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기본적인 개념이 너무너무너무 중요하다.
barrier concepts in structural diagnosis
ROM검사시 능동적 ROM, 수동적 ROM, 끝느낌 등의 개념을 정확하게 이해할 수 있어야 한다.
비대칭성
ROM의 비정상
조직 질감의 비정상(특히 end feel)
DEFINITIONS
1. Active motion: Movement of an articulation between the physiologic barriers limited to the range produced voluntarily by the patient.
능동적 동작 : 환자 자발적으로 생성하는 범위내에서 관절의 생리학적인 범위내에서의 움직임.
2. Anatomic barrier. The bone contour and/or soft tissues, especially ligaments, which serve as the final limit to motion in an articulation beyond which tissue damage occurs.
해부학적 장벽 : 뼈의 외곽과 연부조직(특히 인대)이 움직임의 한계를 만드는 장벽으로 이 관절움직임의 한계를 넘어서면 조직 손상이 일어남.
3. Barrier. An obstruction; a factor that tends to restrict free movement.
장벽 : 자유로운 움직임을 제한하는 요소, 방해물
4. Elastic barrier. The resistance felt at the end of passive range of motion when the slack has been taken out.
탄성장벽 : 느슨함이 없어질때 수동적 움직임의 끝에서 느껴지는 저항느낌
5. Motion: Movement, act, process, or instance of changing places.
동작 : 움직임, 행위, 과정 또는 변화위치의 순간.
6. Para physiologic space. The sensation of a sudden "give" beyond the elastic barrier of resistance, usually accompanied by a "cracking" sound with a slight amount of movement beyond the usual physiologic limit but within the anatomic barrier.
부생리학적 공간 : 탄성장벽을 넘어서 감자기 주어지는 감각. 해부학적 장벽사이에서...
탄성장벽과 해부학적 장벽사이에 약간의 공간이 있는데, 이를 "paraphysiologic space"라고 함
7. Passive motion: Movement induced in an articulation by the operator. This includes the range of active motion as well as the movement between the physiologic and anatomic barriers permitted by soft-tissue resiliency that the patient cannot do voluntarily.
수동적 동작 : 조작자에 의해서 관절에서 일어나는 움직임. 생리학적 장벽과 해부학적 장벽사이에서 연부조직에 의해서 환자의 능동적 움직임 없이 일어나는 동작
8. Physiologic barrier. The soft-tissue tension accumulation that limits the voluntary motion of an articulation. Further motion toward the anatomic barrier can be induced passively.
생리학적 장벽 ; 연부조직 장벽 축적임. 이는 관절의 자발적 동작을 제한함. 해부학적 장벽까지 수동적으로 관절가동가능함.
9. Restrictive barrier. An impediment or obstacle to movement within the physiologic limits of an articulation that reduces the active motion range.
제한 장벽 : 관절의 능동적 움직임 범위를 생리학적 제한내에서 방해하는 것
panic bird..
Within the diagnostic triad of asymmetry, range of motion abnormality, and tissue texture abnormality, perhaps
the most significant is alteration in the range of joint and tissue movement. Loss of normal motion within the tissues of the musculoskeletal system, or one of its component parts, responds most favorably to appropriate manual medicine therapeutic intervention.
- 근골격계질환의 진단을 할때, 비대칭성, 관절가동범위의 비정상, 조직질감의 비정상임.
- 아마도 가장 중요한것은 관절가동범위와 조직움직임에서의 변화임.
- 근골격계 조직에서 정상움직임 손실은 수기치료와 치료적 운동을 통해서 적절한 회복해야...
To achieve the goal of manual medicine intervention and restore maximal, pain-free movement to a musculoskeletal system in postural balance, we must be able to identify both normal and abnormal movements. In the presence of altered movement of the hypomobility type, an appropriate manual medicine intervention might be the treatment of choice.
- 수기치료의 목적을 달성하고, 통증이 없는 완전한 움직임을 달성하기 위해서 우리는 정상과 비정상 움직임을 정의해야함.
- 관절 저운동성이 있을때, 적절한 수기치료는 선택될수 있음.
We must strive to improve mobility of all of the tissues of the musculoskeletal system, bone, joint, muscle, ligament, fascia, and fluid, with the anticipated outcome of restoring normal physiologic movement and maximum functional physiology as well.
- 우리는 정상움직임을 회복해야 함.
