과학적인 촉진법(피부, 근육, 건, 인대, 신경, 관절낭, 뼈의 촉진 테크닉)

[문형철]

정확한 근육, 건, 인대, 관절낭, 뼈의 구조를 알고, 상상하여 정확하게 촉진하는 법을 알자.

촉진의 목적은 세가지

1. 정확한 위치 찾기

2. 조직의 문제평가

3. 평가된 문제, 질병의 치료

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

"You cannot feel what you do not know."

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

The precise palpation of structures is used in physical therapy assessment and treatment of, for example, the

vertebral column segments: Physical therapy assessment:

1) defining the area to be treated.

2) confirm‎ing the presumed location.

3) examining the consistency(반죽질기) of skin and muscles.

4) the provocation of local segmental parts (e.g., facet joint).

5) the assessment of segmental mobility.

6) examining the temporomandibular joint.

Basic principles of regional or local treatment:

- regional treatment: Swedish massage, functional massage. connective tissue massage, electrotherapy,

hydrotherapy, heat therapy, balneotherapy, and manual therapy techniques.

- local treatment: segmental oscillations for pain relief, local segmental manual therapeutic mobilization

techniques to maintain or improve mobility, cross-frictions according to Cyriax. and colon massage.

"You cannot feel what you do not know."

This simple phrase illustrates the necessity of a solid background in topographical and morphological anatomy for local palpation. It does not make sense to look for a specific transverse process if you are unable to visualize its

shape, position, and spatial relationship to its surroundings.

7가지 촉진 전 검진 순서

1. 전체적인 관찰(General observation)

2. 환자의 주관적 증상에 의한 평가(Subjective assessment-subjective symptoms)

3. 국소적인 관찰(Local observation)

4. 기능 검사 전 열감과 부종 촉진(Palpating for warmth and swelling before the assessment of function)

5. 의료인에 의한 객관적 검사(Assessment of function-objective symptoms)

  1) active and passive movements(ROM)

  2) movements against resistance(저항검사)

6. 기능평가와 함께하는 촉진(increase in temperature, swelling, detailed palpation)

7. 추가검사(근육기능, 관절기능, 안정성, 악화 검사 등을 시행)

- If required, additional tests such as the assessment of muscle function, tests of joint play, the measurement

of circumference, tests of stability, additional provocative tests, differentiation tests, etc

Pressure Applied during Palpation

- On the whole, only gentle pressure is applied during palpation. 

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

정확한 촉진 과정

1. 촉진의 대상을 정확히 선정

2. 정확한 준비(촉진을 위한 환자의 시작자세를 정확히)

3. 가장 잘 아는 구조에서 촉지 시작(localization)

4. 촉진하고자 하는 대상의 정확한 촉진

촉진 테크닉(Palpatory Techniques)

1. 피부의 촉진(Palpating the Skin)

Example: Posterior trunk.

Technique:

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

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

• Skin consistency: skin lifting test, skin rolling.

- 연부조직(피부)의 Consistency(점조도, 반죽질기) 검사가 중요함. 리프팅 테스트, 말기 테스트 등

Expectations:

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

• Skin temperature: uniform body temperature.

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

Commentary: The skin qualities described above represent the ideal situation for young patients. Needless to

say, age-related changes to the skin should not be immediately classified as pathological.

- 피부의 평가에서 주의해야 할 것은 나이에 따른 피부의 변화를 병리적으로 분류해서는 안됨.

The skin's consistency is determined by the balance of fluid in the skin. Elasticity tests are used to assess the consistency of skin and include the displacement test, lifting test (Fig. 1.2), and skin rolling. All three tests should provide identical results. The same amount of elasticity, sensitivity, and changes in these parameters should be found. If this is not the case, techniques should be reassessed or patients questioned again. These tests place different tensile stresses on the skin. The displacement test can be used to find a sensitive or significantly inflamed region; small changes in consistency can be detected especially well using skin rolling with a large amount of stretch. 

- 경험많은 치료사는 피부말기(skin rolling)만으로도 인체에 관한 엄청난 정보를 알아낼 수 있다. 

