11

서 론70%

1).

, 2).

, , 3), ,

, 4)

.

고창남1, 민인규, 박성욱

1, 정우상, 문상관, 박정미

1, 조기호, 김영석, 배형섭

1

원 저

Effectiveness of Bee Venom Acupuncture on Shoulder Pain after Stroke

Chang-nam Ko1, In-kyu Min, Sung-wook Park

1, Woo-sang Jung, Sang-kwan Moon,

Jung-mi Park1, Ki-ho Cho, Young-suk Kim, Hyung-sup Bae

1

Department of Cardiocascular & Neurologic Disease(Stroke center) College of Oriental medicine, Kyunghee University, Seoul, Korea

1Stroke Center, East-West Neo Medical Center

Objectives : Hemiplegic shoulder pain is one of the common sequelae of stroke. Although many different methods

of treatment are applied, none have yet been proved to be effective. In this study we assessed the effectiveness of

bee venom in patients with shoulder pain after stroke.

Methods : This study was a double blinded, randomized, placebo-controlled clinical trial. All subjects received

either 0.6 ml bee venom injection (venom:saline = 1:10000) or 0.6ml physiological saline solution (placebo) at three

acupoints. The effectiveness was assessed by visual analogue scale, pain rating score, Fugl-Meyer assessment and

passive external rotation.

Results : There were 24 patients in the venom group and 22 patients in the placebo group. The venom group

showed more effectiveness in VAS and PRS than the placebo group.

Conclusions : This study suggests that bee venom injection has significant analgesic effect on hemiplegic shoulder

pain. Further study based on multi-centers, larger population, and long term follow-up is needed to confirm this

suggestion.

: Bee venom acupuncture, stroke, shoulder pain

2006

(KHU-2006-073)

2006 12 20 2006 12 22

2007 1 16

, 1

2

(Tel: 02-958-9128, Fax: 02-958-9132,

E-mail: dnsehdgkrl@hanmail.net)

28 1 (2007 3 )J Korean Oriental Med 2007;28(1):11-24

28 1 (2007 3 )

12

.

,

, 5).

6)

7)

.

, ,

.

(LI15), (TE14), (GB21)

,

,

.

연구 대상 및 방법

1. 연구대상

1)

2006 7 1 2007 1

(1)

(2)

(2)

.

2)

(1)

(2)

(3)

(4)

(skin test)

(5) (VAS)

3 (6)

(6)

.

3)

, ,

.

2. 임상연구 증례기록지

(Case Form

Report, CRF) .

(Standard Operating Procedures,

SOP)

.

3. 실험 방법

1)

,

.

, 5

7

. , ,

,

(12)

8

13

.

,

, 2

.

.

2)

( :

=1:10000) .

, .

1ml 1:10000

0.1ml 20 , 8) 5mm

11mm Mueller

Grade 2 9-10)

.(Table 1)

2-3 1 , 1 3 2 6

,

. ,

, .

1cc ( 30 gauge)

0.4-0.8cm 0.2ml ,

.

-

, , ,

,

- , 1

.

1 1 , 3 ,

, ,

.

.

3)

(1)

, , ,

, ,

, ,

, , ,

, X ,

.

, , 11)

.

,

Grade Description

0 None or Local reactions only

1 systemic urticaria, pruritus, malaise

2 angioedema, chest tightness, nausea, vomiting, abdominal pain, dizziness

3 dispnoea, wheeze, stridor, dysphagia, hoarseness

4 hypotension, collapse, loss of consciousness, incontinence, cyanosis

(13)

28 1 (2007 3 )

14

12).

4

, ,

13).

Modified Ashworth sacle 2 14)

.(Table 2)

15). X-ray

. 199716)

>126mg/dl,

2 (2 hours)>200mg/dl

.

(2)

(Visual Analog

Scale, VAS) (Pain Rating Score,

PRS) . VAS

10cm

cm -1cm - 0-10

. PRS 1998

. (0-10) (0-5),

(0-5), (0-5)

0-150 17)

.

(painless passive ROM of shoulder

external rotation, PROM) Fugl-Meyer Motor

Assessment(FMMA) . PROM

45° , 90° ,

goniometer18)

.

,

. FMMA

0

, 1 ,

2

Grade Description

0 No increase in muscle tone

1slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the

end of the range of motion when the affrcted part(s) is moved in flexion or extension

1+Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throught the

remainder(less than half) of the ROM

2 more marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3 considerable increase in muscle tone, passive movement dificult

4 affected part(s) rigid in flexion or extention

(14)

8

15

(0-66) 19)

.

(3)

. Melittin,

Apamin -

Corticosteroid hormone

20) .

2 . ,

.

Muller grade .

4. 통계처리

SPSS(Stastical Program for Social

Science) 12.0 for Windows .

