chronic neck pain환자의 주동근, 길항근, 협력근 변화, 부정렬 치료법에 대한 논문. 크레이그 리벤슨

[문형철]

멋진 논문이다 정말로

여태까지 본 논문중에 최고로 함축적이고 압권인 논문이다. 

panic bird...

Functional reactivation for neck pain patients.pdf

Introduction

- neck pain의 natural history는 잘 알려져 있지 않고, neck pain 발생의 원인, 치료전략에 대한 연구는 부족

- 과학자와 임상의로 하여금 이 흔한 질환에 대한 연구를 제한하는 많은 요인이 있다. 두가지가 중요

첫째, 증상이 심각한 정도와 trauma의 심각한 정도는 직접적으로 연관성이 없다

둘째, 객관적인 검사결과(x-ray, mri 등)는 head, neck, upper quarter region 증상과 직접적으로 연관성이 없다. 그래서 통증이 발생한 원인을 정확히 해야 하는데, 불행하게도 불가능함. 

- x-ray, mri등을 이용한 neck pain의 구조적 원인 찾기는 쉽지 않음.  경부통에서 영상사진의 위양성은 75%가 넘는 것으로 보고

- 이러한 poor specificity때문에 x-ray, ct, mri 등 이미지검사는 screening  방법으로 적합하지 않음. 

- 탈출된 디스크는 흡수되기 때문에 심각한 환자 꼬리표 다는 것을 피해야

Medicalization of the problem by excessive diagnostic testing or overly aggressive treatment is not warranted and is likely iatrogenic.

- 근골격계 환자의 경우 과도한 진단, 과도한 치료에 의한 치료로 받아들임은 정당화되지 않고 오히려 병을 악화시키는 의원성일 수 있음

According to a recent meta-analysis review of manual therapy (mobilization, manipulation, massage) it was concluded that there was insucient data to recommend it (Harms-Ringdahl & Nachemson 2000). But, when manual therapy was used in combination with other active treatments there is moderate evidence of benefit.  A recent study found that chronic neck pain patients receive more benefit from a combination of low-technology exercise and manipulation than with either high-technology exercise or manipulation alone.

- 최신 메타분석 리뷰논문에 의하면 manual therapy (mobilization, manipulation, massage)단독으로는 효과가 불충분하다고 보고됨. 하지만 manual therapy는 다른 치료와 병행되어 사용되어야. 

Functional issues

- structural pathology는 환자 통증의 근원적 원인과 연관성이 많지 않기 때문에 치료의 핵심은 "기능 회복" 에 있음

- 그래서 앉기, 물건 나르기, 서있기 등 일상활동에서 functional disturbance는 치료타겟에 초점이 됨

- 특히  내성, 유연성, 협응성 등을 포함한 specific performance deficit가 임상적으로 중요함.

- 가장 중요한 개념은 "functional instability"

- 주동근과 길항근 co-activation은 joint stability의 핵심관점. 

- normal function과 주동근 길항근 balance 손상은 관절 안정성(joint stability)을 손상시킬 수 있음.

- 판자비에 의하면 대부분의 편타성 경추 손상 환자는 mild soft tissue injury를 경험할뿐 완전한 soft tissue failure를 야기하지는 않기 때문에 static imaging로는 진단이 안된다고 보고함.  이러한 soft tissue의 sub-failure injury는 not torn이고, 그 조직이 가지고 있는 탄성한계를 넘어선 늘어남으로 인해 불안정성과 poor healing 상태. 

- instability는 일상생활과 보상성 움직임 속에서 osteoligamentous 구조를 쉽게 repeated strain을 일으키게 함. 

Pain-adaptation model of Lund

- Lund의 가설에 의하면 환자가 통증이 발생하면 움직임 동안 주동근의 muscle activation이 감소하고, 길항근의 muscle activation은 활성화

Pain-spasm-pain model

- 통증자극이 있을때 muscle tension은 악순환처럼 증가하여 reflexive muscle contraction이 발생하면서 악화된다는 이론

Rather, it appears the rule is muscle imbalance, with certain muscles tending towards hyperactivity and others

towards inhibition. It is well known that certain muscles respond to inflammation or injury by becoming inhibited (Barton & Hayes 1996, Jull et al. 1999, Jull 2000, Silverman et al. 1991, Watson & Trott 1993, Treleaven et al. 1994) and atrophying (Hallgren et al. 1994,McPartland et al. 1997). 

