Shoulder gridle complex의 관절가동 테크닉, 수기 저항 운동, 자가운동, 기능적 운동 - 정리중..

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생체역학을 잘 이해하면서 관절가동 테크닉을 잘 활용하면 

초기통증, 중간통증, 구축이 일어난 관절의 통증을 쉽게 치료하고, 기능부전을 정상화시킬 수 있다.

panic bird...

PERIPHERAL JOINT MOBILIZATION TECHNIQUES

The following are suggested joint distraction and gliding techniques for use by entry-level therapists and those

attempting to gain a foundation in joint mobilization. A variety of adaptations can be made from these techniques. Some adaptations are described in the respective chapters where specific impairments and interventions are discussed (see Chapters 17 through 22). 

- 여기서 소개하는 distraction and 활주 테크닉은 초보자 치료사를 위한 것이고, 이 지식을 바탕으로 다양한 방법들이 만들어 질 수 있음. 

The distraction and glide techniques should be applied with respect to the dosage, frequency, progression, precautions, and procedures as described in the previous sections.

N O T E : Terms such as proximal hand, distal hand, lateral hand, or other descriptive terms indicate that the therapist

should use the hand that is more proximal, distal, or lateral to the patient or the patient’s extremity.

Shoulder Girdle Complex (Fig. 5.13)

N O T E : To gain full elevation of the humerus, the accessory and component motions of clavicular elevation and rotation, scapular rotation, and external rotation of the humerus as well as adequate joint play anteriorly and inferiorly are necessary. The clavicular and scapular techniques are described following the glenohumeral joint techniques. For a review of the mechanics of the shoulder complex, see Chapter 17.

Glenohumeral Joint

The concave glenoid fossa receives the convex humeral head. 

Resting Position

The shoulder is abducted 55, horizontally adducted 30, and rotated so the forearm is in the horizontal plane.

Treatment Plane

The treatment plane is in the glenoid fossa and moves with the scapula.

Stabilization

Fixate the scapula with a belt or have an assistant help. 

1. Glenohumeral Distraction (Fig. 5.14)

Indications

Testing; initial treatment (sustained grade II); pain control (grade I or II oscillations); general mobility (sustained grade III). 

Patient Position

Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Hand Placement

# Use the hand nearer the part being treated (e.g., left hand if treating the patient’s left shoulder) and place it in the

patient’s axilla with your thumb just distal to the joint margin anteriorly and fingers posteriorly.

# Your other hand supports the humerus from the lateral surface.

Mobilizing Force

With the hand in the axilla, move the humerus laterally.

N O T E : The entire arm moves in a translatoric motion away from the plane of the glenoid fossa. Distractions may be performed with the humerus in any position (see Figs. 5.17, 5.19, and 17.20). You must be aware of the amount of scapular rotation and adjust the distraction force against the humerus so it is perpendicular to the plane of the glenoid fossa.

2. Glenohumeral Caudal Glide, Resting Position (Fig. 5.15)

Indications

To increase abduction (sustained grade III); to reposition the humeral head if superiorly positioned. 

Patient Position

Same as for distraction.

Hand Placement

# Place one hand in the patient’s axilla to provide a grade I distraction.

# The web space of your other hand is placed just distal to the acromion process.

Mobilizing Force

With the superiorly placed hand, glide the humerus in an inferior direction.

3. GH Caudal Glide: Alternate

Hand Placement

Same as for distraction (see Fig. 5.14).

Mobilizing Force

The force comes from the hand around the arm, pulling caudally as you shift your body weight inferiorly.

N O T E : This glide is also called long-axis traction.

4. Glenohumeral Caudal Glide Progression (Fig. 5.16)

Indication

To increase abduction.

Patient Position

# Supine or sitting, with the arm abducted to the end of its available range.

# External rotation of the humerus should be added to the end-range position as the arm approaches and goes beyond 90.

Therapist Position and Hand Placement

# With the patient supine, stand facing the patient’s feet and stabilize the patient’s arm against your trunk with the hand farthest from the patient. Slight lateral motion of your trunk provides grade I distraction. With the patient sitting, face the patient and cradle the distal humerus with the hand closest to the patient; this hand provides a grade I distraction.

