Lower-Crossed Syndrome 총론은 여기에 뒤 운동법은 파일로.(마침)

[아르구스]

한꺼번에 쓰기 그래서 내일 완성 예정...운동은 논문 직접 보면 이해가 그냥 됩니다. 그림도 있으니깐요...

-이성용-

Lower-Crossed Syndrome
What is it?

Lower-crossed syndrome is a postural distortion syndrome affecting the lower
kinetic chain (lumbopelvic hip complex, knee, and ankle). The lower kinetic chain is one
of two basic parts of the musculoskeletal system that are controlled and innervated
through the CNS.

하지교차증후군은 하지 운동 사슬 (lumbopelvic hip complex, knee, and ankle)에 영향을 미치는 postural distortion syndrome이다. 이 하지 운동 사슬은 근골격계의 기본적인 두개의 파트중 하나로 중추신경계에 의해contorl, innervate 된다.

The muscles can often serve as “windows” to the function of the CNS.
The CNS regulates 2 muscle groups: The tonic muscle group and the phasic muscle
group. These muscle groups oppose each other in function. The tonic muscle group
functions as a facilitator, the phasic muscle groups inhibition. Pain, pathology or adaptive
changes in the system result in compensations or adaptations that lead to systemic and
predictable patterns of muscle imbalance. This results in chronic pain and disability.

근육은 종종 중추신경계 기능의 창으로 간주될수있다. 중추시경계가 조절하는 근육은 2그룹으로 나눠져있다. 하나는 tonic 근육 그룹으로 촉진으로서 작용하고 하나는 phase 근육 그룹으로 억제 하는 근육 그룹이다. 이 두 근육은 기능에 있어 각각 대립된다. 시스템내에서 통증, 병리학적 혹은 적응으로 인한 변화들이 있으면 보상(compensation)이나 적응(adaptation)이 야기되고. 이러한 보상과 적응은 시스템적으로 그리고 예상할수 있는 패턴의 근육의 불균형패턴이다. 이러한 것이 만성통증과 disablility를 야기한다.

 In lower-Crossed syndrome the pattern of muscle imbalances often leads to changes in
movement patterns with hip extension, hip abduction and trunk flexion. “Altered
movement pattern” is a movement pattern in which a change occurs in the coordination
of the muscle firing sequences for a specific group of muscles, facilitating a specific joint
movement.

근육불균패턴으로 하지교차 증후구은 종종 움직임의 패턴에 있어 변화를 야기하며  이것은 hip extension, hip abduction and trunk flexion에 발생한다.  “Altered movement pattern”은 특정 근육 그룹의 근육 발화 과정, 특정 관절의 움직임에 촉진등의 협응에 변화된 패턴이다.

 The primary muscle responsible for specific joint movement may become
weak and inhibited, causing a synergistic muscle/muscles to become hyperactive. As a
result, a different sequence of muscular contractions occurs. This is a sign of muscle
imbalance in the body because of muscular dysfunction.
 특정 관절의 움직에 반응하는 primary muscle이 약화되거나 저해되고, 이로인해  synergistic muscle/muscles 이 hyperactive하게 된다. 이로 인해 근육학적 수축의 과정에 변화가 일어난다. 이것은 근육의 불균형의 sign이고, 근육학적 dysfunction이다.

Because the structural integrity of the lower kinetic chain is compromised in
lower cross syndrome, abnormal distorting forces result on all structures within the
kinetic chain. When any component of the kinetic chain is not working properly (tight or
long muscles, reciprocally-inhibited muscles, adhesions, joint dysfunction),
neuromuscular control is altered. This alteration may be observed with the patient sitting,
standing, or walking.
 하지 운동사슬의 구조적인 완전성이 하지교차증후군이 좋지 않은 영향을 주기때문에 운동사슬내에 모든 구조물에 대한

비정상적인 전단력을 주는 결과를 낳는다. 어떤 운동상의 부분이 적절하게 일하지 않으면 ( tight or
long muscles, reciprocally-inhibited muscles, adhesions, joint dysfunction), 신경근육적 조절이 대체된다.

이러한 대체된 운동은 환자가 앉거나 서거나 걸을때 관찰된다.

