각 조직의 palpation 테크닉

[문형철]

촉진하고자 하는 조직에 따라 촉진테크닉, 촉진 목표가 다르다. 

피부와 뼈의 촉진을 생각해보라. 

피부는 피부 탄성도, 온도, 피부 점도도 등의 상태를 알고 싶지만 뼈는 뼈의 융기부, 경계면 등을 알고 싶을것이다. 

이렇게 멋진 책을 완성하고, 직접 사진까지 제공하는 Bernhard Reichert 저자에게 감사!

촉진의 원리(Basic Principles)

"You must be relaxed to have a good tactile sense."

"When do I have to palpate? always!

"You cannot feel what you do not know."

"Whatever the case may be, you should not give up if you are unable to palpate a structure immediately and with

confidence"

"In general, the amount of pressure applied should be as much as necessary and as little as possible"

1. 피부의 촉진

Example: Posterior trunk.

Technique:

• Skin quality: the palm of the hand strokes the skin.

• Skin temperature: the back of the hand strokes the skin.

• Skin consistency: displacement test, skin lifting test, skin rolling.

Expectations:

• Skin quality: smooth, pliable skin. Light hair growth is sometimes present.

• Skin temperature: uniform body temperature.

• Skin consistency: soft and very elastic. The skin becomes firmer when more tension is placed on it.

Commentary: 

The skin qualities described above represent the ideal situation for young patients. Needless to say, age-related changes to the skin should not be immediately classified as pathological.

-  나이에 따른 피부 질감의 변화를 병리현상으로 이해하지 마라

The skin's consistency is determined by the balance of fluid in the skin. Elasticity tests are used to assess the consistency

of skin and include the displacement test, lifting test (Fig. 1.2), and skin rolling. All three tests should provide dentical results. The same amount of elasticity, sensitivity, and changes in these parameters should be found.

- 피부 점조도는 피부 수분균형에 의해서 결정된다. 

If this is not the case, techniques should be reassessed or patients questioned again. These tests place different tensile

stresses on the skin. The displacement test can be used to find a sensitive or significantly inflamed region; small changes in consistency can be detected especially well using skin rolling with a large amount of stretch.

Tip: Experienced therapists need only use one of these tests when working with patients. The choice of test depends on

the sensitivity of tissues. In principle, skin rolling provides therapists with the largest amount of information.

- 피부 말기 검사는 치료자에게 가장 많은 양의 정보를 제공한다. 

The examination of skin consistency does not provide therapists with information on changes in muscle tension.

- 피부 점조도 검사가 근육긴장의 정도를 제공하지는 않는다. 

2. 뼈의 가장자리(bony edge) 촉진

Examples: Spine of the scapula, edge of the acromion, joint line of the wrist, a variety of joint spaces. Iliac crest,

rib shaft, spinous process, mastoid process, mandibular arch.

Technique: The fingertip palpates perpendicular to the edge of the bone.

Expectations: Hard consistency and a clearly defined border.

Commentary: This technique enables therapists to accurately locate the outer boundaries of a bone. The palpating finger must always be positioned perpendicular to the edge of the structure (Fig. 1.3). All other techniques are less reliable.

- 뼈의 가장자리를 촉진하기 위해 손가락은 반드시 뼈 가장자리에 수직으로 두어야 함. 

Tip: To feel the hard consistency and clearly palpate the bony edge, therapists should palpate the soft tissue first and then

gradually move toward the presumed location of the bony edge.

- 뼈 가장자리의 단단한 점조도를 촉진하기 위해 치료사는 반드시 연부조직부터 촉진하고 뼈조직을 촉진하는 순서를 지켜야

It becomes increasingly difficult to locate bony contours  when superficial tissue is tense. Muscles tense up when patients are positioned in unsupported sitting. Tension increases in all soft tissue when the SP alters the normal curvature of the spine, and tissue is stretched, for example, when padding is placed under the abdomen in the prone position or when sitting patients place their arms in front of them on a treatment table. Arthritic swelling and bone deformations alter the structure's expected consistency and contours.

- 만약 환자의 천층 연부조직이 긴장되어 있으면 뼈의 윤곽을 만지기 어려움. 

- 환자가 틀어진 자세, 잘 지지되지 않은 자세로 앉을때, 연부조직의 긴장은 증가함.

- 촉진시 환자의 척추가 정상 커브를 유지할때, 연부조직은 잘 이완되고 정확한 촉진이 가능함. 

