흉추와 흉곽의 생체역학 - 정리중...

[문형철]

흉추와 흉곽의 흔한 질환(클릭)

흉곽의 촉진과 수기치료(대박자료, 클릭)

흉곽은 다른 관절과는 특성이 많이 다르다. 늑골로 둘러싸고 있어 hypomobile한 특성을 가지고 있다.  

흉곽 전면부에서  흉쇄관절, 늑연골과 흉골의 관절들

흉곽후면부 intervertebral disc, 후관절, costovertebral joint, costotransverse joint

그리고 scapulo-thoracic articulation

hypomobile joint를 찾아서 적절한 추나치료를 시행할때 드라마틱한 효과를 볼 수 있는 관절이다.

깊은 호흡, 경추움직임, 어깨움직임, 요추움직임을 통해 흉추의 문제를 찾아내는 능력, 치료하는 능력이 필수

경추 움직임때 T4-5, 요추 움직임때 T11-12흉추가 많이 움직임

어깨를 150도 이상들어올릴때, 흉추는 신전됨.

깊은 호흡할때, 흉추의 모든 관절들이 mobilization됨

이러한 움직임으로 fascia, muscle, sympathtic system이 잘 기능하면서 자율신경기능이 좋아짐. 

- 팔을 180도 들어올릴때, 경흉추 junction에서 아래로 T6-7번흉추는 신전되면서 움직여줘야함. 

- 팔을 들어올릴때, 경흉추~흉추 6-7번이 신전된다는 지식을 통해서 알 수 있는 것! 

- 팔을 들어올릴때 흉곽통증이 나타나는가?

- 충분한 어깨관절의 외회전과 내회전은 흉추에 회전으로 영향을 미침. 

- 양측어깨를 내회전하면 흉추는 굴곡하고, 외회전하면 흉추는 신전함. 

This close relationship between viscerotomes and dermatomes can be used for diagnosis. Treatment can not only

affect these organs via the reflexes; it can also affect the neurovegatative control of the head and arms. Preganglionic fibers extend from the upper thoracic segments into the cervical sympathetic chain ganglions. The thoracic spine and the thorax are therefore an ideal location to apply mechanical (Swedish massage, connective-tissue massage, manual therapy), thermal, or electrical stimuli to affect sympathetic nervous system activity. 

- viscerotome와 dermatome사이의 연관성은 진단에 이용될 수 있음. 

- 치료는 반사를 통한 기관에 영향을 주는 것 뿐 아니라, 어깨와 두부 neurovegatative조절에 영향을 줄 수 있음.

- 상부흉추분절로부터 이어지는 preganglionic 섬유는 경추 교감신경 사슬 ganglion로 이어짐. 흉추와 흉곽은 기계적 자극(스웨덴 마사지, 결합조직 마사지, 수기치료), 온도, 전기자극을 적용하여 교감신경활성에 영향을 줄 수 있음. 

결국 정확한 촉진과 정확한 생체역학적 움직임을 이해할때 가능한 일이다. 

함께 탐구해보자

panic bird..

Significance and Function of the Thoracic Region

The thoracic region is one of the stabile and comparatively rigid sections of the vertebral column. Initially, this may

appear to be more of a disadvantage. However, on taking a closer look at the functions of the thoracic region it becomes

clear that stiffness is actually an advantage.

- 흉곽은 안정적이고 상대적으로 고정적인 척주를 가지고 있음. 이는 이롭지 않게 느껴지지만 흉곽의 기능을 보면 실제로는 이로움. 

흉추와 흉곽의 네가지 기능

The thoracic spine and the thorax have the following functions:

• Protective function - 보호 기능

• Supportive function - 지지 기능

• Junction between the cervical and lumbar spines - 경추와 요추를 연결

• Respiration - 호흡기능

1, Protective Function

The thoracic spine, combined with the thoracic cage and the sternum, provides a stabile bony cage that protects the heart, lungs, and other important organs. Small and large mechanical stresses can be absorbed by this stabile, yet elastic construction. The vertebral canal is very narrow, almost completely enclosed by bones, and home to a large section of the spinal cord.

- 흉곽은 늑골, 흉골, 척추뼈 등으로 둘러싸 심장, 폐 등 주요기관을 보호함. 

2. Supportive Function

In addition to maintaining our upright posture, this section of the body must be stabile enough to absorb all impulses

arising in the arms. Large muscles, such as the latissimus dorsi and pectoralis major, and the scapulothoracic joint surfaces transmit large compressive and tensile loads. Without this central stability we would be unable to carry the weight of our arms, let alone that of larger loads. 

At the same time, the lateral tract of the erector spinae muscles is very strong in the lumbar region, but gradually loses its effectiveness more superiorly. Other strong muscles such as the spinalis provide the strength for thoracic extension.

- 흉곽은 직립 자세를 유지하면서 팔에서 주어지는 강한 충격을 흡수할만큼 충분히 안정적임

- 광배근, 대흉근, 견흉관절 커다란 움직임은 큰 압박부하와 장력부하를 전달하는데 흉곽은 이를 충분히 흡수할만큼 안정적임

- 흉곽의 강한 안정성이 없다면 우리는 팔로 무거운 물건을 들 수 없음. 

- 척추기립근의 외측 트랙은 요추부위에서 매우 강함(iliocostalis lumborum)

- 하지만 위로 올라가면서 가늘어지고 약해짐. 그래서 다른 근육 spinalis 가 흉추 신전의 근력을 제공함.

3. Junction between the Cervical and lumbar Spines

The thoracic mobility supports extensive arm movements -though not to the same extent as in the lumbar spine

where mobility optimizes leg movement. 

- 흉곽의 움직임은 심한 팔움직임을 지지함. 

Nevertheless, full arm elevation is only possible up to approximately 150° when the thoracic region is unable to move into extension. The expected range is generally 180°. Arm elevation causes movement from the cervicothoracic junction down to approximately T6/T7:

• in the form of extension (with bilateral arm elevation); or

• in the form of extension with rotation (when one arm is elevated). 

