Self-management of shoulder disorders. treatment. 정말 좋은 논문. 아직 정리 못함.

[문형철]

이렇게 함축적으로 논문을 쓸수도 있구나.

이렇게 함축적으로 책한권 썼으면 좋겠다. 김송준 소장님 표현대로 정말 주옥같은 논문이다. 

으아. 

얼릉 읽고 정리하려했는데, 또 새로운 공부자료가 쏟아졌다 ㅎㅎㅎ

Self-management of shoulder disorders—Part 3. Treatment.pdf

Introduction

Rehabilitation focuses on the identification of key functional pathologies related to shoulder instability and their management by reactivation and reconditioning. Exercise is thus important alongside advice and manipulation to improve the patient’s functional performance in their daily activities.

- 재활치료는 어깨 불안정성과 연관된 주요 기능적 병리의 확인과 재활성화, 재조정(reactivation and reconditioning)에 의한 관리에 초점

- 치료적 운동은 환자의 일상생활에 기능적 수행을 개선하는 manipulation과 advice가 중요

The most important type of exercise for the treatment of shoulder problems is correction of abnormal motor control. A recent randomized controlled trial reported that such a program was more cost-effective than a traditional passive care approach (electrical modalities, joint mobilization, range of motion exercise), and is equally effective but has fewer potential risks than corticosteroid injection (Ginn and Cohen, 2005).

- 어깨문제 치료를 위한 exercise에서 가장 중요한 것은 correction of abnormal motor control

- 최신의 이중맹검 데이터는 "치료프로그램이 전통적인 수동적 관리 접근보다는 좀더 비용-효과에 초점이 맞추어짐. 

Patients learn to appreciate that the quality of the movement is more important than the number of repetitions. This is very different from how most people view exercise and so patients are reeducated about ‘‘therapeutic’’ exercise. The first goal is for the patient to learn how to produce and control the movement in his or her functional training range. This is the painless range within which movements are performed in a coordinated way. Such training for coordination during arm abduction tasks has been demonstrated to be successful (Babyar, 1996).

- 환자는 치료적 운동의 반복횟수보다 움직임의 질(quality of the movement)이 중요함을 배움

- 환자의 첫번째 목표는 기능적 훈련 범위(functional training range)에서 운동을 조절하고 실행하는 방법을 배우는 것

- 이것은 협응움직임 수행내에서 통증이 없는 범위(painless range)를 말하는 것임.

An example is teaching the patients to disassociate related movements such as scapulo-thoracic from scapulo-humeral or cervico-cranial from cervico-thoracic. The patient should be able to move their arm in abduction or flexion while fixing the scapulae inferiorly against the thorax. If excessive shrugging of the shoulder occurs this signifies poor scapulo-thoracic kinaesthetic awareness. Another example is that the patient should be able to perform a chin tuck and use this skill dynamically so that when they rise from a chair or a bed they can avoid poking their chin.

- 움직임을 정확히 분리해야

Clinical application

In the self-care articles accompanying this 3-part clinician series on shoulder disorders a number of shoulder exercises have been presented. The utility of these exercises is enhanced if they are prescribed appropriately as part of a functional progression (see Table 1).

Table 1 Functional progressions.

_ Sparing strategies

_ Stabilizing exercises

_ Functional training

Sparing strategies include ergonomic or postural advice to reduce repetitive strain on symptomatic tissues. An example is learning to sit at a desk without rounded or shrugged shoulders. Microbreaks such as Brugger’s relief position are also valuable at this stage. The goal of this initial rehabilitation stage is to find self-care advice which reduces the patients mechanical sensitivity and abnormal motor control. 

