JKPT pissn Vol. 28, No. 5, October 2016 J Kor Phys Ther 2016:28(5):286-291 1229-0475 eissn 2287-156X Original Article Effects of Home Exercise Program and Manual Therapy on Shoulder Function and Quality of Life in Patients with Adhesive Capsulitis Kwang- Il Kwak 1, Bum-Jin Choi 2, Young-Jeoi Yoon 3 1 Rehabilitation center, Gwang ju plant, Kumho tire, Gwangju; 2 Sport Rehabilitation center, Saenarae Hospital, Gwangju; 3 Department of Physical Therapy, Honam University, Gwangju, Korea Purpose: This study was conducted to identify the effects of home exercise programs and manual therapy on shoulder function and quality of life in patients with adhesive capsulitis. Methods: A total of 31 patients were enrolled in the study. All subjects were randomly assigned to a home exercise group (n=15) or a manual therapy group (n=16). Both groups performed each intervention program three times a week for four weeks. After four weeks, both groups performed a home exercise program continuously until week 12. Shoulder function was evaluated using the Korean Shoulder Scoring (KSS) system, while quality of life was evaluated using the WHO Quality of Life-BREF (WHOQOL-BREF) before and 4, 8, and 12 weeks after the intervention. Data were analyzed using two-way repeated measures analysis of variance (ANOVA). Results: There were significant differences in KSS before intervention and 4, 8, and 12 weeks after intervention for both the home exercise group and manual therapy group (p<0.001). There was also a significant difference in KSS at 4, 8, and 12 weeks when compared to the home exercise group and manual therapy group (p<0.001). Moreover, there was a significant difference in WHOQOL-BREF before and 4, 8, and 12 weeks after intervention in the home exercise group and manual therapy group (p<0.001). Conclusion: Home exercise and manual therapy improved shoulder function, but manual therapy led to a greater improvement in shoulder function better than home exercise. Home exercise and manual therapy improved quality of life, but there was no significant difference between groups. Keywords: Home exercise program, Manual therapy, Shoulder function, Quality of life, Adhesive capsulitis 서론견관절유착성관절낭염 (adhesive capsulitis) 은대부분 40-60세이상의중년또는노인인구에발생하는견관절의대표적인질환으로 1 많은연구에도불구하고유착성관절낭염의원인은명확하게밝혀지지않았으나, 2,3 활액막아래층의만성염증으로인한관절막의비후와섬유화, 관절막과상완골경부의유착이발생하여통증이서서히증가하고점차적으로능동및수동관절운동범위가감소하는것으로알려져있다. 