This knowledge is useful when locating the level of thoracic symptoms. Can thoracic symptoms also be provoked using extensive arm elevation? 

- 팔을 180도 들어올릴때, 경흉추 junction에서 아래로 T6-7번흉추는 신전되면서 움직여줘야함. 

- 팔을 들어올릴때, 경흉추~흉추 6-7번이 신전된다는 지식을 통해서 알 수 있는 것! 

- 팔을 들어올릴때 흉곽통증이 나타나는가?

Extensive external and internal rotation at one shoulder joint is transmitted onto the thoracic spine as rotation. Bilateral rotation causes the thoracic spine to flex (with internal rotation) or extend (with external rotation).

- 충분한 어깨관절의 외회전과 내회전은 흉추에 회전으로 영향을 미침. 

- 양측어깨를 내회전하면 흉추는 굴곡하고, 외회전하면 흉추는 신전함. 

From a biomechanical point of view, the thoracic spine has to act as a connection, passing on movement between the cervical spine and the lumbar spine:

• The predominant functional movement in the cervical spine is rotation.

• Flexion and extension are the dominating movements in the lumbar spine.

- 흉추는 경추와 요추의 생체역학적 움직임을 연결하는데, 경추는 회전, 요추는 굴곡신전이 주로 일어남. 

The cervical spine and the lumbar spine couple lateral flexion and rotation in their own specific way. Anatomically, the mobile sections of the vertebral column can be well differentiated from one another. The thoracic spine stands out as the section that supports the ribs. Functionally, there is a fluent transition between its sections. Both lordotic sections extend functionally into the thoracic section of the vertebral column.

It is therefore expected that extensive cervical movements can be palpated down to approximately T4-T5. Lumbar movements are carried over to approximately the level of T10-T11. The real thoracic spine is found between these points.

- 경추와 요추는 측굴과 회전을 그들의 특이한 방법으로 짝으로 연결짓게 함. 해부학적으로 척주의 움직임 부위는 서로서로를 잘 구별할 수 있음. 

- 흉추는 늑골을 지지하는데 우월함. 기능적으로 그것들 사이에 쉽게 이동하는 부분이 있음. 

- 과도한 경추움직임은 흉추 4-5번에서 촉진할수 있고, 

- 과도한 요추의 움직임은 흉추의 10-11번부위에서 촉진할 수 있음. 

- 진정한 흉추는 이부분들 사이에서 발견됨. 

4. Respiration

In healthy people, quiet respiration is completely controlled by activity in the diaphragm. Forced respiration is supported by movement in the thorax. 

- 건강한 사람은 조용한 호흡이 흉격막 활성에 의해서 완전하게 조절됨. 

- 강력한 호흡은 흉곽 움직임에 의해서 지지됨. 

Respiratory movements are the result of:

• Elasticity in the thoracic cage.

• Mobility in the costovertebral joints.

• Supportive movements in the thoracic spine.

• Activity in different intrinsic muscles and the accessory muscles of inhalation. 

호흡움직임은 다음 네가지의 결과임

# 흉곽에서 신축성

# costovertebral joint에서 움직임

# 흉추에서 지지적임 움직임

# 서로다른 내재근의 활성과 흡기의 부근육(사각근과 SCM)활성

The extensive costal joint movements associated with forced respiration are very important for the diagnostic process. Does deep inhalation or exhalation provoke back pain?

- 강력한 호흡과 연관되어 있는 과도한 늑골의 움직임은  진단에 중요한 과정임. 

- 깊은 심호흡을 할때 등통증을 악화시키는가?

How Does this Affect Palpation?

The upper thoracic segmental movement associated with extensive arm elevation can be palpated well. An example of this is seen when the therapist places several finger pads over the cervicothoracic junction on the left side of the spinous process. The therapist can then feel the spinous process's rotation to the left when the right arm moves into full elevation.

- 충분한 팔들어올림과 연관된 상부 흉추분절움직임은 잘 촉진될 수 있음. 

- 예를들어 치료사는 손가락을 극돌기의 옆부위 위의 CT 연접부에 촉진할때 잘 관찰됨.

- 치료사는 우측팔을 완전히 들어올릴때, 흉추의 극돌기가 좌측으로 회전하는 것을 느낄 수 있음. 

Respiratory movements can also be palpated. The opening and closing of the intercostal spaces provides information on the mobility of the ribs at their articular connections to the vertebral column and the flexibility of the intercostal muscles.

- 호흡움직임 또한 촉진할 수 있음. 늑간의 공간이 열리고 닫힘은 늑골의 움직임 정보를 제공함. 

Different techniques can be used to palpate the thoracic segments during movement to assess the presence of restricted mobility. While clear rules exist explaining the relationship between lateral flexion and rotation in the lumbar spine and the cervical spine, it is not possible to set fixed rules for the mid-thoracic region. There is so much variation between individuals that functional relationships have to be newly assessed every time.

- 제한된 움직임의 존재를 찾기위 한 움직임 동안 다양한 테크닉이 흉추분절 촉진에 사용됨. 

- 경추와 요추에서 외측굴곡과 회전 사이의 연관성사이에 분명한 규칙이 존재하는데, 중흉추부위를 위한 고정된 규칙은 없음. 

- 개개인 마다 수많은 변이가 존재하기 때문에 "매번 검사할때마다 기능적 연관성이 조사되어야 함"

참고) 경추, 요추 측굴시 척추회전 규칙(클릭)

Common Applications for Treatment in this Region

The thoracic spine and the thorax are the home for the sympathetic nervous system. It is well known that the

central region of the sympathetic nervous system is found in the lateral horn of the thoracic spinal cord. Important thoracic organs are represented in the large Head zones.

- 흉추와 흉곽은 교감신경시스템의 home

- 흉추 척수의 외측 horn에서 교감신경시스템의 central region이 발견됨. 

