요추의 생체역학 및 촉진법 - 꼭 정리해야...

[문형철]

해부학적 구조, 기능해부학, 생체역학은 정확한 촉진법과 함께 탐구해야

익숙하다고 알고 있는 것은 아님을 꼭 기억해야 한다

panic bird.....

기억해야 할 몇가지

1. facet tropism -  후관절의 형태변화(굴성) 

2. 요추와 천골의 만남은 해부학적, 병리학적 소란상태임. anatomical and pathological "turbulence

This region is supported by different anatomical structures:- 요추와 천골이 서로다른 해부학적 구조에 의해서 지지됨. 

• The alignment of the L5-Sl zygapophysial joints. 요추 5-천골1번 후관절

• Strongly reinforced ligaments or ligaments that have been additionally developed (anterior longitudinal ligament, iliolumbar ligaments). 강력하게 강화된 인대(전종인대, 장요인대)

• Thoracolumbar fascia with its various collagenous layers and muscular dynamization. 흉요근막

3.  촉진을 위한 tip

The L5 spinous process is always smaller than the L4 spinous process. 

- 요추 5번 극돌기는 항상 요추 4번 극돌기보다 작음.

• The T1 2 spinous process is always smaller than the L 1 spinous process.

- 흉추 12번 극돌기는 항상 요추 1번 극돌기보다 작음. 

• Posteroanterior pressure applied to a spinous process moves the vertebra slightly anteriorly (Fig. 10.6).

- 요추를 PA방향으로 압박을 주면 추체는 약간 움직임.

4. 전종인대와 비교하여, 후종인대는 많은 통각수용기를 가지고 있어서 추간판에서 병리적 조건을 알려주는 "알람 벨" 역할을 함.

황색인대 When the trunk is flexed, these ligaments are placed under increasing tension, save energy, and help the vertebral column to return to an upright posture, therefore reducing the required muscle power. 

극상인대는 요추 5번과 천추 1번사이에는 없음. 

Significance and Function of the Lumbar Spine

요추의 중요성과 기능

The embryonic curves change during early childhood development in two sections of the vertebral column. The

lumbar spine represents one of these sections. The mobile sections of the vertebral column (cervical and lumbar

spines) become lordotic. The thoracic spine and the sacrum remain in their original kyphosis. The cervical and lumbar spines also possess deep prevertebral muscles(e g., psoas major).

- 태아때 가지고 있던 척추 커브는 청소년초기에 정상커브를 가진 척주로 발달함. 경추와 요추는 전만, 흉추와 천골은 후만. 

Supporting the Weight of the Body

- 인체 체중의 지지

From a kinetic point of view, the lumbar spine supports the weight of the upper body, the head, and the arms. As already described, approximately 60% of the body's weight in an upright posture is transmitted from the lumbar spine onto the S1 end plate. The lumbar spine adapts to this loading with wider and more solid material in the bones, collagen, and fibrous cartilage (structural stability/force closure ).

- 운동학적 관점에서 요추는 상체, 두부, 상지의 체중을 지지함. 

- 앞에서 언급한바와 같이 선자세에서 상체 체중의 대략 60%를 척추를 따라 천추 1번 종판으로 전달함. 

- 요추는 이러한 체중부하에 적응하기 위해 추체, 콜라겐 섬유, 섬유성 연골은 넓어지고 좀더 단단해짐. 구조적 안정성/힘잠금 기전

참고)  thoracolumbar fascia 의 구조와 형태는 이러한 힘을 지지하기 위해 진화한 것.

Spatial Alignment of the Upper Body

- 상체의 공간적 배열

The lordotic sections of the spine provide spatial orientation for the parts of the body they support. The lumbar

spine supports, props up, and turns the upper body. The cervical spine supports and aligns the head in relation to

its surroundings.

- 척추의 전만부위는 인체지지를 위한 공간적 방향성을 제공함.

- 요추는 상체를 지지하고, 경추는 머리의 배열을 정하고, 지지함. 

The Importance of Stability for Standing and lifting

- 서기와 들기를 위한 안정성

The intervertebral disks, ligaments, and muscles are in particular responsible for stability in the vertebral column

and achieve this using compression and tension banding. The erector spinae are not very active in the upright posture.

Their activity increase s when the body's center of gravity moves anteriorly, for example when:

- 추간판, 인대, 근육은 척주의 안정성을 담당하고, 그것을 이용하여 압박과 장력을 이겨냄. 

- 척추기립근은 선자세에서 매우 활성적이지 않음. 척추기립근 활성은 중력중심이 앞으로 이동할때 증가함. 예를들어...

• The upper body bends forward. 몸통을 앞으로 구부릴때

• The cervical spine is flexed. 경추 굴곡시

• An arm is elevated. 팔을 들어올릴때

It is important that the tissues provide the mobile parts of the chain with force closure to enable controlled movement. For this reason science of human movement states: 

- 조직은 체인으로 연결된 움직임 부분에 힘잠금기전과 함께 움직임을 조절함. 

"Stiffness is a precondition for movement." In a multi-segmental system such as the vertebral column, stability is

maintained by reducing the range of available mobility in individual segments so that the entire system can move harmoniously. The trunk extensors become inactive after approximately 60° of trunk flexion due to the ligamentous

structures taking over the job of decelerating movement . The thoracolumbar fascia is the most important ligamentous structure (see Fig. 1 0.33).

" stiffness는 움직임을 위한 전제조건임. 척추와 같은 다분절 시스템에서 안정성은 각분절에서 가능한 움직임 범위를 줄임에 의해서 유지됨.  그 결과 전체 시스템이 조화롭게 움직일 수 있음. 몸통 신전근은 몸통을 대략 60도 굴곡한 후 인대구조가 움직임 감소의 역할을 담당하기 때문에 활성화되지 않음. 흉요근막은 가장 중요한 인대구조임"

참고) 허리근육 EMG 실험

Movement in the Trunk

- 몸통의 움직임

The lumbar spine is an organ designed for flexion, with movement mainly occurring in the sagittal plane. It is just as natural to move out of the lordosis to bend the trunk backward and forward as it is to develop the lordotic form when standing. The lumbar spine is anatomically constructed and equipped for flexion. It is irrelevant whether the movement s are proper " flexion" or just a "straightening out of the lordosis" for palpation.

- 요추는 굴곡을 위해 디자인된 기관. 

- 서있을때, 요추 전만이 형성됨에 따라 몸통을 앞으로 뒤로 구부리는 것이 자연스러움. 

- 촉진을 위해서 허리를 굴곡 또는 일자로 서기가 적합한지는 아직 밝혀지지 않음. 

Certain anatomical structures assist the lumbar spine in its movement in the sagittal plane :

- 요추 움직임을 도와주는 해부학적 구조들

• The alignment of the lumbar vertebral joints superior to L5 makes extensive movement in the sagittal plane possible (Fig. 1 0. 1 ).

- 요추 5번위 척추배열은 시상면에서 광범위한 움직임을 만듬. 

• Thick intervertebral disks make extensive tilting movements possible in the lumbar segments.

- 두꺼운 추간판은 요추분절에서 광범위한 tilting움직임을 만듬. 

• Structures that decelerate movement and absorb forces: ligamentum flava, interspinous ligaments, thoracolumbar fascia.

- 힘을 흡수하고, 움직임을 제지하는 구조 : 황색인대, 극간인대, 흉요근막

• The exceptionally strong intrinsic muscles of the lateral tract (iliocostalis, longissimus).

- 예외적으로 강한 내재근이 있음(장늑근, 최장근)

Development  of Energy Needed for Locomotion

- 이동을 위한 필요에너지의 발달

According to Serge Gracovetsky ( 1988), the impulse for walking arises in the lumbar spine and is based on the mobility and activity in the muscles that cause rotation (the multifidi and external oblique). The legs only follow and reinforce this movement . Examples from evolution (fish, amphibians) demonstrate how important lateral flexion is for locomotion. 

- 보행의 충격은 요추에서 시작되고, 척추 회전을 일으키는 다열근, 외복사근의 활성화, 움직임에 기초함. 

- 하지는 이러한 움직임을 따르고 강화함. 

- 물고기, 양서류의 진화예를 보면 이동을 위해 외측 굴곡이 얼마나 중요한가를 보여줌.

In human beings, the lumbar spine uses lateral flexion and coupled rotation to transfer the trigger for locomotion onto the pelvis and the legs, whereby a lumbar lordosis and a certain walking speed are important. The impulse and energy arises solely in the legs when gait is slow; this requires a great deal of strength.

- 인간에서, 요추는 측굴과 짝 회전으로 골반과 하지의 이동을 위한 시작을 제공함. 

- 그것에 의하여 요추전만과 보행 스피드는 매우 중요함.

- 충격과 에너지는 보행이 느릴때, 하지에서 오직 발생함. 이는 매우 강력한 힘을 필요로 함. 

Junction between the Rigid and Mobile Vertebral Column

- 단단함과 움직임사이의 척주연접

The junction between the lumbar spine and the sacrum is a region of anatomical and pathological "turbulence."

Anatomical variations in the number of vertebrae (e.g.,hemisacralization) as well as a multitude of pathological conditions are frequently found here. This distinctive feature is probably due to typical biomechanical loading in addition to the lumbar spine acting as the junction between the freely mobile vertebral column and the rather rigid pelvis, in particular the sacrum.