In lower-crossed syndrome the patient usually presents with anterior pelvic tilt,
increased lumbar lordosis (swayback), and weak abdominals muscles. These patients
usually experience chronic low back pain, piriformis syndrome and anterior knee pain.
The predictable pattern of muscle imbalances most often include the following:
하지교차증후군환자는 보통 골반전방경사. 증가된 전만 혹은 (swayback) 그리고 약화된 복부근육들을 보여준다. 이러한 환자들은 보통, 만성요통이나 이상근 증후군, 전방 무릎통증등을 경험한다. 예상할수 있는 근육 불균형패턴은 대부분 다음과 같은 내용을 포함한다.

Other consequences of this syndrome are seen in anterior tilt of the pelvis and flexion of
the hip that exaggerates the lumbar curve. L5-S1 may have soft-tissue and joint stress
with pain and discomfort. This progresses to instability of the sacroiliac joints and
piriformis, and knee involvement.

이러한 증후군의 다른 과정들은 요추 커브를 과도하게 하는 골반 전방경사와 힙의 굴곡이 보여진다. 요추5번-천추1번은

soft-tissue and joint stress로 인해 통증과 불편함을 가질수 있다. 이러한 것들은 천추관절과 이상근, 무릎과 관련된 불안정을 악화한다. 

Lower-cross syndrome may develop from a number of scenarios such as chronic,
repetitive actions such as running. Inaction may also have a negative impact on the
body’s mechanics, such as immobilization, disuse, or chronic postural stress such as
sitting for long periods of time or poor workstation posture. Sports injuries or injuries that
never healed properly can lead to pathology. Pain, pathology, or adaptive changes can
lead to patterns of muscle imbalance that can lead to a situation of lower-cross syndrome.
하지 교차 증후군은 몇가지 시나리오로 부터 야기되는데 예를 들어 만성적이고 반복적인 활동이나 달리기등이있다. 또한 활동저하는 바디메커닉에 좋지 않은 충격을 주는 예를 들어 immobilization, disuse, or chronic postural stress such as
sitting for long periods of time or poor workstation posture가 있다. 스포츠 손상이나 적절하게 치유되지 않은 손상은 병리학적 상황으로 이끌어 갈 수 있다.통증, 병리, 적응적인 변화들 등이 근육 불균형패턴으로 하지 교차 증후군의 상황으로 야기할 수 있다. 

---------------이하 부분은 여기에 편집이 어려워서 한글파일로 올립니다...-----------------

Assessing for Lower-Crossed Syndrome:

1. Postural assessment- The first step in assessing a patient for LCS is to do a
spastic postural distortion analysis. This gives fast and reliable information
indicating whether or not further testing is to be performed.
자세평가에 있어 하지교차증후군(LCS)이 있는 환자의 평가에 첫번째 과정은 정적 자세에 distortion 평가이다. 이것은 빠르고 믿을 만한 정보를 제시해 더 많은 평가를 진행할지를 알려준다.

2. Global Assessment- Overhead Squat Test (OST) is the most basic, full body
functional analysis test that can be done. We recommend using the OST for
assessing because it tests the total kinetic chain neuromuscular efficiency,
integrated-functional strength, dynamic flexibility, and unlike most other clinical
tests, involves a degree of muscular fatigue. Must be aware of patient form while
performing this test.

오버헤드 스쿼트 테스트는 가장 기본적인 것으로, 전신 기능분석검사로 행해질수 있다. 우리는 이 검사를 평가의 도구로 사용하기를 추천한다. 왜냐하면 그것은 the total kinetic chain neuromuscular efficiency, integrated-functional strength, dynamic flexibility를 테스트하며 그리고 다른 임상적 검사와 달리 근피로 정도와 관련된다.이러한 검사가 행해지는 동안 반드시 환자의 모습을 알아차려야한다.

Patient: The patient places his feet shoulder-width apart, with arms straight over
their head and elbows extended. The patient then slowly squats down to a position
that is comfortable. These squats should be done under control for 6-15
repetitions.