4,5 견관절통증은관절가동범위의감소와상지의움직임을제한할수있으며, 이로인하여일상생활동작수행의어려움과삶의질이감소될수있다. 6 유착성관절낭염환자의견관절관절가동범위감소는 점진적인기능감소를반영하며, 7 견관절통증과기능장애는삶의질을감소시킬수있다. 8 유착성관절낭염환자는심한통증과일상생활의기능제한, 높은수면장애발생률과삶의질이낮으며, 9 유착성관절낭염환자의견관절기능장애와삶의질사이에는음의상관관계 (negative correlation) 가있다. 10 유착성관절낭염의치료는통증을감소시키고관절의운동성을촉진하여최대한의운동범위를회복하는것을목표로하며, 11 도수치료와운동치료, 12 자가신장운동, 7 고유수용성신경근촉진법, 13,14 진동자극, 15 그룹운동과가정운동프로그램, 16 테이핑요법 17 등의물리치료적중재가임상에서널리사용되고있다. 유착성관절낭염치료방법의선택과적용은다양한방식으로진행되고있으며, 통증감소와기능회복을위해도수치료적용이효과적이라고보고되었다. 도수치 Received Sep 13, 2016 Revised Oct 31, 2016 Accepted Nov 4, 2016 Corresponding author Young-Jeoi Yoon E-mail yoonyj@honam.ac.kr Copylight 2016 The Korea 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. 286 www.kptjournal.org
Effects of Home Exercise and Manual Therapy on Patients with Adhesive Capsulitis JKPT 료는유착성관절낭염환자의통증감소, 연부조직과관절낭의뻣뻣함을신장시키며, 18 관절낭내의운동저하와기능적움직임을개선하는데효과적이다. 19 가정운동프로그램은경제적제약이적고시설과공간의제한없이쉽게적용할수있는운동으로독립적인일상생활을위한간단한프로그램으로구성되어있다. 20 치료사의감독하에시행되는가정운동프로그램은유착성관절낭염환자의통증과장애를개선시킬수있으며, 21 가정운동프로그램을통하여개인의일상생활활동에필요한능력을향상시킬수있다. 22 유착성관절낭염환자는보존적치료후비교적양호한결과를얻을수있으나회복후에도부분적으로관절운동의제한이있을수있으며, 23 통증과관절강직에따른기능회복을위해서는상당한시간이필요하다. 16 따라서유착성관절낭염환자의치료를위해서장기적인치료적중재가필요하며, 보존적치료후견관절기능을유지하기위한적절한중재가필요한것으로생각된다. 또한최근질환의평가와치료에심리적, 사회적요소가포함된삶의질이중요한요소로생각되고있으나, 견관절질환과관련된삶의질에대한연구는부족한실정이다. 9 이에본연구는 4주간의도수치료와가정운동프로그램적용이유착성관절낭염환자의견관절기능과삶의질에미치는영향을확인하며, 보존적치료후 5-12주까지의가정운동프로그램적용이견관절기능을유지하기위한물리치료적중재로써유착성관절낭염환자의견관절기능과삶의질에미치는영향에대해알아보고자하였다. 연구방법 1. 연구대상본연구는기관생명윤리위원회 (IRB No. 2014-12-019-003) 의심의를거쳐연구승인을받았으며, 모든대상자들은실험절차와주의사항에대해충분한설명을들은후연구참여동의서에자발적으로서명하였다. 본연구의대상자들은 J도의관절전문병원에서입원및외래치료를받고있는환자들을대상으로하였으며, Miller 등 24 의연구에기초하여방사선 (X-ray) 검사상특이소견이없으며, 견관절운동범위감소와자연적으로발생한통증, 정상측외회전및내회전운동범위의 50% 미만제한등의특징이있는사람을유착성관절낭염환자로선정하였다. 또한유착성관절낭염의초기 통증우세 에해당하는환자들을최소화하기위하여최소 3개월이상증상이지속되는환자들을대상으로하였다. 지난 3개월동안손상측어깨에주사치료나물리치료를받은사람, 손상측어깨의회전근개손상, 골절, 수술을받은사람은대상자선정에서제외시켰다. 모든대상자들에게약물을제외하고실험기간동안다른보존적치료를받지않도록요청하였으며, 일주일이상중재프로그램에참여하지못한경우실험에 서제외하였다. 표본크기는검정력및표본크기산출프로그램을사용하였으며, 유의수준 5% (α = 0.05), 검정력 80% (β = 0.80), 실험군과대조군을대상으로총 4회결과값을측정하였을경우교호작용을볼수있는전체표본수는 24명이었다. 실험과정에서약 10% 의탈락률을고려하여대상자수는 26명으로산출되었으며, 실험군과대조군각 13명이요구되었다. 2. 실험방법본연구는 J도관절전문병원에서유착성관절낭염으로진단받은환자들을대상으로 2015년 3월부터 5월까지실험을진행하였으며, 대상자선정기준에적합한환자들을무작위로 2개의그룹으로할당하였다. 첫번째군은열, 전기치료를포함한기본물리치료를받았으며, 중재전가정운동프로그램에대한교육을실시하였다. 가정운동프로그램은유착성관절낭염에대한의학적정보와바람직한생활습관, 통증예방, 자가운동방법에대한교육을실시한후책자를제공하였으며, 경부와견관절주변근육에대한스트레칭, 도르래와 T-bar 운동등이포함된자가운동방법을교육하였다. 