# Place the web space of your other hand just distal to the acromion process on the proximal humerus.

Mobilizing Force

With the hand on the proximal humerus, glide the humerus in an inferior direction.

5. Glenohumeral Elevation Progression (Fig. 5.17)

Indication

To increase elevation beyond 90 of abduction. 

Patient Position

Supine or sitting, with the arm abducted and externally rotated to the end of its available range.

Therapist Position and Hand Placement

# Hand placement is the same as for caudal glide progression. 

# Adjust your body position so the hand applying the mobilizing force is aligned with the treatment plane.

# With the hand grasping the elbow, apply a grade I distraction force.

Mobilizing Force

# With the hand on the proximal humerus, glide the humerus in a progressively anterior direction against the inferior folds of the capsule in the axilla.

# The direction of force with respect to the patient’s body depends on the amount of upward rotation and protraction of the scapula.

6. Glenohumeral Posterior Glide, Resting Position (Fig. 5.18)

Indications

To increase flexion; to increase internal rotation.

Patient Position

Supine, with the arm in resting position.

Therapist Position and Hand Placement

# Stand with your back to the patient, between the patient’s trunk and arm.

# Support the arm against your trunk, grasping the distal humerus with your lateral hand. This position provides grade I distraction to the joint.

# Place the lateral border of your top hand just distal to the anterior margin of the joint, with your fingers pointing superiorly. This hand gives the mobilizing force.

Mobilizing Force

Glide the humeral head posteriorly by moving the entire arm as you bend your knees.

7. Glenohumeral Posterior Glide Progression (Fig. 5.19)

Indications

To increase posterior gliding when flexion approaches 90; to increase horizontal adduction.

Patient Position

Supine, with the arm flexed to 90 and internally rotated and with the elbow flexed. The arm may also be placed in horizontal adduction.

Hand Placement

# Place padding under the scapula for stabilization.

# Place one hand across the proximal surface of the humerus to apply a grade I distraction.

# Place your other hand over the patient’s elbow.

# A belt placed around your pelvis and the patient’s humerus may be used to apply the distraction force.

Mobilizing Force

Glide the humerus posteriorly by pushing down at the elbow through the long axis of the humerus.

8 Glenohumeral Anterior Glide, Resting Position (Fig. 5.20)

Indications

To increase extension; to increase external rotation.

Patient Position

Prone, with the arm in resting position over the edge of the treatment table, supported on your thigh. Stabilize the acromion with padding. Supine position may also be used.

Therapist Position and Hand Placement

# Stand facing the top of the table with the leg closer to the table in a forward stride position.

# Support the patient’s arm against your thigh with your outside hand; the arm positioned on your thigh provides a grade I distraction.

# Place the ulnar border of your other hand just distal to the posterior angle of the acromion process, with your fingers pointing superiorly; this hand gives the mobilizing force.

Mobilizing Force

Glide the humeral head in an anterior and slightly medial direction. Bend both knees so the entire arm moves anteriorly.

P R E C A U T I O N : Do not lift the arm at the elbow and thereby cause angulation of the humerus: Such angulation could lead to anterior subluxation or dislocation of the humeral head. Do not use this position to progress external rotation. Placing the shoulder in 90 abduction with external rotation and applying an anterior glide may cause anterior subluxation of the

humeral head.

9. Glenohumeral External Rotation Progressions (Fig. 5.21)

Indication

To increase external rotation. 

Techniques

Because of the danger of subluxation when applying an anterior glide with the humerus externally rotated, use a distraction progression or elevation progression to gain range.

# Distraction progression: Begin with the shoulder in resting position; externally rotate the humerus to end range and then apply a grade III distraction perpendicular to the treatment plane in the glenoid fossa.

# Elevation progression (see Fig. 5.17). This technique incorporates end-range external rotation.

 Acromioclavicular Joint: Anterior Glide (Fig. 5.22)

Indication

To increase mobility of the joint.

Stabilization

Fixate the scapula with your more lateral hand around the acromion process.

Patient Position

Sitting or prone.