Doctors: Do not tell the patient specifically what you are looking for, as they will
tend to try to “correct” the movement. It is very important for the patient to
perform multiple repetitions in order to display the postural deviations that result
from fatigue. Walk around the patient during the test, making sure to observe the
anterior, lateral, and posterior views checking the feet, knees, lumbar curve, arm
movement, chin elevation, and stomach protrusion. Standard deviations for LCS
that commonly occur are: feet flattened and toe flaring out, knees buckling
inward, and low back arching. These deviations may occur bilaterally or
unilaterally and may present in a combination of one or all of theses deviations.
3. Normal Firing Pattern of the Pelvis- With the patient lying prone the doctor
with his/her superior hand places the thumb and index finger on the erector spinae
muscles bilaterally and with his/her inferior hand places the thumb on the gluteus
maximus and little finger on the hamstring. Having the patient extend his/her leg
the normal firing pattern should be the contralateral erector spinae, followed by
the ipsilateral gluteus maximus, and then the ipsilateral erector spinae and
hamstrings. If the ipsilateral erector spinae fires before the gluteus maximus, this
indicates an inhibited gluteus maximus.
4. Thomas Test- The patient sits and the end of the table bringing one of their
thighs to their chest and holding while lying back onto the table. With the knee
approximated to the chest, the examiner observes the opposite limb. The thigh
and knee should be resting flat on the table. Elevation of the thigh or knee with a
space between the limb and table indicates a positive test. Normally, the lower
limb should have enough hip flexor stretch to allow extension of the thigh so that
it lies flat on the table. With hip flexor tightness or in flexion deformity of the
hip, the extension is deficient. Here, we are specifically testing the iliopsoas
muscle.
5. Forward Bending Test- The patient is seated on the table with their legs
extended and knees locked. The feet should be at right angles with no internal or
external rotation. The examiner instructs the patient to reach as far as they can
towards their toes and hold. The low back should have a natural curve, which
should continue into the upper back. The examiner should notice the angle
between the table and the sacrum. It should be 70-90 degrees. An angle less than
70 indicates tight hamstrings and an angle greater than 90 indicates elongated
hamstrings. The muscles we are testing here are the upper back, lower back,
hamstrings, and calf muscles.
6. Gluteus Maximus Strength Test- The patient is in the prone position with one
knee flexed at 90 degrees. The examiner stabilizes the sacrum, the patient lifts
thigh up off the table while the examiner pushes the raised thigh towards the
table. This test should be performed bilaterally comparing muscle strength.
7. Psoas Major Strength Test- The patient is supine with one leg elevated and
abducted with their foot rotated externally 45 degrees. The examiner stabilizes
the opposite ASIS while pushing straight down on the patient’s elevated leg as
they resists. This test should be performed bilaterally comparing muscle strength.
8. Erector Spinae- Schober's test assesses the amount of lumbar flexion. In this test
a mark is made at the level of the posterior iliac spine on the vertebral column, i.e.
approximately at the level of L5. The examiner then places one finger 5cm below
this mark and another finger at about 10cm above this mark. The patient is then
instructed to touch his toes. If the increase in distance between the two fingers on
the patient’s spine is less than 5cm then this is indicative of a limitation of lumbar
flexion or over-active erector spinae.
9. Transverse Abdominal Muscle- The patient in the prone position (by pulling in
the stomach you increase intra-abdominal pressure stabilizing the lumbar spine
and possible the SI joint)
10. Rectus Femoris- With the patient is supine they flex one hip to a 90 degrees and
their knee is also brought to 90 degrees. The examiner instructs the patient to
resist while they push against the flexed knee. This test should be performed
bilaterally comparing muscle strength.
Stretch
1. Hamstrings- The patient lies supine with their leg extended, knee locked, and
their low back flat on the tale so the pelvis is level. The examiner places the
patients leg with the knee that’s locked onto their shoulder, supporting the knee
while flexing the hip to stretch the hamstring. The examiner instructs the patient
to contract their quadriceps while they hold for a count of ten. This can be done
for 3 to 5 cycles. With each cycle the examiner should be able to increase the
stretch on the hamstring. Always do bilaterally.
2. Hip Flexors- The patient sits and the end of the table bringing one of their thighs
to their chest and holding while lying back onto the table. The examiner places
one hand on the held knee and the other hand on the thigh to be stretched. The
patient can also do lunges to stretch the hip flexors. Another exercise uses the
physioball to stretch the hip flexors. This, however, requires more stability and
should only be done once the patient has regained strength and core balance.
3. Erector Spinae- The patient lies supine in the fetal position, their knees to their
chest with their arms wrapped around their knees. The examiner places their
inferior hand under the sacrum pulling down in a scooping motion with the super
hand pushing up on the patient’s knees.
4. Gluteus Maximus- The patient is supine with one leg flexed at the hip and the
knee. The examiner’s inferior hand is under the leg and their superior hand is on
top of the leg. This gives the examiner more control of the stretch. The examiner
stretches the patient for 10 seconds followed by the 10 seconds of the patient
pushing against the examiner.
Strengthen
1. Hamstrings- There are three choices to choose from using the thera-band
depending upon the patient’s stability. Either seated with their leg extended,
standing with one leg straight, or lying prone with their legs extended. Attach the
tubing around the ankle having the patient contract their hamstring. The patient
should contract for 2 seconds, hold for 2 seconds, and release for 2 seconds. (also
exercise ball)
2. Transverse Abdominals- First, have the patient lie on their back with their knees
bent. Instruct them to pull their umbilicus in towards their spine and then up
without moving their pelvis. Once they can do this repeat the process with the
patient sitting up. Finally, have the patient lie prone with a tennis ball under their
umbilicus. Have them draw their umbilicus up and in towards the spine
attempting to lift their stomach off the tennis ball. Always remind them to do the
motion without moving their pelvis. We want to isolate the TVA.
3. Gluteus Maximus- Have the patient stand facing the wall with the tubing around
their ankle. Instruct them to have their knee locked in extension or bent at 90
degrees to isolate the gluteus maximus while extending the hip away from the
wall. This motion can also be done in the prone position depending on the
patient’s stability. Have the patient contract for 2 seconds, hold for 2 seconds,
and release for 2 seconds.
4. Hip Flexors- Have the patient on the hands and knees with tubing around one
ankle. Instruct the patient to pull their knee towards their chest. The patient
should contract for 2 seconds, hold for 2 seconds, and release for 2 seconds.
5. Erector Spinae- Have the patient lying prone with their hands behind their head
extending their back. The patient should contract for 2 seconds, hold for 2
seconds, and release for 2 seconds.