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

- 피부의 점조도(반죽질기, skin consistency) 검사로 환자의 근육긴장도, 근육문제를 알아낼 수는 없다. 

2. 뼈의 가장자리 촉진법(Palpating Bony Edges)

Examples: Spine of the scapula, edge of the acromion, joint line of the wrist, a variety of joint spaces. Iliac crest, rib shaft, spinous process, mastoid process, mandibular arch.

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

Expectations: Hard consistency and a clearly defined border.

Commentary: This technique enables therapists to accurately locate the outer boundaries of a bone. The palpating

finger must always be positioned perpendicular to the edge of the structure (Fig. 1.3). All other techniques are

less reliable. 

Tip: To feel the hard consistency and clearly palpate the bony edge, therapists should palpate the soft tissue first and then gradually move toward the presumed location of the bony edge.

- 뼈의 단단함을 느끼기 위해 치료사는 먼저 연부조직을 촉진하고 점차 정확한 뼈의 단단한 부위를 만져야

It becomes increasingly difficult to locate bony contours when superficial tissue is tense. 

- 연부조직의 긴장이 있으면 뼈의 윤곽을 만지기 힘듬. 

3. 뼈의 융기부 촉진법(Palpating Bony Prominences)

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

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

Expectations: The bony prominence protrudes from the surrounding bone. The structure itself feels hard when direct

pressure is applied to it.

Commentary: On the extremities, tubercles, tuberosities, etc. are clearly elevated in comparison to their surroundings

and can be clearly differentiated from other tissues with this technique. In most cases, the pelvic spines can be differentiated from their surroundings by their distinctly protruding form. Boundaries cannot always be felt so easily. Their shape is palpated using flattened fingers (Fig. 1.4). 

Too much pressure makes it difficult to feel differences in shape and position, decreasing the chance of success. Direct pressure is only applied to the structure to confirm‎ that bone is being palpated.

- 과도한 압력을 가하면 뼈 융기의 형태와 위치를 감별하기 힘듬. 

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

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

- 뼈의 융기부는 형태적으로 쉽게 찾는다. 하지만 가끔 변이가 있어 주의해야 함.

4. 근육의 근복(muscle belly) 촉진법(Palpating Muscle Bellies)

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

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

Expectations: Soft consistency. Tissue yields slightly to pressure. Deeper structures can frequently be palpated.

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

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

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

- 연부조직(근막)의 점조도는 근육을 둘러싼 근막의 장력이나 강도에 의존함. 

Thickness of the Fasciae

Fasciae can be very soft on the anterior and lateral sides of the trunk, in the neck, along the throat, in the medial forearm, the calf, or the medial aspect of the thigh, for example. Muscles yield easily to the pressure of precise palpation here and have an especially soft, elastic consistency. 

In contrast, extremely hard fasciae feel significantly firmer during palpation, even when the active muscle tension is normal. Typical examples of this are the thoracolumbar fascia superficial to the lumbar erector spinae and the rectus sheath. Therapists may easily conclude that muscles are tense when increased resistance is felt in the tissues. Once they are aware of the qualities fasciae possess, however, they will have correct expectations regarding the consistency of muscle tissue.

Tension in the Fasciae

The consistency of muscle and skin is also influenced largely by the length of tissues. An approximated muscle (where the ends of the muscle are found close to each other) generally feels softer than the resting tension felt in a stretched muscle.

- 근육과 피부의 점조도는 연부조직의 길이에 영향을 받음. 스트레치된 근육일때의 긴장보다 적절한 근육 길이 일때 부드럽게 촉지됨. 

Tissue feels significantly firmer when pressure is applied. Therapists may interpret this as a pathological increase in muscle tension. 

5. 근육의 가장자리 촉진법(Palpating the Edge of Muscles)

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

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

so that the course and the length of the muscle can be perceived.

- 근육의 가장자리를 촉진할때는 근육이 약간 긴장되어야 함

Expectation: When tensed, the edge of the muscle has a firm consistency and a uniform, smooth contour. Large

and small gaps differentiate the edges of the muscle from neighboring muscles.

