oscillation 테크닉(thrust)과 joint mobilization의 완벽 이해!!

[문형철]

드디어 완전히 이해에 도달했다.

가장 중요한 것은 oscillation과 joint play를 언제, 어떻게 얼만큼 할 것인가이다. 

그것을 어떻게 전달할 것인가? 

관절가동법의 생체역학(클릭해서 먼저 읽고)

panic bird...

관절가동 치료테크닉 적용을 위한 4가지 과정

1. Examination and Eval‎uation 검사와 평가

If the patient has limited or painful motion, examine and decide which tissues are limiting function and the state of pathology. Determine whether treatment should be directed primarily toward relieving pain or stretching a joint or soft tissue limitation.5,17

- 환자가 통증으로 움직임 제한이 있다면, 병리가 발생한 제한된 기능을 가진 조직이 정확히 결정되어야 함. 

- 어떤 치료를 시행할 것인지 결정은 ....

2. Quality of pain 통증의 질

The quality of pain when testing the ROM helps determine the stage of recovery and the dosage of techniques used for treatment (see Fig. 10.2). 

- rom검사를 시행할때, 통증의 상태는 치료를 위한 테크닉의 크기와 양을 결정할 수 있음. 

# If pain is experienced before tissue limitation—such as the pain that occurs with muscle guarding after an acute injury or during the active stage of a disease—gentle pain-inhibiting joint techniques may be used. The same techniques can also help maintain joint play (see next section on Grades or Dosages of Movement). Stretching under these circumstances is contraindicated.

- 만약 통증이 급성 손상으로 인한 염증기에 발생하는 반사성 근수축때문에 발생한다면, 부드러운 통증억제 테크닉이 시행될 수 있음. 

- 이러한 테크닉은 관절 움직임을 유지하는데 도움이 됨. 

# If pain is experienced concurrently with tissue limitation—such as the pain and limitation that occur when damaged tissue begins to heal—the limitation is treated cautiously. Gentle stretching techniques specific to the tight structure are used to improve movement gradually yet not exacerbate the pain by reinjuring the tissue.

- 만약 통증이 조직손상후 증식기때문에 발생하는 것이라면, 부드러운 스트레칭 테크닉이 시행되어 점차적으로 움직임을 회복하고 조직재손상을 막을 수 있음. 

# If pain is experienced after tissue limitation is met because of stretching of tight capsular or periarticular tissue, the stiff joint can be aggressively stretched with joint-play techniques and the periarticular tissue with the stretching techniques described in Chapter 4.

- 만약 통증이 조직제한 이후에 단단한 관절낭, 관절주위조직의 강직성 관절이라면 좀더 적극적인 관절가동을 포함한 스트레칭 테크닉이 필요함. 

3. Capsular Restriction 관절낭 제한

The joint capsule is limiting motion and should respond to mobilization techniques if the following signs are present.

- 관절낭은 움직임을 제한하는데, 관절가동테크닉은 아래의 신호반응을 살펴야 함. 

# The passive ROM for that joint is limited in a capsular pattern (these patterns are described for each peripheral joint under the respective sections on joint problems in Chapters 17 through 22).

# There is a firm capsular end-feel when overpressure is applied to the tissues limiting the range.

# There is decreased joint-play movement when mobility tests (articulations) are performed.

# An adhered or contracted ligament is limiting motion if there is decreased joint play and pain when the fibers of the ligament are stressed; ligaments often respond to joint mobilization techniques if applied specific to their line of stress.

- 관절의 수동적 rom은 관절낭 패턴에서 제한됨. 

- 과도한 압력이 제한된 범위에서 적용될때 단단한 관절낭 끝 느낌이 있음.

- 움직임 검사를 시행할때, 감소된 관절움직임이 있음.

- 감소된 관절움직임과 통증이 있다면 인대섬유에 부하가 주어질때, 인대의 유착, 구축은 움직임을 제한함. 인대는 관절가동 테크닉에 때때로 잘 반응함. 

