muscle energy technique의 이론적 기초- Leon Chaitow의 개념

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근육의 생리 - 전도성, 흥분성, 수축성, 탄성

추외근 섬유의 흥분성

추내근 섬유(muscle spinlde)와 GTO의 muscle mechanoreceptor의 기능

이러한 근육의 생리학을 잘 알게 되면 근에너지 기법(PIR, RI)에 의한 근이완은 너무도 당연한 것

그리고 근육의 기능회복과 통증을 줄이기 위해 너무도 중요한 것임을 알게됨.

근육이완 치료 절차

1. 늘리고자 하는 muscle isolated stretch자세

2. 숨을 들이마시고

3. 환자 자신 최대 힘의 10-20%의 힘으로 저항주고 3-7초간 유지

4. PIR 3회 RI 1회

5. 절대로 급격하게 힘을 주면 안됨.

6. 가능하면 제한장벽에서 실시, 근육이 이완되면 다시 새로운 제한장벽에서 실시.

7. RI기법은 이완하고자 하는 근육의 중간범위에서 실시. 

8. Isolytic MET 치료사의 힘이 더 세게 작용하여 치료사가 힘을 쓰는 방향으로 움직이는 MET.

panic bird..

Post-isometric relaxation and reciprocal inhibition: two forms of MET (Box1.2)

A term much used in more recent developments of muscle energy techniques is post isometric relaxation (PIR), especially in relation to the work of Karel Lewit (1999). The term post-isometric relaxation refers to the effect of the subsequent reduction in tone experienced by a muscle, or group of muscles, after brief periods during which an isometric contraction has been performed. The terms proprioceptive neuromuscular facilitation (PNF) and posti-sometric relaxation (PIR) (the latent hypotonic state of a muscle following isometric activity) therefore represent variations on the same theme. A further variation involves the physiological response of the antagonists of a muscle which has been isometrically contracted – reciprocal inhibition (RI).

-  등척후 이완, 상호억제 - 두가지 형태의 근에너지 테크닉

- 등척후 이완은 ...

When a muscle is isometrically contracted, its antagonist will be inhibited, and will demonstrate reduced tone immediately following this. Thus the antagonist of a shortened muscle, or group of muscles, may be isometrically contracted in order to achieve a degree of ease and additional movement potential in the shortened tissues.

Sandra Yale (in DiGiovanna 1991) acknowledges that, apart from the well understood processes of reciprocal inhibition, the precise reasons for the effectiveness of MET remain unclear – although in achieving PIR the effect of a sustained contraction on the Golgi tendon organs seems pivotal, since their response to such a contraction seems to be to set the tendon and the muscle to a new length by inhibiting it (Moritan 1987). Other variations on this same theme include ‘hold–relax’ and ‘contract–relax’ techniques (see Box 1.1).

Lewit & Simons (1984) agree that while reciprocal inhibition is a factor in some forms of therapy  related to postisometric relaxation techniques, it is not a factor in PIR itself, which is a phenomenon resulting from a neurological loop, probably involving the Golgi tendon organs (see Figs 1.1 and 1.2).

근육이완 치료 절차

1. 늘리고자 하는 muscle isolated stretch자세

2. 숨을 들이마시고

3. 환자 자신 최대 힘의 20%의 힘으로 저항주고 7초간 유지

4. PIR 3회 RI 1회

2장. patterns of function and dysfunction 기능패턴과 장애패턴

Why do soft tissues change from their normal elastic, pliable, adequately toned functional status to become short, contracted, fibrosed, weak, lengthened and/or painful?

- 왜 연부조직은 그들의 정상적인 탄성, 휨의 정도, 적절한 긴장도를 가진 기능상태로부터 짧아지고, 수축하고, 섬유화되고, 약화되고, 길어지고 또는 통증이 발생하는 변화가 일어나는가? 

Most musculoskeletal dysfunction can be shown to emerge out of adaptive processes, as the body –or part of it – compensates for what is being demanded of it in its daily activities. As a rule these adaptive demands relate to a combination of processes, repetitive use patterns, postural habits, emotional turmoil, chronic changes (e.g. arthritic) and so on. Onto such evolving patterns sudden blows and strains are all too often superimposed, adding new demands and directions to the adaptive efforts of the body.

- 대부분 근골격계 기능부전은 일상동작수행에서 요구되는 것에 대한 신체가 보상작용을 하기위한 적응과정에서 보여질 수 있음.  과정의 조합, 반복사용 패턴, 자세습관, 감정 혼란, 만성상태(관절염) 등과 연관된 이러한 적응요구의 규칙에 따라서 변화함. 