Hand Placement

# With the patient sitting, stand behind the patient and stabilize the acromion process with the fingers of your lateral

hand.

# The thumb of your other hand pushes downward through the upper trapezius and is placed posteriorly on the clavicle,

just medial to the joint space.

# With the patient prone, stabilize the acromion with a towel roll under the shoulder.

Mobilizing Force

Your thumb pushes the clavicle anteriorly.

Sternoclavicular Joint

The proximal articulating surface of the clavicle is convex superiorly/inferiorly and concave anteriorly/posteriorly.

Patient Position and Stabilization

Supine; the thorax provides stability to the sternum.

1. Sternoclavicular Posterior Glide and Superior Glide (Fig. 5.23)

Indications

Posterior glide to increase retraction; superior glide to increase depression of the clavicle.

Hand Placement

# Place your thumb on the anterior surface of the proximal end of the clavicle.

# Flex your index finger and place the middle phalanx along the caudal surface of the clavicle to support the thumb.

Mobilizing Force

Posterior glide: Push with your thumb in a posterior direction.

Superior glide: Push with your index finger in a superior direction

2. Sternoclavicular Anterior Glide and Caudal (Inferior) Glide (Fig. 5.24)

Indications

Anterior glide to increase protraction; caudal glide to increase elevation of the clavicle.

Hand Placement

Your fingers are placed superiorly and thumb inferiorly around the clavicle.

Mobilizing Force

The fingers and thumb lift the clavicle anteriorly for an anterior glide. 

The fingers press inferiorly for a caudal glide.

Scapulothoracic Mobilization (Fig. 5.25)

The scapulothoracic articulation is not a true joint, but the soft tissue is stretched to obtain normal shoulder girdle mobility.

Scapulothoracic articulation: elevation, depression, protraction, retraction, upward and downward rotations, and winging.

Indications

To increase scapular motions of elevation, depression, protraction, retraction, rotation, upward and downward rotations,

and winging.

Patient Position

If there is considerable restriction in mobility, begin prone and progress to side-lying, with the patient facing you.

Support the weight of the patient’s arm by draping it over your inferior arm and allowing it to hang so the

scapular muscles are relaxed.

Hand Placement

Place your superior hand across the acromion process to control the direction of motion.

With the fingers of your inferior hand, scoop under the medial border and inferior angle of the scapula.

Mobilizing Force

Move the scapula in the desired direction by lifting from the inferior angle or by pushing on the acromion process.

어깨의 수기저항 운동(shoudler manual resistance exercise)

1. 어깨의 굴곡저항운동(Flexion of the Shoulder)

Hand Placement and Procedure

# Apply resistance to the anterior aspect of the distal arm or to the distal portion of the forearm if the elbow is stable and pain-free (Fig. 6.14).

# Stabilization of the scapula and trunk is provided by the treatment table.

2. 어깨의 신전저항운동(Extension of the Shoulder)

Hand Placement and Procedure

Apply resistance to the posterior aspect of the distal arm or the distal portion of the forearm.

Stabilization of the scapula is provided by the table.

Hyperextension of the Shoulder

The patient may be in the supine position, close to the edge of the table, side-lying, or prone so hyperextension can

occur.

Hand Placement and Procedure

# Apply resistance in the same manner as for extension of the shoulder.

# Stabilize the anterior aspect of the shoulder if the patient is supine.

# If the patient is side-lying, adequate stabilization must be given to the trunk and scapula. This can usually be done if the therapist places the patient close to the edge of the table and stabilizes the patient with the lower trunk.

# If the patient is lying prone, manually stabilize the scapula.

3. 어깨의 외전 내전 수기저항운동(Abduction and Adduction of the Shoulder)

Hand Placement and Procedure

# Apply resistance to the distal portion of the arm with the patient’s elbow flexed to 90. To resist abduction (Fig. 6.15), apply resistance to the lateral aspect of the arm. To resist adduction, apply resistance to the medial aspect of the arm.

# Stabilization (although not pictured in Fig. 6.15) is applied to the superior aspect of the shoulder, if necessary, to prevent the patient from initiating abduction by shrugging the shoulder (elevation of the scapula).