- 요추와 천골의 만남은 해부학적, 병리학적 소란상태임. anatomical and pathological "turbulence

- 요추에서 해부학적 변이뿐 아니라 많은 병리적 상태가 요추와 천추가 만나는 이곳에서 자주 발견됨. 

- 명백한 특성은 아마도 전형적인 생체역학적 부하때문임. 게다가 요추는 척주와 단단한 골반(특히 천골)사이의 연접으로 작용하기 때문임. 

This region is supported by different anatomical structures:

- 요추와 천골이 서로다른 해부학적 구조에 의해서 지지됨. 

• The alignment of the L5-Sl zygapophysial joints. 요추 5-천골1번 후관절

• Strongly reinforced ligaments or ligaments that have been additionally developed (anterior longitudinal ligament, iliolumbar ligaments). 강력하게 강화된 인대(전종인대, 장요인대)

• Thoracolumbar fascia with its various collagenous layers and muscular dynamization. 흉요근막

Common Applications for Treatment in this Region

- 요추부위에서 치료를 위한 보편화된 지침들.

Most symptoms in the lumbar region are directly or indirectly related to the intervertebral disks. It is a known fact that the primary and most secondary intervertebral disk pathologies tend to be found in the lower lumbar segments of L4/L5 and L5/S1 . The primary intervertebral disk symptoms range from internal rupturing to the different forms of protrusions and prolapses of intervertebral disk substance (Fig. 10.2). 

- 요추에서 나타나는 많은 증상은 직접적으로 또는 간접적으로 추간판과 관련되어 있음. 

- 추간판의 병리는 요추 4-5, 요추5-천골1번사이에서 주로 관찰됨. 

These symptoms possess a large potential for self-healing. The initial physical therapy management of acute back pain aims to assess the primary pain and relieve affected neural structures, thereby supporting self- healing. The first inflammatory stage ends after a few days. Physical therapy then addresses the increased muscle tension, adaptive postures, immobilization, decreased proprioception, and, when necessary, the repositioning of the intervertebral disk substance.

- 이러한 증상은 자가치유 가능성을 가짐. 초기 물리치료의 목적은 통증을 조절하고 압박된 신경조직의 눌림을 제거하기 위함. 

- 처음 염증기는 며칠이내에 끝남. 물리치료는 증가된 근육긴장, 적응하여 틀어진 자세, 고정, 감소된 고유수용감각을 개선하는 것임. 필요하다면 탈출된 추간판의 원래자리로 되돌아가기. 

The therapeutic approaches to treatment always address the entire lumbar spine. Precise palpation techniques only have limited use here. For instance, it is generally not necessary to ascertain which segment is affected by provoking pain with palpation or assessing the local mobility. It is important to assess whether there is excessive muscle tension in the paravertebral muscles for the treatment of subacute disk-related symptoms. 

- 허리통증 치료접근은 항상 전체 요추를 살펴야 함. 

- 정확한 촉진 테크닉은 ...

- 예를들어 통증을 유발하는 요추의 분절이 어디인지를 찾는 것은 중요함. 국소적 움직임 평가가 중요함. 

- 과도한 근육긴장이 어느 근육에 있는지를 찾는 것은 아급성 디스크관련증상 치료에 중요함. 

This provides therapists with a sensible basis when they are deciding which treatment to use. When patients present with these sets of symptoms, therapists are therefore required to systematically palpate the muscles and have knowledge of in vivo anatomy (see the section "Palpating the Consistency of Muscle [Assessment of Muscle Tension]" in Chapter 8, p. 189).

- 지금 통증을 유발하는 요추분절, 지금 근육긴장으로 통증이 발생하는 근육을 아는 것은 치료사에게 어떤 치료를 급하게 해야 하는지를 알려주는 중요한 정보임. 

The secondary pathological intervertebral disk conditions behave completely differently. In vivo anatomy is often required in this case. Degenerative changes to the lumbar disks cause a surprisingly large range of symptoms. The intervertebral disks can be the source of pain and can be responsible for the involvement of sensitive ligamentous and neural structures ( Fig. 1 0.3).

- 병리적 추간판 상태는 완전히 다름.

- 퇴행성 변화가 있는 추간판은 놀랍게 많은 증상을 가짐. 추간판은 통증의 근원이 될 수 있고, 민감한 인대와 신경구조가 함께 통증에 관여함. 

These types of pathological disorders are mainly in the form of local segmental instability, chronic intervertebral disk irritation, disorders and diseases in the zygapophysial joints, and varying degrees of stenoses. Of course, combinations of these pathological conditions are possible.

- 병리적 질병은 "국소적분절 불안정, 만성 추간판 irritation, 후관절 부딪힘 그리고 다양한 정도의 척추관 협착" 등으로 분류할 수 있음.

- 물론 이러한 병리적 상태는 몇가지가 동시에 조합으로 나타남. 

Just think of the neighboring hyper-mobile and hypo-mobile segments that are frequently present. There are several different approaches to therapeutic management. The main aim of these approaches is pain relief and stabilization. Detailed anatomical orientation is an important foundation for segmental assessment and for the reliable use of local segmental techniques.

- 과움직임분절과 저움직임 분절이 흔히 존재함. 

- 주요 목적은 통증경감과 안정화를 회복하는 것임. 

- 세밀한 해부학적 기초는 요추분절 진찰을 위해 중요한 기초이고, 국소적 분절치료 테크닉을 위해 중요함. 

The role of in vivo anatomy here is:

• To locate the affected segments using provocation.

- 통증 악화검사를 이용하여 문제가 있는 요추분절 찾기

• To identify the affected segments by differentiating them from the neighboring segments (locating their level).

- 이웃 분절과 구별하여 문제가 있는 요추분절을 확인하기

• To assess the segmental stability and mobility using angled or translation tests.

- 분절 안정성과 운동성을 각도계를 이용 또는 translation 검사를 통해 확진. 

Competence in palpation is obtained from the consequential use of in vivo anatomy. It enables the therapist to provide exact information on the functional characteristics of the lumbar spine and therefore substantiates the treatment plan and the targeted use of pain relieving and/or mobilizing techniques.

- 촉진 능력은 생체해부학에서 얻을 수 있음. 

Required Basic Anatomical and Biomechanical Knowledge

- 기초 해부와 생체역학적 지식의 습득

The following information represents only a selection of information available on local anatomy and biomechanics. Several areas, such as the construction and function of the intervertebral disks or neuroanatomy, are not discussed in order to stay on the topic of in vivo anatomy. These sections primarily discuss the anatomical details required for palpation. A basic knowledge of movement segments according to Junghanns is of advantage. 

- 이 책에서는 촉진에 필요한 해부학적 구조에 대해서 자세히 탐구

Anatomical Definitions

The inferior section of the freely moveable vertebral column, the lumbar spine, usually consists anatomically of five freely moveable vertebrae. However, this is not the case in every individual. As already mentioned above, the lumbosacral junction is quite variable and anatomically "turbulent.

- 요추 하부의 자유롭게 움직이는 척주는 5개의 자유롭게 움직이는 척추로 구성됨. 하지만 이것은 모든 사람에게 같은 상황이 아님. 

- 위에서 언급한바와 같이 요천추 연접은 매우 가변적이고 해부학적인 혼란(turbulent)임. 

" Ttindury ( 1968, in Lanz and Wachsmuth, 2004a) wrote about the entire spectrum of variation in the anatomy with respect to the anatomical boundaries of all sections of the vertebral column ( Fig.1 0.4): "Only approximately 40% of all people have their boundaries in the normal location." The boundaries between the thoracic spine and the lumbar spine as well as the lumbosacral junction are of interest here.

- 툔드리 연구에 의하면 척주의 모든분절의 해부학적 경계에서 다양한 변이를 가짐. 

- 오직 인류의 40%에서만 정상위치에서 그들의 경계를 가짐???. 

- 흉추와 요추 사이의 경계뿐 아니라 요천추 연접이 여기서 흥미로움. 

-

When S1 is separated from the sacrum, it takes on the role of a lumbar vertebra and is labeled anatomically as lumbarization. This results in the lumbar spine possessing six vertebrae. The anatomist defines the superior variation

or sacralization as the fusion of L5 with the sacrum. This can be present partially or on both sides ( Fig. 10.5).

- 천골 1번이 천추와 떨어질때, 요추처럼 역할을 하고 요추화(lumbarization)라고 함. 이때 요추는 6개가 됨. 

- 요추 5번과 천골 유합될때 천추화(sacralization)라고 함. hemisacralization도 있음. 

In this case, only four freely mobile vertebrae exist. It becomes quite confusing when the therapist considers that there is even more variety in the number of sacral vertebrae. The terms refer therefore to the possible variations (lumbarization or sacralization) in the freely moveable lumbar vertebrae ( Lanz and Wachs muth, 2004a):

• Five lumbar vertebrae ---> common number in the lumbar spine.

• Four lumbar vertebrae ---> hemi-/sacralization in 3 - 1 2%.

• Six lumbar vertebrae ---> hemi-/lumbarization in 2-8%.

How Does this Affect Palpation?