Mean±SD Number(%)

,

Mann Whitney U test , Chi-square

test ,

Wilcoxon Signed Ranks test . P

Value 0.05

.

결 과

46 .

1 2

2 1

VAS, Consent (n=46)

General Characteristics (n=46)

Patients randomized(n=46)

Venom(n=24) Placebo(n=22)

1st injection(n=24)2nd injection(n=24)3rd injection(n=23)4th injection(n=23)5th injection(n=23)6th injection(n=23)

1st injection(n=22)2nd injection(n=20)3rd injection(n=20)4th injection(n=20)5th injection(n=20)6th injection(n=20)

Assessment

Analysis

(15)

28 1 (2007 3 )

16

.

.(Figure

1)

1. 일반적 특징

64.33±9.88 67.50±9.60

. 12 (50%)

12 (50%) 9 (40.9%)

13 (59.1%) .

20 (83.3%), 4 (16.7%)

19 (86.4%) 3 (13.6%)

12 (50%)

12 (50%) 9 (40.9%)

13 (59.1%) .

5 (20.8%) 2 (9,8%) .

4 (16.7%),

12 (50%), 5 (20.8%),

2 (9.8%), 9 (40.9),

4 (18.2%) .

Venom(n=24) Placebo(n=22) P-Value

Age, Mean±SD, years 64.33±9.88 67.50±9.60 0.391*

Sex, n(%)

Male

Female

12(50)

12(50)

9(40.9)

13(59.1)

0.568+

Type of stroke, n(%)

Infarction

Hemorrhage

20(83.3)

4(16.7)

19(86.4)

3(13.6)

1.000+

First or Repeated stroke, n(%)

First

Repeated

19(79.2)

5(20.8)

20(90.9)

2(9.8)

0.418+

Side of Motor disorder

Right

Left

12(50)

12(50)

9(40.9)

13(59.1)

0.568+

Neglect 4(16.7) 2(9.8) 0.667+

Visual field deficits 12(50) 9(40.9) 0.568+

Hypertonia 5(20.8) 4(18.2) 1.000+

Cointervention 20(83.3) 19(86.4) 1.000+

Comorbidity(Diabetes mellitus) 7(29.2) 10(45.5) 0.361+

Time since onset of stroke

<6months

6months

23(95.8)

1(4.2)

20(90.9)

2(9.1)

0.600+

Time since onset of HSP

<6months

6months

24(100)

0(0)

21(95.5)

1(4.5)

0.468+

*Mann Whitney U test +Chi-square test

(16)

8

17

7 (29.2%) 10 (45.5%) .

20 (83.3%) 19 (86.

4%) .

.(Table 3)

12

. 1

45

. 12

9 (46.7%),

(40%), (31.1%), (31.1%),

(26.7%), (11.1%), (8.9%),

(6.7%), (4.4%)

.(Table 4)

X-ray

16 30 .

14

(93.3%) 4 (26.7%) .

14 (93.3%)

4 (26.7%) .(Table 5)

2. 주요평가척도의 변화

(VAS), (PRS),

(painless passive

ROM of shoulder external rotation, PROM)

Fugl-Meyer Motor Assessment(FMMA)

. ( ) VAS,

PRS, PROM, FMMA 2

. ( )

2 VAS, PRS

, FMMA PROM 2

.(Table 6)

Venom(n=23) Placebo(n=22)

43.5%

43.5%

34.8%

34.8%

34.8%

8.7%

8.7%

4.3%

0.0%

50.0%

36.4%

27.3%

18.2%

27.3%

13.6%

9.1%

4.5%

13.6%

Venom(n=15) Placebo(n=15)

Degenerative change 14(93.3%) 14(93.3%)

Subluxation 4(26.7%) 4(26.7%)

17

28 1 (2007 3 )

18

3. 보조평가척도의 변화

17 7 10

. 7 2

(PP2)

6 .

.

(Table 7)

2 8 (34.8%),

3 (13%), 2 (8.7%)

Venom(n=24) Placebo(n=22) P-Value

Visual Analogue

Scale

Baseline 7.17±1.90 7.09±1.60 0.911*

After 2weeks 4.74±1.66 5.95±1.67 0.022*

P-Value <0.000+ 0.002+

Pain Rating Score

Baseline 72.04±27.7 75.40±27.69 0.676*

After 2weeks 49.57±20.21 68.5±29.30 0.034*

P-Value <0.000+ 0.023+

Fugl-Meyer

Baseline 21.04±19.58 22.14±16.79 0.455*

After 2weeks 23.65±19.84 23.55±17.36 0.961*

P-Value <0.000+ 0.027+

Passive external

rotation

Baseline 40.83±24.88 42.06±27.28 0.938*

After 2weeks 33.48±23.95 36.75±24.30 0.722*

P-Value 0.005+ 0.026+

* Mann Whitney U test, +Wincoxon Signed Ranks test

Glucose(baseline) Glucose(2weeks later) P-Value

Venom, FBS mg/dL 118.42±58.75 113.57±53.15 0.172*

Venom, PP2 mg/dL 207.33±58.58 194.67±35.79 0.293*

*Wincoxon Signed Ranks test

The values are mean ± S.D

Venom(n=23) Placebo(n=20) P-Value

Pruritus 8(34.8%) 2(10%) 0.071*

Burning sensation 3(13%) 1(5%) 0.608*

Pain 2(8.7%) 3(15%) 0.665*

*Chi-square test

(18)