- 어깨통증의 소극적 치료 전략은 통증이 발생한 조직에 반복적인 부하를 줄이는 인체공학적, 자세 관련 advice가 필요

- 예를들어 책상에 앉을때  rounded or shrugged shoulders 피하기

-  Brugger’s relief position으로 긴장하는 근육 이완하기

- sparing strategies 단계의 재활치료 목표는 mechanical sensitivity를 줄이고, abnormal motor control을 정상화하는 것

This self-care should provide some initial pain reduction while improving motor patterns. Many shoulder patients have been performing health club routines which are actually harmful. Exercises such as shoulder press, bench press, and latissimus dorsi muscle pull-downs (behind the neck) should be avoided because of overstress to the superior labrum and anterior glenohumeral joint capsular structures. It is wise to avoid both overhead motions and those where the elbow is behind the plane of the body (see Fig. 1) (Liebenson, 2006).

- 이러한 치료는 움직임 패턴을 개선하여 초기 통증을 줄이는 역할

- 많은 어깨통증 환자가 헬스클럽에서 운동(shoulder press, bench press, and latissimus dorsi muscle pull-downs)을 하면서 통증을 악화시킴. 

- 아래 그림과 같이 shoulder capsule를 overstretch시키고, 통증을 악화시키는 운동을 하면 안됨. 

Shoulder stabilizing exercise include teaching patients to be aware of postural control of the spine, scapulo-thoracic, and glenohumeral articulations while performing arm movements (Liebenson, 2006). Examples include uniplaner exercises such as pull downs, shoulder rotation, protraction, etc. (see Table 2). 

- 어깨 안정화 운동은 환자에게 척추, 견갑흉곽, GH joint의 자세조절에 관한 것을 알려주는 티칭을 포함해야 함.

Table 2 Stability exercises.

_ Push-up with plus(유튜브 동영상 http://www.youtube.com/watch?v=iN3cw5PKrn8) - 전거근 운동

_ Scapular setting training( 유튜브 http://www.youtube.com/watch?v=qVeKpyjFHBQ)

_ Wall wash

_ Push-pull

_ Isometric ball exercise (see Fig. 2)

_ Single arm pull downs( 유튜브 http://www.youtube.com/watch?v=wOXvrSCqJwA)

_ Single arm rows( 유튜브 http://www.youtube.com/watch?v=1gOYkpfT9Hc)

_ Biceps curls

This second stabilizing stage of active rehabilitation follows naturally after teaching the patient sparing strategies (Fig. 2). Stability training focuses on low-load, endurance exercises with all key joints in neutral or ‘‘centrated’’ positions (DeFranca and Liebenson, 2001). Training involves approximately 8–12 repetitions, performed slowly, twice daily, for up to 3 months. Resistance should be light to moderate and in the patient’s pain-free range. The patient can be progressed to increasing repetitions, sets and resistance.

- spraing strategies 이후 안정화 트레이닝이 필요하고, 안정화 트레이닝은 low-load, 지구력운동을 통해 관절의 neutral position을 자리잡게 하는 것이 중요

- 트레이팅은 8-12회 반복, 천천히, 하루에 2회, 3개월 지속

- 무게의 저항은 반드시 저강도에서 중강도로 통증이 없는 범위(pain free range)에서 시행해야

Stability exercises can take advantage of simple tools such as cable, tubing, hand weights, medicine balls, balance boards, or body blade. Using unstable surfaces are a potent tool in stability training (Lphart et al., 1997; Padua et al., 1999). A typical example of how to incorporate unstable surfaces is push-up training. Wall push-ups may be progressed to exercises on all fours. 

- 안정화 운동은 cable, tubing, 아령, 메디신 볼, balance board 등을 사용할 수 있음. 고유수용감각을 훈련하여 안정화 트레이닝 효과를 극대화하기위해 Unstable surface를 사용할 수 있음. 

- unstable push-up traning(짐볼 푸쉬업 등)

참고)

-  tubing(세라 밴드)는 가변저항이므로 주의해서 사용해야

- 예를들어 biceps curl 운동을 할 경우, elbow 90도를 넘어가면 구심성 수축으로 힘은 약해지는데, 세라밴드의 저항은 더 커짐. 더 큰 문제는 90도를 넘어간 상태에서 eccentric(원심성) 수축을 할때 손상, 통증의 위험성이 높음.