가정운동프로그램은어깨재활운동경력 5년이상의전문치료사가운동지도와교육을담당하였으며, 기본물리치료를받으러병원에내원하였을때가정운동프로그램을확인하였으며잘못된동작에대해재교육을실시하였다. 두번째군은열, 전기치료를포함하는기본물리치료와도수치료를실시하였다. 도수치료는 10년이상의임상경험이있는정형도수치료사가전담하여실시하였으며, 칼텐본-에반스컨셉 (Kaltenborn- Evjenth concept) 을기반으로하였다. 기능적마사지와신장은통증감소와조직이완을위하여극상근, 극하근, 소원근, 견갑하근, 대원근, 대흉근및상승모근등에적용하였다. 관절가동화기법은각환자별로증상의진행경과에따라견관절하방및후방활주, 외측견인등을실시하였으며, 흉추의굴곡및신전가동화운동을실시하였다. 모든중재는하루 50분, 일주일에 3회, 총 4주간실시하였으며, 이후부터모든군은 12주까지가정운동프로그램을지속하도록하였다. 중재전과중재후 4주, 8주, 12주에견관절기능과삶의질을측정하였다. 3. 측정도구 1) Korean Shoulder Scoring (KSS) System KSS는어깨질환의치료전후기능적상태를평가하는데국내에서널리이용되고있으며, 다양한어깨질환의평가에서높은신뢰도와정확도를나타내고있다. 25,26 평가항목으로는일상활동을평가하는 www.kptjournal.org 287
JKPT The Journal of Korean Physical Therapy Kwang- Il Kwak, et al. 기능항목 30점, 통증 20점, 만족도 10점, 관절운동범위 20점, 도수근력및근지구력항목 20점만점으로구성되어있으며, 총 100점을기준으로측정을하며점수가높을수록견관절의기능적상태가좋음을의미한다. KSS의 Cronbach s α = 0.840이다. 25 2) WHO Quality of Life-BREF (WHOQOL-BREF) WHOQOL-BREF 는세계보건기구에서개발한것을국내에서 Min 등 27 (2000) 이한국형버전으로축약한것으로신체적건강, 심리적건강, 사회적관계, 환경영역등에속하는 24개의하부척도와전반적인삶의질에대한 2개의문항을포함하여총 26개의문항으로구성되어있다. 각문항의점수는 5점척도로구성되어있고, 총점을 100 점으로환산하여점수가높을수록건강관련삶의질이좋음을의미한다. 28 WHOQOL-BREF는 WHOQOL 고유척도의간편형척도로높은내적일치도 (internal consistency) 와검사-재검사신뢰도 (test-retest reliability) 를가지고있어대규모의임상연구에서많이활용되고있다. 28,29 또한, 근골격계질환을가진환자들을대상으로삶의질을측정하는데유용한도구로사용되고있다. 9,29,30 4. 자료분석모든자료는 SPSS PASW 18.0 windows 을이용하여분석을하였다. 정규성분포는 Shapiro-Wilk 검정을실시하였으며, 대상자의일반적특성은 χ 2 검정과독립표본 t 검정 (Independent t-test) 을실시하여동질성검증을실시하였다. 가정운동프로그램과도수치료에따른시간의효과, 그룹간의비교, 시간과그룹의교호작용을검증하기위하여반복측정이요인분산분석 (repeated measures two-way ANOVA) 을실시하였다. 시간의효과가유의한경우중재전과측정시기에따른차이를확인하기위하여대응표본 t 검정 (paired t-test) 을실시하였으며, 시 간과그룹의교호작용이유의한경우측정시기에따른그룹간차이를확인하기위하여독립표본 t 검정 (Independent t-test) 을실시하였다. 통계학적유의수준은 α= 0.05로하였다. 결과 1. 연구대상자들의일반적특성가정운동프로그램군은 15명 ( 남성 5명, 여성 10명 ) 이었으며, 평균연령은 53.73 ± 4.68세, 증상지속기간은 5.67± 2.12개월, 우세팔에 73.3% 가이환되었다. 도수치료군은 16명 ( 남성 5명, 여성 11명 ) 이었으며, 평균연령은 51.06 ± 6.45세, 증상지속기간은 6.31± 2.05개월, 우세팔에 75% 가이환되었다. 두군의성별분포, 나이, 증상지속기간, 우세측어깨관련요인은통계학적으로유의한차이가없었다 (p> 0.05) (Table 1). 2. Korean Shoulder Scoring (KSS) System 결과견관절기능적상태를평가하는 KSS는가정운동프로그램군에서중재전 45.4 ± 8.43점, 중재후 4주 51.40 ± 8.27점, 중재후 8주 57.60 ± 8.03 점, 중재후 12주 65.07± 8.03점이었으며, 도수치료군에서중재전 44.56 ± 8.21점, 중재후 4주 69.06 ± 6.44점, 중재후 8주 76.56 ± 4.62점, 중재후 12주 80.38 ± 5.81점이었다. 