This close relationship between viscerotomes and dermatomes can be used for diagnosis. Treatment can not only affect these organs via the reflexes; it can also affect the neurovegatative control of the head and arms. Preganglionic fibers extend from the upper thoracic segments into the cervical sympathetic chain ganglions. The thoracic spine and the thorax are therefore an ideal location to apply mechanical (Swedish massage, connective-tissue massage, manual therapy), thermal, or electrical stimuli to affect sympathetic nervous system activity. 

- viscerotome와 dermatome사이의 연관성은 진단에 이용될 수 있음. 

- 치료는 반사를 통한 기관에 영향을 주는 것 뿐 아니라, 어깨와 두부 neurovegatative조절에 영향을 줄 수 있음.

- 상부흉추분절로부터 이어지는 preganglionic 섬유는 경추 교감신경 사슬 ganglion로 이어짐. 흉추와 흉곽은 기계적 자극(스웨덴 마사지, 결합조직 마사지, 수기치료), 온도, 전기자극을 적용하여 교감신경활성에 영향을 줄 수 있음. 

These forms of intervention are the recurring topic of discussion in the treatment of chronic musculoskeletal pain. The thoracic spine and the thorax are also often directly affected by the almost violent interventions used in open thoracic surgery. In older patients, these joints are becoming rigid as part of the adaptive aging process.

- 이러한 치료적 개입으로 만성근골격계 통증을 치료할 수 있음. 흉추와 흉곽은 수술하는 동안 직접적으로 위험한 영향을 받을 수 있음. 

- 노인의 경우 노화에 적응하는 과정에서 흉추와 흉곽의 모든 관절이 rigid될 수 있음. 

During this type of surgery, thoracic segments and costal joints are placed in extreme positions and are then forced into inactivity for weeks on end. In such a case, it takes a lot of effort to train a thorax to breathe properly again. A variety of respiratory parameters are used here for diagnosis: the frequency, rhythm, and direction of respiration, as well as the range of thoracic motion between maximal inhalation and expiration. 

- 흉추와 흉곽의 관절들은 흉추와 흉곽 수술 몇주동안 고정이 되는 상황에 놓여짐. 이러한 경우, 깊은 호흡 등의 훈련은 중요한 역할을 수행함. 

- 다양한 호흡의 지표들(호흡빈도수, 호흡리듬, 호흡방향)은 여기서 진단에 응용될 수 있음. 

The compression of the thorax and the mobilization of soft tissues are important manual techniques used in respiratory therapy that require certain basic palpatory dexterity. Pain and restricted mobility in the costal and vertebral joints not only lead to restrictions in respiration; they also strongly interfere with daily tasks. Hypomobility in connection with pain plays an important role here. In no other section of the vertebral column is the assessment of segmental mobility and extremely localized mobilization as important as in the thoracic spine (Fig. 1 1 . 1 ).

- 흉곽의 압박과 연부조직 가동은 호흡치료에 중요한 치료테크닉임. 

- 늑골과 흉추관절에서 통증과 움직임 제한은 호흡을 제한할 뿐 아니라, 일상생활을 강력하게 방해함. 

- 흉추, 늑골, 흉곽에서 통증과 연관된 저운동성은 중요한 역할을 함. 

- 흉추의 분절움직임과 국소적인 가동의 평가는 흉추에서 중요한 역할을 함. 

Three large groups of pain origin are observed:

# Acute and chronic internal ruptures of the intervertebral disk.

# Painful hypomobility in the zygapophysial joints(ZAJs).

# Painful hypomobility in the costovertebral joints(costal joints).

- 흉추 디스크의 파열, 후관절의 통증성 저운동, 늑골척추 관절의 통증성 저운동 등이 중요함.

Hypermobility is rarely seen to be a cause of symptoms. For a long time intervertebral disks were not considered a possible source of thoracic symptoms until it became clear that not only protrusions and prolapses, but also internal rupturing of the anulus fibrosus, may be a possible source of symptoms. It is recommended that the sudden development of thoracic pain first be treated as an intervertebral disk problem. Axial unloading techniques have been successfully used here (Fig. 1 1 .2).

- 흉추에서 과운동성은 드물게 증상을 야기함. 

- 오랫동안 흉추간판은 통증의 요인으로 중요성으로 고려되지 못했음. 

- 갑작스럽게 발생하는 흉곽의 통증은 흉추디스크가 첫번째로 치료대상이어야 함.

- axial unloading 테크닉(축성 저부하테크닉)은 이 치료에서 성공적으로 이용됨. 

Specific regions display a higher frequency of certain pathological conditions (personal correspondence from the IAOM study group):

• T1-T4: costovertebral joints> acute problem with the intervertebral disk> pathological ZAj.

• T5-T8: acute problem with the intervertebral disk> pathological ZAj > costovertebral joints.

• T9-T12: acute problem with the intervertebral disk> costovertebral joints > pathological ZAj.

- T1-T4 늑척추관절 > 급성흉추간판 문제 > 병리적 후관절

- T5-T8 급성흉추간판 문제 > 병리적 후관절 > 늑척추관절

- T9-T12 급성흉추간판 문제 > 늑척추관절 > 병리적 후관절

The first four costovertebral joints are very rigid and tend to be more hypomobile. A link to strenuous arm activity, or a one-off exertion of force, for example, carrying a very heavy weight, or sudden shortness of breath, is often seen as a cause of symptoms. The role of palpation is to accurately locate a level to provoke the costovertebral joints and to ascertain the position of structures during inhalation and expiration (Fig. 1 1 .3).

- 흉추의 1-4번 늑척추 관절은 매우 단단하기 때문에 대개 저운동성 경향

- 강력한 팔움직임, 과도한 힘씀(무거운 물건 나르기, 호흡의 갑작스러운 짧아짐 등)과 연결된 흉추는 통증의 원인이 됨.

- 깊은 호흡동안 통증을 유발하는 늑척추관절 부위를 찾는 것이 중요함. 

Symptoms arising from the costovertebral joints are often felt "between the shoulder blades." They are also often felt on top of the shoulder. A large portion of the pain in the trapezius probably arises from the first rib being blocked in a position of inhalation. 