- 이렇게 발생된 갑작스러운 충격과 긴장패턴들은 서로 겹쳐져 인체가 적응력을 발휘하는데 새로운 요구와 방향을 더해지게 됨. 

Our bodies compensate (often without obvious symptoms) until the adaptive capacities of tissues are exhausted, at which time decompensation begins, and symptoms become apparent: pain, restriction, limitation of range of movement, etc. The processes of decompensation then progress towards chronic dysfunction and possibly disability.

- 우리의 인체는 (때로는 명백한 증상없이) 조직의 적응능력이 다할때까지 보상움직임이 일어남. 탈보상(decompensation)이 일어나면서 명백한 증상인 통증, 제한, 움직임 범위의 제한 등과 같은 것이 발생함. 탈보상과정을 지난 후 만성기능장애로 진행되고 장애(disability)가 나타남. 

지도와 격자(maps and grids)

- 진단의 순서에 대한 설명

1. Postural (structural) eval‎uation grid: including an anteroposterior perspective showing the relative positions of the major landmarks (ankles, knees, pelvis, spinal curves, head) as well as a bilateral comparison of the relative heights of ears, shoulders, scapulae, pelvic crest, hips and knees. This offers a structural framework onto which the soft tissues are attached.

1. 자세(구조적) 평가 격자

- 앞뒤에서 볼때 중요한 랜드마크인 "발목, 무릎, 골반, 척추커브, 머리"의 상대적인위치

- 또한 양측의 상대적인 높이인 " 양쪽귀, 어깨높이, 견갑골 위치, 골반능 위치, 고관절과 무릎의 위치"

2. Motion (functional) restriction grid: in which joints are eval‎uated for their functional ranges, compared side with side, and with established norms. This would include spinal joints.

2. 움직임(기능)제한 격자

- 관절은 그들의 기능적 범위가 양측을 비교하여 평가됨. 척추도 마찬가지..

3. Individual characteristics map: demonstrating restrictions or dysfunctional patterns specific to the patient, possibly including loss of range of movement, or hypermobility and/or inappropriate firing patterns in muscles when activated, and/or neurological signs.

3. 개별적인 특징적인 지도

- 환자에게 특이한 제한패턴 또는 기능부전 패턴을 검사. ROM, 과운동성, 근육이 활성화될때 부적적한 신경발화패턴, 신경학적 신호. 

4. Postural muscle grid: including evidence of relative shortness of the postural muscles of the body. (See later in this chapter for discussion of different ways of catagorising muscles, as stabilisers or mobilisers, or as global or local.)

4. 자세근 격자

- 인체의 자세유지근의 상대적인 짧아짐의 증거 검사. 

5. Muscular weakness grid: including eval‎uation of relative strength/weakness of muscles associated with the patient’s problem.

5. 근육약화 격자

- 환자문제와 연관된 근육의 상대적인 강화/약화의 측정.

6. Fascial patterns (for example those described by Zink & Lawson (1979) and Myers (1998) –see later this chapter). This is associated with what can be termed ‘loose–tight’ (or ease–bind) eval‎uations, involving a general or specific comparison of the freedom of movement of tissues on one side compared with the other (see below).

6. 섬유막 패턴

- Loose-tight(or ease-bind) 검사

7. Local dysfunction maps: including detailed evidence of, for example, the presence of active myofascial trigger points.

7. 국소적 기능 지도

- TrP 검사

8. Breathing function (and dysfunction) grid: in which aspects of breathing function are eval‎uated.

8. 호흡기능, 호흡기능부전 격자

- 호흡기능 검사.

Postural and phasic muscles

The research and writings of prominent workers in physical medicine such as Lewit (1974), Korr (1980), Janda (1978), Basmajian (1978), Liebenson (1996), and others, suggest that muscles which have predominantly stabilising functions will shorten when stressed, while others which have more

active ‘moving’, or phasic functions, will not shorten but will become weak (inhibited). 

The muscles which shorten are said to be those which have a primarily postural rather than phasic (active, moving) role and it is possible to learn to conduct, in a short space of time (10 minutes or so) an assessment sequence in which the majority of these can be identified as being either short or

relatively ‘normal’ (Chaitow 1991a).