This can be progressed to tripod positioning and eventually the hand may be placed on a balance board or other labile surface. Weight-bearing exercises such as these have been shown to significantly increase muscle activity in the shoulder girdle (Uhl et al., 2003). Another unstable exercise is to have the patient grasp a small medicine ball in the palm and press it against a tabletop (Uhl et al., 1999; Kibler and McMullen, 2003). Scapular setting is cued and then the clinician tries to roll the ball or lightly push it in different directions. The patient will isometrically activate the shoulder stabilizers.

- 이 재활치료 과정은 balance boader, 불안정한 면에서 tripod 자세를 진행되어야

- 이러한 체중부하 운동은 견갑대의 안정성을 위한 근육활성화가 증가됨

- Another unstable exercise는 작은 메디신볼 잡기, 테이블 윗면 누르기 등

- scapular setting을 하고, 치료사는 환자로 하여금 공을 굴리게하고, 가볍게 다양한 방향으로 누르게 함

An innovative device for scapulo-thoracic training is the body blade or similar devices. It is tricky to use at first, but when the correct frequency is learned it automatically isolates the scapular fixation musculature. Traditional hand weights and cables are excellent for shoulder training. Cable exercise can be segued to home use via readily available exercise tubing. The cable/tubing approach is ideal for functional training since the patient’s own activities can be mimicked with the resistance devices. Stabilization training is often slowed down by mobility deficits, especially in impingement patients (see Table 3). 

-  scapulo-thoracic 훈련을 위해 혁신적으로 고안된 도구가 body blade임. 처음에는 사용이 까다롭지만 견갑골 안정화 근육을 고립시켜 사용하는 방법을 배울 수 있음. 

- 유튜브 http://www.youtube.com/watch?v=1XBqeJ4SJ3Y&feature=related

- 아령, 케이블, 튜빙을 이용한 운동도 어깨 트레이닝에 효과적.

Table 3 Stiff, tight structures often requiring mobilization or lengthening/stretching.

_ T4-8 in extension

_ Posterior shoulder capsule

_ Upper trapezius and Levator scapulae muscles

_ Pectoralis muscles

Such mobility impairments cause muscle imbalance and faulty movement patterns. For instance, a fixed kyphotic posture or tight posterior shoulder capsule will need to be mobilized in order for the patient to gain proper

control of the scapulo-thoracic articulation (Godges et al., 2003; Tyler et al., 2000; Young et al., 1996). For this reason T4-8 extension mobility exercises such as the upper back cat or foam roll stretches are invaluable. The rounded shoulders or slumped posture may also require anterior rib cage mobilization or pectoralis  elaxation/stretching. The shrugged shoulders may require relaxation/stretch of the upper trapezius or levator scapulae.

Functional training is the final common pathway for active rehabilitation of shoulder problems. The type of arm movements which the patient uses in daily life (home, work or sport) are incorporated into the rehabilitation prescription. For instance, exercises may be tri-planer and involve functional movements like pushing and pulling (see Table 4).

Table 4 Functional exercises.

_ Angle lunge with reach (push/punch) - 동영상 http://www.youtube.com/watch?v=j7TkKXsVR-c

_ Angle lunge with reach (pull/frisbee toss or backhand)

_ Pull with pulley (external rotation)

_ Sword with pulley

_ Punch with pulley (internal rotation)

_ Seatbelt with pulley

_ Lawn mower

Functional training utilizes the whole body in the active rehabilitation process. Hip rotation and extension mobility and core coordination become crucial for sparing the shoulder during pushing or pulling activities. If the patient can be trained to use their hips when they push or pull they can effectively unload the shoulder complex. Angle

lunges with reaches (push or pull) and pulley exercises are ideal to facilitate appropriate movement patterns. These functional patterns are so effective at unloading the shoulder that often these manouvres are used during the sparing stage!