- 늑척추 관절로부터 나오는 증상은 shoulder blade사이에서 느낄 수 있음. 대개 어깨의 상부에서 통증이 느껴짐. 승모근에서 느껴지는 통증은 공기의 흡입자세를 첫번째 늑골이 방해함으로부터 ....

Required Basic Anatomical and Biomechanical Knowledge

Functional Divisions in the Thoracic Spine

The thoracic spine differs anatomically from the other sections of the vertebral column due to its connection to the 1 st to 12th ribs on each side. The functional thoracic spine is not a single unit:

- 흉추는 1-12번 늑골이 연결되어 있기 때문에, 척주의 다른 부분과 해부학적으로 다름. 

- 그래서 기능적 흉추는 단일 단위가 아님. 

• The upper thoracic spine belongs to the cervical spine. Extensive cervical movements are carried on down to T4/T5.

• The lower thoracic spine belongs to the lumbar spine. Lumbar movements are carried on up to T10/T11. Flexion and extension are especially possible in this section.

• Based on this, the "real" thoracic spine is only found between T5 and T10.

- 상부흉추는 경추와 연결되어 있음. 과도한 경추 움직임은 흉추 4-5번에 영향

- 하부흉추는 요추와 연결되어 있음. 과도한 요추 움직임은 흉추 10-11번에 영향

- 이러한 생체역학적 기초에 의하여 진정한 흉추의 문제는 흉추 5-10번에서 발견됨. 

On further inspection, these sections can also be differentiated from one another morphologically (Fig. 1 1 .4). The shape of the two upper thoracic vertebrae is more similar to a cervical vertebra while the lower thoracic vertebrae gradually take on the shape of a lumbar vertebra. Only the spinous processes in the middle section of the thoracic spine slant down typically at a steep angle. 

- 흉추 5-10번 시진은 구조로 감별할 수 있음. 

- 상부 흉추의 형태는 경추와 유사하고, 하부 흉추의 형태는 요추와 유사함. 

- 오직 중부 흉추가 기울어진 각도(아래로)로 내려가 있음. 

Anatomical Characteristics of the Thoracic Spine

In the next section, only the typical morphological characteristics of the thoracic vertebra will be discussed. All further important information regarding the parts of a movement segment can be read in Chapter 10 in "Required Basic Anatomical and Biomechanical Knowledge," page 243.

- 훙추의 전형적인 형태학적 특성은 다음 장에서 토의

The Thoracic Vertebral Body

The thoracic kyphosis is not only a result of posture; it is also caused by anatomy. The lumbar lordosis is directly related to the wedge-shaped construction of the intervertebral disks at L4/L5 and L5/Sl and the L5 vertebral body. It is the wedge shape of the vertebral body that causes the kyphotic form (Fig. 1 1 .5). 

- 등 후만은 자세의 결과일 뿐아니라 흉추의 해부학적 구조때문임. 

- 요추 전만은 요추 4-5, 5-천추1번에서 추간판과 요추 5번 척추체가 wedge형태인것과 직접적으로 연관됨. 

The superior and inferior end plates of the vertebrae are always parallel to one another in one segment. When examined, it can be seen that the vertebral body is more "heart shaped." This is probably an adaption to the very anteriorly located center of gravity for this section of the body. Most thoracic vertebrae have two articular surfaces on each side that form a joint with the head of the ribs via the disk in the socket (joint of head of rib or costovertebral joint).

- 상부와 하부 척추의 end plate는 항상 서로 평행함. 

- 흉추는 7 joint system임. 추간판, 후관절, costovertebral joint, costotransverse joint

The Thoracic Intervertebral Disk

The thoracic intervertebral disks are quite thin and therefore adjust to the comparatively small movements in a segment. The heads of the ribs stabilize the disk on the sides. The posterolateral direction for a thoracic prolapse (not likely) is therefore occupied by bone. It is very unlikely that intervertebral disk substance will cause nerve root compression. The intervertebral foraminae, with their exiting spinal nerves, are found significantly superior to the intervertebral disk. This is another reason why spinal nerves are rarely affected by a thoracic prolapse. 

- 흉추간판은 매우 얇기 때문에 흉추의 움직임은 매우 적음. 그래서 상대적으로 적은 움직임에 적응함. 늑골두는 흉추간판의 양측에 부착하여 안정화시킴. 그래서 흉추간판 후방탈출은 흔하게 발생하지 않고 흉추신경근 압박이 매우 드뭄. 

vertebral foramen

The vertebral foramen is round and, in comparison to the other sections of the vertebral column, very narrow (Fig. 1 1 .6). As the laminae of the thoracic vertebral arch are very high, the foramen is almost completely enclosed by bone from all sides. The spinal cord takes up almost the entire diameter of the foramen and cannot make way for other masses that may intrude on this space (e.g., fracture, bleeding, or intervertebral disk prolapse). The dura mater and the spinal cord have a particularly high chance of being compressed when these pathological conditions are present in the thoracic spine.

- 흉추간공은 둥글고 경추, 요추 추간공에 비해서 좁음. 

- 흉추에서 척수는 foramen의 직경 대부분을 차지함. 

- 경막과 척수는 흉추의 병변이 발생할때 높은 확률로 압박할 수 있음. 

Spinous Process

The thoracic spinous process is known to be very long and points in an inferior direction (Fig. 1 1 .7). Its shape is the

typical characteristic of a thoracic vertebra.

- 흉추의 극돌기는 매우 길고 아래방향으로 향하고 있음. 

The length and the angle of the spinous process vary between the upper, middle, and lower thoracic sections. The slant results in a significant difference in the level between the tip of the spinous process and the corresponding transverse process. This difference is summarized in the "finger rule." This rule is used to locate the structures belonging to the same vertebra that can be reached using palpation.

- 극돌기의 길이와 각도는 상부흉추, 중부흉추, 하부흉추가 모두 다름. 

- 손가락 규칙으로 촉진에 이용

The spinous processes overlap, especially in the mid thoracic spine. This means that when the thoracic spine is brought into extension, the spinous processes come into contact with each other quickly here and compression increases. Small bursae absorb the friction while the spinous processe,s slide a little over one another and restrict extension. The thoracic spine is locked in this position.

