10. Evaluation of Muscular Imbalance - 아주 기대되는 챕터

[문형철]

먼저 근육불균형에 대한 블라드미르 얀다 선생님의 탐구(클릭)을 읽고

아래 자료를 보자

panic bird....

Eval‎uation of Muscular Imbalance(근육불균형 검사법)

단단해지고 짧아져 스트레칭이 우선적으로 필요한 근육

1. 비복근/가자미근

2. 고관절 굴곡근(대퇴직근, 장요근, 대퇴근막장근)

3. 대퇴내전근

4. 햄스트링

5. 척추기립근

6. 요방형근

7. 이상근

8. 상부승모근/견갑거근

9. 대소흉근

10. 흉쇄유돌근

11. 경추신전근

12. 상지굴곡근

억제되고 약해져 근육활성, 근력강화가 우선적으로 필요한 근육

1. 전경골근

2. 내외측광근

3. 대둔근, 중둔근, 소둔근

4. 복부근육

5. 중,하부 승모근

6. 전거근

7. 심부경추굴곡근

8. 사각근

9. 상지 신전근

Upper crossed syndrome

Lower crossed syndrome

Layer (stratification) syndrome

Eval‎uation Of Tight Muscles - 항상 짧아지고 단단해지는 근육의 검사법

Eval‎uation Of Inhibited Muscles - 억제되고 약화되는 근육

Figure 10.4 Upper trapezius(상부 승모근)

Figure 10.5 Levator scapulae(견갑거근)

Figure 10.6 Pectoralis major(대흉근)

Figure 10.7 Screening test - sternocleidomastoid tightness(흉쇄유돌근)

Figure 10.8 Iliopsoas(장요근)

Figure 10.9 Rectus femoris(대퇴직근)

Figure 10.10 lensor fascia lata lightness(대퇴근막장근)

Figure 10. 1 1 Screening test for the short hip adductors(대퇴내전근)

Figure 10.12 Hamstrings(햄스트링)

Figure 10.13 Thigh adductors(대퇴내전근 단축검사)

Figure 10.14 Screening test for piriformis tightness(이상근단축검사)

Figure 10.15 Screening test for quadratus lumborum tightness(요방형근 단축검사)

Figure 10.16 Screening test for erector spinae tightness(척추기립근 단축검사)

Figure 10.17 Gastrocnemius(비복근)

Figure 10.18 Soleus(가자미근)

Figure 10.19 Hip extension 대둔근 (고관절 신전근) 

Figure 10.20 Hip abduction 중둔근과 소둔근 (고관절 외전근)

Figure 10.21 Trunk curl-up.

Figure 10.22 Push-up - 전거근 기능검사

Figure 10.23 Head flexion

Analysis Of Muscular Imbalance in Standing

Figure 10.24 Shoulder abduction(어깨 외전근 검사)

Figure 10.26 Right thoracolumbar erector spinae hypertrophy.

Figure 10.25 Soleus lightness on the right(가자미근 단축)

Figure 10.27 Abduction and winging of the right scapula(우측견갑골의 winging)

Figure 10.28 Tightness of the levator scapulae

Figure 10.29 Oblique abdominal dominance

Figure 10.30 One-leg standing test - 트렌델버그 검사(중둔근 약화검사)

Gait Assessment

Hypermobility

Figure 10.31 High arm cross

Extension of the elbows

Figure 10.35 The forward bending test

Dysfunction in any component of these systems is ultimately reflected in the muscular system in the form of altered muscle tone, muscle contraction, muscle balance, coordination, and performance. Therefore, a strictly localized lesion does not exist. Muscle imbalance is a systemic change in the quality of muscle dysfunction that results in altered joint mechanics leading to pain, dysfunction, and eventually degeneration. Muscle imbalance is the altered relationship and balance between muscles that are prone to inhibition or weakness and those that prone to tightness or shortness. 

- 이러한 시스템의 어떤 기능부전은 궁극적으로 근육 시스템에 변화를 초래하여 muscle tone, 근육수축, 근육균형, 협응성, 수행능력의 변형을 초래함. 그래서 엄밀하게 국소화된 병변은 존재하지 않음. 근육불균형은 시스템적인 변화이고, 근육기능부전에 의한 변화는 관절mechanics에 변형을 초래하여 통증, 기능부전, 결국은 퇴행성 변화를 초래함. 근육불균형은 억제되거나 약화되기 쉬운 근육과 단단해지고 짧아지기 쉬운 근육사이의 관계와 균형이 변화하는 것임. 

Moderately tight muscles are usually stronger than normal. However, in the presence of pronounced tightness, some decrease of muscle strength occurs. This weakness is called "tightness weakness" (1) to express the closed association between muscle weakness and altered viscoelasticity of the muscle. Therefore, when diagnosing muscle weakness, careful differential diagnoses have to be made. 

- 적당하게 짧아진 근육은 일반적으로 정상보다 강함. 하지만 확연한  tightness는, 근력 감소가 발생함. 이러한 약화를 tightness weakness라고 함. 근육 약화와 변형된 점탄성의 표현... 그래서 근육약화로 진단될때, 주의깊은 감별진단이 되어야 함. 

