰脾經과足陽明胃經에위치하여膝部질환은두경락의所生病이라고보았다 20). 黃帝內經ㆍ靈樞ㆍ經脈 5) 에 膝臏腫痛, 膝內腫厥 이라고기술되어있으며, 膝痛은슬관절질환에서흔히나타나는증상의일종으로서, 鶴膝風, 歷節風및膝腫痛등에서찾아볼수있다 15). 諸病源候論 에처음으로슬관절에대한骨痺症이언급되었고 備急千金要方 에는骨痺가진행되면骨極病이발생한다고하였는데, 이는서양의학에서말하는퇴행성관절염과흡사한기전을보인다 15). 骨極病은虛勞가극도에이른병증인六極중의하나 21) 로퇴행성슬관절염의원인이노쇠와虛勞로볼수있다. 灸法은 說文解字 22) 에서 灸灼也今以艾灼體曰灸 라고하여灸法이바로燒灼을뜻함을설명하고있다. 黃帝內經ㆍ靈樞ㆍ禁服 5) 에서 陷下則灸之, 陷下則徒灸之陷下者脈血結於中中有著血血寒故宜灸之 라하였고, 黃帝內經ㆍ靈樞ㆍ官能 5) 에서는 陰陽皆虛火自當之, 經陷下者火則當之 라하였다. 이는灸法이溫經散寒, 扶陽固脫, 예방및보건작용 12
퇴행성슬관절염환자의뜸치료가양도락점수에미치는영향 이있음을의미한다 15). 퇴행성슬관절염의동통과기능이상의발병을방지하거나진행을둔화시키는치료법이명확하지않고환자의불편감을경감시키는것을주된목적으로하는특성때문에동통은 visual analogue scale(vas) 를, 기능상태는 Western Ontario McMasters Universities Osteoarthritis index(womac) 와 lequesne functional severity index(lfi) 를, 전반적인평가는 global assessment (GA) 등의평가척도를활용하고있다 23). 그러나이러한평가척도는질병의상태와예후를판단하는데주관적일수있다는단점이있다. 양도락은 1950년대경혈부위에전류가잘통하는것에착안하여일본의中谷義雄박사가개발한기기로 12경락의臟腑허실을판단하는진단기기로사용되고있으며양도락의측정점은각경락의대표측정점, 즉원혈을좌측손, 우측손, 좌측발, 우측발의순서로 24개의점을측정하게된다. 생리적인면에서원혈은장부의원기가통과하고머무는중요한부위이고, 병리에있어장부및십이경맥의병변을반영한다. 그러므로원혈은진단방면에있어서중요한작용을한다 24). 이에허손으로오는퇴행성슬관절염치료에슬관절을지나는해당경락인足陽明胃經ㆍ足太陰脾經의穴인犢鼻ㆍ足三里ㆍ梁丘ㆍ陰陵泉ㆍ血海穴에灸法을시행하면퇴행성슬관절염에효과적임을알수있지만灸法을시행했을때치료효과를객관적으로측정할수있는양도락수치의변화를나타내는임상보고가이루어지지않다는점에착안하여 2011년 7월부터 2012년 2월까지가천대학교부속길한방병원침구의학과에퇴행성슬관절염으로내원한환자중수술력이있는환자와염증성질환이나슬관절부위에심한변형이있는경우를제외한 65명을대상으로하였다. 치료기간은 4주이며치료횟수를 12회로하여灸法을시술한군과시술하지않은군으로무작위분류하여양도락을측정한결과灸法을시술한군에서 F1, F6 수치변화에대한유의한결과를얻었기에보고하는바이다. 灸法시술군의치료전과치료종결후 Wilcoxon signed rank test의결과 F1과 F6의 Z가각각 -4.940 과 -5.033으로치료전을기준으로치료종결후유의한 (p<0.01) 감소를나타내었으므로치료기간동안의처치가퇴행성슬관절염의치료효과에유의하게도움을주었음을알수있다. 灸法시술군과대조군두군간의치료전후성적 을비교하면, 灸法치료군의치료종결후에 F1, F6의수치가대조군에비해유의한증가를보여灸法시술군이灸法을시행하지않았을때에비해증상의개선이있음을보여주었고노쇠와虛勞로인한퇴행성슬관절염을灸法으로溫經扶陽하여치료하는데효과가있으며진단의관점에서양도락이허실판단에도유효함을알수있었다. 이상에서살펴본바에따르면퇴행성슬관절염에서灸法시술군이대조군에비해양도락수치가유의성있게증가하여灸法이퇴행성슬관절염치료하는데있어서효과적임을알수있었고, 양도락검사가퇴행성슬관절염질병의진단및치료후의예후를판단해주는기준이될수있는것으로볼수있겠다. 그러나본연구는그수가임상적인의의를가질만큼충분하지못하였으므로향후더많은증례를토대로통계적인유의성을확인해야할필요가있으며퇴행성슬관절염에관한양도락의진단적특이성에대한연구가지속적으로이루어져야할것으로사료된다. Ⅴ. 결론 2011년 7월부터 2012년 2월까지가천대학교부속길한방병원침구의학과에퇴행성슬관절炎으로내원한환자중수술력있는환자와염증성질환이나슬관절부위에심한변형이있는경우를제외한 65명을대상으로하였다. 치료기간은 4주이며치료횟수를 12회로하여灸法을시술한군 ( 灸法시술군, 34명 ) 과시술하지않은군 ( 대조군, 31명 ) 으로무작위분류하여足太陰脾經의양도점인 F1과足陽明胃經의양도점인 F6을비교한결과다음과같은결론을얻었다. 1. 퇴행성슬관절염환자에서灸法시술군의 F1, F6은치료전에비해치료종결후증가를나타내었다. 2. 치료종결후 F1, F6에서灸法시술군의치료성적이대조군에비해유의한증가를나타내었다. 13
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