8

19

2 (10%), 1 (5%),

(15%) . ,

Mueller Grade 0

.(Table 8)

고 찰

,

,

.

- -

, 21)

.

22), NSAID

23),

24),

25-26),

27),

28), Botulinum

toxin29-30)

.

. 6)

7)

.

,

.

.

(Case Form Report, CRF)

.

(Standard Operating Procedures, SOP)

.

5 , 4 ,

1 10

. ,

.

,

. ,

. , ,

31).

.

1 1 , 3 ,

, ,

.

46 .

23 20

.

15). 1

45 ,

(19)

28 1 (2007 3 )

20

.

,

(57.8%) , , ,

, (53.3%)

, ,

, (33.3%) ,

. (40%)

.

.

.

,

.

(VAS) (PRS)

. VAS

,

, VAS

32) PRS

. 1 2

, 2 1

23 20

.

.

VAS PRS

, VAS PRS

.(p<0.05)

.(p<0.001)

.

(painless passive ROM

of shoulder external rotation, PROM) Fugl-Meyer

Motor Assessment(FMMA) .

33)

34). ,

. FMMA

, , 35)

.

23 20

. PROM, FMMA

. PROM,

FMMA

. ,

.

.

. Corticosteroid

hormone20)

.

2 . ,

.

17

7 2

6

.

.(P=0.071) 2

(20)

8

21

8 (34.8%), 3 (13%),

2 (8.7%)

2 (10%), 1 (5%), (15%)

. , Mueller Grade 0

.

, Mueller Grade 2

. ,

36)

.

, , ,

, , , , 20)

,

2-3

,

37),

38),

39),

40-41)

. 42)

, 43)

, 44)

,

.

.

PROM, FMMA

.

2

.

2

4

.

.

,

.

CRF

SOP ,

, , ,

,

.

결 론

2

, ,

,

.

1.

.

2. Fugl-Meyer Motor Assessment

.

(21)

28 1 (2007 3 )

22

3.

.

4. ,

.

5. (34%), (13%),

(8.7%)

. Mueller Grade 0

.

감사의 말씀

2006

.(KHU-2006-073)

참고문헌

1. Bohannon RW, Larkin PA, Smith HB, Horton

MG. Shoulder pain of Physical Medicine and

Rehabilitation 1992; 73; 409-413.

2. Braun RM, West F, Mooney V, Nickel VL,

Roper B, Caldwell C. Surgical treatment of the

painful shoulder contracture in the stroke

patient. Journal of Bone and Joint Surgery,

American Volume 1971; 53: 1307-1312.

3. , , , , ,

, , , .

1 -

1 -. .

117-127.

4. , .

. . 5(1):

43-53.

5. , , . 10

. .

2003; 20(3): 154-165.

6. .

. 2001.

7. , , , , .

. . 2006; 23(4):

69-80.

8. Bernstein IL, Storms WW. Practice parameters

for allergy diagnostic testing. Ann Allergy

Asthma Immunol. 1995; 75(6): 553-625.

9. . . :

. 1993: 313, 316.

10. Mueller HL. Diagnosis and treatment of insect

sensitivity. J Asthma Res. 1966; 3: 331-3.

11. Snels IA, Dekker JH, van der Lee JH, Lankhorst

GJ, Beckerman H, Bouter LM. Treating patients

with hemiplegic shoulder pain. Am J Phys Med

Rehabil. 2002 Feb;81(2):150-60.

12. . 3 . : . 2003:

16-17

13. David OW, Valery LF, Robert DB. Handbook

of Stroke. Lippincott Williams&Wilkins. 2006:

59.

14. Bohannon RW, Smith MB. Interrater reliability

of a modified Ashworth scale of muscle

spasticity. Phys Ther. 1987 Feb; 67(2): 206-7.

15. , , , , , .

. 2003; 16(2): 145-

156.

16. American Diabetic Association. Report of the

expert committee on the Diagnosis and classi-

fication of Diabetes Mellitus. Diabetes Care.

1997; 20: 1183-97.

17. , , .

. . 1998; 22(2):

305-311.