A focus for in vivo anatomy along the vertebral column is defining the exact location, the level of a structure. Topographical knowledge provides the therapist with expected norms. These norms are transferred onto the living body during palpation. What does it mean when our confidence in topographical orientation-our knowledge of anatomy that we learn during training-becomes lost in the variation?

- 생체해부학에서 척주의 정확한 위치, 구조의 레벨을 찾아야

- 표면해부학은 치료사에게 미리 제기된 규범을 제공함. 

- 변이가 있을때를 잘 알아야

Variations in the anatomy of the lumbar spine make it difficult to locate the L5 spinous process. When three protruding and pointed spinous processes are found at the lumbosacral junction, it is difficult to differentiate between L5 and  S1 by simply looking at their shape. What options exist to confirm‎ the location of a structure when no movement in L5 on S1 can be felt, as is seen when mobility is restricted or when hemisacralization is present?

- 요추의 해부학적 변이는 요추 5번 극돌기를 찾기 어렵게 함. 

How can therapists remain confident in their palpation when the suspected S1 spinous process moves on S2 ? Is the localization incorrect or is a lumbarization present? Fortunately, constants also exist in anatomy. Certain structures have a constantly recurring shape, always react to pressure in the same way, and behave typically when they move (changes due to pathological conditions are not included here):

- 치료사가 천골 1번 극돌기에서 2번 극돌기로 옮겨갈때, 촉진의 확신을 어떻게 할것인가?

- 위치가 틀리거나 요추화가 있는가? 

- 운좋게도, 해부학에서 일정한 규칙은 있음. 

- 어떤 구조가 ....

• The L5 spinous process is always smaller than the L4 spinous process. 

- 요추 5번 극돌기는 항상 요추 4번 극돌기보다 작음.

• The T1 2 spinous process is always smaller than the L 1 spinous process.

- 흉추 12번 극돌기는 항상 요추 1번 극돌기보다 작음. 

• Posteroanterior pressure applied to a spinous process moves the vertebra slightly anteriorly (Fig. 10.6).

- 요추를 PA방향으로 압박을 주면 추체는 약간 움직임.

• Rotation (in a coupled movement pattern ) in one segment leads to the development of a palpable step between two neighboring spinous processes.

- 한 분절에서 회전은 두 이웃극돌기사이에서 촉진을 가능케 함. 

Shape of the Inferior lumbar Vertebrae and Intervertebral Disks

- 추간판과 하부요추의 형태

From an anatomical point of view, the lumbar lordosis is supported by the wedge-shaped construction of the vertebral discs, especially at L5 and most notably at the L5/S1 intervertebral disk ( Bogduk, 2000) (Fig. 10.7).

- 해부학적 관점에서, 요추전만은 추간판의 쐐기모양의 구조에 의해서 만들어짐. 특히 요추 5- 천골1번 사이의 추간판에서 두드러짐. 

How Does this Affect Palpation?

The lumbar spine is usually positioned in its physiological lordosis when it is being palpated. This is independent of the patient's starting position ( SP) (prone, side-lying). It may be the most natural position, but it does make the palpatory process more difficult. A lordotic lumbar spine offers certain conditions for palpation :

- 요추는 그것을 촉진할 때, 생리학적인 전만에서 촉진함. 

- 엎드리거나 옆으로 누운 자세에서 잘 촉진할 수 있음. 하지만 촉진은 어려움. 요추전만은 촉진을 위한 어떤 자세가 제공되어야..

• The palpation demonstrates that the superior section of the sacrum is definitely tilted anteriorly and its angled surface can be distinguished.

- 천골의 윗부분은 분명하게 앞쪽으로 기울어져 있고 그것의 각도는 구분될 수 있음. 

• When the erector spinae are prominent, all spinous processes can only be reached at their tips and somewhat to the side.

- 척추기립근이 두드러질때, 극돌기는 다소 옆에서 촉진할 수 있음. 

• The L5 spinous process is mostly found deep in the tissues and in close proximity to L4 and Sl.

- 요추 5번 극돌기는 L4와 S1가까운 근처 조직에서 깊은 위치에서 발견됨. 

• The thoracolumbar fascia and the back extensors are relatively relaxed.

- 흉요근막과 척추신전근은 이완되어야..

Further sections will explain which lumbar spine positions are favorable or less favorable for precise palpation.

Detailed Anatomy of Bony Structures

- 척추뼈 구조의 자세한 해부학

The thick vertebral bodies ( VBs ) are generally shaped like a bean or a kidney. Each VB is a tube made of the bone's

cortical substance filled with the bone's spongy substance. The VB is enclosed superiorly and in feriorly by hyaline end

plates. These end plates are nowadays included functionally as a part of the intervertebral disk ( Bogduk, 2000 ). The vertebral arch connects immediately posterior on to the vertebral body. All vertebral processes are attached to the arch: 

- 두꺼운 척추체는 콩과 같은 형태임. 

- 각각의 척추체는 스폰지 물질을 가득채운 뼈로 만들어짐. 

- 척추체는 초자연골에 의해서 위아래가 둘러쌓임. 

- 종판은 추간판의 일부로 기능함. 

- 척추 아치는 추체에 후면을 연결함. 모든 추체는 연결되어 아치를 만듬. 

• Spinous process.

• Superior and inferior articular processes.

• Costal processes.

Spinous Processes

These processes point directly posterior and are strongly developed (Fig. 10.8). They are the only osseous structure

in the lumbar spine that the palpating finger can reach with certainty. The shape of the lumbar spinous processes

is typical and can be well differentiated from the neighboring sections of the vertebral column during palpation.

- 요추 극돌기의 형태는 촉진동안 척주의 다른 부분과 잘 감별할 수 있음. 

How Does this Affect Palpation?

The L5 spinous process is smaller and more rounded. It almost "points" posteriorly. It can generally be well located.

The therapist may get confused between neighboring spinous processes when the S1 spinous process is pronounced. This can make it more difficult to allocate a segment to a specific level. 

- 요추 5번 극돌기는 작고 둥근 형태. 모두 후면을 향에 있음.

- 치료사는 천추 1번 극돌기가 돌출될 경우 다른 인접한 극돌기와 혼란을 일으킬 수 있음. 

- 이는 정확한 레벨을 정하기가 어려워진다는 뜻임. 

The Shape and Alignment of the lumbar Spinous Processes

-요추극돌기의 형태와 배열

The novice therapists may initially be surprised by the size and morphology of the lumbar spinous processes. The L1-L4 spinous processes are rather broad (superior-inferior dimensions ) and have an exceptionally irregular shape with indentations along their posterior aspect, giving them an undulating appearance (Fig. 10.9). The spinous processes are often expected to be smaller than they actually are.

- 초보 치료사는 요추 글돌기의 크기와 형태에 놀랄 수 있음. 요추 1-4번 극돌기는 위쪽-아래쪽으로 넓고, 유난히 불규칙한 형태로 톱니모양이고, 높낮이가 있는 모양임. 

- 극돌기는 흔히 극돌기 원래크기보다 작을 것으로 기대되는 경향이 있음. 

Bursae are regularly found between the neighboring lumbar and thoracic spinous processes. As with the other sections of the vertebral column, the therapist should not expect the lumbar spinous processes to always form a straight line. The lumbar spinous processes can protrude laterally away from the mid-line by up to a few millimeters and up to one centimeter in the thoracic spine and still be seen as a normal variation in anatomy.

- 점액낭은 요추와 흉추 극돌기사이에 이웃하여 규칙적으로 발견됨. 

- 치료사는 요추 극돌기가 중앙에 위치할 것으로 기대함. 실제 요추 극돌기는 중앙에서 몇 밀리미터정도 외측에 위치하고 흉추 극돌기에서 1cm떨어진 위치도 정상변이로 봄. 

How Does this Affect Palpation?

- 요추 극돌기 촉진법

The palpatory differentiation of spinous processes by locating the interspinal space is made considerably more difficult by their undulating form. Aids must be used once again to ensure that structures have been allocated to the correct level. Provided the condition of tissues does not make palpation difficult in study partners and patients, the long spinous processes can be correctly differentiated from the pointed L5 and the T12 spinous processes after gaining some experience. The T12 spinous process is likewise very thin. 

- 극돌기의 촉진감별은 극돌기의 높낮이가 다름때문에 매우 어려움. 

- 요추 4번 극돌기는 5번 극돌기보다 큼. 요추 1번 극돌기는 흉추 12번 극돌기보다 큼. 

Therapists and physicians often directly connect the position of the spinous processes with a local pathological

condition. A spinous process that deviates from the midline is mostly interpreted as a rotational malpositioning of the respective vertebra. However, this cannot always be the case due to the large variation in anatomy. A palpatory

finding must always be supported by local mobility tests and provocation tests to conclude the presence of a segmental pathological condition. 

- 치료사는 국소적 병리상태에 있는 극돌기의 위치를 흔히 직접 연결함. 중심에서 약간 어긋나 있는 극돌기는 척추의 회전 비정상위치로 해석됨. 하지만 촉진 해석은 항상 국소적 움직임 검사에 의해서 지지되어야 하고, 악화검사로 척추분절 병리적 상태의 존재를 확인해야 함. 

lumbar Transverse Processes

The lumbar transverse processes are remnants of ribs from the times of somitic composition. This arrangement can still be observed in the thoracic spine and is the reason why the transverse process is labeled the costal process. All transverse processes are strongly developed and extend directly sideways from the vertebral arch. 