측정시기에따른유의한차이가있었으며, 가정운동프로그램군과도수치료군은중재전과비교하여중 Table 1. General characteristics of subjects HE group (n=15) MT group (n=16) Age (year) 53.73±4.68 51.06±6.45 Gender (M/F) 5/10 5/11 Duration of symptom (mo) 55.1±10.3 54.7±12.2 Side (dominant/nondominant) 12/3 12/4 HE: Home exercise, MT: Manual therapy. Table 2. KSS score for each intervention group over time Group Pre 4 weeks 8 weeks 12 weeks Time (T) Group (G) T G HE 45.47±8.43 51.40±8.27 57.60± 8.03 65.07± 8.03 0.000 *** 0.000 *** 0.000 *** MT 44.56±8.21 69.06±6.44, 76.56± 4.62, 80.38± 5.81, Mean±S.D., *** p<0.001. HE: Home exercise, MT: Manual therapy. Significantly different for pre intervention compared 4, 8, 12 weeks after intervention (p< 0.001); Significantly different for HE compared MT comparison at 4 weeks (p< 0.001); Significantly different for HE compared MT comparison at 8 weeks (p< 0.001); Significantly different for HE compared MT comparison at 12 weeks (p<0.001). Table 3. WHOQOL-BREF score for each intervention group over time Group Pre 4 weeks 8 weeks 12 weeks Time (T) Group (G) T G HE 60.00±10.37 68.07±7.58 69.33± 5.43 72.80± 4.46 0.000 *** 0.380 0.373 MT 58.81±8.56 64.19± 8.83 66.50± 8.02 71.94± 6.07 Mean±S.D., *** p<0.001. HE: Home exercise, MT: Manual therapy. Significantly different for pre intervention compared 4, 8, 12 weeks after intervention (p< 0.001). 288 www.kptjournal.org
Effects of Home Exercise and Manual Therapy on Patients with Adhesive Capsulitis JKPT 재후 4주, 8주, 12주에유의한차이가있었다 (p < 0.001). 측정시기와그룹간의유의한교호작용이있었으며, 중재후 4주, 8주, 12주에서가정운동프로그램군과도수치료군의유의한차이가있었다 (p < 0.001) (Table 2). 3. WHOQOL-BREF score 결과삶의질을평가하는 WHOQOL-BREF는가정운동프로그램군에서중재전 60.00 ± 10.37 점, 중재후 4주 68.07± 7.58점, 중재후 8주 69.33 ± 5.43점, 중재후 12주 72.80 ± 4.46점이었으며, 도수치료군에서중재전 58.81 ± 8.56점, 중재후 4주 64.19 ± 8.83점, 중재후 8주 66.50 ± 8.02점, 중재후 12주 71.94 ± 6.07점이었다. 측정시기에따른유의한차이가있었으며, 가정운동프로그램군과도수치료군은중재전과비교하여중재후 4주, 8주, 12주에유의한차이가있었다 (p < 0.001). 측정시기와그룹간의유의한교호작용은없었다 (p> 0.05) (Table 3). 고찰본연구는도수치료와가정운동프로그램적용이유착성관절낭염환자의기능과삶의질에미치는영향을확인하며, 보존적치료후가정운동프로그램적용이견관절기능을유지하기위한중재로써유착성관절낭염환자의견관절기능과삶의질에미치는영향에대해알아보고자하였다. 견관절의기능적상태를평가하는 Korean Shoulder Scoring (KSS) System은측정시기에따른유의한차이가있었으며, 가정운동프로그램군과도수치료군은중재전과비교하여중재후 4주, 8주, 12주에유의한차이가있었다 (p < 0.001). 