- 관절염에 의한 부종, 뼈의 변형은 정상으로 기대되는 뼈의 윤곽, 점조도는 변화함. 

3. 뼈 융기부의 촉진

Examples: 

Medial epicondyle of the humerus, Lister tubercle, anterior superior iliac spine, tibial tuberosity,Gerdy tubercle. Posterior superior iliac spine, external occipital protuberance, sacral spinous processes.

Technique: Circular palpation using the finger pads and a minimal amount of pressure.

- 최소한의 압력으로 손가락 패드를 이용하여 circular 촉진을 함. 

Expectations: 

The bony prominence protrudes from the surrounding bone. The structure itself feels hard when direct pressure is applied to it.

- 뼈의 융기부는 뼈 주위에서 가장 돌출된 부분

Commentary: 

On the extremities, tubercles, tuberosities, etc. are clearly elevated in comparison to their surroundings and can be clearly differentiated from other tissues with this technique. In most cases, the pelvic spines can be differentiated from their surroundings by their distinctly protruding form. Boundaries cannot always be felt so easily. Their shape is palpated using flattened fingers (Fig. 1.4). Too much pressure makes it difficult to feel differences in shape and position, decreasing the chance of success. Direct pressure is only applied to the structure to confirm‎ that bone is being palpated.

- 뼈 융기부를 촉진할때 과도한 압력을 주면 뼈의 형태, 위치를 제대로 파악하기 힘듬. 

Tip: The shape of bony prominences can be visualized by looking at their morphology. However, variations are expected

 to be encountered quite often (see, e.g., external occipital prominence). This can be a distinct protrusion or very flat.

4. 근복(muscle bellies)의 촉진

Examples: Infraspinatus, deltoid, erector spinae, semispinalis capitis, gluteal muscles (Fig. 1.5).

Technique: Slow palpation. 

The finger pads (possibly using more than one to create a larger area of contact) are positioned perpendicular to the muscle fibers most of the time. Minimal pressure is applied.

- 손가락 패드(여러개의 손가락 패드를 함께 사용할 수 있음)는 근섬유에 수직으로 두고 촉진함. 

Expectations: Soft consistency. 

Tissue yields slightly to pressure. Deeper structures can frequently be palpated.

- 근복 조직은 가벼운 압력을 적용함. 심부 조직이 종종 촉지될 수 있음. 

Commentary: The muscles are palpated using one or several finger pads. Pressure should target the muscle directly.

The tissue's soft, elastic consistency can only be felt by proceeding slowly.

- 근육은 한개 또는 여러개 손가락을 이용하여 촉진함. 

- 촉진 압력은 직접 근육 촉직이 목표가 되어야 함. 

Tip: Tissue consistency is directly dependent on the strength or tension in the fascia enveloping the muscle or the section

of the trunk or extremities.

- 근육조직 점조도는 근막의 강도와 긴장에 영향을 받음. 

Thickness of the Fasciae

Fasciae can be very soft on the anterior and late sides of the trunk, in the neck, along the throat, in the medial forearm,

the calf, or the medial aspect of the thigh, for example. Muscles yield easily to the pressure of precise palpation here and have an especially soft, elastic consistency.

- 목, 전완의 내측면, 종아리, 대퇴의 내측면, 몸통 등의 앞뒤 근막은 매우 부드러울 수 있음. 

- 근육은 위 부위에서 적확한 촉진 압력에 쉽게 촉지됨. 

In contrast, extremely hard fasciae feel significantly firmer during palpation, even when the active muscle tension is normal. 

- 반면에 단단한 근막은 근육긴장이 정상일때도 촉진하는 동안 딱딱함이 느껴짐.

Typical examples of this are the thoracolumbar fascia superficial to the lumbar erector spinae and the rectus sheath. Therapists may easily conclude that muscles are tense when increased resistance is felt in the tissues. Once they are aware of the qualities fasciae possess, however, they will have correct expectations regarding the consistency of muscle tissue.

- 예를들어 흉요근막은 근육이 충분히 이완되어 있을때도 단단함이 느껴짐.

- 이러한 지식이 없는 치료사는 근육이 긴장되어 있다고 결론을 낼 수 있으므로 주의해야 함

- 이러한 근막의 특성, 질감을 알면 근육조직에 대한 올바른 평가가 내려짐.  

Tension in the Fasciae

The consistency of muscle and skin is also influenced largely by the length of tissues. An approximated muscle (where the

ends of the muscle are found close to each other) generally feels softer than the resting tension felt in a stretched muscle.