- 요추 횡돌기는 늑골의 잔여물임. 

- 흉추에서 이 배열은 관찰되고, 횡돌기가 늑골 돌기로 이름붙여진 이유가 있음. 

- 모든 횡돌기는 강하게 발달했고, 척추아치로부터 직접적으로 확장됨. 

According to Lanz and Wachsmuth (2004a), the L3 costal process is the widest. In rare cases (4-8%), L1 can possess an oversized process that is described in literature as a lumbar rib ( Lanz and Wachsmuth, 2004a). This makes it more difficult to differentiate the thorax from the lumbar spine when using palpation. 

- 요추 3번 늑골 돌기(횡돌기)는 가장 넓음. 

- 드물게(4-8%), 요추 1번은 큰 횡돌기를 소유할 수 있음. 촉진할때 요추와 흉곽을 구분하기 어렵게 만드는 요소임. 

A multitude of muscles attach onto the transverse processes ( Dvorak et aI., 2008 ). As with the spinous processes, the transverse processes are therefore perfect levers for acting forces moving the lumbar vertebrae into lateral flexion and rotation (Fig. 10.10). The transverse processes separate the posterior intrinsic back muscles topographically from the anterior deep abdominal muscles (e.g.,psoas major).

- 많은 근육이 횡돌기에 부착함. 극돌기와 같이 횡돌기는 요추의 측굴과 회전움직임의 힘을 제공하는 완벽한 지레임. 

- 횡돌기는 대요근과 같은 전방 심부 복부근육과 구분하는 기준임. 

Muscular or dynamized connective-tissue structures are currently regarded as functionally very important in the stabilizing treatment of the lumbar spine. These structures insert on the costal processes:

- 근육이나 활성화된 결합조직 구조는 최근에는 기능적으로 요추를 안정화시키는 중요한 구조임. 

• Transversus abdominis over the middle layer of the thoracolumbar fascia.

• Quadratus lumborum.

• Multifidus.

• Longissimus.

How Does this Affect Palpation? 횡돌기의 촉진

The attempt to reach the transverse processes using palpation is only conclusive on slender people. The transverse processes are located several centimeters anterior to the superficial surface of the back and are completely covered by the thick, prominent back extensors. 

- 요추 횡돌기 촉진의 시도는 오직 마른 사람에게서만 가능함.

Only the tips of the L3 and possibly the L4 transverse processes can be reached. This is achieved by applying significant posteroanterior pressure lateral to the back extensors and superior to the iliac crests, then palpating in a medial direction in the hope of coming across a hard structure.

- 오직 요추 3번과 4번 횡돌기의 끝을 촉진할 수 있음. ...

The purpose of this maneuver is questionable, alongside the technical difficulties associated with this procedure. This technique is not suitable for diagnosing the alignment of the structure or for the selective provocation of pain and will therefore not be discussed later. 

- 횡돌기 촉진은 어려움...

Zygapophysial Joints

- 척추 후관절

These are some of the most important functional parts of the vertebra. The largest variety of terms is also used to describe these joints (e.g., facet joints, vertebral joints ). The thickness and construction of intervertebral disks enable segments to move. In principle, the zygapophysial joints (ZAjs ) determine how this potential for movement is used. The alignment of these joints dictates the direction and partially the range of segmental movement. It is well known that the superior articular process of the inferiorly positioned vertebra (more concave) forms a ZAj with the inferior articular process of the superiorly positioned vertebra ( more convex) ( Fig. 1 0. 1 1 ).

- 척추의 가장 중요한기능적 부분이 있음. 후관절과 척추관절

- 추간판의 두깨와 구조는 움직임을 가능케 함. 

- 후관절은 움직임 가능성을 어떻게 사용하는지 결정함. 이 관절의 배열은 방향을 정하고, 분절움직임의 범위를 정함. 

- 후관절의 하부돌기는 좀더 오목하고, 상부돌기는 좀더 볼록함. 

The position of the lumbar joint facets between T12/L 1  and L4/L5 is uniformly described in manual therapy literature (Dvorak, 2008 ): In relation to the vertebral bodies, the superior joint surfaces are arranged upright and converge

at an average angle of 45° from posterolateral to anteromedial ( Fig. 1 0. 1 2). 

- 흉추 12-요추 1 그리고 요추 4-5사이의 요추 후관절위치는 수기치료 문헌에서 균일하게 묘사됨

- 척추에서 상부돌기면은 위로 서있고, 관상면에 대해서 lamina가 이루는 각은 45도, 후관절의 각도는 90도

This angle gradually decreases in the more superior vertebrae ( Bogduk, 2000). This results in the lumbar spine's affinity to movement in the sagittal plane, enables the lumbar spine to laterally flex, and prevents axial rotation. The latter movement can best be visualized by looking at the axes for lumbar movement found in the disk (see the section " Basic Biomechanical Principles" below, p. 256).

- 이 각도는 위쪽 척추로 올라갈수록 감소함. 이는 요추가 시상면에서 척추 움직임 친밀성을 야기하고, 외측굴을 가능케 하고, 축회전을 막아줌. 

The L5/S1 joint facets orient themselves more in the frontal plane, somewhat increasing this segment's ability to axially rotate. The principle of anatomical variation continues in the lumbar ZAjs joint surfaces of the same level can be shaped differently with different spatial alignment without being pathological. Individual differences in the shape of the ZAjs between sides is labeled " facet tropism" (Jerosch and Steinleitner, 2005 ) ( Fig. 1 0.13). 

- 요추 5번과 천추 1번 후관절은 관상면에서 자체배열을 이루고, 다소 축회전 가능성이 증가함.

- 후관절 굴성(facet tropism)

This means that the previously described spatial alignment of the joint surfaces is to be understood as only representing the average and that there are differences between the left and right side in each segment.

참고) facet tropism

How Does this Affect Palpation?

척추 후관절 촉진

The ability to palpate the vertebral column is mainly used to assess segmental mobility and to ascertain the level of individual structures. To be able to do this, the therapist must be aware of the possible range of motion in the sections of the vertebral column. The influence of differently formed joint facets on the palpation during movement will be clarified later. It can be presumed that  facet tropism does not affect the degree of symmetrical movement in the lumbar spine (flexion and extension ). When the anterior tilt of the vertebra is different on the left and right side during flexion. this can not be felt because sagittal movement is simply perceived as an opening or closing of the spinous processes (Fig. 1 0. 1 4). 

- 척주촉진 능력은 주로 척추분절 움직임을 평가하는 것과 각각 구조의 레벨을 확인하는 것

- 이것을 가능하게 하기 위해서, 치료사는 반드시 척주 분절에서 움직임 범위를 알아야 함.

-  움직임 동안 서로 다르게 형성된 후관절촉진의 영향은 후에 확인할 수 있음. 

- 후관절 굴성은 요추 굴곡과 신전에서 대칭적 움직임 정도에 영향을 주지 않음. 

- 척주의 전방 tilt가 굴곡동안 좌우축이 다름. 이는 시상면 움직임이 극돌기의 열림 또는 닫힘으로 인지되기 때문에 쉽게 느낄 수 없음. 

A difference in movement between the sides where the vertebra moves asymmetrically does not change the palpable range of motion. This is different for asymmetrical lateral flexion or rotation movements, where the effect of differently formed joint positions and shapes is important. The range of motion in segmental lateral flexion and rotation to the left and to the right can therefore differ. even in "healthy segments." For this reason. the therapist compares sides when assessing the range of local motion while still being aware of what is happening in the neighboring segments (Fig. 1 0. 1 5 ).

- 척추가 비대칭적으로 움직이는 부위에서 움직임 차이는 촉진할 수 있는 움직임 범위가 바뀌지 않음. 

- 이것은 비대칭적인 측굴 또는 회전 움직임을 위한 차이이고, ...

The ZAjs and their capsules stand out in anatomical specimens with their astoundingly large ball-like form. 

'Their position is approximately at the level of the inferior edge of a spinous process. To palpate the ZAjs. the therapist

must overcome a layer several centimeters thick (25-35 mm) consisting of the thoracolumbar fascia and the multifidus (8jordal et aI., 2003 ) (Fig. 1 0. 1 6). 

- 후관절과 관절낭은 큰 볼모양의 형태..

- 후관절 위치는 극돌기의 약간 아래에 존재..

- 후관절을 촉진하기 위해서 치료사는 2.5cm두깨 몇개층을 극복해야 함. 흉요근막과 다열근으로 이루어진...

ln myopinion, it is not possible to locate the joint by palpating the contours, feeling the different consistencies of the tissues, or through the use of palpation under movement. Pain can be provoked by applying pressure to the soft tissue. However, it is not possible to definitely attribute the pain on pressure to the involvement of the ZAjs.

- 후관절 둥근윤곽촉진은 불가능함. 

- 통증은 연부조직의 압박에 의해서 악화시킬 수 있음. 하지만 후관절에 압박을 가해 발생하는 통증은 정확하게 만들기 힘듬. 

Detailed Anatomy of the ligaments

요추 인대의 세밀한 해부학

Four ligamentous systems can be differentiated from one another in the lumbar spine:

- 요추에는 서로구분할 수 있는 네가지 인대...