- 흉추극돌기는 특히 중흉추에서 중첩되어 있음. 

- 흉추가 신전될때, 극돌기는 서로 부착하여 압박이 증가한다는 의미.

- 작은 점액낭이 극돌기가 부딪히며 신전 움직임을 제한하는 동안 마찰을 흡수함. 

흉추 극돌기의 촉진법

How Does this Affect Palpation?

- 결론....앉거나, 흉추를 신전만 하지 않으면 어느자세에서나 흉추극돌기는 쉽게 촉진함.

In a neutral starting position (SP), the very long spinous processes can be easily palpated and differentiated from one another. It is very simple to draw the outline of the tips on the skin. The sitting position is the only position where the active, tensed muscles may make it harder to access the spinous processes. Furthermore, the therapist must be aware that no spaces exist between the spinous process. The tip of the superior spinous process lies on the posterior side of the inferior spinous process.

- 중립위치에서 매우 긴 흉추 극돌기는 촉진하여 감별하기 쉬움. 

- 앉은 자세는 능동적으로 긴장된 근육이 극돌기를 만지기 힘들게 하는 유일한 자세임. 

The locked position of the thoracic spine resulting from the overlapping thoracic spinous processes in extension is not a suitable SP to palpate segmental mobility. The segments are able to move better when the thoracic spine is slightly flexed-the resting position for the thoracic spine.

- 흉추의 닫힌 자세는 신전시 흉추 극돌기가 중첩될때 만들어짐. 

- 이  자세는 극돌기를 촉진하기  부적당한 자세

The therapist should therefore ensure that the thoracic spine is always positioned in a slight kyphosis for all SPs. The "springing test," the posteroanterior pressure on the spinous processes, is not suited to assessing mobility in the thoracic spine, Pressure on these long processes does not result in translation movement. The vertebra tilts backward instead.

- 치료사는 흉추 후만을 확인해야

- 스프링 테스트(극돌기 압박)는 흉추에서는 적합하지 않음. 

- 왜냐하면 흉추극돌기 압박으로 전방움직임이 일어나지 않기 때문에.

흉추 횡돌기 Transverse Process

Inferiorly, the transverse processes become gradually shorter and point more posteriorly. The length of the Tl transverse process is of particular interest when searching for the costovertebral joint between the first rib and T1. The Tl transverse process is approximately as long as the patient's index finger when it is projected onto the skin.\

- 흉추 횡돌기는 아래로 내려갈수록 짧아지고, 좀더 안쪽으로 들어가 있음. 

- 흉추 1번 횡돌기 길이는 흉추 1번과 첫번째 늑골사이의 costovertebral joint를 찾을때 촉진됨. 

- 흉추 1번 횡돌기는 환자의 두번째 손가락만큼 길이.

Each transverse process has a small joint facet on its anterior aspect that forms the costotransverse joint with a rib. The spatial orientation of the transverse process determines the position of the communal axis for both costovertebral joints (see also "Mechanics of the Costovertebral Joints," below).

- 흉추의 횡돌기는 늑횡돌기 관절이 함께 존재함. 

흉추 횡돌기의 촉진

How Does this Affect Palpation?

The direct paravertebral area is covered by less muscle mass in the thoracic spine than in the lumbar spine. This enables the therapist to confidently access the transverse process and provides an extra lever to affect segmental mobility. The question is, how does the therapist find the transverse process belonging to a specific vertebra?

- 흉추는 요추보다 근육이 적음. 이는 치료사가 횡돌기를 정확하게 촉진할 수 있다는 것을 의미함. 

- 문제는 척추의 정확한 횡돌기를 어떻게 찾는가임. 

This is achieved using two different methods:

• Each transverse process is found at the level of the accessible medial end of a rib.

• The difference in position between the spinous process and the transverse process conforms to the "finger rule." 

- 각각 횡돌기는 늑골의 내측끝에서 촉진됨.

- 극돌기와 횡돌기사이에 손가락 규칙이 있음.

The therapist can reliably locate the level of a transverse process by first palpating the localized tip of the corresponding spinous process.

- 치료사는 극돌기 대응부위 끝에 위치한 횡돌기레벨에서 위치를 찾을 수 있음. 

Tip: Finger rule: The typical thoracic vertebrae is constructed with a difference in height between the spinous process and the transverse process. The extent of this difference varies almost from segment to segment. The therapist attempts to determine this difference by using the patient's index finger during palpation (Fig. 1 1 .8).

- 손가락 규칙 : 흉추는 극돌기와 횡돌기의 높이가 다름. 촉진하는 동안 환자의 두번째 손가락을 이용하여 이 차이를 측정함. 

- 아래 설명됨. 

When the therapist wishes to access the corresponding transverse process, they move a specific number of finger widths in a superior direction from the lower edge of the spinous process: .

• T1, T2 spinous processes: plus one finger-width.

• T3, T4 spinous processes: plus two finger-widths.

• T5-T8 spinous processes: plus three finger-widths.

• T9, T10 spinous processes: plus two finger-widths.

• T11, T12 spinous processes: plus one finger-width.

의문) 횡돌기를 촉진해서 어디에 사용???? 생각중!!

Facet Joints

The alignment of the thoracic ZAJs is quite different from that seen in the lumbar region. In relation to the end plates, the superior joint processes are tilted upright at an average angle of 70° and are tilted 20° anteriorly on the sides ( Fig. 11 .9). 

- 흉추 후관절의 정렬은 요추와 완전히 다름. 

- 수평면과 평균 70도 기울어지고, 관상면에서는 20도 기울어짐. 

This means that the processes lie in a perfect circular arc around the rotation axis found in the disk. Rotation is therefore not significantly restricted by either the ZAJ or the ribs and is evenly distributed between all segments (excluding the thoracolumbar junction) (White and Pandjabi, 1 990).

- 이 말의 의미는 흉추 회전이 후관절이나 늑골에 의해서 제한되지 않는다는 의미. 