In the musculoskeletal system, there are inherent movements, voluntary movements, and involuntary movements.
- 근골격계 시스템에서 세가지 움직임이 있음.
- 1. inherent movements 2. voluntary movements and 3. involuntary movements.
1. inherent movement 호흡과 연관된 선천적인 움직임
- 흡기시 척추가 서고, 호기시 척추의 커브 증가
- 흡기시 상지 외회전, 호기시 상지 내회전
The inherent movement has been described by some authors as relating to the recurrent coiling and uncoiling of the brain and longitudinal movement of the spinal cord, together with a fluctuation of the cerebral spinal fluid.
Inherent motion is also the movement of the musculoskeletal system in relation to respiration. It has been observed that during inhalation the curves within the vertebral column straighten and with exhalation the curves are increased. With inhalation the extremities rotate externally, and with exhalation, internally.
- 선천적 움직임은 호흡과 관련성이 깊음.
- 흡입시 척주는 반듯이 서고, 호기시 척주의 kyphosis 커브는 증가함.
- 흡기시 사지는 외회전하고, 호기시 내회전 함.
2. 자발적 움직임(voluntary movement)과 비자발적인 움직임
The voluntary movements of the musculoskeletal system are active movements resulting from contraction of muscle from voluntary conscious control. The involuntary movements of the musculoskeletal system are described as passive movements. An external force moving a part of the musculoskeletal system through an arc of motion induces passive movement.
- 자발적 움직임은 자발적 의식적 근수축으로 능동적 움직임임.
- 비자발적 움직임은 수동적 움직임임. 외부에서 힘이 가해지는 수동적 움직임.
3. 관절가동 - 비자발적인 움직임
The joint-play movements described by Mennell are also involuntary movements. They are not a component of the normal active or passive range of movement but are essential for the accomplishment of normal active and passive movement.
- 관절가동은 비자발적 움직임임. 관절가동은 정상적인 능동 또는 수동적 움직임이 아니지만 정상적인 능동, 수동움직임 완성을 위해 필수임.
In structural diagnosis, we speak of normal and abnormal barriers to joint and tissue motion. The examiner must be able to identify and characterize normal and abnormal range of movement and normal and abnormal barrier to movement in order to make an accurate diagnosis.
- 구조적인 진단에서 우리는 관절과 조직움직임의 정상과 비정상 장벽(barriers)이 있음.
- 검사자는 반드시 움직임의 정상, 비정상 특성을 규정해야 함. 그리고 정상과 비정상 장벽을 규정해야 정확한 진단에 도달할 수 있음.
Most joints have motion in multiple planes, but for descriptive purposes we describe barriers to movement within one plane of motion for one joint. The total range of motion (Fig. 3.1) from one extreme to the other is limited by the anatomic integrity of the joint and its supporting ligaments, muscles, and fascia. Exceeding the anatomic barrier causes fracture, dislocation, or violation of tissue such as ligamentous tear.
- 대부분의 관절은 multiple plane 움직임을 가짐. 하지만 우리는 관절의 면움직임내에서 장벽을 묘사함.
- 관절가동성 전체에서 관절의 해부학적 완전성에 의해서 제한되고, 인대 근육 근막이 지지함.
- 해부학적 장벽을 넘어섬은 골절, 탈구 또는 인대손상 등이 발생함.
Somewhere within the total range of movement is found a midline neutral point. Within the total range of motion there is a range of passive movement available that the examiner can extraneously introduce (Fig. 3.2). The limit of this passive range of motion has been described as the elastic barrier. At this point, all tension has been taken within the joint and its surrounding tissues. There is a small amount of potential space between the elastic barrier and the anatomic barrier described by Sandoz as the paraphysiologic space. It is within this area that the high-velocity, low-amplitude thrust appears to generate the popping sound that results from the maneuver.
- 전체 관절가동중 어딘가는 중간 중립지점(midline neutral point)이 발견됨.
- 전체 관절가동내에서 수동적인 움직임 범위가 있는데, 검사자가 만날 수 있는 지점이 있음. 수동적 움직임 범위의 한계는 탄성 장벽으로 묘사함.
- 이 지점에서 모든 장력은 관절과 주위조직내에 부하됨.
- 탄성장벽과 해부학적 장벽사이에 약간의 공간이 있는데, 이를 "paraphysiologic space"라고 함.
- paraphysiologic space에서 높은 속도, 낮은 진폭(high velocity, low amplitude) 쓰러스트로 popping소리를 낼 수 있음.