lower-crossedsyndrome.pdf

하지교차증후군.hwp

[송아지]

정말 좋은 자료입니다.
저는 왜 이런 부분이 아직도 한눈에 들어 오지 않을 까요?

[문형철]

의료인으로서 평생 공부해야죠 ㅎㅎㅎ

[문형철]

성용아.. ㅎㅎ 정리 잘했넹 ㅎㅎ

[아르구스]

감사합니다.... 가끔은 해야죠..

[윤연우]

넘 감사합니다~~~^^

[여인호]

<하지교차증후군 lower-crossed syndrome>

1. 통증이나 병리상태에 대한 보상 및 적응으로 근육 불균형 으로 인해
●primary muscle ↓ - hamstring , gluteus muscle , rectus abdominis , oblique
●synergistic muscle ↑ - rectus femoris , tensor fascia latae , adductors , errector spinae , iliopsoas ,
gastrocnemius , soleus
2. 하지의 자세 불균형 이 초래되고
●pelvis의 anterior rotation , lumbar lordosis ↑ , hip in flexion , knee hyperextension
3. 하지 운동사슬에 영향
●lower back pain , anterior knee pain , piriformis syndrome , hamstring strain

[여인호]

#평가
● 정적자세 분석
● overhead squat
* total kinetic neuromuscular efficiency , integrated-functional strength , dynamic flexibiliy 를 평가 할 수 있다.
* 환자에게 무엇을 살필건지 알리지 않아야 한다. 힘들 정도로 여러번 반복시켜 피로로 인한 자세의 변동을 찾는다.
* foot flat , toe out , knee buckling / inward , lower back arch
● pelvis의 발화패턴
* 한 손은 erector spinae 양쪽에, 다른 한 손의 엄지는 gluteus maximus, 새끼는 hamstring 에 둔 후
환자에게 다리를 extension 하게 했을 때, 정상적인 발화 순서는

[여인호]