흉추 후관절 촉진

How Does this Affect Palpation?

Segmental rotation is suitable for the assessment of segmental mobility and also for restoring this mobility with the use of appropriate techniques.

- 분절 회전은 분절 움직임의 측정을 위해 적합하고, 적절한 치료테크닉을 이용하여 이 움직임 회복을 위해 유용함. 

Thorax

The bony thorax is formed by 12 pairs of ribs and the sternum. Two kinematic chains meet at the point where the ribs connect to the vertebrae ( Fig. 1 1 . 1 0 ):

- 흉곽은 12개의 늑골과 1개의 흉골로 만들어짐. 

- 2개의 운동사슬이 늑골과 척추가 만나는 지점에서 존재함. 

• Vertical kinematic chain = thoracic spine.

• Horizontal kinematic chain = costovertebral joints.

The two kinematic complexes affect one another with their mobility and stability. The thorax affects the thoracic spine by increasing its stiffness and reducing its range of motion, for example, during lateral flexion (White and Pandjabi, 1990). This is advantageous when concentrating on the protective and supporting functions of the thoracic spine.

- 두개의 운동사슬복합체는 서로 그들의 운동성과 안정성에 영향을 미침. 

- 흉곽은 측굴하는 동안 움직임 범위 감소와 stiffness 증가에 의해 흉추에 영향을 미침.

- 이것은 흉추의 지지와 보호기능에서 유리함. 

Construction of a Rib

A rib is a curved long bone that seeks contact with the sternum as it turns downward from posterior to anterior. It is made up of different sections (Fig. 11.11). 

- 늑골은 휘어진 긴뼈이고 흉골과 부착

How Does this Affect Palpation?

• The tubercle of the rib can sometimes be palpated. It is found directly adjacent to the tip of the transverse process.

• The angle of the rib is the largest curve in the rib and extends the most posteriorly. The easiest point to feel the rib is at its angle near the vertebral column.

• The superior edge of the body of the rib is rounded; the inferior edge is more sharp-edged. With this knowledge, the therapist can assess whether malpositioning is present in fixed inhalation or expiration during the palpation of the thorax.

- 늑골의 결절은 가끔 촉진될 수 있음. 그것은 횡돌기 끝에서 관찰됨. 

- 늑골의 상방 edge는 둥글고, 하방 edge는 좀더 sharp-edged

- 이러한 지식을 바탕으로, 치료사는 흉곽의 촉진동안 고정된 호기, 흡기에서 malposition이 있는지 아닌지를 검사할 수 있음. 

Articulations between the Ribs and Sternum

The ribs are divided into three groups based on the different types of contact with the sternum (Fig. 11.12):

- 늑골은 흉골 부착의 형태에 따라 3 그룹으로 나뉨. 

# Direct contact with the sternum: the "true" ribs-1 st to 7th ribs.

# Indirect contact with the sternum: the "false" ribs-8th to 10th ribs.

# No contact with the sternum: the floating ribs ("mobile" ribs)-1 1 th and 12th ribs.

- 직접 부착 true rib : 1-7번

- 간접 부착 false rib : 8-10번

- 부착 없음 floating rib : 11-12번 늑골

The 11 th and 12th ribs end without bony contact in the wall of the trunk and demonstrate a firm-elastic consistency

on direct pressure. Their length varies considerably. 

- 11~12번째 늑골끝은 몸통 뼈부착없이 떠 있음. 

The connecting cartilage of the 8th to 10th ribs forms the costal arch. Both costal arches meet at the epigastric angle on the xiphoid process of the sternum. The distance between the costal cartilages of the 10th ribs demonstrates the size of the inferior thoracic aperture. The connection between the costal cartilage and its superior neighbor is not particularly stabile. Subluxations can occur due to trauma ("slipping ribs").

- 8-10번째 늑골의 연골은  costal arch를 만듬. 흉골검상돌기에서 늑골아치는 만남. 

- 10번째 늑골 연골 사이의 길이는  inferior thoracic aperture의 크기임. 

- 늑골연골 사이 연결과 그것의 상부는 특히 안정성이 있음. 

- 이 부위에 subluxation은 slipping ribs syndrome(티에체 증후군)이라 하고 대개 타박상에 의해서 일어남. 

 Slipping ribs syndrome 치료법 “hooking maneuver”

Most of the costosternal junctions to the true ribs are small true joints, very firm and resilient. The second rib is usually attached to the sternal angle (junction between the manubrium and the body of the sternum). Hardly any variations in anatomy are evident here.

- 늑흉골 연접은 true ribs joint임. 매우 단단하고 탄력있음. 

- 두번째 늑골은 일반적으로 sternal angle에 부착함...

Articulations between the Ribs and the Vertebrae

Differences are made depending on which parts of the rib or the vertebra articulate (Fig. 1 1 . 1 3 ):

- 늑골과 흉추의 2개 관절

• Costovertebral joints (joint of the head of the rib): the head of the rib articulates with two vertebral bodies and the disk. Exceptions are the 1 st, 1 1 th, and 1 2th ribs. Only a vertebral body is seen here.

- 늑척추 관절

• Costotransverse joints: the tubercle of the rib forms a joint with the transverse process of the corresponding vertebra. Exceptions are the 1 1 th and 1 2th ribs. No joints exist here.

- 늑횡돌 관절

The superior four ribs share very firm articulations with the vertebrae and tend to be more hypomobile. The first rib in particular stands out in clinical practice. 

- 상부 4개 늑골은 척추와 단단한 관절을 분담하고, 좀더 덜 움직임. 

- 1번 늑골은 특히 더 단단함. 

Mechanics of the Costovertebral Joints

The axis of movement couples both joints functionally and passes through the neck of the rib. The transverse process

differs in length and spatial alignment in the upper, middle, and lower thoracic spine. It determines how far posterior and lateral the costotransverse joint is located. Lastly, it determines the position of the rotational axis for movements of the ribs during inhalation and expiration (Fig. 1 1 . 1 4).