Janda (1978) informs us that postural muscles have a tendency to shorten, not only under pathological conditions but also often under normal circumstances. He has noted, using electromyographic instrumentation, that 85% of the walking cycle is spent on one leg or the other, and that this is the most common postural position for man. Those muscles which enable this position to be satisfactorily adopted (one-legged standing) are genetically older; they have different physiological, and probably biochemical, qualities compared with phasic muscles which normally weaken and exhibit signs of inhibition in response to stress or pathology.

Later in this chapter other models in which muscles are grouped or characterised differently will be examined. Before that, orthopaedic surgeon Gordon Waddell’s (1998) opinion is worth recording: 

Different muscles contain varying proportions of slow and fast muscle fibres. Slow fibres maintain posture; they activate more easily, are capable of more sustained contraction, and tend to become shortened and tight. Fast or phasic fibres give dynamic, voluntary movement; they fatigue more rapidly and tend to weakness. Postural and phasic muscles are often antagonistic … Hypertrophy and atrophy occur at the same time in antagonistic muscles, which may lead to changes in resting length, with contracture of the postural muscles and stretching of the phasic muscles.

Postural muscles

Those postural muscles which have been noted as responding to stress by shortening are listed in Box 2.5. The scalenes are a borderline set of muscles – they start life as phasic muscles but can become, through overuse/abuse, more postural in their function (Fig. 2.9A and B).

Can postural muscles and phasic muscles change from one form into the other?

While Lewit and Janda (Lewit 1999) have suggested that postural muscles under stress will shorten, and phasic muscles similarly stressed will weaken, it is now becoming clear that the function of a muscle can modify its structure. This helps to explain some mysteries – for example why the

scalenes are sometimes short, and sometimes weak, and sometimes both, and yet are classified generally as phasic muscles, and sometimes as ‘equivocal’ (maybe postural and maybe phasic).

Lin et al (1994), writing in The Lancet, examined motor muscle physiology in growing children, reviewing current understanding of the postural/phasic muscle interaction: muscles, Lin observed, are considered to be developmentally static, which is surprising considering in vitro information relating to the development and adaptability of muscles derived from mammals. For example Buller (1960) showed that a committed muscle fibre type could be transformed from slow twitch to fast twitch, and vice versa, in cross innervation experiments, confirm‎ing that impulse traffic down the nerve conditions the fibre type.

The implication of this research is that if a group of muscles such as the scalenes are dedicated to movement (which they should be) and not to stabilisation (which they may have to be if ‘postural’ stresses are imposed), they can become postural in type, and so will develop a tendency to shorten

if stressed. This is precisely what seems to happen in people with chronic upper-chest breathing patterns or asthma.

Characteristics of postural and phasic muscles

The characteristics which identify a muscle as belonging to one or other of these two groups, in this particular model, are given in Table 2.1. 

Embedded in the descriptions of these muscle groupings in some of the writing about them is the assumption that postural muscles have a predominance of type I fibres, and phasic muscles type II. All muscles comprise both red (type I) and white (type II), slow and fast, fibres which produce both postural and phasic functions; however, the classification of a muscle into either a ‘postural’ or ‘phasic’ group is made on the basis of their predominant activity, their major functional tendency. Norris (personal communication, 1999) states:

Gastrocnemius is a mobiliser or ‘task muscle’ [see discussion of stabiliser/mobiliser

categorisations later in this chapter], and has a predominance of type II fibres in most

people. However, training may affect the appearance of muscle as a type I or type II.

For example hard fast calf training will selectively recruit the type II fibres and cause

them to hypertrophy. The muscle now acts as if it had more type II fibres (because they

are bigger and more ‘practised’ at recruitment). Although the actual fibre number is

unchanged it appears functionally to the clinician (not using EMG) that it has. The

change can therefore be one of hypokinetics or hyperkinetics.

Put more simply, function modifies structure, and this may be the result of use patterns, as in the

gastrocnemius example, or of positional (postural) adaptation, as in the effect on suboccipital

musculature resulting from chronic ‘chin-poke’ posture related to strernocleidomastoid shortness. 