Commentary: Many neighboring muscles and borders cannot be differentiated from one another or identified

without selective activation of the muscle. Well-trained muscles with low fat content as well as muscles with

pathologically increased tension are exceptions and project themselves out of their surroundings.

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

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

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

of the muscle to the insertion into bone.

6. 건의 촉진법(Palpating Tendons)

Examples: Tendons in the extensor compartments of the wrist, flexors of the wrist and fingers, biceps brachii tendon,

ankle plantar flexors and toe flexors, hamstring tendons(Fig. 1.7). The trunk muscles rarely attach onto the bone via a tendon. A "fleshy" insertion is more common. Limb muscles near the trunk are more likely to have insertions that feel like tendons when palpated, for example, the communal head of the hamstrings.

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

• Tendon that is difficult to locate: Place the finger pads flatly and directly onto the point where you suspect

the tendon to be, then alternately tense and relax the muscle.

- 만지기 어려운 건은 근육을 이완, 긴장을 번갈아 주면서 정확히 찾아야

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

when necessary.

- 만지기 쉬운 건은 필요할때 근육을 긴장한 후 촉진.

• For pain provocation: Administer transverse friction massage using the finger pads, applying firm pressure

on the presumably affected site.

- 통증이 있는 건은 교차마찰 마사지를 시행하면서 단단한 압력을 적용하여 촉지

Expectation: Firm consistency and, when the muscle is tensed, very firm consistency. A tendon remains somewhat

elastic when direct pressure is applied to it, even when under a large amount of tension. In most cases, the tendon is a rounded structure with a clearly defined contour.

- 근육이 약간 긴장될때 단단한 점조도 느낌으로 건이 촉진됨. 

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

Tip: The treating finger should not slip off from the tendon while Cyriax transverse frictions are being applied to the tendon

for treatment or pain provocation. The tendon remains stabile by positioning the muscle in a stretched position and

placing the tendon under tension.

7. 인대의 촉진법(Palpating Ligaments)

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

Technique

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

sacrotuberous ligament.

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

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

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

Expectation: Firm consistency. Very firm consistency when stretched. A ligament remains somewhat elastic,

even when placed under a large amount of tension.

- 인대는 아주 단단한 점조도. 

Commentary: It is important to be able to accurately visualize the anatomy. You should be familiar with the course of the ligament and, when possible, find its bony attachments. Ligaments providing capsular reinforcement are another type of taut connective tissue. In contrast to tendons, most ligaments cannot be easily differentiated from either those capsules without ligamental reinforcement or from other tissues. When ligaments belong to the fibrous layer of joint capsules, they only rarely show clear edges.

- 건과 다르게 인대는 관절낭과 감별하기 힘듬.

Exceptions to this rule include the patellar ligament and the lateral collateral ligament of the knee joint. In the other cases, therapists must be familiar with the course of the ligament and locate its fixed points on the bones. In the upper cervical area, the local ligaments are examined via their bony partners and their biomechanical relationship (see "Test for the Alar Ligaments" section in Chapter 1 2, p. 347).

Tip: If therapists wish to administer provoking or therapeutic transverse frictions to a ligament, the corresponding structure

must be stabile and should not be allowed to slide away from underneath the finger. The joint is therefore positioned so that the ligament is taut. When patients have only recently overstretched or partially ruptured ligaments, prepositioning

is done with the necessary amount of care, that is, slowly and without aggravating pain. Muscle contraction usually does

not help to make the ligament stabile enough for palpation.

8, 관절낭의 촉진법(Palpating Capsules)

Examples: Test for large effusions in the knee joint, effusions at the elbow joint (Fig. 1.9). Cervical facet joints.

Technique: The palpation is performed at a slow pace with the entire surface of the finger pads palpating directly

over the capsule. The finger pads move repeatedly over the capsule, applying minimal pressure.

- 관절낭을 촉진하기 위해서 손가락은 최소의 압력을 적용시켜 관절낭위로 반복적으로 이동해야

Expectation: A very soft consistency and a fluctuation of synovial fluid inside the swollen capsule is to be expected.

At times, a somewhat softer consistency is to be expected with arthritis in comparison to unaffected capsules.