P R E C A U T I O N : Allow the glenohumoral joint to externally rotate when resisting abduction above 90 to prevent

impingement.

- 90도 외전을 넘어서 저항을 줄때 충돌증후군을 방지하기 위해서 GH 관절의 외회전을 허용해야 함. 

4. 어깨 Scaption 수기저항운동(Elevation of the Arm in the Plane of the Scapula (“Scaption”)

Hand Placement and Procedure

# Same as previously described for shoulder flexion.

# Apply resistance as the patient elevates the arm in the plane of the scapula (30 to 40 anterior to the frontal plane of the body).53,73,184

5. 어깨의 내회전, 외회전 수기저항운동(Internal and External Rotation of the Shoulder)

Hand Placement and Procedure

# Flex the elbow to 90 and position the shoulder in the plane of the scapula.

# Apply resistance to the distal portion of the forearm during internal rotation and external rotation (Fig. 6.16A).

# Stabilize at the level of the clavicle during internal rotation; the back and scapula are stabilized by the table during external rotation.

6. 어깨의 수평내전, 수평외전 수기저항 운동(Horizontal Abduction and Adduction of the Shoulder)

Hand Placement and Procedure

# Flex the shoulder and elbow to 90 and place the shoulder in neutral rotation.

# Apply resistance to the distal portion of the arm just above the elbow during horizontal adduction and abduction.

# Stabilize the anterior aspect of the shoulder during horizontal adduction. The table stabilizes the scapula and trunk during horizontal abduction.

# To resist horizontal abduction from 0 to 45, the patient must be close to the edge of the table while supine or be placed side-lying or prone.

7. 견갑골의 상승과 하강 저항운동(Elevation and Depression of the Scapula)

Hand Placement and Procedure

# Have the patient assume a supine, side-lying, or sitting position.

# Apply resistance along the superior aspect of the shoulder girdle just above the clavicle during scapular elevation(Fig. 6.17).

8. 견갑골의 전인, 후인 수기저항운동(Protraction and Retraction of the Scapula)

Hand Placement and Procedure

# Apply resistance to the anterior portion of the shoulder at the head of the humerus to resist protraction and to the posterior aspect of the shoulder to resist retraction.

# Resistance may also be applied directly to the scapula if the patient sits or lies on the side, facing the therapist.

# Stabilize the trunk to prevent trunk rotation.

shoulder girdle exercise

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어깨 외전운동

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corner press out exercise

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Combined scapular adduction with shoulder horizontal
abduction and lateral rotation against resistance

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Scapular protraction; pushing against elastic resistance.

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Push-ups with a “plus” to strengthen scapular protraction

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Exercises that emphasize the lower trapezius. (A) Shoulder
girdle depression against manual resistance. (B) Closed-chain shoulder girdle
depression using body weight for resistance. (C) Scapular depression with
upward rotation of the scapula against elastic resistance (this also brings in
the upper and middle trapezius and serratus anterior).

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Strengthening external rotation with (A) the arm at the side
using elastic resistance

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B) prone with the arm at 90 using a free
weight, and (C) sitting with the shoulder in scaption using a free weight.

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Resisted internal rotation of the shoulder using a handheld
weight. To resist external rotation, place the weight in the patient’s
upper hand.

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Military press-up. Beginning with the arm at the side in
external rotation with elbow flexed and forearm supinated (thumb pointing
posteriorward), the weight is lifted overhead.

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Abduction in the plane of the scapula (scaption). This is called
the “full can” exercise because the shoulder is held in external rotation as if
lifting a full can. (A) Front view. (B) Top view. If the shoulder is held in internal
rotation, it is called an “empty can” exercise.

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Elastic resistance to the D2 flexion pattern, emphasizing
shoulder flexion, abduction, and external rotation using elastic resistance

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Advanced closed-chain exercise to resist the upper extremity
using a ProFitter™ to provide an unstable, moving surface.

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Functional exercise incorporating body mechanics.

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Plyometric activities catching and throwing a weighted ball
(A) in a stable supine position, (B) in a standing position, (C) in a diagonal
extension pattern, and (D) in a diagonal flexion pattern.