- costovertebral joint와 costotransverse joint는 움직임의 축이 짝으로 기능하고, 늑골경을 통과함. 

- 척추 횡돌기는 길이가 다르고, 상부흉추, 중부흉추, 하부흉추에서 공간적 정열과 길이가 다름. 

The length and alignment of the transverse processes in the upper thoracic spine (Tl-T7) causes the rotational axis to be aligned more in the frontal plane. This results in elevation and expansion of the thorax in the sagittal plane due to the mechanics of the ribs. The more sagittally oriented axes in the middle and lower thoracic spines enable the thorax to expand in a lateral direction.

- 상부흉추(T1-7)에서 횡돌기의 정열과 길이는 Frontal plane에서 좀더 정열을 이루는 회전축을 만듬. 

- 이는 늑골의 생체역학 덕분에 sagittal plane에서 흉곽의 확장과 상승을 야기함. 

- 중간, 히부흉추에서 좀더 시상배열을 이루어 흉곽이 외측방향으로 확장될 수 있게 함. 

Forced inhalation (Fig. 1 1 .1 5 ) always results in intercostal spaces widening in every section of the thorax. The intercostal spaces become narrower during expiration( Fig. 1 1 . 1 6). This movement pattern allows diagnosing through palpation with movement. 

- 강력한 흡기는 항상 늑골사이 공간이 흉곽에서 모든 방향으로 커지게 함. 

- 늑골사이 공간은 호기동안 점점 좁아짐.

- 이 움직임 패턴은 호흡움직임과 함께 촉진을 허용함. 

Movements of the arm have similar effects on the intercostal spaces:

• Arm elevation with flexion raises the upper thorax in a more anterior direction and opens up the upper intercostal spaces.

• Arm elevation with abduction raises the lower thorax in a more lateral direction and opens up the lower intercostal spaces.

- 상지를 굴곡할때, 상부 흉곽이 좀더 앞으로 이동하고, 상부 늑골사이 공간을 넓힘. 

- 상지를 외전할때, 하부 흉곽이 옆방향으로 이동하고 하부늑골사이 공간이 열림. 

The rotation of the ribs around the longitudinal axis in the neck of the rib during deep inhalation and expiration results in the inferior or superior edges of the ribs facing slightly outward. 

- 심호흡동안 늑골경에서 종축 주위로 늑골의 회전은 늑골의 상부 또는 하부의 edge가 약간 outward됨. 

How Does this Affect Palpation?

The inferior or superior edges can be felt at the end of forced inhalation and expiration. The edges are not palpable during quiet respiration. The relationship of structures to one another is interesting when the ribs are pathologically fixed in a position of inhalation or expiration. When the therapist assesses the position of structures, it is noticeable that the blocked rib has another form in comparison to its neighboring mobile ribs (see the section "Assessment of the Costovertebral Joints" below).

- 늑골의 상부 또는 하부 edge는 강한 호흡의 끝에서 느낄 수 있음. 

- 조용한 호흡동안에 늑골의 edge는 촉진할 수 없음. 

- 늑골이 병리적으로 고정되어 있을때, 호흡의 위치에서 서로서로 구조의 관계는 흥미로움

- 치료사는 늑골 구조를 진단할때, 늑골이 병리적으로 움직이지 않을 때, 이웃 움직이는 늑골과 비교하여 알 수 있음. 

Detailed Anatomy of the Anteriorly

Positioned Bones

Figure 11.17 is used in many anatomy books and shows the anatomy of the manubrium as the superior section of the sternum with its articular connections. The edge of the manubrium is equipped with many notches. The jugular notch is the most superior-lying notch. The medial ends of the clavicles form the sternoclavicular (SC) joints lateral to this. The cartilage of the first rib has an articular connection to the manubrium immediately inferior to the SC joint. The sternal angle is found at the level of the connection to the second rib. This connection is described at times in anatomical literature as an articulation or as a synchondrosis. The manubrium moves on the body of the sternum as the thorax moves during respiration.

- 흉골과 늑골, 연골의 관계

- 흉골의 가장자리에는 많은 notches를 가지고 있음. jugular notch, 흉쇄관절면

How Does this Affect Palpation?

The jugular notch is a reliable orientation point to access the manubrium from a superior position. The level of the notch also corresponds to the level of T2 (see the section "Anterior Palpation Techniques" in Chapter 12, p. 365). It is easy to reach the SC joint from here (see the section "Sternoclavicular Joint Space" in Chapter 2, p. 36).

- 흉골절흔은 흉추 2번 레벨과 상응하여 보임. 

- 흉쇄관절 촉진은 쉬움. 

The medial end of the first rib is found immediately inferior to the clavicle and extends posteriorly from here with a tight curve. It is very difficult to palpate. In comparison, the sternal angle is easy to reach and can be marked with confidence. The second rib is found at the same level without fail. The first five intercostal spaces can be reliably reached from here. 

- 첫번째 늑골의 내측끝은 쇄골 아래에서 발견. 촉진이 매우 어려움. 

- 두번째 늑골은 .... 

The anterior thorax is dominated by the pectorals major (Fig. 11.18). It is divided into three functional sections that are difficult to differentiate from one another anatomically.

- 흉곽의 전면부는 대흉근이 지배. 3가닥으로 나뉨. 

Their denominations refer to the surface of origin:

• Medial half of the clavicle: clavicular head.

• Manubrium and the body of the sternum, first to sixth costal cartilages: sternocostal head.

• Anterior rectus sheath: abdominal part.

흉추 척추근육의 촉진법

How Does this Affect Palpation?

All edges of the muscle are palpable and also visible at times when active. The boundaries between the individual sections are not distinctly recognizable. The rough muscle bundles that can be palpated do not usually correspond to the functional divisions.

Thoracic Back Muscles

Intrinsic Back Muscles

Within this group arising from the medial tract of the intrinsic back muscles, two muscle systems are unique to this region:

• Spinalis thoracis: represents the straight, spinal system.

• Rotatores thoracis: from the oblique, transversospinal system.