The treatment of tightness weakness is not in strengthening, which would increase tightness and possibly result in a more pronounced weakness, but in stretching, oriented toward influencing the viscoelastic property of the muscle, i.e., the noncontractile but retractile connective tissue. Stretching of tight muscles also results in improved strength of inhibited antagonistic muscles, probably mediated via Sherrington's law of reciprocal innervation.

- 긴장성 약화의 치료는 근력강화로 치료하면 안된다. 긴장성 약화로 발생한 근육힘의 약함은 근력을 강화하려는 엑서사이즈를 시행하면 더 약해짐. 스트레칭을 하면 근육구조와 결합조직의 점탄성에 영향을 주고 근수축이 잘 이루어지면서 힘이 강해짐. 긴장된 근육의 스트레칭은 또한 상호억제 법칙( Sherrington's law)에 의해 사용이 제한된 길항근의 근력에 긍적적 영향을 줌.

The etiology and terminology of muscle tone is full of controversies, partly because various authors' definitions of muscle tone differ. Therefore, a detailed differential diagnosis has to be made among others because each condition requires a different type of treatment (2). Unfortunately, a precise and adequate analysis is often neglected. An imprecise diagnosis results in disappointing therapeutic results. Unfortunately, the detailed physiology of muscle tone is unknown and studies of muscle tone changes caused by altered or impaired function have not been studied sufficiently in the laboratory or in the clinic.

- 근육 tone의 원인과 용어학은 논란이 있음. muscle tone의 개념에 대한 다양한 정의는 다름. 그래서 감별진단은 반드시 되어야 함.  불행하게도 정확하고 적절한 분석은 때로 무시됨. 정확한 진단은 

In principle it is necessary to differentiate whether the main changes occur in the connective tissue of the muscle (viscoelastic properties) or in over-activation of the contractile components of the muscle (contractile properties). According to Mense and Simons, "Muscle tension depends physiologically on 2 factors: the basic viscoelastic properties of the soft tissues associated with the muscle, and/or the degree of activation the contractile apparatus of the muscle" (9). In the former, we speak about muscle tightness, stiffness, loss of flexibility, or extensibility (length), and

in the latter, it is a real increase of muscle contractile activity such as in spasmodic torticollis or trismus.

In principle, with respect to viscoelastic changes, the muscle gets shorter at rest (decreased extensibility), either because of shortening of contractile muscle fi bers or because of retraction of the connective tissue within the muscle and the adjacent fascia. With respect to contractile changes, the increased muscle tone may involve the majority of muscle fibers of the muscles or only a limited number as found as "taut bands" in trigger points.

Clinically, resting muscle tone presents a combination of both situations (contractile and viscoelastic properties), and it is the role of the clinician to establish an appropriate diagnosis (9). However, measuring muscle tone objectively presents a dilemma. 

Tests of viscoelasticity involve measurements of the velocity of motion, viscosity, thixotropy, and resonant frequency when load is gradually applied (9). Tests of contractile activity are simpler in that EMG can be used; however, this is not without inherent difficulties, as in trigger points where only small loci in the muscle show increased electrical activity (9).

A detailed differential diagnosis of muscle tone is necessary for the proper treatment approach, and this can be accomplished by a combination of inspection and palpation (Table 10.1). Layer palpation of the skin, subcutaneous tissue, fascia, fat, and any other structure in the area concerned, although purely subjective is a practical clinical tool and with much practice and experience, detecting the type of muscle tone present in the concerned area can be skillfully achieved. Inspection of posture, movement patterns, and gait  also yields invaluable clinical information about the

underlying source of increased muscle tension.

Muscle imbalance should be considered a systemic reaction of the striated muscles. It is therefore a general reaction of the whole muscle system and not just an isolated response of an individual muscle (4). This view is strongly supported by the recent findings of neurodevelopmental kinesiology, which show developmental movement patterns corresponding to the muscle imbalance found in children when their motor system is fully myelinized (at the age of 6 to 7 years) or in adults (7,8,12). 

The basis from a neurodevelopmental viewpoint is that neonatal and early infant posture is maintained by a "tonic" muscle system. Subsequent neurodevelopment of the upright posture occurs with the co-activation of a "phasic" muscle system with the "tonic" muscle system. Failure of this co-activation between the tonic and phasic muscle system results in a muscle imbalance and is clearly evident in children with cerebral palsy in which the "tonic" muscle system prevails. In addition, the typical muscle responses seen in chronic low back patients are observed to be identical or very similar to

those that are seen in some structural lesions of the central nervous system. 

For example, in spasticity seen in a cerebrovascular accident or cerebral palsy, muscles that develop spasticity or even spastic contractures are those that commonly respond by tightness in musculoskeletal conditions. It is proposed that these typical muscle responses observed in the typical hemiplegic posture may be an extreme expression‎ of the imbalance between the muscular chains that exist to some extent under normal physiologic conditions. Thus, the tendency for some muscles to develop weakness or tightness does not occur randomly but rather in typical "muscle imbalance patterns"(3). 