- 근육 불균형 규칙 muscle imbalance rule

- 어떤 근육이 과활성화 경향이 있고, 다른 근육은 억제, 위축되는 경향이 있음. 

It is also commonly accepted that other muscles such as the upper trapezius (Balster & Jull 1997, Bansevicius &

Sjaastad 1996, Hall & Quintner 1996, Madeline et al. 1999, Nederhand et al. 2000) and sternocleidomastoid (SCM) (Jull 2000) respond to injury or overload by tensing or becoming overactive.

- 상부승모근과 흉쇄유돌근은 손상에 반응하여 흔히 긴장하고 과활성화된다는 것은 흔히 받아들여지는 진실임.

As a result of agonist-antagonist muscle imbalance movement patterns are altered and synergist overactivity is frequently observed. This type of altered motor control easily escapes traditional functional testing which only assessed strength and flexibility. Edgerton et al. studied altered muscle activation ratios of synergist spinal muscles during a variety of motor tasks in whiplash patients (Edgerton 1996). They discovered that underactivity of agonists and overactivity of synergists was able to discriminate chronic neck pain patients from those who had recovered with 88% accuracy. 

- 주동근 길항근 근육 불균현 움직임 패턴이 변화하고, 길항근이 과활성화되는 것이 흔히 관찰됨. 

- 변화된 운동조절의 이러한 형태는  근력과 유연성 측정인 전통적인 기능적 검사를 쉽게 피함. 

- 에드거톤은 편타증 환자에서 다양한 움직임 동안 척추협력근의 변화된 근육활성비율을 측정함. 그들은 주동근의 저활성과 협력근의 과활성이 만성경부통 환자로부터 완벽하게 회복된 환자를 구분할 수 있다는 사실을 발견함. 

They concluded that, `The nervous system apparently can detect a reduced capacity to generate force from a specific muscle or group of muscles and compensate by recruiting more motoneurons. This compensation can be made by recruiting motor units from an uninjured area of the muscle or from other muscles capable of performing the same task'. 

- 그들은 신경계 시스템은 분명하게 특정 근육으로부터 생성되는 능력과 운동신경 동원에 의해 발생하는 보상의 감소를 찾아낼 수 있다고 결론냄. 

- 보상적 움직임은 근육의 손상된 부위의 운동단위 동원이나 같은 동작의 서로다른 근육사용에 의해서 만들어짐. 

Lauren et al. demonstrated strong support for this element of compensation with their functional study of neck and

shoulder pain incidence (Lauren 1997). Their study showed a higher incidence of neck and shoulder pain in those individuals who performed tasks either extremely fast or slow. While those performing them in a medium range had very low incidence of neck and shoulder pain. 

- 로렌은 강한 증거를 찾아냈음. 

- 그들의 탐구는 경부와 어깨통증의 높은 발생율은 극단적으로 빠르거나 느리게 시행하는 작업하는 개인에게 발생한다는사실을 발견함. 

- 중간 범위에서 작업수행을 할때 경부통과 어깨통증의 발생율은 매우 낮음. 

Nederhand showed that a decreased ability to relax the upper trapezius muscles during static tasks as well as following exercise in mild-moderate whiplash patients correlates with increased neck pain following whiplash type injury (Nederhand 2000).

- 네더핸드는 정적인 동작을 하는 동안 상부승모근 이완하는 능력이 감소할 뿐 아니라 중간정도 편타성 손상환자에서 이어지는 운동은 .....

Watson and Trott (1993) found that two examination findings could differentiate headache from non-headache patients:

. forward head posture

. decreased isometric strength and endurance of neck flexors.

- 왓슨과 트로트는 두가지 검사는 비두통환자로부터 두통을 감별할 수 있음을 발견함. 

