flexibility, hypomobility, contracture의 정의 및 개념 그리고 해결책 - 대박 자료

[문형철]

모든 탐구에서 가장 중요한 기초가 무엇이냐고 묻는다면

그것은 definition이다.

유연성, hypomobility, 구축의 개념정의

그래야 정확한 해결책이 나온다. 

매뉴얼 스트레칭(수동적 스트레칭), 자가 스트레칭, PNF, Muscle technique, joint mobilizaion, 롤핑 등

1. rom진단법(클릭)

2. 조직장벽(클릭)

panic bird.

가. 유연성 Flexibility

Flexibility is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM.  Muscle length in conjunction with joint integrity and the extensibility of periarticular soft tissues determine flexibility. Flexibility is related to the extensibility of musculotendinous units that cross a joint, based on their ability to relax or deform and yield to a stretch force. The arthrokinematics of the moving joint (the ability of the joint surfaces to roll and slide) as well as the ability of periarticular connective tissues to deform also affect joint ROM and an individual’s overall flexibility.

- 유연성은 단일 관절 또는 연결된 관절이 통증과 제한없이 정상 rom범위를 연속적으로 부드럽게 움직이는 능력을 말함. 

- 관절과 연결된 근육의 길이와 관절주위조직의 신장성이 유연성(flexibilty)을 결정함. 

- 유연성은 관절을 가로지르는 근건단위(musculotendinous units)의 신장성과 연관됨. 

- 관절면의 rol and slide 움직임 뿐만 아니라 관절주위 결합조직의 변형능력이 관절 rom에 영향을 미치고 전체적인 유연성에 영향을 줌. 

Dynamic and Passive Flexibility(동적 유연성과 수동 유연성)

1. Dynamic flexibility. 

This form of flexibility, also referred to as active mobility or active ROM, is the degree to which an active muscle contraction moves a body segment through the available ROM of a joint. It is dependent on the degree to which a joint can be moved by a muscle contraction and the amount of tissue resistance met during the active movement.

- 동적 유연성은 능동적 움직임, ROM과 연관된 개념으로 "능동적 근수축과 조직저항의 정도"의 정도에 의존하여 결정됨. 

2. Passive flexibility. 

This aspect of flexibility, also referred to as passive mobility or passive ROM, is the degree to which a joint can be passively moved through the available ROM and is dependent on the extensibility of muscles and connective tissues that cross and surround a joint. Passive flexibility is a prerequisite for but does not ensure dynamic flexibility.

- 수동적 유연성은 수동적 움직임, ROM과 연관된 개념으로 "근육과 결합조직의 신장성"의 정도에 의존하여 결정함. 

- 수동적 유연성은 필수적이지만 동적유연성에 반드시 필요한 것은 아님. 

나. Hypomobility(저운동성)

Hypomobility refers to decreased mobility or restricted motion. A wide range of pathological processes can restrict movement and impair mobility. There are many factors that may contribute to hypomobility and stiffness of soft tissues, the potential loss of ROM, and the development of contractures. These factors are summarized in Table 4.1.

- 저운동성은 제한된 움직임 또는 감소된 움직임으로 정의됨. 

- 많은 병리적 문제들이 움직임을 제한할 수 있고 움직임 손상을 야기함. 

- 많은 요인들이 연부조직의 강직과 저운동성, ROM줄어듬을 야기할 수 있고, 관절 구축으로 진행할 수 있음. 

저운동성을 야기하는 요인들

1. 장기간의 Immobilization

1) 외부 요인 - 깁스, cast and splints

2)  내부요인 - 통증, 염증, 부종, 근육-건 또는 섬유막 질환, 피부반흔조직, 골극

다. Contracture(구축)

Restricted motion can range from mild muscle shortening to irreversible contractures. Contracture is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM, and it may compromise functional abilities.

- 제한된 움직임은 가벼운 근단축부터 비가역적인 구축까지 야기할 수 있음. 

- 구축은 근육-건 단위와 관절을 둘러싼 연부조직의 적응성 짧아짐(adaptive shortening)으로 정의됨. 

There is no clear delineation of how much limitation of motion from loss of soft tissue extensibility must exist to designate the limitation of motion as a contracture. In one reference, contracture is defined as an almost complete loss of motion, whereas the term shortness is used to denote partial loss of motion. The same resource discourages the use of the term tightness to describe restricted motion due to adaptive shortening orf soft tissue despite its common usage in the clinical and fitness settings to describe mild muscle shortening. However, another resource71 uses the term muscle tightness to denote adaptive shortening of the contractile and non contractile elements of muscle.

- 구축에 대한 정의는 논란이 있음. 

- 구축은 움직임의 거의 완전한 소실로 정의됨. 

Designation of Contractures by Location

Contractures are described by identifying the action of the shortened muscle. If a patient has shortened elbow flexors and cannot fully extend the elbow, he or she is said to have an elbow flexion contracture. When a patient cannot fully abduct the leg because of shortened adductors of the hip, he or she is said to have an adduction contracture of the hip.