Rehabilitation implications

Janda suggests that before any attempt is made to strengthen weak muscles, any hypertonicity in

their antagonists should be addressed by appropriate treatment which relaxes (and if appropriate

lengthens) them – for example, by stretching using MET. Relaxation of hypertonic muscles leads to

an automatic restoration of strength to their antagonists, once inhibitory hypertonic effects have

been removed. Should a hypertonic muscle also be weak, it commonly regains strength following

stretch/relaxation (Janda 1978). Commenting on this phenomenon, chiropractic rehabilitation expert

Craig Liebenson (1990b) states:

Once joint movement is free, hypertonic muscles relaxed, and connective tissue

lengthened, a muscle-strengthening and movement coordination program can begin. It

is important not to commence strengthening too soon because tight, overactive muscles

reflexively inhibit their antagonists, thereby altering basic movement patterns. It is

inappropriate to initiate muscle strengthening programs while movement performance

is disturbed, since the patient will achieve strength gains by use of ‘trick’ movements.

(Dr Liebenson discusses these and other treatment and rehabilitation topics more fully in Chapter

5.) 

Global and local muscles

Bergmark (1989) and Richardson et al (1999) have categorised muscles in yet another way. They

describe some muscles as local (‘central’) and others as being global (‘guy rope’). Global muscles

are likened to the ropes supporting a ship’s mast. In this model central muscles are seen as lying

deep or as possessing deep components which attach to the spine. Global muscles are seen as

having the capacity to control the spine’s resistance to bending, as well as being able to influence

spinal alignment, balancing and accommodating to the forces imposed on the spine:

Global muscles: anterior portion of the internal obliques, external obliques, rectus abdominis,

the lateral fibres of the quadratus lumborum and the more lateral portions of the erector

spinae (Bogduk & Twomey 1991).

Local muscles: multifidi, intertrasversarii, interspinales, transversus abdominis, the posterior

portion of the internal oblique, the medial fibres of quadratus lumborum and the more central

portion of the erector spinae.

Richardson et al (1999) describe (discussing low back pain) the essentially practical nature of their

focus on the ‘local’ and ‘global’ characterisation model:

Basically, there are two broad approaches for improving the spinal protection role of the

muscles which can be gleaned from anatomical and biomechanical studies on

lumbopelvic stabilization. The first utilizes the principle of minimizing forces applied

to the lumbar spine during functional activities. The second is to ensure that the deep

local muscle system is operating to stabilize the individual spinal segments.

This model is therefore essentially pragmatic: ‘Lighten the stress load and improve stabilising

function’ would summarise its objectives, and few clinicians would argue with these.

Identification of those muscles under-performing in their stabilisation roles (usually deep rather

than superficial), followed by re-education of the appropriate use of these, plays a major part in the

protocols which emerge from this approach. Little attention is described as being paid to overactive

antagonists which might be inhibiting underactive deep muscles. However, as well as a brief

encouragement to deal with ergonomic factors, these authors do state that: 

Global [i.e. superficial] muscle function can cause potentially harmful effects if there is overactivity

in certain muscles of this system. Methods of treatment aimed at decreasing any unnecessary

activity in these muscles will assist in minimizing harmful forces. Logically this could only be

safely pursued if the protective function of the deep-local muscles was being reestablished at the

same time.

The argument therefore seems to boil down to whether short, tight structures, whatever name they

are given, are treated first, or whether the weak structures (whatever they are named) receive

primary attention, or whether some form of synchronised approach is adopted. Readers will make

their own choices.

Dual role of certain muscles

In the mobiliser/stabiliser model some muscles seem to act as both. Norris (2000) states: 

The quadratus lumborum has been shown to be significant as a stabiliser in lumbar

spine movements (McGill et al 1996) while tightening has also been described (Janda

1983). It seems likely that the muscle may act functionally [differently] in its medial

and lateral portions, with the medial portion being more active as a stabiliser of the

lumbar spine and the lateral more active as a mobiliser. Such sub-division is seen in a

number of other muscles, for example the gluteus medius where the posterior fibres are

more posturally involved (Jull 1994); the internal oblique where the posterior fibres

attaching to the lateral raphe are considered stabilisers (Bergmark 1989); the external

oblique where the lateral fibres work during flexion in parallel with the rectus

abdominis (Kendall et al 1993). 

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근육의 불균형에 대한 탐구와 문제해결은 ... 얀다, 체이토우, 크레이그 리벤슨으로 이어지는구나!!

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김송준 소장님 왈 ... 얀다 선생님이 근육불균형 이론을 잘 끌고오다가 해결책에서 가변저항인 쎄라밴드를 선택했다는 것은 큰오류...

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김송준 소장님 왈 ....크레이그 리벤슨은 근육불균형을 제대로 치료하기 보다는 정렬을 맞추는데 초점을 맞추는 한계를 가짐.