- head forward posture

- deep neck flexor의 감소된 등척성 근력과 근지구력

참고) deep neck flexor = longus colli, longus capitus, rectus capitus

참고) head nod exercise and head lift exercise

1. Head nod exercise

- 베게없이 무릎을 구부리고 등을 대고 눕기

- 눈을 무릎의 한 지점을 보고. 당신의 눈이 무릎의 한지점을 보는 것을 따라서 yes라고 말하듯이 부드럽게 고개를 끄덕임. 

- 마치 당신의 턱이 아담의 사과가로 가져가는 것처럼. 

2. Head lift exercise

-  등을 대고 누워서 hed nod exercise자세와 같이 하고, 당신의 머리는 중립위치에서 3-4인치 들어올린 후 내려감.

- 10-15회를 1세트로 하루에 2회 반복함. 

Treleaven et al. (1994) found the following three factors could distinguish post-concussion headache patients from asymptomatics:

. upper cervical joint dysfunction

. weak neck flexors 

. tight suboccipitals.

- 트레레번은 아래의 세가지 요소는 뇌진탕후 두통과 증상없는 환자를 구분할 수 있다는 것을 발견함.

- upper cervical joint dysfunction

- 약화된 deep neck flexor

- 후두하근 tight

참고) Suboccipital muscles refers to the muscles located below the occipital bone. The muscles are named: Rectus capitis posterior major, Rectus capitis posterior minor, Obliquus capitis inferior, and Obliquus capitis superior. 

- 후두하근은 대후두직근, 소후두직근, 하두사근, 상두사근

Reduced endurance of the deep neck  flexors is also found in a number of other published studies (Barton et al. 1996, Jull et al. 1999, Jull 2000, Silverman et al. 1991). Consistent with these findings are the reports that sustained loading of the neck in static postures leads to muscle fatigue and pain. 

- deep neck flexor의 감소된 근지구력은 ...

- 이러한 발견은 경추의 지속되는 부하는 근피로와 통증을 야기함. 

Hamilton estimated that the critical threshold for static loading is 10% of maximum voluntary contraction (MVC) ability (Hamilton 1996). A load of this intensity can be maintained comfortably for 10 min. Jensen recommended that static work should not be maintained at levels above 2% of MVC (Jensen et al. 1993). Veiersted and Westgaard (1992) eval‎uated functional work tasks and concluded that symptoms were triggered by static loads of only 1.6% MVC.

- 해밀톤은 정적인 부하의 critical 역치는 최대근수축의 10%라고 측정함. 

- 이러한 강도의 부하는 통증없이 편안하게 10분 유지할 수 있는 정도임. 

- 젠슨은 정적인 일은 최대근수축의 2%레벨을 넘는 범위에서 지속될 수 없다고 제안함. 

- 비어에스테드와 웨스트가드는 기능적인 일 수행을 할때, 최대근수축의 1.6%의 정적인 부하에 의해서 증상이 촉발된다고 주장함. 

Functional assessment of neck pain patients

The ideal functions to assess are dynamic tasks such as lifting and carrying and static tasks such as maintenance of neck or shoulder posture. Unfortunately, accurate measurement of these functions is elusive. Two simple forms of

assessment that can yield much clinically useful information are posture and movement pattern analysis.

- 물건들기와 물건 나르기와 같은 동적인 일과 아래 그림과 같은 경추, 어깨자세의 유지..

- 불행하게 이러한 기능의 측정은 애매함. 

두가지 측정법이 있음. 

1. poor posture

2. faulty movement pattern

Poor posture takes joints out of their aligned `centrated' positions and alters muscle balance between antagonist muscles (Figs 1 & 2). 

- 좋지 않은 자세는 관절에 비정상적인 힘을 가하고, 주동근과 길항근의 불균형 변화를 초래함. 

A typical example is a person working on a computer with a head forward position. This will overstress both the upper (hyperextension) and lower (flattening) cervical spine. Movement patterns are important to assess because classic muscle tests eval‎uate strength, but not the quality of movement (Janda 1996, Liebenson 1996, Liebenson et al. 1998, Lewit 1999, Murphy 2000).

- 전형적인 사례는 컴퓨터 작업을 하면서 발생하는 head forward position 임. 