• Vertebral body ligaments - 전종인대, 후종인대

• Columns of segmental ligaments - 황색인대, 횡돌기사이인대, 극간인대, 극상인대.

• Additional lumbar ligaments - 장요인대.

• Thoracolumbar fascia. 

1. Vertebral Body ligaments  - 전종인대, 후종인대

Both longitudinal ligamentous columns accompany the entire vertebral column: the anterior and the posterior longitudinal ligaments. These ligaments are also part of the basic ligamentous structures found in a segment (Fig. 10. 1 7 ).

- 두개의 종인대로 척주를 앞뒤에서 둘러쌈 : 전종인대와 후종인대

전종인대

The anterior longitudinal ligament (ALL) is found anterior to the foramen magnum and extends down to the sacrum

where it attaches inseparably onto the periostium. lt becomes increasingly wider more inferiorly. Superficial layers skip over four to five vertebrae. Deeper layers connect two neighboring vertebrae ( Bogduk, 2000). All sections of the ligament are attached to the middle of the vertebral body and are not firmly connected to the intervertebral disk's anulus fibrosus. This ligament helps to restrict lumbar extension and prevent an increase in lordosis. 

- 전종인대는  foramen magnum 앞쪽에서 천골까지 이어진 구조로, 골막과 떨어질수 없이 붙어 있음.

- 아래쪽으로 내려갈수록 넓어짐. 

- 천층부는 4-5번째 척추를 skip over. 심층부는 두개의 이웃한 척추를 연결함.

- 전종인대의 전부분은 척추의 중앙에 부착하고, 추간판 섬유륜을 단단하게 연결하고 있지 않음. 

- 전종인대는 요추신전을 제한하고 요추전만이 증가하는 것을 막아줌. 

후종인대

The posterior longitudinal ligament ( PLL) is also made up of two layers. The superficial layer runs in a longitudinal direction and is thin. The deep layer runs in a transverse direction and is wider. It connects to the anulus fibrosus, reinforcing the disk. This ligament passes from the occiput to the coccyx, just like the anterior longitudinal ligament. 

- 후종인대는 두개의 층으로 구성됨. 천층은 수직방향으로 내려가고 얇음. 심층은 횡방향으로 이어지고, 넓음. 

- 후종인대는 섬유륜을 연결하고, 추간판을 강화함. 후종인대는 후두에서 꼬리뼈를 연결함. 

The ligament has special nomenclature in its upper cervical section and at the lumbosacral junction. In comparison to the ALL, the PLL possesses a high number of nociceptors and acts as an "alarm bell" for certain pathological conditions in the intervertebral disk.

- 전종인대와 비교하여, 후종인대는 많은 통각수용기를 가지고 있어서 추간판에서 병리적 조건을 알려주는 "알람 벨" 역할을 함. 

2. Columns of Segmental ligaments - 황색인대, 횡돌기 사이인대, 극간인대, 극상인대

- 척주의 분절 인대

A row of short ligaments is found between the vertebral arches and the protruding processes, each connecting two vertebrae.

황색인대

In young people, the ligamenta flava ( Fig. 1 0. 1 8) are mainly made of elastic fibers. They extend between the laminae of the vertebral arch and line the posterior side of the vertebral canal. These ligaments are under tension even in an upright posture. When the trunk is flexed, these ligaments are placed under increasing tension, save energy, and help the vertebral column to return to an upright posture, therefore reducing the required muscle power. 

- 젊은 사람에서, 황색인대는 주로 탄력섬유로 구성. 

- 황색인대는 척추아치와 척추 canal의 후면사이 라미나를 연결하여 이어짐. 

- 황색인대는 서있는 자세에서 장력하에 놓임. 

- 몸통을 굴곡할때, 황색인대는 증가된 장력하에 놓여지고, 에너지를 비축하고 척주가 선자세로 되돌아갈수 있도록 도와줌. 

후관절낭과 횡돌기 사이인대

The anterior section of the zygapophysial joint capsules is formed by the ligamenta flava. The intertransverse ligaments are quite thin and membrane like in the lumbar spine. They connect the transverse processes-called the costal processes here-and are placed under tension when contralateral lateral flexion and rotation are performed.

- 후관절낭의 전방 단면은 황색인대에 의해여 만들어짐. 

- 횡돌기 사이 인대는 매우 얇고 요추에서 막과 비슷함. 횡돌기 사이인대는 횡돌기를 연결하고, 회전과 측굴할때 장력하에 놓여짐.

참고) 횡돌기 사이인대

(The intertransverse ligaments are ligaments that are placed between the transverse processes of the spine. In the cervical region they consist of a few irregular, scattered fibers that are often replaced by muscles. In the thoracic region they are rounded cords intimately connected with the deep muscles of the back. In the lumbar region they are thin and membranous.^[1][2] The intertransverse ligaments often blend with intertransverse muscles.^[2] The function of the intertransverse ligaments is to limit lateral flexion of the spine.^[2]

극간인대

The interspinous ligaments ( Fig. 1 0. 1 8 ) stretch between the spinous processes of two neighboring vertebrae.

The literature describes the alignment of the fibers quite differently. The details vary from a vertical alignment, via the anterosuperior course of fibers (Netter, 2004), to the posterosuperior course of fibers ( Bogduk, 2000), demonstrating the need for clarification in descriptive anatomy. All authors agree that these ligaments limit flexion and rotation.

- 극간인대는 두개의 이웃하는 척주의 극돌기 사이에 뻗어 있음. 문헌은 극간인대의 섬유배열이 완전히 다르다고 기술함.

- 극간인대는 수직배열, 전상배열, 후상배열 섬유로 다양함. 

- 모든 저자는 극간인대가 굴곡과 회전을 제한한다고 동의함. 

극상인대

The supraspinous ligament ( Fig. 1 0. 1 8) is found superficial to the spinous processes and is basically the only ligament that can be palpated in the lumbar spine. This structure should not be seen as a ligament. Rather, it should be viewed as a doubling of the thoracolumbar fascia. Vleeming recently commented on this (personal communication ): "The supraspinous ligament is really an anatomical specimen artifact."

- 극상인대는 극돌기의 천층에서 발견됨. 그것은 요추에서 촉진할수 있음. 

- 극상인대 구조는 인대로 보아서는 안됨. 흉오근막의 두층으로 보아야 함. 

- The supraspinous ligament is really an anatomical specimen artifact...

The following relationships are currently being discussed:  이어지는 관계가 논의됨. 

• The superficial layers of this fascia meet at the midline.

• The connecting line is reinforced with ligament like structures.

• A  section is attached to the periostium of the spinous processes.

• The other section is found in the interspinous space, forms the interspinous ligaments, and even extends into the ligamenta flava deep inside the movement segment.

How Does this Affect Palpation?

As already described, it is very difficult to palpate the posterior  aspect of the spinous processes due to their irregular contours and undulating shape. The presence of the supraspinous ligament makes it even more difficult to feel the interspinous space when searching for the boundaries to the neighboring vertebra using palpation. The supraspinous ligament is absent between L5 and S1 ( Heylings, 1978, in Bogduk, 2000). This may contribute to the fact that the lower edge of L5 can be palpated well (see the section "Local Bony Palpat ion" below, p. 260).

- 앞에서 언급한 바와 같이 요추극돌기는 불규칙한 윤곽이고, 물결치는 공간때문에 촉진이 매우 어려움. 

- 극상인대의 존재는 극간인대 공간을 느끼게 하는데 어렵게 함. 

- 극상인대는 요추 5번과 천추 1번사이에는 없음. 

- 이는 요추 5번 아래 가장자리는 잘 촉진할 수 있다는 것을 의미함. 

3. Additional lumbar ligaments - 장요인대

The iliolumbar ligaments ( Fig. 1 0. 1 9 ) are the most important complex of ligaments that have contact wit h the lumbar

spine but arise elsewhere. They run from different points on the L4 and L5 costal processes to the anterior aspect of the iliac crest and the ala of the ilium. The individual sections vary in their construction and are connected to the lumbar segmental ligaments and the sacroiliac ligaments ( Pool-Goudzwaard et aI., 200 1 ).

- 장요인대는 요추와 함께 연결된 가장 중요한 복잡한 인대구조임. 

- 장요인대는 요추 4, 5 횡돌기에서 장골능, 장골의 날개로 이어짐. 

- 장요인대는 요추분절인대와 천장인대를 연결함. 

The iliolumbar ligaments are also described in the anatomical literature ( Lanz and Wachsmuth, 2004a) as a continuation of the intertransverse ligaments , partially as reinforcement of the thoracolumbar fascia ( middle layer), as well as fibrotic parts of the quadratus lumborum. The position of these structures becomes apparent when the ligament is seen on an anatomical specimen. They are hidden beneath the several-centimeter-thick layer of intrinsic back muscles and lie in a tight corner between the transverse processes and the pelvis.

- 장요인대는 해부학 문헌에 "횡돌기 사이인대의 연결로 묘사됨", 특히 흉요근막 중간층을 강화할 뿐 아니라 요방형근의 섬유성 부분을 강화함. 