Furthermore, the development of these patterns can be predicted clinically and preventative measures should be taken because muscle imbalance does not remain limited to a certain part of the body, but gradually involves the whole striated muscular system(6). A thorough eval‎uation is necessary to introduce preventive measures because muscle imbalance

usually precedes the appearance of pain syndromes. 

Muscle imbalance develops mainly between predominantly "tonic" muscles, that is, muscles that are prone to develop tightness and predominantly "phasic" muscles, that is, muscles that are prone to develop inhibition (Table 10.2). Muscle imbalance involves muscles of the whole body; however, if the imbalance is more evident or starts to develop gradually and predictably in the pelvic region, we speak about the pelvic or distal crossed syndrome, and i fit is more evident or starts in the shoulder girdle/neck region, we term it as a proximal or shoulder girdle crossed syndrome (5).

The proximal ( upper, shoulder-neck) crossed syndrome is characterized by the development of tightness in the upper trapezius, levator scapulae, and pectoralis major, and inhibition in the deep neck flexors and lower stabilizers of the scapula. Topographically, when the inhibited and tight muscles are connected, they form a cross (Fig. 10.1). This pattern of muscle imbalance produces typical changes in posture and motion. In standing, elevation and protraction of the shoulders are evident, as are also rotation and abduction of the scapula, a variable degree of winging, and a push-forward head position. This altered posture is likely to s tress the cervicocranial and the cervicothoracic junctions. In addition, the stability of the shoulder blades is decreased, because of the altered angle of the glenoid fossa, and, as a consequence, all movement patterns of the upper extremity are altered.

The distal (lower, hip-pelvic) crossed syndrome is characterized by tightness of the hip flexors and spinal erectors and inhibition and weakness of the gluteal and abdominal muscles. As in the upper crossed syndrome, a line connecting the tight and inhibited muscles

forms a cross (Fig. 10.2). This imbalance results in an anterior tilt of the pelvis, increased flexion of the hips, and a compensatory hyperlordosis in the lumbar spine. This imbalance tends to over-stress both hip joints as well as the lower back. 

 A combination of these two syndromes is expressed in a layer (stratification) syndrome (Fig. 10.3). When a layer syndrome is observed in a patient, it is a sign of a poorer prognosis in terms of rehabilitation because of the fixed muscle imbalance patterns at the central nervous system level. Examination of joints must precede muscle eval‎uation of muscles to exclude any anatomical batTier. In clinical practice, it is advisable to begin muscle eval‎uation by analyzing erect standing posture and gait. This analysis requires experience and keen observational skill. 

In addition, it serves as a screening tool by providing quick and reliable information to direct the clinician the necessary tests that need to be perrormed in detail and those that can be omitted. The c1i nician is given an overall view of the patient's muscle function through posture and gait analysis and is challenged to look comprehensively at the patient's entire motor system and not to limit attention to

the local level of the lesion. Eval‎uation of muscle imbalance in a patient with an acute pain syndrome, however, is unreliable and must be undertaken with precaution. A precise eval‎uation of tight muscles and movement patterns can be performed only if the patient is pain-free or almost pain-free. Its usefulness is greatest in the chronic phase or in patients with recurrent pain after the acute episode has subsided. 

[heoss]

유익한 자료 감사합니다.^^

[이영진]

정말 재밌는내용 ㅎㅎㅎ 감사 또 감사 ㅎㅎㅎ

[혀기]

감사 감사 합니다. 좋은 자료 정말 감사합니다.

[그거]

잘 보고 갑니다!

[문형철]

단단해지고 짧아져 스트레칭이 우선적으로 필요한 근육
1. 비복근/가자미근
2. 고관절 굴곡근(대퇴직근, 장요근, 대퇴근막장근)
3. 대퇴내전근
4. 햄스트링
5. 척추기립근
6. 요방형근
7. 이상근
8. 상부승모근/견갑거근
9. 대소흉근
10. 흉쇄유돌근
11. 경추신전근
12. 상지굴곡근

억제되고 약해져 근육활성, 근력강화가 우선적으로 필요한 근육
1. 전경골근
2. 내외측광근
3. 대둔근, 중둔근, 소둔근
4. 복부근육
5. 중,하부 승모근
6. 전거근
7. 심부경추굴곡근
8. 사각근
9. 상지 신전근

[문형철]

Moderately tight muscles are usually stronger than normal. However, in the presence of pronounced tightness, some decrease of muscle strength occurs. This weakness is called "tightness weakness" (1) to express the closed association between muscle weakness and altered viscoelasticity of the muscle. Therefore, when diagnosing muscle weakness, careful differential diagnoses have to be made.

- 적당하게 짧아진 근육은 일반적으로 정상보다 강함. 하지만 확연한 tightness는, 근력 감소가 발생함. 이러한 약화를 tightness weakness라고 함. 근육 약화와 변형된 점탄성의 표현... 그래서 근육약화로 진단될때, 주

[이상진]

치료의 시작도 근육
치료의 마지막도 근육이라는 생각이 드네요^^
자료 감사드립니다~ㅋ

[약천]

그림10-4와 그림 10-5 서로 바뀜. 10-5는 상부승모근, 10-4는 견갑거근

[최윤경]

감사합니다 ^^