- 이는 상부와 하부 경추 모두에 과부하를 초래할 수 있음. 

- 움직임 패턴은 진단에 중요함. 고전적인 근육검사인 근력측정이 움직임의 질을 평가할 수 없기 때문ㅇ...

Movement patterns involve coordinated movement involving many muscles. An example of a stable vs unstable movement pattern is if cervical spine neck flexion is performed with or without hyperextension of C0-C1. The deep neck flexors (DNFs) maintain a `neutral' alignment of the C0-C1 joint during head/neck flexion. But, if the sternocleidomastoid (SCM) predominate they can also raise the head, but only with the C0-C1 joint hyperextended (Jull et al. 1999, Treleaven et al. 1994). 

- 움직임 패턴은 많은 근육과 연관된 협응움직임을 평가해야

- 안정적인 vs 불안정성 움직임 패턴의 사례는 C0-C1의 과신전이 있거나 없이 수행하는 것. 

- Deep neck flexor는 두부/경추가 굴곡하는 동안 C0-1관절의 중립정렬을 유지함. 

- 하지만 SCM이 우세하면 그들은 머리를 들어올리고, C0-1관절은 과신전 됨. 

In both coordinated and incoordinated movement patterns the neck flexion movement can test as strong! Poor posture and/or faulty movement patterns are typical kinetic chain dysfunctions which cause functional instability by increasing biomechanical load to injurious levels. Such repetitive strain irritates pain sensitive structures and can be a key perpetuating factor of cervical pain. Common clinical relationships are shown in Table 1.

- 경추굴곡의 협응성과 비협응성 움직임 패턴은 측정할 수 있음.

- Poor posture와 faulty 움직임 패턴은 전형적인 운동사슬기능부전이고 이는 기능적 불안정성을 야기하고.. 생체역학적 과부하를 초래하여 문제를 일으킴. 

- 아래 테이블을 참조. 

Treatment planning requires that the association between different painful tissues and functional deficits is uncovered. Otherwise treatment is purely empirical without even a working hypothesis to guide it. Fortunately, there is a predictable pattern for the relationship between painful joints and muscles (trigger points) and their associated muscle imbalances (short and inhibited muscle antagonists) (Table 2).

-  치료계획은 서로 다른 통증조직과 기능부전의 관계를 고려해야.

- 다행히 통증관절과 근육통의 사이의 관계는 예측할 수 있는 패턴이 존재함.

Pain referred from the SCM muscle(s) or upper cervical joints is related to muscle imbalance involving shortened suboccipitals combined with overactivity of the SCM and inhibition of the DNFs (Fig. 3). A simple screen is to perform the head/neck flexion test (Fig. 4).

-  흉쇄유돌근 또는 상부 경추관절로부터 오는 연관통은 짧아진 후두하근,  scm과활성화,  DNFs  inhibition과 연관됨.

- head/neck flexion 검사로 스크리닝 테스트 함.

The neck flexion coordination test is positive if the chin pokes forward as the patient raises the head off the table. The test is negative if the head and neck curl in as the head is lifted towards the chest. An additional test can involve statically pre-positioning the head just 1 cm off the table with the chin tucked in. Then, ask the patient to hold this position for 10 seconds. If the chin pokes, the head lifts or drops the test is considered positive for poor endurance of the DNFs. 

-  테이블에서 머리를 들어올리때, 턱을 앞으로 들어올리면 neck 굴곡 협응성 검사는 positive

- 턱을 아래로 당긴 상태로 들어올릴 수 있을때 negative

-  그리고 환자에게 10초간 유지하도록 함.

- 만약 턱이 들어올려지면  deep neck flexor의 근지구력은 나쁜 것으로 평강.

Finally, a quantifiable test involves the use of a blood pressure cuff device pre-inflated to 20mmHg under the head to support it without pushing the head up. The patient is instructed to perform chin tuck movements to increase the pressure by 2mmHg increments up to a maximum of 30mmHg (Jull et al. 1999, Jull 2000). Performance ability with this test is compromised in patients with cervicogenic headache compared to asymptomatic individuals.

- 결국 정량화 할수 있는 검사는 혈압계로 측정가능.