18. Bohannon RW, Andrews AW. Shoulder sublu-

xation and pain in stroke patients. Am J Occup

Ther. 1990; 44: 507-9.

(22)

8

23

19. Fugl- Meyer AR, Jaasko L, Leyman I Olsson

S, Steglind S. The post-stroke hemiplegic patient.

Scand J Rehab Med. 1975; 7: 206-7.

20. . . . 2000; 21(3):

3-8.

21. Bender L, McKenna K. Hemiplegic shoulder

pain: defining the problem and its management.

Disabil Rehabil. 2001 Nov 10;23(16):698-705.

22. Chantraine A, Baribeault A, Uebelhart D,

Gremion G. Shoulder pain and dysfunction in

hemiplegia: effect of functional electrical

stimulation. Arch Phys Med Rehabil 1999; 80:

328-331.

23. Green S, Buchbinder R, Glazier R, Forbes A.

Systematic review of randomised controlled

trials of interventions for painful shoulder:

selection criteria, outcome assessment, and effi-

cacy. BMJ. 1998 Jan 31;316(7128):354-60.

24. Chae J, Yu DT, Walker ME, Kirsteins A,

Elovic EP, Flanagan SR, Harvey RL, Zorowitz

RD, Frost FS, Grill JH, Fang ZP. Intramuscular

electrical stimulation in reducing hemiplegic

shoulder pain. Am J Phys Med Rehabil 2005;

84: 832-842.

25. Hanger HC, Whitewood P, Brown G, Ball MC,

Harper J, Cox R, Sainsbury R. . A randomized

controlled trial of strapping to prevent post-

stroke shoulder pain. Clin Rehabil. 2000 Aug;

14(4):370-80.

26. Griffin A, Bernhardt J. Strapping the hemip-

legic shoulder prevents development of pain

during rehabilitation: a randomized controlled

trial. Clin Rehabil. 2006 Apr;20(4):287-95.

27. Snels IA, Beckerman H, Twisk JW, Dekker JH,

Peter De Koning, Koppe PA, Lankhorst GJ,

Bouter LM. Effect of triamcinolone acetonide

injections on hemiplegic shoulder pain : A

randomized clinical trial. Stroke. 2000 Oct;31

(10): 2396-401.

28. Hecht JS. Subscapular nerve block in the

painful hemiplegic shoulder. Arch Phys Med

Rehabil. 1992 Nov;73(11):1036-9.

29. Kong KH, Neo JJ, Chua KS. A randomized

controlled study of botulinum toxin A in the

treatment of hemiplegic shoulder pain asso-

ciated with spasticity. Clin Rehabil. 2007 Jan;

21(1):28-35.

30. Yelnik AP, Colle FM, Bonan IV, Vicaut E.

Treatment of shoulder pain in spastic hemip-

legia by reducing spasticity of the subscapular

muscle: A randomized, double-blind, placebo-

controlled study of botulinum toxin A. J Neurol

Neurosurg Psychiatry. 2006 Nov 6;[Epub ahead

of print]

31. . . ; 1999: 124,

125,524,525,566,567.

32. Price C., Curless R.H., Rodgers H.: Can stroke

patients use visual analogue scale? stroke.

1999; 30: 1357-1361.

33. Joynt RL. The source of shoulder pain in

hemiplegia. Arch Phys Med Rehab. 1992; 73:

409-13.

34. Broeks JG, Lankhorst GJ, Rumping K, Prevo

AJ. The long-term outcome of arm function

after stroke: results of a follow-up study. Disabil

Rehabil. 1999 Aug;21(8):357-64.

35. Gladstone DJ, Danells CJ, Black SE. The

Fugl-Meyer Assessment of Motor Recovery

after Stroke: A Critical Review of Its Measu-

rement Properties. Neurorehabil Neural Repair.

2002 Sep;16(3):232-40.

36. , . Anaphylaxia

. . 2000;

17(4):149-159.

37. , , .

. . 2006; 15

(1):141-160.

(23)

28 1 (2007 3 )

24

38. , . ,

.

. 1998; 15(2):97-104.

39. . ,

.

. 1992; 13(1):283-292.

40. Valentine MD, Schuberth KC, Kagey-Sobotka

A, Graft DF, Kwiterovich KA, Szklo M,

Lichtenstein LM. The value of immunotherapy

with venom in children with allergy to insect

stings. N Engl J Med. 1990 Dec 6;323(23):

1601-3.

41. , , .

pubmed . 2001;

18(6):232-239.

42. , , , , , ,

, , , , .

(protrusion disc patients)

. . 2004; 21(5):13-25.

43. , , , , , ,

, , .

,

. . 2003;

20(2):77-84.

44. , , , , .

. . 2004; 21(4):251-262.

(24)