- 특히 부종이 있는 관절낭은 매우 부드러운 점조도(활액낭의 fluctuation)

Commentary: The joint capsule is palpated to search for lesions in a damaged ligament providing capsular reinforcement and to confirm‎ the presence of capsular swelling.  

- 관절낭은 손상된 인대병변을 찾기 위해 촉진, 부종이 있는 관절낭을 확인하기 위해 촉진

As previously mentioned, a flat, slow technique is used when a soft consistency is to be expected. The palpatory findings, that is, the identification of swelling, must match the results of observation at a local level. Palpation for an increase in temperature is also usually positive. 

- 부종의 확인, 증가된 온도 등은 확인 소견임.

The sacroiliac joints, the lumbar and thoracic facet joints, and the atlanto-occipital joints cannot be directly reached using palpation. It is not customary to palpate for warmth or swelling as there is too much soft tissue overlying these joints. 

The focus is the provocation of pain using palpation to locate the level of the cervical facet joints. The result of this palpation, that is, the discovery of sensitivity to pressure and possible associated swelling, must be accompanied by a functional assessment (end-of-range combined movement).

Tip: The palpation of capsular swelling in the knee joint is performed in three graded steps. Topographical knowledge and good spatial visualization abilities are of great advantage.

9. 점액낭의 촉진법(Palpating Bursae)

Examples: Olecranon bursa, sciatic bursa, trochanteric bursa.

Technique: The palpation is performed at a slow pace with the entire surface of the finger pads palpating directly

over the bursa. The palpatory movements are repeated several times, applying minimal pressure.

- 점액낭의 촉진은 천천히, 손가락 전체를 이용하여, 점액낭 전체를 직접적으로 촉진. 최소의 압력으로

Expectation: Normally, a bursa cannot be perceived as an independent structure as it consists of two capsule-like

layers on top of each other. A bursa that is not inflamed is also not sensitive to pressure. When a bursitis is present, it is expected that the bursa will have a soft consistency and that the fluid in the inflamed bursa fluctuates with the repeated palpation.

- 염증이 없는 점액낭은 압력에 민감하지 않음. 점액낭염이 있을때, 점액낭은 부드러운 점조도를 가지고 ...

Commentary: Irritated bursae at the trunk can only be palpated in the pelvic/hip region and on the spinous processes.

On the extremities this is possible in all prominent bony parts, for example, the olecranon. If the patient indicates local pain, this is a reason for searching for fluctuating fluid in a bursa. This presents when the bursa is compressed during the assessment used for orientation. In the case of a trochanteric bursitis, active resisted abduction and passive adduction of the hip joint are painful.

Tip: The fluctuation of fluid can be felt well when two finger pads are used for the palpation and pressure is alternately

applied using one finger and then the other (Fig. 1.10). Muscular or tendonous structures located superficial to the affected bursa (iliotibial tract over the trochanteric bursa) should not be tensed or stretched during the palpation. The consistency naturally changes when palpating through these tissues. They may lose the softness, and fluctuations can no longer be palpated. In this case, the technique serves only to provoke pain in the suspected bursitis.

10. 신경조직의 촉진법(Palpating Neural structure)

Examples: Median nerve, ulnar nerve, tibial nerve, common peroneal nerve, sciatic nerve, brachial plexus.

Technique: The fingertips palpate at a right-angle to the pathway of the sought neural structure (Fig. 1.11). It is

possible to slide over the nerve if the nerve is placed under tension beforehand. This is similar to plucking a tightened

guitar string. Do not use too little pressure and do not proceed too slowly.

- 기타줄을 튕기듯이 촉진

Expectation: The nerve feels very firm and has an elastic consistency when the nerve has been placed under tension beforehand and direct pressure is applied to the nerve.

Commentary:

• The number of peripheral nerve compressions identified during patient assessment is increasing. These conditions sometimes give the impression that a lesion is present in a muscle or tendon. For example, irritation of the ulnar nerve imitates a "golfer's elbow," while irritation of the radial nerve appears to be an inflammation of the synovial sheath in the first extensor tendon compartment. In addition to further indications, good palpatory differentiation is very useful.