- 구축은 짧아진 근육의 활동으로 정의될 수 있음.

- 만약 팔꿈치 굴곡근이 짧아져 신전이 안된다면 "팔꿈치 굴곡구축(elbow flexion contracture)"이라고 말함. 

Contracture Versus Contraction

The terms contracture and contraction (the process of tension developing in a muscle during shortening or lengthening) are not synonymous and should not be used interchangeably.

- 구축 대 수축

- 구축과 수축은 전혀 다른 개념임. 

Types of Contracture

One way to clarify what is meant by the term contracture is to describe contractures by the pathological changes in the different types of soft tissues involved.32

1. 근육기원성 구축(Myostatic Contracture)

In a myostatic (myogenic) contracture, although the musculotendinous unit has adaptively shortened and there is a significant loss of ROM, there is no specific muscle pathology present.32 From a morphological perspective, although there may be a reduction in the number of sarcomere units in series, there is no decrease in individual sarcomere length. Myostatic contractures can be resolved in a relatively short time with stretching exercises.32,49

- 근육기원성 구축은 근건단위가 짧아져 rom제한이 발생한 것임. 하지만 특별한 근육병리는 없음.

- 근육의 형태학적 관찰을 보면... 근절단위의 숫자가 줄어들수 있을지라고, 개별 근절단위 길이 감소는 없음. 

- 근육기원성 구축은 의학적 스트레칭으로 비교적 짧은시간에 구축을 치료할 수 있음. 

2. 가성근육기원성 구축(Pseudomyostatic Contracture)

Impaired mobility and limited ROM may also be the result of hypertonicity (i.e., spasticity or rigidity) associated with a central nervous system lesion such as a cerebral vascular accident, a spinal cord injury, or traumatic brain injury.32,49 Muscle spasm or guarding and pain may also cause a pseudomyostatic contracture. 

- 중추신경질환으로 rom제한과 움직임 손상이 오면 근육 강직이 있을 수 있음. 이 결과로 구축이 일어날 수 있는데 이를 가성근육기원성 구축이라고 함. 

In both situations the involved muscles appear to be in a constant state of contraction, giving rise to excessive resistance to passive stretch. Hence, the term pseudomyostatic contracture or apparent contracture is used. If inhibition procedures to

reduce muscle tension temporarily are applied, full, passive elongation of the apparently shortened muscle is then possible.24

3. 관절기원성 그리고 주위조직기원성 구축(Arthrogenic and Periarticular Contractures)

An arthrogenic contracture is the result of intra-articular pathology. These changes may include adhesions, synovial

proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation.49 A periarticular contracture develops when connective tissues that cross or attach to a joint or the joint capsule lose mobility, thus restricting normal arthrokinematic motion.

- 관절 기원성 구축은 관절내 병리로 야기됨.

- 유착, 활막비후, 관절부종, 관절면의 손상, 골극 형성 등이 있음.

- 관절주위조직 구축은 결합조직이 움직임을 잃어버리면서 정상 arthrokinematic motion이 안되면서 발생함.

4. 섬유성 구축과 비가역적 구축(Fibrotic Contracture and Irreversible Contracture)

Fibrous changes in the connective tissue of muscle and periarticular structures can cause adherence of these tissues and subsequent development of a fibrotic contracture. 

- 근육과 관절주위조직 결합조직의 섬유성 변화는 조직의 유착과 이어지는 섬유성 구축을 야기함.

Although it is possible to stretch a fibrotic contracture and eventually increase ROM, it is often difficult to reestablish optimal tissue length.33 

- 비록 섬유성 구축을 스트레칭을 통해서 rom을 증진시킬 수 있지만, 정상으로 회복시키는 것은 불가능한 경우가 많음. 

Permanent loss of extensibility of soft tissues that cannot be reversed by nonsurgical intervention may occur when normal muscle tissue and organized connective tissue are replaced with a large amount of relatively nonextensible, fibrotic adhesions and scar tissue33 or even heterotopic bone. 

- 연부조직의 영원한 신장성 손실은 비수술적 방법으로는 치료 불가능함. 

These changes can occur after long periods of immobilization of tissues in a shortened position or after tissue trauma and the subsequent inflammatory response. The longer a fibrotic contracture exists or the greater the replacement of normal muscle and connective tissue with nonextensible adhesions and scar tissue or bone, the more difficult it becomes to regain optimal mobility of soft tissues and the more likely it is that the contracture will become irreversible.

해결책은 무엇인가?

"stretching and mobilization"

1. Manual or Mechanical/Passive or Assisted Stretching 

A sustained or intermittent external, end-range stretch force, applied with overpressure and by manual contact or a mechanical device, elongates a shortened muscletendon unit and periarticular connective tissues by moving a restricted joint just past the available ROM. If the patient is as relaxed as possible, it is called passive stretching. If the patient assists in moving the joint through a greater range, it is called assisted stretching.