- 장요인대는 몇센치미터의 두깨를 가진 척추 등 내재근 아래에 숨겨져 있고 골반과 횡돌기 사이에 단단한 구석에 자리함, 

Individual fibers run along the frontal plane and restrict lateral flexion and rotation at L4-S1. The fibers are also arranged in a variety of ways in the sagittal plane ( Figs. 1 0. 1 9 and 1 0.20), limiting flexion and extension (Yamamoto et aI., 1 990) and helping to prevent the lowermost free vertebra from gliding anteriorly ( Bogduk, 2000). Muscle activity can most likely assist the deep lumbar stability to a large extent by placing these ligaments under tension.

- 장요인대 각각의 섬유들은 전두면을 따라 연결되고, 요추 4, 5, 천골 1번에서 측굴과 회전을 제한함. 

- 장요인대는 시상면에서 다양한 방식으로 배열되어 굴곡과 힌전을 제한하고 하부요추가 전방으로 미끄러지는 것을 막아줌. 

- 장요인대가 장력하에 놓여짐에 의해서 근육 활성이 심부 요추안정성을 상당범위까지 도울 수 있음. 

How Does this Affect Palpation?

장요인대의 촉진

The iliolumbar ligaments help to control lateral flexion and rotation, especially at L5-S1 . This action must be considered when palpating during movement. Some textbooks (Chaitow, 2001 ) recommend palpating these ligaments for diagnostic purposes. Readers should form their own opinion as to whether diagnostically conclusive palpation through the thoracolumbar fascia and the erector spinae, 5-7 cm deep, is possible.

- 장요인대는 요추 5-천추1번사이의 측굴과 회전을 조절하는 것을 도움. 이러한 작용은 움직임 동안 반드시 고려되어야 함. 

- 어떤 책은 장요인대의 촉진을 진단목적으로 시행해야 한다고 조언함. 

- 독자는 반드시 진단에 결정적인 촉진부터 흉요근막과 척추기립근 5-7cm깊이까지 자신만의 의견을 만들어야 함. 

4. Thoracolumbar Fascia 흉요근막 

The collagenous fibers of the thoracolumbar fascia define the appearance during the inspection of an anatomical

specimen of this region. The significance of the sacroiliac (SI) joint has already been described in Chapter 9 on "Palpating

the Posterior Pelvis." It is mentioned there that the superficial parts of the gluteus maximus radiate into the fascia. The collagenous fibers of the latissimus dorsi and gluteus maximus cross over the mid-line when they do this and are connected diagonally with each other (see the section "Ilium-Posterior Superior Iliac Spine" in Chapter 9, p. 222).

- 콜라겐 섬유로 된 흉요근막은 "천장관절 촉진"에서 이미 자세히 기술함. 

- 대둔근이 흉요근막의 천층부분까지 연결되어 있음.

- 광배근과 대둔근의 콜라겐 섬유는 척추중앙선을 가로질러 서로서로 연결됨. 

More dynamizing s tructures are added to this in the lumbar region : 요추부위에서 흉요근막의 좀더 자세한 구조

• Superficial layer: serratus posterior inferior.

• Middle layer:

- transversus abdominis

- internal oblique

- quadratus lumborum

- erector spinae.

The superficial layer of the fascia, the aponeurotic area of origin for the latissimus dorsi, extends from the thoracolumbar junction to the iliac crests, covering the entire lumbar spine and sacral areas. The latissimus aponeurosis turns into a solid ligamentous plate ( Fig. 1 0.21 ). According to Vleeming, the tensile loading capacity amounts to 500 kg and the plate is up to 1 cm thick. 

- 흉요근막의 천층, 건막 부위는 광배근 시작부이고, 흉요추 연접에서부터 장골능까지 이어지고, 요추와 천추 전체를 둘러싸고 있음. 

- 광배근 건막은 단단한 인대판으로 변함. 블리밍에 의하며 흉요근막의 장력부하능력은 500킬로그램이고 두깨는 1cm가 넘음. 

The fibers within the fascia have a mesh-like construction and do not only correspond to the continuation of the latissimus fibers that come from a s uperolateral position and pointing inferomedially. The fascia is at its widest at the level of L3, where it measures approximately 12 cm in width. It is narrowest at the level of T 12.  Below T12, the fibers radiate into the fascial fibers on the contralateral side. They continue over the sacrum as the posterior sacroiliac ligament.

- 섬유막내 섬유는 그물과 같은 구조이고 광배근 섬유의 연속성에만 관련되지는 않고 위옆 위치와 아래내측위치로 배열됨.

- 섬유막은 요추 3번위치까지 넓고, 넓이가 대략 12cm임. 가장 좁은 부위는 흉추 12번 부위. 흉추 12번 부위아래의 섬유는 양측부위로 섬유배열을 함. 흉요섬유막은 천골까지 연결되는데 후천장인대와 연결됨. 

The middle fascial layer is also a solid aponeuros is. It stretches between the most inferior ribs, the L 1 - L4 costal processes, and the iliac crests ( Fig. 1 0.22 ). 

- 중간 섬유막 층은 또한 단단한 건막임. 그것은 늑골아래까지 연결되고 요추 1-4번 횡돌기와 장골능까지 연결됨. 

It separates the back extensors from the quadratus lumborum. In contrast to the superficial layer, the middle layer appears to be a site of origin for the lateral tract muscles and the quadratus

lumborum. The foundation for this strong tendinous plate is the aponeurosis , which is the site of origin for the transversus abdominis (Lanz and Wachs muth, 2004a). The fibers from the internal oblique, in particular, radiate into this.

- 흉요 섬유막은 요방형근과 등근육에서 구분됨. 천층흉요섬유막과 반대로 중간층은 요방형근과 외측 척추기립근 기시부가 됨. 

- 강한 힘줄막의 기초가 건막인데, 이는 복횡근의 기시부임. 안쪽으로 내복사근까지 이어짐. 

Barker et al. (2006) found in a s tudy that the tension in the middle fascial layer significantly increases segmental stiffness and the resistance to flexion. According to their conclusions, tension in the fascia plays a significant role in segmental stability. Richardson et al. ( 1999) also state that the multifidus and transversus abdominis provide basic stability for the lumbar spine ( Fig. 1 0.23 ). 

- 바커는 중간 섬유막층에서 장력은 분절 강직과 굴곡저항에 증가...

- 이러한 결론에의하면, 섬유막에서 장력은 분절안정성에 중요한 역할을 함. 

- 다열근과 복횡근은 요추 안정성에 중요한 역할을 함. 

They described the relationship between delayed activation of the transversus abdominis and lumbar symptoms.

The muscle is normally activated approximately 4 milliseconds before the trunk or the limbs start moving. Core stability is first built up before proceeding with  further action. The muscle is activated too late in patients suffering from back pain. Based on these results, Richardson developed an exercise program that is currently a source of discuss ion and used for therapeutic approaches. Both layers of the thoracolumbar fascia are connected immediately lateral to the back extensors at the lateral raphe (Fig. 1 0.24). 

- 복횡근의 늦은 활성과 허리통증의 연관성 탐구

- 복횡근은 상지 또는 몸통이 움직이기 4milisecond전에 활성화됨. 

- 코어 안정성은 추가 동작에 앞서 완성됨. 요통환자는 복횡근 활성이 너무 느림. 

- 이러한 결과에 기초하여 리처드슨은 치료적 운동프로그램을 개발함. 

- 흉요섬유막 천부와 심부층은 외측선에서 요부 신전근으로 직접 연결됨...

Both of the fascial layers and the serratus posterior inferior form an osteofibrous channel with the vertebral arch and the processes. This channel is the guiding sheath for the erector spinae. The anatomy of this can be recognized by looking at the loose connective tissue superior to the sacrum positioned between the back extensors and the fascia. The osteofibrotic guiding sheath bundles up the back extensors and holds these muscles on the vertebral column when the muscles contract.

- 흉요근막 두개층과 하후거근은 요추아치와 함께 뼈섬유채널을 만듬. 

- 이 채널은 척추기립근을 위한 안내 Sheath임. 

- 이러한 해부학은 요부신전근과 섬유막사이에서 loose 결합조직.????

- 뼈섬유 안내 sheath 는 척추신전근 다발을 짓고, 근육이 수축할때 척주에서 이러한 근육을 고정시킴. 

How Does this Affect Palpation?

The back extensors protrude more than the spinous processes. Together with the firm sheath of fascia on both sides, they form a type of depression over the row of spinous processes. The depth of this can differ depending on the lumbar lordosis form and the bulk of the back extensors. This means that the spinous processes can be reached here quite easily.

- 척추 신전근은 극돌기보다 튀어나와 있음. 양측에서 흉요섬유막의 단단한 sheath와 함께, 그것은 극돌기의 배열위의 depression의 형태를 만듬. 이것의 깊이는 요추 전만의 정도와 요추신전근의 bulk에 따라 구분할 수 있음. 이 말의 의미는 극돌기는 여기에서 쉽게 촉진될 수 있다는 뜻임. 

The osteofibrotic sheath turns the back extensors into a uniform muscle packet. Its medial side can be completely

pushed away from the row of spinous processes and displaced laterally. This characteristic is taken advantage of in the different classical massage and functional massage techniques (Fig. 1 0.25).

- 뼈섬유 sheath는 요추신전근을 근육팩으로 단일화시킴. 그것의 내측 부위는 극돌기 선으로부터 멀리 밀수있고, 외측으로 위치이동할 수 이씅ㅁ. 이러한 특성은 고전적인 마시지와 기능적 마사지 테크닉을 구분할 수 있는 이로움이 있음. 