4. Subluxation or Dislocation 아탈구 또는 탈구

Subluxation or dislocation of one bony part on another and loose intra-articular structures that block normal motion may respond to thrust techniques. Some of the simpler manipulations are described in appropriate sections in this text. Others require more advanced training and are beyond the scope of this book.

- 쓰러스트 테크닉은 아탈구, 탈구로 정상움직임 제한이 발생했을때 적응증이 될 수 있음. 

1. Graded Oscillation Techniques (Fig. 5.9) 단계적인 진동 테크닉

Dosages

Grade I: Small-amplitude rhythmic oscillations are performed at the beginning of the range.

- 작은 진폭의 리드믹한 진동테크닉이 움직임 시작범위에서 시행

Grade II: Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit.

- 큰 진폭의 리드믹한 진동테크닉이 생리적 제한범위이내의 범위에서 시행.

Grade III: Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.

- 큰 진폭의 리드믹한 진동테크닉이 생리적 제한범위를 넘어서 조직에 저항스트레스가 가해진 범위에서 시행

Grade IV: Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance.

- 작은 진폭의 리드믹한 진동테크닉이 조직저항이 가해지는 스트레스범위끝에서 시행

Grade V: A small-amplitude, high-velocity thrust technique is performed to snap adhesions at the limit of the available motion. Thrust techniques used for this purpose require advanced training and are beyond the scope of this book. 

- 일명 쓰러스트 테크닉

- 작은 진폭, 높은 속도의 쓰러스트 테크닉은 유착이 진행된 범위에서 스냅을 이용하여 시행

Uses

# Grades I and II are primarily used for treating joints limited by pain. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels.25,34 These nonstretch motions help move synovial fluid to improve nutrition to the cartilage.

- 단계 1,2 진동테크닉은 통증에 의해서 제한된 관절을 치료함. 

- 진동테크닉은 통증성 자극이 척수를 따라 뇌간으로 전달되는 것을 차단함. 

- 스트레칭되지 않는 움직임은 활액움직임을 돕고, 연골에 영양개선을 줌. 

# Grades III and IV are primarily used as stretching maneuvers.

- 단계 3, 4 진동테크닉은 스트레칭된 상태에서 시행됨. 

Techniques

The oscillations may be performed using physiological (osteokinematic) motions or joint-play (arthrokinematic)

techniques.

- 진동테크닉은 생리적 움직임이나 관절가동에서 모두 시행가능함. 

2. Sustained Translatory Joint Play Techniques (Fig. 5.10)

- 지속적인 활주 관절가동 테크닉

Dosages

Grade I (loosen): Small-amplitude distraction is applied where no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.

- 단계 1 : 작은 진폭의 distraction은 관절낭에 스트레스없이 적용함. 

- 점탄성의 힘, 근육장력, 관절에 가해지는 압력을 동일하게 적용함. 

Grade II (tighten): Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn14 called this “taking up the slack.”

- 단계 2 : 충분한 distraction 또는 활주는 관절주위의 단단해지 조직에 적용함. 칼텐본은 taking up the slack이라고 표현함.

Grade III (stretch): A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures. 

- 단계 3 : distraction 또는 활주가 큰 진폭으로 적용되어 관절낭과 관절주위조직의 늘어남이 적용되는 것임. 

Uses

Grade I distraction is used with all gliding motions and may be used for relief of pain.

- 단계 1 distraction은 통증을 줄이기 위해 활주움직임을 이용함.

Grade II distraction is used for the initial treatment to determine how sensitive the joint is. Once the joint reaction is known, the treatment dosage is increased or decreased accordingly. Gentle grade II distraction applied intermittently may be used to inhibit pain. Grade II glides may be used to maintain joint play when ROM is not allowed.

- 단계 2 distraction은 과민한 관절의 치료에 적용함. 한번 관절의 반을을 알면, 치료 dosage는 줄이거나 늘일 수 있음. 

- 부드러운 단계 2 distraction은 간헐적으로 적용하면 통증을 줄일 수 있음. 이 단계는 관절 rom이 제한이 있을때 관절 움직임을 유지할 수 있음. 

Grade III distractions or glides are used to stretch the joint structures and thus increase joint play.