Upper cervical flexion is important for maintenance of good spinal statics. The results of the head/neck flexion test can often be predicted on the basis of postural analysis of the head and neck. In standing analysis a head forward posture with a chin poke indicates agonist/antagonist/synergist muscle imbalance. In particular, the cervical extensors (the upper trapezius and suboccipitals) are not balanced by the co-activation of the DNFs ± longus colli and capitus. As a result sternocleidomastoid substitution occurs. 

- 상부경추 굴곡은 좋은 척추 정적자세를 유지하는데 중요한 역할.

- 두부/경부 굴곡검사는 두부와 경부의 자세분석의 기초위에 예측할 수 있음.

- 선자세 분석에서 턱이 들린자세와 함께 head forward posture는 주동근/길항근/협력근 불균형을 예측할 수 있게 함.

- 특히, 경추신전근(상부승모근과 후두하근)은 경추심부굴곡근(경장근, 두장근)의 상호-수축에 의해 불균형됨.

The clinical relevance of this imbalance is that treatment of the myofascial or articular pain generators without subsequent neuromuscular reeducation will likely not correct the underlying problem.

- 이러한 불균형의 임상적 중요성은 근육신경 재교육없이 근막 또는 관절통증 generator 치료는 근본적인 문제를 교정할 수 없음을 보여줌.

For instance, if trigger points in the SCM or painful cervical joints are present the inhibition of the DNFs must be corrected or else it is likely the trigger points or joint dysfunction will recur. Sometimes, it is the trigger point or joint dysfunction which is primary. The key is to see the chain reaction in the motor system and determine when the joint dysfunction, trigger points and movement patterns are all normalized.

- 예를들어, 만약 흉쇄유돌근에 발통점 또는 경추에 통증성 관절이 있다면 억제된 DNFs는 반드시 교정되어야 하고, 그렇지 않으면 발통점이나 관절기능부전은 다시 발생함. 

- 때로 발통점이나 관절기능부전이 primary임. 

- 핵심은 운동계에서 사슬반응을 보고 관절기능부전, 발통점, 움직임 패턴이 표준화되어야 함. ....

Other functional tests of relevance in head/neck syndromes are listed in Table 3.

자세분석

1) head forward posture

2) shrugged or rounded shoudlers

3) upper thoracic kyphosis

움직임 패턴

1) head/neck flexion

2) scapulo-humeral rhythm

3) respiration

4) T4-8 extension test

Treatment of neck pain patients

Most head/neck pain patients require a relatively straightforward eval‎uation and treatment approach since for the majority the prognosis is reasonably good. Unless there are `red flags' of serious disease the patient should be reassured and reactivated. If needed pain-relief treatments should be offered.

-  대부분의 head/neck 통증환자는 상대적으로 올바른 측정과 치료접근이 필요함.

- 만약 심각한 질환의 red flags이 없다면 환자는 반드시 reassured and reactivated해야 함.

- 필요하다면 진통주사를 제공해야 함. 

Avoiding unnecessary surgery, overmedication, and overexamination (especially with diagnostic imaging) is important in order to prevent `medicalizing' the problem. In contrast, patients who are not satisfactorily recovering by the subacute phase require more aggressive management since it is easier to prevent than to treat chronic pain. The key time frame where aggressive management should be considered is between 4 and 12 weeks. Those with `yellow flags' (psycho-social) risk factors of chronicity should be more aggressively managed even earlier.

- 불필요한 수술, 과도한 약물투여, 과도한 진단을 피하는 것은 중요한 의학적 문제임. 

- 반면에 아급성기로 치료에 만족하지 못하는 환자는 좀더 적극적인 치료가 필요함. 

Such `yellow flags' include past history of neck injury, low self-rated health, and high levels of psychological distress (Croft et al. 2001). This still does not mean MRIs on every patient, but it does mean a rehabilitation specialist  should be involved. In particular, one with training in cognitive behavioral approaches. The important point is that when a full diagnostic work-up is recommended it should not be limited to MRIs or other structural eval‎uations, but also include functional/physiological testing such as a functional capacity eval‎uation and a psycho-social eval‎uation. Table 4 presents an overview of the key steps to recovery.