The compact fibrotic layer is up to 1 cm thick and raises a question about the accessibility of the muscular structures. The compact fascia prevents the muscle from being directly palpated when the therapist wishes to assess the muscles' consistency with palpation. 

- 단단하게 꽉찬 섬유층은 1cm두깨를 넘고, 근육구조의 점근에 의문을 일으킴. 치료사가 근육의 점조도를 촉진하려 할때,  단단하게 꽉찬 섬유막은 직접적으로 촉진되는 것을 방해함. 

The positioning of patients during diagnosis and treatment is affected by the compact superficial fascia and a number of muscle fibers merging directly and indirectly into it. The patients should be placed in an SP that maximally relaxes or tenses the structure, depending on the aim. The minimal requirements for relaxation in the lumbar region are the physiological lordosis and not allowing the arms to be fully raised in the prone ( Fig. 1 0.26) or side-lying positions .

- 진단과 치료동안 환자의 자세는 단단하게 꽉찬 천층 섬유막과 근육에 의해 그것을 촉진하는데 직접적으로 간접적으로 영향을 받음. 

- 환자를 잘 촉진하기 위해서 시작자세는 근육이 최대한 이완되어야.

Detailed Anatomy of the Muscles

Only the muscles that are important for the palpation of the lumbar region will be described in the following text:

• Latissimus dorsi.

• Intrinsic back muscles- medial tract.

• Intrinsic back muscles-lateral tract.

• Action of the lumbar muscles.

latissimus Dorsi 광배근

This muscle was ontogenetically a gill muscle. The site of origin of the latissimus dorsi has been relocated quite inferiorly.

As a consequence, its innervation from the thoracodorsal nerve ((6-(8 ) was relocated with the muscle. 

- 광배근은 발생학적으로 아가미근육임. 광배근의 기시부는 완전히 아래에서 시작함. 그 결과 그것의 신경지배는 ...

The nomenclature for its sites of origin is divided into thoracic, lumbar, iliacal, costal, and scapular areas. Its aponeurosis

of origin is identical to the superficial layer of the thoracolumbar fascia ( Fig. 1 0.27). 

- 흉요근막의 기시부에 따라 흉추, 요추, 장골, 늑골, 견갑골로 나뉨.

- 그것의 건막기시는 흉요섬유막의 천층부위로 단일함. 

The thoracic site of origin is generally stated to be at the T7 -T8 level, but can vary greatly. The iliacal origin is likewise very variable. The side edge of the site of origin is generally sought at the level of the most superiorly protruding part of the iliac crest ( Lanz and Wachsmuth, 2004a), though it may also be found further medial or lateral. The 3-4 cm-wide and approximately 8- 10 cm-Iong tendon of insertion travels together with the teres major's tendon of insertion toward the crest of the lesser tubercle at the humerus.

- 광배근의 흉추 부착부는 T7-8번이지만, 변이가 많음. 

- 광배근의 장골 부착부는 마찬가지로 변이가 많음. 장골부착부 가장자리는 장골능의 가장 위 돌출부로 생각됨. 실제로 많은 환자들의 경우 장골능 가장 돌출부가 아니라 중간 또는 바깥쪽에서 기시하는 경우가 많음. 

- 3-4cm 넓이와 대략 8-10cm 긴 힘줄 종지부가 대원근 종지부와 함께 상완골의 소결절에 부착함. 

Its function is not limited to the open kinematic chain ; it also acts as a strong adductor to move the body around a

fixed point in a closed chain ( e.g., when a person supports themselves on parallel bars ). Together with the teres muscles, it decelerates the forward swing of the arms during gait. Activity in the latissimus dorsi dynamizes the superficial layer of the thoracolumbar fascia and can therefore affect lumbar stability.

- 열린사슬에세 광배근의 기능은 제한이 없음. 수평바를 잡는 닫힌 사슬에서 강력한 내전근으로 작용함. 

- 대원근과 함께, 보행동안 팔의 전방스윙의 감속기능. 

- 광배근 활성은 흉요섬유막의 천층부를  dynamizes하고, 요추의 안정성에 영향을 줄 수 있음. 

How Does this Affect Palpation?

Aside from toned and very slender people ( Fig. 1 0.27), most people have a thin latissimus dorsi. This means

that the muscle belly rarely presents itself with a clearly definable contour. Only the lateral edge can be palpated

in the thoracic area during contraction (see the section "Tips for Assess mentand Treatment" in Chapter 1 1, p. 3 1 0).

- 마른 사람과 별개로 대부분의 사람은 매우 얇은 광배근 기시부. 이 말의 의미는 광배근 근복부는 분명하게 한정지워진 윤곽과 함께 드물게 존재함. 오직 외측 가장자리가 수축하는 동안 흉추부위에서 촉진됨. 

Intrinsic Back Muscles-Medial Tract

The medial tract consists of sections that run over one segment and sections that are multisegmental. It lies close to

the vertebral column in the triangular depression between the spinous and transverse processes ( Fig. 1 0.28).

- 

The muscles originate and insert into the processes of the lumbar vertebrae. The posterior aspect of the sacrum is the only exception here. The medial tract muscles are mostly covered by voluminous muscle bellies and the aponeuroses of origin for the muscles in the lateral tract (longsimus). The muscle groups belonging to the medial tract are typically innervated by the medial branch of the dorsal rami arising from the spinal nerve that belongs to the segment.

- 

The small muscles mostly run over one segment. They can finely position the lumbar vertebrae and assist in the

development of the necessary axial compression for the approximation of vertebrae with the use of tissue strength. The transversospinales appear to be functionally more important than the straight system. 

Lanz and Wachsmuth (2004a, p. 86) have commented on this :

"The transverso-spinales muscle strand represents the most important tensile system in the vertebral column." The muscular sections of this system extend over three to six segments and are most clearly developed in the lumbar region. They are labeled the multifidus lumborum( Fig. 1 0. 29). 

The origin can be followed to the third sacral vertebra in the space between the median sacral crest and the intermedial sacral crest. As described in the section "Sacrum-Insertion of the Multifidus" in Chapter 9 ( p. 225), contractions in this muscle can also be palpated there. In Lanz and Wachsmuth ( 2004a, p. 89 ) it is further said: "Its mass of flesh represents a s lab oriented in the sagittal plane. Its side surfaces are roun ded and appear as a swelling bulge as soon as the aponeuros is of origin for longissimus is separated from the spinous processes." 

How Does this Affect Palpation?

The sections of the longissimus are quite thin and tendon-like in the lower lumbar and sacral regions. The multifidus can therefore be palpated very well and is sometimes visible directly paravertebrally (approximately 1.5 cm adjacent to the spinous process ) from the sacrum up to the level of l 3 ( Fig. 10.30).

- 최장근은 하부요추와 천골영역에서 매우 얇아 힘줄과 같이 보임

- 다열근은 천골에서 요추 3번 극돌기 양측으로 대략 1.5cm떨어진 부위에서 잘 보임. 

It becomes more difficult superior to this as the covering muscle becomes thicker. The advantage of the muscle being palpable becomes obvious when the stabilizing function of the multifidus is being trained. The patient can attempt to selectively contract the multifidus using palpation for feedback. Hoch- schild (200 1 . p. 37) labels the multifidus as the " key muscle for the segmental stabilization of the lumbar spine." 

- 다열근은 위로 올라가면서 두꺼워짐. 다열근 안정화기능을 잘 트레이닝할때, 근육촉진은 쉬워짐. 

- 다열근은 선택적으로 수축할 수 있고, 요추분절안정성의 핵심근육임. 

Intrinsic Back Muscles-lateral Tract

The lateral tract of the back extensors is made up of two strong individual muscles in the lumbar region. These muscles represent the largest section of the palpable paravertebral muscles ( Fig. 1 0.3 1 ): 

• Longissimus (lumbar part, thoracis, cervicis, capitis).

• Iliocostalis (lumbar part, thoracic part, cervicis ).

The layout of both of these lateral tract muscles in the individual sections of the vertebral column results in the muscles being divided into many sections. The longissimus is the only muscle that extends with one section to the skull. This muscle group is typically innervated by the lateral branch of the dorsal rami arising from the spinal nerve that belongs to the segment.

The longissimus is found more medial and inserts with spikes only. These spikes are noticeable on the ribs. It lies on top of the medial section of the multifidus. It forms a thin tendinous plate in the lower lumbar region, which allows activity in the multifidus to be felt directly adjacent to the vertebral column. Its origin extends over the posterior surface of the sacrum between the inter-medial sacral crest and the lateral sacral crest.

The iliocostalis ( Fig. 1 0.32), on the other hand, is located lateral and more superficial. Its origin extends from the lateral aspect of the sacrum to the iliac crest, covering the medial section of the quadratus lumborum. The muscle originates and inserts further onto the ribs and the rudiments of the ribs only. Both layers of the thoracolumbar fascia meet lateral to the muscle belly.

The Actions of the Lumbar Muscles

Bilateral activity in the back extensors controls and moves the trunk in the sagittal plane. The back extensors tense quickly on both sides when the trunk is displaced anteriorly and work eccentrically until approximately 60° flexion (Fig. 1 0.33). 