An exciting form of functional training especially for the performance minded patient is plyometric training. Plyometric training of the shoulder girdle with the use of medicine balls and a rebounder can be incorporated into shoulder girdle rehabilitation especially of the overhead athelete (Padua et al., 1999). Both throwing and catching are basic skills which can be varied to re-educate motor control. Plyometrics have the advantage that they utilize eccentric and concentric activity in coordination.

Condition-specific clinical considerations

Frozen shoulder

The frozen shoulder is a unique condition with unknown etiology and prolonged course. It is also highly disabling. A key to managing frozen shoulder is finding exercises within the patients functional range which will increase pain-free shoulder abduction and external rotation (Bulgen et al., 1984; Lee et al., 1997). Proprio-sensory training is often a shortcut in such cases. For instance performing closed-chain quadruped exercises progressing to tripod or on unstable surfaces. However, the traditional emphasis on relaxing and mobilizing the subscapularis cannot be ignored. Exercises focusing on the role of the hips and core during pull manouvres can facilitate arm abduction and external rotation.

Impingment and rotator cuff syndromes

A combination of mobilization and strengthening strategies are needed in cases of subacromial impingement and shoulder girdle tendonitis (rotator cuff or biceps) (Bang and Deyle, 2000; Conroy and Hayes, 1998). Several authors have emphasized the importance of scapular muscle strength and neuromuscular control in contributing to normal shoulder function. (Kibler, 1991, 1998; Kibler and McMullen, 2003; Paine, 1994). Lin et al., 2005 has recently confirmed that patients with shoulder problems typically have muscle imbalance (overactive upper trapezius/inhibited serratus anterior), scapular elevation and anterior tilt. Others have also found delayed onset of lower and middle trapezius firing in shoulder impingement vs. asymptomatic subjects during unexpected arm movements (Cools et al., 2003).

Isotonic exercise techniques are used to strengthen the scapular muscles. Furthermore, Wilk and Arrigo (1992, 1993) and Kamkar et al. (1993) developed specific exercise drills to enhance neuromuscular control of the scapulo-thoracic joint. These exercise drills are designed to maximally challenge the scapulo-thoracic muscle force

couples and to stimulate the proprioceptive and kinesthetic awareness of the scapula. Scapular setting (bringing the shoulder blade back and down) during arm movements is the key to such training. 

Avoiding overhead activities, stretching the tight posterior capsule, enhancing dynamic stability of the glenohumeral and scapulo-thoracic joint, rotator cuff muscle strengthening, and functional training should be primary management goals (Jobe et al., 1989). During arm elevation, the scapula upwardly rotates, retracts, and posteriorly tilts. Lukasiewicz et al. (1999) reported that patients with impingement exhibit less posterior tilting than do subjects without impingement. Pectoralis minor muscle stretching and inferior trapezius muscle

strengthening will help ensure posterior scapular tilting (Wilk et al., 1997).

Solem-Bertoft et al. (1993) using MRI, have demonstrated that excessive scapular protraction reduces posterior tilt of the scapula and diminishes the acromial-humeral space, whereas scapular retraction increases the subacromial space. Thus, dynamic protration/retraction exercises are beneficial (Wilk et al., 1997). The last step is a gradual return to previous home, sport or work activities once pain has significantly diminished. Padua et al. (1999) used tri-planer proprioceptive neuromuscular facilitation patterns for 5 weeks and significantly improved their subjects’ shoulder function and enhanced functional throwing performance test scores. Uhl et al. (1999) reported improved proprioception after specific neuromuscular training that challenged the glenohumeral

musculature in weight-bearing or closedchain tasks.

Other exercise drills commonly used during the initial rehabilitation phases include joint repositioning

tasks (Lephart et al., 1997, 2000) and axial loading exercises (such as closed kinetic chain). Active joint compression stimulates the articular receptors. (Lephart et al., 1994). Thus, axial loading exercise drills such as weight shifts, weight shifting on a ball, wall pushups, and quadruped positioning drills are beneficial in restoring proprioception. (Wilk and Arrigo, 1992; Wilk et al., 1993, 1997; Uhl et al., 1999, Kibler and McMullen, 2003; Kibler, 2003). The isometric scapular setting exercise with the medicine ball is ideal for this (Kibler and McMullen, 2003).