근육과 피부의 점조도는 조직 길이에 의해 크게 영향을 받음

근육이 서로 가까워지면 일반적으로 늘어난 근육에서 느낌보다 부드럽게 느껴짐. 

Approximation or lengthening occurs in the limbs due to the angular position of joints. It is very difficult to palpate local quadriceps induration when the knee is bent at 90°.

사지에서 관절의 구부러지는 위치때문에 근육이 가까워지거나 길어지기도 함. 

예를들어 무릎을 90도 굴곡할때, 대퇴사두근 단단해짐(induration)은 촉진하기 어려움

Positioning can influence muscle length in the trunk considerably. The changes to palpation become obvious when the lumbar and thoracic trunk extensors in the sitting SP are palpated and this is compared with palpation in the prone position. Even when resting the upper body on a treatment table and other supportive surfaces, muscles are stretched by the flexion/kyphosis of the lumbar

spine in a sitting position and by the forward bend of the body. 

몸통에서 자세는 근육길이에 영항을 줄 수 있음. 옆드려 촉진할때와 비교하여 앉은 자세에서 요추와 흉추의 신전이 일어날때, 촉진의 변화는 분명함. 

Tissue feels significantly firmer when pressure is applied. Therapists may interpret this as a pathological increase in muscle tension. The amount of tension in the back muscles is also altered when the therapist places padding underneath the abdomen in the prone position, lowers the head end of the treatment table, and elevates the arms. 

촉진 압력이 적용될때 근육조직은 분명하게 단단해짐. 치료사는 정상 근육긴장을 병리적 긴장으로 해석할 수 있음 .

등근육에서 긴장의 양(amount of tension)은 엎드린 자세에서 배에 패드를 대줄때 변화를 줄 수 있음. 

It is not always possible to avoid approximating or stretching muscles during the positioning or skillful examination of patients while keeping symptoms to a minimum.

환자의 증상이 가벼워 필요하지 않을때는 근육의 신장과 가까워짐을 피할 필요는 없음. 

It is important that the therapist takes this into account when looking at the expected consistency of the muscles to be palpated and does not reach the wrong conclusion when interpreting results. The following exercises should clarify how differences in fascial tension can affect the interpretation of palpatory results on the posterior aspect of the body:

치료사는 이러한 근육 길이에 따른 점조도를 잘 이해하여 결과를 해석해야 함.

아래에서 설명하는 운동에서 근막의 긴장이 어떻게  변화하고 다른지를 잘 해석해야 함. 

Exercise 1: The gluteal region is palpated, starting at the sacrum and moving systematically in a lateral direction. A hardened area is frequently palpated between the greater trochanter and the iliac crests. The iliotibial tract is located here (thickening of the fascia in the buttocks and the thigh), running from the iliac crest toward the greater trochanter and the lateral thigh. The therapist changes the hip joint's SP by moving it into more abduction or adduction and attempts to feel how the tract changes under direct palpation (different consistencies due to the muscle being stretched or approximated).

Exercise 2: Firm fascia already restricts direct pressure from being applied to the lumbar trunk extensors. The patient's pelvis is moved toward or away from the therapist. This causes lumbar lateral f lexion. The therapist palpates the trunk extensors and attempts to find out how their consistency changes ( ..... different consistencies due to the muscle being stretched or approximated). Lumbar tension is also increased when patients raise their arms over their heads.

5, 근육 가장자리(edge of muscle)의 촉진

Examples: Sartorius, adductor longus, semispinalis capitis, erector spinae, sternocleidomastoid.

Technique: A muscle edge is usually palpated with the muscle slightly tensed. The palpating fingers can be positioned using all possible variations (fingertips, finger pads, sides of the fingers) and should be placed against the edge of the muscle as best possible (Fig. 1.6). 

근육 가장자리의 촉진은 근육이 약간 긴장될때 잘 촉진됨. 촉진하는 손가락은 손가락 끝, 손가락 패드, 손가락 옆 등 다양하게 사용가능함. 

Once the edge of the muscle has been located, it is steadily followed so that the course and the length of the muscle can

be perceived.

Expectation: When tensed, the edge of the muscle has a firm consistency and a uniform, smooth contour. Large and small gaps differentiate the edges of the muscle from neighboring muscles.

근육이 긴장될때, 근육 가장자리는 대개 단단한 점조도를 갖고,  균일함, 부드러움 등의 점조도를 가짐. 