요추 굴곡60도까지 등의 신전근은 빠르게 긴장함. 

The gluteus maximus helps to control trunk flexion. The back extensors do not have any active function beyond 60° flexion. The back extensors' passive resistance to stretch, the thoracolumbar fascia, and the ligaments found posterior to the movement axis now take over the action of stabilizing the trunk.

- 대둔근은 몸통굴곡 조절에 도움을 줌. 등신전근은 60도굴곡을 넘어서면 더이상 활성화하지 않음. 등근육의 스트레치에 수동적 저항, 흉요건막과 후종인대는 몸통안정화의 활성에 기여함. 

Activity, especially activity arising from the medial tract and the tension in passive structures, results in a build up of axial compression. This should be seen as the approximation of the vertebrae using tissue strength. This activity increases the stability in the vertebral column, which is intrinsically a mobile chain. 

The psoas stabilizes anteriorly when the trunk is extended, especially in the upper lumbar section. One of the most important functions of the intrinsic back muscles is to tighten up the thoracolumbar fascia from inside outward (personal communication, Vlemming).

- 요근은 몸통신전시 안정화. 

- 등내재근의 가장 중요한 기능중 하나는 흉요섬유막을 단단하게 하는 것.

This can be compared with pumping up a bicycle tube ( Fig. 1 0.34) and is achieved when the muscle belly becomes thicker during contraction. This illustrates the therapeutic use of hypertrophic back extensors. The intrinsic back muscles are only slightly active in the upright standing position when the body weight is distributed even ly between the two legs. It is only in the thoracic region that constant activity is necessary to prevent falling. This is due to the weight of the thorax always pulling the vertebral column into flexion (Klein-Vogelbach, 2000).

- 이는 자전거 튜브에 바람을 넣는 것에 비유됨. 그리고 근육이 수축하는 동안 근복이 두꺼워질때 완성됨. 

- 등 내재근은 체중이 양하지에 균일하게 놓여질때, 선자세에서 약간 활성화함. 

- 넘어지지 않기 위해 필요한 것은 흉추부위의 지속적인 활성화임. 

Shifting the body's weight from both legs onto one leg, for example, onto the left leg, results in unilateral activity in an entire synergy on the right side ( Fig. 1 0.35): 

- 예를들어 좌측다리로 체중을 옮겨 놓으면 우측으로 완전한 협력활성을 야기함. 

#  Erector spinae.

# Quadratus lumborum from the deep abdominal muscle group.

# Internal and external obliques from the side trunk wall muscles. 

This activity in the muscles aims to prevent the pelvis from lowering on the right side. This occurs in cooperation with the small gluteals on the weight-bearing side (on the left here).

- 근육에서 이러한 활성은 골반이 아래로 떨어지는 것을 막아주는 것을 목표로 함. 이것은 작은 둔근협력작용으로 일어남. 

The back and the lateral trunk wall muscles have several functions during walking:

- 걷는 동안 등과 몸통의 측면 근육은 몇가지 기능을 가짐.

# They provide the impulse for walking (according to Gracovetsky, 1988) using rotation and lateral flexion. Alternating concentric (start of the swing phase) and eccentric (end of the swing phase) activity causes lateral flexion in particular. 

- 등과 몸통 측면근육은 회전과 측굴을 이용하여  보행을 위한 충격을 제공함.  구심성 수축과 원심성 수축 활성은 특히 측굴을 일으킴. 

# They act as antagonists to the abdominal muscles. The arms swing during walking and give the upper body a rotational impulse. This movement has to be decelerated by the abdominal muscles. The tendency to flex during abdominal muscle contraction is counteracted by the extending strength of the back muscles.

- 등과 몸통 측면근육은 복부근육 길항근으로 작용함. 걷는 동안 팔을 흔들고, 상체에 회전충격을 제공함. 

In total, the muscle activity in standing and during walking is shaped by the constant change from concentric to eccentric activity. This should be integrated into the therapeutic concept for stabilizing treatment: vertical position and alternating activity with impulses for rotation and lateral flexion.

- 걷거나 서있는 동안 근육활성은 구심성 수축에서 원심성수축으로 지속적인 변화에 의해서 모양지워짐. 

- 이는 안정화 치료적 개념에서 통합되어야 함. 

How Does this Affect Palpation?

The energy-efficient contractions in the back and trunk wall muscles during weight-shift in standing and walking can be palpated bilaterally above the iliac crests (Fig.10.36). In cases of central nervous system disorders, such as hemiplegia, the eccentric activity needed to lower the pelvis at the end of the swing phase is impaired.

- 서고 걷는 체중이동 동안 등과 체간근육의 에너지 효율수축은 장골능위 양측에서 촉진될 수 있음. 

- 예를들어 반신마비 환자의 경우 유각기의 끝에서 아래골반이 원심성수축활동이 필요함. 

It is technically very simple to palpate activity in the muscles . Both hands are placed directly superior to the iliac crests using a pinch grip and push slightly into the lateral trunk wall. The therapist then follows as the patient walks with normal speed. Through the alternating muscle activity, the hands feel more or less pressure and the changing consistency between soft and very firm.

- 근육활성 촉진은 기술적으로 간단함. 양측 손을 장골능 위에 대고 pinch grip을 이용하여 외측 몸통을 살짝 밀어줌. 치료사는 환자가 정상속도로 걷는 것을 따라감. 교차되는 근육활성 동안 손에서는 부드럽고 단단함 사이의 점조도 변화와 압력변화를 느낌. 

Basic Biomechanical Principles

The lumbar segment is a kinematic chain consisting of three links-one intervertebral disk and two zygapophysial joints. The three components all affect each other. In a healthy segment, the axes for movement are found in the disk ( Fig. 1 0.37). This results in little translational movement and a lot of tilting. A loss of height in the intervertebral disk shifts the axes and more shear forces develop (White and Pandjabi, 1990).

- 요추 분절은 축간판과 양측 후관절 3 joint system으로 이루어진 운동형상학 사슬임.  세 구조는 항상 서로 영향을 줌. 

- 건강한 요추분절에서 움직임을 위한 축은 추간판에서 발견됨. 건강한 요추분절은 적은 이동움직임과 많은 tilting을 야기함. 

- 추간판 높이 좁아짐은 축을 바꾸고 좀더 높은 전단력을 야기함. 

Symmetrical Movement(대칭적인 움직임)

The joint surfaces glide together (convergent movement) during extension (extension , lordosis ) and away from each other (divergent movement, Fig. 10.38) during flexion (flexion, flattening out of the lordosis ).

- 요추 신전동안 관절면이 함께 이동(수렴 움직임)함. 그리고 서로 멀어지는 움직임이 요추굴곡 동안 일어남. 

Asymmetrical Movements(비대칭적인 움직임)

Lateral flexion is inevitably combined with rotation in all sections of the vertebral column. Rotation likewise always occurs with  simultaneous lateral flexion. This is known as a coupled movement. The direction of the associated movement in the lumbar spine changes according to whether the vertebral column is positioned in flexion or extension.

- 측굴은 척주 모든 단면에서 불가피하게 회전을 동반함. 

- 회전은 마찬가지로 측굴이 함께 일어남. 이는 짝움직임이라고 함. 요추에서 연관 움직임의 방향은 척주가 굴곡 또는 신전에 따라서 변화함. 

Coupled and Combined Movements

When the functional section from Tl0/Tll to L5/Sl is flexed, lateral flexion is automatically accompanied by an ipsilateral axial rotation :

- 흉추 10-11에서 요추 5-천추 1번 기능적 단면이 굴곡할때, 측굴은 동 축회전이 자동적으로 동반됨. 

• Flexion and lateral flexion to the right with rotation to the right ( Fig. 1 0.39).

• Flexion and lateral flex ion to the left with rotation to the left.

In the extended position ( e.g., physiological lordosis ), lateral flexion is automatically accompanied by contralateral

axial rotation. This applies to all segments:

신전자세에서 측굴은 반대측 축회전이 동반됨. 

• Extension and lateral flexion to the right with rotation to the left ( Fig. 1 0.40).

• Extension and lateral flexion to the left with rotation to the right.

Movements are always coupled in the same direction in older patients. This coupling of movements occurs automatically during active and passive movements unless the therapist decides to consciously position the lumbar spine differently.

- 노인 환자에서 짝움직임은 항상 같은 방향으로 나타남. 이러한 짝움직임은 능동적 수동적 움직임동안 자동적으로 일어남. 만약 치료사가 요추의 다른 위치를 결정하지 않으면...

Every other combination of rotation and lateral flexion is labeled as combined, or not coupled. Manual therapy uses

combined positioning in the vertebral column to lock a joint as firmly as possible.

- 회전과 측굴의 조합은 조합으로 이름지워짐. 짝움직임이 아니라.. 수기치료사는 가능한 단단하게 척주를 잠근자세에서 치료를 시행해야...

How Does this Affect Palpation?

Symmetrical and coupled movements can be used to assess segmental movement and to diagnose a restriction in mobility (see the section "Local Segmental Mobility Using Coupled Movements" below, p. 267).

- 대칭적 그리고 짝 움직임은 분절적 움직임을 측정하는데 사용되고, 움직임 제한을 진단하는데 사용함. 

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