The range of active movement (Fig. 3.3) is somewhat less than that available with passive movement, and the end point of the range is called the "physiologic barrier."
- 능동적 움직임 범위는 수동적 범위보다 좁음.
- 능동적 움직임으로 움직일 수 있는 범위를 "physiologic barrier(물리적 장벽)"이라고 함.
The normal end feel is due to resilience and tension within the muscle and fascial elements. Frequently there is reduction in available active motion due primarily to myofascial shortening (Fig. 3.4). This is often seen with aging but it can occur at all ages. It is the stretching of this myofascial shortening that all individuals, particularly athletes, should do as part of physical exercise. Stretching exercise to the muscles and fascia enhances the active motion range available and the efficiency of myofascial function. When motion is lost within the range it can be described as major (Fig. 3.5) or minimal (Fig. 3.6).
- 정상적인 끝느낌은 근육과 근막요소내에서 탄성과 장력때문에 발생함.
- 근막 짧아짐(myofascial shortening)에 의한 능동적 움직임의 감소가 흔하게 있음.
- 이는 흔히 나이와 함께 관찰되지만 모든 나이에서 다 발생할 수 있음.
- 특히 운동선수의 경우 근막 짧아짐의 스트레칭은 physical exercise의 일부로 반드시 시행되어야 함.
- 근육과 근막에 대한 스트레칭 운동은 능동적 움직임 범위를 증가시킴.
- 움직임 장애가 발생할때 major loss or minimal loss로 묘사할 수 있음.
The barrier that prevents movement in the direction of motion loss is defined as the restrictive barrier. The amount of active motion available is limited on one side by the normal physiologic barrier and on the opposite side by the restrictive barrier.
- 움직임을 방해하는 장벽은 제한 장벽(restrictive barrier)이라고 함.
- 능동적 움직임의 양은 한쪽은 생리적 장벽에 의해서, 반대쪽은 제한 장벽에 의해서 제한될 수 있음.
The goal of a manual medicine intervention is to move the restrictive barrier as far into the direction of motion loss as possible. Another clinically describable phenomenon associated with motion loss is the shifting of the neutral point from midline to the middle of the available active range. This is described as the "pathologic" neutral and is usually, but not always, in the midrange of active motion available.
- 수기치료의 목표는 움직임 손실이 일어난 방향으로 가능하면 제한장벽을 움직이게 하는 것임.
Each of the barriers described have palpable findings that can be described as either normal or abnormal end feel. Within a normal range of passive movement, the elastic barrier will have a normal sensation at the end point as a result of the passively induced tension within the joint and its surrounding structures. At the end of the range of active movement, the
physiologic barrier likewise has a characteristic feel that results from the voluntary increase in resistance due to the apposition of the joints and the myofascial tension developed during voluntary muscular activity.
- 각각의 장벽은 정상이거나 비정상 끝느낌으로 묘사할 수 있음.
- 수동적 움직임의 정상범위내에서 탄성장벽은 움직임의 끝에서 정상감각을 가질 수 있음.
- 능동적인 움직임의 끝에서 생리적 장벽은...
Let us return to the layer palpation exercise (see Chapter 2) and begin at the point where one examiner was evaluating the joint space at the proximal radiohumeral joint (Fig. 3. 7). While palpating this joint with the thumb placed anteriorly and the index finger placed posteriorly, have the subject actively introduce pronation and supination (Fig. 3.8).
- 이제 촉진운동 층으로 가보자. ...
You will note that the range is not symmetric in pronation and supination and that the end feel is not the same at the terminal range of pronation and supination. Which range is greater? Which end feel seems tighter? Now grasp the subject's hand and wrist and passively introduce pronation and supination while monitoring at the proximal radiohumeral joint (Fig. 3.9). Note that you are now receiving proprioceptive impulse from your palpating hand at the radiohumeral joint, as well as from your hand as it passively introduces, through the subject's hand and wrist, the pronation and supination effort (Fig. 3.10).
Again, look for total range of movement, the quality of movement during the range, and the end feel. In supination and pronation, which has the greatest range? Which has the tighter or looser end feel? How does this compare with the active movement? Now let us take it one step further. While passively introducing pronation and supination you should notice that tension increases the closer you get to the end points of the range. As you move in the opposite direction, it appears to be easier or freer. See if you can, by decreasing increments of pronation and supination, find the point between the two extremes of movement wherein the joint feel is the freest. Even though pronation and supination are not a symmetric range of movement at this joint, it is possible to find a point within the range that is the freest and could be described as the physiologic neutral point.