Commentary: Many neighboring muscles and borders cannot be differentiated from one another or identified without selective activation of the muscle. Well-trained muscles with low fat content as well as muscles with pathologically increased tension are exceptions and project themselves out of their surroundings.

선택된 근육 활성화없이 많은 이웃 근육과 경계가 잘 감별되기는 힘듬. 지방조직이 없는 잘 훈련된 근육과 긴장이 증가한 병리적 근육의 긴장 증가는 예외임.

Tip: A muscle and its edges can be quickly identified in difficult situations by alternating muscular tension. The patient is

instructed how to quickly alternate between tensing and relaxing the muscle. Reciprocal inhibition is sometimes an option

to help "turn off" neighboring muscles. Occasionally, the edges of the muscles can be followed along the further course

of the muscle to the insertion into bone.

근육과 근육의 가장자리는 변경된 근육긴장에 의해서 확인되기 어려운 상황에서 빠르게 확인될 수 있음. 환자는 근육의 긴장과 이완을 어떻게 빠르게 변화시키는지 교육되어짐. 근육의 상호억제는 이웃근육 이완에 도움을 줄 수 있음. 때때로 근육 가장자리는 근육-뼈를 따라서 따를 수 있음??...

6. 건(tendon)의 촉진

Examples: Tendons in the extensor compartments of the wrist, flexors of the wrist and fingers, biceps brachii tendon, ankle plantar flexors and toe flexors, hamstring tendons(Fig. 1.7). 

The trunk muscles rarely attach onto the bone via a tendon. A "fleshy" insertion is more common. Limb muscles near the trunk are more likely to have insertions that feel like tendons when palpated, for example, the communal head of the hamstrings.

몸통 근육은 건과 뼈부착이 드물고, fleshy insertion이 흔함. 

몸통에 가까운 사지 근육인 햄스트링의 근두가 촉진될때, 건처럼 느껴질 수 있음. 

Technique: The choice of technique depends on how difficult it is to find the target tissue and the aim of palpation:

촉진의 목적과 목표 조직을 찾는 것이 얼마나 어려운가에 따라 건 촉진 테크닉이 선택됨

• Tendon that is difficult to locate: Place the finger pads flatly and directly onto the point where you suspect the tendon to be, then alternately tense and relax the muscle.

촉진하기 어려운 건 : 손가락 패드를 평평하게 그리고 직접적으로 촉진하고자 하는 건부위를 촉진함. 근육 이완과 긴장을 번갈아가면서 바꾸면서..

• Tendon that is easy to locate: Place the tip of the finger alongside the edge of the tendon. Tense the muscle when necessary.

촉진 하기 쉬운 건 : 건의 가장자리를 따라서 손가락 끝을 댐. 필요하다면 근육을 긴장함. 

• For pain provocation: Administer transverse friction massage using the finger pads, applying firm pressure on the presumably affected site.

통증 악화 : 

Expectation: Firm consistency and, when the muscle is tensed, very firm consistency. A tendon remains somewhat elastic when direct pressure is applied to it, even when under a large amount of tension. In most cases, the tendon is a rounded structure with a clearly defined contour.

근육이 긴장될때 건은 단단한 점조도를 보임. 건은 직접적인 압력이 가해질때 다소 탄성(elastic)이 있음. 심지어 상당한 장력이 가해질때도 탄성이 있음. 대부분의 경우 건은 분명한 경계선을 가진 둥근 구조임.

Commentary: Tendons and their insertions belong to the soft tissue structures in the musculoskeletal system that most frequently present with local lesions. It is therefore imperative to familiarize oneself with the different techniques used for this taut connective tissue.

건과 건부착부는 연부조직구조임. 이렇게 단단한 결합조직 촉진을 위한 다양한 촉진법을 잘 알아야 함. 

Tip: The treating finger should not slip off from the tendon while Cyriax transverse frictions are being applied to the tendon for treatment or pain provocation. The tendon remains stabile by positioning the muscle in a stretched position and placing the tendon under tension.

치료하는 손가락은 시리악스 교차마찰 마사지를 적용할때 slip off해서는 안됨. 

7. 인대의 촉진

Examples: Medial collateral ligament or the patellar ligament at the knee joint (Fig. 1.8), talofiblilar ligament at the ankle. With very few exceptions the precise palpation of spinal ligaments is rarely possible. The pelvic ligamental structures, e. g., the sacrotuberous ligament (Fig. 1.8), as well as the sllpraspinoslls and the nuchal ligaments, are the only ligaments on the trunk that can be palpated well. Fig. 1.8 Palpating ligaments, demonstrated here with the patellar ligament.