• Peripheral nerves occasionally accompany or cross over tendons and ligaments. Futile and unpleasant irritation

of a peripheral nerve may result from the application of therapeutic transverse friction to the nerve that actually aims to relieve pain in an affected tendon or ligament. For this reason, local palpation is again helpful in gaining clear orientation.

• The compression and tension of neural structures plays a significant role when examining patients with spinal symptoms. The results indicate the type and severity of damage.

Tips:

• In most cases, it is not possible to palpate and locate neural structures without initially placing the neural

structures under tension.

• The important peripheral nerves for the upper and lower limbs are especially thick near the trunk.

• Nerves can tolerate direct pressure and short-term adjustments in their pathway quite well. Extreme caution is

not necessary. The nerves have to be stretched past their physiological boundaries, undergo repeated frictioning,

or experience long-lasting pressure before they show signs of intolerance. Sensitive people report a "pins and needles"

sensation when the preliminary tension on a nerve is uncomfortable.

o Once therapists have experienced the typical "plucking" of a nerve, they will be able to recognize this feeling in

every other nerve. It is not comparable to any other palpatory findings.

o Lines can often be used as an aid to make the location of a neural structure clear (e.g., sciatic nerve at the pelvis).

11. 혈관의 촉진법(Palpating Blood Vessels (Arteries))

Example: Brachial artery, femoral artery, anterior tibial artery (Fig, 1. 12), occipital artery.

Technique: A finger pad is placed flat and with very little pressure over the presumed position of the artery.

Expectation: The different consistencies are not being addressed here and pain is not being provoked as a test. Instead,

the palpation of arteries involves feeling how the artery "knocks" on the finger pad. This can only be achieved when the applied pressure is minimal. The finger pad receptors are unable to discriminate between the pulsation and the consistency of the surrounding tissues when too much pressure is applied. Excessive pressure can also compress small arteries, making it more difficult to feel the pulse.

Commentary: When assessing patients of internal medicine through palpation, knowledge of the position and course of blood vessels is used to eval‎uate the peripheral arterial supply to the arm and leg using palpation. This knowledge is not as important for the physical therapy assessment of the trunk as it is for the assessment of the limbs. Arteries are rarely palpable on the trunk wall. They can only be clearly felt on the posterior side of the head, along the throat, and in the face. 

Nevertheless, compression of neural structures and blood vessels in the trunk should be avoided when applying manual techniques. For this reason, it is important to be able to recognize the palpable blood vessels and their location.

Tip: When palpating arteries of the extremities, the superficial tissue should be as relaxed as possible. Therefore, the

patient is instructed to relax as much as possible. The joint is positioned at an angle that relieves tension in the surrounding soft tissue. The brachial artery on the medial aspect of the upper arm is thus palpated with the elbow slightly flexed. If it is difficult to find the pulse of a blood vessel, the area of contact can be increased by using one or two extra finger pads. Therapists should take their time when palpating as the pulse cannot be felt immediately.

촉진법의 도움(aids)

- 어떤 구조물은 정확하게 위치를 찾아도 촉진하기 어려움. 이런 경우 해부학적인 구조를 이용하여 추정하는 것이 도움.

- 도움이 되는 사례(Examples)

1) The tendon of the sternocleidomastoid guides the palpating finger to the sternoclavicular (SC) joint space.

2)  The tendon of the palmaris longus reveals the position of the median nerve in the forearm.

3)  The scaphoid can be found in the anatomical snuffbox. The snuffbox is formed by two tendons.

4) The distal radioulnar joint space lies immediately beneath the tendon of the extensor digiti minimi.

5)  The tip of the patella is always found at the same level as the joint space of the knee.

6)  The common peroneal nerve is found in the popliteal fossa, running parallel to the biceps femoris, approximately

1 cm away from it.

7)  The 1 2th rib and the T1 2 transverse process are found at the same level as the Tll spinous process (Fig. 1.13).

8)  The sternocleidomastoid muscle can be used to guide the palpation to the mastoid process.