반대측 erector spinae → 동측 gluteus maximus → 동측 erector spinae , hamstring
(만약 동측 erector spinae 가 동측 gluteus maximus 보다 먼저 발화되면, gluteus maximus 가 inhibition 된 것.)
● iliopsoas test
* 환자가 테이블 끝에 앉아서 한쪽다리를 가슴에 갖다 댄 후, 그대로 누워서 반대쪽 다리가 테이블에서 뜨는지 검사.
* 정강이가 수직으로 떨어지는지 (rectus femoris) , patella가 superolateral 하게 벗어났는지 (tensor fascia latae)
● 앞으로 구부리기
* 다리를 완전히 extension 하여 무릎을 lock 시키고 , 발을 똑바로 하늘을 향하게 놓고 상체를 앞으로 구부린다.

[여인호]

* sacrum 과 바닥사이의 각도가 70~90 도 → 정상
70도 이하 → hamstring tight
90도 이상 → hamstring lengthening
* 검사해야 하는 근육 : upper and lower back muscle , hamstring , calf muscle
●gluteus maximus 근력검사
* 환자가 바닥을 보고 누운 상태에서 무릎을 90도 flexion 시키고, 다리를 extension 할 때
검사자는 한손으로는 sacrum 을 고정하고, 다른 한손으로는 움직임에 저항하여 양측의 힘을 비교한다.

[여인호]

● psoas major 근력검사
* 환자가 다리를 elevation , abduction , external rotation (45도) 한 후 다리를 extension 할 때
검사자는 한손으로 반대측 ASIS을 고정하고 한손으로는 움직임에 저항하여 양측 힘을 비교.
● erector spinae
* L5 의 위 10cm , 아래 5cm 에 각각 점을 찍은 후, 상체를 구부리게 했을 때
5cm 이하로 늘어나면 erector spinae shortening
● transverse abdominis muscle
* 하늘을 보고 누운 후 배를 안으로 당겨 복압을 높혀서 lumbar spine 과 SI joint 를 안정화한다.
● rectus femoris 근력검사
* hip 과 knee 를 90도 flexion 한 후, 무릎을 extension 하는 것에 저항하여 양측을 비교.

[여인호]

# stretching
● hamstring
* 환자의 발목을 어깨에 걸치고, 한손으로는 knee를 다른 한손으로는 femur를 잡아당겨서
다리를 완전히 extension 시킨다. (환자도 능동적으로 quadriceps 를 수축) 이 상태로 다리를 수동적으로 들어올림.
허리가 뜨지 않게 주의.
* 10초 , 3~5회
● hip flexor
* iliopsoas test 에서 반대쪽 다리를 뜨지 않게 잡아줌.
* 짐볼로 스스로 할 수도 있으나 이는 환자가 strength 와 core balance 를 가졌을 때.
● erector spinae
* 환자가 하늘을 보고 누운 상태에서 몸을 동그랗게 만다. (무릎을 가슴으로 당기는 자세로.)
검사자는 더 둥글게 말아준다.

[여인호]

● gluteus maximus
* 하늘을 보고 누워 hip 과 knee 를 flexion 한 상태로 10초간 stretching 한 후, 10초간 검사자에 저항하여 push 한다.

# strengthening
● hamstring
* 눕거나 앉거나 서서 발목에 밴드르 고정한 후 당긴다.
* 이때 ankle , hip 의 움직임이 없도록 하여 hamstring 만 isolation 시킨다.
* 2초 수축, 2초 유지 , 2초 이완
● transverse abdominis
* 무릎을 구부리고 누워 배를 아래쪽으로 당김. 이때 pelvis 의 움직임이 없게 한다.
* sitting up 과 같이 시키고, 바닥에 놓은 테니스 공에 배가 안 닿게 할 수 있을 정도로 시킨다.

[여인호]

● gluteus maximus
* hamstring 강화와 같은 방법으로 하되, 서서 무릎을 굽힌 상태로 한다.
* 2초 수축 , 2초 유지 , 2초 이완
● hip flexor
* 기어가는 자세에서 발목에 밴드를 고정한 후, 무릎을 앞으로 당긴다.
* 2초수축, 2초 유지, 2초 이완
● erector spinae
* 바닥을 보고 누운 상태에서 손을 머리 뒤에 두고 허리를 extension 시킨다.
* 2초 수축, 2초 유지, 2초 이완