- yellow flags은 과거의 경추손상, 자아만족감의 저하, 높은 스트레스를 포함함. 

- ....

The musculoskeletal medicine approach to neck pain embraces the current evidence for advice, manipulation and exercise. Most importantly it recognizes the importance of reassurance and reactivation for promoting a quick recovery and minimizing the risk of chronicity.

Advice

Advice for patients with head and neck pain is designed to reassure them about the positive prognosis for their condition and the safety of gradually resuming normal activities. Activity modification advice is more valuable than advice to avoid activities (Borchgrevink et al. 1998). Helpful biomechanical advice includes ergonomic suggestions for the workstation (chair, computer, phone, and desk) or when performing movement stereotypes such as carrying a briefcase, reaching overhead etc.

Reassurance that hurt does not necessarily equal harm is vital. If movements or postures cause symptoms to peripheralize from the neck down to the arm those activities should be reported to the clinician and modified (Rosenfeld et

al. 2000). But, other activities which may only be locally uncomfortable are usually not harmful and patients should be reassured of this through a problem-solving approach (Vlaeyen et al. 2001, Shaw et al. 2001).

While improved biomechanics during sustained static tasks or repetitive dynamic tasks is important, patients should not be overly vigilant about posture in all activities (Indahl et al. 1995). Full range of motion will be lost if one is educated to stay in a `neutral range' all the time. Full range activities that involve light load will beneficially stretch and mobilize tissues.

Traditional back school should be replaced with a cognitive-behavorial approach emphasizing that hurt doesn't 

necessarily equal harm (Indahl et al. 1995, Manniche et al. 1999). Patients suffering neck pain do have injured tissues. They should be informed that those tissues will heal better with light activity than with rest (Indahl et al. 1995). Pain `¯are-ups' are normal and to be expected and are not a sign of further injury.

Stress and emotional tension will tend to reduce an individual's pain threshold and intensify the symptoms associated with such `¯are-ups' (Indahl et al. 1995). Patients should be educated that stress plays a role, but that it does not cause injury and that the pain will run a course. Advice about physiologic coping strategies such as breathing techniques, light exercise, meditation etc is also important.

Manipulation

Manual therapy and manipulation is important for facilitating recovery from neck pain. Normalization of afferent information from joints, muscles, skin, and fascia is important for promotion of healing and rehabilitation of function. If joints are `locked' in the mid- thoracic or upper cervical regions movement will follow the `path of least resistance' and overstrain vulnerable areas such as the lower cervical spine. 

Thus, joint mobilization/manipulation will improve load-sharing and thus functional stability. Gentle techniques include post-isometric relaxation, muscle energy, or other non-thrust techniques. Adjustments ± by highly trained experts in high- velocity short amplitude thrust manipulation such as chiropractors ± are appropriate for joints which are carefully examined and found to have restricted motion.

Shortened muscles and taut fascia should be relaxed and lengthened to improve functional stability. The suboccipitals, latissmus dorsi, pectorals, and hip ¯exors are prime examples. Adjunctive therapy to manual therapy can include physical agents such as heat/ice, electrical muscle stimulation, traction etc. Many of these methods are well suited for early care in the acute phase, but they can lead to patient dependency. These passive modalities should be seen as means

to facilitate active rehabilitation and not as ends in themselves.

Exercise

While advice can reduce the source of external repetitive strain, and manipulation can improve the performance of key muscles or joints, exercise is also frequently needed to improve the overall ?tness of the entire kinetic chain as well as

to facilitate `deep' muscles important for spinal segmental stability. 

Exercises aimed at improving motor control are usually recommended. These movements focus on control rather than power. In fact, it is poor motor control not poor strength that has consistently been found to be of importance in

functional instability. Patients learn to appreciate that the quality of the movement is more important than the resistance or repetitions. This is very different from how most people view exercise and so patients are re-educated about `therapeutic' exercise. 

The ?rst 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).