- 단계 3 distraction 또는 활주는 관절구조를 스트레치하여 관절가동을 증진시킴. 

Techniques

This grading system describes only joint-play techniques that separate (distract) or glide/translate (slide) the joint surfaces.

- 이 단계적 시스템은 오직 joint play 테크닉에서 기술함. distraction, glide, slide

Comparison

When using either grading system, dosages I and II are low intensity and so do not cause a stretch force on the joint capsule or surrounding tissue, although, by definition, sustained grade II techniques take up the slack of the tissues whereas grade II oscillation techniques stay within the slack. Grades III and IV oscillations and grade III sustained stretch techniques are similar in intensity in that they all are applied with a stretch force at the limit of motion. The differences are related to the rhythm or speed of repetition of the stretch force.

# For clarity and consistency, when referring to dosages in this text, the notation graded oscillations means to use the dosages as described in the section on graded oscillation techniques. The notation sustained grade means to use the dosages as described in the section on sustained translatory joint-play techniques.

# The choice of using oscillating or sustained techniques depends on the patient’s response.

• When dealing with managing pain, either grade I or II oscillation techniques or slow intermittent grade I or II sustained joint distraction techniques are recommended; the patient’s response dictates the intensity and frequency of the joint-play technique.

• When dealing with loss of joint play and thus decreased functional range, sustained techniques applied in a cyclic manner are recommended; the longer the stretch force can be maintained, the greater the creep and plastic deformation of the connective tissue.

• When attempting to maintain available range by using joint-play techniques, either grade II oscillating or sustained grade II techniques can be used.

 Hints

• Warm the tissue around the joint prior to stretching. Modalities, massage, or gentle muscle contractions increase the circulation and warm the tissues.

• Muscle relaxation techniques and oscillation techniques may inhibit muscle guarding and should be alternated with the stretching techniques, if necessary.

• When using grade III gliding techniques, a grade I distraction should be used with it. A grade II or III distraction should not be used with a grade III glide to avoid excessive trauma to the joint.

• If gliding in the restricted direction is too painful, begin gliding mobilizations in the painless direction. Progress to gliding in the restricted direction when mobility improves a little and it is not painful.

• When applying stretching techniques, move the bony partner through the available range of joint play first, that is, “take up the slack.” When tissue resistance is felt, apply the stretch force against the restriction.

• Incorporate MWM techniques (described later in the chapter) as part of the total approach to treatment. 

Speed, Rhythm, and Duration of Movements

1. Oscillations

# Grades I and IV are usually rapid oscillations, like manual vibrations. 

# Grades II and III are smooth, regular oscillations at 2 or 3 per second for 1 to 2 minutes.

# Vary the speed of oscillations for different effects such as low amplitude and high speed to inhibit pain or slow speed to relax muscle guarding.

- 진동테크닉 1단계와 4단계는 빠른 진동을 이용함

- 진동테크닉 2단계와 3단계는 1-2분동안 초당 2-3회 부드럽게 진동

- 진동 속도의 변화는 목표하는 효과가 달라짐. 예를들어 통증을 줄이기 위해서는 작은 진폭으로 빠른 스피드로 적용함. 반사성 근수축을 줄이려면 늦은 스피드로 시행해야 함. 

Sustained

# For painful joints, apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles. Note the response and either repeat or discontinue.

- 통증성 관절을 위해 간헐적 distraction을 7-10초 적용함. 

# For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4- second intervals.

- 제한된 관절을 위해 최소한 6초 스트레치 힘을 단계 1-2힘으로 시행함. 그리고 나서 천천히, 간헐적 스트레치를 3-4초간격으로 시행함. 

[heoss]

감사합니다.

[기네쉬]

감사합니다.

[ChulhwanKim]

좋은 자료 감사합니다. Dr. Lederman Eyal 박사도 oscillation therapy로 런던에서 박사학위받고 Harmonic Technique, Fundamentals of Manual Therapy, The Science and Practice of Manual Therapy, Neuromuscular Rehabilitation in Manual and Physical Therapies and Therapeutic Stretching 저자 이니 같이 참고 하셔도 좋을 듯 합니다.