- 흉추부위 내재근은 두가지로 구분

- spinalis thoracis and rotators thoracis

The interspinales muscles from several segments unite to form the spinalis thoracis (Fig. 11.19). This muscle can only be found in the thoracic part of the vertebral column. It extends from L 1 -L3 to 0-T1 and is found directly adjacent to the row of spinous processes. The transition to the semispinalis cervicis is almost completely smooth. It forms the bulge of  paravertebral muscles in the neck region and is consciously disregarded here.

The cross-section of the lateral tract gradually decreases here. The spinalis thoracis takes over its function of supporting the weight of the trunk against gravity. It also appears to be the muscle that has enough strength to extend the thoracic spine into extension: The spinalis plays the most important role in the interplay between the extensors when correcting the posture of a strongly kyphotic thoracic spine.

- spinalis thoracis는 중력에 대하여 몸통의 체중을 지지하는 기능을 담당함. 

- 흉추 신전을 가능케 하는 충분한 근력을 가짐. 

- 강력하게 흉추후만의 자세를 바로잡을때 몸통 신전가운데 spinalis thoracis는 가장 중요한 역할. 

참고) spinalis thoracis(dorsi)

Spinalis dorsi[edit]

Spinalis dorsi, the medial continuation of the sacrospinalis, is scarcely separable as a distinct muscle. It is situated at the medial side of the longissimus dorsi, and is intimately blended with it; it arises by three or four tendons from the spinous processes of the first two lumbar and the last two thoracic vertebrae: these, uniting, form a small muscle which is inserted by separate tendons into the spinous processes of the upper thoracic vertebrae, the number varying from four to eight. It is intimately united with the semispinalis dorsi, situated beneath it.

How Does this Affect Palpation?

In the lumbar region, a depression is palpated directly next to the row of spinous processes before the palpating fingers rest against the medial side of the erector spinae muscle mass. This is not possible in the thoracic region. When palpating laterally from the tip of the spinous processes, the therapist immediately encounters a spinalis muscle approximately one finger-breadth wide. Enormous muscle tension is frequently found here, which often feels unpleasant when direct pressure is applied to it.

rotatores thoracis muscles

The rotatores thoracis muscles (Fig. 1 1 .20) are short muscles found very deep in the tissue. They are in close contact with the ZAJs (from Lanz and Wachsmuth, 2004a). The decisive factor for the exact terminology used for the muscles is their length:

• Extending over one segment: rotatores brevis.

• Extending over two segments: rotatores longs.

Their prominence corresponds well to the ability to rotate to almost the same extent in all thoracic segments. The actions

of the rotatores thoracis include the extremely differentiated fine adjustment of position and the local stability of the thoracic movement segments.

- rotators thoracis는 자세의 정밀한 조절과 흉추 분절움직임의 국소적 안정성을 담당함. 

How Does this Affect Palpation?

Some authors call the rotatores muscle "monitoring muscle." This means that this muscle tenses when disturbances

in segmental mobility are present and can provide the therapist with information regarding pathology when they palpate (Dvorak et aI., 2008). However, the author doubts whether clinicians are actually able to selectively palpate the rotatores and to clearly perceive increased tension in this muscle. When examined on an anatomical specimen, the muscle's deep position hidden beneath several other muscles is revealed. 

- 어떤 저자들은 rotators thoracis를 monitoring muscle라고 함. 

흉추 외재근 등근육 촉진

Extrinsic Back Muscles

The thoracic section of the back is dominated superficially by the latissimus dorsi and the most important representatives of the thoracoscapular muscle group. The latter muscle group extends from the trunk (from the row of spinous processes) to the scapula and belongs functionally to the upper limb. These are, in particular:

• The descending and transverse parts of the trapezius.

• The rhomboids.

The originating fibers of the latissimus dorsi extend to the level of T7 -T8 (see Fig. 1 1 .21 ), and therefore also to the

thoracolumbar fascia. The thoracolumbar fascia additionally receives fibers from the serratus posterior at this point. In comparison to the lumbar region, the latissimus dorsi fibers do not cross the mid-line in the thoracic region. All further information about this muscle can be found in the section "Detailed Anatomy of the Muscles" in Chapter 10, page 252.

How Does this Affect Palpation?

The superior sections of the muscles can be recognized only in very muscular and very slim people. It is highly unlikely that this muscle can be reliably differentiated from other structures. Generally, the lateral edge can be demonstrated and palpated on toned people when their arm is active in extension.

According to Lanz and Wachsmuth (2004), the most important parts of the trapezius for this section (Fig. 11.21) have the following anatomical course:

• Ascending part: the fibers converge from the their origin on the T4-T11/T12 spinous processes onto the medial end of the spine of the scapula, where they are evident posteriorly. Here they meet with the posterior fibers of the spinal part of the deltoid muscle.

• Transverse part: this part generally passes from the C7-T3 spinous processes to the upper edge of the spine of the scapula (lateral half). This is the thickest part of the trapezius. It becomes a prominent bulge when the scapula is adducted toward the vertebral column.

The therapist can generally note that the origins of this very superficially located muscle do not always have to involve

attachment to both sides of the spinous processes. The fibers from both sides can merge into one another without bony contact; they sometimes form an aponeurosis that glides freely over the spinous processes, especially at the cervicothoracic junction. 

Bursae are frequently found on anatomical specimens. These bursae reduce friction. The question is: Could bursitis also be a possible cause for gradually developing local symptoms in this area?

How Does this Affect Palpation?

The junction between both parts of the muscle can only rarely be identified as a gap on anatomical specimens and is therefore not of interest for palpation. The inferior edge of the ascending part can be palpated when the muscle is active. The superiorly running fibers angled from medial to lateral become distinct when this part of the trapezius pulls the scapula posteriorly and inferiorly against resistance. Therefore, the hand palpates from an inferior position, perpendicular to the edge of the muscle, and hooks onto the muscle.

[heoss]

감사합니다.

[로또야 내가가]

도움이 많이 되네요... 영어가 좀 있지만...ㅋㅋㅋ

[박정성]

정말 좋은 자료네요 매번 감사드립니다