Training the `deep' muscles which guide and control movement is dicult since these muscles are not ordinarily under voluntary control. Learning theory has been applied to this type of training (Shumway-Cook & Woollacott 1995). The ?rst stage involves gaining conscious awareness of the poor postures and movement patterns. This is called the cognitive-kinaesthetic stage. The second stage is where awareness of the corrected postures and movements is achieved and thus

corrective movements can be performed and practiced. 

This is called the associative stage. The third and ?nal stage occurs when after daily practice of corrected movements and postures for many weeks a new motor program forms in the central nervous system such that improved motor control becomes more automatic. This is the autonomous stage. Many forms of exercise share these principles such as Pilates training and segmental spinal stabilization training.

Thus, while exercises initially require conscious control, the goal is to automatize coordination to lessen the consequences of poor

motivation and compliance. Patients

should ?rst become consciously

aware of the muscle or part of the

body that is to be activated.

Exercises and coordinated activities

are prescribed which train the

patient how to gain this volitional

control. Finally the motor program

becomes a subcortical engram and

the patient achieves the desired

effect without having to vigilantly

concentrate on the function. Thus

the patient is able to protect the

vulnerable region during ADLs and

when exposed to unexpected

perturbations.

In the cognitive-kinaesthetic stage

the clinician must initially ?nd the

patient's functional range ± the

position or movement which

centralizes or decreases pain without

unwanted super?cial muscle activity

(i.e. upper trapezius). The patient

should then demonstrate that they

have the kinaesthetic awareness to

produce isolated movements of

different joints and that they can

?nd and maintain a `neutral

position' of certain key joints such

Liebenson

64

JOURNAL OF BODYWORK AND MOVEMENT THERAPIES JANUARY 2002

Functional reactivation for neck pain patients

as the cervico-cranial or scapulo-

thoracic. This will show that they

have learned to coordinate and

co-activate antagonist muscles.

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 ¯exion while

?xing the scapulae inferiorly against

the thorax. If excessive shrugging of

the shoulder occurs this signi?es

poor scapulo-thoracic control.

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. This type of postural

correction is a key component in

Alexander training methods.

In the associative stage the

corrected postures and movements

are trained repetitively to build

endurance of the `deep' stabilizers.

The key here is to ?nd two or three

faulty or pain producing movements

and focus on improving their

function. The movements are not

threatening since load is kept light

(less than 50% of maximum

voluntary contraction ability). But

frequent repetitions (8±10) of very

slow movements (up to 10 seconds/

repetition) are required at least twice

a day and sustained hold times

(5±6 seconds). A minimum duration

of 4±6 weeks is required.

In the autonomous stage

improved motor control is

integrated into ADLs on an

automatic basis. This should begin

to become `habit' so that a low

degree of attention is required and

compliance and motivation issues

recede into the background.

Conclusion

Neck pain syndromes require an

approach which focuses on restoring

function. This necessitates a

biopsychosocial approach not a

biomedical one. Structural diagnosis

is often overemphasized thus

making patients fear movement and

think of themselves as damaged.

Such `labeling' distracts patients

from the real issues interfering with

recovery which are functional/

physiological and psycho-social.

Immediate reassurance coupled

with early reactivation and pain

relief advice is the standard of care

for acute neck pain. Treatment

should be based on functional

assessment, and thus progress at

regular intervals can be monitored

with functional outcomes. Patient

reactivation requires a studied

approach which is both not too

aggressive in the acute phase, nor

too passive in the subacute phase.

Most patients recover

uneventfully, but it is the minority of

sufferers who challenge health care

professionals and the health care,

legal, and disability systems to come

up with a better approach.

Avoidance of the iatrogenic

in¯uence of over diagnosis and over

treatment of acute patients is part of

this. So is the reliance on purely

structural (imaging and surgery) or

symptomatic (medication,

injections, physical therapy

modalities, massage, and

chiropractic adjustments)

approaches for both acute and

chronic syndromes. The modern

approach is a `problem-solving'

one. Reassurance that there is

nothing structurally wrong

combined with reactivation advice

or functional restoration treatments

are the mainstays of this new

paradigm.

[이상진]

자주 자주 봐야 겠어요^^
감사합니다..

[김영환PT]

잘봤습니다 감사합니다~^^