We now have another concept of joint motion, the concept of "ease" and "bind" (Fig. 3.11). The more one moves in the direction of the neutral point, whether a midline neutral point in a normal range of motion or a "pathologic" neutral point somewhere within the range of altered motion, it becomes more free, or there is more "ease." Conversely, as one moves away from the neutral "free" point, one begins to sense a certain 'amount of "bind," or increase in resistance to the induced movement. Understanding this concept of ease and bind, and the ability to sense this phenomenon, is essential to mastering the functional (indirect) techniques (see Chapter 10).
In the elbow exercise that you just accomplished, the hand palpating over the proximal radiohumeral joint was the
"sensing hand," and your other hand that introduced passive supination and pronation at the subject's hand
was the "motor hand."
RESTRICTIVE BARRIERS
The restrictive barriers limit movement within the normal range of motion and have placatory characteristics different from the normal physiologic, elastic, and anatomic barriers. The restrictive barrier can be within the following tissues:
Skin
Fascia
Muscle, long and short
Ligament
Joint capsule and surfaces
Restrictive barriers can be found within one or more of these tissues and the number and type contribute to the palpable characteristics at the restrictive barrier. Different pathologic changes within these tissues can give quite different end feel sensations. For example, congestion and edema within the tissues will give a diffuse, boggy sensation quite like a sponge filled with water.
Chronic fibrosis within these tissues will give a harder, more unyielding, rapidly ascending end feel when compared to the more boggy, edematous sensation. A restrictive barrier due to altered muscle physiology, whether it be spasm, hypertonus, or contracture, will give a more jerky and tightening type of end feel than one due to edema or fibrosis. Do not forget that pain can be a restrictive barrier as well. If a movement is painful, it will result in restriction as the body attempts
to compensate for relief of pain by reduction of movement.
When examining ranges of movement, and particularly when looking for normal and abnormal barriers to movement, one should constantly keep in mind the potential for hypermobility. The classic feel of a hyper mobile range of motion is one of looseness for a greater extent of the range than would be anticipated, and with a rapidly escalating, hard end feel when one
approaches the elastic and anatomic barriers.
Restrictive barriers may be long or short. They may involve a single joint or spinal segment, or cross over more than one joint or series of spinal segments. It is important to identify the tissue or tissues involved in the restrictive barrier, their extent, and the functional pathology found within the tissues. Some types of manual medicine intervention are more appropriate for certain restrictive barriers than others.
In structural diagnosis, alteration of range of movement is an essential criterion for a diagnosis of somatic dysfunction. It is necessary to evaluate the total range of movement, the quality of movement available during the range, and the feel at the end point of movement in order to make an accurate diagnosis of the restrictive barrier. Therapeutic intervention by manipulative means can be described as an approach to these pathologic barriers. Multiple methods are available and different activating forces can be used toward the goal of restoring maximal physiologic movement available within the anatomy of the joint(s) and tissue (s).
DEFINITIONS
1. Active motion: Movement of an articulation between the physiologic barriers limited to the range produced voluntarily by the patient.
2. Anatomic barrier. The bone contour and/or soft tissues, especially ligaments, which serve as the final limit to motion in an articulation beyond which tissue damage occurs.
3. Barrier. An obstruction; a factor that tends to restrict free movement.
4. Elastic barrier. The resistance felt at the end of passive range of motion when the slack has been taken out.
5. Motion: Movement, act, process, or instance of changing places.
6. Para physiologic space. The sensation of a sudden "give" beyond the elastic barrier of resistance, usually accompanied by a "cracking" sound with a slight amount of movement beyond the usual physiologic limit but within the anatomic barrier.
7. Passive motion: Movement induced in an articulation by the operator. This includes the range of active motion as well as the movement between the physiologic and anatomic barriers permitted by soft-tissue resiliency that the patient cannot do voluntarily.
8. Physiologic barrier. The soft-tissue tension accumulation that limits the voluntary motion of an articulation. Further motion toward the anatomic barrier can be induced passively.
9. Restrictive barrier. An impediment or obstacle to movement within the physiologic limits of an articulation that reduces the active motion range.
첫댓글 감사합니다.
읽기 ROM장벽