Connecting lines

Supporting Measures for Confirm‎ing a Palpation

Several measures can be used to confirm‎ the location of a structure when the clinician is not sure what structure is

being palpated:

o The successful palpation of a cervical facet joint gap is best confirmed by passively moving one side of the joint.

o The successful palpation of an intervertebral space is best confirmed by passively moving one of the vertebrae

involved (see Fig. 1.15).

o The insertions of a muscle belly into a bone or the edge of a muscle can be palpated by tensing the muscle in

several short repetitions.

o If a therapist feels they are palpating a peripheral nerve, they can position the joints differently in order to place the nerve under tension or to relax it.

o Palpable ligaments (e.g., medial collateral ligament at the knee joint) can be tightened using a wide-range movement to allow the change in consistency to be felt.

These measures are used to change the feel of the tissue, indicating exactly where the structure is to be found. It is, however, the aim of routine palpation to find structures without these aids. Some measures cannot be used on patients,

for example confirm‎ing the location of an intervertebral space if a painful vertebral segment cannot be moved without aggravating symptoms.

Marking Structures

Marking anatomical structures is not imperative and therefore tends to be rarely done on patients. However, marking the position or course of a structure when practicing can be very helpful. Drawing clarifies the location of different anatomical shapes and develops spatial orientation abilities.

A drawing can also ensure that a third person can examine the findings and check whether they are correct. Drawing a structure is a moment of truth. In this book, the structures found during palpation are marked on the skin. Bony borders, edges of muscles and tendons, etc. are illustrated exactly where they have been felt. This helps to visualize where the specific structure can be found.

Marking an anatomical structure on the skin means placing a palpated three-dimensional structure onto an almost two-dimensional surface. Hence a drawing always appears more extensive and wider than the palpated structure actually is. A drawing is more reliable in demonstrating the actual size of a structure when the structure is more superficial.

Starting Positions for Practice (Practice SPs)

Generally it is necessary to practice palpatory techniques on a study partner in appropriate SPs. It is permissable to use SPs that do not always correspond to the clinical situation when practicing. The application of the recommended techniques is described later in this book. Once the techniques can be confidently performed in the practice SPs, the study partner should be placed in more difficult positions that mirror clinical practice and an attempt made to relocate the structure. Fast, confident location of structures in any SP is a sign of experience.

[박건용]

촉진의 목적은 위치 찾고, 평가하고, 그에 따라 치료하는 것. 촉진의 원칙은 항상 만져보고, 알아야 만져서 평가할수 있으며, 정확하게 만져질 때까지 포기하지 않는것. 항상하는 촉진이지만 근육의 층이 여러겹일 때, 건과 근육, 인대가 복잡하게 겹쳐있을 때 등 어려울 때가 많습니다. 정확한 해부학적 지식과 상상력, 손의 민감도가 관건인 듯 합니다. 그래도 가장 중요한 것은 항상 만져보는 것! 촉진을 통해 몸(근골격계뿐만 아니라 내장기까지)을 훤히 들여다 보는 것, 임상 수준이 높아질 때야 가능할 듯 합니다.

[큰목소리]

잘 보고 갑니다. 좋은정보 감사드립니다.

[09정문권]

촉진의 3원칙 : 항상 만져라, 아는만큼 만질수있다, 포기하지말고 만져라.
정확한 촉진과정 : 대상선정, 준비, 가장잘아는구조에서 시작, 정확한 촉진
촉진 테크닉-
피부 : skin lifting, skin rolling
뼈 가장자리, 뼈 융기부
근복 : slow하게, soft
근육가장자리 : 근육이 약간 긴장된 상태에서 촉지
건 : 근육이 약간 긴장된 정도의 점조도
인대 : 아주 단단한 점조도, 표면해부학중요
관절낭 : 최소의 압력으로 반복적으로 관절낭위를 이동
점액낭 : 최소의 압력, 점액낭 전체를 촉진, 천천히 손가락 전체이용
신경조적 : 기타줄 튕기듯
혈관 : 혈관 위치에 최소압력으로, 박동

[유현일10]

촉진은 해도해도 어려운 것 같습니다
좋은 자료 잘 봤습니다!