Technique:

Ligament that is easy to locate: The tip of the finger is positioned on the edge of the ligament, for example, sacrotuberous ligament. 

Ligament that is difficult to locate: Initially place the ligament under tension and use direct pressure to palpate

the firm, elastic consistency, for example, nuchal ligament.

For pain provocation: Administer transverse friction using the finger pads, applying firm direct pressure onto the ligament, for example, supraspinous ligament.

Expectation: Firm consistency. Very firm consistency when stretched. A ligament remains somewhat elastic, even when placed under a large amount of tension.

Commentary: It is important to be able to accurately visualize the anatomy. You should be familiar with the course of the ligament and, when possible, find its bony attachments. Ligaments providing capsular reinforcement are another

type of taut connective tissue. In contrast to tendons, most ligaments cannot be easily differentiated from either those capsules without ligamental reinforcement or from other tissues. When ligaments belong to the fibrous layer of joint capsules, they only rarely show clear edges. Exceptions to this rule include the patellar ligament and the lateral collateral ligament of the knee joint. In the other cases, therapists must be familiar with the course of the ligament and locate its fixed points on the bones. In the upper cervical area, the local ligaments are examined via their bony partners and their biomechanical relationship (see "Test for the Alar Ligaments" section in Chapter 1 2, p. 347).

Tip: If therapists wish to administer provoking or therapeutic

transverse frictions to a ligament, the corresponding structure

must be stabile and should not be allowed to slide away

from underneath the finger. The joint is therefore positioned

so that the ligament is taut. When patients have only recently

overstretched or partially ruptured ligaments, prepositioning

is done with the necessary amount of care, that is, slowly and

without aggravating pain. Muscle contraction usually does

not help to make the ligament stabile enough for palpation.

[09정문권]

교수님께서 항상 강조하셨던 촉진의 3원칙이 여기에 있었군요..

"When do I have to palpate? always!

"You cannot feel what you do not know."

"Whatever the case may be, you should not give up if you are unable to palpate a structure immediately and with
confidence"

항상 만져라.
아는만큼 만질수 있다.
포기하지말고 만져라!

그리고 저자가 얘기했던 두가지를 추가하면..
- 좋은 촉진감각을 가지기 위하여 반드시 노력하라.
- 가능한한 최소의, 필요한 정도의 압력을 가하라.

[09정문권]

<피부의 촉진>
피부의 질감은 손바닥으로
피부의 온도는 손등으로

skin roll test는 가장 많은 양의 정보를 제공
피부 점조도 검사가 근육긴장의 정도를 제공하지는 않음!


<뼈의 가장자리>
뼈 가장자리의 단단한 점조도를 촉진하기 위해 치료사는 반드시 연부조직부터 촉진하고 뼈조직을 촉진하는 순서를 지켜야
촉진시 환자의 척추가 정상 커브를 유지할때, 연부조직은 잘 이완되고 정확한 촉진이 가능함.

<뼈 융기부>
최소한의 압력으로 손가락 패드를 이용하여 circular 촉진을 함
뼈 융기부를 촉진할때 과도한 압력을 주면 뼈의 형태, 위치를 제대로 파악하기 힘듬.

[09정문권]

<근복의 촉진>
근육조직 점조도는 근막의 강도와 긴장에 영향을 받음.

목, 전완의 내측면, 종아리, 대퇴의 내측면, 몸통 등의 앞뒤 근막은 매우 부드러울 수 있음.
반면에 단단한 근막은 근육긴장이 정상일때도 촉진하는 동안 딱딱함이 느껴짐.
이러한 지식이 없을 때,, 근육이 긴장되어 있다고 결론을 낼 수 있으므로 주의!!

<근육가장자리>
근육 가장자리의 촉진은 근육이 약간 긴장될때 잘 촉진됨

<건>
몸통 근육은 건과 뼈부착이 드물고, fleshy insertion이 흔함.
몸통에 가까운 사지 근육인 햄스트링의 근두가 촉진될때, 건처럼 느껴질 수 있음.

[09정문권]

촉진하기 어려운 건 : 손가락 패드를 평평하게 그리고 직접적으로 촉진하고자 하는 건부위를 촉진함. 근육 이완과 긴장을 번갈아가면서 바꾸면서
촉진 하기 쉬운 건 : 건의 가장자리를 따라서 손가락 끝을 댐. 필요하다면 근육을 긴장함.