The throwing athlete The throwing athlete presents with unique problems and goals. One recent study of professional handball players showed that while 93% of throwing shoulders had abnormalities on magnetic resonance imaging, only 37% were symptomatic (Jost et al., 2005). With such poor correlation of symptoms with

imaging findings, care should not be based on structural findings (Jost et al., 2005). Initial care includes discontinuing throwing activities until the scapulo-humeral rhythm and muscle strength ratios between the external and internal rotator muscles are normalized. The external rotators should be at least 64% of the strength of the internal rotators (optimal goal, 66–75%). (Brown et al., 1988; Wilk et al., 1993, 1997) Second, the athlete is placed on anaggressive strengthening program for the rotator cuff and scapular depressor muscles. Serratus

anterior training is also emphasized as is mobility in retraction. Once strength levels have improved, the exercise program should emphasize eccentric muscle training. In particular, the external rotator muscles and the lower trapezius muscle are thefocus of the eccentric program.

Shoulder instability

Patients with unstable shoulders such as labral tears are the most challenging patients to rehabilitate. Many such patients will ultimately opt to have surgical stabilization as well. Scapular setting and strengthening exercises are important. Taping can also be used to enhance stability. Superior labral (SLAP) lesions The nonoperative treatment of superior labral lesion extending anterior to posterior (SLAP) lesions depends on the type of lesion present (Wilk et al.,2005). Using the classification system developed by Snyder et al. (1990) type I SLAP lesions appear as fraying of the labrum with a firm attachment and often respond favorably to a nonoperative treatment

regimen. Throwers who exhibit this type of lesion are treated with a program similar to the impingement protocol (previously discussed). Conversely, players with a type II, III or type IV SLAP lesion are probably best served by undergoing surgical intervention. If rehabilitation is indicated before surgery, the program should emphasize

neuromuscular control of the glenohumeral and scapulo-thoracic joints. Additionally, shoulder sparing biomechanical advice is important. Avoidance of overhead motions with excessive external rotation is recommended. A strengthening program should be performed in an attempt to prevent muscle atrophy. The

strengthening exercises should initially be performed with the arm below shoulder level to prevent further damage to the glenoid labrum. 

Strengthening exercises such as external/internal rotation with the arm at the side or scapular plane, and deltoid muscle exercises to 901 of abduction can be safely performed. Isometric external rotation training with external perturbations such as with rhythmic stabilization can be administered. The isometric ball exercise is also valuable and can be done with the arm down or elevated 901 in the scapular plane. Exercises such as shoulder press, bench press, and latissimus dorsi muscle pull-downs (behind the neck) are avoided because of increased stress applied to the superior labrum and anterior glenohumeral joint capsule. Furthermore, the

clinician should be cautious with closed kinetic chain exercises that result in excessively high joint compressive loads that could result in further compromise of the glenoid labrum.

[여인호]

<scapular stability>
* 어깨 치료를 위한 exercise 에서 가장 중요한 것은 correction of abnormal motor control.
(corticosteroid injection 은 효과는 같으나 잠재적 risk 가 더 큼.)
* 환자는 치료적 운동의 반복횟수 보다는 움직임의 질이 중ㅇ요함을 인식해야 함.

● functional progression
① sparing strategies
- 재활치료의 첫번째 목표는, 환자가 반복 지속적인 strain 을 받는 상황을 인지하고,
painless range 내에서 올바른 movement 를 produce 하고 control 하는 방법을 배워서,
mechanical sensitivity 를 낮추고, abnormal motor control 을 정상화 시키는 것. 그럼 통증이 바로 줄어듦.