측정시기와그룹간의유의한교호작용이있었으며, 중재후 4주, 8주, 12주에서가정운동프로그램군과도수치료군의유의한차이가있었다 (p < 0.001). O Kane 등 31 의연구에서물리치료와함께실시된간단한가정운동프로그램은유착성관절낭염환자의견관절기능평가와건강상태를개선하였으며, Miller 등 24 의연구에서기본물리치료를포함한약물치료와가정운동프로그램을병행하여 10년간장기추시한결과대상자들은통증과관절가동범위의제한없이일상활동에복귀하였다. Seo와 Shin 7 은자가신장운동이포함된가정운동프로그램은자기- 제어적 (self-control) 운동으로써장소와시간의제약이적으며, 접근의용이성과지속적인운동을통하여근육불균형을방지하고질병의진행을예방할수있어유착성관절낭염치료에대한효과적인중재방법으로고려될수있다고하였다. Ma 등 32 의연구에서기본물리치료와도수치료적용은유착성관절낭염환자의통증감소, 관절가동범위회복과견관절기능을향상시켰으며, Seo 등 33 의연구에서치료사에의해적용된관절가동운동 은관절가동범위증가와통증을감소시켰다. Mangus 등 34 은관절가동운동은유착된관절조직의유리화및관절낭교원섬유의재배열, 연골기질과활액사이의흐름증가를통하여관절의움직임과기능을회복시킨다고하였다. 삶의질을평가하는 WHOQOL-BREF 점수는측정시기에따른유의한차이가있었으며, 가정운동프로그램군과도수치료군은중재전과비교하여중재후 4주, 8주, 12주에유의한차이가있었다 (p < 0.001). 측정시기와그룹간의유의한교호작용은없었다 (p> 0.05). Cho 등 9 의연구에서유착성관절낭염환자의 WHOQOL-BREF 점수는 77.6점으로 93.6점의정상군과비교해서통계학적으로유의하게낮았으며, WHOQOL-BREF 하부척도점수도전반적인삶의질과신체적건강영역에서정상군보다낮게나타났다. 또한동통과기능정도를평가한 KSS 점수는전반적인삶의질및신체적건강과양의상관관계를보였다. Cho 등 35 의연구에서유착성관절낭염환자의통증은일상생활의어려움과삶의질을저하시킬수있으며, Fernandes 10 의연구에서유착성관절낭염환자의기능적상태의회복은삶의질향상으로이어질수있다고하였다. 본연구와선행연구의결과가정운동프로그램과도수치료는중재전과비교하여유착성관절낭염환자의견관절기능을유의하게향상시켰으며, 본연구의결과도수치료는가정운동프로그램과비교하여치료후 4주부터빠른기능적상태의회복을보였으며최종 12 주추시결과에서도유의한차이가있었다. 가정운동프로그램과도수치료는중재전과비교하여유착성관절낭염환자의견관절기능을향상시키지만도수치료적용이유착성관절낭염환자의기능향상에더욱효과적인중재방법으로생각된다. 본연구와선행연구의결과유착성관절낭염환자에서낮은삶의질을확인할수있었으며, 본연구의결과가정운동프로그램과도수치료는중재전과비교하여유착성관절낭염환자의삶의질을유의하게향상시켰다. 유착성관절낭염환자의삶의질향상은가정운동프로그램과도수치료적용후견관절기능향상에따른결과로생각된다. 본연구의결과견관절기능회복은가정운동프로그램과도수치료에서 4주, 8주, 12주에유의한차이가있었으나삶의질은 4주, 8주, 12주에유의한차이가없었다. 도수치료에서의삶의질향상은견관절기능회복에따른결과로생각되며, 가정운동프로그램에서의삶의질향상은견관절기능향상외에가정에서치료를통한심리적, 사회적요인이작용한것으로생각된다. Bagheri 등 36 은유착성관절낭염환자의삶의질은통증, 기능장애와상당한관련이있지만이차적으로심리적인요인도많은영향을미친다고하였다. 4주간의중재후지속적으로실시된가정운동프로그램은중재전과비교하여 8주, 12주에유착성관절낭염환자의견관절기능과삶의질을유의하게향상시켰다. 이는유착성관절낭염환자의적절한치료를위해서는장기적인치료적중재 www.kptjournal.org 289
JKPT The Journal of Korean Physical Therapy Kwang- Il Kwak, et al. 가필요하며, 가정운동프로그램은보존적치료를통한기능향상후 유착성관절낭염환자의견관절기능과삶의질향상및유지를위해 적용할수있는중재방법으로생각된다. 본연구는표본의크기가적고, 추시기간이짧아연구의결과를 일반화하는데어려움이있으며, 가정운동프로그램과도수치료의 중재자가동일하지않다는제한점이있다. 또한가정운동프로그램과 도수치료중재후견관절기능과삶의질향상을확인하였으나그에 따른상관관계를확인하지못한제한점이있다. 앞으로의연구는본 연구의제한점들을보완하여유착성관절낭염치료를위한효과적인 중재방법에대한다양한연구가필요한것으로생각된다. 참고문헌 1. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Physiotherapy. 2003;89(6):335-6. 2. Hsu JE, Anakwenze OA, Warrender WJ et al. Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;20(3):502-14. 3. Wong PL, Tan HC. A review on frozen shoulder. Singapore Med J. 2010; 51(9):694-7. 4. Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995;77(5):677-83. 5. Hannafin JA, DiCarlo EF, Wickiewicz TL et al. Adhesive capsulitis: capsular fibroplasia of the glenohumeral joint. J Shoulder Elbow Surg. 1994; 3(5):435-40. 6. 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