- 지속적 또는 간헐적 외부의, end range 스트레칭힘이 과도한 압력을 적용하고, 수기적 접촉 또는 기계적 기구에 의해서 짧아진 근-건 단위와 움직임 제한된 관절의 주위조직 결합조직을 늘려 rom을 회복함. 

- 수동적 스트레칭, 보조적 스트레칭 방법 등이 있음. 

2. 자가 스트레칭( Self-Stretching)

Any stretching exercise that is carried out independently by a patient after instruction and supervision by a therapist is referred to as self-stretching. The terms self-stretching and flexibility exercises are often used interchangeably. However, some practitioners prefer to limit the definition of flexibility exercises to ROM exercises that are part of a general conditioning and fitness program carried out by individuals without mobility impairment. 

- 스트레칭 운동법은 

Active stretching is another term sometimes used to denote self-stretching procedures. However, stretching exercises 

that incorporate inhibition or facilitation techniques into stretching maneuvers have also been referred to as active 

stretching.

3. 신경근 촉진과 상호 억제 테크닉(Neuromuscular Facilitation and Inhibition Techniques)

Neuromuscular facilitation and inhibition procedures are purported to relax tension in shortened muscles reflexively

prior to or during muscle elongation. Because the use of inhibition techniques to assist with muscle elongation is associated with an approach to exercise known as proprioceptive neuromuscular facilitation (PNF),134,147 many clinicians and some authors refer to these combined inhibition/muscle lengthening procedures as PNF stretching, 19,71,110 active inhibition,71 active stretching,158 or facilitated stretching.119  Stretching procedures based on principles of PNF are discussed in a later section of this chapter.

4. 근에너지 기법 Muscle Energy Techniques 

Muscle energy techniques are manipulative procedures that have evolved out of osteopathic medicine and are designed to lengthen muscle and fascia and to mobilize joints.22,26,46,109,157 The procedures employ voluntary muscle contractions by the patient in a precisely controlled direction and intensity against a counterforce applied by the practitioner. Because principles of neuromuscular inhibition are incorporated into this approach, another term used to describe these techniques is post isometric relaxation.

5. 관절가동, 수기치료 Joint Mobilization/Manipulation

Joint mobilization/manipulation methods are manual therapy techniques specifically applied to joint structures and are used to stretch capsular restrictions or reposition a sublimed or dislocated joint.82,104 Basic techniques for the extremity joints are described and illustrated in detail in Chapter 5. Mobilization with movement techniques for the extremities are described and illustrated throughout the regional chapters (see Chapters 17 to 22).

6. 연부조직 가동, 수기치료 Soft Tissue Mobilization and Manipulation

Soft tissue mobilization/manipulation techniques are designed to improve muscle extensibility and involve the application of specific and progressive manual forces (e.g., by means of sustained manual pressure or slow, deep stroking) to effect change in the myofascial structures that can bind soft tissues and impair mobility. 

Techniques, including friction massage,71,137 myofascial release,21,65,97,137 acupressure,71,137,146 and trigger point therapy,97,137,146 are designed to improve tissue mobility by mobilizing and manipulating connective tissue that binds soft tissues. Although they are useful adjuncts to manual stretching procedures, specific techniques are not described in this textbook.

7. 신경가동 Neural Tissue Mobilization (Neuromeningeal Mobilization)

After trauma or surgical procedures, adhesions or scar tissue may form around the meninges and nerve roots or at the site of injury at the plexus or peripheral nerves. Tension placed on the adhesions or scar tissue leads to pain or neurological  symptoms. After tests to determine neural tissue mobility are conducted, the neural pathway is mobilized through selective procedures.20,71,104 These maneuvers are described in Chapter 13.

과스트레칭과 과운동성(Overstretching and Hypermobility)

Overstretching is a stretch well beyond the normal length of muscle and ROM of a joint and the surrounding soft

tissues,85 resulting in hypermobility (excessive mobility).

- 과도한 스트레칭은 근육의 정상길이와 관절과 연부조직의 정상가동범위를 넘어선 스트레칭으로 과운동성을 야기함. 

Creating selective hypermobility by over stretching may be necessary for certain healthy individuals with normal strength and stability participating in sports that require extensive flexibility.

- 과도한 스트레칭에 의해서 만들어진 과운동성은 정상근력을 가진 건강한 사람에게 필수일 수 있음. 그리고 과도한 유연성이 필요한 스포츠에서 안정성이 필요할 수 있음. 

Overstretching becomes detrimental and creates joint instability when the supporting structures of a joint and the strength of the muscles around a joint are insufficient and cannot hold a joint in a stable, functional position during activities. Instability of a joint often causes pain and may predispose a person to musculoskeletal injury.

- 과도한 스트레칭은 해롭고, 관절불안정성을 만듬. 

[정기홍]

유연성, 저운동성, 구축. 대략적이나마 개념 정리가 된다. 고마워~!