[여인호]

- 많은 어깨 통증 환자가 헬스클럽에서 잘못된 운동으로 통증을 악화시킴
(overhead motion 과 elbow 가 몸의 뒤로 빠지는 동작 피해야,,,)

② stabilizing exercise
- 안정화는 low load and endurance exercise 를 통해 관절의 neutral position 을 유지시키는게 중요.
- 고유 수요감각을 훈련하기 위해 unstable surface 를 이용할 수도 ( 짐볼 push-up 과 같은)
- 8~12회 , slow and painless , 2 set , 3개월
- Push-up with plus , Scapular setting training , Wall wash , Push-pull , Isometric ball exercise
Single arm pull downs , Single arm rows , Biceps curls

[여인호]

③ stretching
- posterior shoulder capsule , upper trapezius , levator scapulae , pectoralis
→ tight 되기 쉬움 (shrugged shoulder , rounded shoulder)
- upper back cat , foam roll stretch , anterior rib cage mobilization

④ functional training
- shoulder 에 load 를 줄일 수 ㅇ
- plyometric training 은 overhead athlete 의 회복에 중요함.
- Angle lunge with reach , Pull with pulley , Sword with pulley , Punch with pulley , Seatbelt with pulley
Lawn mower

[여인호]

● frozen shoulder
* frozen shoulder 를 관리하는 방법은 shoulder 를 painless 하게 abduction , external rotation 시키는 것.

● impingement and rotator cuff syndrome
* subacromial impingement 나 shoulder girdle tendonitis → mobilization , strengthening 전략이 필요
* 과거엔 scapular muscle strength 와 neuromuscular control 을 중요시 했으나
최근 연구는 shoulder 의 문제를
1) muscle imbalance 로 봄 ( upper trapezius ↑ ,serratus anterior ↓ )
2) scapular elevation and anterior tilt
* unexpected arm movement : mid and low trapezius 의 지연된 발화.

[여인호]

* isotonic exercise 는 scapular muscle 을 강화하는데 사용됨.
* overhead activity 피하고,
tight 된 posterior capsule 을 stretching 하고,
glenohumeral joint 와 scapulo-thoracic joint 의 움직임 중 안정성을 강화ㅏ하고,
rotator cuff muscle 을 strengthening 하고,
팔을 들어올리는 동안 scapula 가 위로 upwardly rotation , retraction , posteriorly tilt 되는지 봐야함.
impingement 환자는 scapula 가 늘 posteriorly tilt 됨.
* pectoralis minor 를 stretching , lower trapezius 를 strengthening.
* excessive scapular protraction 은 posterior tilt 를 감소시키고 acromio-humeral space 를 감소시킴.

[여인호]

● throwing athlete
* scapulo-humeral rythm 과 internal · external rotation 의 힘비율이 정상화 될 때까지 던지는 동작 금지
( external rotation 이 internal rotation 의 65~75% 가 정상.)
* rotator cuff , scapular depressor muscle , serratus anterior → strengthening

● shoulder instability
* 매우 어려움...
* scapular setting and strengthen exercise
* type 1 SLAP 은 확실히 붙어있으나 닳아서 해진 모양이며, impingement 환자와 유사하게 치료한다.
but type 2~4 SLAP lesion 은 수술적 치료가 필요하다.

[여인호]

* 재활은 glenohumeral joint 와 scapulo-thoracic joint 의 neuromuscular control 을 중점적으로.
+ shoulder sparing (overhead, excessive external rotation x)
+ strengthening (∵ atrophy) - glenohumeral joint 에서 먼곳부터
+ exteranl · internal rotation , deltoid muscle → strengthening exercise
+ closed kinetic chain exercise 할 때 주의 (∵joint compressive load...)

not shoulder press , bench press , latissimus dorsi pull-down behind the neck
∵increased stress applied to superior labrum and anterior glenohumeral joint capsule.

[손형우]

좋은자료네요. body blade 유사한장비가 있는데 사용을 안하고 있었습니다. 유용하게 쓸수 있겠네요.
단계별 전거근 강화운동 잘나와있는 블로그주소입니다.
http://blog.naver.com/bosujjang?Redirect=Log&logNo=90128522887&jumpingVid=956F189CE23F6B058FBCC85F575D27570885

[이한봉]

감사합니다~